Healthcare and You

Congratulations to The Cancer Center

2009-12-21T22:11:00.007+08:00

All staffs of MW Medical would like to extend our warmest wishes to TCC's opening of a second clinic at Mount Elizabeth Medical Centre.

The new clinic is located at:
3, Mount Elizabeth Medical Centre
Singapore 228510

Thoughts - Medisave for Palliative Care

2009-10-03T23:33:00.006+08:00

There has been a lot of interest on this topic with many patients asking if this programme has started. The government has taken a step of reviewing the possibility of using Medisave in home palliative care. This is important as these patients want to be home and yet receive medical treatment as well. The use of Medisave in this scenario is also considered finite. The big question is – when does palliative care start? Many palliative care practitioners would probably feel that palliative care should start once a disease with significant impact of life has been diagnosed.

Palliative care originated from Latin palliare, which means to cloak. The aim is to reduce the severity of disease symptoms. The essence of palliative care treatment is to prevent and relieve suffering and to improve quality of life. Some palliative care is not dependent on prognosis while other forms of palliative care look at end of life issues.

It is precisely the difficulty in defining palliative care that we need to look carefully at how we can use Medisave in providing care at home.

We need to consider the time frame, the need of interventive procedures, the need of paramedical services like physiotherapy, speech therapy.

Finally, there is the right of every patient to choose the form of treatment and where the treatment can be done.

We will need time to review this topic carefully and develop systems to ensure that patients receive home hospital care if they so decide.

Dr Madeleine Chew Him Lim
MBBS (Singapore)
Senior Physician
MW Medical (Singapore)

Extension of Chronic Disease Management Programme for Outpatient Treatment of Mental Illnesses

2009-07-08T09:54:00.007+08:00

Medisave has been allowed for use in the outpatient treatment of chronic diseases namely: diabetes mellitus, hypertension, lipid disorders, stroke, asthma and COPD since October 2006.

The Ministry of Health has reviewed the prgramme to include more chronic diseases under the Chronic Disease Management Programme (CDMP). the use of Medisave for outpatient treatment will be extended to includeSchizophrenia and Major Depression.

The extension will be rolled-out in October 2009.

New from ASCO - Update by Dr Wong Seng Weng on Breast Cancer Treatment

2009-07-08T09:38:00.005+08:00

New treatments

New class of "smart drugs" with promising new results in treating "resistant" forms of breast cancer.

Results announced in the American Society of Clinical Oncology Annual Meeting in Orlando 29 May-2Jun 09: PolyADP-ribose polymerase inhibitors (PARP inhibitors).

"Smart drugs" (targeted therapy) in cancer are like "smart bombs" in warfare. They zoom in to hit the cancer cells by incapacitating cancer cells by way of recognition of unique targets on the cancer cells thereby avoiding harm to the normal cells of the body. Advances in the use of anti-cancer antibodies and hormonal therapy are examples of such targeted therapy in breast cancer in recent years.

However, there is a significant percentage of breast cancer types that do not display such targets and are resistant to these new treatments methods. These breast cancer types are described as "triple negative" ie negative for the 3 common targets that "smart drugs" in breast cancer go after.

Patients with these form of breast cancer tends to have a poorer prognosis due to the greater resistance of these cancers to treatment and they tend to afflict younger breast cancer patients.

Research has revealed a new vulnerability of these cancer types. They have an impaired ability to repair any damage to their genetic material which is critical to their survival. The new class of targeted drugs (PARP inhibitors) are able to jam this vulnerable repair mechanism thus increasing the damage chemotherapy cause to these cancer cells improving the results of treatment.

Dr Wong Seng Weng
MBBS (Singapore), MRCP (UK), FAMS (Medical Oncology)
Consultant Medical Oncologist & Physician
The Cancer Centre, Paragon Medical

Diabetes in Children

2009-01-24T17:07:00.004+08:00

Does diabetes occur in children ? Yes, but it is not as common as in adults and it is mostly not the same as in adults, so the treatment is very different in most cases.

Diabetes in children may be due to the following causes :

Type 1 Diabetes Mellitus – Occurs when the beta cells of the pancreas have been attacked by an autoimmune process ( cell-mediated immunity) and they are too few too produce sufficient insulin.

Type 2 Diabetes Mellitus – When the body is resistant to the effects of insulin, and the body fails to compensate by producing enough insulin to overcome the effects of this resistant state.
People who have had Type 2 diabetes for a long time often need insulin injections as well because the body is not only resistant to insulin but also no longer able to respond to oral medications Secondary diabetes – when the pancreas has been damaged due to another medical condition – for example, thalassemia major, effects of chemotherapy or surgery.

The approach to treatment of diabetes in children and teenagers is very different to that for adults because of the need to take into account issues of growth, puberty and adolescence, emotional development and matching the medication doses to the child’s timetable and CCA which need to be addressed at the same time as the diabetes. A children’s diabetes specialist ( a paediatric endocrinologist who specializes in diabetes ) is the better option to help provide the best care for the child with diabetes, or who is at risk for diabetes.

In adults with Type 2 diabetes, treatment is geared towards getting the body to make more insulin and make it work betterIn children with Type 1 diabetes, the body cannot make insulin any more, and the treatment is to replace the insulin in as natural a way as possibleEven when children develop Type 2 diabetes, they may need insulin right from the start as well, in addition to oral medications.

Some children may be at risk of diabetes but may not yet have diabetes or may only have impaired glucose tolerance ( prediabetes . Children and adult with prediabetes can go on to develop diabetes. Help is available to reduce the risk of progression to diabetes too, and it includes medication and lifestyle changes. Risk reduction strategies include helping pregnant women with diabetes achieve good blood glucose control in pregnancy and identifying high risk children for intervention as early as possible.

