MEDICAL
www.singhealth.com.sg
A SINGHEALTH NEWSLETTER FOR MEDICAL PRACTITIONERS MCI (P) 148/12/2012
02
Screening for
Osteoporosis in
Women
04
First Trimester
Screening &
Chromosomal
Disorders
06
Maternal Mental
Illness and its
Impact on the
Family
Focus:
Women’s
health
AprJUn 2013
SingHealth Academic Healthcare Cluster
Singapore General Hospital • KK Women’s and Children’s Hospital
• National Cancer Centre Singapore • National Dental Centre of Singapore • National Heart Centre Singapore
• National Neuroscience Institute • Singapore National Eye Centre • SingHealth Polyclinics • Bright Vision Hospital
Medical Update
Focus:
Women’s
health
Appointments: 6294 4050
Email: [email protected]
AprJUn 2013
Screening for Osteoporosis in Women
Dr Ang Seng Bin, Head & Family Physician and Consultant – Family Medicine Service; Menopause Unit,
Department of Obstetrics & Gynaecology, KK Women's and Children's Hospital
Osteoporosis is a silent disease which many people are not aware of until
they suffer a fracture. With an ageing population in Singapore, the disease
burden of osteoporosis is expected to rise, thereby increasing healthcare
resource utilisation.
Lifetime risk for any osteoporotic fracture
in a woman 50 years and above is
estimated to be between 40-50%. This
is higher than that for cardiovascular
disease, stroke and breast cancer.
With effective medications that are
available now and many more in
the pipeline for the treatment of
osteoporosis, early detection and
treatment of the disease would add
quality of life to the increased longevity
of the elderly.
Definition
Osteoporosis is a systemic skeletal
disease characterised by low bone
density and micro-architectural
deterioration of bone tissue with a
consequent increase in bone fragility.
The World Health Organization
(WHO) has categorised osteoporosis
based on the Standard Deviation
from a young adult mean from
Bone Mineral Density (BMD)
measurement using Dual Energy X-ray
Absorptiometry (DXA) into normal,
low bone mass, osteoporosis and
severe osteoporosis. See Table 1.
Diagnostic Criteria for Osteoporosis
WHO Diagnostic
Category
Normal
Low Bone Mass
Osteoporosis
Severe
osteoporosis
(Established
Osteoporosis)
Table 1
Bone Mineral
Density (T-score)
> -1
-1 to -2.5
≤-2.5
≤-2.5 with one
or more fragility
fractures
Diagnosing osteoporosis
Dual Energy X-ray Absorptiometry
(DXA) of hip and spine
DXA of the hip and spine remains
the Gold Standard for diagnosis of
osteoporosis. It remains the only method
for monitoring the skeletal effects of
medical treatments for osteoporosis.
Qualitative ultrasound of the heel (QUS)
has been shown to predict fragility
fractures in postmenopausal women
but quite often there are discordant
results between QUS and DXA. It is also
not used for follow-up for patients on
medical treatment of osteoporosis.
Fracture risk estimation
FRAX®
FRAX® is a tool that was developed by
WHO to evaluate fracture risks based
on clinical risk factors and bone mineral
density at the femoral neck. The tool is
available free online from http://www.
shef.ac.uk/FRAX/. It provides a 10-year
probability of hip fracture and the 10year probability of a major osteoporotic
fracture (at the spine, forearm, hip
or shoulder fracture). Currently, the
database available includes the various
major races in Singapore and as such,
it is a useful tool for management of
osteoporosis in patients.
Strategies for screening
osteoporosis in women
Singapore Clinical Practice
Guidelines 2009
In the previous Singapore Clinical
Guidelines on Osteoporosis in 2009, it
was recommended that a case-based
strategy to screen women with high
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risk of fracture be used. Osteoporosis
Self-Assessment Tool for Asians (OSTA)
is recommended for use to select
patients with high risk of fracture
for BMD measurement. Those where
age minus weight is more than 20 is
recommended for BMD measurement
while those between 0 to 20 and with
risk factors stated in Table 2 should
also have a BMD measurement.
Population-based screening
In USA, all women above the age
of 65 years are recommended to
have BMD measured. Several Asian
countries have since adopted this
population-based screening strategy
for women 65 years and above.
High-risk population screening
For women 65 years and below,
screening in the high-risk population
has been advocated. This can either be
done by using the OSTA, a simple tool
developed by Koh et al. Where age
minus weight is more than 20, one
should measure the BMD.
FRAX® can be used for high-risk
population screening. While the
threshold has not been determined
for the Singapore population, the
threshold recommended by the
US Preventive Services Task Force
(USPSTF) can be adopted for use in
the meantime. In the recommendation
by USPSTF, BMD should be measured
when the 10-year fracture risk is
≥9.3% on FRAX® (i.e. same fracture
risk as a Caucasian woman at 65
years old).
Medical Update
Repeating BMD
In a prospective study of women with
mean age of 72±4 years, repeating
the BMD measurement eight years
later did not add value to the initial
BMD measurement for the predicting
of fractures. A more recent study
involving women 67 years or older
followed longitudinally for 15 years,
repeat measurement of BMD for
women with initial T-score of > -1.5
can be delayed for up to 15 years.
For women with T-score between
-1.50 to -1.99, reassessment at five
years would be beneficial. For women
with T-score between -2.00 to -2.49,
screening one year later may detect a
significant number with progression
to osteoporosis.
Proposed model of screening
With the availability of FRAX®, a
population-based screening strategy
combining high-risk population
screening using OSTA and FRAX® can
be adopted. See Figure 1.
Risk Factors for Osteoporosis and Fractures
Non-Modifiable
• Personal history of previous fragility fracture as an adult
• Height loss of more than 2 cm over 3 years
• History of fracture in a first degree relative (especially maternal)
• Low body weight (High risk on OSTA)
• Elderly age group (High risk on OSTA)
• Poor health or frailty
Potentially Modifiable
• Current cigarette smoking
• Alcohol abuse
• Low calcium intake (<500mg/day among Asians)
• Lack of regular physical activity
• Prolonged immobilisation
Secondary Osteoporosis
• Drugs e.g. corticosteroids (equivalent to prednisolone >7.5mg/day for more
than 6 months), excessive thyroxine, anticonvulsant
• Ongoing disease e.g. hypogonadism, hyperthyroidism, hyperparathyroidism,
Cushing’s syndrome, chronic obstructive airways disease, liver disease,
malabsorption, chronic renal failure, rheumatoid arthritis, organ
transplantation and anorexia nervosa
• Early natural or surgical menopause before age 45 years, or prolonged
premenopausal amenorrhea lasting > 1 year
Table 2 Adapted from MOH CPG on osteoporosis 2009
Strategies for Osteoporosis Screening
All postmenopausal women
Women<65 yrs old
Conclusion
Like hypertension, hyperlipidaemia
and diabetes mellitus, osteoporosis
is a chronic disease that can be
managed if detected early before
the complication sets in.
