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No. 5 | April 2014 A quarterly publication of the NUHS FOOD FOR THOUGHT A NEW CENTRE FOR NUTRITIONAL SCIENCE OPENS PAGE 02 SECOND OPINION THE MAKING OF a NUHS RESIDENT Evidence+_Cover_Apr_FA.indd 1 CLINICAL CARE FINDING NEMO BENCH TO BEDSIDE HOPE FOR ALL 3/12/14 11:12 AM No. 5 | April 2014 CONTENTS FEATURE Food for Thought A New Centre for Nutritional Science Opens Solutions to dietary and nutritional problems among Asians are at hand. Read about it on page 02 Dear Reader, There is a small room tucked away on the seventh floor of a building on Medical Drive that is unlike any other in Singapore—or pretty much anywhere else in Asia. The prison cell-sized room is kitted out with a bed, a desk, an exercise bike and a toilet, and it was specially designed to measure oxygen consumption as well as carbon dioxide production of a volunteer test subject, who may spend as long as 48 hours in the chamber. Called a whole-body calorimeter, this intriguing room is part of the facilities in the newly opened Clinical Nutrition Research Centre (CNRC). It was established to provide dietary solutions to Asian nutritional problems. Put simply, the CNRC aims to help us get the best out of what we eat, so that we are the better for what we eat. The CNRC’s establishment couldn’t have come at a better time: Asian diets are shifting from traditional high-carbohydrate, low-fat based ones to ones that are high in fats, cholesterol, sugar and other refined carbohydrates. These new diets, together with the adoption of sedentary lifestyles associated with urbanisation, are fuelling “an epidemic of obesity,” noted Professor Tan Chorh Chuan, NUS President and National University Health System Chairman, in an article for the University of Melbourne last year. In another first for Singapore, an extensive study by clinician-scientists from the National University Cancer Institute, Singapore, and the National University Hospital (NUH) has uncovered certain characteristics of microRNA 335, a regulatory gene that can raise the survival chances of young leukaemia patients. This discovery allows doctors to design treatment regimens that will help patients with poor prognoses. Yet another first: a recent, packed symposium addressed issues of sexuality faced by cancer survivors and patients. The emotional, psychological as well as physical difficulties that they grapple with on the long road to recovery are not topics of everyday conversation in a conservative Asian society like Singapore, according to a gynaecological oncologist and a psychiatrist. But it is a conversation that has finally begun. Last, and also a first, the NUH and the National Healthcare Group Polyclinics have teamed up to help patients at the early stages of Diabetic Kidney Disease. Through the Nephrology Evaluation, Management and Optimisation programme, staff remind patients when their check-ups are due, when to go for screening for diabetic kidney disease, how their medication dosage is adjusted, if any, and what constitutes a healthy diet for their condition. The results—fewer patients suffering complications. And so, this issue of Evidence+ is a celebration of a quartet of firsts. Their outcomes promise to bring about progress and change for the better for patients, as well as for every one of us. 01 FYI 06 GRAND ROUNDS Life, Love & Cancer 08 CLINICAL CARE Finding NEMO 09 THE PROFESSIONS Mind & Body 10 BENCH TO BEDSIDE Hope for All 12 SECOND OPINION The Making of a NUHS Resident INSIDE BACK ON THE BACK GEAR Sensei Shows the Way FAST FACTS Supporting Natural Birth Evidence+ is published quarterly by the Communications Office of the National University Health System, 1E Kent Ridge Road, Tower Block, L13, Singapore 119228. Please address comments to [email protected]. Edited and designed by: Copyright © is held by the publishers. All rights reserved. Reproduction in whole or in part without permission is prohibited. Printed in Singapore by NPE Print Communications Pte Ltd. MCI (P) 074/03/2014 The Editorial Committee www.novusasia.com IFC_NUHS_Evidence+_TOC.indd 2 3/13/14 11:59 AM The Business Times © Singapore Press Holdings Ltd. Reproduced with permission. FYI MOTORISED HOSPITAL BEDS The Straits Times © Singapore Press Holdings Ltd. Reproduced with permission. Moving a hospital bed used to be a twoperson job—one at the back to push, one at the front to lead and navigate. However, with the SESTO—a motorised, omni-directional wheel that can be easily clipped onto hospital beds—only one person is required. Manoeuvring is done from a control panel at the foot of the bed. The operator doesn’t even have to walk, as he can stand on a flip- down platform if he chooses. The SESTO comes with a nifty safety feature: the bed comes to a halt when the operator’s hand breaks contact with the panel. This cool contraption is based on an invention by Dr Yu Haoyong, from the Department of Medical Engineering at the National University of Singapore (NUS), and developed in collaboration with HOPE NEW ‘EYES’ FOR SURGERIES The NUH is working with technology companies Sony and Olympus to finetune