No matter what has caused the diabetes, treatment is geared towards :

1. Replacing the insulin needed to control blood glucose levels
2. Reducing the risks of hyperglycemia ( too high a sugar level in the blood ) and hypoglycemia ( too low a sugar level)
3. Allowing the person with diabetes to have as normal a life as possible .

Methods to achieve this include :

1. Insulin injections
2. Insulin pumps
3. Insulin sensitizers
4. Cholesterol lowering agents
5. Renalprotective medications6 Glucose monitoring

Maintaining a normal glucose level is important because high glucose levels lead to diabetes complications such as blindness, kidney failure, nerve damage, strokes and heart attacks as well as mood changes.Low blood glucose levels can lead to epileptic fits and lowered IQ. Research has shown that good glucose control can reduce by half, the rate of diabetes complications. Poorly controlled glucose , on the other hand can also give rise to stunted growth, delayed puberty, mood swings and poor performance in work and interpersonal relationships.

In the past, people with diabetes used to be on 2 insulin injections a day and had to accept a lot of restrictions on their lifestyle. Conventional insulin injections have many limitations. Even when the same dose is given each day, the amount of insulin released into the bloodstream can vary up to 55%, giving rise to high and low blood glucose levels when least expected. Conventional insulins also have a poor peak performance , which means that children with diabetes could not eat many favourite foods.

Nowadays, with newer insulin analogues such as Novorapid, Humalog, Detemir, Glargine / Lantus and so on, children with diabetes can eat a wider variety of foods and they no longer have to wait half an hour after their injections before they can start eating. With the newer insulins, the danger of having a very low glucose level is lowered.

In fact, with the new insulin pumps, the variation in the delivered insulin is only about 3% per day, compared to up to 55% variability in conventional insulins. With an insulin pump, the dose is infinitely variable, so that children active in sports and who have healthy appetites have much lower danger of highs and lows. Even quite young children can safely be put on an insulin pump, and many parents whose children are on an insulin pump tell of the great freedom and improved peace of mind which the pumps give them.

Whether the patient with diabetes is using insulin injections or using an insulin pump, it is useful to know what the blood glucose level is like so that dose adjustments can be made more accurately. While multiple daily finger pricks were the norm, new Continuous Glucose Monitoring Systems ( CGMS ), such as Medtronics’ Guardian Real-time system, can give blood glucose readings updated every 5 minutes for 3-5 days by having a small sensor inserted just under the skin. Besides being used in children and adults who want to have good control, CGMS is also useful for pregnancy diabetes patients who want to reduce the risk of complications in their unborn child.

Dr Warren Lee,
MBBS, M Med Paeds, FAMS, FRCP ( London ) , FRCPCH ( UK)
Senior Consultant Paediatrician and Paediatric Endocrinologist
Dr Warren Lee’s Paediatrics, Growth and Diabetes Centre Pte Ltd

Euthanasia

2008-11-09T16:38:00.012+08:00

This is Nov 2008… Euthanasia is such a hot topic in Singapore that the only other topic that shadows it is the global financial meltdown. Both are depressing and chilling…

What is Euthanasia? This word, from Ancient Greek means good death - "eu" for good and "thanatos” means death. Doctors are traditionally not keen on Euthanasia because of our oath to our patients - The Hippocratic Oath. This oath states : "To please no one will I prescribe a deadly drug nor give advice which may cause his death.." However, since the 1970s, it has largely fallen out of use.

The truth about euthanasia is that we have been practising this in Singapore for years but in a passive sort of way. Many old and or dying patients usually want to stop treatment and we do so by withdrawing medications that would treat the underlying conditions – this is passive euthanasia. This form of euthanasia is more accepted though there are relatives who still feel strongly against this.

What we are discussing now is active euthanasia – a way for sound minded people to decide when to die…

The key to the answer lies in our mind… These scenarios can happen and we should examine these before making an informed consent for euthanasia.

Scenario A

Mr U is 40 years old, decided that he will go for euthanasia after reading all about the topic. At 50 years old, he was diagnosed with cancer, given a limited life expectancy. He had consented for euthanasia 10 years ago but now, he wants to change his mind because he is scared. How is he going to explain to his loved ones this change of heart? Is he going to appear weak and cowardly? How do we create an avenue for people to opt out with dignity? Does this whole process minimise his pain?

Scenario B

Mr V is an 80 year old who has dementia. He can remember his loved ones but relies on them for activities of daily living. He wants to die because he is a burden and he is going to become worse. His family is reluctant as they have just received a new bundle of joy and do not want to spoil the mood. Who has the right to decide his death? Do they go to court to settle their differences? Does this process minimise pain?

Scenario C

Mrs U is a 60 year old with a terminal disease. She has had treatment but still has significant pain. She is tired of fighting for her life, she wants to die. Her family is not certain but tries to be supportive. She gets her wishes and planned her funeral, the make-up artist, the floral arrangement, the coffin. She felt very excited about all these arrangement. The D day arrived and everyone at home is awkward. Her working children took leave – to witness my mother’s death. No one in the office dared to ask them about their feelings. Are they happy? Are they sad? They feel uncomfortable. Mrs U wants to go ahead. She invites her children and husband to witness her ‘good death’ – they shook their head. She was alone with the doctor. She was walking up and down the flight of stairs. Finally, after a long 45 min of struggle…she …

This is the tensed moment, the auspicious hour and this story is true. In the real story, the patient chose finally to die. Her children who documented the whole event had some regrets but respected her decision. However, we can imagine if she chose to give up, they may even celebrate! But, with all the arrangements made, would these arrangements make her lose face if she changes her mind? Does the 45 min of struggle minimise her pain?

