singapore health nov/dec 2012

M2 singapore health noV⁄ Dis 2012

Berita

Pembedahan turunkan berat badan bantu dua pesakit lawan diabetes, obesiti dan penyakit lain

Oleh Valerie lee

Rawatan kecantikan ekstrem

Berat badan En Shaun Lawrence, 32, dan Puan Rozita Ramlee, 36, melebihi 100kg sebelum ini.

Hari ini, tiada siapa yang dapat menduga mereka pernah obes. Atau pernah men-gambil pelbagai jenis ubat untuk pelbagai penyakit yang berkaitan dengan obesiti.

Mereka berdua telah menjalani pin-tasan gastrik, satu pembedahan membantu menurunkan berat badan atau prosedur bariatrik yang berkesan untuk memper-baiki/memulihkan diabetes dan gangguan metabolisme lain. Untuk melawan obesiti, diabetes dan penyakit lain yang berkai-tan, mereka telah menjalani pembedahan tersebut di Hospital Besar Singapura (SGH) hujung tahun lalu. “Sebelum ini, saya tidak boleh berjalan

jauh atau menaiki MRT dan bas awam. Pem-bedahan ini telah memberi saya kehidupan baru,” ujar En Lawrence, yang sekarang ber-lari, berenang dan pergi ke pusat senaman dengan kerap.

En Lawrence turun dari 117kg dengan indeks jisim tubuh (BMI) 35 kepada 85kg, sementara Puan Rozita turun kepada 93kg dari 128kg, BMI 50, selepas pembedahan masing-masing pada November dan Sep-tember tahun lepas.Mereka tidak lagi perlu mengambil ubat

untuk mengawal diabetes, tekanan darah tinggi, kolestrol dan rawatan untuk apnea tidur obstruktif, keadaan di mana seseorang itu berhenti bernafas disebabkan saluran pernafasan tertutup semasa tidur lena. Penilaian rapiMereka menjalani temuduga dan kaunsel-

ing rapi di Pusat Pembaikan Gaya Hidup dan Peningkatan Kesihatan (LIFE), di mana kakitangannya terdiri daripada doktor, pakar pemakanan, ahli fisioterapi, ahli psikologi, jurupulih pekerjaan dan pekerja sosial perubatan berbilang disiplin. LIFE menggalakkan penjagaan bersepadu dan holistik untuk pesakit dengan kondisi peru-batan berkaitan-gaya hidup, seperti gang-guan pemakanan dan obesiti.

En Lawrence mendapatkan rawatan daripada Dr Tham Kwang Wei, Perunding, Jabatan Endokrinologi, SGH, dan Pengarah, Unit Obesiti dan Metabolik setelah diru-jukkan ke Pusat Diabetes di SGH semasa penyaringan pra-pengambilan perkhid-matan negara.

“Dia seorang pesakit diabetes tipikal yang berat badannya turun naik. Setelah mendapatkan rawatan selama tujuh tahun

kesan jika pesakit tidak merubah gaya hidup mereka.

Selepas pembedahan, perut pesakit dikecilkan ke saiz kantung kecil yang dis-ambung ke bahagian tengah usus kecil. Pesakit akan muntah jika makan berlebi-han daripada apa yang boleh diterima oleh kantung tersebut. En Lawrence biasanya memakan

sekeping roti untuk sarapan, sekeping kecil ikan untuk makan tengahari dan sekeping kecil ikan untuk makan malam. Puan Rozita, yang mengakui beliau sebe-

lum ini tidak memahami erti “kenyang” apabila makan, telah mengajar dirinya untuk berkata “tidak” kepada sebahagian besar makanan.

Kedua-duanya kini komited dengan pemakanan sihat, senaman, regimen makanan tambahan harian dan lawatan tetap ke Pusat LIFE untuk mengawasi kemajuan mereka. Mereka kini penyokong gaya hidup sihat dan melibatkan juga ahli keluarga serta rakan-rakan mereka untuk mengikut tabiat baru mereka. “Seorang individu yang menjalani pem-

bedahan dan telah diajar mengenai pemak-anan menjadi nukleus perubahan bagi ses-ebuah keluarga,” ujar Dr Shanker lagi.

Pesakit dibantu melalui sokongan pesakit yang mempunyai masalah serupa. Bakal pesakit dan pesakit yang sedang melalui pelbagai fasa selepas pembedahan menghadiri mesyuarat kumpulan sokon-gan di Pusat LIFE, setiap petang Rabu.

dia menghilangkan diri dan timbul semula dengan diabetes yang tidak terkawal dan berisiko terkena serangan sakit jantung menjangkau usia 40 tahun.” Puan Rozita pula bosan keluar masuk

hospital sebanyak empat kali kerana men-galami diabetes, radang ulser perut, apnea tidur dan sista ovari. Beliau berazam dan komited untuk menjalani pintasan gastrik kata Dr Shanker Pasupathy, Perunding Kanan, Pembedahan Am, dan Pengarah, Pusat LIFE, SGH.

“Terdapat salah tanggapan umum bahawa pembedahan boleh menyelesaikan semuanya dan, selepas itu, anda boleh meneruskan hidup anda. Pembedahan ini sekadar butang set semula dan selepas itu, anda mesti mulakan pendekatan baru kepada kehidupan anda namun bukan hanya dari segi pemakanan saja.”Pesakit pergi ke Pusat LIFE untuk belajar

mengubah suai tabiat pemakanan mereka. “Kami berbincang tentang pemakanan, memilih makanan dan bersantai. Mereka perlu membuat perubahan kerana pem-bedahan hanya membantu menurunkan sekadar 20 sehingga 30 peratus berat badan mereka,” ujar Dr Shanker.Prosedur bariatrik – sama ada pintasan

gastrik, pembedahan ikat perut (gastric lap band) atau ‘gastric sleeve’ – tidak ber-

Prosedur

Lingkaran laparoskopik gastrik boleh laras(Laparoscopic adjustable gastric banding)

Gastrektomi lengan Laparoskopik(Laparoscopicsleeve

gastrectomy)

Laparoscopic Roux-en-Y gastric bypass

Apa yang terjadi

lingkaran silikon yang boleh dilaras diletakkan di sekeliling bahagian atas perut untuk mengurangkan saiznya, supaya seseorang itu lebih cepat berasa kenyang dan makan kurang lagi dan dengan itu dapat mengurangkan berat badan

satu porta diimplankan di bawah kulit untuk membolehkan pelarasan halus diameter outlet Kira-kira 75 peratus perut dikeluarkan hasil awal prosedur yang agak baru ini memberansangkan

Kantung gastrik yang kecil dicipta terlebih dulu, kemudian pintasan kepada usus kecil dijalankan ini mengurangkan pengambilan

kalori dan mengubah cara makanan dihadam

Pro

pembedahan yang agak ringkas tidak memerlukan perut dibedah

Kadar komplikasi selepas pembedahan yang agak rendah Boleh menjadikan diabetes peringkat awal bertambah baik

Boleh diterbalikkan (jika lingkaran dikeluarkan sebelum terjadi komplikasi)

tiada benda asing dimasukkan sepertimana teknik lingkaran

pembedahan sekali sahaja penurunan berat badan awal yang pantas Mengurangkan kelaparan lebih daripada teknik lingkaran Boleh menjadikan diabetes peringkat awal bertambah baik

pesakit boleh makan dengan lebih baik berbanding teknik lingkaran, tetapi masih lagi mengalami penurunan berat badan yang baik

penurunan berat yang lebih banyak berbanding kaedah lain Boleh menterbalikkan diabetes jenis 2 yang sedia ada prosedur yang sangat difahami

memandangkan ia telah dijalankan lebih dari 40 tahun

Kontra

Benda asing dimasukkan kedalam badan Memerlukan pelarasan yang kerap di klinik lebih kurang 10 peratus pesakit tidak berjaya mencapai sebarang penurunan berat badan Komplikasi lewat yang ketara, termasuk jangkitan, hakisan atau

gelinciran lingkaran, memerlukan pembedahan ulangan

Kekal dan tidak boleh diterbalikkan hasil jangka panjang (melebihi lima tahun) tidak diketahui garis pengokot pada perut boleh berdarah atau bocor

pakar bedah memerlukan lebih banyak latihan garis pengokot dan penyambung

gastrousus boleh berdarah atau bocor

Komplikasi lewat, seperti ulser perut dan usus terpulas, boleh berlaku

Kekurangan nutrisi boleh berlaku Memerlukan penjagaan pakar dan nutrisi tambahan sepanjang hayat

Lingkaran dan pengokot

Dr Tham Kwang Wei (paling kiri) dan Dr Shanker Pasupathy (paling kanan) bersama pe-

sakit pintasan gastrik mereka En Shaun Lawrence dan Puan Rozita Ramlee.

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Prosedur yang baru ditemui boleh membantu pesakit

mengawal tekanan darah tinggi yang sukar dikawal

Apabila segala

yang lain gagal

Puan Malia Dawan, 71, tidak dapat

menurunkan tekanan darahnya

– meskipun memakan enam jenis ubat

berlainan setiap hari untuk menga-

walnya.Tekanan sistoliknya berada di sekitar

200 dan 210 milimeter raksa (mmHg) - lebih

daripada paras140 mmHg yang wajar untuk

seorang seusianya.

Anaknya Puan Yusminah Yusi, 55, juru-

rawat terlatih, mengubah cara pembungku-

san pil untuk memastikan ibunya memakan

ubat dengan betul namun ini tidak juga

memulihkan keadaan Puan Malia.

Tiada respons terhadap rawatan

Puan Malia didapati mengalami hipertensi

resisten di mana tekanan darah tingginya

tidak memberi respons kepada rawatan

meskipun menggunakan kombinasi

sekurang-kurangnya tiga ubat.

Beliau sentiasa sesak nafas walaupun

ketika bercakap atau berbaring. Keadaan

ini membuat ibunya berisiko mendapat

strok dan penyakit jantung.

Pada Januari tahun ini, Puan Malia

menjalani denervasi renal di Pusat Jantung

Nasional Singapura (NHCS). Prosedur baru

kurang invasif ini menggunakan gelom-

bang frekuensi radio untuk menghapus-

kan saraf simpatetik di sekitar arteri renal

untuk menurunkan tekanan secara drama-

tik ke paras yang disasarkan.

“Kesannya dapat dilihat pada hari yang

sama juga dan dia tidak lagi berasa sesak

nafas,” ujar Puan Yusminah. Hipertensi

– “pembunuh senyap” – hanya dapat dike-

san apabila ia bertambah teruk dan pesakit

mengalami komplikasi strok atau serangan

jantung atau simptom seperti sakit kepala,

sesak nafas dan pening kepala.

Menurut Dr Jack Tan Wei Chieh,

Oleh Thava Rani

Perunding, Jabatan Kardiologi, Pusat Jan-

tung Nasional Singapura (NHCS) dalam

varieti resisten ini tekanan darah pesakit

kekal tinggi walaupun memakan ubat

dengan betul.

“Se per lima daripada populasi dewasa

hari ini yang berusia 60 tahun ke atas

menghidap hipertensi dan sekitar 3 - 5%

mengalami sejenis bentuk rintangan.

Dengan penduduk yang semakin menua,

kadar ini akan meningkat, begitu juga kes

rintangan,” tambahnya.

Hipertensi resisten disebabkan oleh

beberapa keadaan seperti ketidak seimban-

gan hormon, kegagalan ginjal atau sebab

yang diketahui. Ia bertambah teruk pada

individu lebih tua, obes atau menghidap

kencing manis.

Namun pesakit kini mempunyai pilihan

untuk menjalani prosedur denervasi renal.

Saraf simpatetik renal mengandungi saraf

aferen dan eferen yang menghantar isyarat

kepada otak yang bertindak balas sewajarnya.

Otak menghantar semula isyarat kepada

Dr Jack Tan Wei Chieh memeriksa tekanan darah Puan Malia Dawan sementara anaknya

Puan Yusminah Yusi memerhatikan.

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laluan ini sambil menurunkan tekanan

darah,” ujar Dr Tan.

Prosedur yang lebih selamat

Konsep mengganggu isyarat otak bukanlah

baru. Para pakar bedah telah mengeluarkan

saraf di sekitar arteri ginjal sejak 1930an

lagi menggunakan pembedahan terbuka

yang amat invasif. Walaupun berkesan, ter-

lalu ramai pesakit mengalami komplikasi

seperti pembuangan air kecil yang tidak ter-

kawal dan masalah fungsi seksual. Kaedah

ini dihentikan apabila ubat anti-hipertensi

yang berkesan berada di pasaran.

Kini, teknologi kurang invasif telah men-

jadikan prosedur selama 40 minit sehingga

sejam itu lebih selamat. Kaedah yang berke-

san dan tahan lama ini telah diamalkan di

negara luar selama dua tahun.

Walaupun ia tidak menyembuhkan

tekanan darah tinggi, ia mampu mengu-

rangkan tekanan sebanyak purata 32/12

mmHg. Kesemua tiga pesakit, yang telah

menjalani prosedur ini di NHCS Septem-

ber tahun lalu, mencapai penurunan lebih

daripada 20 mmHg. Penurunan sekecil 5

mmHg sekalipun boleh mengurangkan

risiko strok sebanyak 14 peratus, penyakit

jantung 9 peratus dan kematian 7 peratus.

Tekanan darah Puan Malia kini berada

di paras 140/90 mmHg dan dia juga men-

gambil dos ubat yang kecil.

“Semua adik beradik ibu saya ada

tekanan darah tinggi dan telah meninggal,

ada sebelum menjangkau 50 tahun. Mereka

tiada pilihan menjalani prosedur baru ini

tidak seperti ibu saya,” kata Puan Yusminah

gembira.

ginjal (melalui saraf renal) supaya arteri

mencerut dan menyimpan lebih garam dan

air, sekaligus meningkatkan tekanan darah.

Ginjal juga menghantar semula isyarat

kepada otak mengarahkan jantung berde-

gup lebih kencang apabila tertekan dan ini

juga menjejas tekanan darah.

“Saluran ini mengamuk dalam bentuk

hipertensi resisten. Otak dan ginjal sentiasa

menghantar jumlah isyarat yang keter-

laluan kepada satu sama lain, bukan hanya

semasa tertekan atau kekurangan air,

malahan ketika keadaan tenang. Dengan

melumpuhkan secara terpilih saraf simpa-

tetik di sekitar arteri renal, denervasi renal

membantu mengurangkan isyarat keter-

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Tekanan darah normal sepatutnya

berada di bawah paras 140/90

mmHg (angka pertama adalah

tekanan darah sistolik, manakala

yang kedua adalah tekanan

darah diastolik). Dengan setiap

peningkatan sebanyak 20 mmHg

dalam tekanan darah sistolik

melebihi paras normal, risiko

penyakit kardiovaskular seseorang

itu berganda.

Bagi pesakit yang mempunyai

masalah diabetes, ginjal dan jantung,

paras sasaran tekanan darah adalah

di bawah 130/80 mmHg.

Bagi pesakit yang menghidap

hipertensi tetapi tiada masalah

Apakah rintangan tekanan darah?perubatan lain, paras sasaran

tekanan darah patut berada di

bawah 140/90 mmHg.

Hipertensi resisten berlaku

apabila tekanan darah tidak

boleh diturunkan ke paras

sasaran tekanan darah dengan

menggunakan tiga atau lebih jenis

ubat, termasuk diuretik pada dos

yang optima.

Diagnosis rintangan tekanan

darah perlukan penjagaan kerana

hipertensi tidak terkawal mungkin

berlaku kerana kurang pematuhan

dalam pengambilan ubat, atau

hipertensi 'white-coat' (cemas

berada di klinik)

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NOV⁄ DEC 2012 siNgapOrE hEalth 03

News

There’s hope in the long run

It will be the second time that Ms Fay Lim and her 16-month-old miracle baby, Eliza Tok, will take part in the annual Run For Hope to raise funds for cancer research.

The last time they participated, Eliza was carried by her father. “This time, I will walk and she’ll be in her stroller,” said Ms Lim, 33, who conceived Eliza just eight months after she completed a stem cell transplant to treat her cancer.

“It was such a surprise. I never expected to get pregnant so soon after recovering,” she said.

In focus

A cancer survivor gives back by joining a run with her baby to raise funds for cancer research

Ms Lim, who was a strategic business development analyst, and her husband, then a market access manager, were thinking of starting a family when her cancer struck.

It started in 2009 with a backache and some inflammation. “An orthopae-dic specialist told me it was a slipped disc. But the pain got increasingly worse till I could barely walk or bend down to put on my socks or wash my face,” she said.

Her husband took her to the hospital one night after she broke down and cried because of the intense pain. An MRI scan and a biopsy revealed the worst possible news – she had Stage 4 Non- Hodgkin’s Diffused Large B Cell Lymphoma. This is a cancer of the lymphatic system, which is made up of organs such as the bone marrow, thymus, spleen and the lymph nodes. Non-Hodgkin’s Lymphoma is one of the more common forms of lymphoma.

“I was devastated and wondered how it could happen to me,” said Ms Lim.

She pulled through six cycles of che-motherapy and a stem-cell transplant, which felt like a marathon to her. The swelling in her back gradually decreased, allowing her to walk normally again.

Aware that women face challenges balancing work and family, she is inspired by her colleagues. She said: “Healthcare is a demanding industry that attracts a high percentage of female employees who effectively juggle their multiple roles.

“At SingHealth, many of our female staff take on leadership and manage-ment responsibilities in clinical care, nursing, allied health and healthcare administration.

“We support them with initiatives that help them balance their career demands with family commitments.”

She said working alongside them has inspired her personally and profession-ally. “I see my role as encouraging them to be confident that there are no limits to the positive impact we can make in the lives of others – whether they are patients, colleagues, junior staff or family members.”

