Five years ago, Dinesh Kumar s/o Thangavelu, 36, a civil servant, was diagnosed with acute lymphocytic leukaemia (ALL), a type of cancer of the blood and bone marrow that progresses rapidly. Although more common in children, ALL can also occur in adults, albeit very rarely, so it was a bit of a shock to Mr Kumar to learn that he was suffering from the disease.

On the 20th of February in 2008, Mr Kumar didn’t know that his life would change forever. Upon his wife’s insistence, he went to Tan Tock Seng Hospital (TTSH) for severe headache and blurred vision on his right eye. After doing several eye tests, the doctors found many rock spots on both of his eyes. “After consulting with his two superiors, the doctor informed my wife that I have a long way to go. At that moment, both of us did not understand,” Mr Kumar shared. He was admitted at TTSH, and the next day the doctors broke the news to him by explaining that his red blood counts were very low and his white blood cells were abnormally high. At that moment Mr Kumar blurted out, “Do I have leukaemia?” One of the doctors replied, “Sorry to say, but yes.” In an effort to raise awareness about the disease, Mr Kumar shares his story with Ezyhealth.

Ezyhealth: Please tell us the symptoms you felt before you were diagnosed.

Mr Kumar: The main symptoms I had were severe headache on the back of my head. I would also easily feel tired and breathless. I had a reservist duty at that time and thinking that I lacked exercise, I tried to do a 2.4km practice run for my IPPT. I was only able to run less than 200m and I was very breathless. I also found red spots on my arms whenever I carried my two-year-old daughter. I thought that was some kind of rashes. One day my right eye became blurred; that was when my wife forced me to go to TTSH A&E.

Ezyhealth: What was running through your mind upon learning that you had ALL?

Mr Kumar: The moment the doctor mentioned ‘Sorry to say, but yes you have leukaemia’, I collapsed emotionally. Tears rolled down my eyes uncontrollably. I could only think of my poor wife and my children. How are they going to take my death? Being the sole breadwinner for my family, how is she going to manage them through without me? I had no idea on the treatment process and the survival rate. I only knew a classmate who was diagnosed with leukaemia and within three months he passed away.

Ezyhealth: What was your treatment like?

Mr Kumar: My treatment was under the charge of Dr Koh Liang Piu of National University of Singapore. I was put on a customised chemotherapy. Each cycle is four weeks. I will take in chemo dosage on the first week as in-patient. Into the second week, the blood and platelets counts will drop and immunity will be low. Due to this, I will have fever, diarrhoea, runny nose, cough, ulcers, throat infections, and loss of appetite. The third week will be my recovery week. I will overcome the side effects slowly and will be slightly stable. The fourth week will be my “rest” week where I have to gain strength mentally and nutritiously for the chemo dosage the following week. These four weeks (one cycle) was the worst roller coaster ride in my life. I had to go through six cycles to keep my cancer cells at the minimum until a cord blood transplant was recommended by my doctor. The transplant coordinator worked with the local and international registries and found an unrelated match for me. Procurement of overseas cord blood is expensive and cannot be covered by my Medisave or Healthshield. The Leukemia & Lymphoma Foundation (LLF) came to my rescue by funding an amount of $33,000 to cover the full costs of cord blood procurement and confirmatory tests.

Ezyhealth: What kept you going when you were undergoing treatment?

Mr Kumar: Going through this turmoil, my wife, son and daughter always appear whenever I felt like giving up. The thought of them living without a husband and father strengthen me against cancer. Family members and family friends, hospital staff, Leukemia & Lymphoma Foundation’s encouragements, their visits and jokes created more positive ions in the room and made it more lively. Another important point that kept me going was the reduced financial burden. As my salary was not disrupted, I was able to maintain my family’s daily expenses. Although most of the hospital bills were covered by my health insurance and Medisave, I received additional financial and moral assistance from LLF which helped me further reduce
my burden.

Ezyhealth: You’re in remission now, how did you manage to go back to your old routine?

Mr Kumar: Upon discharge after my transplant, I wanted to resume my job. Using that as my motivation, following strict diet advice and light exercises, like fetching my son from school, I joined office on light duty in February 2009.

Ezyhealth: What have you learned from this whole ordeal?

Mr Kumar: Family support is very important to any patient. This ordeal had definitely proved the strong family and friends I have around me. I also realised the importance of insurance. I strongly believe that when a patient’s and the family’s financial burden is reduced, the recovery will be better and faster. Another lesson learnt was to have a good relationship with your employer. That may be the reason my employer made special arrangements for me to receive 11 months of salary during my stay in the hospital in 2008 so that I could cover my living expenses for my family.

Ezyhealth: What do you do to pay it forward and spread awareness about your condition?

Mr Kumar: I do not want anyone to go through what I went through. Whenever people approach me to know more about my situation and queries, I will try my best to share my experience with them. I had an opportunity when I was approached by NUH to present during the First Stem Cell Transplant Reunion annual event. I had prepared the slides and video, but my story was presented without me as I was infected with shingles. Another opportunity came when LLF invited me to present during a doctor’s talk workshop. Occasionally, my family and I get invites from LLF for “get together” events where I can meet other patients and caregivers.

Ezyhealth: Any word of advice/encouragement to our readers who might be suffering or have family members who are suffering from leukaemia?

Mr Kumar: To the patients who are suffering from leukaemia, always remain strong and positive. Continue loving and appreciating your family/friends. The doctors and nurses are our weapons against cancer. Trust your weapons. Keep your mind occupied with other thoughts. Always remember to laugh with positive energy. To the families/caretakers, your support is very vital to us, patients. Your positive energy towards us will work wonders. You should treat patients as how they were before. Your presence will be a major factor in our recovery. To the employers of patients, you will be bound by company policies, but your assistance to employees-patients will definitely make the journey to recovery easy. Thus, we seek your kindness in handling us.

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The number of cervical cancer cases in Singapore has been declining for the last 10 years. It is now the ninth most common cancer among women, but the number of cases of cervical cancer diagnosed remains high. Around 250 women are diagnosed with cervical cancer every year, and these cases are often picked up at a late stage. Analysis of these cases show that most of these women have either never had a pap smear before, or haven’t had one in the last five years.

The Importance of a Pap Smear

The Pap smear can pick up pre-cancer changes in the cervix many years before cancer actually develops. Only women over the age of 25 and who have been sexually active need to have the Pap smear, as cervical cancer is extremely rare in women under the age of 25 and almost never occurs in women who have not been sexually active. It is rare that a known cause can be identified for most of the cancers that occur in the body. However, cervical cancer is an exception because we know that it is caused by an infection with certain strains of a virus known as Human Papillomavirus (HPV). This is an extremely common virus that is transmitted during sexual intercourse. Infection with HPV usually does not result in any symptoms, so the majority of people with HPV are unaware of it.

Early Vaccination

Vaccination for the most dangerous strains of HPV is now available, and by preventing the infection with these HPV types, it is estimated that there could be up to 70% to 80% reduction in the number of cases of cervical cancer. Two vaccines are licensed for use in Singapore – Cervarix (GSK) and Gardasil (Merck). These are given as injections in the upper arm, and three doses are given over a six-month period. Experts believe that the best results from vaccination are achieved if we vaccinate girls in the adolescent years before the onset of sexual activity. Many countries have started vaccinating girls as part of a national vaccination programme. These include Australia, United Kingdom and Malaysia where girls are being vaccinated in schools around the ages of 11 to 13 years. It is expected that this group of girls will have a much lower risk of developing cervical cancer in the future.

Both the HPV vaccines have been licensed for use in hundreds of countries around the world and have a proven safety record. The most common side effects from the vaccines are temporary soreness, redness and itching at the injection site. Occasionally, generalised reactions like headaches or fever can also occur.

Medisave Payments

In Singapore, females aged 26 and under can use up to $400 from their Medisave accounts to pay for HPV vaccination. Either their own Medisave account or that of their immediate family members can be used. It is important to understand that the HPV vaccines do not protect against all strains of HPV, and that women and girls who have been vaccinated should still have regular screening with Pap smears from the age of 25 if they are, or have been sexually active.

With this ‘twin-approach’ of HPV vaccination and regular screening, we can expect that in generations to come, cervical cancer rates will decline even further. More importantly, women will be assured of the best protection against this preventable, but potentially deadly disease.

Dr Quek Swee Chong is a Clinical Director and Consultant Gynaecologist at Parkway Gynaecology & Screening Centre, Gleneagles Hospital.

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The cervix is that organ connecting the uterus and vagina. When abnormal cells on the cervix grow out of control, cervical cancer develops. Cervical cancer is usually a slow-growing cancer that may not have symptoms but can be detected early with regular Pap tests (also called Pap smear, cervical smear or smear test) – a procedure in which cell samples are scraped from the cervix and checked under the microscope to look for abnormalities and determine pre-cancerous or cancerous processes in the endocervical canal. Sexually active women above age 25 are advised to go for a Pap test regularly. The test can be done every one to three years as advised by your doctor.

The Culprit: HPV

HPVs or human papillomaviruses are a group of more than 150 related viruses, and more than 40 of these viruses can be sexually transmitted. According to the National Cancer Institute, HPV infections are the most common sexually transmitted infections in the United States.

There are two categories of sexually transmitted HPVs, low-risk and high-risk. Low-risk HPVs do not cause cancer, but cause skin warts (condylomata acuminata) on or around the genitals or anus. HPV types 6 and 11 cause 90% of all genital warts. These HPV types can also infect the mouth or throat (i.e. RRP or recurrent respiratory papillomatosis, a rare condition in which warts grow in the throat). High-risk or oncogenic HPVs can cause cancer, and at least a dozen high-risk HPV types have already been identified. HPV types 16 and 18 are responsible for 70% of cervical cancers.

Anyone (male or female) who is sexually active is at risk of HPV infection. HPV is transmitted through genital contact, most often during vaginal, anal and oral sex, and can be passed on between straight and same-sex partners.

Screening HPV Infection

While a regular Pap test can detect cell abnormalities as a precursor to cervical cancer, HPV infections can be detected by testing a sample of cells from the cervix to see if they contain viral DNA or RNA. These HPV DNA and RNA tests are able to detect HPV infections before evidence of cell abnormalities appear. However, these tests are approved for two indications only – for follow-up testing of women with abnormal Pap test results and for cervical cancer screening in combination with a Pap test among women over age 30. Unfortunately, there are no approved tests for the detection of HPV infections in men.

Treatment Options for HPV-infected Individuals

There is no treatment for HPV infection, but genital warts and precancerous lesions resulting from HPV infections can be treated.

Commonly used methods to treat precancerous cervical lesions include cryosurgery (freezing that destroys tissue), LEEP (loop electrosurgical excision procedure, or the removal of cervical tissue using a hot wire loop), surgical conisation (surgery with a scalpel, a laser, or both to remove a cone-shaped piece of tissue from the cervix and cervical canal), and laser vaporisation conisation (use of a laser to destroy cervical tissue). Treatments for other types of precancerous lesions caused by HPV (vaginal, vulvar, penile, and anal lesions) and genital warts include topical chemicals or drugs, excisional surgery, cryosurgery, electrosurgery, and laser surgery.