I think that euthanasia is fine – active euthanasia is also fine. However, there are too many details, too many scenarios. Euthanasia should not be equated to painless death. It cannot be… It can be a good death if patient family and all the loved ones feel that the decision is right and that I think is the challenge. My eight year old daughter listened to the Scenario C and commented… “I don’t want you to die like that…I am scared…The aunty was scared too… for 45 min”… my daughter paused …”Death no good, no good death”…she added, switching to her baby talk to show me how the story disturbed her…

There is probably no good death. Death is a permanent separation and a definite step towards unknown. For those with omnipotent powers by their side, perhaps this process is easier but there is no easy way out…

Dr Madeleine Chew Him Lim
MBBS (Singapore)
Senior Physician
MW Medical (Singapore)

Growth Hormone Deficiency and Short Stature in Children

2008-09-29T21:58:00.004+08:00

Children with growth hormone deficiency are short, but not all short children have growth hormone deficiency and not all short adults have had growth hormone deficiency.

Children can be short for a variety of reasons. Some people will be short as adults because they lacked growth hormone production, others will be short as adults because they were unable to respond to growth hormone. Some people can be short as adults because they grew too fast as children.

Growth in length is fastest in the womb, then continues to be rapid in the first year of life. It then slows down in childhood and there is a period of rapid growth again in puberty before we stop growing at the end of the pubertal years. The height gained during each phase of growth is important. If growth during any of these phases is poor or the duration of any of these phases of growth is somehow shortened, the growth in the other phases may not be able to make up the difference and we can end up with a short adult.

Children who were born premature or too small for their gestational age , children who had serious illness and growth failure during infancy or childhood, and children whose puberty comes too early or too late are therefore at risk of being short adults. For example, if a girl has periods too early, then she may start the puberty growth spurt before the childhood growth phase has ended and this may limit her total time for growth – leading to a short adult height. Some boys have delayed puberty and they may also have a poor potential for being tall because both parents are short.

Growth hormone therapy can help some of the children who are short to grow taller, if the problem is a lack of growth hormone production. It is less able to help if there is a problem with the ability of the body to respond to the growth hormone. In children who are no longer able to make enough growth hormone, such as those who have had certain brain tumours and had the pituitary gland removed as a result, growth hormone will restore growth in the majority of cases, unless they had also radiotherapy to the neck and spine, in which case growth hormone can still help but results may not be as good.

For children whose puberty has come too early, we may have to hold back puberty with medications and we may also need to give growth hormone if the estimated final height as an adult is too short.

If a child is short and wants to seek help, we will need to do some xrays and blood tests before deciding on the best course of action. In summary, we may need to treat an underlying illness which is preventing proper growth, or we may need to give growth hormone to promote better height growth. Sometimes we may need to also treat the other hormone disease that are associated with being short. For example we need to be aware that some chromosome disorders ( eg Turner’s Syndrome ) and some metabolic conditions ( eg hypothyroidism) may be the cause of the poor growth.

Growth hormone has to be given by injections but this does not appear to be a big problem. Modern needles for growth hormone are very fine and almost painless. Special needle-less injector devices are also available to administer growth hormone. However, one should be wary of taking products which claim to be able to stimulate growth when inhaled or taken by mouth as they not work as claimed. Growth treatment may take months to years to complete but the results are often worth it. Other medications may sometimes need to be given and potential side effects need to be looked for and managed.

Not all short children need to be given growth hormone therapy and some may need more than growth hormone . Sometimes the problem is the timing of the growth spurt. In other cases, the underlying illness, such as poorly controlled asthma , may need to also be addressed

The first thing to do is to realize that there is something wrong with your child’s growth and have him or her be assessed by a doctor experienced in assessing and treating growth problems. Secondly, the doctor can assess and find out what is wrong and what needs to be investigated or treated. Thirdly, while growth hormone will make many short children taller, not everyone is suitable for treatment with growth hormone and potential side effects need to be looked out for, treated, and ideally prevented in order to optimize the risk benefits and cost benefits of treatment. Finally, children with short stature may also need some emotional support and sufficient exercise to keep them healthy.

Dr Warren Lee,
MBBS, M Med Paeds, FAMS, FRCP ( London ) , FRCPCH ( UK)
Senior Consultant Paediatrician and Paediatric Endocrinologist
Dr Warren Lee’s Paediatrics, Growth and Diabetes Centre Pte Ltd

Implications of Hepatitis Infection

2008-08-20T13:06:00.011+08:00

Hepatitis A

Hepatitis A is always self limiting. Even without any treatment, the infection will always resolve and the virus will be cleared. In otherwise healthy individuals it hardly ever threatens life and will not result in any serious long term complications or residual effect. There is no carrier state for Hepatitis A. Once the individual recovers from the infection, he can no longer infect another individual and should be immune to a subsequent infection.

Hepatitis B and C

Hepatitis B and C infections are very different from Hepatitis A. A person who gets infected can either clear the virus or become permanently infected. This latter group of individuals becomes “carriers” of the virus. These asymptomatic carriers can then potentially infect others. In Hepatitis B, the risk of becoming a carrier is dependant on the age at which the infection occurs. The younger the individual at the time of infection, the higher the risk of becoming a carrier. If infected at birth, the risk of becoming a carrier is almost 100%. If infected as an adult, only 10-20% will become carriers. For Hepatitis C, almost all infected individuals will become carriers.

