MAY JUN 2018

THE FLAGSHIP PUBLICATION OF THE SINGHEALTH DUKE-NUS ACADEMIC MEDICAL CENTRE MCI (P) 039/04/2018

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IPPT FOR SENIORS DETECTS FRAILTY AT EARLY STAGE

P3 06 Artificial intelligence in eye care

08 More pre-hospital emergency care ahead

17 Why he’s called the ‘Mad Scientist’

21

PHOTO: ANGELA GUO PHOTO: When teenagers still wet their beds

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All rights reserved. Copyright by SGH (registration no: 198703907Z). Opinions expressed in Singapore Health are solely those of the writers and are not necessarily endorsed by SGH, SingHealth Group and/or Focus Publishing, a subsidiary of Singapore Press Holdings Ltd (registration no: 198402868E), and their related companies. They are not responsible or liable in any way for the contents of any of the advertisements, articles, photographs or illustrations contained in this publication. Editorial enquiries should be directed to the Editor, Singapore Health, 168 Jalan Bukit Merah, #13-01 Surbana One, Singapore 150168. Tel:+65 6222-3322. E-mail: [email protected]. Unsolicited material will not be returned unless accompanied by a self-addressed envelope and suff icient return postage. While every reasonable care will be taken by the Editor, no responsibility is assumed for the return of unsolicited material. ALL INFORMATION CORRECT AT TIME OF PRINTING. MCI (P) 039/04/2018. Printed in Singapore by Times Printers (registration no. 196700328H).

SH51 02 Glory Box.indd 2 17/04/2018 16:22 Upon approval Please sign: image<200dpi 161 dpi Name and Date: MAY–JUN 2018 SINGAPORE HEALTH NEWS 03

Catch them before they fall Hospitals and community services are partners in running a fitness test to detect the early signs of frailty in senior citizens, before they become vulnerable to serious health problems. By Eveline Gan

ROWING OLD AND BECOMING weak aged 55 and older at risk of frailty. likelihood of the last 10 years of life being living in the community, so that targeted and frail oft en seem to go together. The Individual Physical Proficiency spent in disability,” said Dr Laura Tay, interventions can happen [before they GBut frailty doesn’t have to be a Test for Seniors (IPPT-S) – much like Senior Consultant, Department of General end up in hospital].” consequence of growing old. And even the physical fitness test for national Medicine, SKH. A pilot run of the IPPT-S done in for those who have begun showing signs servicemen – assesses the flexibility, According to Associate Professor Ng June-July 2017 and involving 100 senior of weakness, the condition can be turned range of motion, strength, balance, Yee Sien, Senior Consultant, Department residents in the Rivervale neighbourhood around with better nutrition, exercise and coordination and endurance of older of Rehabilitation Medicine, SGH: “The of Sengkang picked up a number of frail greater social interaction. people, and is conducted in partnership development of frailty as one ages is very and pre-frail seniors. Prof Ng said 30 For that reason, a team from with community partners and volunteers. subtle, and oft en goes unnoticed until a per cent of the participants were found Singapore General Hospital (SGH) and “While Singapore’s life expectancy is health crisis occurs. to be in the pre-frail and 2 per cent in the Sengkang General Hospital (SKH) has one of the highest in the world, people “Based on evidence-based practices, frail stages. developed a simple but comprehensive living longer may not be mirrored by the IPPT-S programme aims to identify screening programme to identify people them living healthier in old age, with the the robust, pre-frail and frail in the elderly

Comprising nine THE DEVELOPMENT OF fitness stations, the Individual Physical FRAILTY... IS VERY SUBTLE, Proficiency Test for AND OFTEN GOES Seniors or IPPT-S measures fitness UNNOTICED UNTIL A indicators such as flexibility, endurance, HEALTH CRISIS OCCURS. strength, balance and ASSOCIATE PROFESSOR NG YEE SIEN, SENIOR coordination. Those CONSULTANT, DEPARTMENT OF REHABILITATION who do not meet the MEDICINE, SGH “Pass” requirements are considered to be frail or at the pre-frail stage. For example, A questionnaire – a part of the test the grip strength test, that looks at nutritional status, ability which Mr Loy See Wee to perform daily living activities, and is doing in this picture, other health aspects such as mood and gauges upper-limb strength and general cognition – found that more than 22 per physical health. Mr Loy cent were at risk of being malnourished, is in his late 60s. while more than 26 per cent might be depressed. Both malnutrition and depression can significantly contribute to frailty. For instance, an elderly person who is malnourished is seven times more likely to suffer from frailty than someone who isn’t. Studies have shown that frailty, Identifying the robust, pre-frail when detected early, is reversible with and frail in the lifestyle changes such as exercise, neighbourhood’s nutritional support and cognitive elderly will facilitate interventions. “In other words, we timely, targeted can help these seniors make lifestyle intervention.

PHOTOS: ANGELA GUO > Continued on page 4

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> Continued from page 3 Catch them before they fall

changes to nip any problems before a vital role in community screening activities, One of the their conditions get more complex,” said said Prof Ng. fitness tests Prof Ng. “From the word ‘go’, we wanted to work includes a The IPPT-S provides an objective with community partners like AMKFSC 10m walk to assess measure of the physical fitness of the for both screening and post-screening the strength elderly, and comprises nine tests that take follow-up activities,” he said, adding and general about 30 to 40 minutes to complete. that these organisations will conduct the health of the For example, a six-minute walk gauges IPPT-S at their senior activity and day participant. the level of endurance, while the 10m walk rehabilitation centres in housing estates assesses strength and general physical for the convenience of their residents. health. The back-scratch test, where one Community partners and volunteers hand reaches over the shoulder to touch will also be trained to follow up with the other which is placed behind the back, participants, including running structured indicates upper limb flexibility. exercise and nutrition programmes Other tests include 30-second co-developed with SKH. chair stands, a grip strength test, and a modified sit-and-reach test performed while seated on a chair. Upon completing the programme, Frailty red flags participants receive a Pass, Silver or A frail older person may experience three or more of the Gold award and a health booklet of their following symptoms, said Associate Professor Ng Yee results. Those who do not meet the “Pass” Sien, Senior Consultant, Department of Rehabilitation requirements are considered to be frail or Medicine, SGH. Those who experience one or two signs pre-frail, and will be referred to primary are considered to be in the pre-frail stage. health or specialist care for further assessment and follow-up. • Unintentional weight loss every task feels like it In the next three years, the team hopes of at least 4.5kg in the requires a huge eff ort to reach out to at least 2,000 seniors past year • Low level of physical living in the eastern part of Singapore • Feeling weak, having activity, including things that the SingHealth Regional Health diff iculty standing or such as housework and Systems serve. climbing stairs unassisted exercise Social services like AMKFSC, which • Feeling so exhausted that • Slow walking speed was a partner in the pilot project, will play

SH51 03-04 Cover Story/IPPTS.indd 4 Upon approval 13/04/2018 16:26 Please sign: image<200dpi 161 dpi Name and Date: MAY–JUN 2018 SINGAPORE HEALTH NEW FRONTIERS 05

Diabetes and obstructive sleep apnoea seem to go together Greater public awareness of the possible links between type 2 diabetes and obstructive sleep apnoea is needed to help patients with either condition better manage their health. By Lediati Tan

F YOU HAVE TYPE 2 DIABETES, there is a chance that you might also be Isuff ering from obstructive sleep apnoea (OSA), a sleep disorder in which the patient experiences pauses in breathing and loud snoring throughout the night. No firm link has been established, but studies have suggested an association between the two conditions: people with diabetes tend to have OSA, and vice- versa. Diabetics with OSA also tend to have a poorer ability at controlling their blood sugar levels. Still, people suffering from either condition should be wary of the possibility of the other developing, doctors from the SingHealth Duke-NUS Sleep Centre warned. “We know that lots of patients with OSA may not know they have OSA, including those with diabetes. If their OSA isn’t treated, their diabetes may not be well controlled,” said Dr Toh Song Tar, Head, SingHealth Duke-NUS Sleep Centre. “We have patients whose glucose was not well controlled, but once their OSA was treated, their blood sugar control improved,” added Dr Toh, who is also Senior Consultant, Department of Otolaryngology, and

Director, Sleep Disorders Unit, Singapore PHOTOS: ALVINN LIM General Hospital (SGH). People with type 2 diabetes might also suff er from obstructive sleep apnoea, according to a study by SingHealth Duke-NUS Sleep Centre’s Dr Toh Song Tar (left ) and Dr Mok Yingjuan.

“They get sleep deprivation, which developing diabetes, she said, citing sets up a whole cascade of endocrine various studies done overseas. You are susceptible THE EXISTENCE OF A abnormalities that predisposes someone Singapore has the second highest to take in more high caloric food. Bingeing incidence of diabetes among developed to obstructive sleep LINK BETWEEN OSA AND on food leads to obesity again, and alters countries, after the United States. apnoea if you DIABETES WOULD NOT the glucose metabolism again,” said According to 2015 statistics from the • Are overweight, male and BE SURPRISING BECAUSE Dr Toh. International Diabetes Federation, nearly middle-aged The body responds to the periodic falls 13 per cent of those aged 20 to 79 in this • Smoke BOTH SHARE A COMMON in blood oxygen levels – or intermittent country have diabetes. • Frequently snore – and loudly RISK FACTOR: OBESITY. hypoxia – in a number of ways, which At the same time, data from the • Wake up feeling unrefreshed DR MOK YINGJUAN, DIRECTOR, EPIDEMIOLOGY together affect glucose metabolism Singapore Health Study 2012, a cross- • Oft en feel tired and sleepy AND PUBLIC HEALTH, SINGHEALTH DUKE-NUS and insulin sensitivity, said Dr Mok sectional population study conducted through the day SLEEP CENTRE Yingjuan, Director, Epidemiology and on adults aged 21 to 79, estimated that 18 Public Health, SingHealth Duke-NUS per cent of Singapore’s adult population Sleep Centre. have OSA. “The existence of a link between OSA Singapore’s diabetes rate is expected People who are overweight have a and diabetes would not be surprising to worsen with more young adults getting greater chance of developing OSA. This because both share a common risk obese: 35 per cent of people between 25 is because fat tends to get deposited factor: obesity,” said Dr Mok, who is also and 36 years of age can be expected to be around the neck or soft tissue of the Consultant, Department of Respiratory diabetic by the time they are 65. upper airways, leading to a narrowing of and Critical Care Medicine, Changi the airways and subsequent development General Hospital. of OSA. They are pulled out of deep sleep A 10 per cent increase in weight Diabetes patient Mr Koh Lai Hwa underwent an overnight repeatedly during the night when airflow has been shown to cause a six-fold polysomnography at SGH to is blocked – this automatic response increase in the risk of developing OSA, analyse his sleep patterns, and prompts the person to wake so that the while a weight gain of 5kg or more was later found to suff er from airway reopens for normal breathing. significantly increases the risk of obstructive sleep apnoea.

SH51 05 New Frontiers/DOSA.indd 5 13/04/2018 16:35 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 06 NEW FRONTIERS SINGAPORE HEALTH MAY–JUN 2018

Prof Wong Tien Yin (right) and Dr Daniel Ting (below, right) have their Artificial intelligence sights set on deploying the AI system by the comes to eye care end of 2018. The future has arrived. Machines with artificial intelligence can now accurately screen patients for some major eye diseases. By Veronica Koh

Eye aff ected by referable diabetic retinopathy (far left ). Near left , a heat map generated by the AI System shows areas aff ected by diabetic eye- related changes.

retinopathy cases that require treatment.” There are plans to develop more complex algorithms to train the Deep Learning System to do even more.