Individuals whose HPV infection has developed into cancer are generally treated in the same manner as patients whose tumours do not harbour HPV infections, depending on the type and stage of their tumours.

Cervical Cancer Treatment

Depending mostly on the stage of the cancer, the three main types of cervical cancer treatment are surgery, radiation therapy and chemotherapy. In the early stages of cervical cancer, where the cancer is still confined to the cervix, surgery is the first line of treatment. Most commonly, hysterectomy is conducted – a surgical procedure that involves removal of the uterus (womb) and the cervix. The second treatment option is radiation therapy (use of high energy X-rays or other types of radiation), which can also be used after surgery. The type of radiation therapy (external or internal) depends on the type and stage of the cancer. In cervical cancer, if radiation therapy is the main treatment, it is usually given in combination with low-dose chemotherapy.

Like most cancer types, the last course of treatment is chemotherapy (oral or intravenous) – the use of drugs in order to help kill cancer cells and shrink tumour size. There are a few branded drugs approved for the treatment of cervical cancer, namely Blenoxane (bleomycin), Hycamtin (topotecan hydrochloride), Platinol (cisplatin), and Platinol-AQ (cisplatin). The generic versions available in the market are bleomycin, cisplatin and topotecan hydrochloride. Some drug combination (i.e. gemcitabine-cisplatin) is also used against cervical cancer. Bleomycin, cisplatin and topotecan hydrochloride have varying mechanisms of action that eventually lead to cell death or apoptosis. Bleomycin, administered by injection, is a type of antibiotic that is only used in cancer chemotherapy. Cisplatin is the first member of a class of platinum-containing anti-cancer drugs, and is administered intravenously; while topotecan hydrochloride, a topoisomerase inhibitor, is an oral chemotherapeutic agent. Generally, chemotherapy is administered to women with widespread or recurrent cervical cancer that are difficult to treat.

Prevention is Much Better than Cure

The most reliable way of preventing HPV infection is putting on the chastity belt so to speak, that is, avoiding any skin-to-skin oral, anal, or genital contact with another person. Sexually active individuals will most likely prevent infection if they are in a long-term, mutually monogamous relationship with an uninfected partner. But even that is not a 100% guarantee. While correct and consistent use of condoms has demonstrated prevention of HPV infection, areas not covered by a condom can be infected and most unlikely to prevent virus from spreading. In the market today, there are two HPV vaccines approved by the US Food and Drug Administration – Gardasil and Cervarix.

Manufactured by Merck and FDA-approved in June 2006, Gardasil is recommended for the prevention of cervical, anal, vulvar, and vaginal cancer, as well as pre-cancerous lesions in these tissues and genital warts caused by HPV infection (Gardasil prevents against HPV types 6, 11, 16 and 18). Gardasil also protects males against most genital warts and anal cancers. It is recommended for boys as young as 11 years old and for males through 26 years old. Gay, bisexual, and men who have sex with men should receive the vaccine through age 26. Cervarix, on the other hand is manufactured by GlaxoSmithKline, and approved by the US FDA in October 2009. Cervarix is designed to prevent infection from HPV types 16 and 18, and also contains AS04, a proprietary adjuvant that has been found to boost the immune system response for a longer period of time. Unlike Gardasil, Cervarix doesn’t prevent from HPV types 6 and 11, the types that cause genital warts

In Singapore, both Gardasil and Cervarix are approved for use, and HPV vaccination is covered by Medisave. These vaccines are recommended for girls as young as nine years old, prior to becoming sexually active. The old adage “prevention is always better than cure”, can never be more apt in the case of cervical cancer and HPV infection. Like any other cancer, treating cervical cancer doesn’t come without risks and side effects. Regular Pap test and preventing HPV infection is, indeed, critical.

References:

http://www.cancer.gov/cancertopics/factsheet/Risk/HPV http://www.cancer.gov/cancertopics/types/cervical http://www.cancer.gov/cancertopics/druginfo/cervicalcancer#dal2 http://www.cdc.gov/std/hpv/stdfact-hpv.htm http://www.hpb.gov.sg/HOPPortal/article?id=8768 http://www.ncis.com.sg/cancer-information/types-of-cancer/cervical.html http://www.webmd.com/cancer/cervical-cancer/cervical-cancer-topic-overview

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by Prof Peter Lim

Most people desire an improved sex life with their partners. For some, it may simply be an issue of satisfaction levels; while for others, it could be part of their management of medical conditions such as erectile dysfunction (ED). Regardless, there are multiple lifestyle changes that couples can adopt to achieve improved performance. Even for those in their 20s without any problems, making the right lifestyle choices is a preventive measure against erectile dysfunction that plagues 50% of Singaporean men in varying degrees.1

Exercise Regularly

Exercise lowers cholesterol, which minimises deposits on artery walls that narrow the walls and reduce blood flow. Fundamentally, an erection depends upon blood flow into the penis and as such, arterial health is crucial for a satisfactory erection and therefore good sex. Regularity in exercise is key – the equivalent of an hour of brisk walking each day would make a significant impact. Weight loss from exercise would also be a great contributing factor to better sex life, as obesity is strongly associated with ED and poor sexual performance.

Along with improving erectile function, exercise can reduce stress, tension, anxiety and depression, which are all psychological factors that affect sexual performance. In fact, a study showed that more physically fit men rated their own sexual desirability higher than those who were less active.2 Looking fitter boosts self-image and self-esteem – a definite bonus for feeling confident and at ease during sexual activity. A good session of exercise will also release endorphins, a hormone that can increase the level of pleasure or satisfaction during subsequent sexual activities.

Quit Smoking and Reduce Alcohol Intake

Smoking greatly accelerates plaque build-up in the arteries, which in turn obstructs blood flow through vessels and causes circulatory problems such as erectile dysfunction. Not only does quitting smoking bring about a greater change of better sex life, it would reduce the risk of many other health conditions that can cause erection problems such as cardiovascular diseases and diabetes.

Try to avoid excessive alcohol intake before sex as it decreases blood flow to the penis. In the long term, overconsumption actually damages the vessels and contributes to heart disease, a contributing factor of erectile dysfunction. As such, always keep alcohol intake to a moderate amount according to the recommended limits.

Manage Stress and Learn to Relax

Being stressed out in a fast-paced city like Singapore is inevitable. According to the Philips’ Health & Well-being index, young Singaporean adults worry the most, with 78% experiencing mild to severe stress.3 The human body responds to stress with the release of hormones cortisol and adrenaline – both of which reduce blood flow to the genitals, affecting sexual performance.

In the case of short-term stress, the body should be able to respond sexually once the stress has passed. However, with long-term stress that might have manifested into a medical condition, patients will need to treat the problems in order to restore sexual function.

To cope with stress, identifying stressors in life and learning ways to redirect or reduce stress are key. Engaging in activities that can relieve stress such as meditation and exercise has been proven to help manage stress levels. It is always helpful to be open about it with partners to understand the source of stress and engage their help. Putting aside more time for social interactions and talking about feelings always help.

Apart from managing stress, relaxation with partners can also serve as a great boost for improved sexual activity. Before engaging in intercourse, try winding down with a hot bath, soothing music and by giving each other back rubs. This will put both partners in a similar relaxed mood, which will more often than not lead to greater satisfaction.

Get Sufficient Sleep

Lack of sleep also has a negative impact on a good sexual relationship. Not getting sufficient rest and sleep can also cause lethargy and consequently become bogged down by negative moods. The drain of intense workload, parenting or social activities can have a profound impact on the energy required for a satisfying sexual relationship. Sleep is imperative not just for sexual function but also for general health.

If you or your partner is experiencing erection difficulties or other sexual problems, it is advisable to consult a doctor. For more information on ED or to locate your local clinic for advice, you can visit edmobile.lilly.com.sg/.

Prof Peter Lim is a Senior Consultant Urologist at Gleneagles Hospital.

References: Singapore Med J 2003 Vol 44(1) : 021 2Sexual Desirability and Sexual Performance: Does Exercise and Fitness Really Matter? Electronic Journal of Human Sexuality, Volume 7, October 5, 2004 3Philips’ Health & Well-being Index Reveals that Young Singaporeans are the Most Concerned about Their Health and Feel the Most Stress, http://www.newscenter.philips.com/sg_en/standard/about/news/press/20101027_philips_health_well_being_index_launch.wpd#.USLcUlqPiFc

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by Dr Perry Lau

M, AN EIGHT-YEAR-OLD girl, was born with a developmental disorder of her kidneys, resulting in kidney failure and requiring dialysis since she was seven years old. After her afternoon school session, she had to rush home to start her peritoneal dialysis session of 10 hours daily. Every night her mother had to inject her every night with a hormone that can help her to grow. In addition, she received another injection every week that could help her to build more red blood cells so that she would not feel tired easily during physical activities. M hated the chalky medicine that she had to take during every meal. She was told that her kidneys could not clear the phosphate found in food, hence she required this chalky medicine, and she had to avoid foods like chocolate and peanut butter which her siblings and friends enjoyed.

All these restrictions in her life changed after she received a kidney from her father when she was eight years old. She no longer required peritoneal dialysis every night, and her parents could bring her out to play with her siblings until late into the night. This is just one example of a child with kidney failure whose quality of life improves dramatically after a kidney transplant. Kidney transplantation is the treatment of choice for children suffering from irreversible kidney failure as it results not only in better survival rates but also better quality of life compared to dialysis.

Paediatric Kidney Transplant in Singapore

In Singapore, the first paediatric kidney transplant was performed in a three-year-old kid in February 1989 at the Department of Paediatrics, National University Hospital. This first child transplant recipient is currently a young man who has just finished his post-graduate degree in biomedical science, and his transplanted kidney is still functioning normally. Up to the end of 2012, there were about 60 children and adolescents who had received kidney transplants in Singapore.

The common causes of irreversible kidney failure in children are congenital abnormalities of the kidneys and urinary tract and immune disorders affecting the kidneys. Around two-thirds of the paediatric kidney transplant recipients received their kidney from living donors, and the majority of the living donors were their parents. For these children, the average time from start of dialysis to getting a kidney transplant was less than a year. In fact, some of these children were able to do the transplant once their kidneys had failed completely, without having to start dialysis. One-third of the paediatric kidney transplant recipients received their kidney from donors who had died, and their average waiting time on the national deceased donor kidney organ list was seven years.

Donation and Transplant Operation

With regard to living donation, anyone in the family can donate their kidney so long as they are at least 21 years old, in good health, and have a blood type that matches the child. It is a myth that a kidney from an adult is not suitable because it is unable to fit into the small body size of a child. Studies have shown that a kidney transplanted from an adult donor into an infant or small child has equal chance of success as other age groups receiving the kidney transplant. In Singapore, one-tenth of the paediatric kidney transplant recipients received their kidneys before five years of age, and the youngest child to receive a kidney transplant was two and a half years old.

Before a child has a kidney transplant, he or she needs to be prepared physically and psychologically. The child has to undergo a series of investigations and complete the immunisations. Parents and children are encouraged to control the complications of kidney failure well and keep healthy. The child psychologist and child life therapist can help the children to accept the idea and become familiar with the procedures involved in transplant via toys and pictures.