The award recognises women who have contributed to society. Previous recipients include Professor Chan Heng Chee, Ambassador at Large, Ministry of Foreign Affairs, as well as Mdm Halima Yacob, Minister of State for Community Development, Youth and Sports.

Professor Ivy Ng, Group CEO of SingHealth, has been given the Woman of the Year 2011/2012 award by Her World magazine.

The award recognises her contribution as a clinician-leader and for being an inspi-rational role model for women.

At SingHealth, Prof Ng strives to ensure that each patient receives better care than the last. She achieves this by building “a culture where our clinicians are not satisfied with the status quo, but are constantly looking for answers, examin-ing gaps in medical care and innovating treatment”.

SingHealth Group CEO named Woman of the Year

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BY AudrinA GAn

Time 7amVenue the padangRun categories 3.5km/10kmFees adult: $45; child/youth: $25 (participants must be five to 18 years old at the time of race. Entry is free for those four years old and below); Buddies special (2 adults): $80; group special (only for 20 adults or more): $35 per person For more information, visit www.runforhopesingapore.org.

JOiN thE ruN FOr hOpE 2012

Nov 18 (Sun)

Her encounter with cancer has changed her views on life. She has no plans to return to work just yet, and sees life as a passage through seasons. “I have gone through a season of recovery, and now I’m in the season of being a mother,” she said.

Joining the run is her way of doing her bit to support cancer research. “I benefited from the research and I hope we can raise enough money to keep it going strong, so that others can benefit too.”

This year’s run, held in the city area for the first time, will see participants cover 3.5km or 10km in the Marina Bay and Kallang River areas.

The organisers – National Cancer Centre Singapore, Four Seasons Hotel Singapore and Regent Singapore – hope to raise more than $700,000 from the run.

Ms Fay Lim and her baby Eliza Tok will join the Run For Hope 2012 event in November.

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SingHealth raised a record amount for beneficiaries of the President’s Challenge this year, the highest since it started fundraising for the challenge nine years ago. The cheque for $388,000 was presented to the President at Symphony for Health – the finale event of SingHealth’s fundraising efforts held at Punggol Waterway. At the ceremony were (from left) Mr Peter Seah, Chairman, SingHealth; President Tony Tan Keng Yam; Professor Ivy Ng, Group CEO, SingHealth; and Professor Ang Chong Lye, Deputy Group CEO, SingHealth, and CEO, Singapore General Hospital.

04 singapore health noV⁄ DeC 2012

News

A step forward in battle against dengue

an antiviral drug may prove effective for treating patients with early stages of dengue fever – an illness for which there is cur-rently no vaccine or cure.

The clinical trial of Celgosivir, a medicine derived from the seeds of the Moreton Bay Chestnut tree, was started in mid-July, and conducted by researchers at the Singapore General Hospital (SGH) and the Duke-NUS Graduate Medical School (Duke-NUS).

This is the first time that Celgosivir is being tested on patients with dengue fever.

Dengue fever affects up to 100 million people worldwide each year. Last year alone, about 5,330 cases were reported in Singapore.

Associate Professor Subhash Vasudevan, who directs the Emerging Infectious Diseases Therapeutics Laboratory at Duke-NUS, said: “Laboratory experi-ments at Duke-NUS have shown that Celgosivir inhibits four serotypes of dengue virus, so we took this important next step to find out how well it works in patients.”

Dr Jenny Low, the principal inves-tigator of the study and consultant at SGH’s Department of Infectious Diseases, said: “The trial aims to find out if Celgosivir can reduce the amount of virus, fever duration and pain in patients who receive the treatment early in the course of dengue fever.

“The approach is different from that of dengue vaccines, which cannot be used to treat a dengue patient once he becomes ill.”

Assoc Prof Subhash said the trial will also investigate whether Celgosivir can be used to treat dengue fever, and whether it is able to prevent more severe forms of dengue, such as dengue hemorrhagic fever and dengue shock syndrome.

A drug that may be effective for treating dengue fever is being tested for the first time on patients

BY Lediati tan

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The $1.6 million clinical trial was approved by the ethics board of Singapore Health Services and the Health Sciences Authority of Singapore.

It is funded by the STOP Dengue Translational Clinical Research Pro-gramme under the Ministry of Health’s National Medical Research Council and the National Research Foundation.

Conducting the trial The trial is ongoing and the investigators are aiming to recruit 50 dengue patients, aged 21 to 60.

To be eligible, the patients must be suffering from the early stages of dengue fever, diagnosed within one to two days of infection.

The participants are to be referred by doctors from polyclinics, general prac-titioner clinics and the Communicable Diseases Centre (CDC).

They will be given Celgosivir tablets or a placebo, and monitored by SGH’s Investigational Medicine Unit (IMU), where they will stay for five days.

After completing the course of the medicine, they will be assessed to see if they are well enough to be discharged.

After discharge, the participants will

Associate Professor Subhash Vasudevan and Dr Jenny Low want to test Celgosivir on 50 patients suffering from the early stages of dengue fever.

there is currently no vaccine for dengue and no approved medicine for treating dengue fever. however, supportive care with intravenous fluids and frequent blood tests can help to reduce complications. in severe cases, blood transfusions may be required.

patients need plenty of bed rest. they should drink a lot of fluids and take medicine to reduce the fever.

Adapted from information available on the Ministry of Health, Health Promotion Board and National Environment Agency websites.

Dengue fever is caused by the dengue virus, which is carried and spread by an infected aedes mosquito. the disease cannot be spread by physical contact between humans.

there are four types of dengue virus. infection by one type usually provides lifelong immunity to that virus strain, but only short-term immunity to the other types of dengue. the incubation period is between three and 14 days.Dengue haemorrhagic fever and dengue shock syndrome are more severe forms of dengue which can result in death.

What is dengue fever?

What are the symptoms?

symptoms usually develop four to seven days after infection. symptoms include:

sudden onset of fever severe headache, especially behind

the eyes severe joint and muscle pain nausea and vomiting Body rash

What are the treatment options available?

A painful experienceDuring his second-year law exams at the national University of singapore in 2009, Mr sean Yeo swee Quan (left) suddenly came down with a high fever.

Mr Yeo, now 25, consulted a doctor who prescribed paracetamol for the fever and pain. he continued to sit his exams even though his fever persisted for about three days.

after his exams, his parents took him to the hospital when the fever did not recede. Mr Yeo was eventually diagnosed

return to the IMU on three separate occa-sions – seven, 10 and 15 days later – for further assessment. Their medicine and treatment are provided for free.

A safe medicineCelgosivir is a safe medicine that was tested in the United States, Canada and Europe against other viral infections, said Dr Low.

About 600 patients took Celgosivir in those studies. The medicine was tested on human immunodeficiency virus (HIV) patients in the early 1990s, and on patients with chronic hepatitis C virus infections from the late 1990s to around 2007 in the US and Europe.

In those studies, when patients first started taking the medicine, there were mild gastro-intestinal side effects such as gas production and mild diarrhoea. But these did not affect the patients’ lifestyle, said Dr Low.

She added that the symptoms disap-peared for some patients who took the drug for three to six months as their bodies adapted to the drug.

The side effects can also be mitigated by changes in dietary habits and the types of food eaten, said Dr Low.

with dengue fever and was warded for about three days.

as there are no drugs to treat dengue fever, he was given medicine to alleviate the fever and aches, and was put on an intravenous drip and told to drink lots of water.

it was a “painful” experience, Mr Yeo said. he suffered intermittent headaches and “it felt like someone was hammering my head”.

his body ached and rashes developed

all over his body. he lost close to 6kg during his hospital stay as he could swallow only some biscuits and iced Milo.

Mr Yeo still cannot figure out where he contracted dengue. “You can get bitten by mosquitoes anywhere, and that’s kind of scary,” he said.

he added: “When you get a high, persistent fever, it may not be dengue, but it’s probably good to see a doctor and see what he says.”p

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Safe to be pregnantA woman who has been diagnosed with lupus does not need to shelve her plans for starting a family, said Dr Andrea Low, Consultant, Depart-ment of Rheumatology and Immu-nology, Singapore General Hospital.

The illness does not directly affect fertility. Dr Low said she has seen many lupus patients go through successful pregnancies, with the children of many patients now grown up.

“In the past, we advised female lupus patients to avoid pregnancy,” she said. “But today, the survival and management treatments have advanced to a level where we can tell patients how to control their disease for at least six months, and then do family planning together with their doctors.”

For many female patients, the key is to ensure that their autoim-mune disease does not flare up and attack major organs before they start their family planning.

“We will monitor things like kidney function and ensure the patients are taking their medicines correctly,” said Dr Low.

20 & 40years of age

Women are usually diagnosed with lupus between

WoMen are More prone

90%Over

of lupus patients are women

When the body becomes its own enemy

Our immune system is meant to protect us from “foreign invaders” such as viruses and bacteria. But when someone suffers from an autoimmune disorder, his immune system mistakes his own body as the “enemy” and starts attacking it.

“The best way to describe this is to imagine a civil war breaking out inside your body,” said Dr Andrea Low, Consultant, Department of Rheumatology and Immunology, Singapore General Hospital (SGH).

Autoimmune disorders can affect any part of the body, including the joints, skin and internal organs, such as the kidneys or the brain. There are over 80 types of such diseases, which include rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus and systemic sclerosis.

Rheumatoid arthritis, spondyloarthri-tis and lupus are among the most common autoimmune disorders in Singapore.

Detective workThe conditions are thought to be caused by genetic predispositions, or by envi-ronmental factors such as infections and viral attacks. Drugs or chemicals can also trigger such diseases in some people.

0� SInGApoRe HeALTH nov⁄ DeC 2012

news

As these symptoms can be evidence of other diseases, being able to recognise patterns of behaviour that typically show up in autoimmune disorders is key to cor-rect diagnosis, said Dr Low, adding that it is also important to examine the patient and his medical history closely.

“It’s very much like detective work, supported by thorough investigation,” she said.

Autoimmune disorders can some-times be life-threatening. Lupus, an auto-immune disease characterised by acute and chronic inflammation of various tis-sues anywhere in the body, can become dangerous when it affects the kidneys or leads to bleeding in the lungs.

Autoimmune diseases are treated with immunosuppressant drugs. They suppress a patient’s overactive immune system, but must be used with care as the drugs can weaken the immune system by too much and increase the risk of infections.

There is room for optimism. The 10-year survival rate for lupus patients today, for example, exceeds 90 per cent.

“The sooner an autoimmune disease is detected and brought to the attention of doctors, the earlier it can be treated and the better we can prevent or reverse some of the organ damage,” said Dr Low.

New Autoimmunity and Rheumatology Centre at SGHA lot of research on autoimmune dis-eases has been conducted in the last five to 10 years and doctors “are hoping that new treatments will become available”, she added.

And in a step towards serving more patients and improving the care of people with autoimmune diseases, SGH’s

The immune system stops foreign invaders from harming the body. Sometimes, though, it mistakes the body as the enemy and causes harm instead

BY SOl E SOlOmOn

The effects of autoimmune disor-ders vary. For some patients, the disease causes the autoimmune system to attack their kidneys or brain, while in other people, it could be their blood or lungs that are affected.

The symptoms vary too, depending on the type of autoimmune disorder. A disease may manifest itself in one patient as weight loss or fever, while another patient may suffer a rash or an inflamma-tion of the skin.

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Department of Rheumatology and Immu-nology will be opening the Autoimmunity and Rheumatology Centre in November.

The centre, which synergises service, education and research, will have clinics dedicated to the treatment of specific auto-immune diseases such as scleroderma, systemic lupus erythematosus and rheu-matoid arthritis.

Multidisciplinary services such as physiotherapy and occupational therapy will be available to patients suffering from autoimmune disorders and senior nurses trained in rheumatology will be on hand to educate and counsel patients.

Patients suffering from autoimmune diseases need long-term care, but Dr Low urged them to stay positive as effective treatments are available. To keep the dis-eases under control, regular reviews are also important, she said.

She added: “Get in touch with other patients to understand the illness. Aim to build a support network among your friends and family. There is no need to be frightened.”

autoimmune diseases occur when a person’s immune system turns against his own body, but Dr andrea Low urged patients to stay positive as effective treatments are available.

What is lupus? It is one of the more common

types of autoimmune diseases in Singapore.

Butterfly-shaped rashes on the face are one of the “textbook” signs of the disease, appearing in about 30 per cent of lupus patients, said Dr Andrea Low, Consultant, Department of Rheumatology and Immunology, Singapore General Hospital.

It is common for lupus patients to have some form of joint problem.

patients may feel fatigued at times. They may also suffer intermittent

fevers that do not go away after a month.

Lupus can affect the heart, lungs and kidneys.

What is scleroderma? Scleroderma is another type of

autoimmune disorder, but it is relatively less common in Singapore.

The disease affects the blood vessels and the body’s fibrous tissues. It is often characterised by the hardening of the skin.

When scleroderma attacks the blood vessels, the fingers and toes may turn bluish-purple or white because of poorer blood circulation, and cuts may take longer to heal. ulcers may also develop on the fingers and toes and, in more serious cases, gangrene may set in.

Another common symptom is swelling of the hand. The skin thickens and becomes very tight and the hand looks shiny. In some patients, the joints are affected, making it hard to use the hand.

Scleroderma can be life-threatening if it affects the vessels that supply blood to the heart, lungs and kidneys.

NOV/DEC 2012 siNgapOrE hEalth 07

News> Continued from page 1

Local discovery advances brain tumour research

biochemical pathways associated with the abnormal regulation of parkin. If all goes well, new findings will open up possibili-ties for more drugs to treat brain tumours and bring new hope to patients.

“But it is still early days,” cautioned one team member, Associate Professor Christopher Ang Beng Ti, Consultant, Department of Neurosurgery, National Neurological Institute (NNI). Assoc Prof Ang is also the Senior Principal Inves-tigator, Singapore Institute for Clinical Sciences (SICS) at A*STAR.

The landmark discovery The discovery was made by the collab-orative team of Assoc Prof Ang with Dr Carol Tang, Research Scientist, NNI, and Associate Professor Lim Kah Leong, Department of Physiology, National Uni-versity of Singapore.

Assoc Prof Ang said: “The parkin gene, when present, prevents uncontrolled growth of cells and, thus, the develop-ment of cancer. We found that the parkin gene in gliomas (a type of brain tumour) becomes disrupted or dysfunctional.”

Parkin is not the only tumour sup-pressor available, but it is the first that is well established in medical and research circles for movement disorders. When medical literature showed that the parkin gene could be linked to cancer, the Singapore team explored its possible link with GBM, the most common but highly malignant glioma.

In the lab, they showed that parkin regulated the growth of cancer cells. They searched international patient databases for survival outcomes and gene expres-sion of patients with gliomas. From this, they proved that low levels of parkin led to poorer patient survival.

“That was the Eureka moment! We knew we were on the right track when

we saw the patient survival data corrobo-rate the lab data,” said Assoc Prof Ang.

Now, the team wants to find details of how parkin disruption leads to tumours developing. They hope this will shed more light on the biochemical pathways involved.

“Once we narrow that down, we may be able to identify some commercially available drugs to target those path-ways. Then, we’ll be able to run clinical trials to test our theory. We’re hoping that can happen in the next five to 10 years,” said Assoc Prof Ang.

What is GBM?The brain’s nerve cells (neurons) and sup-porting cells (glia) optimise brain func-tion. If the “checkpoints” that inhibits the growth of the glia cells are disabled, the cells grow uncontrollably and form a glioma.

About 50 new cases of gliomas are seen annually at the NNI. GBM is the most malignant glioma, because its cancer cells reproduce quickly and are fed by a large network of blood vessels.

When a glioma first forms, it is usu-ally very small and the patient will not experience any symptoms, which makes it hard for doctors to detect GBM early. As it grows, it infiltrates the rest of the brain. It builds up pressure in the skull as it enlarges, causing tell-tale symptoms like headaches, nausea and vomiting.

Other symptoms may appear, depend-ing on the glioma’s location in the brain. For instance, if it is near the area of the brain that controls leg and arm movements, the patient may experience weakness in one half of his body. If it is in the area that controls speech, the patient may slur or find it difficult to recall words.

Treatment optionsIdeally, the glioma should be surgi-cally removed as soon as possible. With advances in neurosurgery, operations can now be done safely even with the patient

awake, if the tumour is close to critical functional areas of the brain. After sur-gery, the patient would need a few weeks of radiotherapy and chemotherapy. This is the current international standard of care for GBM.

However, obstacles exist. If the glioma has spread from one half of the brain to the other, it cannot be removed com-pletely. It would be challenging even to remove substantial parts of the tumour.

Even if it is successfully removed, there is no guarantee that chemotherapy will work, as different patients respond differently to treatment.

“We may be able to surgically remove every visible part of a tumour but, inevi-tably, there will be microscopic seeding of tumour cells in the brain that may lead to the recurrence of the tumour,” said Assoc Prof Ang.

With each recurrence, the outcome of treatment will deteriorate, and patients will become increasingly disabled. Over-all, only 60 to 80 per cent of GBM patients survive longer than a year.

Hope present if research goes wellIf the new study bears fruit, treatment options for patients will increase. If the team successfully identifies the molecu-lar pathways linked to parkin, existing chemotherapy drugs could potentially be used to target them.

This type of targeted treatment is not new and has already been employed in other cancers, such as breast and lung cancers.

“A one-size-fits-all regimen does not work on everyone. By the time a suitable alternative regimen is found, the patient may have deteriorated so much that the outcome is uniformly poor. But now, if we can profile each patient for parkin expression, the chemotherapy can poten-tially be tailored to the patient to maxi-mise survival,” said Assoc Prof Ang.