a cutting-edge 3D imaging system for operating theatres and surgical training facilities. It is believed that the system will benefit even experienced surgeons, especially in the field of keyhole surgery. As 3D technology restores depth perception lost in regular twodimensional imaging, it gives medical professionals a truer spatial view of the patient’s anatomy. Although it’s an old technology, it was only recently enhanced and refined enough for surgeons to use without them getting nauseous and giddy. “3D or stereoscopic vision improves patient safety, reduces mental fatigue for surgeons, is more ergonomic and less tiring,” says Associate Professor Davide Lomanto, a senior consultant with the Department of Surgery at the NUH. Fifty surgeons surveyed in Germany reported that they showed improvements in surgical precision Technik, a privately owned, Singapore-registered, highperformance engineering company. Test-bedding of SESTO prototypes began in Sep 2013 at the National University Hospital (NUH) under the direction of Mr Melvin Loh and Ms Rachel Hong, from the Medical Engineering Research & Commercialization Initiative (MERCI) at the NUS Yong Loo Lin School of Medicine. “We plan to commercialise this product by early 2014,” says Mr Manolo Sta Cruz, an engineer with HOPE Technik. “I am happy to see my research work being brought to fruition via an inter-faculty collaboration between the NUS Faculty of Engineering and the NUS Yong Loo Lin School of Medicine,” says Dr Yu, underlining the interdependency of the various aspects of healthcare. and speed when they used this new technology. A/Prof Lomanto himself has been able to halve the duration of hernia repairs and stomach reductions, and predicts that the technology will be employed for most keyhole surgeries in a few years. The NUH helped in the clinical evaluation and to introduce this new 3D technology to a wider audience. “Surgeons had an opportunity to watch a live transmission of 3D surgery and have a real contact with 3D technology in a hands-on session,” reveals A/Prof Lomanto. “For the very first time, a live surgery demonstration was performed using 3D laparoscopic camera system, and the audience had the opportunity to be immersed in a 3D environment by watching surgical procedures in 3D.” 01 1_NUHS_Evidence+_FYI_FA.indd 1 3/13/14 10:03 AM FEATURE FOOD FOR THOUGHT The recently launched Clinical Nutrition Research Centre lends scientific credence to the realisation that food is the best medicine. 02 2-5_NUHS_Evidence+_CNRC_FA.indd 1 3/13/14 11:00 AM “We are in the midst of a global food revolution, where food is not only for sustenance, but food becomes medicine.” — Prof Jeyakumar Henry, CNRC Director T he chamber is cramped, brightly lit and spotless. There’s only enough room for the bare essentials—bed, desk, toilet—and an exercise bicycle. The door is surprisingly heavy, as though it’s meant to prevent either entry or egress. There are two portholes through which food is delivered to the suite’s temporary resident. But this is not a prison cell. It’s called a ‘whole-body calorimeter.’ The calorimeter measures a person’s energy intake and output for the purpose of studying the science of nutrition. And you’ll find a pair of them—along with a range of cutting-edge equipment [see sidebar]—in the Clinical Nutrition Research Centre (CNRC). The Centre, which launched in Jan 2014, aims to promote healthier lifestyles by better understanding how the food we consume affects us. After all, as the saying goes, “You are what you eat.” Located in the Yong Loo Lin School of Medicine at the National University of Singapore (NUS), the CNRC is a $20 million joint venture between the Agency for Science, Technology and Research (A*STAR) and the National University Health System (NUHS). It will collaborate with academia and industry to develop a broad knowledge base and then translate those findings into applicable solutions, such as food products and diet programmes. “The CNRC is a one-stop research centre that applies state-of-the-art technology to address contemporary nutritional issues,” states Professor Jeyakumar Henry, Director, CNRC. “The research and technological expertise that we have here will provide deep and clear dietary solutions to nutritional problems among Asians.” While there are similar institutions dotted across the globe already, the CNRC is the first of its kind in Asia. Having access to Singapore’s multiethnic population means the CNRC will be able to focus on the Asian phenotype. Research conducted there, unlike those from centres located in the West, will be applicable to patients from Taiwan to Thailand—or more than half of the world’s population! “We are in the midst of a global food revolution, where food is not only for 03 2-5_NUHS_Evidence+_CNRC_FA.indd 2 3/13/14 12:01 PM Left: Prof Jeyakumar attends to a young subject in the BodPod. Above: The sensory booth uses white, red, green and blue lights to investigate the effect of colour on the way we eat. sustenance, but food becomes medicine,” Prof Jeyakumar declares. “Food is the new medicine. This concept is not new in this part of