Life after Transplant Operation

After the kidney transplant operation, these children have to take medications for the rest of their lives to prevent their new kidneys from being rejected. These medications work by suppressing the immune system, resulting in a higher risk for infections. These children may have to make minor adjustments in their lifestyle to protect themselves from infections. Children with kidney transplants can also grow better than under dialysis since there are less dietary restrictions with normal kidney function.

Many of the children do quite well after the kidney transplant operation and are able to return to school in two to three months after their transplant. In Singapore, nine out of 10 paediatric kidney transplant recipients who have completed their studies are now working to support themselves and their family. A handful of them participate actively in sports. Overall, the quality of life after the kidney transplant has improved in these children.

Every child is unique and every transplant is different, hence it is difficult to predict how long each child’s new kidney will last. Many of the children have kidney transplants that have lasted for ten years or even longer. In Singapore, around 20% of our paediatric kidney transplant recipients lost their kidney transplants due to rejection or infection. Rejection is a major problem in adolescence due to non-adherence to medications. Thus, it is important to involve the children and adolescents in educational activities that teach them the importance of adherence to transplant medications.

There are still a proportion of children afflicted with irreversible kidney failure and are dependent on dialysis and injections for years. Being an organ donor can make a big difference to the lives of these children. A kidney transplant is likely the best option to give these children a longer and healthier life. To them, a kidney transplant is a gift of a new life.

Dr Perry Lau is a Consultant at the Division of Paediatric Nephrology, National University Hospital.
8th Singapore Transplant Games The Society of Transplantation is organising the 8th Singapore Transplant Games on 20 April at the Toa Payoh Stadium. Please support our local transplant athletes as they compete for a place to represent Singapore in the world transplant games hosted by South Africa in July this year. Lots of excitement, fun and goodies await supporters. Bring your families along for a fun-filled Sunday morning. Registration is free but spaces are limited. To register, go to www.singaporetransplantgames.com .

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by Dr Dharambir S Sethi

ALLERGIC RHINITIS IMPLIES an inflammation of the mucosal lining of the nasal airways primarily caused by an “allergen”. It is one of the most common medical conditions encountered globally. It affects 10% to 40% of the population in industrialised countries. The incidence of allergic rhinitis in the US is about 17% of the population; and in Singapore, a study showed the incidence to be around 13%. The economic impact of allergic rhinitis in the United States is estimated to be roughly 8 billion dollars annually. The time lost from work is estimated at 10 million days a year; and for children the time lost from missing school is 2 million days a year.

The Development of Allergy

For the patient to develop allergy, the allergen must enter the body to produce symptoms. The most common portal of allergy is the respiratory route – in other words, most of the times we inhale the allergens. Not surprisingly, most symptoms caused by inhalant allergens occur in the respiratory tract.

When an allergen – something that one is allergic to – enters the body, it incites certain cells (B cells) of the immune system to produce antibodies specific to that particular allergen. These antibodies then bind to some other type of cells called the mast cells. This binding causes the mast cells to become “sensitised” to that particular allergen. When these sensitised mast cells come in contact with the allergen they liberate histamine and other chemical mediators responsible for the symptoms of allergy. This process is triggered when the allergen enters the body and binds to the specific antibodies already present on the surface of the mast cells.

The structure with which the public most commonly associate with allergy is the nose. But in actual fact, allergy may be the root cause of a wide variety of complaints presenting to a doctor in ENT practice. Unknown to the patient and sometimes the physician, allergy may be lurking in the background as the great masquerade for a wide variety of presenting symptoms.

Types of Allergens

For practical purposes, the inhalant allergens are generally divided into two types: perennial and seasonal. Perennial offenders are present throughout the year. These include house dust, which has been considered as the universal antigen. The best known antigen present in house dust is the mite Dermatophagoides. Other allergens include insects such as cockroach and cricket.

Epidermal allergens include hair of furry animals where cats and dogs top the list. The dander and other allergens produced by the furry animals are light and become an intimate part of the drapes, carpets and other décor.

Mould allergy is worldwide and present in all seasons. Moisture and decay promote mould growth. Area around plumbing and water pipes is subject to condensation and accumulates major amounts of mould growth. There are currently more than 80,000 species of mould identified!

Food allergy includes allergy to milk, wheat, corn, yeast, egg and soy. Food allergy is even more insidious. Its manifestations have been well described by the term “many syndrome” i.e. many symptoms, many organ symptoms, many physicians, many tests, many failures.

Inhalant allergy may vary in its manifestation depending on the type of allergen. In perennial allergic rhinitis, the signs and symptoms may be indistinguishable from the common cold. The patient often complains of a “cold that never goes away”.

Diagnosing Allergy

The presumptive diagnosis is usually made from history and physical examination.

Skin Prick Test

Among the tests to confirm the diagnosis of allergy, the skin prick test is quite popular. This test is inexpensive and can be safely performed in the clinic. The skin prick test is very sensitive but is, however, subject to a variety of external influences. Antihistamines, several tranquilisers, cough medications, and drugs with similar actions may depress skin activity making readings unreliable. The skin tests can also be time consuming.

Radioallergosorbent Test

For patients not suitable for skin prick test, a blood test is available. This is called the Radioallergosorbent Test (RAST). Each antigen produces an antibody specific to the antigen. This test measures the serum level of that specific antibody. This test overcomes or entirely eliminates the variability of the skin tests. It saves time and causes less discomfort to the patient. The cost, however, may be a concern as it can be expensive to test a whole panel of allergens. It is also not as sensitive as skin prick test.

Treatments of Allergic Rhinitis

Once the allergen/s is/are identified, some definitive form of therapy is planned. In most cases, more than one approach will be needed before the patient reaches the maximal benefit. Treatment includes environmental control, pharmacotherapy, and immunotherapy.

Ideally, allergy should be controlled by elimination of the offenders. Inhalant allergens consist of pollen (in seasonal countries), moulds and various members of the dust group including animal dander. Unfortunately, elimination of these from the environment is far from easy. Pollen allergy is not common in Singapore, but dust, mould and animal dander are abundant.

Pharmacotherapy includes antihistamines, decongestants and steroids. Antihistamines have been in general use since the 1940s. Chemically, they compete with histamine for attachment sites on the target organs. Antihistamines function best when administered before allergen exposure. Almost all antihistamines tend to be sedative in nature; therefore, operating machinery and driving a vehicle may be dangerous while on antihistamines. Steroids exert probably the most profound effect on both allergic and other related inflammatory conditions of any drug available. Over a short period they are also among the least likely to produce side effects. The most appropriate use of systemic steroids is the short burst necessary to control an intolerable acute condition.

Immunotherapy aims at hyposensitising the patients to the allergens and offering a reasonable possibility of a cure at least for a time. It is a form of immunisation which is accomplished by intentional exposure to regular, progressive doses of the same specific aeroallergens that are responsible for producing symptoms. It results in down-regulation of the immunologic response and control of symptoms associated with usual levels of environmental exposure to the treated allergens. It is, however, expensive and may take as long as three to five years to be effective. Therefore, a firm commitment from the patient is necessary before considering this mode of treatment.

Allergy Can Affect Any Part of the Body

• Nose. In the nose, allergy causes inflammation of the nasal passages and is usually associated with runny nose, sneezing, itchy and blocked nose.
• Ears. In the ears, allergy may be the cause of “otitis externa” i.e. chronic inflammation of the pinna or the ear canals. Allergy may also cause “glue ear”, recurrent ear infections, barotrauma and Eustachian tube dysfunction.
• Throat. The throat is not as commonly involved as the nose and ears, but allergy can be the cause of chronic sore throat in some patients. The sinuses may be affected as well.

Dr Dharambir S Sethi is a Senior ENT Consultant and Director of Nose, Sinus and Allergy Services at Novena ENT – Head & Neck Surgery Specialist Centre, Mount Elizabeth Novena Specialist Centre.

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by Dr Adeline Wong

Bad breath or halitosis is a common problem that can affect anyone at any age. It affects about 2.4% of the adult population, and most people at some point. The odour often depends upon the source or underlying cause of the bad breath. This condition is not infectious and is caused by sulphur-producing bacteria that normally live within the surface of the tongue and in the throat.

Causes of Bad Breath or Halitosis

Bad breath can be caused by a variety of factors, but the most common is usually poor oral hygiene and bacteria build up in a person’s mouth.

Poor Oral Hygiene

Bacteria that build up on teeth, tongue and gums can cause plaque, gum disease and tooth decay. The bacteria combine with saliva to break down food particles and proteins, producing an unpleasant smelling gas. Residual food trapped between teeth, dentures or braces will be broken down by bacteria, causing bad breath.

Smoking

Smoking is a well-known cause of bad breath. It does not only make your breath smell, it also causes staining and loss of taste, irritates your gums, and increases the risk of tooth decay.

Food and Drinks

Eating strongly flavoured foods, is likely to make your breath smell. Strong-smelling drinks, such as coffee and alcohol, can also cause bad breath. Certain supplements such as fish oil or garlic capsules can also contribute to bad breath.

Crash Diets

Low carbohydrate diets may also cause what is known as “ketone breath”. Low carb diets cause the body to burn fat as its energy source. The end-product of making this energy is ketones, which cause a fruity acetone-like odour on the breath when exhaled.

Dry Mouth

Dry mouth or xerostomia can be caused by general illness, medicines and simply by dehydration and not drinking enough water.

Medicines

Some types of medication that can cause or are associated with bad breath include nitrates, which are sometimes used to treat heart conditions like angina, some chemotherapy medication, and phenothiazines (tranquilisers).

Medical Conditions

Medical conditions that can cause bad breath include lung, throat or nose infections, diabetes, gastritis/GERD, liver or kidney disease, and Sjorgren’s Syndrome (causes xerostomia).

Dentures or Dental Appliances

Dentures or dental appliances, such as braces, can contribute to bad breath due to food particles that are not properly cleansed from the appliances. Loose-fitting dentures can contribute to sores and localised infections in the mouth, which can cause bad breath.

When to Seek Medical Care

If good oral hygiene practices do not eliminate the bad breath, see a dental professional. In most cases, a dentist can treat the cause of bad breath. You may want to consult your doctor in the following instances: persistent post-nasal drip, dry mouth or sore throat, sores in the mouth, pain with chewing or swallowing, just started a new medication, and any other symptoms that are of concern.

Treatment of Halitosis/Bad Breath

Your dentist is likely to recommend you brush your teeth at least twice a day using fluoride toothpaste. Keep a toothbrush at work or school so you can brush your teeth after lunch. Use dental floss to clean in between your teeth, as brushing alone only cleans about 60% of the tooth’s surface. Your dentist may also suggest using an anti-bacterial or anti-odour mouthwash. If you wear dentures, take them out at night to give your mouth a chance to rest. Clean your dentures thoroughly by brushing before putting them on the next morning.

Dr Adeline Wong is the co-partner and clinical director of the The Oral Care Centre, www.theoralcarecentre.com.