Carriers of Hepatitis B and C are at risk of developing complications of the disease. In the initial stages, they are usually completely asymptomatic. Only when severe liver damage has already occurred will they feel unwell. Progression is very slow and complications with symptoms become apparent only after many years to even decades after the initial infection. These complications include liver hardening (cirrhosis), liver failure and liver cancer. It is estimated that a Hepatitis B carrier is at 200-400 times the risk of developing liver cancer compared to a non carrier.

However these outcomes are not inevitable and it is only with further tests that we can stratify the risks for any individual carrier.

Diagnosis of Hepatitis

Blood test will be able to diagnose Hepatitis A, B, C infections and also identify carrier states for Hepatitis B and C. Early detection is important as it allows counseling, life style modifications and close follow up to detect complications in their earliest stages. It also alerts other close contacts and family members to undergo screening and, if needed, to get vaccinated against catching the infection.

Protection and Precautions

Vaccination is available for Hepatitis A and B. Protection is however never absolute. Despite being successfully “immunized”, infection can still occur if an exceptionally large load of virus is acquired. There is no vaccination for Hepatitis C.

For Hepatitis A, 2 vaccinations are required, spaced 6 months apart. Some degree of protection is already present 2 weeks after receiving the first injection but the full course will still require a second injection to be given 6 months later. Almost all individuals will develop protection and this is life long after the second injection. No further boosters are required. Individuals seeking vaccination before they travel to a high risk area should be vaccinated at least 2 weeks prior to departure. The second injection may be taken upon return at the scheduled time. Since it is acquired through eating and drinking contaminated food or water, the usual precautionary measures for all travelers with regard to food and water consumption will apply.

Hepatitis B immunization requires 3 injections to be administered over a period of about 6 months. It can be given at the same time as Hepatitis A vaccination. Not all individuals successfully develop immunity after vaccination. It is therefore advisable that a blood test is performed about a month after the 3rd injection to confirm successful immunization. Generally, for individuals with no high risk profile, no booster is needed once immunity is confirmed.

Conversely, for individuals who regularly come into contact with Hepatitis B carriers, regular 3-5 yearly immunity level checks are advisable. It is however still controversial if booster doses need to be given. As the transmission methods are similar, precautionary measures applicable to HIV infection would apply in casual sexual relationships. This is particularly so in high risk scenarios e.g. sexual contact with a commercial sex worker. In a monogamous spousal relationship, no special precautions are recommended as long as the partner is successfully immunized.

Treatment

Hepatitis A infection is usually self-limiting and in most cases, requires no medical intervention.

In contrast, Hepatitis B and C are serious diseases and there is ongoing research for drug therapy. Several drugs are now available but none are perfect. Tests need to be performed to determine if an individual will require or benefit from treatment. A specialist needs to be consulted for this decision to be made. Treatment is expensive, often requires injections, usually takes several months to a year to complete and is often associated with many side effects.

Dr Cheong Wei Kuen
MBBS (Singapore), MRCP (UK), M Med (Int Med), FAMS (Gastroenterology)
Consultant Physician & Gastroenterologist
Mount Elizabeth Medical Centre
WK Cheong Gastrointestinal & Liver Specialists Pte Ltd

The ABCs of Hepatitis

2008-08-20T13:04:00.007+08:00

Introduction

Hepatitis refers to an inflammation of the liver. There are many causes of which viruses are but one category. Hepatitis A, B and C are infections of the liver by 3 different viruses.

All 3 forms of hepatitis are infectious.

Hepatitis A is acquired through consumption of fecally contaminated water or food, particularly shellfish. It can also be transmitted through oral-anal sex with a recently infected individual. The likelihood of an individual having had an infection by the Hepatitis A virus increases with age. In Singapore, by the age of 50 years, about 90% would have been exposed to the virus.

Hepatitis B and C, on the other hand, are acquired as a result of sexual intercourse with another infected person or contact with the blood of an infected person. Hepatitis B is more infectious than Hepatitis C. Sexual promiscuity and having multiple sexual partners are known high risk factors in the acquisition of both infections. Blood contact most commonly occurs during acupuncture, tattooing or piercings performed contaminated needles. Sharing of needles by drug addicts or those experimenting with “mainlining lifestyle drugs” is another mode of infection. In less developed medical services, contaminated blood products and even improperly sterilized surgical/dental equipment may serve as sources of infection. Sharing of razors, toothpicks, toothbrushes, nail clippers, combs with an infected person can also potentially transmit the viruses.

About 4% of Singaporeans are infected with Hepatitis B. They are said to be Hepatitis B carriers. Carriage rates varies between countries, e.g. China 43%, Taiwan 20%, Philippines 17%, Australia 1%, Japan 3%. Singapore has a Hepatitis C carriage rate of about 0.4 % – 1.7%.

Another very important mode of Hepatitis B transmission is from an infected mother to her children at the time of birth. This mode of transmission can be largely prevented by timely treatment of the newborn at birth. Transmission while the baby is still in the womb has also been documented but this is probably rare. All pregnant mothers should therefore be screened for Hepatitis B so that the appropriate precautions may be taken at birth to protect the newborn.

Hepatitis C transmission during birth can also occur but is much less common than Hepatitis B.

Because of similarities in transmission methods Hepatitis B and C, a single individual can often be infected by more than one virus. Lastly, HIV is also transmitted in much the same scenarios (sexual intercourse, blood contamination and contact) and therefore should be screened if Hepatitis B or C is diagnosed.