the world, where both traditional Chinese and Indian medicines have for millennia understood the link between food and medicine. But we are seeing a renaissance in this idea that is sweeping all across the world. And right in the heart of this nexus is nutrition, the link between food and health.” But with a field as broad as this, where will Prof Jeyakumar and his team start? TOP PRIORITIES The CNRC has opened at the right time for Singapore. Type II diabetes and obesity, both strongly linked to food, are two increasingly worrying problems for the citystate. From 1998 to 2010, obesity and diabetes rose by five percentage points and two percentage points respectively. Confronting the twin threats of obesity and diabetes are the CNRC’s biggest task. To that end, Prof Jeyakumar and his team will study: • how food components and ingredients influence glucose uptake • how the structure of food (carbohydrates, proteins, fats, etc) leads to certain metabolic outcomes • how blood glucose can be modulated to minimise spikes in blood glucose level, effectively lowering the risk of diabetes Combating these twin public health concerns is one of five priority research themes the CNRC has established. The others are: • regulation of body weight • the senses and nutrition • women and children’s nutrition • nutrition in the elderly According to Prof Jeyakumar, studying nutrition as it applies across the human life cycle will allow the Centre to “The key is to grow highly competitive clinical research in nutritional science, and to build the nutrition and food industries in Singapore.” — Prof Tan Chorh Chuan, NUHS Chairman enhance the health and wellness of future generations. Professor John Wong, chief executive of the NUHS, says Singapore is witnessing an explosion of diabetes. “So what are the issues behind that? We’ve always said that Singapore has to study problems that its population faces. We cannot expect the rest of the world to study a problem that may not be as relevant to them as it is to us.” To achieve its goals, the CNRC will deploy a multidisciplinary team of researchers and scientists, stresses Prof Jeyakumar. Collaborations with other institutions—such as A*STAR, the EpiGen Consortium and the Monell Chemical Senses Center—ensure that CNRC explores all angles to the relationship between food and health. There are even plans for the CNRC to develop post-graduate courses in nutrition with the NUS. “The CNRC brings together researchers across a broad spectrum of disciplines, from basic sciences in A*STAR and the NUS to clinical nutrition and medicine in the NUHS,” adds Professor Tan Chorh Chuan, chairman of the NUHS. “The key is to grow highly competitive 04 2-5_NUHS_Evidence+_CNRC_FA.indd 3 3/13/14 12:03 PM clinical research in nutritional science, and to build the nutrition and food industries in Singapore.” IN THE PIPELINE The CNRC already has a slew of programmatic and strategic collaborations lined up. One of the bigger projects it is involved with is the Singapore Centre for Nutritional Sciences, Metabolic Diseases, and Human Development (SiNMeD). SiNMeD began in 2013 as a partnership between A*STAR and the NUHS, and has been awarded $148 million over three years to: • anticipate novel discoveries that improve the health of Asians • develop talent in the nutritional sciences • attract investments from the industry Adds the founding director of SiNMeD, Associate Professor Chong Yap Seng, “One of the approaches we are taking is to see how we can modify factors such as pre-pregnancy, pregnancy and early-life nutrition and lifestyle to promote health and prevent diseases, especially non-communicable diseases such as obesity and diabetes. The CNRC will bring new precision to our understanding of how food can be used for good.” Additionally, the CNRC will be working on two programmatic collaborations: • The Singapore Gastric Cancer Consortium and Genetic Predilection, Epigenetic Change, MicroRNA Profiling • Experimental Therapies in Heart Failure The former strives to improve the early detection of gastric cancer as well as the treatment of the disease; the latter has set its sights on using genetic products to predict the onset of heart failure. Both programmes have already commenced. Courting the food and nutrition industry is also a crucial move in the CNRC’s game plan. The Centre will assist top-tier companies such as Abbott, Nestlé and Danone, all of which have R&D centres in Singapore, in strengthening innovation and developing food products that are as delectable as they are nutritious. For example, rice and bread that can lower blood glucose levels without tasting any different—perfect for diabetics. Engaging in science that has a commercial spin-off, according to Prof Jeyakumar, is part of the CNRC’s very clear vision. “We have the best ensemble of techniques and technology in nutritional research,” he sums up. “I want to end by making two comments. In 1825, the great French gastronome, Jean Brillat-Savarin, uttered these immortal words: ‘Tell me what you eat and I will tell you who you are.’ But I want to propose a Singaporean parallel, which is: ‘Tell me what you eat, and I will tell you what you ought to eat.’” A technician using the DEXA scanner on a subject. HARD SCIENCE The equipment used in the CNRC won’t look out of place on the set of a sci-fi movie. Here are a few of them. Whole-body Calorimeter • Two units in the CNRC, the first Centre in Asia to operate these systems • Subjects will live in the 12m3 chamber for a couple of hours to a few days, depending on the study • Measures oxygen consumption and carbon dioxide production • Determines human energy balance to better understand obesity and its related disorders BodPod • A capsule that measures body composition using air displacement plethysmography technology • Monitors difference in air pressure when empty and when a subject is inside • Replaces the previous standard of using water with air Sensory Booths • Investigates how taste, odour, colour and texture affect appetite, food intake and satiety • White, green, red and blue lights bathe the entire room in different colours, depending on what is required DEXA Scan Room • A non-invasive method to measure total body composition such as the percentage of body fat Roche Cobas Machine • Measures metabolites using immunoassay Food Development Kitchen • Develops new food for testing • Equipped with stoves, tabletops and cooking implements Food Analysis Lab • Analyses protein, carbohydrate, moisture and fat in food, drinks and biological samples 05 2-5_NUHS_Evidence+_CNRC_FA.indd 4 3/13/14 12:02 PM GRAND ROUNDS life, love & cancer For many cancer survivors, entering remission isn’t the end of their problems, but the beginning of new ones. Two experts explain how fighting the disease involves more than just the body. A ltered body image. Chronic pelvic pain. Frequent diarrhoea. Difficulty reaching orgasm. Loss of clitoral sensitivity. These are some of the consequences women have to contend with when they are afflicted with gynaecological cancers—uterine cancer, ovarian cancer and cervical cancer are among the top 10 cancers afflicting Singaporean women. Breast and colorectal cancers, the first and second most common diseases, obviously come with their own sexual and emotional issues. Triple whammy It’s a cruel irony that the harder one fights against cancer, the more one is likely to develop scars—both mental and physical. Cancer treatment, says Associate Professor Jeffrey Low, Head, Division of Gynaecologic Oncology, National University Cancer Institute, Singapore (NCIS) and Senior Consultant, Department of Obstetrics and 06 6-7_NUHS_Evidence+_Life,Love & Cancer.indd 1 3/12/14 10:12 AM A/Prof Jeffrey Low Gynaecology, National University Hospital (NUH), revolves around three main modalities: surgery, chemotherapy and radiotherapy. Many patients require multiple modalities, if not all three. “While they are very effective at bringing about remission, they carry their own side effects and long-term impact.” Treatment often means removing the affected organs entirely. Although it results in remission, the patient could now feel less of a woman as there is “loss of fertility or loss of sex drive,” details A/Prof Low. In addition, surgical scars and stomas may mark the patient’s body, severely affecting her self-esteem. These issues can then radiate outwards to affect her family as well. More than a cure A/Prof Low says that it is vital that these realities are addressed by carers. “After healing them physically, what about the emotional and sexual aspects?” he asks. Even radiotherapy, which he points out is fairly gentle, carries a raft of side effects that can remain 10 or 20 years down the road: diarrhoea, irritated bladder, blistered skin and a narrowing of the vagina. It used to be that cancer patients and doctors only talked about being cured (ie. remission). It’s time to realise that we can and should aim for more. “Although cured,” notes A/Prof Low, “patients need to be able to go back to the person—wife, mother—they were before.” That’s why events such as the recent Cancer & Sexuality Symposium are important. Open to professionals and the public, it covered practical topics that are often neglected because they are either too intimate to be discussed, or regarded as unimportant. Talks on topics such as ‘Staying Sexual after Cancer—Practical Guide on Intimacy’ were designed to change these mindsets. Mind & body A/Prof Low spoke at the event, as did Dr Cornelia Chee, Director and Senior Consultant, Women’s Emotional Health Service, NUH. The two doctors have developed a framework for cancer patients that ensures that their emotions are as closely monitored as their physical symptoms. In fact, a case manager is embedded in the gynaecological oncological team. “She follows the team on their rounds every morning,” describes Dr Chee. “They see her as part of routine care. She will take time to talk to the patients and do a full psychiatric and psychosocial assessment.” As “After healing them physically, what about the emotional and sexual aspects? Although cured, patients need to be able to go back to the person—wife, mother—they were before.” — A/prof JEFFREY LOW an advanced practice nurse, the case