Download A New Centre for Nutritional Science Opens

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.”
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FEATURE
FOOD
FOR
THOUGHT
The recently launched Clinical Nutrition Research
Centre lends scientific credence to the realisation
that food is the best medicine.
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“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
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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
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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
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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
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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.”
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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.
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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
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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
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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.
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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
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