Symptoms vary depending on the location of the tumour in the brain, but may include

headaches nausea/vomiting blurred vision loss of appetite weakness in the limbs changes in mood changes in the ability to think

and learn new seizures speech difficulty

Symptoms are usually progressive in the onset, for example,

progressive weakness in the arm intractable, meaning they are

persistent and do not go away

Headaches are usually of exceptional severity persistent of a different pattern from what you

may usually experience particularly bad in the early mornings associated with vision problems

or nausea

people in their 40s to 60s. the condition is rare in children.

Unlike nose cancer (nasopharyngeal carcinoma) which is frequently diagnosed in the Chinese, particularly the Cantonese, GBM does not affect any particular ethnic group.

there are no gender associations locally, although some European studies have suggested that males have a slightly higher risk of suffering the condition.

Who Gets GBM?

When it may not be just a headachea headache will usually respond to medication, but brain tumours may exhibit the following characteristics:

Associate Professor Christopher Ang Beng ti and his colleagues showed that parkin regulated the growth of cancer cells, and proved it with data from around the world.

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News> Continued from page 1

Pharmacists take charge

the safety of patients on warfarin, the anticoagulation clinic was staffed mainly by doctors. But as a growing number of patients began to be put on warfarin, pharmacists joined the team in 2001 to take on the work of reviewing patients whose condition is stable, allowing the doctors – haematologists or blood spe-cialists – to focus on patients with more complex conditions or new cases. More healthcare professionals at the clinic means that patients enjoy a longer con-sultation time and greater attention.

The anticoagulation patients are seen by their primary physician once a year. In between these annual visits, they are seen more frequently – every two weeks to every three months, depending on their condition – by the clinic’s pharma-cists, said SGH Pharmacist Lim Seng Han. Apart from reviewing the patient’s blood test result, the pharmacist will also probe the patient for significant changes in his lifestyle and diet. Exercise, for instance, can cause the body to metabolise warfa-rin, and the patient may then need to be prescribed a higher dose of the drug.

“During our pharmacist consulta-tion, we will titrate (adjust) the warfarin dose for the patient if necessary and pre-scribe the necessary amount of medica-tion for the patient. We also look out for side effects and symptoms of bleeding or thrombosis,” said Mr Lim.

Educating patients about warfarin, how it works and reacts with certain foods and drugs, and the danger signs to be wary of – the darkening of urine and stool can indicate internal bleeding – is an important part of the consultation.

Lower hospitalisation rateThanks to the clinic’s collective efforts, the overall quality of care has improved. This was recently published in a study by the clinic’s pharmacists and doctors. The study, which tracked the performance of the clinic after pharmacists came on board, found that the hospitalisation rate of patients due to warfarin-linked com-plications dropped to less than 2 per cent in 2011, from about 9 per cent in 2001.

The study also found that the per-centage of time that patients’ interna-tional normalised ratio or INR readings stayed within target increased over the same period, from about 47 per cent to 66 per cent. The INR is a standard test to measure blood-clotting time.

Having the INR fall out of range often can be dangerous: when it is above the target range, the risk of bleeding increases; while the risk of forming a blood clot rises when it is below the target range, said Mr Kong Ming Chai, Senior Principal Pharmacist, SGH, and the lead investigator of the study.

The data are the more impressive as the clinic is seeing a growing number of patients on warfarin. Since 2001, the number of patients referred to the antico-agulation clinic has doubled to about 500, about one-third of the 1,500 SGH patients who have been prescribed warfarin.

Warfarin patients who are not seen by the clinic continue to be managed by their doctors, who come from various disci-plines, such as cardiology and neurology.

In the meantime, the anticoagulation clinic has embarked on research projects to further improve warfarin therapy.

For example, its pharmacists are investigating why Indian patients tend

Vitamin K, found in food like broccoli and green tea, can neutralise the effect of warfarin. Vitamin K is used by the liver to make blood-clotting proteins.

patients need not stop eating broccoli or other foods rich in vitamin K, but they do need to maintain a moderate and consistent weekly consumption of the vitamin.

Changes in a patient’s lifestyle and diet can amplify or nullify the effect of the drug, causing a patient’s blood to become too “thin” or too “thick”.

if green tea isn’t part of a patient’s regular diet, drinking it can cause his inr to drop from two to one the next day, said Mr lim seng han, pharmacist, sgh. But he added: “if green tea is already part of the patient’s usual diet, then drinking it should not affect the inr.”

this is why warfarin patients must be monitored regularly and have their dosage altered when necessary.

the drug helps patients with conditions that cause blood clots to be formed in the blood vessels. When a blood clot breaks free, it can travel in the bloodstream until it lodges in a narrow blood vessel leading to or within the brain, causing a stroke. Warfarin alleviates these conditions by slowing the blood’s ability to clot.

How warfarin works

a warfarin patient must take regular blood tests to determine if his blood can clot within a target range, measured by the international normalised ratio or inr.

the average person has an inr of one. Most patients who are prescribed warfarin must maintain inrs of between two and three.

this means they must take just enough warfarin for their blood to clot two to three times slower than the average person.

an overly high inr places the patient at greater risk of bleeding, and can be potentially fatal in cases like severe gastric bleeding or bleeding in the brain. But an overly low inr raises the risk of stroke.

Careful monitoring needed

Watch your diet

Warfarin

Users must undergo blood tests and medical reviews

every few weeks as changes in diet can disrupt the drug’s

effectiveness.

Users need only an injection of vitamin K to boost their

blood’s ability to clot and, hence, counteract the effects

of the drug.

Dabigatran and rivaroxaban are relatively unaffected by diet.

Both drugs take effect in a few hours, compared to a few days

for warfarin.

no “antidote” is available for dabigatran or rivaroxaban, raising the risk of bleeding

to death if the patient meets with an accident.

Warfarin and its alternativesAlternative drugs

to breach their target ranges more often than patients from other ethnic groups. In another project, they are examining how fasting affects the blood-clotting ability of Muslim patients during the Ramadan period.

“The results can help us manage our Muslim patients better, especially during the Ramadan month. If we know that fasting can increase the INR, we can adjust their dosage pre-emptively,” said Mr Lim, who is also part of the investigat-ing team.

The clinic aims to increase the time the INR is within the therapeutic range (or TTR) to 70 per cent and higher. That is, the blood of warfarin patients must be adequately “thin” for at least 70 per cent of the therapy period.

Mr Kong said: “We hope to increase the range to 70 or 80 per cent, so that war-farin can keep pace with new drugs. If we can push this up to 80 per cent, it may mean that warfarin is even better than the new drugs.”

Ultimately, the safety of patients is key. “The important thing is patient safety and satisfaction, and we want to reduce unnecessary hospitalisation,” said Mr Kong.

Warfarin costs about

cents a day

alternatives to warfarin became available only recently.

of them are dabigatran – known commercially as Pradaxa –

and rivaroxaban, commonly known as Xarelto

Warfarin came into common usage almost

years ago

Mr Kong Ming Chai (right), Senior Principal Pharmacist, and Mr Lim Seng Han, Pharma-cist, work together to lighten the load of the clinic’s doctors.

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Dabigatran(must be taken

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a day

costs about

Rivaroxaban

a day

costs about

the choice of drug depends heavily on a patient’s profile. pharmacist lim seng han said the new drugs may be more suitable for patients who are taking many different medicines, whose blood-clotting time often strays from target, or who don’t have time for regular follow-ups.

10 singapore health nov⁄ Dec 2012

New heart valve, new babyNews

One lucky man becomes a new dad after getting donated heart valve

Mr Lim Hwee Chong calls his daughter, Gracia, a miracle baby as she was conceived only months after he received a heart valve transplant.

The transplant in March 2011 was to fix a leaky heart valve which caused blood to flow back into his heart. Without it, he would have risked heart failure.

The operation’s success was cause for celebration, but baby Gracia was even more. Cradling the infant in his arms, the 33-year-old-youth pastor, who had been married for three years, said: “I didn’t expect to have a child so soon after the operation. I’m sure the transplant con-tributed to this success.”

Now, he is not only enjoying being a new father, but is also much fitter. The breathlessness, tiredness and tightness in his chest have gone. The avid cyclist is now back on track. He was given the green

the national cardiovascular homograft Bank (nchB) was accredited by the american association of tissue Banks in February this year, making it the first tissue bank outside north america to be accredited by the association.

all nchB staff also sat an exam, conducted by the association, to become certified tissue-bank specialists.

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light to resume sports three months after the operation.

Mr Lim is no stranger to heart prob-lems. As a child, he had tetralogy of fallot, a heart defect that is present from birth. His heart had four abnormalities, includ-ing a hole.

When he was eight years old, he had surgery to mend the hole in his heart. His health was stable until 2011, when his faulty pulmonary valve caused a severe backflow of blood into his heart. He was told he needed a heart valve transplant to fix the leak.

The bank for valves and tissuesMr Lim received the heart valve tissue from an anonymous donor through the National Cardiovascular Homograft Bank (NCHB). The bank recovers, screens and stores donated human cardiovascular tis-sues (homografts), such as heart valves, vascular tissues and tracheas (recovered homografts are transplanted from a deceased donor into a recipient).

He is among 45 patients, almost half

of them aged 18 and below, who have received homografts since NCHB was set up in 2008.

Dr Lim Chong Hee, Senior Consultant, Department of Cardiothoracic Surgery, National Heart Centre Singapore, and NCHB’s Programme Director, said recipi-ents who receive a cardiovascular homo-graft do not suffer side effects like organ rejection and do not require long-term medication.

Donors are scarceMr Lim did not wait long for his heart valve but this is not always the case, as demand for cardiovascular homografts outstrips supply. Patients typically wait about three months for a transplant. On average, there are six to eight patients on the waiting list.

It can be difficult to get donors, as some people believe that donations will interfere with having an open casket funeral. “This is a misperception as the cardiovascular homograft recovery is per-formed by a trained surgeon in the most respectful manner,” said Dr Lim.

He said human heart valves, are required mainly for patients with tetral-ogy of fallot or infected valves. Patients with mechanical valves need to take life-long blood-thinning medication, which pose a high risk of stroke, and tissue valves from animals, only last for eight to 10 years.

Studies show that a human heart valve can last for 15 to 20 years. Mr Lim is profoundly grateful to the donor. “I thank him for his selfless decision. He has added years to my life,” he said.

He intends to pledge his body for dona-tion and encourages those around him to do the same. He also plans to share his experiences with his daughter, and looks forward to bonding with her.

“I look forward to teaching her to enjoy sports when she grows up. And, thanks to my improved stamina, I would love to give her a piggyback ride!”

BY Tan MaY Ping

NCHB gets accreditationcommenting on nchB’s

accreditation, Dr lim chong hee, senior consultant, Department of cardiothoracic surgery, national heart centre singapore, and nchB’s programme Director, said: “When we recover cardiac and vascular tissues from a deceased person, there is always a risk of contamination and infection. We need to make sure we have standards in place to make sure the tissues are of a high standard.”

An NCHB employee storing the homograft in a metal column, which is then submerged in liquid nitrogen at minus 180 deg C.

Mr Lim Hwee Chong and his wife Ms Emily Chia became new parents to baby Gracia just months after Mr Lim received a heart valve transplant in March 2011.

ms tracy seck, senior clinical coordinator, national cardiovascular homograft Bank (nchB) has a challenging job: she seeks donors.

most people do not want to discuss death with family members before they die. “as a result, they don’t know the wishes of the deceased, and decision-making process is difficult,” she said.

When a suitable donor is identified, ms seck said she will try to understand the potential donor’s personality and ask the family whether he was a generous, caring person, and would have wanted to help someone in need. about one third of the families agree to donate.

after consent from the family and clearance by nchB’s medical Director, the following takes place:

1 a surgeon recovers the section of the heart with the aortic and pulmonary valves from the deceased.

2 the aortic and pulmonary valves are separated in the nchB laboratory.

3 the valves are incubated with antibiotics and tested for contamination.

4 they are packed using cryopreservatives and stored in liquid nitrogen at minus 180 deg c.

5 they are stored in a quarantine tank until cleared by lab results, then moved to a clinical tank, ready for transplants. homografts can be stored for up to five years.nchB also holds roadshows and

gives talks to students to increase awareness among the young of the need for donors. “We hope, that when they grow up, they will decide to pledge their organs or tissues,” said ms seck.

Donors needed

tissues such as human heart valves, vascular tissue and trachea are covered under the medical (therapy, education and research) act (mtera).

people can opt into this scheme to donate their tissues after they die, for transplant or research purposes.

an individual has to be 18 and above to pledge to donate his tissues.

Under mtera, a donor can specify which tissues he wants to donate.

if an individual has not pledged his tissues, his family can choose to donate them through mtera upon his death.

those who wish to pledge their tissues can do so by completing the yellow organ Donation pledge Form (go to the live on website at www.liveon.sg). send the form to the national organ transplant Unit.

How to become a donor

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Prosedur yang baru ditemui boleh membantu pesakit mengawal tekanan darah tinggi yang sukar dikawal

Apabila segala yang lain gagal

Puan Malia Dawan, 71, tidak dapat menurunkan tekanan darahnya – meskipun memakan enam jenis ubat berlainan setiap hari untuk menga-walnya.

Tekanan sistoliknya berada di sekitar 200 dan 210 milimeter raksa (mmHg) - lebih daripada paras140 mmHg yang wajar untuk seorang seusianya.

Anaknya Puan Yusminah Yusi, 55, juru-rawat terlatih, mengubah cara pembungku-san pil untuk memastikan ibunya memakan ubat dengan betul namun ini tidak juga memulihkan keadaan Puan Malia.

Tiada respons terhadap rawatanPuan Malia didapati mengalami hipertensi resisten di mana tekanan darah tingginya tidak memberi respons kepada rawatan meskipun menggunakan kombinasi sekurang-kurangnya tiga ubat.

Beliau sentiasa sesak nafas walaupun ketika bercakap atau berbaring. Keadaan ini membuat ibunya berisiko mendapat strok dan penyakit jantung.

Pada Januari tahun ini, Puan Malia menjalani denervasi renal di Pusat Jantung Nasional Singapura (NHCS). Prosedur baru kurang invasif ini menggunakan gelom-bang frekuensi radio untuk menghapus-kan saraf simpatetik di sekitar arteri renal untuk menurunkan tekanan secara drama-tik ke paras yang disasarkan.

“Kesannya dapat dilihat pada hari yang sama juga dan dia tidak lagi berasa sesak nafas,” ujar Puan Yusminah. Hipertensi – “pembunuh senyap” – hanya dapat dike-san apabila ia bertambah teruk dan pesakit mengalami komplikasi strok atau serangan jantung atau simptom seperti sakit kepala, sesak nafas dan pening kepala.

Menurut Dr Jack Tan Wei Chieh,

Oleh Thava RaniPerunding, Jabatan Kardiologi, Pusat Jan-tung Nasional Singapura (NHCS) dalam varieti resisten ini tekanan darah pesakit kekal tinggi walaupun memakan ubat dengan betul.

“Se per lima daripada populasi dewasa hari ini yang berusia 60 tahun ke atas menghidap hipertensi dan sekitar 3-5% mengalami sejenis bentuk rintangan. Dengan penduduk yang semakin menua, kadar ini akan meningkat, begitu juga kes rintangan,” tambahnya.

Hipertensi resisten disebabkan oleh beberapa keadaan seperti ketidak seimban-gan hormon, kegagalan ginjal atau sebab yang diketahui. Ia bertambah teruk pada individu lebih tua, obes atau menghidap kencing manis.

Namun pesakit kini mempunyai pilihan untuk menjalani prosedur denervasi renal. Saraf simpatetik renal mengandungi saraf aferen dan eferen yang menghantar isyarat kepada otak yang bertindak balas sewajarnya. Otak menghantar semula isyarat kepada

Dr Jack Tan Wei Chieh memeriksa tekanan darah Puan Malia Dawan sementara anaknya Puan Yusminah Yusi memerhatikan.

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laluan ini sambil menurunkan tekanan darah,” ujar Dr Tan.

Prosedur yang lebih selamatKonsep mengganggu isyarat otak bukanlah baru. Para pakar bedah telah mengeluarkan saraf di sekitar arteri ginjal sejak 1930an lagi menggunakan pembedahan terbuka yang amat invasif. Walaupun berkesan, ter-lalu ramai pesakit mengalami komplikasi seperti pembuangan air kecil yang tidak ter-kawal dan masalah fungsi seksual. Kaedah ini dihentikan apabila ubat anti-hipertensi yang berkesan berada di pasaran.

Kini, teknologi kurang invasif telah men-jadikan prosedur selama 40 minit sehingga sejam itu lebih selamat. Kaedah yang berke-san dan tahan lama ini telah diamalkan di negara luar selama dua tahun.

Walaupun ia tidak menyembuhkan tekanan darah tinggi, ia mampu mengu-rangkan tekanan sebanyak purata 32/12 mmHg. Kesemua tiga pesakit, yang telah menjalani prosedur ini di NHCS Septem-ber tahun lalu, mencapai penurunan lebih daripada 20 mmHg. Penurunan sekecil 5 mmHg sekalipun boleh mengurangkan risiko strok sebanyak 14 peratus, penyakit jantung 9 peratus dan kematian 7 peratus.

Tekanan darah Puan Malia kini berada di paras 140/90 mmHg dan dia juga men-gambil dos ubat yang kecil.

“Semua adik beradik ibu saya ada tekanan darah tinggi dan telah meninggal, ada sebelum menjangkau 50 tahun. Mereka tiada pilihan menjalani prosedur baru ini tidak seperti ibu saya,” kata Puan Yusminah gembira.

ginjal (melalui saraf renal) supaya arteri mencerut dan menyimpan lebih garam dan air, sekaligus meningkatkan tekanan darah. Ginjal juga menghantar semula isyarat kepada otak mengarahkan jantung berde-gup lebih kencang apabila tertekan dan ini juga menjejas tekanan darah.