Symptoms of Hepatitis

Nausea, loss of appetite, jaundice (yellowing of the eyes and skin), abdominal discomfort and the passage of tea coloured urine are the most common symptoms of Hepatitis A, B and C. Infection can however often occurs without any symptoms and infected individuals can feel and look perfectly normal. This explains why many individuals do not realize they have been previously infected until tests are performed, either during general health, blood donation or insurance related screenings or when pregnant. Each type of infection has a different incubation period. This means that symptoms may only be apparent only several weeks to even a few months after the point of contact with an infected individual.

Dr Cheong Wei Kuen
MBBS (Singapore), MRCP (UK), M Med (Int Med), FAMS (Gastroenterology)
Consultant Physician & Gastroenterologist
Mount Elizabeth Medical Centre
WK Cheong Gastrointestinal & Liver Specialists Pte Ltd

MW Medical Congratulates Dr Wong Seng Weng

2008-07-30T15:58:00.007+08:00

Everybody at MW Medical would like to congratulate one of our partner doctors, Dr Wong Seng Weng, on the opening of his new clinic The Cancer Centre along Singapore's shopping strip - Orchard Road.

This is a milestone for Dr Wong as he expanded his facilities from a smaller clinic to better serve his patients. The Cancer Centre is located at:

Building: Paragon Medical, Paragon Shopping Centre
Street: 290, Orchard Road
Unit No.: #17-05/06
Tel. No.: (+65) 68351000
Website: http://tcc.sg/

Gastroscopy

2008-07-15T16:00:00.005+08:00

Gastroscopy refers to an examination whereby the inner lining of the first past of the gastrointestinal tract (esophagus, stomach and duodenum) is visualized using a flexible instrument inserted through the mouth or the nose. The procedure is done under light sedation and is therefore performed without discomfort. It is done as an outpatient and usually takes about 5 minutes to complete. Results are available immediately.

Gastroscopy allows for the detection of diseases of the upper gastrointestinal tract. These range from cancer to benign growths (e.g. polyps) to ulcers. The procedure also allows the diagnosis of a bacterial infection (Helicobacter pylori) which can increase the risk of cancer and ulcers of the stomach. If abnormalities are detected, tissue can be obtained for detailed microscopic examination. If growths are detected (e.g. polyp-s), they can also be removed at the same time through the examining instrument.

Situations where gastroscopy is indicated included:

Evaluation of symptoms of

Abdominal pain
Recurrent vomiting, bloating and nausea
Unexplained weight loss
Unexplained anaemia
Unexplained abdominal swelling or lump

Consultations for evaluation of abnormal blood tests and X-rays

Elevated cancer markers (e.g. CEA, CA19-9)
Low hemoglobin of unknown cause
Positive stool blood test
Abnormal X-rays (e.g. Barium meals, computer scans)

Dr Cheong Wei Kuen
MBBS (Singapore), MRCP (UK), M Med (Int Med), FAMS (Gastroenterology)
Consultant Physician & Gastroenterologist
Mount Elizabeth Medical Centre
WK Cheong Gastrointestinal & Liver Specialists Pte Ltd

Handling Death at Home in Singapore

2008-07-15T15:45:00.002+08:00

Death and Its Issues

Death is often a painful separation. No amount of preparation can prepare one for the moment of loss. The hapless feeling of loss of a loved one is inexplicable and sometimes even traumatic.

Care givers or family members with elder relatives can use the following recommendations to tide through these difficult times.

Be Prepared

Upon discovery of the passing away of a patient or elder, family members would frantically call for a doctor to certify the death of their loved ones. Unfortunately, medical practitioners need to be able to inform the authorities what is or are the medical condition(s) that has resulted in the death.

Medical practitioners will have difficulty in identifying the cause of death from deceased with no recent review by doctors or no recent admissions to hospitals. As such, it is recommended that patients receive at least a regular follow up with the doctors once in every 2 months. Obtain a letter from the regular doctor that documents the diseases and tests done. The documents together with the test results would allow medical practitioners to ascertain the cause of death of the patient.

Get a Breather

With the passing of a loved one, initial emotions can be dramatic. It would be preferred for the family to take some time to stabilise their emotions before proceeding with the administrative tasks. There are many legal and ritual procedures to see through. Family members therefore do not have the time to imbibe in the event and accept the outcome. Some will need to express their pain through tears. Take some time for every family member to get over the emotion, including little ones who may find the adult behaviour out of proportion and become fearful.

CCOD - Certification of Cause of Death

This is a legal document issued by the doctor to the police to certify that a death has occurred as a result of certain medical conditions. It can only be performed by a registered doctor. The doctor may need to answer inquiries from the various disease registries, the Ministry of Health and Immigration & Checkpoints Authority. As such, medical documents from the various doctors and hospitals may need to be given to the doctor certifying the death for future reference.

Death Certificates

This is a legal document issued by the police from their police post to the relatives. Any person (above 21 years of age) can report the death. The person reporting must bring along their Identity Card, the CCOD and the deceased's Identity Card. The family must decide whether the deceased is to be cremated or buried and where the process is done.

Once the death certificate is given, please make a few copies as they will be required for uses such as making of insurance claims.

Certifying Cause of Death

Certifying cause of death is not simply a matter of certifying that a body is breathless and has no pulse. Any medical practitioner can certify cause of death provided there is a valid discharge summary from the hospitals, or records of diseases and tests (including test results) in recent months.

If there is no known cause of death, the doctor can only come to inform the relatives if the patient has passed away but will not be able to issue the CCOD. After confirming the death, the police will need to remove the body of the deceased to the mortuary for the pathologist to certify and sign up the cause of death. Not everybody will undergo autopsy and families and relatives can usually collect the body quite soon after the body has been examined.