No risk
factors
Clinical
risk factors
FRAX without BMD
Fracture risk ≥9.3%*
History of fragility fracture
OSTA
High risk
Measure BMD (T-score)
>-1
The suggested algorithms
shown in Figure 1 will provide
a simple and systematic way
for physicians, physician
assistants, nurses or allied
health professionals to
advise patients on the need
for a bone mineral density
measurement.
Women≥65 yrs old
<-1 and >-2.5
≤-2.5
Assess 10-year fracture risk (FRAX)
<20% Major or
<3% Hip
≥20% Major or
≥3% Hip
• Diet and lifestyle advice
• Encourage adequate calcium and vitamin D
intake, weight-bearing and balance exercises
Consider repeating BMD
at 65 years old or when
clinical risk factors develop
Start appropriate medical treatment and
ensure adequate calcium and vitamin D
after excluding secondary causes
Repeat BMD in 2-5 years'
time or when clinical risk
factors develop
Figure 1
GP CONTACT
GPs can call for appointments through the Specialist Outpatient Clinic Appointment Centre at 6294 4050.
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Medical Update
Focus:
Women’s
health
Appointments: 6294 4050
Email: [email protected]
AprJUn 2013
First Trimester Screening &
Chromosomal Disorders
Prof Tan Kok Hian, Senior Consultant, Antenatal Diagnostic Clinic, Department of Maternal Fetal
Medicine; Head, Perinatal Audit & Epidemiology Unit; Chairman, Division of Obstetrics & Gynaecology,
KK Women's and Children's Hospital
Pregnant patients above 35 are at higher risk of chromosomal disorders
like Down syndrome (Trisomy 21), Patau syndrome (Trisomy 13) and
Edward syndrome (Trisomy 18). In the past, age alone was used as a
screening tool for prenatal diagnostic procedures like amniocentesis.
The cut-off age then for indication for prenatal diagnostic procedures
was previously 40 years of age and this gradually dropped to 38, 37 and
then 35 over the years. However, using age alone as the sole cut-off for
prenatal diagnostic testing is suboptimal as the detection rate is much
lower for a given testing rate.
Now with First Trimester Screening
- FTS (includes age, ultrasound
measurements and serum tests) as a
standard for the last decade, age is no
longer the only factor in the calculation
of the risk for the decision for the need
for prenatal diagnostic procedures. This
combination of screening has improved
the accuracy of detection to around 95%
compared to only 30% using age solely
as a criterion, for a diagnostic testing rate
of 2.5% to 5% for the population.
Incidence of fetuses affected with
chromosomal disorders in Singapore
In a study of all Singapore births, (Tan KH
et al. Singapore Med J 2005; 46(10): 545552), the incidence of fetuses affected
with chromosomal disorders was 4.35 per
thousand births of which Down syndrome
was 1.88 per thousand births. In terms of
risks of chromosomal disorders, the 45-49
years age group (38.0/1,000 live births)
showed a much higher (18.3-fold) risk
than the 25-29 years age group (2.1/1,000
live births). Education of the population is
necessary to ensure that mothers and the
community are aware of the optimal age
of motherhood in terms of such risks.
Nuchal Translucency (NT) of the fetus
One of the most important measurements
is that of Nuchal Translucency (NT) of
the Fetus. There is a normogram that
has been created by the Fetal Medicine
Foundation, UK which computes the
risk of chromosomal disorders according
to the measurement of NT in mm. In
general, the thicker the measurement,
the higher the risk of chromosomal
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disorders. A thickened NT also sheds light
on the possibility of an increased risk for
fetal death, perinatal loss, chromosome
disorders like Turner syndrome and
genetic diseases, including some cases
of alpha thalassaemia. An increased NT
is also associated with many structural
malformations such as cardiac defects in
the fetus.
Medical Update
Patient Profile
Mdm A, a 35-year-old lady had two previous first trimester miscarriages. She has no
surgical or family history of note and was a non-smoker. She was booked at six weeks
amenorrhea. She had ultrasound dating at 6.6 weeks and gestation corresponded to
dates. She was offered first trimester screening for Down syndrome and she was keen.
Results
FTS was performed at 12 weeks gestation:
Crown-Rump Length CRL = 52 mm (equals to 11 weeks plus gestation)
Fetal heart activity present. Nuchal translucency = 4.1 mm (high)
Background risk of Down syndrome (Trisomy 21) for maternal age of 35 years = 1: 210
Adjusted risk of Down syndrome (Trisomy 21) for this patient = 1: 5
Background risk of Trisomy 13 + 18 for maternal age of 35 years = 1: 362
Adjusted risk of Trisomy 13 + 18 for this patient = 1: 9
of pregnancy (MTPT) at 18 weeks
gestation.
Referral for FTS
It is important for GPs to refer
pregnant patients early for FTS as it
can only be effectively performed from
11 weeks gestation to 13 weeks + 6
days (corresponding to Crown-Rump
Length or CRL of 45 mm to 84 mm).
It is thus essential for the pregnant
patient to seek care earlier and for
women to come early to see the doctor
if they suspect they are pregnant.
This would ensure that their gestation
can be accurately dated and properly
counselled for FTS to be performed
from 11 weeks to 13 weeks + 6 days.
Conclusion
FTS improves the accuracy of screening
for Down syndrome and other
chromosomal disorders. It is important
that doctors refer patients early for
the screening test and patients avail
themselves early in pregnancy.
Counselling
Mdm A was counselled regarding the
high risk of chromosomal abnormalities
(1:5 for Down syndrome). With increased
NT, there was also increased risk of
structural abnormalities and increased risk
of genetic syndromes.
The patient was offered fetal karyotyping
namely, chorionic villus sampling
(CVS) or amniocentesis. She was keen
for amniocentesis and she underwent
amniocentesis at 16 weeks gestation. The
scan just before amniocentesis showed
Cervical Skin 5.3 mm & Femur Length
16.6 mm both sides (3rd centile). The
result of karyotyping revealed 47, XX,
+21 (Down syndrome).
An example of NT measurement - 2.3 mm
Mdm A was counselled on the results
of Down syndrome and the options
(continuation or termination). She
opted for mid-trimester termination
GP CONTACT
GPs can call for appointments through the Specialist Outpatient Clinic Appointment Centre at 6294 4050.