“Saluran ini mengamuk dalam bentuk hipertensi resisten. Otak dan ginjal sentiasa menghantar jumlah isyarat yang keter-laluan kepada satu sama lain, bukan hanya semasa tertekan atau kekurangan air, malahan ketika keadaan tenang. Dengan melumpuhkan secara terpilih saraf simpa-tetik di sekitar arteri renal, denervasi renal membantu mengurangkan isyarat keter-

DIS

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2012

TerbiTan HosPiTal besar singaPura Dan KuMPulan singHealTH.

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ObeSItI mOrbID

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meNgembalIkaN SeNyumaN SemPurNa

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SeNamaN uNtuk tulaNg

yaNg kuat

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Satu laNgkah Saja ke arah VISI

yaNg teraNg

Tekanan darah normal sepatutnya berada di bawah paras 140/90 mmHg (angka pertama adalah tekanan darah sistolik, manakala yang kedua adalah tekanan darah diastolik). Dengan setiap peningkatan sebanyak 20 mmHg dalam tekanan darah sistolik melebihi paras normal, risiko penyakit kardiovaskular seseorang itu berganda.

Bagi pesakit yang mempunyai masalah diabetes, ginjal dan jantung, paras sasaran tekanan darah adalah di bawah 130/80 mmHg.

Bagi pesakit yang menghidap hipertensi tetapi tiada masalah

Apakah rintangan tekanan darah?perubatan lain, paras sasaran tekanan darah patut berada di bawah 140/90 mmHg.

Hipertensi resisten berlaku apabila tekanan darah tidak boleh diturunkan ke paras sasaran tekanan darah dengan menggunakan tiga atau lebih jenis ubat, termasuk diuretik pada dos yang optima.

Diagnosis rintangan tekanan darah perlukan penjagaan kerana hipertensi tidak terkawal mungkin berlaku kerana kurang pematuhan dalam pengambilan ubat, atau hipertensi 'white-coat' (cemas berada di klinik)


Berita

Pembedahan turunkan berat badan bantu dua pesakit lawan diabetes, obesiti dan penyakit lain

Oleh Valerie lee

Rawatan kecantikan ekstrem

Berat badan En Shaun Lawrence, 32, dan Puan Rozita Ramlee, 36, melebihi 100kg sebelum ini.

Hari ini, tiada siapa yang dapat menduga mereka pernah obes. Atau pernah men-gambil pelbagai jenis ubat untuk pelbagai penyakit yang berkaitan dengan obesiti.

Mereka berdua telah menjalani pin-tasan gastrik, satu pembedahan membantu menurunkan berat badan atau prosedur bariatrik yang berkesan untuk memper-baiki/memulihkan diabetes dan gangguan metabolisme lain. Untuk melawan obesiti, diabetes dan penyakit lain yang berkai-tan, mereka telah menjalani pembedahan tersebut di Hospital Besar Singapura (SGH) hujung tahun lalu.

“Sebelum ini, saya tidak boleh berjalan jauh atau menaiki MRT dan bas awam. Pem-bedahan ini telah memberi saya kehidupan baru,” ujar En Lawrence, yang sekarang ber-lari, berenang dan pergi ke pusat senaman dengan kerap.

En Lawrence turun dari 117kg dengan indeks jisim tubuh (BMI) 35 kepada 85kg, sementara Puan Rozita turun kepada 93kg dari 128kg, BMI 50, selepas pembedahan masing-masing pada November dan Sep-tember tahun lepas.

Mereka tidak lagi perlu mengambil ubat untuk mengawal diabetes, tekanan darah tinggi, kolestrol dan rawatan untuk apnea tidur obstruktif, keadaan di mana seseorang itu berhenti bernafas disebabkan saluran pernafasan tertutup semasa tidur lena.

Penilaian rapiMereka menjalani temuduga dan kaunsel-ing rapi di Pusat Pembaikan Gaya Hidup dan Peningkatan Kesihatan (LIFE), di mana kakitangannya terdiri daripada doktor, pakar pemakanan, ahli fisioterapi, ahli psikologi, jurupulih pekerjaan dan pekerja sosial perubatan berbilang disiplin. LIFE menggalakkan penjagaan bersepadu dan holistik untuk pesakit dengan kondisi peru-batan berkaitan-gaya hidup, seperti gang-guan pemakanan dan obesiti.

En Lawrence mendapatkan rawatan daripada Dr Tham Kwang Wei, Perunding, Jabatan Endokrinologi, SGH, dan Pengarah, Unit Obesiti dan Metabolik setelah diru-jukkan ke Pusat Diabetes di SGH semasa penyaringan pra-pengambilan perkhid-matan negara.

“Dia seorang pesakit diabetes tipikal yang berat badannya turun naik. Setelah mendapatkan rawatan selama tujuh tahun

berkesan jika pesakit tidak merubah gaya hidup mereka.

Selepas pembedahan, perut pesakit dikecilkan ke saiz kantung kecil yang dis-ambung ke bahagian tengah usus kecil. Pesakit akan muntah jika makan berlebi-han daripada apa yang boleh diterima oleh kantung tersebut.

En Lawrence biasanya memakan sekeping roti untuk sarapan, sekeping kecil ikan untuk makan tengahari dan sekeping kecil ikan untuk makan malam.

Puan Rozita, yang mengakui beliau sebe-lum ini tidak memahami erti “kenyang” apabila makan, telah mengajar dirinya untuk berkata “tidak” kepada sebahagian besar makanan.

Kedua-duanya kini komited dengan pemakanan sihat, senaman, regimen makanan tambahan harian dan lawatan tetap ke Pusat LIFE untuk mengawasi kemajuan mereka. Mereka kini penyokong gaya hidup sihat dan melibatkan juga ahli keluarga serta rakan-rakan mereka untuk mengikut tabiat baru mereka.

“Seorang individu yang menjalani pem-bedahan dan telah diajar mengenai pemak-anan menjadi nukleus perubahan bagi ses-ebuah keluarga,” ujar Dr Shanker lagi.

Pesakit dibantu melalui sokongan pesakit yang mempunyai masalah serupa. Bakal pesakit dan pesakit yang sedang melalui pelbagai fasa selepas pembedahan menghadiri mesyuarat kumpulan sokon-gan di Pusat LIFE, setiap petang Rabu.

dia menghilangkan diri dan timbul semula dengan diabetes yang tidak terkawal dan berisiko terkena serangan sakit jantung menjangkau usia 40 tahun.”

Puan Rozita pula bosan keluar masuk hospital sebanyak empat kali kerana men-galami diabetes, radang ulser perut, apnea tidur dan sista ovari. Beliau berazam dan komited untuk menjalani pintasan gastrik kata Dr Shanker Pasupathy, Perunding Kanan, Pembedahan Am, dan Pengarah, Pusat LIFE, SGH.

“Terdapat salah tanggapan umum bahawa pembedahan boleh menyelesaikan semuanya dan, selepas itu, anda boleh meneruskan hidup anda. Pembedahan ini sekadar butang set semula dan selepas itu, anda mesti mulakan pendekatan baru kepada kehidupan anda namun bukan hanya dari segi pemakanan saja.”

Pesakit pergi ke Pusat LIFE untuk belajar mengubah suai tabiat pemakanan mereka. “Kami berbincang tentang pemakanan, memilih makanan dan bersantai. Mereka perlu membuat perubahan kerana pem-bedahan hanya membantu menurunkan sekadar 20 sehingga 30 peratus berat badan mereka,” ujar Dr Shanker.

Prosedur bariatrik – sama ada pintasan gastrik, pembedahan ikat perut (gas-tric lap band) atau ‘gastric sleeve’ – tidak

Prosedur

Lingkaran laparoskopik gastrik boleh laras(Laparoscopic adjustable gastric banding)

Gastrektomi lengan Laparoskopik(Laparoscopicsleevegastrectomy)

Laparoscopic Roux-en-Y gastric bypass

Apa yang terjadi

lingkaran silikon yang boleh dilaras diletakkan di sekeliling bahagian atas perut untuk mengurangkan saiznya, supaya seseorang itu lebih cepat berasa kenyang dan makan kurang lagi dan dengan itu dapat mengurangkan berat badan

satu porta diimplankan di bawah kulit untuk membolehkan pelarasan halus diameter outlet

Kira-kira 75 peratus perut dikeluarkan

hasil awal prosedur yang agak baru ini memberansangkan

Kantung gastrik yang kecil dicipta terlebih dulu, kemudian pintasan kepada usus kecil dijalankan

ini mengurangkan pengambilan kalori dan mengubah cara makanan dihadam

Pro

pembedahan yang agak ringkas tidak memerlukan perut

dibedah Kadar komplikasi selepas

pembedahan yang agak rendah Boleh menjadikan diabetes

peringkat awal bertambah baik Boleh diterbalikkan (jika

lingkaran dikeluarkan sebelum terjadi komplikasi)

tiada benda asing dimasukkan sepertimana teknik lingkaran

pembedahan sekali sahaja penurunan berat badan awal

yang pantas Mengurangkan kelaparan lebih

daripada teknik lingkaran Boleh menjadikan diabetes

peringkat awal bertambah baik pesakit boleh makan dengan

lebih baik berbanding teknik lingkaran, tetapi masih lagi mengalami penurunan berat badan yang baik

penurunan berat yang lebih banyak berbanding kaedah lain

Boleh menterbalikkan diabetes jenis 2 yang sedia ada

prosedur yang sangat difahami memandangkan ia telah dijalankan lebih dari 40 tahun

Kontra

Benda asing dimasukkan kedalam badan

Memerlukan pelarasan yang kerap di klinik

lebih kurang 10 peratus pesakit tidak berjaya mencapai sebarang penurunan berat badan

Komplikasi lewat yang ketara, termasuk jangkitan, hakisan atau gelinciran lingkaran, memerlukan pembedahan ulangan

Kekal dan tidak boleh diterbalikkan

hasil jangka panjang (melebihi lima tahun) tidak diketahui

garis pengokot pada perut boleh berdarah atau bocor

pakar bedah memerlukan lebih banyak latihan

garis pengokot dan penyambung gastrousus boleh berdarah atau bocor

Komplikasi lewat, seperti ulser perut dan usus terpulas, boleh berlaku

Kekurangan nutrisi boleh berlaku Memerlukan penjagaan pakar

dan nutrisi tambahan sepanjang hayat

Lingkaran dan pengokot

Dr Tham Kwang Wei (paling kiri) dan Dr Shanker Pasupathy (paling kanan) bersama pe-sakit pintasan gastrik mereka En Shaun Lawrence dan Puan Rozita Ramlee.

Foto

: ale

cia

neo

Dengan kanta masa kini, pesakit yang menjalani pembedahan katarak boleh “membetulkan” penyakit mata yang lain pada masa yang sama

NOV/DIS 2012 SINgapOre health M3

hapuskan tulang yang lemah dan rapuh dengan bersenam secara tetap

Oleh ClarenCe Chen

Bersenam dengan penuh semangat

Selama hampir tiga tahun, En Roger Kang, ejen hartanah, hidup dengan penglihatan yang semakin teruk disebabkan oleh katarak. Tetapi meskipun penglihatannya semakin kabur, beliau tetap meneruskan aktiviti hariannya dan merasakan beliau tidak memerlukan pembedahan.

Akhirnya, beliau menjalani pembeda-han pada tahun lepas dan gembira men-getahui bahawa beliau bukan hanya boleh membuang kataraknya, malahan juga boleh membetulkan astigmatismenya, rabun dekat (hiperopia) dan penglihatan jarak dekatnya (presbyopia) sekaligus.

Tidak memerlukan cermin mataKanta multifokal premium telah dimasuk-kan ke mata En Kang, satu demi satu, selang dua minggu. Selepas prosedur itu, beliau tidak lagi perlu menggunakan cermin mata multifokalnya, yang telah digunakan selama 10 tahun. “Penglihatan saya hampir sempurna sekarang. Yang paling bagus

Mungkin agak pelik apabila diberi-tahu bahawa senaman bagus untuk osteoporosis. Tetapi itulah yang disa-rankan oleh doktor kepada Puan Mary Gnanapragasam, yang telah didiag-nos dengan kondisi tersebut sewaktu umurnya menjangkau 50an.

“Saya amat bimbang sewaktu saya mula-mula didiagnos dengan osteoporosis. Saya tidak ingin jatuh dan mengalami patah atau retak tulang,” katanya.

Sekarang pada umur 70an, Puan Mary percaya sepenuhnya dengan man-faat senaman, dan boleh ditemui di pusat senamanLIFE Hospital Besar Singapura hampir setiap hari.

Osteoporosis adalah penyakit tulang yang terjadi apabila badan gagal untuk membentuk tulang baru yang mencukupi atau apabila terlalu banyak tulang lama yang diserap semula oleh badan, atau kedua-duanya, yang menyebabkan tulang menjadi lemah dan rapuh.

Wanita tua cenderung kehilangan tulang dengan cepat semasa menopaus, iaitu apabila badan mereka tidak lagi menghasilkan estrogen, hormon pelindung tulang, kata Dr Manju Chandran, Perund-ing dan Pengarah, Unit Osteoporosis dan Metabolisma Tulang, Jabatan Endokrinologi, Hospital Besar Singapura.

Selain daripada lenguh-lenguh dan sakit-sakit badan, Puan Mary tidak mengal-ami apa-apa tanda lain bahawa beliau menghi-dap osteoporosis. Penya-kit ini biasanya dikesan agak lewat tetapi Puan Mary bertuah kerana penyakitnya didiagnos pada tahap awal semasa kajian semula perubatan.

Beliau dirawat di klinik osteoporosis oleh pakar osteopo-rosis dan dirujuk ke Pusat LIFE, di mana sepasukan doktor, jururawat pakar, pakar diet, ahli fisioterapi dan profesional peru-batan lain mengajar pesakit yang meng-hidap kencing manis, obesiti dan kondisi

di Pusat LIFE hadir sama sewaktu pesakit bersenam, merawat seorang sehingga empat pesakit semasa sesi latihan. Mereka memastikan para pesakit melakukan senaman mereka dengan betul, dan mem-buat pemeriksaan kerap untuk memasti-kan para pesakit tidak menghadapi kesu-karan atau berasa tidak selesa.

Para pesakit juga diawasi secara tetap oleh doktor, jururawat dan ahli fisioterapi pusat tersebut, dan kemajuan mereka dil-aporkan kembali kepada pakar perubatan utama mereka. “Doktor pesakit tersebut pasti gembira dengan kemajuan yang dicapainya,” ujar Puan Ng, menambah bahawa pesakit melalui dua pusingan pro-gram untuk setiap rujukan, sama ada yang baru atau berulang, dan selepas itu mereka dibenarkan keluar.

Kembali kepada asas

Dengan bantuan Puan Ng Deng Peng, Ahli Fisioterapi

Kanan di SGH, Puan Mary Gnanapragasam

menunjukkan beberapa senaman asas yang kerap

dilakukannya untuk meningkatkan kekuatan, kefleksibelan, postur dan

keseimbangannya.

Tekan kaki: Untuk menguatkan bahagian bawah badan, kuadriseps atau otot bahagian depan peha.

Tekan bahagian aTas badan aTau dada: Untuk menguatkan bahagian atas badan.

lain yang berkaitan dengan gaya hidupb-agaimana untuk hidup secara sihat melalui senaman dan diet.

Pesakit osteoporosis menerima rawatan yang merangkumi ubat untuk merangsang pertumbuhan tulang, terapi senaman dan diet yangkaya-kalsium. “Diet dan senaman adalah elemen pelengkap rawatan mereka yang penting,” ujar Ahli Fisioterapi Kanan SGH, Puan Ng Deng Peng.

Di pusat tersebut, Puan Mary dinilai ter-lebih dahulu untuk mengetahui keadaan kesihatannya dan bahagian bermasalah sebelum pelan senaman dibuat untuknya. Senaman ini termasuk latihan rintangan, keseimbangan, postur serta kekuatan, dan juga senaman menahan berat untuk

merangsang pertumbuhan tulang.Puan Ng dan ahli terapi lain

Pembedahan katarak semua-dalam-satu

Oleh Tan May Ping

sekali ialah saya tidak perlu lagi menggu-nakan cermin mata,” ujarnya. En Kang ialah di antara sejumlah pesakit katarak yang semakin bertambah di Pusat Mata Nasi-onal Singapura (SNEC) yang telah memilih implan kanta intraokular premium.

Dalam pembedahan katarak, lapisan kabut yang mengaburkan penglihatan dibuang dan kanta diimplankan. Beberapa tahun kebelakangan ini, pembedahan kata-rak telah menjadi bukan hanya sekadar membuang katarak saja. Kanta premium membolehkan keadaan-keadaan lain sep-erti yang dialami oleh En Kang, serta juga miopia (rabun jauh) dirawat pada masa yang sama.

Kanta premium adalah hasil

penumpuan katarak dan teknologi pem-bedahan biasan. Menurut Profesor Madya Chee Soon Phaik, Perunding Kanan Oftal-mologi, SNEC, 11 peratus daripada 10,500 prosedur katarak yang dijalankan setiap tahun di SNEC melibatkan penggunaan implan kanta intraokular premium.

Sekitar 50 sehingga 70 peratus pesakit-nya – dari profesional muda sehingga suri rumah lebih tua – memilih kanta pre-mium. “Kanta premium membolehkan pakar bedah menawarkan pesakit pili-han bukan saja untuk mensasarkan jarak penglihatan yang baik, tetapi juga memb-etulkan astigmatisme untuk memberikan penglihatan yang sangat jelas,” ujar Prof Madya Chee.

apa yang dilakukan oleh kanta“Di samping itu, ia boleh memperbaiki aber-asi visual, menjelaskan lagi penglihatan apabila anak mata mengembang pada waktu malam.”