Reporting of Death

There is a 24 hours grace period given for the reporting of death at home. However, it is easier to proceed with the various preparations with the death certificate.

Death Certification without Touching the Body

There are some religions that believe that the body should be left untouched for a few hours upon passing away. However, certain examinations have to be performed to ascertain that death has occurred. The doctor can be contacted in advance, but asked to arrive only after this time period is over.

The digene HPV Test

2008-06-27T14:20:00.009+08:00

The digene HPV test is approved by U.S. FDA capable of directly detecting high risk types of HPV virus. This test can be administered together with the Pap when screening women from the age of 30 and over, and can accurately identify who is at risk of developing cervical cancer.

More information can be found at the digene HPV test website about the test, getting the test done, and real life stories of survivors of cervical cancer.

Cancer of the Cervix

2008-06-11T11:17:00.013+08:00

Many would recall that the late Hong Kong celebrity Anita Mui lost her life to cancer of the cervix in 2003. And many wondered: Isn’t cancer of the cervix supposed to be a largely preventable disease? What have we understood about the disease?

Cancer, in general, is number one killer in Singapore. One in every three Singaporeans will develop cancer at some point in their lives. One in four Singaporeans is destined to loose his or her life to the disease.

Against such alarming statistics, cancer of the cervix represents one of the success stories in our continuous struggle against cancer. In countries with a good health-care system in place, the consistent application of the three-pronged strategy of prevention, early detection and improved treatment has, to a significant extend, tamed the beast that is cervical cancer. While cancer of the cervix is the second commonest cancer affecting women all over the world, it has been relegated to the sixth position in Singapore. Cervical cancer, however, has not become a disease just of the developing world. It remains a significant scourge in developed societies.

What is cervical cancer? What causes it? Who are at risk? How can women be protected against it?

The cervix is located at the lower end of the womb; it is the entrance of the womb, so to speak. The growth of cancer in this region is closely related to infection of the area by a family of viruses known as the human papilloma virus (HPV). This virus can be transmitted by sexual contact. Hence, women who are sexually active, particularly women with multiple sexual partners, are more at risk. The other significant risk factor for cervical cancer is smoking. There is controversy surrounding the use of oral contraceptive and multiple childbirths leading to increased risk.

The Pap (Papanicolaou) smear is the main test, since its introduction in the 40’s, for detection of pre-cancerous changes in the cervix so that therapy can be instituted before a full-blown cancer develops. This simple test has reduced the incidence of cervical cancer by 70%. A Pap test can be done in a doctor’s office or a hospital. While a woman lies on an examination table, the clinician inserts a speculum into her vagina to widen it. A sample of cells is taken from the cervix with a wooden scraper and/or a small cervical brush. The specimen (or smear) is placed on a glass slide and preserved with a fixative, or is rinsed in a vial of fixative, and is sent to a laboratory for examination. Current general guidelines recommend that women have a Pap test at least once every 3 years, beginning about 3 years after they begin to have sexual intercourse, but no later than age 21. It is safe to wait 3 years, because cervical cancer usually develops slowly. Testing for the presence of the causative human papilloma virus is also increasingly used.

The latest breakthrough in the fight against cervical cancer is the availability of vaccines against human papilloma viruses. The currently available vaccine GardasilÔ confer immunity to the common strains of human papilloma viruses that causes approximately 70% of all cervical cancer cases. Vaccination is estimated to be able to eventually prevent half of all aggressive pre-cancerous changes and two third of all cervical cancers. The vaccine is generally safe and well tolerated. The current recommendation is that the vaccine should be administered to all girls and women between the ages of 9 and 26.

While the human papilloma virus vaccine is a major advance in the prevention of cervical cancer, but it will not replace the need for other preventive strategies, such as the Pap smear. Pap smear screening is of paramount importance since HPV immunization is not effective in clearing infections or pre-cancerous changes that are already present.

The strategy for prevention of cervical cancer in future is likely to combine vaccination with screening by regular Pap smear. Not forgetting, the best that medical technology offers, will have little impact on the disease if the strategies do not gain widespread implementation and acceptance by women at risk. Medical advance has delivered the solution. It is up to us now, let’s get the word out and relegate cancer of the cervix to the pages of history.

Dr Wong Seng Weng
MBBS (Singapore), MRCP (UK), FAMS (Medical Oncology)
Consultant Medical Oncologist & Physician
The Cancer Centre, Paragon Medical

Echocardiogram

2008-05-28T11:18:00.006+08:00

The heart is a moving structure and is deep in our chest cavity, making it difficult to get a picture of. Fortunately, the echocardiogram was invented and is a good and convenient tool to examine the function and structure of the heart. The echocardiogram is made up of a machine which contains the computing chip or the brains and a probe which is attached to the machine and which is the “eye” of the machine through which the image of the heart is obtained.

The echocardiogram uses sound waves and the principle of reflection of sound very much like that of a train moving in relation to a person. When the train is approaching you, the sound of the whistle gets louder and when it moves away, the the sound gets softer. The sound waves that are reflected off the heart are then processed by powerful computers in the echo machine to reconstruct an image of the moving heart. Because the pulses of sound released by the probe of the echo machine are in rapid pulses, the heart can be viewed in real-time motion.

The echocardiogram is useful for determining the heart function, the valve function and is able to measure the pressures in the various chambers of the heart. It can be use to measure the dimensions of all the structures in the heart and the major blood vessels that are attached to the heart. It can also be combined with an exercise stress test to look for blockages in the blood vessels of the heart.