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Medical Update
Focus:
Women’s
health
Appointments: 6294 4050
Email: [email protected]
AprJUn 2013
Maternal Mental Illness and its Impact on
Children and the Family
Dr Helen Chen, Head and Senior Consultant, Mental Wellness Service,
KK Women's and Children's Hospital
Case study
Mrs Lim’s seven-year-old daughter is eating her breakfast slowly, more focused on
reading her favourite storybook. Her four-year-old son is throwing a temper tantrum
because he wants potato chips for breakfast instead of the sandwich on his plate. The
domestic helper tells her that the washing machine is leaking, while Mrs Lim tries to
pacify her wailing infant who is teething. To add to it all, she has not slept much, and
is feeling lousy. If it was just one of those days, she would surely have gotten through
the day, perhaps with a little firm handling of her two older kids, some help from the
washing machine repair man and maybe a good scream into the mirror.
But because she has been feeling dispirited and poor in mood for some time, all that
was happening made her feel overwhelmed and disheartened. She started to think
that her life was a dread – going round in circles with problems, and being stuck
in the doldrums. And then when her children would not follow her instructions, it
was only so easy for her to lose control, to whack her son hard, and scream at her
daughter. She also put her wailing baby in the playpen and did not want to bother
about anything much.
When her husband came home and said he was too tired to play with the kids, yet
later wanted intimacy, Mrs Lim lashed out at him for being an unsupportive and
uncaring husband, and that started off another tiff for yet another night.
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The scenario is not an uncommon one
indeed. Whilst there are no available
statistics on the prevalence of depression
in mothers, we know from the recent
landmark Singapore Mental Health
Study (published in Annals Academy
of Medicine 2012, by Prof Chong SA
and his colleagues) that women have
higher odds than men for having lifetime
mood disorders (prevalence of major
depression was 7.2% in women versus
4.3% in men, P <0.0003). Whilst the
sample was not studied in terms of
who was a mother, 63% were in the
childbearing age 18-49 years, and 65%
were currently married.
Experts have long recognised that a
woman’s emotional well-being can
greatly influence how she relates to her
children, and her spouse, and those
Medical Update
around her. Women who are under stress,
or suffering from depression can be easily
irritable, short-fused, and overly sensitive
to comments, in situations that they
would otherwise not react emotionally to
in normal times. The emotional outburst
itself brings on a vicious cycle, as there
tends to be an accentuation of conflict
when negative emotions are expressed,
and this makes everyone feel worse, thus
escalating the conflict and so on.
Adding to this, the whole experience
tends to undermine the woman’s sense
of self-confidence, making her feel
incapable of getting out of the situation,
and perhaps over time wearing her
down, and eventually leading to a sense
of hopelessness. This is exactly what we
typically observe in mothers who suffer
from depression.
Symptoms of depression
Depression is a clinical syndrome
characterised by the presence of either
one or both of two cardinal symptoms of:
1) low mood
2) and loss of interest (otherwise
termed anhedonia) for a duration
of at least two weeks,
together with other accompanying
symptoms, which include:
3) poor sleep (classically early morning
awakening)
4) poor appetite
5) loss of concentration
6) poor energy levels
7) excessive self-blame
8) restlessness or agitation
9) thoughts about dying or suicide
These symptoms can be present in
varying degrees and severity, giving rise
to a spectrum of depressive disorders
ranging from mild to severe, or
categories such as major depression or
minor depression (otherwise known as
depression not-otherwise specified) or
dysthymia (chronic low-grade depression).
Most importantly, other than just
identifying the symptoms of depression,
it is imperative to explore the patient’s
current situation, especially if she is caring
for young children.
Impact of depression in mothers
The effects of maternal depression
can be seen right from the time a
mother carries her little one growing
inside her. Women who are pregnant
and depressed can turn to unhealthy
lifestyle habits to cope, such as
drinking, smoking or taking drugs. All
these have potentially harmful effects
on the growing fetus. Some depressed
women also cannot feel positively
towards the baby inside, and whilst not
conclusively demonstrated by scientists,
there is a suggestion that the fetus
is sensitive to emotional changes in
the mother due to changes in blood
levels of stress hormones. There is
also evidence that antepartum stress,
depression and anxiety can lead to
early labour, and this in turn results in
prematurity with implications on the
outcomes for the baby.
When the baby is born, a depressed
mother will have difficulties bonding with
her baby, as she may be locked into her
Women who are pregnant and depressed
can turn to unhealthy lifestyle habits
to cope, such as drinking, smoking or
taking drugs. All these have potentially
harmful effects on the growing fetus.
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depression, and being withdrawn, she will
not be emotionally attuned to the needs
of her baby. Researchers have found that
there is robust evidence to suggest that
infants of depressed mothers can suffer
from behavioural, attentional, intellectual
and emotional problems over time. Even
when the child grows up, the risks of
depression in adulthood is also increased.
Depression in women also affects
another important aspect: their marital
relationship. Very often, marital
problems are the main reasons why
women develop depression, or remain
depressed if the marital issues persist.
Conversely, just as common is when
depression in a woman leads to, or
exacerbates marital conflicts.
This can happen for a variety of reasons:
1) because she is depressed, she is overly
sensitive and irritable, leading to
frequent quarrels
2) because she is depressed, her interest
in sex or libido is diminished, and this
causes a rift in the marriage
3) perhaps her husband is unable to
understand her depression, and thinks
she is just wallowing in self-pity, and
this distances the couple
Management of depression
in mothers
Whilst all this sounds dismal and
worrying, there is much good news.
Depression and stress are manageable in
a woman’s life, and with help, she can
regain her emotional well-being, and
much of these negative effects on her
children and her family can be averted.
Very often, women and their families
believe that depression arises due to
weakness of character or because one is
“not good enough”. But depression is a
medical condition, often resulting from
a combination of internal and external
stresses impacting on a woman’s mind
and body, leading to changes in bodily
hormones and chemicals. Some of
these include brain neurochemicals (e.g.
serotonin, noradrenaline), and it is the
changes in these levels that lead to the
symptoms that women experience when
depressed, anxious or stressed.
Medical Update
The mainstay of management is
psychological support and therapy,
and depending on the severity of
the depression, medication will be
recommended and chosen with
consideration of the woman’s individual
needs and requirements.
Women often worry about the effects
of antidepressants on their nursing
infants, but we now know that there are
medications that can be compatible with
breastfeeding, so mothers can continue
to breastfeed their babies while they
receive antidepressant medication. There
are also safer options of antidepressants
that can be considered during pregnancy,
although it remains preferable that no
medications are used during the first
trimester as organogenesis takes place.
If left untreated, depression will have
adverse effects not only on the woman’s
well-being, her marriage, family life
and career, but also on the child. It has
been shown that infants of depressed
mothers show impaired emotional and
cognitive development.
In mothers who are not pregnant or
lactating, the choice of antidepressants will
not have to be so carefully scrutinised, and
treatment principles would apply as for
that of depression at any other time.