Sesetengah butik, kanta intraokular pre-mium boleh juga mempertingkatkan peng-lihatan, tetapi perlu disesuaikan mengikut individu tersebut. Namun, keadaan mata serentak boleh membataskan kejayaan visual yang boleh capai. Pakar bedah boleh memberi nasihat mengenai kanta mana yang paling sesuai untuk mata pesakit.

Prof Madya Chee mengingatkan bahawa tidak semua orang dapat meman-faatkan kanta premium ini dan kebebasan sepenuhnya dari menggunakan cermin mata mungkin tidak berlaku kepada seba-hagian pesakit kerana hasilnya bergantung kepada keadaan mata individu tersebut.

Contohnya, kanta intraokular mono-fokal dan torik boleh digunakan untuk sebarang keadaan mata, termasuk mata yang mengalami astigmatisme. Walau bagaimanapun, implan dengan komponen multifokal dikhususkan untuk mata yang betul-betul sihat dan hanya menghidap katarak.

“Keputusan bergantung kepada keadaan mata pesakit, keperluan visual, gaya hidup dan kos,” ujar Prof Madya Chee.

Kanta premium juga umumnya adalah lebih mahal. Kos pembedahan katarak boleh dituntut dari Medisave dan bergan-tung kepada polisi tertentu yang dilang-gan oleh seseorang itu insurans kesihatan mungkin melindungi prosedur ini untuk sebarang jenis kanta.

Kanta premium seperti yang di atas boleh meningkatkan hasil visual pembedahan kata-rak dengan membetulkan astigmastisme, rabun dekat (hyperopia) dan penglihatan jarak dekat (presbiopia).

Keliru dengan peringatan SMSBapa saya meninggal beberapa bulan lalu. Kenapa Hospital Besar Singapura (SGH) masih terus menghantarkan per-ingatan SMS kepada kami mengenai temujanji kliniknya?

Kami bersimpati atas kema-tian bapa anda. Sistem data pesakit kami mendaftar-

kan secara automatik kematian pesakit jika dia meninggal di SGH. Jika pesakit meninggal di rumah, rumah penjagaan atau hospis, ahli keluarganya perlu me-maklumkan kepadapihakhospital bagi mengemaskini fail pesakit.

Ahli keluarga boleh berbuat demikian dengan menghantarkan satu salinan sijil kematian kepada hospital, melalui pos atau e-mel. Jika tiada sijil kematian, ahli keluar-ga boleh menyerahkan dokumen lain sep-erti laporan polis atau hospis. Ahli keluarga juga boleh menulissuratkepada pihakhos-pital surat atau menghantar e-mel kepada [email protected], menyatakan hubungannya dengan pesakit.

Sebelum kami menerima makluman, sistem hospital tidak akan mengetahui

Berita


Jika anda kehilangan gigi, implan gigi adalah yang paling hampir dengan gigi sebenar yang boleh anda dapati.

Pusat Pergigian Nasional Singapura (NDCS) mendapati lebih ramai pesakit yang mahukan implan, dan bilangan implan yang dijalankan, meningkat tiga kali ganda sejak 2005 sehingga 2010.

Kemajuan dalam teknologi dan teknik, di samping kesedaran yang semakin menin-gkat, telah meningkatkan permintaan, ujar Dr See Toh Yoong Liang, Pendaftar Kanan, Unit Prostodontik, Jabatan Pemuli-han Pergigian.

Katanya: “Dalam dekad kebelakangan, permintaan meningkat ketika sains sema-kin maju. Kita sekarang boleh menjangka dengan ketepatan yang lebih baik menge-nai kadar kejayaan implan. Implan rahang bawah, contohnya, mempunyai kadar kejay-aan 95 peratus manakala 90 peratus untuk rahang atas.”

Pilihan untuk gigi yang hilangDr See Toh memberitahu bahawa ter-dapat beberapa kelebihan dalam penggu-naan implan untuk menggantikan gigi yang hilang. Implan tidak menjejaskan gigi yang lain, tidak seperti jejambat gigi

(dental bridge), di mana gigi bersebelahan perlu dikikir. Implan juga lebih selesa dan kurang menonjol di dalam mulut berband-ing gigi palsu, dan ia tidak memerangkap makanan.

Warga tua yang kehilangan hampir kes-emua gigi mereka boleh memilih implan yang berfungsi seperti klip untuk mengikat gigi palsu. Untuk ini, dua implan dimasuk-kan ke dalam rahang. Tetapi sebaliknya, gigi palsu dengan sisipan sepadan bahagian bawah dipasang ke atas implan dan bukan-nya gigi prostetik.

Tetapi implan mempunyai beberapa risiko berkait dan bukannya untuk semua orang. Pesakit dengan ketumpatan tulang rendah pada rahang atau masalah peru-batan yang menghadkan penyembuhan luka mungkin tidak sesuai mendapatkan implan.

Dr See Toh memberitahu bahawa ianya penting untuk doktor gigi menjalankan prosedur diagnostik, seperti x-ray dan imbasan ‘conebeam’ untuk menilai lebar dan ketumpatan tulang rahang sebelum pembedahan. Imej tersebut membolehkan

doktor gigi menilai sama ada terdapat tulang yang mencukupi untuk menyokong implan dan menentukan panjang implan.

Prosedur implan gigi boleh mengam-bil masa lebih kurang tiga hingga empat bulan. “Dalam kes-kes yang sukar, di mana terdapat tulang yang tidak mencukupi dan graf tulang diperlukan, prosesnya boleh memakan masa enam hingga lapan bulan,” ujar Dr See Toh. Graf tulang adalah prose-dur untuk “menumbuhkan” lebih banyak tulang. Proses ini membantu doktor gigi mengenal pasti struktur yang perlu dielak-kan, seperti saraf dan tulang, dan menggu-nakan implan dengan saiz yang betul.

Doktor gigi biasanya memberikan dua bulan untuk penyembuhan, dan tulang untuk bercantum dengan implan sebe-lum memasang korona (crown). “Anda tidak ingin membebankan implan (dengan korona kekal) terlampau cepat,” beritahu Dr See Toh.

Adakah implant mini selamat?Baru dalam pasaran adalah implan mini, yang menggunakan beberapa skru lebih kecil untuk memasang korona kepada tulang rahang. Ia alternatif yang lebih murah dan lebih cepat, tetapi ia mempun-yai risikonya sendiri.

“Biasanya, implan mini digunakan di NDCS sebagai pengangkoran dalam rawatan ortodontik,” kata Dr See Toh. “Tidak ada banyak bukti jangka masa panjang implan untuk menyokong penggunaan implan mini sebagai penyelesaian pengganti gigi yang kekal. Ini kerana ia mempunyai diam-eter yang amat sempit dan, oleh itu, lebih berisiko untuk pecah atau patah selepas beberapa lama.”

“Implan agak banyak terdedah kepada haus dan lusuh kerana mengunyah dan meng-gigit, jadi ia amat penting untuk memilih jenis yang betul,” tambah Dr See Toh.

Oleh Sheralyn Tay

Mendapatkan senyuman yang sempurna tanpa gigi palsu telah menjadikan implan gigi pilihan yang semakin popular

Hampir kepada perkara sebenar

Beritahu kamibahawa pesakit telah meninggal dan ahli keluarganya mungkin akan terus meneri-ma peringatan SMS dan peringatan lain berkenaan temujanji.

Bergegas ke sana tetapi tidak boleh mendaftarSaya tiba di Poliklinik pada pukul 11.35 pagi tetapi diberitahu bahawa pendaf-taran telah ditutup kerana klinik ter-lalu sesak. Laman web menyatakan bahawa pendaftaran ditutup pada pukul 12 tengah hari. Saya diberitahu agar datang semula untuk sesi tengah hari. Ianya tidak adil memandangkan saya telah bergegas untuk tiba sebe-lum waktu sesi pagi tamat.

Kami cuba sedaya upaya untuk merawat seramai mungkin pesakit setiap

hari. Apabila klinik sesak, kami menu-tup pendaftaran bagi memastikan doktor-doktor kami mempunyai masa yang mencukupi, bagi menjaga keselamatan pesakit, untuk memberikan rawatan dan jagaan yang sewajarnya kepada setiap pe-sakit. Pendaftaran terakhir untuk semua poliklinik SingHealth (SHP) adalah pada pukul 4 petang. Tetapi kes-kes kecemasan akan dirawat dengan segera. Klinik kami

biasanya sangat sibuk pada malam cuti umum dan hari selepasnya, hari Isnin dan hari Sabtu. Orang awam boleh memeriksa bilangan pesakit di klinik melalui Penga-wasan Giliran di laman web SHP. http://poly-clinic.singhealth.com.sg.

Menggunakan agensi luar untuk mengutip bil tertunggakSaya menerima surat peringatan dari-pada agensi kutipan hutang menuntut pembayaran segera bil hospital berjum-lah $150, atau Hospital Besar Singa-pura (SGH) akan memulakan tindakan undang-undang. Kenapa hospital tidak mengingatkan saya mengenai bil terse-but tetapi sebaliknya melantik agensi kutipan hutang luar?

Ia adalah amalan standard hospital, termasuk SGH, untuk melantik firma luar

bagi membantudalamproses kutipan hutang yang rumit dan menyusahkan, supaya mereka boleh memberi tumpuan untuk merawatpesakit. Salah satu tugas agensi kutipan ialah untuk memaklum-kan pesakit bahawa mereka telah terlupa membayar bil mereka.

Klinik pesakit luar mengenakan bayaran ke atas pesakit selepas rawatan-mereka, dan pesakit yang tidak mampu untuk melangsaikan akaun mereka ketika itu boleh membayarnya kemudian. Para pesakit yang dibenarkan keluar dari wad akan menerima bil akhir mereka selepas tiga hingga empat minggu kemudian, apabila tuntutan dari Tabung Simpanan Pekerja (CPF) dan syarikat insurans peru-batan telah diselesaikan.

Para pesakit boleh melangsaikan akaun mereka yang tertunggak melalui cek, di cawangan Singpost, kedai-kedai 7-Eleven dan stesen SAM atau AXS.

Agensi kutipan akan mengingatkan pesakit apabila bil telah tertunggak lebih dari sebulan. Sekiranya bil masih tidak dibayar, dua lagi surat peringatan akan dihantar – setiap satunya dalam jarak seb-ulan – sebelum tindakan undang-undang dimulakan. Ketika ini, agensi akan beru-saha untuk menghubungi pesakit melalui telefon jika terdapat nombor telefon.

Pesakit yang mempunyai kesukaran untuk membayar bil mereka boleh diru-juk kepada Pekerja Sosial Perubatan kami, yang akan menilai dan memberita-hu mereka jika mereka layak menerima bantuan kewangan, seperti Medifund.

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Dr See Toh Yoong Liang menjalankan implan gigi untuk pesakit.

Lifting the veil on cosmetic eye surgery

Nov⁄ Dec 2012 siNgapore health 17

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Many people go to private clinics – or even overseas – for cosmetic eyelid surgery, but few realise that doctors at the Singapore National Eye Centre (SNEC) perform these procedures as well.

Specialists at SNEC’s Oculoplastic Service, who deal with medical condi-tions affecting the eyes, also perform surgery – creating double eyelids, remov-ing eyebags and correcting droopy eye-lids – for purely aesthetic reasons. All three are cosmetic concerns, but droopy eyelids can turn into a medical condi-tion, if they begin to affect sight, which sometimes happens in older patients.

Droopy eyelidsDr Sunny Shen, Consultant, Oculoplastic Service, said: “Having droopy eyelids is like having a curtain in front of your eyes.”

They are caused by weak levator mus-cles – the muscles which create double eyelids and are responsible for raising the eyelids. Some people are born with weak levator muscles, but most find these muscles weaken through wear and tear with age, giving rise to droopy eye-lids. Dr Shen said if the problem is just a case of slight asymmetry between the eyes, it may be a cosmetic concern, but if it affects vision and normal activities, it becomes a medical condition.

People with droopy eyelids often find the top part of their vision blocked. In

severe cases, they may even have to tilt their heads and lift their chins to see what is ahead of them. They tend to raise their eyebrows constantly to lift their eyelids, and this can cause headaches.

They also suffer from eye strain and have difficulty reading for a long time when looking down. In young patients without congenital problems, the most common cause of weakening levator muscles is the use of contact lenses. Blinking makes the edges of the lenses rub constantly against the levator mus-cles, weakening them over time.

Fixing droopy eyelids Some patients can be managed with medication and “crutches” (metal wires mounted on the back of spectacles to hold the upper eyelids open) but most need surgery to lift their upper eyelids, and in some cases, remove excess skin.

“But eyelids cannot be lifted too high as this can result in incomplete eye clo-sure. Moisture can then escape from your eyes and you’ll end up developing corneal problems,” said Dr Shen.

In cases of congenital droopy eyelids, the surgery might also involve a sling operation, where a piece of tissue is used as a “sling” to connect the upper eyelid to the forehead muscle.

What causes eyebags?They occur when fat tissue behind the lower eyelids bulge forward. This happens when the membrane in the eyelid which holds the fat back, weakens with age, said

apart from treating medical conditions, the singapore National eye centre also does cosmetic surgery. By celine lim

Dr Audrey Looi, Senior Consultant and Head, Oculoplastic Service, SNEC.

Surgery removes eyebags by reposi-tioning the protruding fat, and in some cases, by removing excess skin under the eyes. But doctors are conservative when removing excess skin to prevent the lower eyelid from turning out after surgery – which would expose the inner membrane along the lower edge of the eye. “We have to judge carefully how much excess skin we can remove, with-out risking such complications. So, some-times, there may still be fine lines under the eye after surgery.”

She said surgeons also avoid the infe-rior oblique muscle hidden in the fat, as disturbing it can cause double vision. The muscle – located at the base of the eye – is responsible for the movement of the eye. Dr Looi said surgeons take care not to pull excessively on the fat as this can trigger haemorrhage behind the eye and cause visual loss. “This is very rare, but it has been reported in the past when the trend was to remove as much fat as possible.”

Surgery for eyebagsThere are two different approaches to eyebag surgery.

Transconjunctival approach: A cut is made on the inner lower eyelid through which a bit of fat is removed. There is no scar, so healing is faster. It is suitable for patients in their late 30s to early 40s who have fairly elastic skin and mild bulging of fat. It is also

ideal for young thyroid patients with increased fat volume around the eyes.

Subciliary subcutaneous approach: A cut is made below the lower lash line and the inner membrane is opened up. The sagging fat is repositioned. If the lower eyelid is lax, the muscle or tendon of the outer eye corner is tightened for improved support. It is suitable for patients with excess skin, which can be removed as well.

High demand for double eyelids Double eyelid surgery is the most common cosmetic surgery among Asians, said Dr Elaine Chee, Consultant, Oculoplastic Service, SNEC.

The upper eyelid, controlled by the levator muscle, is attached to the skin above the eye. In Westerners, this forms a fold that results in a double eyelid but, in some Asians, this attachment does not occur, said Dr Chee, who was trained locally and in South Korea. In addition, some Asians have bulky fat tissue in their upper lids, resulting in protruding or puffy eyelids, which may even hide natural double eyelids. They also tend to have prominent skin folds (epicanthic folds) in the upper eyelids that cover the inner corners of the eyes. These folds can cover the upper eyelashes and part of the upper eyelids, making the eyes look “almond-shaped” and smaller.

While surgery may alter these physical traits, differences such as bone structure around the eyes, cannot be changed. Dr Chee advises Asians with these character-istics to have realistic expectations. “We cannot look like Angelina Jolie or Cindy Crawford because we don’t have deep-set eyes. But we can enhance what we have, even as we maintain our Asian features. Doing so allows our eyes to complement the rest of our face,” she said.

Surgery for double eyelids The following surgical methods for double eyelid surgery are done under local anaesthesia.

Open: Some fat and excess skin is removed from the upper eyelid, and the wound stitched to create a double eyelid crease. It is suitable for patients with excess skin and fat in the upper lid area.

Small incisions: Three 2mm cuts are made in the upper eyelid. Small amounts of fat are removed and the incisions stitched up. Recovery time is faster compared to open surgery. It is suitable for those with a small amount of fat and skin in the upper lid area.

Non-incision: Three small punctures are made and a thread is passed through the openings to create the double eyelid crease. This procedure can be done quickly. Recovery time is usually very short, but the results may not last as long. It is suitable for younger patients with thin skin.

Epicanthoplasty: An operation to reduce prominent epicanthic folds so the new double eyelid fold created is not hidden.

Estimated surgery costs

Droopy eyelid surgery $2,400-$5,500

Double eyelid surgery $2,300-$3,600

eyebag surgery $2,300-$3,600

Medisave may be used only for non-cosmetic treatments.

Surgery to correct droopy eyelids and eyebags, and to create double eyelids, can be performed by SNEC’s Oculoplastic Service.

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During a morning ward round in Ward 48 of Singapore General Hospital, my medical oncology team and I met Mdm Goh, who had advanced breast cancer.

She was undergoing radiation therapy to control her headaches, which were caused by cancer spread to the brain.

Mdm Goh, a mother of two teenage children, smiled broadly as she made two requests in Mandarin.

“Doctor, my husband wants to take me to Marina Bay Sands to stay over the weekend. Can I take home leave?”

Her second request was: “Doctor, I am not afraid to die, but can you make sure I am not in pain when it happens?”

She had received several lines of che-motherapy before her cancer progressed to the brain, usually a sign of poor prognosis.

Her schoolteacher husband was the sole breadwinner and, despite their finan-cial situation, I could sense her happiness at the thought of spending a memorable “staycation” weekend with her husband.