manager sees all patients in question, and will follow up to make sure they’re doing all right. Is all this really necessary? Unfortunately, says Dr Chee, it very much is. NUH data shows that roughly half of such patients have a psychiatrically diagnosable illness. She is quick to point out that a large part of this is something known as ‘adjustment disorder,’ namely the stress one faces when adjusting to a life-threatening illness. “On follow up post-surgery, most patients no longer Dr Cornelia Chee fall into this group,” she reveals. “But we do have a small proportion of patients who have severe depression, anxiety or a pre-existing psychotic illness. We have to look out for them.” An unfair fight Although the general thinking is that the younger you are, the healthier you’ll emerge after sparring with cancer, Dr Chee has anecdotal evidence that suggests otherwise. From an emotional point of view, she argues, younger women tend to be harder hit by illness. A woman in her 60s or 70s tends to be less sexually active than a female a generation younger. “So if you get a gynaecological cancer later in life, it’s less likely to impact your sexual function.” But for younger women, “for whom sexual function is more important, that correlates to a lower quality of life.” This is just one of the complexities that makes cancer so difficult to fight. Often, Dr Chee explains, it is only when treatment stops that the emotional sucker-punch really hits. “In fact, patients are often less anxious when undergoing active treatment like chemotherapy,” she muses. The side effects can be excruciating, of course, but they are to be expected. “In their minds, the patients are also thinking ‘I’m doing something active to fight this.’” As such, Dr Chee sees a lot of patients who experience an increase in anxiety once treatment stops. Patients “are just watching and waiting to see if there’s a recurrence.” Total care With social, psychological and sexual issues more widely acknowledged nowadays, it is hoped that these sucker-punches can be dodged. A lot of it, insists A/Prof Low, comes down to how doctors view those they treat. “We should treat not just the cancer but also manage the patient as holistically as possible.” 07 6-7_NUHS_Evidence+_Life,Love & Cancer.indd 2 3/13/14 12:03 PM CLINICAL CARE FINDING NEMO The incidence of diabetes-derived kidney complications can be slashed just by getting patients to abide by diets, regular tests and drug dosage adjustments. This is all done by coordinators from the new NEMO programme. F or most of us, the word ‘Nemo’ conjures up images of a cute animated fish. But it’s also an acronym for a disease management programme targeted at diabetics and their caregivers. The Nephrology Evaluation, Management and Optimisation programme is a joint effort by the National University Hospital (NUH) and the National Healthcare Group Polyclinics (NHGP) to help patients at the early stages of Diabetic Kidney Disease (DKD). NEMO coordinators will remind patients when their checkups are due, when to go for screening for DKD, how their medication dosage is adjusted, and what constitutes a healthy diet for their condition. Fishing for problems In Singapore, kidney disease is the ninth leading cause of death while diabetes is the leading cause of kidney failure. NEMO was implemented in 2011 to bring those numbers down. A 2009 study found that every year, more than 7% of Singaporeans with earlystage DKD went on to develop advanced stages of DKD. But among NEMO patients, that proportion was about half of what the study found. The striking results came about because of simple measures. Early detection and treatment is vital, so monitoring blood pressure and regular blood and urine tests are effective tools in the fight against DKD. The urine tests detect the protein, albumin, high levels of which indicate kidney problems likely due to DKD. As a result of this focused care, 29% of those with DKD enrolled in the programme saw their albumin levels return to normal over time; 11% saw their DKD reversed from advanced to early stage, thus adding years to their life expectancy. “We are very encouraged by the results of our NEMO programme, which required much collaboration between nephrologists from The NEMO team: Dr Loh (standing, left), Ms Samantha Ong (standing, right, the programme manager), Dr Lim (seated, right) and Prof Vathsala (seated, left). the NUH and doctors from the NHGP to review the treatment guidelines and therapy dosage for DKD patients,” says Dr Loh Ping Tyug, Co-Programme Director of NEMO and Consultant, Division of Nephrology, NUH. Helping patients help themselves The success of NEMO is largely due to the fact that it is not viewed as a crutch. Dr Lim Chee Kong, Co-Programme Director of NEMO, and Deputy Director of Clinical Services and Family Physician-Consultant, NHGP, explains, “Our doctors work with the NEMO coordinators to spend time with the patients to understand their lifestyle, advising them to modify areas where necessary so as to empower them to manage their conditions better.” Given that a 2010 National Health Survey saw a diabetes prevalence of 11.3% among those aged 18–69, there are many more who can benefit from NEMO. Nearly 50% of diabetics were not even aware that they had the condition. Among those who were aware, nearly one in three had poor control over their condition, which can lead to complications, chief among them DKD. “We still have a population of 30,000 to 40,000 diabetic patients whom we haven’t looked into, so that’s next for NEMO. The best prevention for diabetics is really at the primary care with early detection and treatment optimisation,” says Professor A Vathsala, Head, Division of Nephrology, NUH, and Programme Director of NEMO. Looks like DKD rates are likely to sink further into Nemo (the fish, not the programme) territory. 