Alternative management of
maternal depression
There are also many alternative methods
and tips recommended to women which
can be beneficial. Talking and expressing
their feelings and worries also can be
very therapeutic – be it to a friend, their
spouse, family, or a professional.
At KK Women's and Children's Hospital
(KKH), regular support groups for women
who suffer from perinatal depression
and anxiety have been very beneficial in
providing an avenue for women to draw
support from each other, as the shared
experience, mutual care and affirmation
can be very powerful in moving the women
towards recovery. Time out is also very
important – because until a mother takes
care of herself well, she can’t take care
of her baby. This is where husbands and
families can come in to provide support too.
Other interventions that address the
disrupted mother-infant bond, or
mother-child relationship, often seen in
association with maternal depression
or anxiety, include baby massage and
Watch Wait and Wonder, an infant-led
psychotherapy based on attachment
theory. This latter technique is especially
helpful in providing a safe space for
mother to explore her feelings in relation
to her infant, as she is guided to allow
her infant to direct play, and learns to be
attuned to the infant’s needs.
Role of General Practitioners in maternal depression
GPs who have received training in managing depression will be able
to provide good care to these patients, especially since the rapport
would be well-established in the community. However, there
are sometimes concerns that warrant referral to a specialist with
expertise in women's health and perinatal psychiatry, such as:
- when the mother's depression is affecting her capacity to tend to
the needs of her children (e.g. when she reports feeling irritable,
losing her temper, or is not bonding well with her children)
- when the patient is pregnant or nursing, as treatment options
need to consider safety issues for the fetus or nursing infant,
balanced against the ill effects of untreated depression on fetal/
neonatal outcomes
The goal of interventions remain centred on returning mothers
to optimum functioning in their roles to nurture their children, as
treatments just targeting symptom resolution alone are inadequate.
To this end, the role of the GP is crucial in the early identification
of mothers who are depressed, counselling them on the benefits
of receiving attention, primary care management of uncomplicated
cases, and facilitating referral for specialised attention for those
with special needs (if pregnant, nursing or with issues related to
caring for their children).
GP CONTACT
GPs can call for appointments through the Specialist Outpatient Clinic Appointment Centre at 6294 4050.
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Medical Update
Appointments: 6321 4402
Email: [email protected]
Saving Limbs, Preserving Lives: Recent Advances
in Endovascular Surgery for Diabetic Patients
Dr Benjamin Chua Soo Yeng, Head and Consultant, Department of Vascular Surgery,
Singapore General Hospital
Patients with diabetes mellitus are at an
increased risk of developing significant
narrowing or stenosis of their leg
arteries, otherwise known as peripheral
vascular disease (PVD). The patients
present with a spectrum of symptoms
ranging from severe leg pains or cramps
on walking to pain at rest and in very
severe cases, the development of nonhealing foot ulcers and gangrene of the
toes. If not well-managed, patients risk
undergoing a major amputation and
limb loss.
In Singapore, an estimated two major
amputations are carried out daily for
diabetes. After a major amputation,
a patient’s quality of life decreases
significantly and many patients become
dependent on a caregiver. Therefore,
limb preservation is a key goal in our
management of these patients for we
strongly believe that mobility is life.
Successful management of patients
with PVD revolves around two key
principles: successful restoration
of adequate blood flow through
narrowed limb arteries and removal
of infected/gangrenous tissue and
adequate wound care.
In the past, open surgical bypass was
the standard of care. However, bypass
surgery required general anaesthesia
and many incisions at the surgical
site. Moreover, bypass surgery usually
treated only a single narrowed or
blocked artery segment. Post-surgery,
many patients require in-hospital care
for up to two weeks.
With the advent of endovascular
surgery, patients can now be treated
under local anaesthesia through a very
small wound. Moreover, we can also
treat multiple diseased segments of the
artery. Patients also recover much faster
and can be discharged a few days after
the procedures. Recent advances in
endovascular technology and techniques
for restoration of blood flow have
helped in achieving better results in limb
salvage for diabetic patients.
Advances in techniques:
Angioplasty
One of the major advances in limb
salvage is the use of balloon angioplasty
for treatment. In this procedure, a
small needle puncture is made in an
artery that leads to the diseased or
affected segment. A small tube or
access sheath is then inserted at the
puncture site. Through the sheath,
wires are manipulated past the diseased
artery segment followed by angioplasty
balloons. The balloons are then inflated
at the narrowed disease site, thus
widening the artery segment.
This procedure does not require
general anaesthesia or big incisions.
Patients also recover faster and
do not have to stay in hospital for
prolonged periods. At the Singapore
General Hospital (SGH), we have
adopted an angioplasty-first
approach as first-line treatment to
manage patients with diabetic PVD
with good outcomes.
Crossing long-segment artery blockage
Long-segment arterial blockage or CTOs
(Chronic Total Occlusion) presents a
difficult challenge during angioplasty.
The use of special angioplasty wires and
catheters and improved techniques have
now made it easier to cross these CTOs
to allow angioplasty and stenting.
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Below-knee and foot vessel angioplasty
In the past, angioplasty was limited to
the bigger arteries on the thigh and calf
and was confined largely to vessels at
the level of the ankle and above. With
the development of smaller caliber wires
and balloons with smaller diameters,
we can now re-open narrowed arteries
up to the level of the toes. This has
helped many patients heal better as
many diabetic patients have arterial
narrowing that affect the smaller vessels
in the foot and toes. We have also used
new puncture techniques to help get
access to small vessels in the foot so
that we can pass wires and balloons
across blocked arteries. Some of these
new techniques include puncturing the
foot arteries (dorsalis pedis and posterior
tibial) and passing wires upwards from
the foot. These techniques require skilled
operators for success.
Advances in technology:
Newer, better stents
Stents are metallic struts that are used to
keep arteries open following successful
angioplasty. They work by exerting an
outward force against the inside of
arteries. Stents are recommended for use
especially after crossing long-segment
occlusions of arteries. Older generation
stents have very strong outward forces and
therefore induce a reactive re-narrowing
of the arteries after the stents have been
deployed. This process, in-stent stenosis,
can take place months after the stent has
been implanted. If left undetected and
untreated, it can lead to narrowing and
blockage of the stents.
We now use newer stents that are
“softer” and exert less outward force
so that they incite much less reactive
narrowing. These newer stents are also
Medical Update
Figure 1 Bare metal stents
made much smaller in diameter and can
be used in the small arteries below the
knee – something that was previously not
possible. The use of stents has helped
keep arteries open for longer periods of
time, thus allowing for wound healing.
See Figure 1.
Drug-eluting balloons
These are angioplasty balloons that
are coated with a drug (paclitaxel) that
help slow down the process of artery
re-narrowing. The drug is delivered to
the artery wall during angioplasty when
the balloon is inflated and in contact
with the wall. Studies have shown these
balloons help in keeping arteries open
for longer periods of time compared to
plain balloon angioplasty.