This incident evoked haunting images from an award-winning Hong Kong film called That’s Life, My Love, in which Anita Yuen portrayed a spunky street opera artiste afflicted by terminal bone cancer.

So, pain is like a warning light that steers us away from deadlier danger, destruction, disintegration and demise.

Pain makes us more aware of being alive and human.

But towards the end of life, pain is also no longer that vital.

On the morning the medical ward team met Mdm Goh, we also met Mdm Haslinda, an 80-year-old granny with terminal pancreas cancer.

She was surrounded by generations of her supportive family, including squealing toddlers merrily playing by her bedside.

With the morning sun streaming onto her face and thin, cancer-racked body, her pain was nevertheless well controlled and she was a portrait of peace, calm and dignity.

She was ready.Helping to make last wishes come true

is part of making the trial of cancer an easier journey.

Viewpoint

Family members will do everything they can to fulfil

the last wishes of their terminally ill loved one.

The last wish of most terminally ill patients is simply to be free of pain in their final days

Nov⁄ dec 2012 siNgapore health 19

Up to 70 per cent of patients will encounter pain in their cancer journey.

Today, modern medicine and solid supportive care can alleviate 90 per cent of such cancer pain. The late Dame Cicely Saunders, founder of the hospice movement, coined the term “total pain”, which encompasses not just physical pain, but also social, psychological and spiritual pain.

The “gift of pain”So, while we can use pain medication and state-of-the-art interventions to relieve physical pain, we must not ignore these other pain dimensions which require a more holistic approach.

Pain hurts. Why does it exist? As a young medical student, I had the privi-lege of hearing the great pioneer surgeon in leprosy, the late Dr Paul Brand, speak.

In his talk, he explained why pain was an essential part of the human experi-ence and called it the “gift of pain”.

Leprosy patients are infected with bacteria that eat into their nerves and skin, causing them to lose the sensation of pain.

Their numbed bodies experience damage from trauma and burns, and their limbs even get ravaged and scavenged by animals.

Not able to blink from normally annoy-ing irritants, their eyes become scarred.

BY TOH HAN CHONGMovie company

Pixar organised a special home screen-ing of its then yet-to-be released film Up for a 10-year-old girl Colby, who was weak from termi-nal cancer and des-perately wanted to watch it. Seven hours after the screening of the film, Colby died.

Then there was five-year-old Bethany Fenton with terminal brain cancer, whose last wish was to sing for celebrity Simon Cowell.

Her wish was granted at the Britain’s Got Talent final, where she sang Twinkle Twinkle Little Star backstage to a visibly moved Cowell.

She died peacefully two days later in her parents’ arms at an Oxford hospice.

As cancer specialists, we do receive such “last wish” requests.

From the father with terminal colon cancer determined to be alive and strong enough to walk his daughter down the aisle on her wedding day, to the young pregnant mother-to-be with advanced breast cancer receiving chemotherapy and fighting for time to deliver her child safely and in good health.

Alleviating painThe cancer specialist will work hard to achieve this with the latest in medi-cal treatment, which includes tailoring drug therapy.

Unlike the slim odds of winning at the casino, the odds of cancer shrink-age, as a result of anti-cancer treatment, keep improving.

More importantly, the odds of survival have also risen for many cancer patients.

Recent landmark discoveries that unique gene profiles of patients can pre-dict specific anti-cancer drug benefits fur-ther push up cancer treatment responses and survival rates significantly.

But, in cases where there is no evi-dence that life can or should be pro-longed, there comes a point when it is no longer meaningful to keep prescribing anti-cancer drugs.

Instead, the patient may end up suffering more undue side effects and unnecessary financial burden.

The focus then should be to best con-trol the patient’s symptoms, thereby enhancing his quality of life.

Most cancer patients’ last wish, like Mdm Goh’s, is simply to be free of pain.

This article was first published in The Straits Times on May 3, 2012. Dr Toh Han Chong is Head and Senior Consultant, Department of Medical Oncol-ogy at the National Cancer Centre Singapore.

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One night in hospital, she mentions to her struggling musician boyfriend, played by Lau Ching Wan, that she is hungry.

He then faithfully rushes out to buy her favourite woon jai ko (Chinese kueh) but, upon his return to her bedside, he finds her dead.

There have been many poignant stories recounting the last wishes of cancer patients.

Up to 70 per cent of patients will encounter pain in their cancer journey. Today, modern medicine and solid supportive care can alleviate 90 per cent of it.

Finding peace despite the pain


Viewpoint

Recently, an exasperated doctor remarked that more patients nowadays seem incapable of trust-ing their doctors’ clinical judg-ments. They question almost every decision, and insist on many “high-tech” investigations before accepting their doctors’ advice.

Although I think such patients are in the minority, they remind me of a story:

A man ran into a vet’s office carrying his dog and screaming for help. After examining the dog, the doctor told him it was dead.

Agitated, the man demanded a second opinion. The vet went into the back room and returned with a cat, which sniffed and poked the dog, then looked at the vet and meowed. The vet told the man: “I’m sorry, but the cat thinks your dog is dead too.”

Unwilling to accept it, the man threatened to sue. The vet shrugged and brought out a labrador, which sniffed the dog, then looked at the vet and barked. The vet told the man: “I’m really sorry, but the labrador also thinks your dog is dead.”

Resigned, the man thanked the vet and asked for the bill but, when he saw it, he exclaimed: “What? $1,650 just to tell me my dog is dead?”

The vet replied: “I charged you only $50. The rest is for the cat scan and lab test.”

The importance of trustTrust between doctor and patient is critical, so what can both sides do to build and sustain it?

There is also inherent uncertainty in the findings of “evidence-based medi-cine”. It is impossible for a layperson to understand all the medical methodology on which his diagnosis rests. Despite this, doctors must still provide their profes-sional opinion on what is best for their patients.

Nurturing “smart trust”So, how should doctors cope?

The answer lies in trust, which is the basis of any good patient-doctor rela-tionship. With trust, a patient can be assured that every doctor in the system is properly trained, certified and able to provide safe and competent medical care. He knows his doctor will do what’s best for him, adhere to ethical and professional standards, and make full disclosure if there is a medical error.

At the highest level, the patient will continue trusting his doctor even if the outcome is negative, because he accepts that the result was unavoidable despite his doctor’s best efforts.

Without trust, the patient-doctor relationship is untenable.

In his books, The Speed of Trust: The One Thing That Changes Everything and Smart Trust, Stephen Covey and his colleagues advocate “smart trust”, which balances the propensity to trust with an equally high level of analysis. With “smart trust”, a patient’s trust in his doctor is comple-mented with the doctor’s efforts to help him understand his illness, analyse his treatment options and make an informed decision based on his doctor’s advice.

Regulations not a long-term answerIn societies where medical litigation is an almost habitual response to negative outcomes, doctors will manage the legal threat by practising defensive medicine.

When a patient does not trust his doctor, and the doctor does not believe the patient will be reasonable and forgiving, the doctor will use technology (deemed less fallible) in place of his professional judgment.

Defensive medicine is not always

unprofessional, but can lead to a surren-der of professional autonomy. Extra tests and procedures may help “cover the doc-tor’s back”, but they come with risks that often outweigh the reassurance they are intended to provide.

Some people in the profession think regulations and litigation will ensure good professional standards and conduct. I disagree. These can ensure a minimal standard of care and professional behav-iour, but relying solely on them may make litigation more important than the patient’s welfare.

The doctor’s primary goal then may be to stay out of trouble. A trusting patient-doctor relationship is unlikely to grow in a hostile environment dominated by fear.

Invest in a culture of professionalismIn the long term, trust in the medical profession cannot be sustained by regu-lations and litigation. What is needed is a continuous investment in a culture of professionalism and good doctors to drive it.

Good Medical Practice, published by Britain’s General Medical Council (GMC), offers a simple and succinct description: “Patients need good doctors. Good doctors make the care of their patients their first concern. They are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity.”

I am confident that the majority of doctors in Singapore strive to be the good doctors described here. They are techni-cally dependable, earnestly uphold high ethical standards, and always do their best to provide good care while within the defined boundaries of the profession.

Doctors should practise in a way that enhances, not erodes the trust of their patients and the public. They should nur-ture this trust with the help of health-care institutions and professional organi-sations such as the Singapore Medical Association (SMA). They should share medical methodology and the intrin-sic limitations of clinical research with patients, to manage their expectations without compromising their confidence.

The SMA is committed to lead the profession in this mission, and increase its impact by collaborating with fellow professional organisations, the Academy of Medicine and the College of Family Physicians. Ultimately, winning and strengthening trust should be the mission of every doctor.

BY Chin Jing Jih

Associate Professor Chin Jing Jih is President of the Sin-gapore Medical Association and Chairman of Tan Tock Seng Hospital’s Division of Integrative and Community Care. He serves on several medical ethics committees and is actively engaged in

medical education here. This is an abridged version of his article, The Importance of Trust, which was first published in SMA News, Vol. 44 No. 7, in July 2012.

With ‘smart trust’, a patient’s trust in his doctor is complemented with the doctor’s efforts to help him understand his illness, analyse his treatment options and make an informed decision.

The majority of doctors here strive to be technically dependable. They uphold high ethical standards and do their best to provide good care.


We may laugh, but the story raises important points. It reminds us that despite advances in medical technology and research, the doctor’s ability to make clinical judgments is still key. This is a composite skill, honed through experi-ence, knowledge, practice and years of fine-tuning.

Medicine is a scientific discipline without absolutes. Outcomes and patient responsiveness are never certain. Some patients closely comply with treatment guidelines but fail to recover, while others don’t comply and do recover.

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People


By Sol E Solomon

Beating burnoutListening to other people’s problems every day can take its toll,but Medical Social Worker Chee Ching Yee is not fazed

Looking back to when she gradu-ated in 1992, Ms Chee Ching Yee said that out of the 90-strong cohort of social work graduates, only about 10 still do social work.

“Burnout is a big issue for social work-ers, especially among the new ones. I was lucky because I had strong support.”

But that does not mean it is plain sail-ing for her. A social worker’s life revolves around the problems and hardships of patients.

Three things in particular keep her going. First, she avoids taking problems home by creating a buffer between work and home. Every day before heading home, she spends an hour doing something

simple to unwind and relieve stress. It could be window shopping, browsing in the library or stopping at the supermar-ket to pick up some groceries before head-ing home.

“It’s my ‘me’ time when I unwind,” said Ms Chee, who has two children, aged 13 and nine. This way, she returns home relaxed and in a much lighter mood.

The second thing that helps her is her love for the job. In university, when inspecting the prospectus, she was delighted to discover that social work would allow her to do good while still earning a living.

Attitude makes the differenceThe third thing is her attitude. As a medical social worker with SingHealth Polyclinics, she helps assess the financial needs of patients, many of whom have chronic illnesses and need help to pay their medical bills.

But she feels that her patients help her as much as she helps them.

“They often share their stories with me and when I recall what they’ve done – whether they’ve done it well or not so well – I learn from their experiences. This way,

they help me become a better person.”Most of her patients are middle-aged

or older. “Many are in the sandwiched class, with children still schooling and parents who need their support. They may also be people who have difficulty finding jobs because their skills are no longer in demand. There are also better-educated people who were retrenched in their 50s and have difficulty getting re-employed.”

While she tries her best to help them, she hopes society can be more under-standing. “When people can’t find suit-able jobs, others often think they are not trying hard enough. For the majority, however, this is not true.”

She is happiest when situations improve for her patients. She is touched by the handful of patients who return to thank her and tell her that they are fine. However, she hopes that social workers will get more recognition and support for what they do.

“Many people think social workers just want to do good deeds. They’re surprised that we’re professionals. To do this job, you need a lot of commitment and a degree. We’re not the same as volunteers.”

Ms Chee Ching Yee always takes some time out before going home from work.

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as an award-winning clinician scientist involved in cutting-edge cancer research, while also pur-suing further studies, Dr Iain Tan, 34, is a very busy man. But it is precisely the work he does that makes the father of two even more devoted to his family. With his packed schedule, time is some-thing Dr Tan has little of, so he counts the time he spends with his family as a bless-ing. At home, he spends most of his time with his daughters, aged five and two. He enjoys teaching them and taking them swimming. “My work makes me treasure life more,” he said. “Good lifestyle habits generally lead to better health but there are people who lead healthy lifestyles and still get stricken by diseases. If nothing else, my work has made me even more acutely aware of the gift of life.”

Dr Tan exercises regularly and relaxes by listening to music. “I have to admit that after a hard day’s work, it takes a lot of effort to exercise,” he said. “But I view it not only as a way to keep fit, but also as a form of enjoyment.”

The Associate Consultant Medical Oncologist specialising in digestive tract cancers at the National Cancer Centre Singapore (NCCS) is pursuing a PhD at

Job makes him value family moreDr Iain Tan’s work in cancer research makes him acutely aware of how precious life and family are

pinpoint specific treatments likely to benefit patients, to tailor treatment appro-priately and improve the overall quality of patient care.

In his research on gastric cancer, Dr Tan has identified several molecular char-acteristics of stomach cancer. Each could benefit from specific novel or new treat-ment strategies. This could potentially pave the way for personalised treatments for patients.

“This is perhaps how the next gen-eration of ‘stratified medicine’ will trans-form healthcare,” he said.

“I’m a big advocate of research to improve outcomes for patients. It is only by applying research knowledge to patient care that we can truly make a difference.”

the Duke-NUS Graduate Medical School under the National Research Foundation – Ministry of Health Healthcare Research Scholarship.

His current research involves charac-terising molecular features of patients with gastric cancer (a top cause of cancer deaths worldwide) so physicians can cus-tomise the best treatment for patients.

Dr Tan has several international and local research-related awards under his belt, including the 2010 Young Investiga-tor Award from the American Society of Clinical Oncology for his research on per-sonalised treatment of stomach cancer.

His most recent accolade was the SingHealth Publish! Award (Outstand-ing) in August for his research paper on gastric cancer that was published in Gastroenterology last year.

Quality of care is keyMolecular science has always fascinated him. As a medical student, he was spell-bound by the field of oncology.

He said: “Cancer has a stigma and people fear it. Yet, advances in science and medicine have made monumental inroads in this disease, making certain cancers curable and substantially pro-longing the lives of people with advanced cancers.

“For instance, certain patients with late stage (Stage 4) colon cancer can now be cured. The average survival of patients with Stage 4 colon cancer has more than tripled in the last 15 years.”

But he added that there is no “one size fits all” treatment for cancer patients. “Patients of the same age, from the same demographic group and who appear to have the same type of disease, may end up with very different treatment outcomes.

“Some do very well with standard treatment regimens, while others don’t and might benefit from novel treatment strategies.”

This is where research comes in – to identify molecular features that can help

By EvElinE Gan

Dr Iain Tan believes applying research to healthcare is key to improving outcomes for patients. His current research may help doctors tailor treatment for cancer patients.

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Distributes and provides supplies to healthcare professionals

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

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

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

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

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

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25 MONEY LastingPowerofAttorney v2 WF path.indd 25 17/10/12 2:59 PM

Public forum: my child can Hear but Just isn’t listening!Time 10am-12pm (registration starts at 9.30am)Venue lecture Theatre,SGH block 6, level 9 Registration call 6326-5859 for more information and to register. on-site registration at event will be subject to availability.Price $5 per person (cash payment only on actual day). free for children below seven years old.

Public forum: one Generation caring for Another: for caregivers of the ElderlyTime 10.30am-12.30pm (registration starts at 10am)Venue School of Nursing Auditorium, block A (opposite carpark E onSGH campus)Registration register by Nov 6 for an Elderly care Gift. Seats are limited, so please register early. registration will close on Nov 14. call 6326-5859 for more information to register. on-site registration will be subject to availability.Price freeEach attendee will get a goodie bag containing pamphlets and samples sponsored by bW Generation.

courSE: cPr and AED course for the PublicTime 8.30am-12.30pm or 1.30pm-5.30pmVenue SingHealth Polyclinics Prime Training centre, Jade room, connection one (Tower 3), #07-07, 168 Jalan bukit merahRegistration for more details, email [email protected]. Price $128.40 (including GST)learn to respond to cardiac emergencies using cardiopulmonary resuscitation (cPr) and the Automatic External Defibrillator (AED). The course teaches the basics of cPr and how to use the AED. Participants will learn the theory and practice of emergency resuscitation. A certificate, valid for two years, will be issued to those who pass the theory and practical tests.

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Visit www.singhealth.com.sg/eventsor the websites of respective institutions for more information and other listings.

26 SiNGAPorE HEAlTH Nov⁄ DEc 2012

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All rights reserved. copyright by SGH (registra-tion no: 198703907Z). opinions expressed in Singapore Health are solely those of the writ-ers and are not necessarily endorsed by SGH, SingHealth Group and/or SPH magazines Pte ltd (registration no: 196900476m) and their related companies. They are not responsible or liable in any way for the contents of any of the adver-tisements, articles, photographs or illustrations contained in this publication. Editorial enqui-ries should be directed to the Editor, Singapore Health, 7 Hospital Drive, #02-09 block b, Singa-pore 169611. Tel:+65 6222 3322, Email: [email protected]. unsolicited material will not be re-turned unless accompanied by a self-addressed envelope and sufficient return postage. While every reasonable care will be taken by the Editor, no responsibility is assumed for the return of un-solicited material. All iNformATioN corrEcT AT TimE of PriNTiNG. micA (P) 070/06/2012. Printed in Singapore by Singapore Press Holdings limited (registration no: 198402868E).

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1. What is the name of the drug being tested for the first time on dengue fever patients?