PHOTO: SNEC “The next step is to train the AI system to predict which patients will have eye diseases in the future, by simply looking T THE SINGAPORE NATIONAL Eye including those in Australia, China, the replacing a large proportion of what now at their retinal images before they Centre (SNEC), screening machines United States, Mexico and Hong Kong. requires human assessment.” develop any disease,” said Prof Wong. Awith artificial intelligence are Many of the retinal images used in the It will also make it easier to set up proving that they can think and decide system came from these countries. screening programmes in communities like humans. of the future, as it could largely be done These machines can screen patients It thinks like a person by artificial intelligence. Stocking the for diabetic retinopathy and other related The AI System is able to screen for eye “It will also save costs, and image bank eye diseases by referencing a database of diseases like a trained professional improve the efficiency of Researchers hope to boost the almost half a million retinal images from because it has, at its core, a Deep healthcare systems by allowing number of retinal images they have multi-ethnic populations in Singapore Learning System. ophthalmologists and optometrists to five million in the future. and globally. According to Professor Wong Tien Yin, to concentrate only on diabetic “Ours is currently the largest The images are stored in what is Medical Director, SNEC, and Chairman, dataset in a Deep Learning called an Artificial Intelligence System (AI SERI, the Deep Learning System uses System to screen for diabetic System), which was jointly developed by an innovative algorithmic approach to retinopathy and other sight- SNEC, Singapore Eye Research Institute “train” technology to think and decide threatening conditions such as (SERI) and the National University of like humans. glaucoma and age-related macular Singapore’s (NUS) School of Computing. “It can process large amounts of raw THE DEEP LEARNING degeneration,” said Dr Daniel Ting, Claimed as a world’s first, the data, and recognise intricate structures SYSTEM CAN PROCESS Associate Consultant, Cataract and system has proved to be highly and patterns that may not be visible to the LARGE AMOUNTS OF RAW Comprehensive Ophthalmology accurate in identifying images with human eye,” said Prof Wong, the study’s Department, SNEC. and without eye disease. It can also senior author, and Vice-Dean, Duke-NUS DATA, AND RECOGNISE “Artificial Intelligence is deemed detect glaucoma and age-related Medical School. INTRICATE STRUCTURES to be the fourth industrial revolution macular degeneration. He said it will be useful in screening AND PATTERNS THAT in human history. In healthcare, we Results of a study on its use were patients for diabetic retinopathy in need to embrace this technology published in the peer-reviewed Journal Singapore and elsewhere. MAY NOT BE VISIBLE TO early to improve work eff iciency, of the American Medical Association in “In countries that have these THE HUMAN EYE. while maintaining the high December last year. screening programmes, such as the PROF WONG TIEN YIN, MEDICAL DIRECTOR, standards of clinical care,” said For the study, researchers worked United Kingdom and Singapore, it will SNEC Dr Ting, who is also Assistant with several leading global eye centres, increase eff iciency and reduce costs by Professor, Duke-NUS Medical School, and lead author of this study. The AI system is being further tested in the Singapore Integrated Why artificial intelligence is needed Diabetic Retinopathy Programme Diabetic retinopathy is a leading cause The most eff ective way of on the rise, screening challenges include alongside screening by professional of preventable blindness among preventing unnecessary vision the training and retention of professional graders or optometrists. working Singaporeans. There are loss from diabetic retinopathy is graders and optometrists, the availability Once tests are satisfactorily about 600,000 people with diabetes early screening and treatment. The of and access to screening services, and completed, it could be in use by the aged between 18 and 69 here. Singapore Integrated Diabetic the financial sustainability of these end of 2018. Diabetic patients can suff er vision Retinopathy Programme was set up to programmes in the long run. Other possible objectives are loss from damaged blood vessels do just that. These challenges indicate a clear need to have it predict other diabetes- in the retina. An estimated one in Currently, the programme relies for a more accurate, eff icient and cost- related complications, such as three people with diabetes has this on the grading of retinal photographs eff ective method of detecting diabetic stroke, coronary diseases and condition, but many aff ected are by trained professional graders or retinopathy. This is where artificial chronic kidney diseases in people unaware they have it. optometrists. However, with diabetes intelligence comes into the picture. with the illness.

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Campus-wide expertise for SGH casualties unit This unit will be housed at new Emergency Medicine Building to be built, and linked to SGH, national centres.

S THE POPULATION grows and seldom seen even 20 years ago, partly demographics change, patients because people are living longer on Aneeding urgent medical services advances in medical care. In 2017, 34 per are likely to seek treatment for highly cent of SGH emergency patients were 65 serious and complex conditions. So in the years and older, versus 25 per cent in 2007. coming years, when a casualty arrives at The patient-centric approach that Singapore General Hospital’s (SGH) new the Department of Emergency Medicine emergencies unit, he will benefit from – which began 70 years ago in 1948 as the the expertise of multiple disciplines from Casualty and Outpatient Services Unit – across SGH as well as its sister institutions will be possible because it will take up a within the SingHealth Group. larger area at a new 12-storey hospital SingHealth’s senior management and guests at the groundbreaking ceremony of “Complex illnesses are becoming more structure being built. the new SGH Emergency Medicine Building: (from left ) Professor Ang Chong Lye, common, and will need faster and even To be known as the Emergency former SGH CEO who played a key leadership role in the development of the project; Associate Professor Ng Wai Hoe, Medical Director, NNI; Professor Kenneth Kwek, more effective interventions involving Medicine Building, it will be connected CEO, SGH; Dr Lam Pin Min, Senior Minister of State in the Ministry of Health; different medical specialties,” said to the main SGH complex and its full Professor Ivy Ng, Group CEO, SingHealth; Mr Chan Heng Kee, Permanent Secretary, Professor Kenneth Kwek, Chief Executive range of diagnostic and interventional MOH; and Professor Fong Kok Yong, Chairman, Medical Board, SGH. Officer, SGH, and Deputy Group CEO facilities, as well as the expertise of the (Organisational Transformation and hospital’s specialists and those of the Informatics), SingHealth. SingHealth Group’s national centres at multiple disciplines,” said Prof Kwek. When ready by 2023, the new He noted that the needs and types SGH Campus, including for stroke, heart- “For example, teams from National structure will house acute medical wards, of patients seen at the emergency related conditions and cancers. Heart Centre Singapore, National pharmacy and support operations, and department have evolved over the years “Our new flagship multi-storey Neuroscience Institute and our a decontamination station for mass – patient attendances have increased Emergency Department will not only Department of Emergency Medicine will casualties in the event of industrial or from about 64,000 in 1979 to more than be supplying the hardware to keep up come together to introduce new patient- terror incidents. In a national health 130,000 in 2017. Meanwhile, more elderly with growing patient numbers, national centric care pathways for stroke and crisis, all capabilities at SGH and the patients with complex conditions like needs and our emergency team’s cardiac treatments, to improve outcomes national specialty centres on the Campus cancer, stroke, heart disease and kidney advancements, but also the heart-ware, and a smooth patient journey in an can be activated quickly to mount a problems are being treated, with features as we bring together specialists from emergency care setting.” concerted response.

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Helping more cardiac arrest victims survive Four new initiatives are underway to enable paramedics to do more for victims on the way to hospital. By Annie Tan

HEN SOMEONE COLLAPSES from a sudden cardiac arrest and Wno one is on hand to quickly pump his chest to get his heart to beat again, the victim is unlikely to make it alive to a hospital. That is why a slew of initiatives have been introduced in recent years to get bystanders to perform CPR (cardiopulmonary resuscitation) and to use an AED (automated external defibrillator) to administer electric shock to restart the heart of the person who suff ers a sudden cardiac arrest. Survival rates have increased markedly as a result. Singapore General Hospital (SGH) and the Singapore Civil Defence Force (SCDF) want to scale up these life-saving eff orts by having ambulance and other emergency services staff perform more interventions on the way to hospital. They will introduce four initiatives, one a year from 2018: manual defibrillators; team cardiopulmonary resuscitation; a new impedance threshold device that increases blood flow to the heart; and the drug amiodarone. “We have been partnering the SCDF in rolling out various interventions to improve the survival rate of cardiac arrest victims. It is our hope that more lives can

be saved by paramedics through the PHOTOS: JUSTIN LOH timely administration of ambulance- Functioning like an F1 pit-stop crew, the team of four firefighters will rotate tasks and provide continuous CPR in the quickest based interventions,” said Associate possible time. In addition, an impedance threshold device – to enhance blood flow back to the heart during CPR – will be added to Professor Marcus Ong, Senior Consultant, their life-saving kits. Department of Emergency, SGH, and Medical Director, Unit for Pre-hospital to determine if a shock is necessary. To further boost the effects of CPR Emergency Care, Ministry of Health. Chest compressions then need to be and raise the chances of survival, Colonel (Dr) Ng Yih Yng, Chief Medical halted while the AED is analysing the an impedance threshold device will Off icer, SCDF, added: “We are compressing THROUGH THESE heart rhythm. be added to the array of equipment everything within the first few minutes so NEW INTERVENTIONS, To minimise these pauses during carried by paramedics. The device as to complete resuscitation before the resuscitation, paramedics will be trained enhances blood flow back to the heart person arrives at the hospital. This gives WE HOPE TO BRING to perform manual defribillation. “A well- during CPR, and significantly improves victims the best chance of survival.” SURVIVAL RATES UP BY trained paramedic can recognise heart blood circulation to the brain and During a cardiac arrest, blood stops 10 PERCENTAGE POINTS rhythms that need defibrillation in one to vital organs. flowing to the brain and vital organs. two seconds [instead of 10 to 20 seconds To correct heart rhythm problems Every minute that the heart stops TO 30 PER CENT. that the AED needs to analyse heart and help restore a normal heart beat, working, the odds of surviving a cardiac ASSOCIATE PROFESSOR MARCUS ONG, rhythm]. This minimises unnecessary the drug amiodarone will be given to arrest are lowered by 10 per cent. So SENIOR CONSULTANT, DEPARTMENT OF pauses,” said Prof Ong. cardiac arrest victims, in addition to EMERGENCY, SGH CPR should be applied in the first few Another key initiative is to off er victims adrenalin (now routinely administered to minutes of the heart stopping. Aft er 20 high-performance team CPR. A trained enhance resuscitation). to 30 minutes, he would have suff ered fire-biker starts CPR and defribillation “Through these new interventions, permanent brain damage. Worse, he can be improved further, given that places as soon as he reaches the victim. The we hope to bring survival rates up by 10 might already have died. like Seattle are able to achieve a 50 to 60 fireman on a bike can reach the victim percentage points to 30 per cent,” said The survival rate for cardiac arrest per cent survival rate for this group. in about half the 11 minutes that an Prof Ong. victims whose hearts could be restarted The four ambulance-based ambulance typically takes. Still, he added, the assistance by defibrillation increased from 2.5 per interventions relook current practices, To beat the ticking clock, a team of provided by the public is “pivotal”. cent in 2001 to 21 per cent in 2015 aft er the and are tweaked to make CPR and other four firefighters will be dispatched in “The public can help by calling 995, introduction of mechanical CPR devices, first responses more efficient. They addition to the fireman on the motorbike. performing CPR, and using an AED when more AEDs in public areas, CPR public will be implemented nationwide, with Together with paramedics, the team will they see someone collapse,” he said, education, and other programmes. data collected and analysed each year function like a Formula one pit-stop crew, noting that the percentage of bystanders Although the tenfold increase over the to judge their eff ectiveness. rotating tasks and providing continuous performing CPR has improved from 22 per last 15 years is encouraging, that figure For instance, paramedics use an AED CPR in the quickest possible time. cent in 2011 to 54 per cent in 2015.

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13 SH51 MDIS Branding Ad.indd 09 18/04/2018 15:28 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 10 NEWS SINGAPORE HEALTH MAY–JUN 2018

New drugs for cholesterol Patients find the People with high cholesterol levels who cannot tolerate statins, or find it does not work for subcutaneous jab off - them, now have new drugs that may help. By Suki Lor putting, even though it is convenient and almost painless. BOUT 70 PER CENT OF patients admitted to National Heart Centre ASingapore (NHCS) with heart attacks have unhealthy low-density lipoprotein (LDL) or bad cholesterol levels. Aft er a heart attack, doctors typically start them on high doses of statins. These are drugs proven to save lives and prevent deaths by reducing both inflammation in coronary arteries and recurrent heart attacks. However, after a year on statins following a heart attack, one in two on the medication still cannot reach target cholesterol levels, said Dr Jack Tan, Deputy Head and Senior Consultant, Department of Cardiology, NHCS. This led Dr Tan to start giving two new drugs – alirocumab or evolocumab – to patients. The drugs were approved by the Health Sciences Authority last year for use on people who have had a heart attack, or are at a high risk of one. These are patients who cannot reach their target levels while on conventional treatment, or cannot tolerate the usual high-intensity statins.

The drugs have had positive data PHOTO: 123RF from a worldwide study that also included participants from Singapore. Alirocumab was found to be much Alirocumab is prescribed in two strongest doses of statins cannot reduce condition is more severe, they can have doses (no difference in price), and it to target levels. heart attacks as young as in their 20s evolocumab in a standard dose. Both One in 300 to 500 people have this because their cholesterol is sky-high,” are taken once a fortnight through condition in the milder heterozygous said Dr Tan. subcutaneous injections. form. “From young, their baseline Patients have two considerations THE PREFERRED WAY Except for patients who cannot cholesterol is very high. So they have regarding the drugs: cost, and that the tolerate statins, Dr Tan said the preferred heart attacks earlier in life. If their drugs have to be injected, which some TO USE BOTH DRUGS IS way to use both drugs is in combination find off-putting, although the jabs are IN COMBINATION WITH with a statin, because they complement convenient and almost painless. A STATIN, BECAUSE statins and produce better results when One month’s treatment with paired up. He said they complement alirocumab or evolocumab is about $600 THEY COMPLEMENT statins in treating patients who are at at NHCS, as subsidies are not available STATINS AND PRODUCE a high risk of a heart attack but cannot Dr Jack Tan for these non-standard drugs. BETTER RESULTS WHEN reach target LDL cholesterol levels with said that Comparatively, the high dose of the statins alone. patients with generic statin, atorvastatin, costs $18 per PAIRED UP. The drugs are also given to people with very high month before subsidy, and $4.50 on a 75 cholesterol DR JACK TAN, DEPUTY HEAD AND SENIOR an inherited condition called homozygous levels may have per cent subsidy. CONSULTANT, DEPARTMENT OF CARDIOLOGY, NHCS familial hypercholesterolemia, where the heart attacks bad cholesterol is so high that even the earlier in life.

more effective in reducing LDL levels Try lifestyle than high-dose statins, while having changes first barely any side effects, said Dr Tan, Doctors recommend lifestyle who is also Adjunct Assistant Professor, Side eff ects of statins changes as the first line of Duke-NUS Medical School. Statins work for the majority of statins to see if the drugs are defence to attain healthier LDL Made by different companies, both patients with high cholesterol, but working, and to check for side cholesterol levels, said Dr Tan. alirocumab and evolocumab act similarly. some people suff er side eff ects. eff ects. The tests look into liver While how much LDL the They target and inhibit a protein called These include myalgia (muscle enzymes, kidney function and the body produces is largely PCSK9, which prevents the breakdown of pain) and fatigue. In very rare cases lipid cholesterol panel. predetermined by a person’s LDL receptors in the liver. These receptors (less than 3 per cent of patients), “Side eff ects are uncommon. genes, diet is still important. remove harmful LDL cholesterol from it can cause liver abnormalities. For liver failure to result from “If you eat bad, oily food the blood. Rarer still is that less than one in a statins is very rare, but to cause a and have the bad genes, it’s thousand develop rhabdomyolysis, bit of enzyme rise is not uncommon, doubly worse,” said Dr Tan. He Who are these drugs for? where muscles die, causing the so when we see that, they’d be advised cutting back on meat Currently, NHCS has 20 patients on either kidneys to fail. classified as statin-intolerant. This and oily and processed food, one of the two new drugs. They are those Dr Tan said doctors usually do means they have side eff ects from and moving towards a plant- at high risk of a heart attack, who cannot blood tests for patients within the statins, and we can’t push up the based diet to help bring LDL tolerate high-dose statins, or have not first three months of prescribing dose anymore.” cholesterol to healthier levels. been able to reach target levels.