Drug-eluting stents
These stents extend the concept of drugeluting balloons by having a similar drug
coating layer as the balloons. Therefore,
the drugs are delivered over a longer
period of time as opposed to drugeluting balloons alone since the stent is
in place permanently. The drugs have
been shown to be delivered (eluted)
over up to a 1-year period. Studies
have shown that drug-eluting stents
keep arteries open for longer periods
compared to plain, uncoated stents. See
Figure 2.
as well as stent breakdown after one
year. Because the stent bio-degrades after
one year, there is no permanent stent
footprint left in the artery. Therefore, the
problems associated with long-term stent
implantation are negated. See Figure 3.
Figure 2 Drug-eluting stent
Bioresorbable drug-eluting stents
These stents seek to address the problem
of post-stenting arterial re-narrowing by
having the dual properties of drug-elution
The team in the Department of Vascular
Surgery has used these new advanced
techniques and technologies to help
in the management of patients with
diabetes and peripheral vascular
disease for the last five years. We have
managed to achieve better results for
patients. Our main aim is to prevent
major amputations and improve the
quality of life for our patients.
Figure 3 Bioresorbable drug-eluting stent
GP CONTACT
GPs can call for appointments through the GP Appointment Hotline at 6321 4402.
- 10 -
Services at SingHealth
Appointments: 6321 4402
Email: [email protected]
The Department of Vascular Surgery:
A Step in the Right Direction
iv.Regional fellowship programme for physicians in
Endovascular Aneurysm Repair (EVAR)
The newly-formed Department of Vascular Surgery (DVS)
at the Singapore General Hospital (SGH) commenced its
operations on 1 April 2013. It is the first independent
department dedicated to the care of patients with vascular
diseases in Singapore and the region. Previously, vascular
surgery units have always been a service or division housed
under a larger Department of General Surgery.
• Renal dialysis vascular access creation and
maintenance:
i. Clinics for vascular access creation, and maintenance
ii. Increasing pre-emptive fistula/TK catheter creation and
reduction of perm catheter insertion rates
iii.Educational programmes for care of vascular access
The formation of a Department dedicated to the care of
vascular problems underscores the increasing importance
and severity of vascular diseases in our population. It is
widely recognised that patients with vascular conditions
need holistic and comprehensive care to achieve better
clinical outcomes. Under the DVS, patients will receive the
required dedicated and comprehensive specialist care for
their vascular conditions.
Some of the key cornerstone programmes under the DVS
include the following:
• Diabetic limb salvage and peripheral vascular disease:
i. Formation of multidisciplinary specialty clinics with
endocrinologists, wound care nurses and podiatrists
ii. Provision of one-stop service and care for limb salvage,
including clinical consult (diagnosis and risk factor
management), diagnostic imaging (ultrasound), surgery
planning, wound care, podiatry and rehabilitation
iii.Collaborations with regional academic medical centres
to develop research and interventional programmes for
Asian patient-based diabetic limb salvage
iv.Regional fellowship programme for physicians in limb
salvage surgery
• Venous diseases including deep venous and
arteriovenous malformations:
i. One-stop ambulatory clinic for diagnosis and surgical
management of varicose veins (same-day on-site
surgery)
ii. Multidisciplinary clinic for arteriovenous
malformations, adult/congenital – diagnostic imaging,
endovascular and surgical therapy
iii.Clinic for management of complex deep venous
disease and lymphedema – advanced diagnostic
ultrasounds, endovenous and surgical reconstruction,
symptom management and education
iv.Regional fellowship programmes in ambulatory
varicose vein surgery and deep venous reconstruction
The new Department has five consultant surgeons
trained in all aspects of Vascular and Endovascular
Surgery. It also works closely with a specialist wound
care team comprising advanced practice nurses and
expert podiatrists. The DVS provides acute and nonemergency care for all patients with vascular disease
and its specialist are on-call 24 hours daily.
• Aortic aneurysm detection and treatment:
i. Development of screening programmes for aortic
aneurysms
ii. Specialist clinics for diagnosis and treatment for aortic
aneurysms
iii.Programme for surgical treatment for complex aortic
aneurysms
GPs can call for appointments through the
GP Appointment Hotline at 6321 4402.
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Services at SingHealth
GP Hotline: 6321 4402
Email: [email protected]
New Minimally Invasive and Robotic Section at
the Department of Obstetrics & Gynaecology,
Singapore General Hospital
Robotic surgery now available for a wide range of gynaecological conditions
Since the first laparoscopic hysterectomy
was performed by Harry Reich in the
USA in 1988, we have learned that
minimally invasive surgery has considerable
benefits for the patient compared with
open surgery. These are mainly less postoperative pain, shorter hospital stay and a
faster return to normal activities as well as
improved cosmesis.
Robotic surgery is a recent technological
advance that potentially improves
outcomes in more complex cases
and allows more gynaecologists the
opportunity to offer minimally invasive
surgery to their patients so that they can
benefit from the above advantages.
Robotics
Robotic surgery was first introduced for
gynaecology in 2005 and now offers an
alternative minimally invasive approach
for benign and oncological procedures
including simple and radical hysterectomy,
myomectomy, complex endometriosis,
sacrocolpopexy and lymph node dissections.
Robotic surgery has three main advantages
over conventional laparoscopy: an
enhanced 3D HD view, more precise
instrumentation with much greater ranges
of movement and superior ergonomics for
the surgeon. Consequently, the benefits
for the doctor are clear; surgeons have
found that the technology allows them
to acquire minimally invasive surgical skills
more easily. Adding 3D alone improves
even an expert conventional laparoscopic
surgeon’s ability by reducing errors and
improving the speed taken to complete
tasks (Figures 1 & 2). More precise
instrumentation and less physical stress
on the surgeon can only enhance these
benefits further.
Therefore, in the USA, more gynaecologists
are now able to offer a minimally invasive
approach. Up to 25% of all hysterectomies
Figure 1
Figure 2
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in the USA are now done robotically and
robotics has already overtaken conventional
laparoscopy despite being available for
less than a quarter of the time since its
introduction (Figure 3).
Up until now the benefits for the
patient have been less well established.
However, in the last two years, Canadian
and Irish National Health Technology
Assessment meta-analyses that analysed
the current published studies of robotics
in gynaecology have suggested that
robotics is not only superior to open
surgery as one would expect for a
minimally invasive approach, but is also
superior to conventional laparoscopy for
length of hospital stay and post-operative
complications with a tendency towards it
being better for blood loss and the need
for blood transfusion too. Additionally,
compared with conventional laparoscopy,
there is a reduced chance of having to
convert to open surgery.