2. Which story in this issue did you find the most informative?

Closing date: Dec 7, 2012

Singapore Health issue 19 contest

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

email: [email protected] Post: The Editor, Singapore Health, Singapore General Hospital, communications Department, outram road, Singapore 169608

Winners of Contest 18Each will receive a bottle of ultra b-Power (120 capsules) worth $42.80.

Send in your answers and stand to win a bottle of Spirulina 100% Extra 10% Deep Ocean Water (750 tablets) worth $69.

Prizes must be claimed by Dec 7, 2012.

1. Ho Kok Guan2. Kee Su Keyau3. lakhani Girish ramchand4. lee meng Sun5. Shi Xinmei

Nov 10(Sat)

Nov 17(Sat)

Eating cherries can reduce the risk of gout attacks, a study has suggested.

Researchers at Boston University in the US found that gout patients who ate cherries over a two-day period had a 35 per cent lower risk of attacks compared to those who did not.

The day before a marathon, eat extra calories, especially high-carbohydrate foods such as bread, cereal, rice, pasta or potatoes.

Drink fluids at least four hours before exercise.

Most marathoners find that they perform better if they eat carbohydrates during the race. Sports drinks, bars and gels are good options.

To avoid runners’ diarrhoea, stay away from sweeteners at least a day before running. These are found in foods such as sugar-free candies and ice cream. Three to six hours before running, avoid or limit intake of caffeine and high-fat foods.

Within two hours after the marathon, eat foods that contain protein, such as peanut butter or string cheese.

Source: Mayo Clinic

New research shows that looking at images of cute animals may actually

improve your work performance.Tests show that pictures of cute

animals “not only improve fine motor skills, but also increase perceptual

carefulness”, according to researchers at Hiroshima University.

Such images could be used “to induce careful behavioural tendencies in

specific situations, such as driving and office work”, they said.

Professor Hiroshi Nittono, who led the study, said: “The feeling that

something is adorable can prompt a person to want to be closer to and know more about the object.

That, perhaps, creates the effect of increased concentration.”

The study, entitled The Power of Kawaii (kawaii means “cute” in Japanese),

was published in the online version of American journal PLOS ONE.

Eating cherries may cut gout risk

The study showed that eating up to three servings of cherries over two days would progressively lower the risk of gout attacks. Eating more cherries after that provided no further benefit.

The scientists said cherries contain anthocyanins, which are antioxidants that have anti-inflammatory properties. More clinical trials are needed to investigate and confirm the initial findings, they added.

Gout is a common type of arthritis that can cause sudden and very

severe attacks of pain and swelling in the joints, particularly in the feet. It is caused by too much uric acid in the bloodstream.

Source: BBC

Cute animal photos can make you

a better worker

How to stay healthy before a marathon

Meow...

Marathon runners train long and hard. Here are some tips for them to avoid injuries just before their big race.

Source: The Japan Times

Dec 18 (Tue)

男性也有生理钟

新加坡中央医院

与新加坡保健服务

集团的双月刊

11月

201212月

> 文转 page 28

原本是非常普通的一天，可是叶亚进先生的手臂却骤然出现肿胀，几小时内呈黑色，状况严重到必须马上入院治疗。

由于患有心律不齐，叶亚进需要定时服用华法林来预防中风。华法林是一种抗凝血剂，能使血液变得较为稀薄，防止血块形成。服用这种药物的病人必须多加注意自己的饮食和生活习惯，以避免这种强效药与某些食品或药物发生相互作用时可能出现的严重副作用。

在最糟的情况下，华法林会令病人的血液变得太稀薄，乃至出现严重出血。叶亚进的状况就是如此产生的。但值得庆幸的是，自从他大约七年前

开始接受新加坡中央医院抗凝血治疗诊所的照料后，这“血淋淋”的插曲就再也没有发生过。

更多的关注，更长的就诊时间据叶亚进称，抗凝血治疗诊所所提供的照料服务，协助他对华法林及其安全事项有着更好的了解。自从药剂师的加入，协助两名分身乏术的主治医生，他也得到了更多关注。目前，诊所有25名药剂师。

“我宁可去见药剂师，因为他们比较有时间向我详细解释正确用药的方法，”现年56岁的叶亚进解释道。

“他们就诊时会问很多问题，例如我是否有锻炼身体、是否吸烟、是否有便血等等。他们也提高了我对华法林的使用意识。现在我知道了，倘若出现任何出血症状，就必须要去看医生。”

在新加坡中央医院抗凝血治疗诊所，药剂师林承翰（左）不只监测叶亚进的情况，也详细解释正确服用华法林的方法。

原文 Teh Joo Lin

本地一支研究团队做了一项具有里程碑意义的研究，发现目前有一种癌症化疗药物可能可以抑制具侵袭性的脑肿瘤，既多形性胶质细胞瘤（GBM, Gliobastoma Multiforme的缩写）。

于今年5月在国际领先刊物《癌症研究》上发表，研究发现癌细胞中的帕金蛋白含量越高，患者的存活期就越长。这也确认了帕金基因所产生的蛋白质，又称帕金蛋白，有如同肿瘤抑制的功能。

由于帕金森病（运动障碍疾病）的关系，医生们对帕金蛋白早已有所认识。如果将来研究揭露它对治疗脑肿瘤的功效，那么不必从零开始研发新药，也能很快地找到治疗药物。

所以研究团队希望在这第二阶段的研究里，找出各种与帕金蛋白异常调节有关的生化途径。如果一切顺利，新发现将开启更多药物来治疗脑肿瘤的可能性，更为患者带来新希望。

“目前还言之过早呢，”国立脑神经医学院脑神经外科顾问医生洪明智教授提醒道，也是新加坡科技研究局旗下新加坡临床科学研究院的高级首席研究员。

里程碑式的发现与洪教授一同协力合作获得此发现的是国立脑神经医学院科学家邓淑伶博士，以及国大杨潞龄医学院生理学系林嘉隆副教授。

洪教授说：“帕金基因可以阻止细胞不断迅速或不受控制地生长防止癌症

（肿瘤）恶化。可是我们发现，帕金基因突变可能会扰乱或出现功能异常导致胶质瘤（一种脑肿瘤）。”

帕金蛋白并非肿瘤唯一抑制物，可是它丰富完善的研究资料在医学和研究界里是数一数二的，尤其在运动障碍疾病方面。当新加坡研究团队从医学文献中获悉帕金基因可能与癌症有关时，便决定去探讨是否与那既普遍又高度恶性的胶质瘤有任何的关联。

新发现推进了脑肿瘤疗法本地医生的一项研究，意味着脑肿瘤患者将得到更好的治疗

> 文转 page 28

药剂师与服用华法林的病人风雨同舟

原文 Thava Rani图

：A

LVIN

N L

IM

page 30

患心脏病的风险

page 31

情感遗嘱能避免争议

page 31

已逝病人屡接短信提醒

近年来，抗凝血治疗诊所就诊的病人数字有增无减。自2001年，被转介到该诊所的病人人数已经达到500名左右。

抗凝血治疗诊所成立于1986年，旨在促进使用华法林疗法的病人的安全性。当时，诊所的医护人员全以血液病专科医生为主。但随着越来越多病人开始服用华法林，诊所在2011年增添了一批药剂师，协助状况稳定的病人进行复诊，让专科医生有更多时间专注于病况复杂的病人或新病例上。诊所医护团队人员增多了，对病人来说，也能有更长的就诊时间和得到更多关注。

新加坡中央医院的药剂师林承翰说，抗凝血病人每年需要看主治医生一次，而在下个诊期到来之前，他们得经常去看诊所里的药剂师，具体频度取决于病人自己的状况，可以是每两周一次，或是每三个月一次。除了评估病人的验血结果之外，药剂师还会询问病人的生活和饮食习惯是否有显著变化。举例来说，锻炼能促进身体对华法林的代谢，这就可能需要更高剂量的华法林。

“在药剂师的问诊中，若有必要，我们会调整病人华法林的剂量，也确定他们有充足的药物。我们还查看是否有出现副作用，或是否有出血或血栓的症状，”林承翰说道。

新加坡中央医院抗凝血治疗诊所的药剂师，协助照料服用华法林的病人。华法林是一种可预防中风的药物，但服用起来必须小心谨慎

向病人开展关于华法林的教育，像它如何发挥作用、如何与某些食品和药物相互作用，以及提防具有威胁性的信号，比如尿液和大便颜色变黑，可能指示体内出血，这是就诊中的一个重要部分。

研究：住院率降低该诊所近期发表的一项研究证实了药剂师加入治疗过程后，病人的总体护理素质得到提升。研究结果发现，因华法林相关并发症而导致住院的病人，已从2001年约9%降到了2011年的2%以下。

> 文接 page 27

药剂师与服用华法林的病人风雨同舟

28 新脉动 NOV⁄ DEC 2012

与此同时，研究也还发现病人的国际标准化比值（ INR, international normalised ratio的缩写）标准范围之内的读数，从46.6%上升到了65.9%。 INR值是测量凝血时间的一项标准试验。

无法把INR值维持在标准范围之内是有危险性的，新加坡中央医院的高级药剂师，也是此研究的首席调查员龚铭泽先生说。当 INR值超出范围时，出血的风险将会提高；如果低于范围，则会提高血栓形成的风险。

近年来，抗凝血治疗诊所就诊的病人数字有增无减。自2001年，被转介到该诊所的病人人数已经增加了一倍，达到500名左右，占新加坡中央医院1,500名接受华法林疗法约三分之一的病人。

没有到诊所就诊的华法林病人，则继续由各自的医生（分别来自心脏科和神经科等各个学科的医生）负责照料。

在这期间，抗凝血治疗诊所的药剂师已经开始着手以进一步改善华法林疗法为目标的研究项目。

例如：与其他种族群体相比，为何印族同胞病人更倾向于超出标准范围。还有研究斋戒如何影响回教徒病人的凝血能力。

“研究成果能帮助我们更好地管理回教徒病人，尤其在斋月期间。如果我

们知道斋戒会提高 INR值，我们就可以事先为他们调整剂量，”研究团队成员之一的林承翰说。

诊所的目标是要把INR值还处于治疗时间的范围（TTR, time in therapeutic range的缩写）提高到70%或以上，也就是说，华法林病人的血液能够在至少70%的治疗时间中，维持适当的“稀释”度。

龚铭泽说：“我们希望把TTR提升到70%或80%，这样，华法林就能不落后于各种新药。如果我们能将这个指标再升到80%，有可能就意味着华法林比新药还要好。”

不过最终关键还是病人的安全。“病人的安全性和满意度并减少不必要的住院次数才是最重要的，”龚铭泽说。

新闻> 文接 page 27

新发现推进了脑肿瘤疗法

他们在实验室里证实了帕金蛋白可以调节癌细胞的生长，然后进一步将国际患者数据库里的胶质瘤患者的存活状况与基因表达资料做对比。终于让他们成功地证实帕金蛋白水平越低，患者的存活率相对地更低。

“这可说是守得云开见月明！当我们看到患者存活数据与实验数据相符时，就知道我们已上了轨道，” 洪教授说。

目前，为了更清楚涉及的生化途径，团队希望能找出帕金蛋白如何扰乱引发肿瘤的发展过程。

“途径范围一旦被缩小，我们就可以从一些成药中，寻找合适的药物再对症下药。我们希望能够在未来的五到十年内在临床试验上验证我们的理论。”

洪教授说。

治疗方案尽快切除胶质瘤是最理想的方法。随着神经外科技术发展，即使肿瘤靠近脑部最关键的部位，也能在患者清醒状态下安全进行手术。手术后，患者会需要接受几周的电疗和化疗。这是目前GBM治疗的国际标准。

当让阻碍还是存在的。例如，如果胶质瘤从原本的位置扩散到脑部的另一半，即使是肿瘤的主要部分，也难以将它完全切除。这就是非常具有挑战性的地方。

即使成功地切除胶质瘤，也不能保证化疗能起

作用，因为不同患者对治疗的效应

不同。“ 我们虽然可以将

显而易见的部分切除，但始终不能避免可能造成

复发的微小肿瘤播种，”洪教授说。

洪教授说，每一次的复发会造成治疗效果每况愈下。更不幸的是，患者丧失的功能就会加剧。总

的来说，仅有60%至80%的多形性胶质细胞瘤患者可存活超过一年。

研究进展顺利将带来的希望如果新研究取得了成果，治疗方案将可以有更多的选择。如果该研究团队成功地找到与帕金蛋白有关的分子途径，现有的化疗药物便可能被用来针对这种病症。

其实这类针对性治疗并不新颖，而且已应用在乳腺癌和肺癌等其他癌症。

“不是每种疗法都适合每一个人。等找到另一种合适的疗法时，患者的状况可能已经变差了，治疗效果肯定不会好。但现在如果我们能确定每名患者帕金蛋白表达的特征，就有可能为患者量身定制化疗方案，大大提高其存活率，” 洪教授说。

谁会患上GBM?不是简单的头痛头痛通常会对药物作出响应，但脑肿瘤可能显示出下列特征: 取决于肿瘤在脑部的位置，症状有所不同，但可能包括……

头痛恶心或呕吐视力模糊无食欲肢体无力情绪变化思考和学习能力的变化新的痉挛讲话困难

症状通常…… 在开始发病时是渐进性的，例如，手

臂的渐进性无力顽固，即症状持续，不会消失

头痛通常是…… 特别严重的持续的模式与你一般的头痛不同在清晨特别严重伴有视力问题或恶心

患者年龄通常介于40岁至60岁。病状在儿童中罕见。

没有任何特定种族群体中发病。

本地并无性别关联性，但一些欧洲研究提示，男性出现病状的风险略高。

很多因素都可干扰华法林的药效。象富含维生素K的花椰菜和绿茶等，可以中和华法林的药效。维生素K是肝脏用来制造人体中凝血的蛋白质。

这并不代表病人必须停止食用花椰菜或其他富含维生素K的蔬菜或食物。他们每个星期还是得需要继续保持一贯维生素K的摄入量；如果病人

洪明智教授与研究团员证实了帕金蛋白可以调节癌细胞的生长，他们的发现与国际患者数据相符。

图：

MO

RVEN

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药剂师龚铭泽（右）和林承翰合力协助减轻诊所的医生的工作量。

图：

VEE

CH

IN

的生活作息和饮食习惯发生了改变，便会扩大或抵消药效，导致病人的血液变得过“稠”或过“稀”。

如果绿茶并非病人常规饮食中的一部分，喝绿茶就可能致使他的INR值在第二天从2降到1。但如果绿茶已经是病人常规饮食中的一部分，那么，喝茶就不应该影响到 INR值。因此，服用华法林的病人必须定期监视其状况，在必要时改变他们的剂量。

服用华法林的病人必须做定期验血，以确定血液是否能在设定的时间标准范围内凝结，测量指标是国际标准化比值（INR, international normalised ratio的缩写）。

一般人的INR值为1，但大多数接受华法林处方的病人必须把INR保持

在2至3之间。这意味着，他们必须服用足够华法林的剂量，使血液凝结的时间比一般人慢两到三倍。

确保病人维持在INR标准的范围内是一项挑战。INR值过高，不只会增加病人出血的风险，还会有可能在严重胃出血或颅内出血（脑部出血）这类病例中造成死亡。但如果INR值过低，则会提高中风的风险。

密切监测

注意饮食

华法林如何发挥作用对于有心房颤动等病状的病人来说，华法林是一种“灵丹妙药”。心房颤动造成心律不齐，从而导致心脏上部腔室形成血栓。当一个血栓松脱后，它会进入血流，并沿着血流，嵌入通

向脑部或脑内的狭窄血管处，导致中风。其他血液病况包括血栓凝结在下肢的深静脉血栓以及凝结在肺部的肺栓塞。

华法林可以通过减缓血液的凝结能力来缓和这些病状。但此药物也必须小心使用。

对于年满40岁想要孩子的男性而言，

生理钟对其来说已经很紧迫了。

男性也会受到生理钟左右

起作用，在准爸爸体内也一样，”陈医生说。

由竹脚妇幼医院和杜克 - 国大医学研究生院联合开展的这项研究进一步证实，男性的年龄不仅影响生育力，而且还会影响妊娠和婴儿的健康。

“尽管女性年龄对生育影响的研究众所周知，但有关男性年龄对生育影响的研究还很少，”陈医生说。他也是杜克-国大医学研究生院的助理教授。

女性的生理学分界点很明确地限定在35岁。而对于男性，该分界点可能在40岁左右，陈医生说。

“对于超过40岁的男性，我们更担心的是男性基因可能发生变化，这会使其后代易于出现先天性障碍，甚至导致流产，”他说道。

跟女性一样，随着年龄增加，男性也会出现身体和生殖系统的变化，从而影响生育力和后代的健康。

“男性虽然不会停止产生精子，但随着年龄增加，产生和输送精子的结构会发生衰退。譬如，精液产生变慢且生殖管道变窄，”竹脚妇幼医院生育医学科顾问医生刘世瑰说。

男性性功能也会发生衰退。随着年龄增加，

男性的睾丸酮水平降低，性欲减退，并且更容易发生诸如勃起等性功能障

碍，刘医生说。

Nov⁄ Dec 2012 新脉动 29

说到生孩子，时间未必总利于男方。“越来越多的研究证明，男性也有

生理钟，可在40岁左右开始影响他们的生殖能力，”竹脚妇幼医院妇产科顾问医生陈添财说。最近由他在新加坡所领导的一项研究显示，丈夫年龄越大越会增加妻子流产的危险。

该研究持续16周，监测了139名先兆流产（妊娠早期出现阴道出血）的女性。结果发现，与年龄介于30至40岁的男性相比，超过40岁的男性会使流产的危险性增加8倍。

而与年龄介于 20至30岁的男性相比，年龄介于30至40岁的男性会使流产的危险性增加约4倍。

“流产风险较高与年龄较大的男性精液质量降低有关，”陈医生表示。

“ 我们已经发现胎儿流失的危险性因男性年龄超过40岁而增加，因此我们可以推断，生理钟不仅在准妈妈体内

原文 Jamie ee

随着年龄增加，男性的精子质量会退化，引起精子DNa损伤并增加女性流产的几率。

新闻

一项本地研究发现丈夫年龄越大越会增加妻子流产的危险

“勃起障碍与供血障碍密切相关。随着年龄增加，如果患上糖尿病或高胆固醇，则容易出现血管问题。如果此类问题影响到阴茎，则会导致勃起障碍，”他补充道。

年龄较大的男性精液质量也会变差。因为精液产生速度降低，暴露于感染和吸烟等因素产生的毒素的风险也会较高。这会损伤精子的基因，刘医生说。如果四成以上的精液基因受损，那么流产的几率就会升高。