Going for an echo study is relatively easy. There is no need for any fasting prior to the study. It is a non-invasive procedure. The patient is required to remove his shirt and don on an examination gown to protect his or her modesty. Then ECG electrodes are applied to the chest wall. The patient is then required to lie down on a special couch with his face and body turned to the left. A small cut-out hole in the couch is opened up to allow for better access to the left side of the body. The sonographer will then apply some gel to the probe and place the probe on various positions on the chest to obtain the various views of the heart. The whole study will take about 30 minutes to complete.

After the echo study, the all the electrodes and gel will be removed form the chest and the patient can proceed to change back into his own clothing.

Dr Kenneth Ng
MBBS (Singapore), MRCP (UK), M Med (Int Med), FAMS
Consultant Cardiologist
Novena Medical Centre
Novena Heart Centre

Colonoscopy

2008-05-02T09:20:00.006+08:00

Colonoscopy refers to an examination whereby the entire inner lining of the large intestines is visualized using a flexible instrument inserted through the anus. The procedure is done under light sedation and is therefore performed without discomfort. As the large intestines is filled with feces, a 2-3 hour period of colon cleansing is performed before the examination in order to allow for unobstructed visualisation. The procedure is done as an outpatient and usually takes only about 20-30minutes to complete. Results are available immediately.

This is now the procedure of choice for the detection and diagnosis of diseases of the large intestines, ranging from cancer to benign growths ( eg polyps ) to unusual infections and inflammatory conditions ( eg Crohn’s Disease , ulcerative colitis ). If abnormalities are detected, tissue can be obtained for detailed microscopic examination. If growths are detected ( eg polyps ) , they can also be removed at the same time through the examining instrument, without the need for “open” operation.

Colonoscopy is a very powerful tool for large intestinal cancer screening and prevention. This now the most common cancer in Singapore. A normal examination gives re-assurance that the risk of developing large intestinal cancer should be minimal for the next 5-8 years. If polyps ( pre-cancer tumors ) are found, they can also be removed to prevent their transformation to cancer in the future. Generally, the risk of developing large intestinal cancer increases after the age of 45 years and this is the age when screening may be considered. Individuals with family members who have developed large intestinal cancer are at increased risk and should be screened earlier and regularly.

Other situations where colonoscopy is useful include

Evaluation of symptoms of possible large intestinal disease

- Abdominal pain
- Abdominal lump
- Lump or pain at the anus
- Vomiting or passage of blood in stools
- Prolonged diarrhoea with or without blood
- Pain on passing motion
- Feeling of incomplete bowel evacuation
- Constipation
- Change in bowel habits and stool characteristics ( eg fragmentation, small caliber stools )
- Unexplained weight loss
- Unexplained anaemia
- Unexplained abdominal swelling

Consultations for evaluation of abnormal blood tests and X-rays

- Elevated cancer markers ( eg CEA, CA19-9 )
- Low hemoglobin of unknown cause
- Positive stool blood test
- Abnormal Xrays eg Barium enemas, computer scans

Dr Cheong Wei Kuen
MBBS (Singapore), MRCP (UK), M Med (Int Med), FAMS (Gastroenterology)
Consultant Physician & Gastroenterologist
Mount Elizabeth Medical Centre
WK Cheong Gastrointestinal & Liver Specialists Pte Ltd

Advances in Cancer Treatment

2008-04-10T12:19:00.012+08:00

One in three people in developed countries will suffer from cancer. And one in four wll lose their lives to this dreaded disease.

What exactly is cancer?

The term “cancer” originated from the Greek term for “crab”. This description came from a physician-philosopher in ancient Greece- Hippocrates. When he first studied the nature of cancerous growths, the typical appearance of cancer as a mass with extension and invasion of the surrounding normal organ reminded him of the appearance of a crab with legs extending out of a body.

Cancer cells evolve from normal cells. The behavior of normal cells is regulated by the genetic code. They multiply, grow and die a natural death in a controlled fashion. However, the genetic code can be frequently damaged. Cells are usually able to self-repair the damage. Cells that fail to self-repair will usually undergo self-death. However, if a damaged cell fails to self-repair or undergo self-death, this abnormal cell may then multiply and grow in an uncontrolled fashion with abnormal characteristics enabling it to invade its surrounding and to spread through the blood circulation to other parts of the body leading to damage of vital organs and ultimately, death.

Many factors may contribute to the damage of the genetic code of cells and also to the lost of ability of self –repair. Some factors are inherited. Other factors involve the environment such as pollution and radiation. Life-style factors such as cigarette smoking and the use of alcohol also play a significant role.

The growth of cancer cells occurs in an exponential way. By the time a cancer can be detected, it is usually at lease 1 centimeter in size. A one-centimeter tumor carries within itself 1 billion cancer cells. It would have under gone the multiplication process 30 times. If the tumor were to undergo the cycle a further 10 times, there would be a trillion cancer cells in the body invariably causing death.

The symptoms of cancer depend on the site of the growth. Lung cancer, for instance, typically cause cough, chest pain and shortness of breath. Unfortunately, early cancer often produces no symptoms. By the time any discomfort is felt, the cancer is often advanced and the window of opportunity for a cure would have been lost.

The rapid rate of growth of cancer cells and the propensity to disseminate, makes early detection a corner stone of the successful fight against the disease. Screening mammogram, Pap smear and colonoscopy are tools that have been successfully employed for the early detection of breast, cervix and colon cancer respectively. With advances in technology, non-invasive means of cancer screening, such as virtual colonoscopy using advanced 64-slice tomography, is fast gaining popularity.