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by Dr Cindy Ho

CHILDHOOD OBESITY IS an increasing problem and it is a common health problem in Singapore school children. As a society becomes more affluent, there is better nutrition and an increased intake of dietary fat. Compounded by the fact that children nowadays participate more in sedentary activities like computer games, handheld games, and TV viewing, it is no wonder they’re unable to get rid of the excess calories they’re taking each day.

Childhood obesity is linked to many problems. This includes hypertension (high blood pressure), hyperlipidaemia (high cholesterol), Type 2 diabetes, obstructive sleep apnoea syndrome, increased risk of coronary heart disease, degenerative joint disease, and gallstones. Often, it also affects the psychological well-being of the child as they may get teased or bullied in school for being obese.

Obesity in childhood leads to approximately 30% of obesity in adulthood. Many fat adults were fat infants, and the natural history suggests that the obese child who becomes an obese adult will have more severe adult obesity than adults whose obesity began in adulthood. It is therefore paramount to assess and intervene in childhood.

A Health Promotion Board (HPB) survey showed that 60% of adult Singaporeans eat out as often as four times a week, and their children tend to eat out with them. With more money and access to a wider variety of food, Singaporeans began to eat more but less healthily. The same survey also showed that only one in four children aged seven to 12 ate fruit and vegetables on a daily basis. It is very important to make dietary changes in tackling obesity. Other lifestyle measures like getting more involved in physical activity is very important as well.

Ways to Help Your Overweight Child

Be supportive

Overweight children need support, acceptance and encouragement from their parents. They need to understand the reasons behind all the concern and to have a chance to share their concerns with you.

Get everyone involved

Do not isolate your overweight child but get everyone in the family involved in eating healthily and changing their lifestyle to include more physical activity. Family involvement helps to teach everyone good, healthy habits and does not single out the overweight child.

Be a role model

Children are good learners and they learn best by example. Setting a good example for your children by eating a variety of food and being physically active will teach them healthy lifestyle habits that they can follow for the rest of their lives.

Instill healthy eating habits

Do not put your child on a restrictive diet. Limiting what children eat may be harmful to their health and interfere with their growth and development. Parents should offer the whole family a wide variety of food from each of the food groups displayed in the Food Pyramid and have appropriate portions depending on the food group (as shown above). Items in the top part of the pyramid ought to be served sparingly. Plan for snacks and be the gate keeper at home Snacks should be as nutritious as possible, without depriving your child of the occasional chocolate or chips. Parents are responsible for stocking food in the home fridge and pantry. Buy lots of different types of wholesome food for your home. This will help your children learn how to make healthy food choices.

Do not use food to punish or reward

Sending children to bed without dinner will make them worry that they will go hungry. They would then eat whenever they get a chance “in case” they get punished later. Rewarding them with treats will also cause them to perceive that such foods are more valuable. This will send the wrong messages about food that are “freely available” such as rice, fish, fruits and vegetables.

Involve your children in food shopping and preparing meals

Shopping together gives you a chance to teach your children about good nutrition. It also helps you to learn their food preferences. Children get a feeling of accomplishment and may be more willing to try food they helped to shop for and prepare.

Do not eat in front of the TV

Eating in front of the TV makes it difficult to pay attention to feelings of fullness and may lead to overeating. When the children eat slowly, they can also detect fullness better and prevent overeating.

Make sure your child’s meals outside of home is balanced

Children these days eat out a lot especially for lunch and school recess. Find out what is available at the school canteen and help your child make proper food choices. Also, select healthier items when eating out together.

Get active

Take the stairs instead of the lift if you can. Encourage your child to play outdoors instead of watching TV and playing computer games. Provide them with toys that involve physical activity. Get a group of friends together for some games. Get active yourself by playing along! It’s great fun and does wonders for everyone’s health.

If you find all measures taken on your own don’t seem to work, it may be worthwhile getting a doctor’s consultation to make sure there aren’t any pathological problems causing the rapid gain in weight. See a dietitian for more detailed meal plans to reduce caloric intake and even work with a physiotherapist to come up with some exercise regimen to follow.
Dr Cindy Ho is an Associate Consultant at the Division of Paediatric Endocrinology, National University Hospital.

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by Dr Cheong Wai Kit

COLORECTAL CANCER IS cancer of the colon and rectum (large intestines) which arises from the mucosa (inner lining) of the wall of the intestines. Most of these cancers begin as a small non-cancerous polyp (growth), which may become cancerous over a prolonged period of time.

Latest Statistics in Singapore

Colorectal cancer is the most common cancer here in Singapore. Since 2002, colorectal cancer has overtaken lung cancer as the number one cancer among Singaporean men, and it maintains the second most common cancer among Singaporean women after breast cancer. For the past 35 years, the ASR (age-standardised incidence rate) of colorectal cancer has risen steadily in Singapore. However, these rates appear to have reached a plateau among men and showed a slight dip among women in Singapore. The Singapore Chinese have the highest ASR compared to the other races, followed by Malays and Indians, respectively. The average age at diagnosis for colorectal cancer for both men and women in Singapore is approximately 67 years old. Over the years, the statistics showed an encouraging overall increasing trend in the survival rate of colorectal cancers. The age-standardised trend of death from colorectal cancer also appears to have decreased, especially for women.

In Singapore, approximately 90% of colorectal cancer cases were diagnosed at or above the age of 50 years and less than 1% of cases were diagnosed below the age of 30 years. Because of the fact that the age-specific rates rises sharply from age 50 years onwards, our current screening guidelines recommend annual screening for adults aged 50 and above.

Causes of Colorectal Cancer

The natural history of the formation of colorectal cancer is quite well studied. Most colorectal cancers evolve from colorectal polyps (adenoma). Epidemiological studies estimated that the transformation of colorectal adenoma to cancer takes approximately 10 years. Therefore, diligent detection and removal of colorectal polyp (adenoma) has been shown to prevent colorectal cancer. However, according to the 2010 Singapore National Health Survey, only 14.2% of Singaporean aged 50 to 69 years reported having a screening examination of the colon and rectum (using colonoscopy and sigmoidoscopy) at least once. In addition, the majority of the colorectal cancer cases here in Singapore are diagnosed at stage 2 or later. It is known that the chances of survival increase the earlier the cancer is diagnosed. Health education to create better awareness and understanding of this condition is crucial in battling this cancer. The common symptoms of colorectal cancer are changes in the bowel habit, presence of blood in the stool and new onset abdominal pain. It is, therefore, important to educate the general public who are 50 years and above and those with family history of colorectal cancers on how to recognise the symptoms. Everyone has to be vigilant for any subtle ‘red flag’ symptoms as patients with early stage colorectal cancer may not be able to discern or experience them.

Diagnosis and Screening

Detecting colorectal cancer at its early stage and especially in its pre-cancerous stage can improve the chances of survival. This screening process for colorectal cancer should begin for all from age 50 and above with no symptoms. The present recommended screening tests are stool blood test (faecal immunochemical test – FIT) and screening colonoscopy. FIT is a test used to detect the presence of minute amount of blood (not seen with the naked eye) in the stools. It is a simple, safe, quick and easy test to perform and can be done at home without any preparation. It is recommended to be done once a year and performed twice with two stool samples over two days for a more accurate result. Screening colonoscopy is the examination of the mucosa (inner lining) of the colon and rectum using a long flexible scope. It is firstly used to detect early small ‘asymptomatic’ tumour and secondly more importantly, to detect and remove any colorectal polyps. As the saying goes, no polyp, no cancer! Screening colonoscopy should be done once every 10 years.

Latest Modes of Treatment

Surgical advances, newer chemotherapy drugs, and better understanding of the cancer have expanded the treatment options for this cancer. There are basically three main treatment options for colorectal cancer – surgery, chemotherapy and radiotherapy. When the cancer is discovered at an early stage, resection of the tumour can be performed using key-hole surgery (minimally invasive surgery). The surgery is performed using instruments inserted through small incisions on the abdominal wall with visual guidance from a camera scope. Recovery from this kind of surgery is faster with shorter length of stay, less wound pain with less usage of painkillers and quicker resumption of oral intake and mobilisation as compared to conventional open surgery. Newer surgical techniques evolved from modification of this minimally invasive surgical platform which uses robotic technology for higher precision, better visualisation and better range of movements has been employed especially for rectal cancer. Early non-invasive colorectal cancer discovered during colonoscopy can be removed at the same time using specialised instruments through the colonoscope. This technique called the endoscopic submucosal dissection (ESD) allows more precise dissection along the submucosal plane of the large intestines for total removal of the cancerous growth. At times, combination technique using colonoscopy and laparoscopic assisted surgery can be performed to remove large colonic polyps located at difficult sites.

Chemotherapy is used to destroy cancer cells before and after surgery. New chemotherapeutic drugs are now available to target and destroy cancer cells after surgery. These are more targeted with a safer drug profile and with less side effects.

Radiation therapy uses X-rays to destroy cancer cells that might remain after surgery and can also be used to shrink large tumours before surgery in order to achieve complete removal of the tumour. Newer therapy modality and technique are now available to improve local recurrence rates.

In summary, even though colorectal cancer is the number one cancer in Singapore, we can take a proactive role by living a healthy lifestyle, understanding and have a better awareness of the cancer and attending regular screening programmes for colonic polyps and removing them before they turn into invasive colorectal cancer.

Dr Cheong Wai Kit is the Head and Senior Consultant at the Division of Colorectal Surgery, National University Hospital.

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by Dr Suresh Nair

THE INABILITY TO conceive is something many couples never expected to face when they make the decision to start a family. However, the reality is that, in most populations, at least one in six couples has issues conceiving a child. If this problem does not get resolved and childlessness becomes a prevailing situation, couples fall into despair and hopelessness – that is indeed a life crisis.

Thankfully, since the birth of the world’s first in-vitro fertilisation (IVF) baby more than three decades ago in July 1978 and with the advent of modern science, there have been great strides in making the dreams of childless couples to have a child come true.

Issues in the Early Years of IVF

The early years were fraught with poorer success rates and a very arduous and uncomfortable journey for women who might, unfortunately, not end up having a baby. In addition, the two big problems associated with IVF are one that involves daily injections to stimulate the ovaries in producing follicles or egg-bags (which contain the eggs, where problems can arise when there is overproduction), and the other is when too many babies from too many embryos transferred cannot be accommodated in the womb (resulting in the serious risks of premature births). Consequently, the very premature baby needs special intensive care to address the medical conditions which may be associated with not only permanent long-term neurological handicap, but physical and mental life-long problems as well.

In recent years, stimulation of the ovaries to produce eggs has been simplified. The medications are now injected under the skin of the abdomen – literally painless – for a shorter duration, to allow egg “pickup” or collection. The most critical issue, however, is that of excessive “ovarian hyperstimulation syndrome or OHSS” which can occur in about 1% to 2% of cases, sometimes with dire consequences. In this condition, there is fluid accumulation into the abdomen, as a result of a shift of fluid (containing proteins) from the blood stream, into the abdomen. This results in the thickening of the blood and an increased risk of blood clotting (thrombosis). If clots occur in the vital organs (e.g. the brain), this can result in a stroke; or can cause heart malfunction, if in the pulmonary (lung) blood vessels.