研究还证明，对于年龄较大的男性，其后代出现遗传问题，如自闭症和侏儒症的危险性也会增加。

除了老化过程，男性的生活方式也会影响到精液中的精子计数值和质量。研究已经发现很多因素都会降低精液中的精子计数值和质量，例如压力、吸烟、饮酒、在高温环境下工作等，陈医生说。

他还强调说，男性生育力在全球范围内都在降低，新加坡的男性也不例外。“正常情况下，1毫升的精液标本中应该有1千5百万以上的精子。但是，我们看到的一些标本中可能只有一个精子。”

当前的趋势是男女婚育年龄推迟，这样就对年龄较大的准父亲不利的吗？

刘医生不那么认为。他说，只要男性继续生成精子并能完成正常性交，就仍有可能生育孩子。女性能育就能弥补男性生育潜能降低的不利影响。宫内人工授精（IUI）和体外受精（IvF）生殖技术也可用于帮助受孕困难的夫妇。

不过，随着男性年龄增加，发生生育问题的危险性也相对增加，因此医生建议那些想当父亲的男性要及早做计划。

陈医生说：“年龄40岁及以上的男性如果想要孩子就不应该再拖延了。”

1 定期锻炼有助于保持较高的睾丸酮水平，改善精子质量并降低勃起功能障

碍的危险。

2 保持健康体重和摄入富含抗氧化剂如维生素A、c和e的健康膳食。

3 减少毒素暴露，如戒烟和避免染上性病。

有助于逆转生理钟的措施

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在过去10年，卓荻钊先生曾进行过两次左眼角膜移植手术，现在他担心右眼也需要同样的手术。

“那时不仅缝合需要20针，复原期也达6个月，” 现年59岁，已半退休的卓荻钊说。

不过，他已不必再担心了。通过新加坡全国眼科中心展开的一项改良角膜移植术，他模糊的视力只持续短短几天。“手术后的第四天，我的视力已恢复到不需要旁人的协助也能够自己外出的程度了，”他说。

该手术名为后弹力层内皮角膜成形术（Descemets Membrane endothelial Keratoplasty，简称DMeK），是最新改良的微创角膜移植术。目前手术所需移植的那层纤薄角膜细胞的厚度只有0.01毫米，是新加坡全国眼科中心以往在常用手术中的0.1毫米再薄上10倍。

角膜是眼睛外侧的透明保护层，对因老化或疾病而引起角膜混浊患者，角膜移植是最有效的治疗方式。

使用DMeK技术，患者本身的角膜基本上保持完好无损，因此手术后效果不会立竿见影，患者也可能在几周内便能恢复100%的视力。

新加坡全国眼科中心医药总监陈长慧教授说：“今后将是DMeK的时代。手术后，患者也可获得完美视力，而排斥率不超过1%。”

这种新颖无缝合技术起源于欧洲，陈教授于2010年9月首次在亚洲采用该技术。此后，通过该技术，他已在新加坡全国眼科中心完成了11例角膜移植术。每例手术费可高达5,900新元，但如果扣除医药津贴，费用是介于1,500-1,700新元之间。

唯一不利的地方是这项改良手术极为复杂。因为移植的角膜极为纤薄，在触碰时易产生皱褶，所以可能在将其展开时损坏角膜细胞。

为克服这个难题，陈教授与新加坡眼科研究院团队成功地找到了一种既安全又容易进行的新DMeK手术插入装置的方法，目前该装置正在申请专利当中。

新加坡每年大约会进行350例角膜移植术，其中约四成是属于角膜老化的患者。随着人口老化，预计这数字将会增加。

全新眼科手术带来完美视力手术可使患者获得完美视力，且排斥率不超过1%

原文 Thava RaNi

全新手术可使患者获得完美视力，且排斥率不超过1%。

陈添财医生（右）和刘世瑰医生（左）建议年龄40岁及以上的男性如果想要孩子

就不应该再拖延了。

30 新脉动 Nov⁄ Dec 2012

保健

帮助中风患者克服困难对家中做出一些改变可减少中风患者对其看护人的依赖

对中风患者来说，扣个钮扣、系上鞋带或手握汤匙可能都是些非常困难的动作。而根据中风的严重程度，患者有可能是局部胳膊、腿或身体其他部位丧失活动能力或全身瘫痪。

那些日常动作如起身、坐、走路、吃饭、穿衣服以及上卫生间等，原是一般的本能反应，忽然间也得花上一段时间或需要他人的协助下，才能完成的事情。

新加坡中央医院职能治疗师张妙珍表示，对家中进行基本的改造，能让情况已稳定，并返回家中休养的患者，更容易且安全地移动。

在患者返回家之前，张妙珍通常都会先往其住家进行评估，并对可能或必须改进的地方提出建议。她说：“我会观察居住环境和周围情况，了解哪些可能会阻碍患者行走安全，哪里可能会绊倒他。环境周遭应该尽可能保持整洁有序。”

即使是非常小的房间也可以进行改

造。张妙珍说：“家具可以重新摆设，使小房间更宽敞、舒适，尤其是对坐轮椅的患者。有些公寓的浴室非常狭小，不能容纳洗澡椅或患者和其看护者两人，但可以在其他房间或空间进行改造，例如，患者可选择在厨房淋浴。”

住处的一些基本改造包括，在卫生间和浴室里安装扶手杆和防滑垫，以防止患者滑倒或摔倒。那些不能够站立的患者应该使用洗澡椅。卫生间里也可安装斜坡道，方便轮椅或座便椅移动自如。能见度非常重要，所以光线要充足。在卧室里安装小夜灯也是一种安全措施，使患者在夜晚时不用摸黑也能行动。

尽管有许多设施和装置能助于患者穿衣、吃饭以及烹饪等的日常活动。可是对于行动不便却力求独立的中风患者来说，不能一如既往地进行曾经得心应手的事情，始终会带给他们一些挫败感。

橡胶柄餐具更容易握紧且能够防滑，而弯角汤匙对手腕或手部移动受限的人来说更易使用。

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使用和处理如菜刀等利器时，患者的安全是至关重要的。如左（图），如这

款特殊的砧板，,它的底部装有强力的吸盘，不只能紧紧

地固定在桌面防滑，也能单手轻松调节钳子夹紧各式各样的食物。既降低受伤的风险也让那些只能靠单手活动的使用者更放心地烹饪。

洗澡

湿滑的浴室通常是最容易发生摔伤的地方。如果设有扶手杆和洗澡椅就能让行动不便或缺乏灵活性的人士更安全地使用。比起一般平滑的钢铁扶手杆，波纹扶手杆也较为安全，因为即使扶手杆湿了也能抓牢。

长柄的弯梳更容易使用，这样一来胳膊行动不便的患者不用抬高胳膊也能在后脑勺梳头。

梳洗

中风后，患者的手或胳膊可能无法活动自如，像吃饭这样简单的事情可能一下子会变得非常困难。定制餐具如改装盘子、饭碗和杯子都有助于克服这些困难。使用凸边盘能避免患者在盛舀食物时外溅。经改造的汤匙能辅助患者的手腕动作，让患者轻而一举地从盘子中舀取食物送入口中。

吃饭

穿衣

要一名仅能活动一只手的中风患者扣上衬衫的纽扣是件非常费力的事。要是使用个像缝针穿线器的钮扣钩，便能轻松又快速地将扣子扣好。其他辅助装置如穿衣辅助杆（一个末端带有钩子，能让中风患者轻易地拉上裤子、袜子或袖子的长杆)和鞋拔都能够帮助有穿衣困难的人。

烹饪

谷蛋白和糖尿病面筋是否富含碳水化合物？对糖尿病患者是否有害？我经常在素食里吃的人造肉替代品是不是用面筋来做的？面筋是从大麦、小麦和黑麦等谷类制成的食品含有的一种谷蛋白质。面筋本身不含任何碳水化合物，而是素食中的面粉（并非面筋）含有碳水化合物。

目前没有任何证据证明谷蛋白会导致第 2 型糖尿病患者的血糖控制恶化。相对的，也没有研究显示无谷蛋白的饮食能改善第2型糖尿病患者的血糖控制。

第1型糖尿病患者主要是在童年和青春期确诊，患者有可能患上称为乳糜泻的肠道相关疾病。患有乳糜泻的患者对谷蛋白非常敏感，一旦服食可造成腹泻。这类患者需服食无谷蛋白的饮食。

新加坡中央医院内分泌科顾问医生苏华逸

患心脏病的风险我今年38岁。最近感觉胸口疼痛，双手麻痹。血液检查和心电图的结果都显示一切正常。这可能是因为压力而造成的，因此拒绝了血管造影。我应该做进一步的检查吗？心脏病，特别是冠状动脉疾病，虽然在年轻人中较少见，但仍然可能发生。而且，随着现代生活方式的影响，年轻人患上心脏疾病有上升的趋势。

只要胸口疼痛超过数分钟以上就要认真看待，尤其是有家族心脏病史或有其它引起冠状动脉疾病的危险因素，如高血压、糖尿病、抽烟、高胆固醇或甚至是年事渐高。

您可能需要进一步确诊是否患上冠状动脉疾病，因为疼痛停止后所做的血液检查和心电图虽然结果正常，但也有可能因此而忽略了这个可能性。最好是找个心脏专科医生就诊。视检查结果而定，你未必需要再进一步作检测。检测方法有很多种，各有优劣利弊。

血管造影非常准确，但侵入性较高，令人望而生畏。视情况而定，还有其他侵入性较低的测试如跑步机的压力测试、核素心肌灌注或负荷超声心动图和心脏冠状动脉ct扫描。

您可以咨询心脏病专家最合适的测试。

新加坡国家心脏中心心脏病科顾问医生陈培德

专家解答

Nov⁄ Dec 2012 新脉动 31

财经

有遗嘱就有办法为亲人留下一份遗嘱对他们而言可能受益匪浅

“最终，我想是时候给你说些以前没有说过的事情了。那事不宜迟，开始吧……”

给亲人留下一份‘情感’遗嘱或许能够为他们解答这一生中未曾试着回答的问题。“酝酿一份‘情感’遗嘱能抚平临终

者的心灵，因为它代表了维系子孙的一道桥梁，”连氏基金会首席执行长李宝华先生说。“活着的人因获得意义深远的‘遗

产’而感到充实、然后随之成长并从逝去亲人的悲伤中得到解脱，从而更能节哀顺变。”

因此于2011年10月，作为一项大义运动的一部分，连氏基金会以鼓励的

方式向公众推行‘情感’遗嘱的概念，即‘有生之年’，力图提倡人们给予临终者更好地照料还有没有忌讳地谈论死亡课题。‘情感’遗嘱是该基金会一系列积极对待生命的其中一种方式。

情感遗嘱的价值李宝华说，写一份‘情感’遗嘱能帮助我们正视自己、坦然地面对死亡并思考如何诚恳地与亲人分享一些重要东西。它也提醒我们不要拖延表达我们的感激、歉意、宽恕和爱。对某些人而言，这样深思熟虑的抒发行为足以让我们将之铭记于心，改变我们的人生态度并积极地看待活着的意义。

在用意和目的上，‘情感’遗嘱与情书类似，李先生说。

‘情感’遗嘱采用了日常对话方式和语言而非法律用语，简单地通过记忆、生活教训与价值观细腻地抒写来体现个人情感和对他人的祝愿，特别是对深爱的人。例如“我对你未来的祝愿是……”或“不知道我以前是否告诉过你，但我……很抱歉”等。这些都能帮助人们依环境随意地传递未曾表达的感情。

根据新加坡律师公会（ T h e La w Society of Singapore）会员Simon Tan先生所说，‘情感’遗嘱不须要与传统遗嘱区别开来，一般传统遗嘱是死后财产的分配方式。

遗嘱里也可以包含临终者的心里话、感情和意愿。他说，如果一份文件只有个人对他人的情感表达，却没有死后财产分配说明，则不能将此作为法律文件。

意见箱

避免争议一份遗嘱要有效力且在法律上可以执行，它就必须准确地包括立遗嘱人全部关切和意愿。模棱两可的遗嘱可能引发争议并有被宣布为无效的风险。

为避免争议，请考虑下述方面：立遗嘱人必须神志清晰。立遗嘱人可能患有身体疾病或身体虚弱，但他在立遗嘱时必须神志清醒。建议请医生证明在签署遗嘱时，立遗嘱人在神志上没有问题，且他的判断力还足以判断他正在给予的是何物。

立遗嘱人必须身份明确。应在遗嘱中写明立遗嘱人的姓名和身份证号码。

*上述资讯由新加坡律师公会会员Simon Tan先生提供。

验血没有病假单如果我到医院只为验血，院方是否能给我一张病假单？竹脚妇幼医院答复：医生一般会在就诊时先对病情进行评估，再决定患者是否须要请病假休息。而验血则是由护士来执行，所以院方只能出示一张时间记录单据，为您的缺勤或缺课提供证明。

为什么挂号需要病人在场?当我在综合诊疗所为我既年迈又行动不便的父母挂号时，挂号室服务人员告诉我说，父母本人

对短信提醒百思不解我的父亲几个月前就去世了。为何新加坡中央医院还不断发送简讯提醒我们他的就诊预约呢？新加坡中央医院答复：对您父亲过世的噩耗，我们深表遗憾并请节哀顺

变。如果病人在新加坡中央医院去

世，我们的资料系统会

自动记

若有任何关于入院手续、账单及程序等疑问，可电邮至[email protected]，我们会在这个栏目解答您的问题。

从www.lienfoundation.org/news下载情感遗嘱

小册子。

必须在场才能挂号。我理解核实病人身份的必要性，但这还不如就诊时确认身份来得更重要。况且，挂号时仅核实姓名，那病人何必亲身在场才能挂号呢？新加坡保健服务集团综合诊疗所答复：对于我们给您与您的父母造成的不便感到抱歉。病人的安全对我们而言至关重要。因此在每一个服务站我们都要核实其信息，例如姓名和居民证号码，以确保为每名患者提供的医疗服务正确无误。由于挂号室是我们与病人接触的第一站，所以在见到医护人员之前，确保病人信息的准确性是非常重要的。

“这两类遗嘱的区别是在于各自不同的目的。一类是反映情感愿望的，另一类则是实现物质的，”陈先生说。

不过，他宁可把两者都视为遗嘱，而不是区分它们。这是因为‘情感’遗嘱能让逝世者的家属、甚至法院知道逝世者生前内心深处的想法、未吐露的愿望以及懊悔，是为法院提供至关重要的信息。譬如，逝世者指明某资产对他来说非常重要，并不希望这资产在自己出现任何状况时被变卖或处理掉，诸如此类。

陈先生说，在遗嘱里包含我们的‘情感愿望’、精神状态、生活价值观、待人处世态度以及感情十分重要。“这些都是经过深思熟虑后表达出来的情感，也表示立遗嘱人已经慎重考虑了其财产的分配方式。”

至亲或亲戚要是感到有任何不满都

录病人的死亡信息。如果病人在家里、疗养院或临终关怀机构去世，则需要病人的家属通知医院以便更新资料。

家属可以通过邮寄或电子邮件发送死亡证明书的副本给医院。如果没有死亡证明书，家属也可以发送其他证明文件，比如警察局或临终关怀机构的报告。家人还可以给医院写信或发送电子邮件至[email protected]，并说明与病人的亲属关系。

在未收到通知之前，医院的资料系统没有病人去世的记录，所以其家人还会收到有关预约的简讯或其他提醒。敬请谅解。

原文 Celene Ting

应该指定一位执行人和/或受托人。执行人将办理丧葬事宜、支付费用、确定要分配的财产，并指定一名律师授予遗嘱认证书，以赋予他在遗嘱规定下分配财产的权力。若涉及到子女或未成年人，则应该指定一名受托人。若财产不能立即分配，那么在执行人保全了财产并准备好将来分配后，受托人开始履行其职责。

必须指定受益人。否则，就不是一份遗嘱。不过，如果某人只是想表达情感，而不想在去世后分配其财产，那么可以通过信件的方式办理，其格式不必与有效力且可执行的遗嘱一致。

遗嘱必须在有两位证人在场的情况下签署。

不能争辩逝世者不是在神志清晰的状态下做出的决定，这也降低法院做出可能有悖立遗嘱人意愿的判决风险。

如果当事人给律师的指令具体明了，那么法院就没有充分的理由或审判权裁定此人是否存有对他人立遗嘱的了解。不然在没有铁证如山的医学证据证明，那么法院就会实施判决。

遗嘱中的情感意愿通常示意法院立遗嘱人本身清楚地知道他在做什么，而毋须法院去解读他的意愿。因此，写份易于理解的‘情感’遗嘱不仅是解决临终问题的一种方式，也是可以让家人免于诉讼的纷扰。

毕竟，在失去亲人后他们最不愿面对的就是不满的亲戚发起的诉讼风波。

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singapore health nov/dec 2012

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