SH51 10 News/Cholesterol Drugs.indd 10 Upon approval 13/04/2018 17:16 Please sign: image<200dpi 161 dpi Name and Date: ADVERTORIAL MAY–JUN 2018 SINGAPORE HEALTH 11 PHOTO: DARREN CHANG

What’s more, she has found studying while balancing a full-time job beneficial. TO BETTER NURSING “I personally think that studying while working MDIS student and full-time nurse Sim Ying Yen is studying to become better at her gives me the drive I need and helps me apply what I learn in the wards to my academic knowledge and vice job, and one day attain a leadership position to improve nursing as a whole. versa. I also think that this has made me become a better critical thinker simply by applying what I learnt in school.” hen she was studying for her diploma in “The knowledge and soft skills acquired will allow Though nursing was not initially her first career nursing, Sim Ying Yen remembers fondly me to pursue a position of leadership in nursing. choice – she wanted to be a psychologist – she W being a nurse on the go. Community health Teaching has become a future goal, and I hope to calls herself blessed and is thankful to have found nursing being one of her favourite subjects, it meant pursue graduate education in the future.” her vocation. she learnt on the job as part of a mobile clinic team As a Staff Nurse II at a private hospital, Ying Yen’s “I love how this career teaches me to be providing healthcare to rural communities. duties include providing routine nursing care in a empathetic and professional with day-to-day "I learned a lot from this experience and felt a real multidisciplinary ward (general and surgical cases). challenges. It’s a career that offers financial sense of fulfilment from being able to use the limited “We emphasise patient care by providing focused stability and lifelong learning.” resources we had to help the impoverished,” says Ying care to the patients, with a ratio of one nurse to two or As for her current studies, she highly recommends Yen, 26, who now wants to be upwardly mobile. three patients. My ward is also known as the ‘happy the course to other nurses who wish to challenge Eager to improve her skills and knowledge in ward’ as I take care of maternity [and postnatal] their skills and look forward to changing the nursing, with an eye on a future leadership position, cases too!” landscape and practice of nursing for the better. the Malaysian is now concurrently working at a private Ying Yen enjoys the content of her classes and the hospital in Singapore and studying for a Bachelor of nurturing approach of her lecturers, and she also Science Nursing (Top-up) at MDIS. appreciates the flexibility she has to fit both work and She started the two-year programme, which study into her schedule. is accredited by the Singapore Nursing Board, in “Classes [at MDIS] are scheduled according to the January 2018 and will graduate in 2020 with a degree student’s flexibility and work hours. Thus, this would awarded by Edinburgh Napier University in the UK. include day and night classes to accommodate nurses Edinburgh Napier is ranked among the top 5 per who are working day or night shifts.” cent of universities, according to the Times Higher With a commute of up to 30 or 40 minutes from her Education World University Rankings 2018. workplace to school, she has found her programme Ying Yen says she chose this programme because “challenging but manageable”. it would help her attain the knowledge and soft skills “Our lecturers are friendly and very approachable, required to be a nurse leader for tomorrow, such as which creates a safe learning environment for us taking a bigger-picture view of health care as a whole to make mistakes and learn from them. I look up and understanding the processes that can help to them as role models for their professionalism improve the overall standard of nursing. and experience.”

SH51 09 Advertorial/MDIS.indd 11 18/04/2018 15:35 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 12 NEWS SINGAPORE HEALTH MAY–JUN 2018

Now, fewer surgeries cancelled Better evaluation of patients before operations has reduced last-minute cancellations. By Sol E Solomon

These include the following steps: attack while waiting for a new operation • Blood tests are reviewed a week or two date,” she said. before surgery. In their review of previous • A pharmacist will go through patients’ cancellations, the team nurses found that medication to ensure they do not self- a common reason was the inadequate medicate (for example, use traditional stopping of patients’ antiplatelet (blood herbal medicine). thinning) medication. • Patients with loose teeth or poor oral Patients scheduled for a heart hygiene will be referred to a dentist bypass operation need to stop taking before surgery. these drugs five to seven days before • Patients will also be referred for financial surgery. This is to clear the drug from the counselling to medical social workers body, or there may be excessive bleeding if needed. during or aft er surgery. • Patients and their families will be shown Another reason was patients not a pre-operation Intensive Care Unit having dental clearance for the operation. orientation video so that they better Oral bacteria is the most common cause understand the hospitalisation process. of prosthetic valve infections, so patients

PHOTO: NHCS PHOTO: going for heart valve surgery need a When elective surgeries are cancelled at the last minute, they lead to, among other Ms Huang Na, Senior Staff Nurse, NHCS dentist’s confirmation that oral infections things, booked operating theatres that cannot be used at short notice. said these checks and the video will help are not present. allay patients’ anxieties, and ensure they Yet another reason was the need to N IMPROVEMENT PROJECT by The main change was the setting are better prepared for their operations further investigate patients for whom nurses has more than halved up of a Pre-Operative Evaluation Clinic mentally, physically, psychologically and general anaesthesia could pose a risk. Athe last-minute cancellations run by the cardiothoracic surgery unit. even financially. It was obvious that they had to reduce of elective surgeries at National Heart It is staffed by a doctor and a nurse “We ensure all pre-op tests are done last-minute cancellations. Booked Centre Singapore (NHCS). from the unit, two clinic nurses and a and results are within the acceptable operating theatres could not be used Previously, around 11 per cent of physiotherapist. range. If there are abnormalities, the at short notice, wasting the time of operations at the Cardiothoracic Surgery Together, they do comprehensive surgeon will be alerted. The aim of surgeons and others, and frustrating Unit were unavoidably cancelled. Aft er pre-admission checks on patients to proper and early assessment is to patients and their families, who arrive some changes, cancellations dropped to avoid, as far as possible, any reason to reduce avoidable cancellations. In mentally and psychologically prepared 5 per cent. cancel surgeries. addition, these patients risk a heart for the operation. Singapore Cord Blood Bank

Cord blood donation poses offers family storage minimal health risks, as the New initiative combines family storage of cord blood with cord blood is collected aft er the option for donation later on. By Veronica Koh delivery.

INGAPORE’S ONLY PUBLIC CORD and public cord blood banks, while the 123RF ILLUSTRATION: blood bank is off ering cord blood numbers worldwide range between 65 Sstorage services following demand and 80 per cent. for such a facility from parents. SCBB was established in 2005 as a Under Singapore Cord Blood Bank’s non-profit organisation for collecting (SCBB) new community cord blood cord blood donations. Its priority is to banking service, introduced earlier this ensure that Singapore has a healthy year, parents can now store their baby’s pool of cord blood available to meet the store it for our family provides us with the processing and testing. The service cord blood for their own use, with the transplant needs of the country’s multi- best of both worlds. SCBB has facilitated contract can be renewed every five years. choice of donating the cord blood later ethnic population. many transplants in Singapore and Cord blood donation is medically for others to utilise. “The biggest use of cord blood stem around the world, which assures me that safe, posing minimal health risks to the “The service arose from repeated cells is in the area of allogeneic bone my baby’s cord blood is in good hands.” mother and baby as the cord blood is requests from parents who wanted to marrow transplantation, where an SCBB’s eff orts have saved at least 226 only collected aft er delivery. The blood store their baby’s cord blood with SCBB, unrelated recipient is transplanted lives around the world. Conditions treated is taken from the umbilicus vein in the with the option to donate later,” said Mrs using cord blood for a variety of blood include blood cancers and disorders section of the cord that remains attached Tan-Huang Shuo Mei, Chief Executive disorder diseases,” said Associate such as different types of leukaemia to the placenta, not the baby. Off icer, SCBB. Professor Aloysius Ho, Medical Director, and lymphoma, as well as immune SCBB’s community cord blood banking With more than 50 per cent of cord SCBB, adding that with advances in stem disorders like the potentially fatal severe service is available at KK Women’s and blood neither donated nor stored cell research, cord blood stem cells may combined immunodeficiency and chronic Children’s Hospital, National University privately, offering cord blood storage be used to treat more conditions and granulomatous disease. Hospital and Singapore General Hospital, services could encourage more donations. diseases in the future. Donating cord blood to SCBB is and will be made available soon at local According to SCBB, about 60 per cent of Mrs Caz Lim has used SCBB’s family free, but family storage for an initial private hospitals. patients who require life-saving stem cell banking service. According to this mother: five years will cost between $1,800 For more information about transplants in Singapore are unable to “The option to donate to the public cord and $2,200. The fee is to cover donating or storing cord blood, visit find a match from bone marrow donors blood inventory aft er we choose not to administration, registration, collection, www.scbb.com.sg.

SH51 12 News/Cancel + SCBB.indd 12 13/04/2018 17:21 Upon approval Please sign: image<200dpi 161 dpi Name and Date: MAY–JUN 2018 SINGAPORE HEALTH 13

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1. To be eligible for coverage, the insured must be a non-smoker, whose diabetic condition was diagnosed after age 25, with no pre-existing diabetes-related complications. 2. Discount applicable from the second policy year onwards will depend on the AIA Vitality Status attained. There are certain conditions whereby no benefits will be payable. Waiting period and survival period are applicable before the benefits will be payable. You are advised to read the relevant policy contracts for details. Important Notes: These insurance plans are underwritten by AIA Singapore Private Limited (Reg. No. 201106386R) (“AIA”). All insurance applications are subject to AIA’s underwriting and acceptance. This is not a contract of insurance. The precise terms and conditions of these plans, including exclusions whereby the benefits under your policy may not be paid out, are specified in the policy contracts. You are advised to read the policy contracts. Buying a life insurance policy can be a long-term commitment. You should consider carefully before terminating the policy or switching to a new one as there may be disadvantages in doing so. The new policy may cost more or have fewer benefits at the same cost. The information is correct as at 19 March 2018. SGPD2016018-884-19032018

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13 SH51 AIA Ad.indd 13 17/04/2018 17:01 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 14 NEWS SINGAPORE HEALTH MAY–JUN 2018

Colour blindness linked to diabetes People who have had type 2 diabetes for six years or more are more prone to developing colour blindness, a study has found. By Sim Ee Waun

LTHOUGH WORLDWIDE ONLY A small percentage of people Aare born with colour blindness (colour vision impairment), a local study has found a link between this eye condition and type 2 diabetes. Researchers found that age and the duration of diabetes are factors associated with colour blindness – a condition where patients cannot see the correct colour of things, and their life and work are aff ected by it. The study revealed that colour Types of colour blindness affects 22.3 percent of blindness people with type 2 diabetes. Those who have had the illness for six years Deuteranomaly: Reduced or more have a higher incidence of sensitivity to green light. colour blindness. The risk of getting it Deficiency in the red-green increases with each year that patients colour spectrum. suff er from it. As the incidence of diabetes is Protanomaly: Reduced sensitivity expected to rise in the future, so may the to red light. Diff iculty in number of people with colour blindness, distinguishing diff erent shades said Dr Tan Ngiap Chuan, Director, of the same colour in the red- Research, SingHealth Polyclinics, who led yellow-green spectrum. the research with Ms Samasri Kallakuri, Normal vision Lecturer, Singapore Polytechnic. Tritanomaly: Reduced “Diabetes makes people more prone sensitivity to blue light. to eye diseases. It can damage the retina Deficiency in the blue-yellow and cause blood vessels to bleed, which is spectrum. It is the most prevalent the main cause of blindness in Singapore. form of colour blindness in But little has been done to understand people with type 2 diabetes. how it contributes to colour blindness,”

Who is most aff ected?

Cooks: They may find it hard DIABETES MAKES PEOPLE Deuteranomaly Protanomaly Tritanomaly to tell fresh vegetables from MORE PRONE TO EYE discoloured ones – for example, DISEASES. IT CAN DAMAGE they see red tomatoes as brown, Studying the problem arranged diagram would indicate which or are unable to tell raw meat THE RETINA AND CAUSE About 850 people aged 21 to 80, from type of colour blindness they have. from cooked ones. BLOOD VESSELS TO different ethnic groups, who had Dr Tan said that ultimately, the take- BLEED, WHICH IS THE diabetes for at least two years, took part home message is to live a healthy lifestyle Electricians: Their jobs can in the study at Pasir Ris Polyclinic from and not to succumb to diabetes as far become dangerous since they MAIN CAUSE OF COLOUR 2013 to 2015. as possible. cannot distinguish between BLINDNESS IN SINGAPORE. Researchers collected data on the “If you already have diabetes, then you coloured wires and so cannot tell DR TAN NGIAP CHUAN, DIRECTOR, RESEARCH, duration of type 2 diabetes and its have to manage it properly to prevent the which is the dangerous live wire. SINGHEALTH POLYCLINICS complications and treatment, blood onset of colour blindness,” he said. pressure, weight, body mass index, and Drivers: They cannot tell red demographic and medical profiles. from green traff ic lights, and Participants also did tests for oral glucose dangerously rely on the position said Dr Tan who is also Academic Vice tolerance, glycated haemoglobin and of the coloured lights instead. Chair (Research), SingHealth Duke- fasting lipid profiles. This was one reason which NUS Family Medicine Academic Clinical The next thing for researchers is to prompted the study. A colour Programme. explore if a simple colour screening test blind man had come to the It was also found that people with can be incorporated into the primary polyclinic for an eye test to renew poorer vision are more prone to getting health screening process, particularly his driver’s licence, but he could this eye problem. of diabetes patients, because early not tell the stop and go signs “Interestingly, ethnicity, gender detection is key to managing it. apart. Instead, he relied on the and employment were not significant Patients are currently screened with position of the lights to guide him. factors associated with colour blindness. a Farnsworth D-15 instrument where There was also no association with they have to arrange 15 coloured discs Others: Also aff ected are pilots, Dr Tan emphasised the hypertension, dyslipidemia, coronary, onto numbered caps, in a graduated importance of living a architects, designers, marine cerebro-vascular and renal diseases,” sequence of closely matching hues, to healthy lifestyle in order navigators and horticulturalists. he said. form a circular diagram. An abnormally not to succumb to diabetes.