Services at SingHealth
Figure 3
Conditions we treat
The new Minimally Invasive and Robotic
Surgery Section at the Department of
Obstetrics & Gynaecology (O&G) at the
Singapore General Hospital (SGH) brings
international expertise and technologies
to provide a service in which more
women can benefit from the advantages
of minimally invasive surgery. The main
conditions dealt with are:
1. Heavy menses and abnormal bleeding
Abnormal bleeding affects women
of many ages from hormonally
imbalanced cycles at either end of the
age range through to problems caused
by endometrial abnormalities, uterine
fibroids and ovarian cysts.
We aim to offer women a wide
range of options including:
• Antifibrinolytics
• Hormonal manipulation including
Mirena IUDs
• Trans Cervical Resection of polyps,
fibroids and thickened endometrium
• Minimally invasive and robotic
hysterectomy
2. Pelvic pain
Pelvic pain affects many women for
many reasons and causes significant
morbidity, particularly at a psychosocial level, in terms of career, social life
and relationships. Its management is a
multidisciplinary problem requiring input
from specialties such as gynaecology,
urology,
gastroenterology,
psychology and
pain clinics due
to the wide range
of potential
underlying
problems.
These include
endometriosis,
irritable bowel
syndrome, interstitial cystitis, neuropathic
pain and psycho-sexual issues.
The clinic establishes links across these
disciplines to ensure that the patient
has a truly holistic approach to their
problem to help them to take control
and get their lives back on track.
3. Endometriosis
Endometriosis is more common in
Asian women affecting at least 8%
of the population and results in
problems of pain or subfertility. We
offer a comprehensive range of medical
and surgical treatments on a tailored
individual case-by-case basis.
This is crucial for the management of
endometriosis as age, symptoms and
desire for fertility all have to be taken
into account when deciding upon the
best approach and to avoid unnecessary
surgery that may compromise fertility.
As endometriosis is often a recurring
problem during the fertile period of
a woman’s life, we aim to establish a
relationship of trust and a consistency
of care to help them through this whole
period of their lives.
We assess and diagnose patients using
state-of-the-art ultrasound techniques
or 'see and treat' laparoscopy using
excisional techniques that are the most
effective method in pain reduction or
fertility optimisation. A full range of
primary or adjuvant or medical therapies
are considered, as is referral for assisted
conception techniques as required.
For endometriosis surgery, robotics offers
us the ability to achieve greater accuracy
in disease clearance and reduce the high
risks of morbidity associated with surgery
for complex endometriosis cases and
colorectal surgery support is available
when required.
4. Uterine fibroids
Fibroids are a common cause of multiple
symptoms including menorrhagia,
pain, bloating sensation, back pain,
constipation and urinary frequency. Often
no treatment is needed. For those that do
have significant symptoms, if caught early
enough they can be managed without
the need for major open surgery using
a minimally invasive approach or uterine
artery embolisation.
Women are assessed using imaging
techniques and, taking into
consideration their requirements for
fertility and cultural beliefs, are offered
the most appropriate treatments that
reduce the risks to them whilst still
achieving the aim of symptom relief.
Robotic surgery makes the technical
aspects of minimally invasive
myomectomy surgery easier mainly
due to the wristed instrumentation
that allows easier dissection and
suturing. Therefore more complex
cases can safely be performed
minimally invasively.
Conclusion
Robotics now offers the surgeon
substantial advantages over conventional
approaches that can be translated into
benefits for patients and who would
not want their surgeon to have the best
view, most precise instruments and most
optimal ergonomics!
GP CONTACT
GPs can call for appointments through the GP Appointment Hotline at 6321 4402.
For referrals, a friendly chat or discussion, our GP partners can call the Department of O&G at 6321 4673
and ask for the Minimally Invasive and Robotic Surgery section.
- 13 -
News at SingHealth
New Initiatives to Improve Patient Care at the
National Heart Centre Singapore New Building
artery bypass graft and heart valve surgery can now have their
blood test and pre-operation orientation done during the preadmission testing a week before the surgery, rather than the
day before. Patients save a day of ward charges and are able
to rest comfortably at home the day before surgery.
The National Heart Centre Singapore (NHCS) unveiled a
series of initiatives designed to deliver better patient care
at the topping out ceremony of its new 12-storey building
in March 2013. The initiatives will allow a more seamless
delivery of care leading to cost savings, reduced waiting
time and better experience of care for patients.
A Simpler, Faster Queue and Payment System
Patients only need to register once, upon arrival at the clinic, for
the medical services that they will need for the day. With the
new 1Queue1Bill system, the queue number given is transferred
across all locations during their visit, saving the need to queue
at multiple stations. A single payment point that combines clinic
consultation, cardiac investigations and medication charges
for the day into a single bill also helps to make it a faster and
simpler experience. This improvement compares to the previous
4 queues and 3 bills that patients had to deal with.
The project was successfully piloted at the current NHCS
building and will be rolled out at the NHCS new building with
enhancements such as a smart journey planning system that will
minimise patient waiting time by sequencing their appointments
according to the service stations with the shortest waiting times.
An electronic charge form with the consolidated charges for the
day will also add to patients’ convenience.
Same Day Admissions Helps Save Time and Cost
NHCS has introduced a redesigned Same Day Admissions
(SDA) process that has increased the number of SDA patients
by almost four times from an average of 10 to 37 cases a year.
Patients requiring simple cardiac surgery such as coronary
At the NHCS new building, the SDA process will be further
enhanced as patients will only need to go to one location for a
range of services like clinic consultation, pre-admission testing
and surgery. This compares to the current three separate
locations to have the services done.
New and Expanded Facilities
The NHCS new building will double its current facilities. It
will house 38 specialist outpatient clinic rooms, six cardiac
catheterisation labs and three major operating theatres. A new
short-stay unit for day procedures or surgeries will also free
up more beds for patients with more severe heart conditions.
One and a half floors will be dedicated to research facilities for
cardiovascular research. The new building will also be linked
to the Singapore General Hospital via a pedestrian underpass
providing convenience and ease of access for patients.
The NHCS new building is expected to be ready by March 2014.
CONTACT NHCS
GP Appointment Hotline
Tel: 6436 7848
General Enquiries
Tel: 6436 7800
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Research at SingHealth
Calcium Vital
During Pregnancy
More to this mineral than
just bone strength
Pre-eclampsia is a leading cause of maternal and fetal morbidity
and mortality, and is also one of the major reasons for
premature delivery in Singapore. Potential complications include
eclampsia, a severe form of pre-eclampsia where the patients
suffer from seizures, fetal growth restriction and stillbirth.