The Role of Antagonists in OHSS Prevention

The recent introduction of a medication called “antagonist” efficiently prevents the egg from being released before they are ready for collection. Egg collection is a minor surgical procedure. A thin needle is passed through the vagina and the eggs are aspirated (withdrawn through suction) from each follicle. The eggs collected are handed over to the embryologist (a laboratory expert) for processing and inseminating with the sperm in the laboratory, and eventually growing them into embryos. The embryo is then transferred back in into the womb.

However, the dangerous problem of OHSS, has been for many years, is that it is consistently hard to predict or circumvent. Now with the use of antagonists, rather than using the more traditional “agonist” method where there is a longer duration of injections to quieten-down the ovaries, “antagonist cycles” are more compact and easier for patients. The major advantage of the “antagonist cycle” is that we can ripen the eggs (takes 36 hours) by using a high dosage of agonists as a single injection. OHSS is a situation likened to a race car that has been driven to maximum speed (i.e. production of eggs) but the engine begins to overheat in the process. Using the antagonist, one can just turn off the engine and then use a fast high impact “ripening” injection (i.e. the “agonist”) to trigger or set-off ripening rather than the traditional lingering-effect type of trigger (e.g. Pregnyl or chorionic gonadotropin) that continues to run the engine despite the overheating. By using an antagonist, the system is shut down after collecting the eggs, inseminating them and creating embryos out of them. The resulting embryos can be frozen, so that when the engine cools down, the womb can be prepared with hormones to receive the embryos after they have been taken out of storage. This whole process totally averts the risk of OHSS!

A Lot Simpler and Safer IVF

The other perennial problem used to be high order multiple pregnancy (i.e. triplets and beyond) which is risky to both mother and child. This is truly something avoidable. By growing embryos longer in an extended laboratory environment and selecting the very best embryos, we can get good pregnancy rates, and at most have twins (but not more than that) if only two embryos are replaced each time. This means we get good pregnancy rates and yet minimise the premature births of babies and the possible associated long-term disabilities.

Another reason why IVF has become a lot safer and more patient-friendly is because of the shortened duration of injections which are literally pain-free, thus very easy these days for women to self-administer. A recent advancement is to use a long-acting singular injection that lasts seven days and after an additional two or three days of “top-up”, the stimulated ovaries are ready for collection of the eggs. This is a convenient way for most working women, as reducing the need for daily injections minimises the risks of mistakes. These developments have made IVF a less stressful and arduous journey of getting couples realise their dreams of being a “mum” and “dad” to little babies growing up into healthy children.

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by Dr Wong Soong Kuan

COLORECTAL CANCER IS the most common cancer in Singapore, having overtaken lung cancer as the top cancer for men and remaining second for women. The lifetime incidence of colorectal cancer in Singapore is roughly one in 50 patients. This means that one in 50 people will have colorectal cancer in their lifetime. While incidences of the cancer peak at 50 to 70 years of age, it doesn’t just strike the old either.

Causes of Colon Cancer in Younger People

According to the data gathered by the Singapore Cancer Registry between 2006 and 2010, colorectal cancer cases are on the rise, and one out of 10 diagnosed with the cancer of the large intestine was aged below 50. Such cases of young patients with colorectal cancer usually have a genetic component to it. It can be due to one of four reasons: familial adenomatous polyposis, cancer family syndrome, a chronic condition called inflammatory bowel disease (IBD) and lastly, sporadic mutation. Familial adenomatous polyposis is a condition where a child is born with his or her entire colon being carpeted by polyps – an abnormal growth of tissue projecting from a mucous membrane.

Hence, by the age of 18 to 30, they have a higher chance of one of the polyps developing into cancer.

There’s another possibility known as cancer family syndrome. Also called lynch syndrome, it is a genetic condition where those affected have an increased risk of developing cancers of the digestive tract. Such patients have a higher risk of developing colorectal cancer – which often manifests between the ages of 30s and early 40s – and can also develop cancers of the breast, ovaries and uterus.

The third possibility is a chronic condition called inflammatory bowel disease, which is very rare in this part of the world but very common in the Caucasian population. This is when a person’s intestine becomes inflamed over many years, increasing the risk of it developing into cancer. Typically, if the process has been going on for more than 20 years, there is a condition called dysplasia that can occur, and this increases the risks of cancer.

The last possibility is sporadic mutation, where a spontaneous mistake in gene duplication predisposes a patient to developing cancer at a young age. Sporadic mutation is the most common cause of colorectal cancer in young patients. The reason is unknown, although exposure to more carcinogens may be a possibility.

Rare but Dangerous

While cases of colorectal cancer in the young are very rare – with the four possibilities combined having less than a 5% chance of occurring in the Singapore population – the problem is that they are often detected late. Statistically, the chances of surviving for at least five years after treatment stands at 90% for those diagnosed at stage 1 of the disease. However, this number drops drastically to 15% if diagnosed at stage 4.

After the cancer has spread to either the lymph nodes or distant organs, surgical removal alone is not an option and chemotherapy becomes necessary. For colorectal cancer, it more or less progresses in a step wise fashion – from the wall, spreading out into the nearer lymph nodes, then the further lymph nodes and finally to the other organs. Hence, especially so for colorectal cancer, the earlier the stage of the cancer, the better the treatment is going to be.

Signs and symptoms include looser stools, as a result of the intestinal wall becoming partially blocked and the blockage being released intermittently. It can also be the other way around, where patients complain of stools becoming increasingly difficult to pass as the passage becomes narrower. Rectal bleeding or unexplained weight loss should definitely be investigated as well. More uncommon symptoms include pain due to perforation of the intestinal wall, as the tumour gets so large that it breaks through the wall.

Unfortunately, by the time a patient shows any obvious signs or symptoms, the disease has likely progressed to the later stages where the prognosis is bleaker. In fact, more than 50% of patients present themselves in stage 3 or stage 4 of the cancer. That’s why everyone above the age of 50 should go for colonoscopy.

The Importance of Colonoscopy

Colonoscopy involves a flexible tube with a small camera inserted via the anus to examine the large intestine. If polyps are found, they can be removed at the same time. Colorectal cancer starts with a pre-cancerous growth called a ‘polyp’, and the pre-cancerous growth progressively enlarges. Once it reaches a certain size – typically up to 2cm to 2.5cm – changes may occur that will cause the polyp to invade and become a full blown cancer.

While the chances of finding a polyp through colonoscopy screening for patients above 50 stands at about 20%, less than 3% of patients test positive for cancer during screening. The aim of a colonoscopy is to find and remove these pre-cancerous growths before they have a chance to develop into early stage colorectal cancer.

About 1,600 new colorectal cases and 660 deaths are recorded per year in Singapore. Yet according to the Ministry of Health, only one in nine men and one in 13 women aged between 50 and 70 have done a colonoscopy at least once. And when symptoms do show, young people tend to dismiss them on the mistaken belief that colorectal cancer only affects the old.

Colorectal cancer screening is normally recommended for those above 50, but if a person experiences anything out of the ordinary with his or her bowel habits, have rectal bleeding or unexplained weight loss at any age, a doctor should be consulted immediately. Change in bowel habits includes diarrhoea, severe constipation and change in the calibre or consistency of the stool such as it becoming more mucous or long and pencil-like.

In addition, if you have a family history of cancer, screening should be done five to 10 years before the youngest age of a first degree (immediate family) relative diagnosed with cancer.

For example, if you have a first degree relative who was diagnosed with cancer at 40, you should start going for a regular screening once you hit 30.

Other Colorectal Cancer Screening Methods

Because of the difficulty in the symptomatic detection of colorectal cancer in the early stages, the focus is now on identifying individuals more susceptible to the cancer. While the gold standard for colorectal screening is still colonoscopy, a new method called faecal occult blood testing (FOBT) is being advocated by polyclinics. This is essentially stool testing where patients handle and send samples of their own stool to a laboratory to be tested for hidden blood. However, the test depends on whether the tumour is bleeding and has a 60% to 70% success rate.

Screening involves either an annual faecal occult blood test or 10-yearly colonoscopy, beginning at age 50 for average risks individuals.

There is also another test called virtual colonoscopy, where X-rays and computers are used to produce two- and three-dimensional images of the colon. However, virtual colonoscopy involves some radiation, and in cases of poor bowel preparation, stool sometimes can be mistaken for polyps and vice versa, increasing the chances of a higher false positive or negative result. In addition, a positive result for both stool testing and virtual colonoscopy will still require a colonoscopy to confirm the findings and remove the polyp. Colonoscopy is medisave-deductable and is recommended for a more precise diagnosis.

Dr Wong Soong Kuan is a General Surgeon at The Colorectal Clinic, Mount Elizabeth Novena Specialist Centre.

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by Dr Peter Lim

WHILE IT’S NO secret that men who suffer from erectile dysfunction (ED) will have sexual difficulties, what many people fail to realise is that continued dissatisfaction with their sexual experiences has spillover effects that lead to friction in an otherwise stable relationship. Accordingly, in order to avoid this, it is imperative for couples to take action to resolve their sexual issues.

Identify the Problem

Before fretting over the inability or difficulty in achieving the desired erection and sexual experience, the most important distinction to make is whether one is suffering from a physical or psychological problem. This is simply because the solution to the problem depends very much on the root cause.

As ED sufferers try to make sense of their condition, many traditional male’s values about sexuality are threatened. Many men have the misconception that if they are not able to satisfy their partners sexually, they are not considered “real” men. The vicious cycle repeats itself as sufferers’ feelings of shame and fear arising from their inability to satisfy their partners often result in performance anxiety, thus intensifying the problem of ED.

What many sufferers may not realise is that performance anxiety is a psychological problem that often arises when they become fearful of failure or feel embarrassed when they cannot achieve or maintain an erection. In fact, for some men, it is actually the anticipated failure of achieving a desirable erection that culminates in a less-than-satisfactory sexual experience.

The key to breaking the cycle and achieving a healthy sexual relationship is to first identify and admit that the performance anxiety issue exists, as well as change misguided beliefs about sexual performance. Many men believe that sexual performance is the most defining and important characteristic of every sexual experience. Many men need to understand and accept the fact that erectile response varies with every sexual experience. Occasional sexual difficulties are normal and do not necessarily mean that there is something wrong.

Seek Treatments

While ED is strongly linked to performance anxiety, sometimes it is in fact a biological problem and may require medical attention. ED as a medical condition can be comprehensively defined as a persistent difficulty in getting an erection, having problems in maintaining an erection with or without an overall reduced sexual desire. If you are experiencing any of these symptoms persistently, you should consult a doctor who will be able to advise you on the appropriate treatment.

Oral medication known as PDE-5 inhibitors is usually the first line of treatment for ED, working by increasing blood flow to the penis when stimulated. There are also other more invasive treatment options such as intracavernosal injections, a form of self-injection therapy by patients. This involves injecting a medication into the male organ or a less invasive form using pellets or a gel known as trans-urethral agents through the urine channel. Another method using an external device placed onto the male organ can be used to create a very good erection as and when needed. These injectables or urethrally-applied chemicals and the external suction device pull blood into the penis to maintain an erection for intercourse. Surgery is also another option that doctors may recommend, depending on the severity of the patient’s condition.