SH51 14 News/Colour Blindness.indd 14 13/04/2018 17:25 Upon approval Please sign: image<200dpi 161 dpi Name and Date: MAY–JUN 2018 SINGAPORE HEALTH MONEY 15 Critical illness cover comes in different

shapes, sizes 123RF ILLUSTRATIONS: Having insurance to cover critical illnesses like cancer is important. But how should one choose from the array of diff erent products available? By Corinne Kerk

ECEIVING A DOCTOR’S diagnosis of a serious illness can be worrying. It’s Rnot just because of the illness, which can involve major surgeries and long-term hospital care, but the costs of treatment and potential loss of income also add to the burden of coming to grips with what is oft en a life-changing disease. This is where critical illness insurance comes in. Those with such insurance will rider to a life policy. Riders attached to a definitions across the industry. medical leave, so the financial impact welcome the fixed lump sum that is paid whole life insurance plan may expire when Definitions of their early stages, and for isn’t huge. Moreover, Singapore citizens following diagnosis or after a surgical the insured reaches the age of 65 years. other conditions and their stages, are and permanent residents are already procedure covered by the policy. The So buying one that is lifelong is preferred, set by individual insurers. So a payout protected against large hospital bills with payout at least helps ease anxiety. especially with people generally living will only be made if an illness fits the MediShield Life, or a private Integrated Before rushing out to buy a critical longer these days, said Ms Ee. description in the policy. For instance, Shield Plan (for higher hospital and illness policy, however, note that such Choosing critical illness products NTUC Income defines early thyroid surgical or H&S coverage). policies are structured diff erently. isn’t just a matter of deciding between cancer as a tumour that is less than 2cm “So about 80 to 90 per cent of their “There are a lot of ifs and buts in riders or individual products. They in diameter, whereas for Tokio Marine, it medical expense will likely be covered insurance policy terms and conditions. come in a plethora of permutations is less than 1cm. under a comprehensive H&S policy,” said So you need to read the fine print – coverage of one, some or all the 37 Serious illness products can cover the Ms Ee, noting that while early critical very carefully, especially since policy critical conditions defined by the Life illness at diff erent stages, or for the full illness cover may off er peace of mind, the wordings for all stages of critical illness Insurance Association Singapore, as duration of the disease. But coverage of premium is significantly higher than for coverage can be very complicated,” well as those outside this group, and the earlier stages is usually not crucial, a conventional policy covering just the said Ms Michelle Ee, Director of Wealth for diff erent stages of disease. as out-of-pocket expenses at that point advanced stage of the disease. Management, Financial Alliance. How the disease is defined is aren’t usually very large. Early stage For instance, for a sum assured of For a start, a critical illness policy can important. Only the severe stages of cancers like breast or prostate, for $250,000, a 35-year-old non-smoker male be bought as an individual product or as a 37 medical conditions have standard instance, don’t usually require lengthy pays a $720 annual premium for a critical illness rider covering just the advanced stage, compared to $3,395 to cover the illness through every stage. Moving away from standard features in critical illness policies As with most insurance products, To meet changing demands, some insurers have introduced policies in recent years with features such as allowing for multiple critical illness policies usually have a critical illness claims or specific to certain diseases like diabetes and cancer. For more information on these and products waiting period of 90 days from the date off ered by other insurers, go to their respective websites. that coverage begins. If certain illnesses are diagnosed or surgery is carried out Policy Name Insurance Company Features during the waiting period, no benefits will be paid. PRUmultiple Prudential Three critical illness claims, including two cancer claims Then there is the survival period – My MultiPay Aviva Early critical illness cover that potentially allows for more than one critical which can range from seven to 30 days – which is how long the insured must live Triple Critical Cover AIA illness claim, with limits and restrictions for multiple claims aft er being diagnosed before benefits are Diabetes Care AIA Covers five diabetes-related complications – blindness, kidney failure, stroke, paid. If the insured dies within this period, heart attack and coronary artery by-pass surgery – with premiums that remain the death benefit will be paid, but not for unchanged throughout policy the critical illness, which is likely to be Cancer Protect NTUC Income 25 per cent of sum assured upon diagnosis of early stage cancer, without the significantly higher. The death benefit of payout reducing the basic sum assured standalone term plans that cover critical illnesses may be nominal, such as $10,000 Upon diagnosis of advanced stage cancer, 100 per cent of sum assured is paid out If no claim is made for an early stage cancer, an additional 25 per cent of the sum assured or $15,000. will be paid out Once a serious illness is diagnosed and a claim made, most critical illness policies TM Protect Cancer Tokio Marine 50 per cent of sum assured upon diagnosis of early stage cancer will terminate. Apart from leaving the Upon diagnosis of advanced stage cancer, 100 per cent of sum assured is paid out consumer without insurance protection, If a claim is made for early stage cancer, only remaining sum assured is paid upon it is usually diff icult or almost impossible subsequent diagnosis of advanced cancer to buy another health insurance plan.

SH51 15 Money.indd 15 13/04/2018 17:28 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 16 PEOPLE SINGAPORE HEALTH MAY–JUN 2018

How to really help Handling a heart-rending case of a teenager with vision loss taught this optometrist real ways of helping such patients. By Corinne Kerk

HE PATIENT, A 16-YEAR-OLD such as smartphone apps for the Ukrainian girl, was suffering from visually impaired. Ttoxic optic neuropathy, a condition “They’re often hesitant about using where the optic nerve is damaged, vision aids because they think people find causing vision loss. them weird. But we tell them not to care She was referred to Optometrist Ms what others think as long as the device Lynn Tan, Low Vision and Optometry helps them,” she said. “One patient, who

Service, Singapore National Eye Centre was prescribed a magnifier, took the WONG VERNON PHOTOS: (SNEC) for help in adapting to life with advice and later declared that his quality Ms Lynn Tan said helping patients as part of a multidisciplinary team, which includes low vision. of life had improved.” opthalmologists, occupational therapists and medical social workers, is more eff ective Ms Tan, who is also a certified low But sometimes even vision aids because together they are able to render holistic care. vision therapist, found that she had to pull cannot help. “Then we’ll refer them to an out all the stops in order to really assist occupational therapist who specialises the teenager. in low vision, who can teach them how being able to do things at home, I could She rang organisations that specialise to cope with the basics of daily life, such only prescribe visual aids. Now, as a team, in helping the blind to get help for the as preparing a simple meal, doing we can give them holistic care.” teen, but the girl’s language limitations This care includes sending patients proved a barrier. aged 50 and above for subsidised Eventually, the teen was referred to rehabilitation, where they learn how to an occupational therapist at Singapore cope safely and confidently at home and General Hospital (SGH) to learn how to IF WE HAVE THE SPACE, in the community. cope with her daily living activities, and WE CAN SHOWCASE ALL Aft er means testing, they may join the also the Singapore Association of the Senior Eye Rehabilitation programme, Visually Handicapped, where she learnt THE DEVICES WE HAVE which is available at SNEC, SGH, National mobility skills and even took up art and AND DO MOCK-UPS. University Hospital and Tan Tock music lessons. THIS WOULD MAKE THE Seng Hospital. Ms Tan stayed in touch with the patient It is a programme by Temasek for around a year, monitoring her status SITUATION AS CLOSE TO Foundation Cares in partnership with One of Ms Tan’s main tasks is and coordinating help for her. During that REAL LIFE AS POSSIBLE, the Agency for Integrated Care, and prescribing vision aids to patients, time, she picked up valuable information AND HELP PATIENTS IN supported by the Tote Board. Its aim is to which may include smartphone apps. on how to really help such patients. “I build community capability among older got a clearer idea of what to do to really THEIR DAILY LIVES. people in low vision rehabilitation. since obtained a Bachelor of Science in help them.” OPTOMETRIST MS LYNN TAN, LOW VISION Patients on the programme often Optometry and specialised in the area of AND OPTOMETRY SERVICE, SNEC. retain usable vision, and can learn low vision rehabilitation. It takes a team ways to function eff ectively and safely Her dream as a low vision therapist is The majority of patients at the low vision within their homes and community to have a low vision rehabilitation centre. clinic are elderly people with conditions household chores, getting a drink and with the help of a multidisciplinary “Right now, we only have a room. If such as macular degeneration, diabetic caring for themselves.” team of ophthalmologists, optometrists, we have the space, we can showcase retinopathy and glaucoma. A small She finds that helping patients is occupational therapists and all the devices we have, do mock-ups, number – about 5 per cent – are young more eff ective now that she is part of a social workers. and have a proper room for doctors, patients aged 20 and under. multidisciplinary team that includes optometrists and occupational therapists One of her main tasks is prescribing ophthalmologists, occupational Outside of work to see patients,” she said. “That way, vision aids such as glasses and magnifiers therapists and medical social workers. Ms Tan has her family to thank for we can make the situation as close to for them. She also explores with “Previously, when patients told us how encouraging her to study optometry real life as possible, and help patients them the use of assistive technologies they kept bumping into people, or not at Singapore Polytechnic. She has in their daily lives.”

SH51 16 People/Lynn Tan.indd 16 13/04/2018 17:38 Upon approval Please sign: image<200dpi 161 dpi Name and Date: MAY–JUN 2018 SINGAPORE HEALTH PEOPLE 17

Meet the ‘Mad Scientist’ His mind is full of questions, he takes work home, and if there are tissue samples for his research, he will personally go and get them – day or night. By Suki Lor

Dr Chen developed a specific way to Biology at the Agency for Science, test blood flow in the intestines with a Technology and Research (A*STAR). special microscope, which tracks how While working there, he completed a blood flow changes in baby mice during doctorate in molecular biology before feeding. He hopes his research will lead to joining KKH in 2009. a change in clinical practice, to fine-tune He now spends 30 per cent of his time the feeding regimen of premature babies, on research and the rest on patients. “I’m and prevent the disease. part clinician, part scientist. It’s the best way for me to work since I like both.” Part clinician, part scientist As a scientist, he is always curious. Medicine was an obvious career for “When faced with a disease, I always ask Dr Chen, who hails from Wuhan, China, how does it happen, how can I cure it, but he is now a Singapore citizen, living and most importantly, how to prevent it.” here with his wife and two children. He hopes to spend more time on In high school, he had a penchant for research because it could ultimately biology. “I was able to remember the save lives, and to continue clinical work contents of biology easily, compared to because treating patients keeps the other subjects,” he said. With this talent, research questions coming. he easily tackled the heavy medical In fact, he is so driven, he takes work tomes at university and became one of home. “Many nights, aft er dinner, I work the top medical graduates in the school. till bedtime.” Fortunately for this “Mad Aft er a master degree in surgery and Scientist”, his wife, who is a teacher,

PHOTO: JUSTIN LOH practising as a surgeon in China, he understands, and his children are Dr Chen Yong clinched the celebrated but tongue-in-cheek “Mad Scientist Award” for his came to Singapore as a researcher for proud of his work... not to mention his wholehearted dedication to research. His biggest current project is looking for the cause the Institute of Molecular and Cell cool award. of a lethal intestinal inflammation in premature babies, so that it can be prevented.

HOSE WHO KNOW Dr Chen Yong, If the whole intestine is lost, the say he deserves the accolade. infant will never be able to feed by T Dr Chen, Staff Physician, mouth but rely on intravenous feeding, Department of Paediatric Surgery, which may be costly, and puts them at KK Women’s and Children’s Hospital risk of infections and liver damage. (KKH), was one of 10 people honoured Dr Chen’s mission is to pin down at the SingHealth Duke-NUS Research the cause and prevent the disease. So Appreciation Awards, all of which were far, he has had one hypothesis, which humorously named. he tested and proved at the Hospital He received the “Mad Scientist for Sick Children in Toronto in 2016, Award” while others received similarly when he was there on a grant from the tongue-in-cheek ones such as the “Most Ministry of Health’s National Medical Caff einated Award” and the “Yoda Grand Research Council. Master Award”. Known for his complete dedication to his research, his award citation gave one example of this – that as long as he is in town, he personally collects tissue EVERY SAMPLE IS specimens for his research, no matter PRECIOUS. ITS QUALITY what time of the day they are available. “Every sample is precious,” he IMPACTS THE FINDINGS explained. “Its quality impacts the OF THE RESEARCH. SO, findings of the research. So, as the AS THE INVESTIGATOR, I investigator, I try my best to ensure they are collected and preserved well.” TRY MY BEST TO ENSURE THEY ARE COLLECTED Premature babies the focus AND PRESERVED WELL. Currently, the samples are for his DR CHEN YONG, STAFF PHYSICIAN, research into necrotising enterocolitis DEPARTMENT OF PAEDIATRIC SURGERY, – a lethal inflammation of the intestines, KKH. especially of the small intestine of premature babies. It occurs soon after birth and can turn gangrenous. His hypothesis was that the Worldwide, around 7 per cent of babies disease is caused by a lack of oxygen with very low birth weight develop it, in the intestines during feeding, which and one in three of those aff ected die. together with digestion need oxygen. Dr Chen said many babies lose part As the intestines of premature babies of their small intestine, and in extreme are not yet fully developed, they lack cases, almost the whole organ. “If they the mechanism to drive suff icient blood lose half, they can still survive, but if it’s there during feeding, thereby depriving most, it’s very diff icult for them.” the organ of oxygen.