08 8_NUHS_Evidence+_NEMO.indd 1 3/12/14 10:25 AM MIND & BODY THE PROFESSIONS Helping her patients deal with sexual dysfunction gives Dr B Srilatha much satisfaction. Dr B Srilatha is not above prescribing her patients a touchy-feely sort of physiotherapy. The clinical sexologist at the National University Hospital says touching yourself is a crucial part of sexual health, and recommends it to those who have problems in the bedroom. Dr Srilatha routinely talks to her patients about what goes on in there. As a clinical sexologist, she uses biology, physiology, psychology and sociology (called the ‘biopsychosocial approach’) to diagnose sexual issues such as erectile dysfunction and vaginismus. Treatment usually involves therapy, counselling, drugs and even surgery—but getting people to talk about what happens between the sheets is not easy. According to the doctor, most people are uncomfortable talking about their bedroom activities. As sexual concerns aren’t usually life threatening, people often ignore them or postpone seeing a professional. “It’s still kind of taboo [in Asia],” sighs Dr Srilatha. “So you have to create a rapport [with the patient] first and then open up a discussion on this. But it takes time.” When patients do seek her help, Dr Srilatha first identifies their complaints before assessing their sexual history in detail. As she consults predominantly female patients of all ages (her youngest patient is 14; the oldest, 66), those concerns range from menopausal symptoms to intolerably painful sex to the struggle to conceive. At times, her patients have other medical conditions, such as cancer, that affect their sex lives. She then searches for the presenting problem and tailors a course of treatment based on the complaints. Dr Srilatha employs in most of her cases the PLISSIT model: Permission Giving, Limited Information, Specific Suggestions and Intensive Treatment. ‘Permission giving’ means reassuring the patient, and ‘Limited Information’ is, for example, letting someone undergoing menopause know its effects on a relationship. “Then, ‘Specific Suggestions’ would be what she can do to cope, adapt and acclimatise to these changes,” Dr Srilatha adds, “and ‘Intensive Treatment’ refers to the various intervention options.” COUNSELLOR & THERAPIST About 18 years ago, while embarking on her PhD in Sexual Medicine at the National University of Singapore, Dr Srilatha met Professor P Ganesan Adaikan of the Department of Obstetrics & Gynaecology at the Yong Loo Lin School of Medicine. It was Prof Ganesan who spurred her to pursue clinical sexology. Today, she splits her time between the office and two weekly sessions at the clinic. “There’s quite a bit of research work,” she discloses. In those clinical sessions, Dr Srilatha takes on the twin roles of counsellor and therapist. If a patient comes to her, say, with vaginismus—a condition in which a woman is unable to engage in vaginal penetration— she will first counsel the patient alone. “We don’t even have a nurse there,” she reveals. “Then they are able to confide every detail. We then call the husband in and make him understand what [his wife] is going through. It becomes couple therapy. And then we give them some kind of assignment or homework.” If the issue persists, Dr Srilatha will suggest medical treatment: drugs, plant products, moisturisers, lubricants and, in rare cases, surgery. When asked if she finds her work difficult, she replies, “No, it’s not. It’s interesting, and it’s about helping the patients. In the end, when they understand what they’re going through and they’re happy with making a behavioural change or lifestyle modification, then I’m pleased that my work has helped them.” Dr Srilatha counselling a patient in her clinic. 09 9_NUHS_Evidence+_Sexiologist_D2.indd 1 3/14/14 4:04 PM BENCH TO BEDSIDE HOPE FOR ALL The discovery of a link between paediatric leukaemia and the microRNA 335 gene may increase the rate of survival for young patients suffering from the disease. C olorectal and breast cancer are the No. 1 cancers for men and women respectively in Singapore. Sadly, cancer doesn’t spare children, for whom acute lymphoblastic leukaemia (ALL) is the most prevalent form in Singapore as well as the rest of the world. The name sounds rather intimidating, but it’s not all bad news. Patients suffering from ALL generally respond well to treatment, but 10–15% relapse. Doctors are troubled by this 10–15% who do not fare nearly as well. Prednisolone and its sister drugs are key chemotherapy drugs given to all ALL patients. Those who fall into the 10–15% group are resistant to the drugs—something in the patient’s body is preventing the drugs from fighting the leukaemia cells. For years, scientists have been trying to figure out what that ‘something’ is. Solving that riddle was the subject of an extensive study led by Associate Professor Chng Wee Joo from the National University Cancer Institute, Singapore (NCIS), and Associate Professor Allen Yeoh from the National University Hospital (NUH). They have unveiled certain characteristics of microRNA 335 (miR335), a regulatory gene that has the potential to boost the survival chances of young leukaemia patients. BREAKING THE CODE A study of bone marrow samples collected from 136 paediatric leukaemia patients revealed that miR-335 plays a crucial role in how patients respond to treatment for cancer. It was found that the level of miR-335 expression is related to the clinical outcome in prednisolone treatment. “MiR335 controls the mitogen-activated protein kinases (MAPK) pathway, which is important for the therapeutic effectiveness of prednisolone. When miR-335 is at a low level, the MAPK pathway is activated. This leads to They have unveiled certain characteristics of microRNA 335 (miR-335), a regulatory gene that has the potential to boost the survival chances of young leukaemia patients. prednisolone resistance, which explains the poorer clinical outcome,” explains A/Prof Chng. Based on the expression levels of miR-335, doctors can now work out the risk level of a child with leukaemia and his rate of survival at the point of 10 10-11_NUHS_Evidence+_Hope for all.indd 1 3/13/14 12:06 PM A/Prof Chng Wee Joo A/Prof Allen Yeoh diagnosis. That way, the right amount of treatment can be administered, thus preventing or reducing the severity of side effects. Furthermore, when combined with other diagnostic methods, the genetic indicator enables doctors to better plan treatment strategies for paediatric leukaemia patients. HARNESSING SYNERGIES One of the key factors that contributed to the success of the study was the synergy among the NUH, the NCIS and the Cancer Science Institute of Singapore (CSI Singapore). Bone marrow samples were collected by clinicians in the NUH, then stored and made readily available for the NCIS and the CSI Singapore to study. In fact, the crossexamination of patients who were cured and those who experienced adverse outcomes was exactly how the researchers discovered ALL’s Achilles’ heel in miR-335. Since tests conducted in a laboratory environment can differ in many ways from real-world results, being able to move quickly between the laboratory and the patient in the hospital was a boon to the study as a whole, reveals A/Prof Chng. A/ Prof Yeoh adds, “The work that we are doing here at the NUH, the NCIS and also the CSI Singapore is a very good example of the adult-paediatric capabilities and synergies that the National University Health System is able to deploy as an academic medical centre.” Looking ahead, there are already cancer drugs being tested in clinical trials that could reverse drug resistance. Researchers are also working on adapting this paediatric treatment protocol for adult cancer trials. The team behind this study hopes that, in time, the benefits of their research will reach an even wider population, thus providing all leukaemia patients—both children and adults—with a better quality of life in the long run. 11 10-11_NUHS_Evidence+_Hope for all.indd 2 3/12/14 11:05 AM A/Prof Shirley Ooi SECOND OPINION THE MAKING OF A NUHS Resident Training medical residents is not only about imparting clinical knowledge. It’s also about encouraging concern for others and stoking curiosity about medical mysteries, insists Associate Professor Shirley Ooi, Designated Institutional Official of the NUHS Residency Programme. W hat makes a great institution is its people. In 2010, when the Ministry of Health introduced the Accreditation Council of Graduate Medical Education—International Residency System to Singapore, the NUHS took the opportunity to go beyond producing competent specialists: we wanted leaders who will shape the future of medicine in Singapore and beyond. As such, we recognised that we needed to train their minds, mould their hearts, and imbue them with our institution’s corporate values (Teamwork, Respect, Integrity, Compassion, Excellence). The saying “It takes a village to raise a child” is an apt description of the way the programme works. It begins with choosing the correct people to be on board. Together with our CEO and Chairman Medical Board (CMB), we select specialists who have nurturing and mentoring attributes. Team bonding Our signature bonding programme is a three-day, two-night orientation course at Outward Bound Singapore. Also in attendance are senior management, programme directors and associate programme directors, nursing colleagues and me. Through activities such as kayaking, climbing and raft building, our residents see and experience