Commit to Open Communication and Lifestyle Changes

Regardless of the root cause of your sexual difficulties, open communication with your partner is extremely crucial in restoring a healthy sexual relationship. Refusal to talk about your erection problems may result in confusion or even suspicion from your partner. Emotions can run high, and feelings can get hurt, which may lead to a reduction in intimacy that in the long run can be destructive to the relationship.

In fact, it is always beneficial to gain the help and emotional support from your partner when overcoming ED. Recent trends have shown that more couples are seeking medical advice together and better understand the condition. Many men are surprised to find that their partners are just as interested and keen in overcoming the problem and are willing to lend their full support. After all, their sex life is affected as well.

Besides medical attention, ED patients can also look at making some positive lifestyle changes to improve their situation. It is always advisable to exercise regularly and maintain a healthy diet, get sufficient sleep, eliminate all tobacco products as well as limit alcohol intake. Especially for those with performance anxiety, reducing stress and learning effective means of relaxation – such as warm baths and massages – can assist greatly in combating their condition.

Most importantly, as ED is not a condition that can be overcome overnight, sufferers need to remain positive as self-motivated lifestyle changes and treatment options are widely available in allowing them to achieve the healthy sexual relationship they desire. If you or your partner is experiencing erection difficulties or other sexual problems, it is advisable to consult a doctor.

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by Woon Hoe Tang

STARTED IN 2006, World Kidney Day is celebrated every year on the second Thursday of March. Its mission is to raise awareness on the importance of our kidneys and the impact of kidney diseases worldwide.

Do you know that three people lose the use of their kidneys in Singapore daily? This means over 1,000 cases of kidney failure a year! With the average waiting time for a kidney transplant being nine years, dialysis is the next treatment option for patients whose kidneys have failed. Currently, there are two forms of dialysis treatment available, namely haemodialysis and peritoneal dialysis. Haemodialysis (HD) requires patients to travel to a dialysis centre for treatment. In contrast, peritoneal dialysis (PD) can be carried out at home, at work, or on trips.

How does Peritoneal Dialysis work?

A PD catheter is inserted permanently at the abdomen to allow filling and draining of about two litres of PD solution into and out of the peritoneum or abdominal cavity, which is surrounded by the peritoneal membrane. The peritoneal membrane then filters waste and fluids from the blood into the solution. The PD solution is allowed to remain in the abdomen for four to six hours before it is drained and replaced with fresh PD solution. The replacing of fresh PD solution with the used PD solution is called an exchange. Each exchange takes about 30 minutes. PD patients perform an average of four exchanges per day.

Different types of PD have different schedules of daily exchanges.

Continuous Ambulatory Peritoneal Dialysis (CAPD).

This is the manual way of performing PD exchanges. Using the PD bag system, CAPD patients perform PD exchanges four times daily. No PD exchange is required when the patient is sleeping.

Automated Peritoneal Dialysis (APD).

PD exchanges are performed by connecting the patients’ PD catheters to a cycler for 10 hours. APD patients start their therapy by programming the cycler to perform PD exchanges for them while they sleep.

What do PD patients need to remember?

• Be diligent to stick with their PD prescription. Adhering to their PD prescription daily has a direct impact on their wellness.

• Manage their diet. It is very important to follow the meal plan recommended by their dietitian, so that they can stay healthy physically and mentally.

• Stay active by doing sports and exercise after checking with their doctor.

• Plan ahead. If they need to travel, they will need to bring their dialysis supplies along and may even need to have some sent to their destination in advance.

Advantages of PD

 No need for vascular access and needling. In haemodialysis, two needles are inserted every session to allow blood to drain and return to the body after filtering. Vascular access-related complications are the most common causes of hospitalisation in haemodialysis patients.

 Better time flexibility. PD patients are not restricted to dialysis centre schedules. They can fit PD into their work schedules as it is home-based.

 Better quality of life. Patients can enjoy the independence of being in charge of their own treatment. However, they will need to work closely with their healthcare team including the nephrologist, dialysis nurse and dietitian to do well on PD therapy.

PD Community Support Programme

In view of the increasing incidence and prevalence of kidney failure patients, the National Kidney Foundation (NKF), the largest dialysis provider in Singapore, launched the PD Community Support Programme, where experienced PD nurses visit patients regularly at their homes to ensure good PD self-management and provide advice and care.

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by Dr Ho Siew Hong

BEING A PARENT is hard enough without being bombarded with so many decisions to make for your newborn child. Perhaps one of the most important decisions you will face even before you take your baby boy home from the hospital is whether or not to have him circumcised.

For some parents, the decision is simple and non-arguable due to religious or cultural predispositions. For others, however, they need to heavily weigh the pros and cons. Circumcision is the removal of some of the excess foreskin (prepuce) from the penis. The reasons and benefits for circumcision include religious, medical and personal preferences.

Religious Practice
Male circumcision is religiously practiced by the followers of Judaism and Islam. The ceremony, with great rejoicing and festivities, usually takes place one week after birth for Jews and within the early few years of age among Muslims.

Medical Benefits
Phimosis or tight foreskin which prevents complete retraction and exposure of the glans (head) of the penis will benefit from circumcision. The tight foreskin harbour bacteria and become infected if not cleaned properly. This medical condition is called balanoposthitis, which is an infection and inflammation of the foreskin. Forcible retraction of the tight foreskin can be very uncomfortable and can lead to tears and infection of the foreskin. Tight foreskin may also cause discomfort during full erection of the penis and sexual intercourse.

The World Health Organization (WHO) recommends that circumcision is efficacious for HIV prevention, but it does not provide complete protection. Circumcision provides a 50% to 60% reduction in HIV transmission from female to male. However, this cannot be the recommended method to control the spread of AIDS. Circumcision at a very early age (within the first month of life) confers protection from penile cancer, but circumcision at any later age does not seem to confer such protection.

Personal Preference
Circumcision is not indicated if the foreskin can be completely retracted to expose the head of the penis. In some individuals, circumcision is perceived to provide better hygiene. The head (glans) of the penis can be exposed and cleaned. There is also less problems of urine accumulation around the foreskin. There is much data comparison for sexual pleasure before and after circumcision, but there is no clear evidence if circumcision will enhance or decrease sensation during sexual intercourse.

Circumcision Procedure
There is no age limit to circumcision. It can be done at birth and all the way until an elderly age. It may be uncommon to hear of an elderly gentlemen undergoing circumcision, but it is often done for repeated infection of the foreskin, especially in men with diabetes. Circumcision can be performed under local or general anaesthesia and can be completed within 15 to 20 minutes. There is minimum pain, and the procedure is done as day surgery. Patients are discharged with tablet painkillers and antibiotics for one to two days only. The excess foreskin is removed. A couple of stiches are placed to bring the edges of the skin together after removal of the excess skin. These stiches are self-absorbable and do not require removal in a later date. The stitches will dissolve within two weeks.

Risks and Complications
Generally, risk of complications in a competently-performed circumcision is very low. Minor bleeding and infections are the two most common complications.

Dr Ho Siew Hong is a Consultant Urologist at Urology Specialists Pte Ltd, Mount Elizabeth Novena Specialist Centre.

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by Dr Ernest Wang

BACK PAIN IS a common complaint. Most people above the age of 65 years would experience some form of back pain. It can also occur at a much younger age. While it is a leading source of disability, limiting one’s lifestyle and work, in most cases, back pain can be treated and controlled.

What are the causes of back pain?

The complexity of the spine is such that pain can arise from degenerate joints, bony spurs, worn out discs, pinched nerves or muscle spasms. Determining the source of the pain would help you in managing this pain.

What is sciatica?

Sciatica refers to shooting pain down the legs when a nerve is impinged. It can be extremely painful. A common cause of sciatica is a ‘slippped disc’ or sometimes narrowing of the spinal canal, causing the nerve to be impinged.

When should I seek treatment?

Back pain that is associated with sciatica, pain that does not go away with simple mediation, and pain that is aggravated by prolonged sitting, standing and walking are the typical scenarios that warrant further investigations. If your pains progresses over time, it would be wise to seek a specialists opinion.

If I consult a doctor, what should I expect?

A detailed history of your symptoms together with a thorough neurological examination of the spine is necessary. A simple evaluation would entail an X-ray of the spine. Sometimes, an MRI scan is necessary especially if your pain has progressed or if there are clinical signs of nerve or spinal cord compression. An MRI of the spine is usually more useful than a CT scan as the former can evaluate the soft tissue, discs and nerves more clearly.

What is the best treatment for back pain?

It is best to prevent back pain! Physiotherapy, back strengthening exercises, and general measures to avoid aggravating a sore back go a long way in relieving your pain. Avoid carrying heavy loads, avoid standing for prolonged periods of time, and sit on a sturdy chair with a good back rest. General low impact exercises are useful in limiting one’s weight. It is important to realise that physiotherapy alone is insufficient – daily back exercises are the trick to recovery. Medication prescribed by your physician can also help alleviate a sore back.

What are some of the other options in treatment?

When conservative measures have failed, less invasive procedures like injection of the joints, lesioning of some nerves, or steroid injections can help alleviate your pain.

How about surgery, isn’t it dangerous?

Many people have heard horror stories of the risks of spinal surgery. While there is always the risk of nerve damage, the incidence is low. Today, Minimally Invasive Surgery (MIS) is available. MIS techniques minimise injury to the surrounding tissue, resulting in less pain post-operatively and faster recovery times. Moreover, surgery is often performed with an operating microscope which gives the surgeon a clear and magnified view – making surgery safer.

What other technologies are available today?

Spinal surgery today is safer than before. Surgeons can monitor the nerves and spinal cord during surgery; and this is helpful. Spinal navigation (an extension of brain neuronavigation) is now a reality in spine surgery. Especially in complex cases, such systems allow the surgeon to ‘operate at unseen targets’ with the use of a ‘GPS-like’ tool.

So do I need surgery?

Surgery is usually required only if medical means of controlling pain has failed, or if there is progressive weakness or risk to one’s bowel or bladder control.

If I have back surgery, do I need to be on crutches or a wheelchair for months?

Most back surgeries are not debilitating. Rather, the purpose of an operation is to make one’s symptoms better, putting him back on the road to recovery. A typical patient undergoing a microsurgery for a slipped disc can return home the following day. If MIS is used for more complex cases, hospital stay can be reduced from a week to several days.

I also suffer from neck pain! What can I do?

It is not uncommon for people with back pains to be suffering from neck pains. Again, the mainstay of treatment is focused on physiotherapy and specific neck exercises. X-rays and MRI scans are often needed to rule out any damage to the spinal cord. See your doctor if you experience neck pain with pain/numbness down the arms, difficulty walking or difficulty with fine movement of the hands (e.g. doing your buttons).

Dr Ernest Wang is a Consultant and Neurosurgeon at Neurosurgery Partners, Mount Elizabeth Novena Hospital.

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by Dr Lim Min Yu

As pleasurable as it may be while you are making love, sometimes sex can lead to some uncomfortable symptoms. Up to two thirds of couples may experience pain or discomfort during sex. Unfortunately, most women will not report this to their gynaecologist because they may be either too embarrassed to talk about it, or they may think that nothing can be done about it. However, in most cases, there is an explanation and a solution.