SH51 17 People/Chen Yong.indd 17 13/04/2018 17:45 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 18 FYI SINGAPORE HEALTH MAY–JUN 2018

Get outdoors to lose fat A research team led by Professor Peter Light of the Alberta Diabetes Institute has found that fat cells lying just Nerve pain? Try under the skin are sensitive to sunlight. eating less gluten “When the sun’s blue Gluten sensitivity is known to cause light wavelengths – the abdominal pain, bloating and gas, but light we can see with recent research indicates that it is also our eyes – penetrate our linked to nerve pain. skin and reach the fat Nerve damage (neuropathy) causes cells just beneath, lipid weakness, numbness, and pain in the droplets reduce in size hands and feet. and are released out of According to Dr Panagiotis Zis, lead the cells. In other words, author of a study at the University of our cells don’t store as Sheff ield, for susceptible individuals, much fat.” eating gluten causes an immune The fat cells shrink reaction that, in this case, damages in size too. This layer nerves, which can be painful. of fat is the “major fat “A strict, gluten-free diet removes depot in humans”, say the main factor triggering the the study authors. inflammation, allowing the immune In light of this, response to calm down.” anyone for spending The team found that patients on more time outdoors? gluten-free diets were 89 per cent less likely to suff er pain, although they Source: University of Alberta could not confirm why.

PHOTO & ILLUSTRATION: 123RF Source: American Academy of Neurology

SH51 18 FYI.indd 18 13/04/2018 17:53 Upon approval Please sign: image<200dpi 161 dpi Name and Date: MAY–JUN 2018 SINGAPORE HEALTH UPCLOSE 19

EVERY HOUR EVERY DAY EVERY YEAR A healthy adult has 4-5 LITRES of blood, and it is safe to donate 14 325 118,750 350-450ML units of blood are units of blood units of blood are required for 2018. every three months. used in Singapore. are needed.

IT IS SAFE • Donating blood will not harm the body nor weaken the immune 1 HOUR TO system. • One won’t catch diseases by donating blood, as strict hygiene protocols are observed. All equipment used are new, SAVE 3 LIVES sterile and discarded Donating blood is easy, safe and helps save lives. aft er one use.

• Before the process, a medical examiner screens the potential donor’s health and haemoglobin level – as of January 2018, the WHO CAN Registration minimum level required DONATE? for females is 12.5g/dL, DONORS MUST: and at least 13.0g/dL for males. • be 16 to 60 years old Rest and • The donated blood • weigh at least 45kg refreshments goes through stringent testing for diseases • generally be in good 10-15MIN and blood typing. It is health then separated into red blood cells, platelets and • not have had plasma for later use. symptoms of infection such as a sore throat or cough one week before, or a fever Medical HOW BLOOD three weeks before screening IS USED donation Donated blood is used either in its original form – For more information, for medical emergencies go to www.hsa.gov.sg/ or surgical procedures content/hsa/en/ – or broken down into Blood_Services/Blood_ platelets. Beneficiaries Donation/Can_I_Donate/ include those with cancer Donor_Criteria.html Haemoglobin check or leukaemia, patients with Blood donation blood disorders, or new- born babies with medical 5-10MIN conditions.

1 BAG OF BLOOD Regular blood donations ensure a steady 6-day supply of blood CAN SAVE 3 LIVES is maintained in Singapore’s national inventory.

Avoid the walk-in queue and make an appointment online at Donorcare@HSA or call 6220-0183 to donate at four centrally located donation centres: • Bloodbank@HSA, at the Health Sciences Authority (opposite Outram Park MRT Station) • Bloodbank@Dhoby Ghaut, at Dhoby Xchange of Dhoby Ghaut MRT Station • Bloodbank@Westgate Tower (near Jurong East MRT Station) • Bloodbank@Woodlands, at Woodlands Civic Centre (opposite Causeway Point, Woodlands MRT Station) FIND OUT MORE AT WWW.HSA.GOV.SG OR WWW.REDCROSS.SG ILLUSTRATIONS: 123RF ILLUSTRATIONS: TEXT: SOL E SOLOMON

SH51 19 Upclose/Donate Blood.indd 19 13/04/2018 17:56 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 20 SINGAPORE HEALTH MAY–JUN 2018

Heart devices may ward off sudden death In an emergency such as a heart attack, heart devices already implanted in the body can prevent the attack from becoming serious or fatal. By Annie Tan

CARDIAC ARREST TAKES PLACE same side as the operation, such as hard when the heart stops beating. swings and pull-ups. Patients with an ICD A Sudden and deadly, it can happen should also avoid arc welding, and be without warning. careful when operating heavy vibratory In a public place, a person can be tools such as drills, because these quick, rescued if someone uses an Automated repetitive movements may confuse the External Defibrillator (AED), which ICD device,” said Dr Ching. delivers an electric shock to the heart to restore a normal rhythm. Why the low take-up rate? But AEDs are not usually kept in homes, Although the quality of ICDs has improved where 70 per cent of cardiac arrests over the years, the take-up rate is still low. occur, said Dr Ching Chi Keong, Senior The latest generation of devices are Consultant, Department of Cardiology, smaller (about 40cc in volume) and more and Director, Cardiac Electrophysiology comfortable. They have evolved to also

and Pacing, National Heart Centre reduce inappropriate shocks caused by PHOTO: 123RF Singapore (NHCS). abnormal heart rhythms not associated Once the heart is damaged, there are no known reliable and consistent therapies “Patients typically only have a window with cardiac arrest. The battery life has that can restore its function, said Dr Ching. of 10 minutes to be rescued. Without also increased from four to seven years, timely rescue, they may suff er permanent and most ICDs are now MRI-safe. brain damage, which may leave them bed-bound or in a wheelchair, or result Like a miniature in death,” said Dr Ching who is also AED, the ICD Adjunct Associate Professor, Duke- pictured on the right, is NUS Medical School. able to pick up PATIENTS TYPICALLY life-threatening Enter the ICDs ONLY HAVE A WINDOW heart rhythms This is where Implantable Cardioverter OF 10 MINUTES TO BE and deliver Defibrillators (ICDs) come in. They are lifesaving RESCUED. WITHOUT shocks, usually like miniature AEDs implanted in the within a minute. chest wall. They can help patients by TIMELY RESCUE, THEY automatically picking up life-threatening MAY SUFFER PERMANENT

heart rhythms and delivering lifesaving NHCS PHOTO: shocks, usually within a minute. BRAIN DAMAGE. NHCS does about 200 ICD DR CHING CHI KEONG, SENIOR CONSULTANT, implantations every year. Dr Ching said DEPARTMENT OF CARDIOLOGY, AND DIRECTOR, CARDIAC ELECTROPHYSIOLOGY this device is 99 per cent effective in AND PACING, NHCS prevent cardiac arrest, and 48 per cent palpitations that lasted for minutes, and preventing deaths from cardiac arrests. were not aware that the key function that led to unexplained fainting spells.” Implanting an ICD in a patient is a of an ICD is to prevent cardiac arrest. He said greater awareness will help to minimally invasive operation, which can Once the heart is damaged, there are no prevent high-impact complications and be done within an hour with sedation and Despite the benefits, studies show known reliable and consistent therapies sudden deaths from cardiac arrests. local anaesthetic. that patients still fight shy of them. One that can restore its function,” said Dr Post-operation discomfort is study of 704 Singaporean patients who Ching, highlighting the importance manageable, and the risk of complication were eligible for ICDs found that only 9.4 of awareness. is less than 1 per cent. per cent underwent the procedure. “The paper suggests that patients Patients can expect to be on their feet Another showed that out of the 240 don’t know they are at risk of sudden aft er surgery and return home the very patients who declined having the devices death. They also perceived that their next day. The wound will heal over the implanted, the death rate at two years doctor’s recommendation wasn’t a next seven to 10 days. was 20 per cent. One in three deaths strong recommendation,” said Dr Ching. Aft er surgery, patients will not have to was due to cardiac arrest, which might His advice to patients is to actively make major lifestyle changes. They can have been prevented if the ICDs were find out their ejection fraction (EF) go jogging, swimming and even travelling. implanted, said Dr Ching. from doctors. The EF measures how Some famous people who have had an Top reasons for refusing the well the heart is pumping out blood. ICD implanted include former US Vice- implantation were the high cost, the A normal EF should be 55 and above. President Dick Cheney. invasive nature of the procedure, fear of Patients with an existing heart condition But there are precautions that complications, and the advanced age of and EFs of less than 40 per cent should NHCS PHOTO: they have to take after having the patients, according to a paper published consider ICD therapy, on top of their Dr Ching highlighted the importance of raising device implanted. in the Singapore Medical Journal last year. current medication. awareness about ICDs “We don’t recommend extremely “The majority of patients believed that “This is especially important if they and their key function of vigorous shoulder exercises on the medication or diet and exercise could had previous episodes of sustained preventing cardiac arrest.

SH51 20 Health+/ICDs.indd 20 13/04/2018 18:03 Upon approval Please sign: image<200dpi 161 dpi Name and Date: MAY– JUN 2018 SINGAPORE HEALTH 21

Teenage bed-wetting: a cause for worry? PHOTO: ISTOCK; ILLUSTRATION: 123RF When teenagers still have “accidents”, it’s time to get to the underlying cause of their problem. By VK Santosh Kumar

HEN A TEENAGER suddenly Children typically learn to control is okay during the day, but then he For some, it may be a simple case of starts to wet his bed, he might their bladder by the age of three years, passes a lot of urine at night. From the drinking too much water before bedtime. Wdo well to adopt a more relaxed although some will continue to have patient’s profile and diary, we can go When advised to drink less, the problem attitude, especially towards school. “accidents” till they are older. “Beyond the on to investigate further. If we think it’s goes away. Burning the midnight oil in a bid to age of 12 years, we should investigate for sleep apnoea, we would refer them to an The diary may show that this is an get high grades – and oft en with pressure underlying issues,” said Dr Ng. otolaryngologist,” she said. issue throughout the day. In such cases, from parents – can lead to physical and One way of getting to the root of the From the diary, a pattern might show treatment will depend on the underlying mental exhaustion, and such deep sleep problem involves keeping what Dr Ng that the patient passes a lot of urine at bladder issue. Urinating excessively can at night that he fails to get the signal called a voiding diary – a record of the night, which is not common, said Dr Ng, be due to many things. Some people may to wake up to empty his bladder, said amount of liquids consumed; when the noting that urinating excessively at night have an overactive bladder, which leads Dr Ng Lay Guat, Senior Consultant, patient empties his bladder; the amount; can happen to children who are very to poor bladder control, or they have a Department of Urology, Singapore as well as when he accidentally wets obese and suff er from obstructive sleep problem with a small and stiff bladder. General Hospital (SGH). himself – for three days. apnoea, where breathing is interrupted Seemingly unrelated conditions like This is oft en a phase that the young The diary provides an insight into the during sleep. People with sleep apnoea diabetes insipidus – an imbalance of water person grows out of once the stressful person’s habits and condition. have raised atrial natriuretic hormone in the body that leads to intense thirst period passes, she said. While bed- “That diary is very important. For secretion, which leads to increased even aft er drinking fluids, and subsequent wetting among teens isn’t common, instance, it might tell us that the patient urination at night. excretion of large amounts of urine – or the three or four cases she sees in a undiagnosed diabetes mellitus can also year are typically secondary school lead to excessive water consumption and “high-flyers” who get “accidents” urination throughout the day, said Dr Ng. before a major event like their O-level The toilet habits noted in the voiding diary examinations, for instance. Bed-wetting provide cues on the patient’s condition, teens tend to be “They work hard in the day, so we high-achieving so they can then send the patients to see might ask them to moderate the amount secondary school the relevant internal medicine physicians of work that they do to get them to students. for further treatment, she added. have adequate rest and sleep better,” Treatment is based on identifying what said Dr Ng. will work best for the situation. Lifestyle Because of the stigma and changes – such as limiting fluid intake in embarrassment associated with bed- the evening and studying in a stress-free wetting, these young people mostly environment – may be all that is needed. don’t seek advice until they really need Alarms and medication are other to – for instance, before attending a options. For instance, the alarm is set school camp. Ironically, because they to wake the person during the night to may not sleep well in camp, they don’t go to the toilet, so that he doesn’t sleep tend to wet their bed when they attend through and wet his bed. such events. Drugs to reduce urine production at “The sleep pattern is very important. night, help reduce bladder contractions If they don’t sleep well, they are easily or increase bladder capacity can also woken up by the feeling of urinary urge. help. However, conservative measures They wake up to go to the toilet. But like drinking less in the evening should because of their high-flying status, they go hand in hand with medications to help get very stressed before such events,” wean the patient off medications as soon said Dr Ng. as possible.