what TRICE values mean. Residents who attend never fail to respond with enthusiasm. “We started off not as colleagues, but as friends, as family!” one former resident reminisces. serving the community One cannot lead unless one has first learned to serve. That’s why our residents are encouraged to give their time and effort to help the wider community, especially the underprivileged, through participation in local and overseas outreach programmes. Through these, our residents also gain exposure to more challenging healthcare environments. Creativity encouraged The Residency Programme also aims to produce people who think creatively, with a strong emphasis on research. The Resident Research Committee, the brainchild of one of our residents, was established to encourage research among residents. The Junior Pitch for Fund is an event we conduct biannually to encourage residents to propose research ideas, receive feedback from judges who are experienced researchers, and obtain start-up grants to test their concepts. To elicit enthusiasm, the NUHS has introduced a Clinician Scientist grant of S$15,000. We are very encouraged that our residents have stepped up to become mentors themselves. Among this year’s 21 Outstanding Tutor Awards handed out by the NUS Medical Society, three out of 10 recipients from the NUHS are Senior Residents/Registrars. Finally, residents are also exposed to decision-making processes through representation at the monthly hospital Medical Board meetings attended by Heads of Departments and other senior staff. We believe that our Residency Programme is producing competent doctors who are also able leaders and managers, and they will be a vital part of a corps of medical professionals who will be responsible for Singaporeans’ healthcare in the coming years. 12 12_NUHS_Evidence+_Residency Programme.indd 1 3/13/14 11:03 AM GEAR SENSEI SHOWS THE WAY The National University Heart Centre, Singapore (NUHCS), has a new Hansen Sensei-X Robotic Catheter System that provides a more precise way to treat patients with heart arrhythmia. Heart rhythm disorders (arrhythmias) are often amenable to treatment or cure through ablation, which uses heat energy to destroy abnormal areas of the heart causing these arrhythmias. Remote Workstation Multi-dimensional View Doctors operate the Sensei-X robot from a remote workstation using a joystick and 3D mapping system. This reduces radiation exposure to doctors, staff and patients, and lowers the risk of musculoskeletal injuries from heavy X-ray protective equipment. Instead of relying solely on X-ray imaging to perform the procedure, the system also comes with a sophisticated 3D mapping system that provides an accurate, real-time look at the heart. Control & Stability The system allows doctors to scale the movement of the joystick at a 4:1 ratio—a movement of 4cm on the joystick translates to a movement of 1cm on the catheter—thereby increasing the degree of control and stability. All Rhythm, No Blues Atrial fibrillation (AF), a form of heart arrhythmia, has always been a pressing health issue in Singapore and other parts of the world. Arrhythmia affects approximately 50,000 Singaporeans and is associated with 15% of all stroke cases. AF can be treated with ablation therapy. Conventionally, a catheter is manually inserted into the heart to deliver heat energy to the heart muscle to prevent abnormal electrical activity in IBC_NUHS_Evidence+_Gear_Hansen Sensei.indd 1 Robotic Catheter The robotic catheter is highly manoeuvrable, allowing it to reach inaccessible areas of the heart during ablation therapy. The Sensei-X’s builtin feedback system allows doctors to know the exact amount of pressure to apply, leading to higher precision. the pulmonary veins from disrupting the heart rhythm. The new Hansen Sensei-X Robotic Catheter System can increase procedural accuracy and make it safer for patients. Dr Seow Swee Chong, clinical director of the Heart Rhythm Programme at the NUHCS, says, “With the ageing population and the increased prevalence of hypertension and heart disease, we expect to see more patients with AF, who will benefit from treatment using this machine.” 3/12/14 11:06 AM FAST FACTS Supporting Natural Birth The Enhanced Midwifery Maternity (EMMa) Care is an optional service offered by the National University Hospital that makes available the expertise of midwives to pregnant women already under the primary care of obstetricians. Launched in 2011, EMMa Care is gradually gaining acceptance by Singaporean mothersto-be, especially those who prefer natural, unassisted births. 7 30 number of Singaporean women who chose EMMa Care WHEN IT WAS FIRST LAUNCHED 10 weeks number of Singaporean women who chose this PROGRAMME in 2013 8 weeks how long the programme lasts after she has given birth how early in her pregnancy a woman can enrol 4 number of midwives in the programme 3 in 4 proportion of women in the programme who gave birth unassisted (no C-sections and no instruments such as forceps and vacuum suction) *all information accurate as of Jan 2014. OBC_NUHS_Evidence+_Fast Facts_Natural Birth.indd 1 3/12/14 11:07 AM