A meta-analysis by a team of doctors from Singapore General
Hospital’s (SGH) Department of Obstetrics and Gynaecology
(O&G) has found that antenatal calcium supplementation in
women with low calcium intake is associated with a reduced
risk of developing pre-eclampsia. The team was led by head
of department Associate Professor Tan Hak Koon and their
findings were presented at the SingHealth Duke-NUS Scientific
Congress 2012, where they won the Best Oral Presentation in
the Evidence-Based Medicine (Clinical) category.
“As the only known ‘cure’ for pre-eclampsia is delivery of the
fetus, there has been great interest in methods for preventing
its development. Calcium supplementation appears to be one
practical and effective way of doing this,” said Assoc Prof Tan.
Dr Yang Liying, a Medical Officer at SGH’s Department of
O&G who presented the study said, “Based on our analysis,
we would recommend 1g of calcium supplementation
daily for women whose baseline calcium intake falls below
the recommended dietary allowance of 1g per day. This is
particularly so for women who have additional risk factors for
developing the condition.”
Risk factors for developing pre-eclampsia include nulliparity,
new paternity, long birth interval, age (teenagers and women
over 40 are at greater risk), obesity, past or family history of
pre-eclampsia, gestational diabetes and multiple pregnancies.
Women with pre-existing conditions such as hypertension,
diabetes, renal disease and connective tissue disease are also at
greater risk.
“Primary care health professionals are best placed to identify
these at-risk women. Besides educating them about preeclampsia and encouraging adequate dietary calcium intake
or calcium supplementation, awareness of red flag symptoms
such as headache, visual disturbances, epigastric pain or rapid
development of edema will also enable timely referral to
tertiary care,” said Dr Yang.
CONTACT SGH
GP Appointment Hotline
Tel: 6321 4402
Email: [email protected]
General Enquiries
Tel: 6222 3322
- 15 -
Appointments
Singapore General Hospital
GP Hotline: 6321 4402, Email: [email protected]
Appointments
Dr Wong Gee
Chuan
Senior Consultant
Dr Peter Charles
Barton-Smith
Senior Consultant
Dept
Dept
Haematology
Dr Yeo Siaw Ing
Consultant
Dept
Rheumatology &
Immunology
Obstetrics &
Gynaecology
Sub-specialty
Acute Leukemia
Sub-specialty
Rheumatoid Arthritis
Sub-specialty
Minimal Access and
Robotic Surgery
Dr Khor Jen Lock Christopher
Senior Consultant
Dept
Gastroenterology & Hepatology
Promotions
Dr Nausheen
Edwin
Consultant
Dr Ng Yung
Chuan Sean
Consultant
Dr Tan Shian Ming
Associate Consultant
Dept
Dept
Psychiatry
Orthopaedic
Surgery
Emergency
Medicine
Dept
Sub-specialty
Foot & Ankle
Surgery
Sub-specialty
Pre-hospital emergency care,
Emergency airway management,
Trauma care
Dr Lim Ciwei Cynthia
Associate Consultant
Dr Sewa Duu Wen
Associate Consultant
Dr Tan Aik Hau
Associate Consultant
Dept
Dept
Dept
Renal Medicine
Respiratory & Critical Care Medicine
Respiratory & Critical Care Medicine
KK Women’s and Children’s Hospital
Appt Hotline: 6294 4050, Email: [email protected]
Appointments
Dr Arni
Prabhakaran
Subash Kumar
Senior Consultant
Dr Mark Koh
Jean Aan
Head and
Consultant
Dept
Dept
Breast Department
Dermatology
Service
- 16 -
Dr Rukshini
Puvanendran
Consultant
Dept
Family Medicine
Service
Appointments
Dr Ayesha
Jabeen Ali
Consultant
Dr Rajat
Bhattacharyya
Consultant
Dept
Dept
Paediatric
Anaesthesia
Paediatric
Subspecialties
(Haematology/
Oncology Service)
Dr Rachana
Neelum
Sukhnandan
Koura
Consultant
Dept
Paediatrics (General
Paediatrics &
Adolescent Medicine)
Dr Sita Padmini
Yeleswarapu
Associate Consultant
Dr Jean Jasmin
Lee Mi Li
Family Physician
Dept
Dept
Obstetrics &
Gynaecology
Dr Chin Hsuan
Associate Consultant
Dr Wee Wei-Wei
Associate Consultant
Dept
Dept
Dr Jeyanthi
Carolin Joseph
Associate Consultant
Child Development
Family Medicine
Service
Dr Tan Toh Lick
Associate Consultant
Dept
Promotions
Obstetrics &
Gynaecology
Obstetrics &
Gynaecology
(MIS Unit)
Dept
Dr Loh Wenyin
Associate Consultant
Dr Siew Jia Xuan
Associate Consultant
Dept
Dept
Dr Wong Mun
Yee Sharon
Associate Consultant
Paediatrics
(Allergy Service)
Paediatrics
Paediatrics
Dept
Dr Shephali Tagore
Head, Peripartum Unit;
Consultant
Dr Christina Ong
Head,
Gastroenterology
Service;
Consultant
Paediatrics
New Appointments
Dr Mark Koh
Jean Aan
Head and
Consultant
Dept
Dermatology
Service
Dept
Maternal Fetal
Medicine
Dept
Paediatrics
Dr Ng Yong Hong
Head,
Nephrology Service;
Consultant
Dept
Paediatrics
- 17 -
Courses
19th Asian Congress of
Surgery & 1st SingHealth
Surgical Congress
The 19th Asian Congress of Surgery and 1st SingHealth Surgical Congress is a highly
anticipated event that brings together surgical, medical and healthcare professionals
in quality fellowship and educational activities.
Some of our distinguished speakers include:
Prof Raj Mohan Nambiar
Tan Tock Seng Hospital,
Singapore
GB Ong Lecture
A/Prof Michael Hollands
Westmead Hospital,
Australia
RACS Foundation Lecture
Prof Takeshi Sano
The National Cancer Institute,
Japan
Law-Lui Lecture
Prof Theodore N Pappas
Duke University Medical Centre,
United States
1st SingHealth Surgical Lecture
Prof Stanley Goldberg
University of Minnesota,
United States
Plenary Speaker
Prof Kent Man Chu
The University of Hong Kong,
Hong Kong
Plenary Speaker
The congress will include a series of pre and post congress workshops, including:
• Advanced Transplant Course
• Advanced Trauma Life Support Course
• Definitive Surgical Trauma Care Course
• SGH Colorectal Scientific Week 2013
• ENT Instructional Week 2013
• Fundamentals in Airway and Central Line Inserted
Techniques Workshop
• Operating Theatre Management Course
• Theatre Sterile Supplies Unit Workshop
• SGH Live Course on Endovascular Surgery and Techniques
- 18 -
Date
18 – 23 July 2013 (Thursday
to Tuesday)
Venue
The Academia (open in July)
Singapore General Hospital
CME Points
In application
Contact
Ms Diane Tan
19th ACS & 1st SSC Secretariat
Tel: 6513 7321
Fax: 6659 8946
Email: [email protected]
Registration is required.