SH51 21 Health+/Bedwetting.indd 21 17/04/2018 16:53 Upon approval Please sign: image<200dpi 161 dpi Name and Date: 22 SINGAPORE HEALTH MAY–JUN 2018 ADVERTORIAL A

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ƌĞƐƚ ĐĂŶ ŚĂǀĞ ĂŶ ŝŶĐƌĞĚŝďůĞ ƐĂůƵƚĂƌLJ ŝŵƉĂĐƚ ŽŶ ĨĞǁĞƌ ĞƌƌŽƌƐ ǁŚĞŶ ĐŽŵƉĂƌĞĚ ƚŽ ƚŚĞ ƉůĂĐĞďŽ ŽǀĞƌĂůůŚĞĂůƚŚĂŶĚǁĞůůďĞŝŶŐ͘ 'ƌŽƵƉ͘dŚŝƐǁĂƐƉĂƌƟĐƵůĂƌůLJĞǀŝĚĞŶƚŝŶƚŚĞĮŶĂů ϭϱŵŝŶƵƚĞƐǁŚĞŶĨĂƟŐƵĞƐĞƚƐŝŶ͘ DŽƌĞŽǀĞƌ͕ ŝƚ ŝƐ ǁĞůůͲĚŽĐƵŵĞŶƚĞĚ ƚŚĂƚ ƐƉĞĐŝĮĐ ƚĂƌŐĞƚĞĚŶƵƚƌŝƟŽŶĐĂŶďŽƚŚƉƌŽƚĞĐƚĂŶĚŝŵƉƌŽǀĞ dŚĞ /ŶƚĞƌŶĂƟŽŶĂů :ŽƵƌŶĂů ŽĨ ^ƉŽƌƚƐ DĞĚŝĐŝŶĞ ŵŝƚŽĐŚŽŶĚƌŝĂů ĞĸĐŝĞŶĐLJ ƚŽ ĞǀĞŶ ŐƌĞĂƚĞƌ ůĞǀĞůƐ͕ ƌĞƉŽƌƚĞĚ ƚŚĂƚ ƉƌŽĨĞƐƐŝŽŶĂů ĐLJĐůŝƐƚƐ ƌĞĐĞŝǀŝŶŐ ďƵƚǁĞŚĂƌĚůLJŐĞƚĞŶŽƵŐŚĂŶƟŽdžŝĚĂŶƚƉƌŽƚĞĐƟŽŶ ĂƐƚĂdžĂŶƚŚŝŶ ĨŽƌ ϲ ǁĞĞŬƐ ǁĞƌĞ ĂďůĞ ƚŽ ƐŚĂǀĞ ĂŶ ĨƌŽŵ ĂŶ ĂǀĞƌĂŐĞ ĚŝĞƚ͕ ůĞƚ ĂůŽŶĞ ƚŚĞ ƵŶŚĞĂůƚŚLJ ĂǀĞƌĂŐĞ ŽĨ Ϯ Ъ ŵŝŶƵƚĞƐ Žī ƚŚĞŝƌ ϮϬŬŵ ĐLJĐůŝŶŐ ŝŶĚƵůŐĞŶĐĞƐ ǁĞ ƐŽŵĞƟŵĞƐ ƉĂŵƉĞƌ ŽƵƌƐĞůǀĞƐ ƟŵĞ ƚƌŝĂůƐ ĐŽŵƉĂƌĞĚ ƚŽ ƉůĂĐĞďŽ͘ /Ŷ ĂŶŽƚŚĞƌ ǁŝƚŚ͘ŶƐƵƌŝŶŐƚŚĂƚƚŚĞŵŝƚŽĐŚŽŶĚƌŝĂŝŶĂůůĐĞůůƐ͕ ƐƚƵĚLJ͕ Ă ŐƌŽƵƉ ŽĨ ƵƌŽƉĞĂŶ ƐŽĐĐĞƌ ƉůĂLJĞƌƐ ǁŚŽ ƟƐƐƵĞƐ ĂŶĚ ŽƌŐĂŶƐ ƌĞĐĞŝǀĞ ĂďƵŶĚĂŶƚ ŶƵƚƌŝƟŽŶ ŚĂĚďĞĞŶƌĞĐĞŝǀŝŶŐĂƐƚĂdžĂŶƚŚŝŶĞdžŚŝďŝƚĞĚƌĞĚƵĐĞĚ ĂŶĚ ĞŶĞƌŐLJ ƚŽ ƉĞƌĨŽƌŵ ŵĂdžŝŵĂůůLJ ŝƐ ĞƐƉĞĐŝĂůůLJ ďůŽŽĚ ůĞǀĞůƐ ŽĨ ŝŶŇĂŵŵĂƚŽƌLJ ďŝŽŵĂƌŬĞƌƐ ĂŶĚ ŝŵƉŽƌƚĂŶƚ ĨŽƌ ƚŚŽƐĞ ǁŚŽ ĞdžƉĞƌŝĞŶĐĞ ddd͘ ůŽǁĞƌ 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ƌĞƉĞůŚĂƌŵĨƵůZK^͕ƚŚĞƌĞďLJƉƌĞǀĞŶƟŶŐŽdžŝĚĂƟǀĞ &ĂƟŐƵĞĂŶĚdŝƌĞĚůůƚŚĞdŝŵĞ;dddͿ Ɛ Ă ƉƌĞƌĞƋƵŝƐŝƚĞ ĨŽƌ ƚŚŝƐ ĞŶĞƌŐLJ ƐƵƉƉůLJ͕ ƚŚĞ ƐƚƌĞƐƐĂŶĚƐƵƌǀŝǀŝŶŐƚŚĞĐƌŝƐĞƐ͘ ͞/ŚĂǀĞŶŽĞŶĞƌŐLJ͕͟͞/͛ŵĂůǁĂLJƐƟƌĞĚ͟ͲƚŚĞƐĞĂƌĞ ŵŝƚŽĐŚŽŶĚƌŝĂ ǁŝƚŚŝŶ ƚŚĞƐĞ ĐĞůůƐ ƌĞůLJ ŽŶ ŚĞĂůƚŚLJ ƚŚĞ ŵŽƐƚ ĐŽŵŵŽŶ ĐŽŵƉůĂŝŶƚƐ ŵĂĚĞ ďLJ ƉĞŽƉůĞ ŶƵƚƌŝƟŽŶ;ĨƵĞůƐͿ͕ŽdžLJŐĞŶ͕ǁĂƚĞƌ͕ĂŶĚŽƚŚĞƌƚĂƌŐĞƚĞĚ DŽƌĞŽǀĞƌ͕ ƌĞƐĞĂƌĐŚ ŚĂƐ ĚĞŵŽŶƐƚƌĂƚĞĚ ƚŚĂƚ ǁŚŽĞdžƉĞƌŝĞŶĐĞĨĂƟŐƵĞ͘/ƚŝƐĂƵŶŝǀĞƌƐĂůƉƌŽďůĞŵ ŶƵƚƌŝĞŶƚƐƚŽĨƵŶĐƟŽŶŽƉƟŵĂůůLJ͘tŚĞŶĞǀĞƌƚŚĞƐĞ ƐƚĂdžĂŶƚŚŝŶ ŚĂƐ Ă ŚŝŐŚ ĂĸŶŝƚLJ ĨŽƌ ŚƵŵĂŶ ƚŚĂƚŵĂŶLJƉĞŽƉůĞŵƵƐƚĚĞĂůǁŝƚŚĚĂŝůLJ͘dŽƵƉƌŽŽƚ ĞƐƐĞŶƟĂůƐĂƌĞůĂĐŬŝŶŐŽƌĚĞĮĐŝĞŶƚ͕ŵŝƚŽĐŚŽŶĚƌŝĂ ĐĞůůƵůĂƌŵĞŵďƌĂŶĞƐĂŶĚĮƚƐƉĞƌĨĞĐƚůLJǁŝƚŚŝŶƚŚĞ ƚŚŝƐƉƌŽďůĞŵ͕ǁĞĮƌƐƚŵƵƐƚĚĞĮŶĞǁŚĂƚĨĂƟŐƵĞ ŽŌĞŶƐƚƌƵŐŐůĞƚŽƉƌŽĚƵĐĞďĂƌĞůLJƐƵĸĐŝĞŶƚĞŶĞƌŐLJ ŵŝƚŽĐŚŽŶĚƌŝĂͲĞdžĂĐƚůLJǁŚĞƌĞŝƚŝƐŶĞĞĚĞĚŵŽƐƚƚŽ ŝƐĂŶĚƵŶĚĞƌƐƚĂŶĚŝƚƐĐĂƵƐĞƐĂŶĚĐŽŶƐĞƋƵĞŶĐĞƐ ƚŽĐŽƉĞǁŝƚŚƐƚƌĞƐƐĨƵůĐŽŶĚŝƟŽŶƐ͘ŶĚǁĞƐƚĂƌƚƚŽ ƉƌŽƚĞĐƚƚŚĞŵŝƚŽĐŚŽŶĚƌŝĂĨƌŽŵŚĂƌŵĨƵůZK^͘ ďĞĨŽƌĞǁĞĐĂŶƉƌŽĐĞĞĚƚŽĐŽƌƌĞĐƚŝƚ͘ ĨĞĞůƟƌĞĚďĞĐĂƵƐĞŽƵƌĞŶĞƌŐLJƐƵƉƉůLJŝƐƵŶĂďůĞƚŽ ĐĂƚĐŚƵƉǁŝƚŚƚŚĞƌĞƋƵŝƌĞŵĞŶƚ͘ ƐƚĂdžĂŶƚŚŝŶŚĂƐďĞĞŶƐŚŽǁŶƚŽ͗ dŽďĞĐůĞĂƌ͕ƚŚĞŬŝŶĚŽĨĨĂƟŐƵĞǁĞĂƌĞĚĞƐĐƌŝďŝŶŐ ϭ͘ ZĞĚƵĐĞ ŽdžŝĚĂƟǀĞ ƐƚƌĞƐƐ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ŚĞƌĞŝŶ͕ŝƐŶŽƚƚŚĞƚLJƉĞŽĨĨĂƟŐƵĞƚŚĂƚŝƐƌĞůĂƚĞĚ ,ŽǁhŶŚĞĂůƚŚLJ>ŝĨĞƐƚLJůĞƐ>ĞĂĚƚŽddd ŵŝƚŽĐŚŽŶĚƌŝĂůĚLJƐĨƵŶĐƟŽŶ ƚŽ Ă ĚŝƐĞĂƐĞ ƐƵĐŚ ĂƐ ŚĞĂƌƚ ĨĂŝůƵƌĞ͕ ůŽǁ ƚŚLJƌŽŝĚ hŶŚĞĂůƚŚLJ ĂŶĚͬŽƌ ďƵƐLJ ůŝĨĞƐƚLJůĞƐ ĂƌĞ ŽŌĞŶ ƚŚĞ Ϯ͘ WƌĞƐĞƌǀĞŵŝƚŽĐŚŽŶĚƌŝĂůŵĞŵďƌĂŶĞŝŶƚĞŐƌŝƚLJ ĨƵŶĐƟŽŶ͕ ĂŶĞŵŝĂ͕ ĐŚƌŽŶŝĐ ĨĂƟŐƵĞ͘ ^ƵĐŚ ĨĂƟŐƵĞ ŵĂŝŶĚƌŝǀĞƌƐďĞŚŝŶĚůŽǁĞƌŵŝƚŽĐŚŽŶĚƌŝĂůŽƵƚƉƵƚ ĂŶĚĞŶĞƌŐLJƉƌŽĚƵĐƟŽŶ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ĚŝƐĞĂƐĞƐ ŚĂƐ ĂŶ ƵŶĚĞƌůLJŝŶŐ ĂŶĚŝŶĐůƵĚĞĨĂĐƚŽƌƐƐƵĐŚĂƐ͗ƉŽŽƌĚŝĞƚ͕ŝŶƐƵĸĐŝĞŶƚ ϯ͘ WƌŽŵŽƚĞĨĂƩLJĂĐŝĚ;ĨƵĞůͿƚƌĂŶƐƉŽƌƚŝŶƚŽƚŚĞ ƉĂƚŚŽůŽŐŝĐĂů ĐĂƵƐĞ͘  ZĂƚŚĞƌ͕ ƚŚĞ ĨĂƟŐƵĞ / Ăŵ ůůŽĨƚŚĞƐĞƐƚƵĚŝĞƐƌĞŇĞĐƚĂƐƚĂdžĂŶƚŚŝŶ͛ƐĨĂƟŐƵĞͲ ƐůĞĞƉ͕ ŝŶĂĚĞƋƵĂƚĞ ŚLJĚƌĂƟŽŶ͕ ůĂĐŬ ŽĨ ĞdžĞƌĐŝƐĞ͕ ŵŝƚŽĐŚŽŶĚƌŝĂ ĨŽƌ ĐŽŶǀĞƌƐŝŽŶ ŝŶƚŽ ƌĞĂĚLJͲƚŽͲ ƌĞĨĞƌƌŝŶŐƚŽ͕ŝƐƚŚĞŬŝŶĚƚŚĂƚĞǀĞƌLJŽŶĞĞdžƉĞƌŝĞŶĐĞƐ ĮŐŚƟŶŐĞīĞĐƚƐĂƐƚŚĞLJƉĞƌƚĂŝŶƚŽŵŝƚŽĐŚŽŶĚƌŝĂů ƐŵŽŬŝŶŐ͕ ĞdžĐĞƐƐ ƐƚƌĞƐƐ ĂŶĚ ŽǀĞƌͲŝŶĚƵůŐĞŶĐĞƐ ƵƐĞĞŶĞƌŐLJ Ăƚ ƐŽŵĞ ƉŽŝŶƚ͕ ĚƵƌŝŶŐ ƚŚĞ ĚĂLJ͕ ƚŚĞ ǁĞĞŬ ĂŶĚ ĨƵŶĐƟŽŶ͕ ǁŚŝĐŚ ŝƐ ĐƌƵĐŝĂů ŝŶ ĞŶƐƵƌŝŶŐ ĞĸĐŝĞŶƚ ;ĨŽŽĚ ĂŶĚ ĂůĐŽŚŽůͿ Ͳ Ăůů ŽĨ ǁŚŝĐŚ ŐĞŶĞƌĂƚĞ ϰ͘ ZĞĚƵĐĞ ŝŶŇĂŵŵĂƚŽƌLJ ƌĞƐƉŽŶƐĞ ŝŶ ĞƐƉĞĐŝĂůůLJĚƵƌŝŶŐƐƚƌĞƐƐĨƵůƟŵĞƐ͕ĂŶĚŝƚĚŽĞƐŶŽƚ ĞŶĞƌŐLJ ƉƌŽĚƵĐƟŽŶ ĨŽƌ ƚŚĞ ĂĐƟǀŝƟĞƐ ŝŶǀŽůǀĞĚ͘ ĞdžĐĞƐƐŝǀĞ ĂŵŽƵŶƚƐ ŽĨ ZĞĂĐƟǀĞ KdžLJŐĞŶ ^ƉĞĐŝĞƐ ŵŝƚŽĐŚŽŶĚƌŝĂ ^ƵĐŚ ƚĂƌŐĞƚĞĚ ŶƵƚƌŝƟŽŶ͕ ƚŽŐĞƚŚĞƌ ǁŝƚŚ ŚĞĂůƚŚLJ ƐŝŵƉůLJŐŽĂǁĂLJǁŝƚŚĂĚĚŝƟŽŶĂůƌĞƐƚ͘/ƚŵĂŬĞƐLJŽƵ ;ZK^ͿĐĂƵƐŝŶŐŽdžŝĚĂƟǀĞƐƚƌĞƐƐ͘ZK^ĂƌĞŚĂƌŵĨƵů ůŝĨĞƐƚLJůĞƐ͕ŐŽŽĚŚLJĚƌĂƟŽŶĂŶĚƐƚƌĞƐƐƌĞůŝĞĨǁŝůůŶŽƚ ĨĞĞů͞ƟƌĞĚĂůůƚŚĞƟŵĞ;dddͿ͘͟ĚĚŝƟŽŶĂůůLJ͕ƚŚŝƐ ďLJƉƌŽĚƵĐƚƐ ŽĨ ŵĞƚĂďŽůŝƐŵ ĂŶĚ ŽŌĞŶ ĂƩĂĐŬ Ɛ ŵŝƚŽĐŚŽŶĚƌŝĂ ĂƌĞ ƵďŝƋƵŝƚŽƵƐ ŝŶ Ăůů ĐĞůůƐ ŽĨ ŽŶůLJƌĞƐŝƐƚƚŚĞĨĂƟŐƵĞŽĨƚŚĞĚĂŝůLJŐƌŝŶĚ͕ŝƚǁŝůůĂůƐŽ ĐŽŵŵŽŶĨŽƌŵŽĨdddͲĨĂƟŐƵĞŝƐĂĐŽŵďŝŶĂƟŽŶŽĨ ŚĞĂůƚŚLJ ĐĞůůƐ ǁŝƚŚ ƚŚĞŝƌ ƐƚƌŽŶŐ ŽdžŝĚŝnjŝŶŐ ƉŽǁĞƌ͕ ƚŚĞďŽĚLJ;ĞdžĐĞƉƚƌĞĚďůŽŽĚĐĞůůƐͿ͕ƚŚĞƉƌŽƚĞĐƟǀĞ ƉĂLJ ŚƵŐĞ ĚŝǀŝĚĞŶĚƐ ŝŶ ŝŵƉƌŽǀŝŶŐ ĞŶĞƌŐLJ ůĞǀĞůƐ͕ ďŽƚŚŵĞŶƚĂůĂŶĚƉŚLJƐŝĐĂůƟƌĞĚŶĞƐƐƐŝŶĐĞƚŚĞLJĂƌĞ ĐĂƵƐŝŶŐŝŶŇĂŵŵĂƟŽŶ͕ŝŶũƵƌLJĂŶĚĚLJƐĨƵŶĐƟŽŶ͘ ĞīĞĐƚƐŽĨĂƐƚĂdžĂŶƚŚŝŶĐĂŶďĞĂƉƉůŝĞĚƚŽŵƵůƟƉůĞ ƉĞƌĨŽƌŵĂŶĐĞŵĞĂƐƵƌĞƐĂŶĚŽǀĞƌĂůůǁĞůůŶĞƐƐ͘ ƐŽŝŶĞdžƚƌŝĐĂďůLJůŝŶŬĞĚƚŽŐĞƚŚĞƌ͘ ŽƌŐĂŶͲƐƉĞĐŝĮĐdddĐŽŶĚŝƟŽŶƐ͘ hŶĚĞƌ ŶŽƌŵĂů ĐŝƌĐƵŵƐƚĂŶĐĞƐ͕ ƚŚĞ ďŽĚLJ ŚĂŶĚůĞƐ ,ŽǁĞǀĞƌ͕ ƚŚĞ ŽŶůLJ ĚŝĞƚĂƌLJ ƐŽƵƌĐĞƐ ŽĨ ŶĂƚƵƌĂů ůĂƐƐŝĐ ĞdžĂŵƉůĞƐ ŽĨ ŝŶĚŝǀŝĚƵĂůƐ ǁŚŽ ĞdžƉĞƌŝĞŶĐĞ ƚŚĞƐĞ ĂŐŝƚĂƚŽƌƐ ǁŝƚŚ ŝƚƐ ŽǁŶ ƐĞƚ ŽĨ ĂŶƟŽdžŝĚĂŶƚ ǀŝĚĞŶĐĞͲĂƐĞĚŶƟͲ&ĂƟŐƵĞīĞĐƚƐ ĂƐƚĂdžĂŶƚŚŝŶ ĨŽƌ ŚƵŵĂŶƐ ĂƌĞ ƌĞĚ ƐĞĂĨŽŽĚ ƐƵĐŚ dddŝŶĐůƵĚĞ͗ďƵƐLJƉĂƌĞŶƚƐͲǁŚŽĂƌĞĐŽŶƐƚĂŶƚůLJ ĂƐ ǁŝůĚ ĐĂƵŐŚƚ ůĂƐŬĂŶ ^ŽĐŬĞLJĞ ƐĂůŵŽŶ͕ ĂŶĚ ŝƚ ĚĞĨĞŶƐĞ͖ ŚŽǁĞǀĞƌ͕ ƵŶĚĞƌ ŚŝŐŚ ŽdžŝĚĂƟǀĞ ƐƚƌĞƐƐ͕ ŽĨƐƚĂdžĂŶƚŚŝŶ ŽŶͲƚŚĞͲŐŽ ĨƌŽŵ ŵŽƌŶŝŶŐ ƵŶƟů ŶŝŐŚƚ͕ ĚĂLJ ĂŌĞƌ ƌĞƋƵŝƌĞƐŬŝůŽŐƌĂŵƐŽĨƐĂůŵŽŶƚŽďĞĞĂƚĞŶĞǀĞƌLJ ƚŚĞ ďŽĚLJ͛Ɛ ŝŶƚƌŝŶƐŝĐ ĂŶƟŽdžŝĚĂŶƚ ƌĞƐĞƌǀĞƐ ŚĂǀĞ ĚĂLJ͕ũƵŐŐůŝŶŐďĞƚǁĞĞŶǁŽƌŬĂŶĚĨĂŵŝůLJ͘͘͘ǁŝƚŚŽƵƚ ĚĂLJ ƚŽ ĐĂƉƚƵƌĞ ŶĂƚƵƌĂů ĂƐƚĂdžĂŶƚŚŝŶ͛Ɛ ŚĞĂůƚŚ ďĞĞŶ ĚĞƉůĞƚĞĚ͕ ƚŚĞ ŚĂƌŵĨƵů ĞīĞĐƚƐ ŽĨ ĞdžĐĞƐƐ ŽƵďůĞͲďůŝŶĚ ƉůĂĐĞďŽͲĐŽŶƚƌŽůůĞĚ ƐƚƵĚŝĞƐ ŝŶ ĂďƌĞĂŬ͊ŶĚŶŽƚƚŽĨŽƌŐĞƚĂďŽƵƚŶƵƌƐĞƐ͕ĚŽĐƚŽƌƐ͕ ďĞŶĞĮƚƐ͘/ƚŝƐƚŚĞƌĞĨŽƌĞƌĞĐŽŵŵĞŶĚĞĚƚŽŽďƚĂŝŶ ZK^ ďĞĐŽŵĞ ŽƵƚ ŽĨ ĐŽŶƚƌŽů ĂŶĚ ǁƌĞĂŬ ĐĞůůƵůĂƌ ŚƵŵĂŶƐ ŚĂǀĞ ĚĞŵŽŶƐƚƌĂƚĞĚ ƚŚĂƚ ĂƐƚĂdžĂŶƚŚŝŶ ŽĸĐĞ ǁŽƌŬĞƌƐ͕ ƐĞĐƌĞƚĂƌŝĞƐ ĂŶĚ ĞdžĞĐƵƟǀĞƐ Ͳ ŚŝŐŚ ƋƵĂůŝƚLJ ŶĂƚƵƌĂů ĂƐƚĂdžĂŶƚŚŝŶ ŝŶ ƚŚĞ ĨŽƌŵ ŚĂǀŽĐ͘dŚŝƐŚĂƐĂƚƌĞŵĞŶĚŽƵƐůLJŶĞŐĂƟǀĞŝŵƉĂĐƚ ƌĞĚƵĐĞƐ ŵĞŶƚĂů͕ ǀŝƐƵĂů ĂŶĚ ƉŚLJƐŝĐĂů ĨĂƟŐƵĞ ĂŶĚ ĂŶLJŽŶĞ ǁŝƚŚ ĚĞĂĚůŝŶĞƐ ƚŽ ŵĞĞƚ͕ ƚĂƌŐĞƚƐ ƚŽ ŽĨ ŚĞĂůƚŚ ƐƵƉƉůĞŵĞŶƚƐ͕ ŝŶ ŽƌĚĞƌ ƚŽ ƌĞĂĐŚ ƚŚĞ ŽŶƚŚĞŵŝƚŽĐŚŽŶĚƌŝĂ͕ĐĂƵƐŝŶŐĂĐŽŶĚŝƟŽŶŬŶŽǁŶ ŝŵƉƌŽǀĞƐ ĞŶĚƵƌĂŶĐĞ͘  KŶĞ ƐƚƵĚLJ ĐŽŵƉƌŝƐĞĚ ŽĨ ĂĐŚŝĞǀĞ ĂŶĚ ƌĞƐƉŽŶƐŝďŝůŝƟĞƐ ƚŽ ĨƵůĮůů͘ /Ŷ ƚƌƵƚŚ͕ ƚǁŽŐƌŽƵƉƐŽĨŝŶĚŝǀŝĚƵĂůƐ͗'ƌŽƵƉǁĂƐƐƵƉƉŽƌƚĞĚ ƚŚĞƌĂƉĞƵƟĐůĞǀĞůƐŽĨŶĂƚƵƌĂůĂƐƚĂdžĂŶƚŚŝŶƐŚŽǁŶŝŶ ĂƐ ͚ŵŝƚŽĐŚŽŶĚƌŝĂů ĚLJƐĨƵŶĐƟŽŶ͛͗ ŵŝƚŽĐŚŽŶĚƌŝĂ ĂůŵŽƐƚĞǀĞƌLJŽŶĞŬŶŽǁƐŚŽǁŝƚĨĞĞůƐƚŽďĞddd͘ ďLJĚĂŝůLJ ĂƐƚĂdžĂŶƚŚŝŶ͕ǁŚĞƌĞĂƐ'ƌŽƵƉ ƌĞĐĞŝǀĞĚ ĐůŝŶŝĐĂůƐƚƵĚŝĞƐ͘ ŐĞŶĞƌĂƚĞ ůĞƐƐ ĞŶĞƌŐLJ͕ ǁŚŝĐŚ ƚŚĞŶ ůĞĂĚƐ ƚŽ ƚŚĞ Ă ƉůĂĐĞďŽ͘ ŽƚŚ ŐƌŽƵƉƐ ǁĞƌĞ ƚŚĞŶ ƐƵďũĞĐƚĞĚ ĐŽŶĚŝƟŽŶǁĞĐĂůůddd͘KŶĂƐŝĚĞŶŽƚĞ͕ŝƚŚĂƐĂůƐŽ ƚŽ Ă ƟŵĞĚ ;ϯϬ ŵŝŶƵƚĞƐͿ ĐŽŶƟŶƵŽƵƐ ĐĂůĐƵůĂƟŽŶ ŝŽůŽŐLJŽĨdddĂŶĚDŝƚŽĐŚŽŶĚƌŝĂ ďĞĞŶƐƵŐŐĞƐƚĞĚƚŚĂƚŵŝƚŽĐŚŽŶĚƌŝĂůĚLJƐĨƵŶĐƟŽŶŝƐ ĐŚĂůůĞŶŐĞ͘ dŚĞ ƌĞƐƵůƚƐ ŝŶĚŝĐĂƚĞĚ ƚŚĂƚ 'ƌŽƵƉ  ĞĨŽƌĞǁĞĐĂŶĚĞĐŝƉŚĞƌƚŚĞƌĞĂƐŽŶďĞŚŝŶĚƐƵĐŚ ŽŶĞŽĨƚŚĞŵĂũŽƌŚĂůůŵĂƌŬƐŽĨƚŚĞĂŐĞŝŶŐƉƌŽĐĞƐƐ͕ ƉĞƌĨŽƌŵĂŶĐĞǁĂƐƐƵƉĞƌŝŽƌ͕ĂĐŚŝĞǀŝŶŐƐŝŐŶŝĮĐĂŶƚůLJ ƉĞƌƐŝƐƚĞŶƚƟƌĞĚŶĞƐƐ͕ŝƚŝƐŝŵƉŽƌƚĂŶƚƚŽƵŶĚĞƌƐƚĂŶĚ ǁŚŝĐŚŝƐĐůŽƐĞůLJĂƐƐŽĐŝĂƚĞĚǁŝƚŚƐƵĐŚƉĞƌƐŝƐƚĞŶƚ ǁŚĞƌĞŽƵƌĞŶĞƌŐLJĐŽŵĞƐĨƌŽŵƚŽƉŽǁĞƌĂůůƚŚĞ ƟƌĞĚŶĞƐƐ͘ ĂĐƟǀŝƟĞƐŽĨƚŚĞďŽĚLJ͘KďǀŝŽƵƐůLJ͕ĨŽŽĚŝƐŽƵƌĨƵĞů͕ ďƵƚ ƚŚŝƐ ĨƵĞů ŵƵƐƚ ĮƌƐƚ ďĞ ĞĸĐŝĞŶƚůLJ ĐŽŶǀĞƌƚĞĚ dŚĞ'ŽŽĚEĞǁƐ ŝŶƚŽĂƵƐĂďůĞĨŽƌŵͲ͚ďŝŽůŽŐŝĐĂůĞŶĞƌŐLJ͛ŬŶŽǁŶĂƐ ƐƚĂZĞĂů® dϮĐŽŶƚĂŝŶƐŶĂƚƵƌĂůĂƐƚĂdžĂŶƚŚŝŶǁŚŝĐŚ dŚĞŐŽŽĚŶĞǁƐŝƐƚŚĂƚŵĞĚŝĐĂůƐĐŝĞŶĐĞŚĂƐďĞĞŶ ĂĚĞŶŽƐŝŶĞ ƚƌŝƉŚŽƐƉŚĂƚĞ ;dWͿ Ͳ ǁŚŝĐŚ ƐƵƉƉůŝĞƐ ƉƌŽǀŝĚĞƐLJŽƵƌďŽĚLJǁŝƚŚƚŽƚĂůĂŶƟŽdžŝĚĂŶƚƐƵƉƉŽƌƚ ĂďůĞ ƚŽ ƵŶĐŽǀĞƌ ƐŽŵĞ ŽĨ ƚŚĞ ŵĂŝŶ ƉĂƚŚǁĂLJƐ ƚŚĞĞůĞĐƚƌŝĐŝƚLJƚŚĂƚĚƌŝǀĞƐĂůůƚŚĞĨƵŶĐƟŽŶƐŝŶƚŚĞ ŝŶǀŽůǀĞĚ ŝŶ ŵŝƚŽĐŚŽŶĚƌŝĂů ĚLJƐĨƵŶĐƟŽŶ ĂŶĚ ƚŚƵƐ ĂŶĚĐůŝŶŝĐĂůůLJƉƌŽǀĞŶĂŶƟͲĨĂƟŐƵĞĞīĞĐƚƐ͘WƌŽĚƵĐƚŝƐŐ ďŽĚLJ͘ dŚŝƐ dW ĞŶĞƌŐLJ ŝƐ ŵĂŶƵĨĂĐƚƵƌĞĚ ŝŶ ƟŶLJ ŝƚ ŚĂƐ ƉƌŽǀŝĚĞĚ ƵƐ ǁŝƚŚ Ă ͚ƌŽĂĚŵĂƉ͛ ďLJ ǁŚŝĐŚ ĂǀĂŝůĂďůĞĂƚƐĞůĞĐƚĞĚĐůŝŶŝĐƐďLJďLJ ƉŽǁĞƌƉůĂŶƚƐĐĂůůĞĚŵŝƚŽĐŚŽŶĚƌŝĂͲĨŽƵŶĚǁŝƚŚŝŶ ǁĞ ĐĂŶ ƉƌĞǀĞŶƚ ĨƵƌƚŚĞƌ ŵŝƚŽĐŚŽŶĚƌŝĂů ĚĂŵĂŐĞ͕ ƉƌĞƐĐƌŝƉƟŽŶŽŶůLJ ƚŚĞĐĞůůƐŽĨŽƵƌƟƐƐƵĞƐĂŶĚŽƌŐĂŶƐ͕ĂůůŽĨǁŚŝĐŚ ƌĞƉĂŝƌ ĚĂŵĂŐĞĚ ƉĂƚŚǁĂLJƐ ĂŶĚ ůĞĂĚ ƵƐ ďĂĐŬ ƚŽ ĐŽŵƉůĞƚĞůLJ ƌĞůLJ ŽŶ ƚŚĞ ŵŝƚŽĐŚŽŶĚƌŝĂ ƚŽ ƐƵƉƉůLJ Ă ĨƵŶĐƟŽŶĂů  ĂŶĚ ŽƉƟŵĂů ƐƚĂƚĞ͘ dŚŝƐ ŝŶǀŽůǀĞƐ ƚŚĞĞŶĞƌŐLJƌĞƋƵŝƌĞĚƚŽĨƵŶĐƟŽŶ͘/ŶŽƚŚĞƌǁŽƌĚƐ͕ &ŽƌŵŽƌĞĚĞƚĂŝůƐ͗ ĂĚũƵƐƚŵĞŶƚƐ ĂŶĚ ŵŽĚŝĮĐĂƟŽŶƐ ŝŶ ŽƵƌ ŚĂďŝƚƐ ĞǀĞƌLJĂĐƟǀŝƚLJ;ƚŚŝŶŬŝŶŐ͕ĚƌŝǀŝŶŐ͕ƌƵŶŶŝŶŐ͕ƐĞĞŝŶŐ͕ нϲϱϲϮϮϮϭϳϳϴ ƚŽǁĂƌĚƐ ŚĞĂůƚŚLJ ůŝĨĞƐƚLJůĞƐ͕ ƐƵĐŚ ĂƐ͗ ƐŵŽŬŝŶŐ ĞǀĞŶďƌĞĂƚŚŝŶŐ͙ͿƌĞƋƵŝƌĞƐĞŶĞƌŐLJƉƌŽĚƵĐĞĚďLJ ĐĞƐƐĂƟŽŶ͕ĞdžĞƌĐŝƐĞ͕ŚĞĂůƚŚLJĚŝĞƚƐĂŶĚĂĚĞƋƵĂƚĞ ĞŶƋƵŝƌLJΛĂƐƚĂƌĞĂů͘ƐŐ ƚŚĞŵŝƚŽĐŚŽŶĚƌŝĂ͘ Made in Japan