Common Problems for Painful Sex

Insufficient Lubrication

This is the most common reason for uncomfortable or painful sex. The body responds to foreplay by releasing moisture from the glands in the vagina. This lubricates the vagina in preparation for intercourse. The other response to foreplay is engorgement, where the tissues of the vagina have increased blood flow, helping to expand the vaginal walls. Trying to have sex before enough secretions have been released will cause pain. Therefore, one way of trying to have more comfortable sex is to spend longer on foreplay, to allow more lubrication. An alternative is to use an external lubricant. There are several water- and silicon-based lubricants available nowadays in shops. Remember that petroleum-based lubricants (e.g. Vaseline) should be avoided if you are using a condom as they can react with the latex, causing the condom to fail.

Positions

Sometimes the sexual positions that you use may cause discomfort, for example if your partner is bumping on your cervix during thrusting. It can be fun to experiment with different positions to find some that are more comfortable for you, but it helps to be open with your partner, telling him what you find comfortable and what you don’t. Sex is meant to be pleasurable for both you and your partner, and sharing how you are feeling about sex can go a long way to improving your sex lives.

Infection

If you have vaginal discharge, you may have an infection. While it is normal to have some amount of vaginal discharge because of normal vaginal secretions, an excessive amount of vaginal discharge, especially if it is not white in colour or is clumpy, or has an offensive smell, may be associated with infection. You may also feel itchiness. Infected vaginal tissues and the cervix can be swollen and tender to touch, therefore the act of having sex can feel like torture.

The most common infections are fungal infection, otherwise known as candidiasis or thrush, and bacterial infection known as bacterial vaginosis. If you have recently started having sex with a new partner, or have more than one sexual partner, you may be at increased risk of a sexually transmitted infection (STI). If you are feeling pain or a burning sensation when you pass urine, or if you find yourself having to pass urine more often than normal, you may have a urinary tract infection. The so-called “honeymoon cystitis” arises from having frequent sex while a couple is on honeymoon, which can push bacteria into the urethra, leading to an infection.

If you think you may have an infection, you should see your gynaecologist who can advise on appropriate investigations to confirm the diagnosis and correct treatment.

Other Medical Conditions

Endometriosis

Endometriosis can be associated with uncomfortable sex. This is a condition where the tissue that normally lines the uterus is found in other locations, such as the back of the uterus, the ovaries (where it forms cysts), and even in locations such as the bladder and the bowel. This tissue responds to your monthly cycle, and can develop an inflammatory reaction, with bleeding and formation of scar tissue inside you. This can lead to the development of tender spots which may be painful during intercourse. Endometriosis can be associated with painful and heavy periods. If you think you may have endometriosis, then you should see your gynaecologist, who can help to advise on diagnosis and treatment.

Ovarian Cysts

Each month, a small cyst should develop on the ovary as part of the normal process for an egg to be matured. When ovulation occurs, this cyst should go away, and another one forms during the next cycle. However, sometimes these cysts are not reabsorbed by the body and become filled with fluid or blood. These cysts may lead to discomfort during intercourse. Although most cysts will gradually become smaller and disappear over time, there will be a few that persist, and will require surgery to remove them. Ovarian cysts can be detected by ultrasound scan, and your gynaecologist can advise whether a scan should be performed.

Less Common Conditions

Vulvodynia

Vulvodynia is the medical term for a painful vulva. Why this happens in some women is poorly understood. Women often describe it as a burning, stinging, itching, irritating or raw feeling on their vulva and labia, and some say it sometimes hurts even when they’re just sitting or walking around. There are topical creams and oral medications that can help.

Vaginismus

Some women experience involuntary contractions of the vaginal muscles during intercourse, and this results in sex being very painful for them. Those who have had traumatic experiences with sex in the past, such as being the victim of a rape or child molestation, often experience pain with intercourse.

A woman’s body can show physical signals in response to psychological issues. If any of these issues might play a role in the pain you feel, you may want to consider consulting a therapist at a sexual dysfunction clinic who can help you work through what you’ve experienced.

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by Dr Elizabeth Tan

EZYHEALTH SPOKE WITH Dr Elizabeth Tan, Specialist in Paediatric Dentistry at Specialist Dental Group, about some of the common issues relating to children’s dentistry. Here are some useful tips for parents on how they can ensure that their children’s teeth are in good shape.

What to do when your child’s teeth are knocked out?
When there is a displacement of a tooth totally out of its socket, it is called avulsion. In children, most are caused by falls, sports, and play accidents. Peak incidents occur at two to four years old, and rise again at eight to 10 years old.
Avulsed baby (primary) teeth should not be replaced as it may injure the developing permanent tooth. Space maintenance is not an issue as only minor drifting, if any, of the adjacent teeth occurs.

In the case of permanent teeth, re-implantation should nearly always be attempted. The time the tooth is out of the mouth is a critical factor. First-aid protocol that should be followed are the following:

• Don’t touch the root – pick up the tooth by the crown
• If the tooth is dirty, wash under cool running water for about ten seconds. Re-plant the tooth into its socket and hold in place by biting gently on a handkerchief. If not possible, place the tooth in milk or the tooth can be transported in the cheek pouch of the mouth of the child. In very young children, where this is not possible, get parents/child to spit into the container and transport tooth in it. Avoid storage in water.
• Seek dental treatment immediately.

Why is it important to bring children to see the paedodontist as early as one year old when the milk teeth will fall out eventually?

Baby teeth are as important, if not more so, than the permanent dentition. The first baby teeth appear when the child is about six months old. Besides being important in the development of chewing and speech, they are also important for appearance and holding space in the jaw (space maintenance) for the eventual eruption of the permanent teeth.
Ideally, the child should be seen by a dentist as soon as his/her first tooth erupts at around six months and no later than the first birthday. First dental visits at this age are shorter with little or no treatment. This “well-baby” check-up is more often than not a visit where topics pertaining to the good oral health of the child are discussed. These include good oral hygiene procedure, cavity prevention, fluoride needs, poor dietary or detrimental oral habits, dental developmental milestone, and concomitant potential problems.

How to prevent Baby Bottle Tooth Decay (and tips to get off the milk bottle)?

Tooth decay in infants and very young children is often referred to as Baby Bottle Tooth Decay. It occurs when sweetened liquids and those with natural sugar (milk, breast milk, fruit juice) cling to an infant’s teeth for long periods of time. Bacteria then decompose these sugars, turning them into acids which attack the teeth.

Preventive measures that help stave off Baby Bottle Tooth Decay include:

• Wiping baby’s gums with a clean gauze pad/cloth, after each feeding. When the child’s first tooth erupts, start brushing it.
• Reducing the frequency of consumption of milk as well as the length of time for the infant to feed.
• Preventing your child from falling asleep with a bottle of milk, fruit juice, honey, or other sweetened liquids.
• Giving him/her a clean pacifier without dipping it into sweetened liquids when your baby needs a pacifier during their naps or at night.
• Bringing your child to visit a paedodontist by his/her first birthday. However, if he/she has dental problems before their first birthday, take them to see a paedodontist as soon as possible.

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by Dr Seo Wei Leo

A CATARACT IS a clouding of the natural lens of the eye. It affects more than 80% of Singaporeans over 60 years of age. Cataract surgery is the most common surgery done in Singapore. A laser that vaporises cataracts in a fraction of a second is set to revolutionise treatment by making cataract surgery “bladeless”. In addition, there are different types of intraocular lenses that can be inserted to correct the various types of refractive errors so that the surgery not only removes the cloudy lens but also corrects refractive error and is more aptly called “cataract refractive surgery”.

Traditional treatment involves surgically removing the cloudy lens and replacing it with an artificial implant, known as intraocular lens (IOL). The technique is called phacoemulsification, during which the eye surgeon uses a blade to make very small incisions on the cornea (one main port and one side port). The surgeon uses forceps to tear an opening in the front of the lens capsule in order to access and remove the lens. The cataract is separated manually and the lens is emulsified with high frequency ultrasonic energy. The chopped up pieces are then removed from the eye through a fine tube, before an artificial lens (IOL) is inserted.

Bladeless Cataract Surgery

As the name suggests, bladeless cataract surgery differs from the traditional methods of cataract surgery by the absence of the blade. It utilises femtosecond laser technology. The equipment incorporates a machine called an optical coherence tomographer (OCT), which is used to create a detailed three-dimensional image of the inside of the eye, meaning the surgeon can plan, customise, and perform the entire procedure to an unparalleled level of accuracy.

Femtosecond lasers emit optical pulses of extremely short duration in the domain of femtoseconds, as short as one-quadrillionth of a second (10-15 sec). With these ultra-short yet intense bursts of near-infrared light pulses, tissue can be cut more precisely and with practically no heat development. The laser essentially vaporises tissue by creating a plasma and then a cavitation bubble, which expands and collapses to separate the tissue. This technology has already been used widely in refractive surgery and is set to revolutionise cataract surgery, too.

In bladeless cataract surgery, the computer-guided femtosecond laser makes the openings into the eye (cornea incisions), which can be programmed to a precise shape. It makes the opening in the lens capsule through which the dissolved cataract is then removed in the same way as in phacoemulsification. The femtosecond laser also divides the lens into smaller pieces so that less ultrasonic energy is needed to remove the cataract. In addition, all these are done with image guidance systems which provide real time, three-dimensional and high-resolution images of the eye. The femtosecond laser can also perform cuts on the eye to correct astigmatism.

A Precise and Accurate Surgery

The incisions made by the laser are more precise and predictable. In addition, the circular opening created by the femtosecond laser is more architecturally round and perfectly centred. Studies have shown that this is very important in intraocular lens positioning, stability and refractive predictability of surgical outcomes. Lens fragmentation by laser reduces the amount of ultrasound energy used during phacoemulsification, reducing risk of capsule complications and corneal injury. The image guidance system also increases the accuracy and allows customisation. In short, the femtosecond laser has replaced many of the steps in the cataract surgery that were previously performed by human hands, resulting in higher precision and better reliability.

Prior to delivering the laser, a patient’s eye must be stabilised relative to the optical system of the laser. This is achieved by a curved lens and suction system. As a result, side effects include rise in eyeball pressure and subconjunctival haemorrhage (bleeding in the white of the eye). Other disadvantages include increased cost and the need for additional space for the laser machine. Early adopters of bladeless cataract surgery have reported some intraoperative complications initially, but now it appears that these problems are attributable to the human learning curve, not laser error. However, not everyone is suitable for bladeless cataract surgery. Patients who are not suitable include those with cornea disease, patients with glaucoma, eyes which cannot tolerate or cooperate with the docking (suction system to stabilise the eye before the laser).

Cataract Refractive Surgery

The most common type of Intraocular Lens (IOL) is called a posterior chamber lens, meaning it is placed behind the iris within the capsule, which is the elastic bag where the natural lens used to be. The main job of the IOL is to focus light onto the back of the eye (retina), just as a natural, healthy eye lens would. Conventionally, Monofocal IOLs provide a set focal point, usually for distance vision. This allows cataract surgery patients to see clearly within a range. However, patients still require glasses for reading.