For more information, programme
details and registration, log on to
www.acs2013.org.
Courses
7th KKH Annual
Scientific Meeting
Innovating
Healthcare for
Women and Children
The 7th Annual Scientific Meeting at KK Women’s and
Children’s Hospital focuses on 'Innovating Healthcare
for Women and Children', and will encompass a variety
of medical specialties. A panel of experts from KKH and
Duke-NUS will present topics ranging from Obstetrics
& Gynaecology, Women’s Anaesthesia, Reproductive
Medicine, Mental Health, Radiology, Paediatrics,
Neonatology to Medical Education.
Registration is required.
Date
6 – 7 September,
(Friday to Saturday)
To register via email, please email your full name,
organisation name, MCR number, contact number
and postal address to [email protected].
Please also specify if you are a General Practitioner,
Paediatrician, or other type of
Specialist. This forum is for
healthcare professionals
only. You may be required
to produce identification.
Time
8.30 am – 6 pm
Venue
KKH Auditorium (Training
Centre)
Level 1, Women’s Tower
CME Points
Application in process
Fees
Free
Contact
Tel: 6394 8746
Email: [email protected]
For more
information,
please call
6394 8796
(Mon to Fri,
8.30 am –
5.30 pm). Seats
are confirmed on
a first-come-firstserved basis.
Recruitments
Recruitment
SingHealth is the largest not-for-profit public Academic Healthcare Cluster in Singapore. We have two acute hospitals
and five centres of excellence operating 2,500 beds within the group. We also operate primary care and intermediate
care facilities. We offer a comprehensive range of multidisciplinary and integrated healthcare services with 43 specialties
across the group. Our institutions are renowned regionally as referral centres for complex medical cases and provide a
wide spectrum of medical treatment options.
Amongst our expansion plans is a new 1,400-bed acute and intermediate care hospital which will be completed in 2017.
If you are a qualified doctor, a challenging career awaits you at SingHealth. We seek suitably qualified candidates to join us as:
Associate Consultants/Consultants/Senior Consultants
(Anaesthesia, Diagnostic Radiology, Gastroenterology, Geriatric Medicine, Haematology, Infectious Disease, Internal Medicine,
Neurology, Neurosurgery, Pathology, Rehabilitation Medicine, Renal Medicine, Respiratory Medicine, Rheumatology)
Requirements
• Recognised postgraduate Medical Degree such as MRCS,
MRCP, FRCR, FRCA or its equivalent in its relevant discipline*
• Completed specialty training in the relevant specialty in
countries such as UK, USA, Hong Kong, Australia or
New Zealand
• Registered as a specialist and has working experience at
the level of a specialist
• Strong interest and/or credentials in research and/or
education activities will be an advantage
history, present and expected salary, contact number and
e-mail address to:
*Medical schools which are recognised by The Singapore Medical Council (SMC) are
listed in the Schedule of the Medical Registration Act (http://www.smc.gov.sg).
E-mail
[email protected]
The Director, Medical Manpower (MN1210)
Singapore Health Services Pte Ltd
168 Jalan Bukit Merah, Surbana One,
#17-01, Singapore 150168
Fax
+65 6377 4208
Please send in your resume stating the reference number,
your full personal particulars, educational qualifications, career
- 19 -
(Only shortlisted candidates will be notified.)
Courses
Public Forum
Ovarian
Cancer –
Can It Be
Prevented?
GPEP HOTLINE
6377 8550
[email protected]
Ovarian cancer is the fifth most common cancer affecting women in Singapore,
with one in 88 women likely to be diagnosed with ovarian cancer during their
lifetime. However, ovarian cancer has a good chance of cure with early detection and
treatment. Conducted by medical experts from KK Women’s and Children’s Hospital,
this forum will provide an overview of the symptoms and risk factors for ovarian
cancer, and the role of diet and traditional Chinese medicine in cancer prevention.
Time
10.30 am
Programme
Registration
11.00 am
Welcome address
by A/Prof Yam Kwai Lam Philip,
Head & Senior Consultant
Dept of Gynaecological Oncology, KKH
Video Presentation
Is Ovarian Cancer Preventable?
by Dr Elisa Koh, Associate Consultant
Dept of Gynaecological Oncology, KKH
Role of Traditional Chinese Medicine (TCM) in
Prevention of Cancer
by Ms Huang Fang, Advanced Practice Nurse
Division of Nursing, KKH
Diet for Cancer Prevention
Ms Jeanette Yee, Dietitian
Nutrition and Dietitics Department, KKH
Question & Answers
Lunch
11.10 am
11.15 am
11.35 am
11.55 am
12.15 pm
12.30 pm
When
2 June 2013, Sunday
11 am – 12.30 pm
(Registration starts at 10.30 am)
Where
KKH Auditorium (Training Centre)
Level 1, Women’s Tower
GP FAST TRACK APPOINTMENT HOTLINES
6321 4402
6294 4050
6436 8288
6324 8798
6436 7848
6321 4402/
6357 7095
6322 9399
DIRECT WARD REFERRAL
CONTACT NUMBERS
Fees
$8 (Lunch will be provided)
6321 4822
Registrations by 30 May 2013.
For more details, please call 6394 5038/1026
(Mon to Fri, 8.30 am – 5.30 pm) or log on to
www.kkh.com.sg. Seats are confirmed upon full
payment and on a first-come-first-served basis.
6394 1183
SingHealth Academic Healthcare Cluster
Correction Notice
In the previous JAN-MAR 2013 issue of Medical News, incorrect references were printed on page
7 of the article Practical Management of Atopic Dermatitis in Children by Dr Mark Koh, Head and
Consultant, Dermatology Service, KK Women’s and Children’s Hospital. We apologise for the error
and herewith attach the correct references.
References
1.Tay YK et al. The prevalence and descriptive epidemiology of atopic dermatitis in Singapore school children.
Br J Dermatol 2002;146:101-106
2.O’Regan GM et al. Filaggrin in atopic dermatitis. J Allergy Clin Immunol 2008;122:689-693
3.Bieber T. Atopic dermatitis. N Eng J Med 2008;358:1483-1494
4.Brenninkmeijer EE et al. Diagnostic criteria for atopic dermatitis: a systematic review. Br J Dermatol
2008;158:754-765
5.Illi S et al. The natural course of atopic dermatitis from age 7 years and the association with asthma. J
Allergy Clin Immunol 2004;113:925-931
6.Brenninkmeijer EE et al. The course of life of patients with childhood atopic dermatitis. Pediatr Dermatol
2009;26:14-22
- 20 -
Partner in Academic Medicine