Biochimica et Biophysica acta - Biomembranes, Volume 1512, issue 2. 2001. 251-258. Conley, J Exp Biol. 2016 Jan; 219(Pt 2):243-9. Shiratori et al., J Clin Therap Med. 2005; 21(6):637-50. Djordjevic et al., J Sports Med Phys Fitness. 2012; 52(4):382-92. Earnest et al., Int J Sports Med. 2011; 32:882-88. Takahashi et al., J Clin Therap Med. 2005; 21(4):431-36. ,ŽŶŐŽĞƚĂů͕͘:ŽƵƌŶĂůŽĨĐůŝŶŝĐĂůƚŚĞƌĂƉĞƵƟĐƐΘŵĞĚŝĐŝŶĞƐ͘ϮϬϭϲ͖ϯϮ;ϳͿ͗ϱϳϳͲϱϵϭ͘ <ĂŬŬĂƌĞƚĂů͕͘DŽůĞůůŝŽĐŚĞŵ͘ϮϬϬϳEŽǀ͖ϯϬϱ;ϭͲϮͿ͗ϮϯϱͲϱϯ͘   sŝĐƚŽƌĞƚĂů͕͘ƵƌƌWŚĂƌŵĞƐ͘ϮϬϬϳ͖ϭϯ;ϴͿ͗ϴϰϱͲϲϯ͘ EĂŐĂŬŝĞƚĂů͕͘:ůŝŶdŚĞƌĂƉDĞĚ͘ϮϬϬϱ͖Ϯϭ;ϱͿ͗ϱϯϳͲϰϮ͘   WĂƌŬĞƚĂů͕͘EƵƚƌDĞƚĂď;>ŽŶĚͿ͘ϮϬϭϬ͖ϳ͗ϭϴ͘    tŽůĨĞƚĂů͕:EƵƚƌŝŽĐŚĞŵ͘ϮϬϭϬDĂLJ͖Ϯϭ;ϱͿ͗ϯϴϭͲϵ͘ WŝĞĐnjĞŶŝŬĂŶĚEĞƵƐƚĂĚƚ͕džƉDŽůWĂƚŚŽů͘ϮϬϬϳƵŐ͖ϴϯ;ϭͿ͗ϴϰͲϵϮ͘  ^ĂǁĂŬŝĞƚĂů͕͘:ŽƵƌŶĂůŽĨůŝŶŝĐĂůdŚĞƌĂƉĞƵƟĐƐĂŶĚDĞĚŝĐŝŶĞ͘ϮϬϬϮ͖ϭϴ;ϵͿ͗ϭϬϴϱͲϭϭϬϬ͘

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CONTEST Bringing baby out safely TEST YOUR MEMORY Is it safe to take my baby out in from harmful direct sunlight. The hands before and aft er changing public, and for how long? American Academy of Paediatrics diapers, and also before carrying It is important to give your baby a recommends that children under six your baby. chance to explore the world, but months of age should be kept out of Remind friends it is equally important to consider direct sunlight because of the risk of and family, even if things like where you are going, the skin cancer. they aren’t sick, to weather and available facilities. Before heading out, check that wash their hands For instance, going to an the place you are going to is baby- before touching enclosed, crowded environment friendly, as you will need facilities your baby.

with poor ventilation raises the for changing diapers and breast- Dr Alvin Ngeow, Associate chance of catching an infection, feeding. But diaper-changing Consultant, Department of Neonatal & Developmental especially an airborne one such as stations can be breeding ground for Medicine, Singapore respiratory pathogens and even germs, including those that cause General Hospital chicken pox. So limit the time hand, foot and mouth disease. Be that your baby spends in places sure to use antiseptic wipes to clean Answer these simple questions to like expo fairs, crowded shopping the diaper-changing table before stand a chance to win a bottle of centres and eateries. Babies, placing your own diaper-changing Turmercare worth $84. Sponsored by Vitahealth Asia Pacific (S) Pte Ltd especially newborns, can also be mat on top of it. Also, wash your www.vitaHealth.com.sg overwhelmed by light and loud noise at these places. QUESTIONS Likewise, limit time in • When it comes to assessing frailty in the elderly, what does the back scratch gardens and parks, as babies test entail? can get bitten by mosquitoes • Which former US Vice-President has and other insects, and had an ICD implanted in his chest? contract infections like dengue fever or the zika virus. Spending Send your answers with details of your name, age, gender, address and telephone number to: too much time outdoors in sunny Email [email protected] (or) Singapore can also put your baby Post The Editor, Singapore Health, Singapore at risk of heat exhaustion and General Hospital, Communications Department, #13-01 Surbana One, Blk 168, Jalan Bukit Merah, sunburn. But this doesn’t mean Singapore 15016. your infant shouldn’t spend time outdoors, as limited exposure to Deadline May 31, 2018

sunlight puts it at risk of developing Winners will be notified by phone or email. vitamin D deficiency. This deficiency Please remember to send in all the details can cause rickets – a soft ening and indicated above. Incomplete or multiple entries weakening of bones, and bone will not be considered. deformities. Before going out in the sun, WINNERS OF CONTEST 50 wear protective clothing and apply 1. Idris Rahim 2. Serene Lee Siling sunscreen to shield your baby 3. L Lim 4. Lim Thian Seng 5. Catherine Tay ILLUSTRATION PHOTO: & 123RF Don’t scratch that itch Some of my grandkids are turning four stickers may cause contact dermatitis in years old, and one is two years old next patients with eczema/sensitive skin. If you month. There are lots of mosquitoes in notice any rash or itch, please stop using it our garden, and despite using citronella and consult a doctor. stickers that stick onto the outside of Reactions to mosquito bites can be clothes, they still get bitten on their arms very itchy. Thus, barrier methods (like and exposed ankles. long-sleeved pants and shirts) and What can we do if they get bitten, avoidance may be the most eff ective way scratch feverishly and cannot sleep? to prevent the child from being bitten by Is baby Benadryl cream okay to use at mosquitoes. If the child has already been their age? Can it be harmful to scratch, bitten, he or she will probably benefit from such that it opens up the bite and the use of anti-inflammatory topicals. spreads the toxins so that it is not such a Do not touch or scratch the aff ected concentrated itch? area because that may cause further Generally, the citronella stickers without inflammation and discomfort.

chemicals are safe for children to use. Dr Uma Alagappan, Consultant, Dermatology Service, However, evidence has shown that these KK Women’s and Children’s Hospital

Our experts answer all your questions about health Visit our website for the latest topics for discussion at www.healthxchange.com.sg, Singapore’s first interactive health and lifestyle portal.

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