The treatment strategy for cancer has to be customized according to the tumor-type, the stage of the cancer as well as the characteristics of the patient.

Surgery remains an important corner stone of cancer treatment. The total surgical removal of a tumor is often necessary to achieve a cure. Advances in surgical care aim to reduce the morbidity of surgery without compromising the cure rate. A technique for breast cancer surgery known as axillary sentinel lymph node biopsy is now a widely accepted alternative to the traditional procedure of removal of large number of axillary lymph nodes which may lead to a higher incidence of chronic swelling of the affected arm.

In the field of radiation, image guided radiotherapy intensity modulated radiotherapy promises to deliver the required treatment to the tumor in a far more accurate way thereby improving treatment effectiveness while at the same time, reducing treatment related side effects.

Chemotherapy advancement has made impressive strides. While more effective treatments are available, conventional chemotherapy nevertheless suffers the drawback of significant associated toxicity. The problem arises from the relatively non-specific mechanism of action of most chemotherapy leading to damage of not only cancer cells, but also of normal cells of the body. More potent combinations of chemotherapy therefore often carry with them more severe side effects. In the quest for better treatment, specific therapy that targets the cancer cells and boosts efficacy while minimizing the “collateral damage” to normal cells of the body, remains the holy grail of anti-cancer treatment strategy.

Over the last few years, targeted therapy has become a reality. Anti-cancer drugs now have characteristics of “smart bombs” with the ability to home in to destroy caner cells while sparing the normal cells of the body. The era of “smart drug” has thus arrived.

In the field of early breast cancer treatment, the use of the antibody HerceptinÒ in patients with tumors displaying the target has lead to a dramatic decrease in relapse rate not seen in several decades. In the treatment of non-Hodgkin lymphoma, the use of the antibody rituximab in patients with tumors displaying the target has lead to a dramatic decrease in relapse rate not seen in several decades. Further development in the field has yielded a newer generation of radioactive monoclonal antibodies such as ZevalinÒ with promising results in early clinical trials.

The treatment of lung cancer has also seen important breakthroughs in the recent years. The use of the antibody AvastinÒ has improved the survival in advanced lung cancer over the use of conventional chemotherapy alone. Apart from antibodies, a class of special molecules has been developed to block specific targets on cancer cell responsible for cancer growth. Members of this class of drugs, IressaÒ and TarcevaÒ have entered clinical use and have found applications in the treatment of advanced cancer of the lung. Their favorable side effect profile and ease of oral administration are especially attractive. These drugs have made available a treatment option for patients who are either unable to receive chemotherapy or who suffer from tumors that are not responsive to chemotherapy.

These improvements give us cause for optimism in our relentless pursuit of better cancer treatment.

Dr Wong Seng Weng
MBBS (Singapore), MRCP (UK), FAMS (Medical Oncology)
Consultant Medical Oncologist & Physician
The Cancer Centre, Paragon Medical

Medical Care for the Elderly

2008-04-05T16:24:00.001+08:00

The medical standard in Singapore has long been highly regarded in Asia, and is evident from the many overseas patients seeking medical care in Singapore.

While Singapore is medically advanced among her neighbours, medical care can only reach patients who are willing to reach out to receive help.

Elderly in particular, often refuse to go to a clinic or hospital to seek treatment when they are struck with illness or suffer a relapse from an existing condition. They often brush off with an excuse that “they are alright” or “there is no big deal”. The common reasons why many elderly are disinclined to visiting a medical facility are because,

They feel that medical fees are exorbitant.
They detest taking medicines.
They fear of being admitted to the hospital after reaching there, and eventually die at the hospital. This is especially believed by those who are very old, or had an existing condition (e.g. heart attack) that is very serious.
They are unwilling to travel as they are physically weak due to deteriorated muscles, and believe that they will be a burden their family members when they have to accompany them to the clinic or hospital.

However advanced we are in the medical arena, there is no way to help these group of people if they are unwilling to seek for help. Family members often find themselves in a dilemma as they are unwilling or find it difficult to “compel” their elders to seek medical assistance. Some of these cases were delayed until the damage was irreversible.

In 2002, 2 doctors decided to look into these problems and thought of how to bring the hospital to these people if they refused to go to one. As healthcare professionals, they felt that they should not just be good at treating and healing, but they should also be able to help all those who needed medical help. MW Medical was born with these objectives in mind.

MW Medical created a new process to bring hospital care to the home, and the 2 doctors become “operationally ready medical doctors”. They would perform house calls at the ring of the phone, reaching the patient’s doorstep fully equipped with portable machines purchased from different parts of the world.

At reasonable rates, most families do not have to hesitate to call for medical assistance. Neither do they need to worry of having to persuade their elderly member to visit a clinic or hospital for medical treatment.

A year later, premier home services were started with Mobiledoctor, Mobilenurse, and shortly after that, Mobiletherapist. Mobiledoctor was the first licensed clinic specialising in providing house call medical care.

Mobiledoctor operates 24/7, making house call services available day and night throughout the year and bringing healthcare standards equivalent to that of a hospital.

Mobilenurse is dedicated to and stays with the patient at his premises for the duration of the treatment and procedure, and can provide up to 12 hours private nursing duties. A nurse in the hospital is assigned to several patients in a ward and is not dedicated to any particular patient.

To MW Medical, patients have the right to choose to stay at home to receive medical care. MW Medical’s services had solved the dilemma faced by many families and achieved her objective of bringing hospital healthcare to the patient’s home. Elderly receives their well-deserved medical assistance the way they want it to be. The service had also transformed into a concept known as Hospital@Home.