Monovision is a technique the surgeon may choose to perform that involves inserting an IOL in one eye for near vision and an IOL in the other eye for distance vision. This technique requires adaptation, since each eye will then be oriented toward different needs.

Multifocal IOLs, or advanced technology IOLs, are a newer type of lens that treats multiple focal points and reduces or eliminates the need for eyeglasses or contact lenses after cataract surgery. Part of the rapid evolution in IOL innovations, these newer lenses are made from cutting-edge materials with unique features. This is made possible through highly specialised optics that divide light and focus it on more than one point to provide a range from near to far eyesight.

Some IOLs can also correct astigmatism at the time of surgery. These lenses will minimise the need for distance vision glasses after surgery. No single lens works best for everyone. The eye surgeon will determine the most appropriate option for the patient. With appropriate intraocular lens selection, high precision “bladeless cataract refractive surgery” has become a reality!

Dr Leo Seo Wei is an ophthalmologist at Dr Leo Adult & Paediatric Eye Specialist Pte Ltd.

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by Dr Lim Lian Arn

SOME PEOPLE LOOK forward to the Chinese New Year festivities with much joyful anticipation and a tiny bit of dread. That tiny bit of dread is the anticipation of waking up after a night of feasting with a painful, swollen big toe. The problem – gout.

The Disease of Kings

Called the disease of kings because it mainly afflicted the rich, gout has increased in frequency in populations with rising affluence and a correspondingly richer diet. Men are affected much more than women; and the overweight middle-aged male is the one most likely to be affected.

The classical presentation of gout is swelling, redness and pain at the base of the big toe. This particular presentation occurs in more than 50% of people with gout. Other joints that are commonly affected are the heels, knees, elbows and wrists. Gout can also present in other ways. Tophi are painless nodular deposits of gout crystals in the soft tissues around joints and sometimes in the ear lobes. Deposits in the kidney can sometimes lead to kidney stones and kidney failure.

The underlying cause of gout is hyperuricemia, a raised level of uric acid. There are two essential reasons for hyperuricemia – either the body produces too much uric acid or the body is unable to excrete uric acid fast enough. The causes for these include genetic predisposition, dietary habits, and other medical conditions such as diabetes and metabolic syndrome.

Diagnosis of Gout

A doctor recognises gout from its clinical presentation of joint pain and swelling. The diagnosis is supported by blood tests and sometimes by an analysis of fluid taken from the inflamed joint. Blood levels of uric acid predict the risk of developing gout, although some patients with gout may have normal levels of uric acid and some people with higher levels of uric acid may not have clinical gout.

So how do we negotiate the festive season and not encounter this disease? Unfortunately for the food lover, dietary prudence is key. In the short term, avoid or minimise foods that are rich in purines, which our body converts to uric acid. These foods include organ meats, beans and peas, and seafood, especially shellfish, sardines, herring and mackerel. The list also includes alcohol, especially beer. Other measures include avoiding high non-alcoholic fluid intake. In the long term, maintaining a healthy diet following these guidelines and regular exercise leading to gradual weight loss will also reduce one’s risk of gout.

What to do During an Acute Attack

When you have an acute attack of gout, you need to rest, elevate the affected joint, and apply ice on it. You may take an over-the-counter anti-inflammatory agent such as ibuprofen, but it is safer to get medication from a physician. Even if the attack subsides without medication, it would be wise to see a physician to evaluate the risk of future attacks or complications of gout. Depending on your test results, your doctor may start you on medications to stop pain and inflammation. These include anti-inflammatory agents such as ibuprofen, mefenamic acid, indomethacin or the newer Celebrex or Arcoxia. Later, after the acute episode subsides, he may start you on medications to lower your uric acid levels.

The long-term complications of gout include joint damage leading to arthritis, tophaceous gout leading to the deposition of painless deposits of crystals under the skin, and kidney damage from the accumulation of crystals in the kidney. The way to avoid these complications is to do an early and accurate diagnosis and adherence to treatment and dietary advice.

Moderation is Key

As the Chinese New Year season beckons, we may be tempted to recall the words of a wise man who once wrote, “So I commended enjoyment, because a man has nothing better to do under the sun than to eat, drink, and be merry; for this will remain with him in his labor all the days of his life…” But we have to balance that with a healthy dose of prudence – eat, drink and exercise in moderation, and keep your doctor’s clinic number on your quick dial.

Foods to Choose When You have Gout

• Complex carbohydrates – whole grains, fruits, vegetables
• Low fat or fat free dairy products
• Plenty of fluids, especially water

Foods to Avoid 

• Organ meats
• Herring, anchovies, mackerel
• Red meat
• Fatty fish
• Seafood – shrimp, lobster, scallops
• Alcohol, especially beer
• High fructose foods, such as corn syrup

Dr Lim Lian Arn is the Medical Director and Consultant Orthopaedic Surgeon at Alpha Joints & Orthopaedics, Gleneagles Medical Centre.

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by Dr Peter Yan

If you think YOU or SOMEONE you are with is having a heart attack, call for medical assistance immediately. Dial 995!

Thousands of people die each year because people did not seek medical help in time.

THE BAD NEWS is heart attack kills. Worldwide in 2008, 7.3 million people died from heart attack. In Singapore, heart attack is the number two killer, accounting for 18.7% of deaths. Approximately one in five deaths is due to heart attack (2010 Singapore Health Facts).

The good news is heart attack is a treatable condition. If medical attention can be given early, it is potentially life-saving. You can save your life or somebody else’s, if you know how to.

The Truth about 
Heart Attack

A heart attack occurs when one of the blood vessels (known as coronary arteries) that supply oxygen and nutrients to the muscles of the heart is suddenly blocked off. The mechanism of blocking-off a coronary artery is due to a rupture of a cholesterol plaque which has been building up in the coronary artery. The plaque rupture exposes the cholesterol material to the circulating blood with the resultant formation of a blood clot that blocks the channel of the coronary artery, leading to a loss of blood supply, oxygen and nutrients reaching that portion of the heart muscles. If the blood supply is not re-established and left shut out long enough (usually between 30 minutes to two hours), there will be irreversible muscle damage and loss of function, i.e. the inability of the heart muscles to contract. If the muscle damage is extensive enough, the heart will stop, resulting in death. Heart attack usually occurs very suddenly. When a heart attack occurs, there are many consequences.

If the heart attack is severe, the heart muscle may go into fibrillation with loss of contraction. The heart attack victim usually will collapse due to loss of blood supply to the brain and the body within seconds. And if there is no medical attention to reverse this process, brain damage will issue within two to four minutes from the time of collapse, and brain death is almost certain by 10 minutes. Thereafter, the success rate of reviving the victim is remote. It is known that at least 50% of heart attack victims will not be able to get medical attention or reach the hospital in time for the doctors to treat this condition. If delays in medical treatment are inevitable, within the next two to three hours, the bulk of the muscles of the heart will die. So even if the victim survives the heart attack, the heart function will be reduced significantly, and this will lead to heart failure and also a shortening of one’s life span.

Recognising a Heart Attack

Recognition of early symptoms and sign of a heart attack is the key to saving a life. Bear in mind that heart attack is a medical emergency.

Chest pain is usually the most common presenting symptom. The chest pain is usually sudden in onset and severe in intensity. The pain is usually described as severe crushing pain, constricting of the chest not dissimilar to a “bear hug”, vise-like grip, strangling, feeling like a heavy weight on the chest. The pain is usually associated with generalised profuse sweating (described as cold sweats) associated with difficulties in breathing. There is a sense of impending “doom”. The pain is usually located in the centre of the chest behind the breast bone. However, the chest pain may also radiate to the neck, lower jaw, the left shoulder and arm. Occasionally, it could mimic gastric pains, which is located at the lower chest and the upper abdominal area. The face of a heart attack victim looks “ashen” and pale, and lips appear white.

This is to be differentiated from other atypical non-cardiac chest pain which is usually described as brief, sharp, poking, “needle-pricking” kind of pain, lasting only for a few seconds and located in a small area of the chest. This kind of pain is rarely due to heart attack. In addition, chest pain which is related to or aggravated by chest movements and deep breathing is also not classical of heart attack chest pains. The reason to try and differentiate this is to prevent unnecessary alarm and concern and unnecessary visits to a doctor or a hospital.

What Can we do in a Heart Attack

The first thing to do is to rest the victim comfortably in a sofa chair or on the bed. Immediate alert for ambulance service or for a medical assistance is priority. If there is availability of household medications like Aspirin, this can be given, usually 100 to 300 mg of Aspirin. Some who already have medications for treatment of coronary artery disease should use them. Most important is a medication called glyceryl trinitrate (GTN). This can be administered as sublingual (under the tongue) tablet or as a spray or a dermal patch.

A patient who is suspected to have a heart attack should get to the hospital as soon as possible. As mentioned above, there is a time window of about two to three hours before the heart muscles are irreversibly damaged. A heart specialist can salvage the heart muscles to prevent extensive damage when he can be reached within the time window.

In the Hospital

The heart victim will be identified immediately and rushed to the coronary intensive care unit where several tests including a 12-lead ECG, cardiac enzymes (CK-MB and cardiac Troponins) will immediately confirm the diagnosis of a heart attack. The patient will be administered blood-thinning medications and will be rushed to the coronary interventional lab and undergo an immediate procedure called coronary angiography.

In the cardiac catheterisation lab, an interventional cardiologist will perform a procedure called coronary angiogram to visualise the status of the coronary arteries so as to determine which artery/arteries are acutely blocked off by clots. This usually takes less than five to 10 minutes to do. Once this has been determined, the effective way to save a heart attack patient is to deliver an aspiration catheter to suck out the blood clot at the site of the blockage and then to follow by the deployment of a stent (a metal scaffolding) to hold and support the artery up. Immediately when this has been completed, the blood supply will return to that portion of the muscles of the heart, providing oxygenation and nutrition to the muscles. This way, the heart attack is aborted and the amount of heart muscle damage will be minimised. There is almost immediate relief of the severe chest pain as well as stabilisation of the patient.

The patient will stay in the hospital for three or four days more and will then be discharged with blood-thinning medications to prevent further clot formation. He or she will also be given a series of medications to reduce cholesterol and to improve the function of the heart.

Pointers to Prevent a Recurrent Heart Attack

• Ideal body weight (BMI 18.5 to 24.9 kg/m2)
• LDL-C < 70 mg/dl  BP = 130/80 mmHg
• Healthy diet – Low in cholesterol/trans fat and carbohydrates
• Regular cardiovascular fitness exercise
• Medications – Aspirin/clopidogrel/statins/ACEI/betablocker
• If diabetic – HbA1c 6.5% to< 7% (fasting blood sugar < 7.0 mmol/L or 126 mg/dl); ideally < 6.0 mmol/L or 108 mg/dl
• Smoking cessation
• De-stress programmes

Dr Peter Yan is the Medical Director of Parkway Heart & Vascular Centre and Consultant Cardiologist at Gleneagles, Mt Elizabeth & Mt Elizabeth Novena Hospitals

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