APRIL-JUNE 2014
A PUBLICATION FOR PRIMARY CARE PHYSICIANS
MCI (P) 088/03/2014
Scan the QR code
using your iPhone or
smart ...
20
in every issue
030 editor’s note
040 in the news
270 fitness
310 healthy recipe
in this issue
06 	Improving Function Fo...
in the newsin the news
WRIST ANGIOPLASTY:
FROM THE WRIST TO
THE HEART
INTERACTIVE EYE
WORKSHOP AND ‘LO HEI’
FOR GP PARTNER...
Improving
Function
for Elderly
Fractures
Mobility and the Ageing Population
T
he ageing population in Singapore has been o...
cover story cover story
Loss in mobility proves more of a
concern in the lower limb, as the
patient will not be able to si...
cover story cover story
Dr. Hitendra K. Doshi
Dr. Hitendra K. Doshi is a Consultant in the
Department of Orthopaedic Surge...
feature feature
InGoodHandsA multi-disciplinary approach is adopted for many common hand
and wrist conditions. The hand th...
Treatment Options And
Medical Developments
Recalcitrant, chronic or specialised
cases requiring specific opinions
should b...
KNOWING
YOUR
DRUGSAND
ALLERGIES
featurefeature
A
dverse reactions to
medications are common
and may present themselves
in ...
featurefeature
Danger signs of a severe drug
allergy include:
•	 Dyspnea or breathlessness;
abdominal pain or diarrhoea;
g...
feature
With old age comes inevitable
forms of physical limitations.
These include reduced vision,
hearing, body balance, ...
feature feature
perform daily tasks in a seated
position safely. Front load washing
machines and portable low height
laund...
featurefeature
Fixingthe
LeakyTap-
Incontinence
inElderly
Urinary incontinence is a prevalent problem
among the elderly. W...
Fitness
Protect
YourJoints
withthese
Strengthening
Workouts
O
ur joints are meant to last a
lifetime. Due to sedentary lif...
fITNESS Fitness
Joints get lubricated by movement, and
modern conveniences are depriving us of the
much needed stimulation...
Cantonese
Stir Fry
Kailan
Cantonese Stir Fry Kailan
(Serve 4)
Ingredients
Minced chicken breast	 200g
Kailan, chopped	 3 c...
Clinic B1B
–	 Orthopaedic Surgery
• Hand Procedure Suite
–	 Rheumatology, Allergy and
	Immunology
• Intravenous Infusion D...
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GP Buzz April - June 2014

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In this issue of GP BUZZ, the cover
story outlines the treatment options
for elderly fractures and how Tan
Tock Seng Hospital’s (TTSH)
multidisciplinary, integrated care
pathways can help patients regain
their pre-fracture mobility. An
account of a patient who has
undergone a total hip replacement
surgery will also be shared.

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GP Buzz April - June 2014

  1. 1. APRIL-JUNE 2014 A PUBLICATION FOR PRIMARY CARE PHYSICIANS MCI (P) 088/03/2014 Scan the QR code using your iPhone or smart phone to view GPBUZZ on the TTSH website or visit www.ttsh.com.sg/gp/. Improving Function for Elderly Fractures In Good Hands KNOWINGYOUR DRUGS AND ALLERGIES Incontinence in Elderly Healthy Recipe Stir Fry Kailan
  2. 2. 20 in every issue 030 editor’s note 040 in the news 270 fitness 310 healthy recipe in this issue 06 Improving Function For Elderly Fractures 12 In Good Hands 16 Knowing Your Drugs And Allergies 20 Healthy Living In Your Golden Age - Enhancing Daily Living For Seniors With Physical Limitations 24 Fixing The Leaky Tap - Incontinence In Elderly 12 16 n a paper issued by the National Population and Talent Division in July 2012, Singapore’s population of citizens aged 65 years and above will triple to 900,000 by 2030. With the challenges of a rapidly ageing population and falling birth rates, the prevalence of chronic conditions and musculoskeletal conditions such as Osteoarthritis (OA) are set to increase. In Singapore, musculoskeletal conditions were listed as the fifth leading cause of morbidity in 2004, accounting for 4.9% of ‘years lost to disability’ (YLD)1 . As one grows older, the likelihood of sustaining a fracture due to the presence of conditions like OA will be higher. In this issue of GP BUZZ, the cover story outlines the treatment options for elderly fractures and how Tan Tock Seng Hospital’s (TTSH) multidisciplinary, integrated care pathways can help patients regain their pre-fracture mobility. An account of a patient who has undergone a total hip replacement surgery will also be shared. We also cast the spotlight on hand and wrist conditions and how patients can benefit from advances in hand surgery. We are pleased to introduce TTSH’s Hand Procedure Suite (HPS), a certified operating theatre, located within the outpatient clinic. A patient’s account of her surgery in HPS will be featured. Drug allergies can manifest in different ways and the reactions can be mild or severe. GP BUZZ brings you through the types of drug allergies and how they can be managed and diagnosed. In conjunction with the World Continence Week in June 2014, we will also profile urinary continence, its contributing factors and individual treatment options. Seniors with physical limitations do not need to succumb to their disabilities. TTSH’s Occupational Therapist shows you practical strategies and interventions to help seniors cope with these limitations for a more active and fulfiling life. Finally, we get physical with a series of joint strengthening workouts by TTSH Physiotherapist and not forgetting a nutritious and simple high calcium dish for stronger bones to end on a delicious note. Happy reading. I editor’s notecontents The GP BUZZ editorial team: Jessie Tay Celine Ong ADVISORY PANEL: Emeritus Professor Feng Pao Hsii Associate Professor Thomas Lew Associate Professor Chia Sing Joo Associate Professor Chin Jing Jih Adjunct Assistant Professor Chong Yew Lam Dr Tan Kok Leong Mr Joe Hau GP Buzz is a magazine by Tan Tock Seng Hospital, designed by We value your feedback on how we can enhance the content of GP Buzz. Please send in your comments and queries to gp@ttsh.com.sg. © All rights reserved. No part of this publication may be reproduced or transmitted in any form by any means without prior consent from the publisher. APRIL - JUNE 2014 1 Phua HP, Chua AV, Ma S, Heng D, Chew SK (2009) Singapore’s burden of disease and injury 2004. Singapore Med J 50 (5),468–78. APRIL-JUNE 2014 A PUBLICATION FOR PRIMARY CARE PHYSICIANS MCI (P) 088/03/2014 Scan the QR code using your iPhone or smart phone to view GPBUZZ on the TTSH website or visit www.ttsh.com.sg/gp/. 04 02 03
  3. 3. in the newsin the news WRIST ANGIOPLASTY: FROM THE WRIST TO THE HEART INTERACTIVE EYE WORKSHOP AND ‘LO HEI’ FOR GP PARTNERS A t Tan Tock Seng Hospital (TTSH), about 9 in 10 angioplasty patients undergo trans-radial artery angioplasty, a newer method of unclogging a blocked artery. TTSH currently performs around 1,000 angioplasty cases a year, and started adopting the trans-radial approach in 2010. Traditionally, an angioplasty is done via the groin, but with medical advances, angioplasty through the wrist is now the preferred method, if patients are assessed and suited for this procedure. To unclog a blocked artery, stents or balloons are inserted through a small opening from the radial artery at the wrist to the heart, hence making it easier for the Cardiologist to manage. This procedure is more comfortable for patients. Using the trans-radial method, the risk of serious complication is lessened since the stent or balloon is inserted in the smaller radial artery, instead of the major femoral artery in the groin method. T an Tock Seng Hospital (TTSH) and National Healthcare Group Eye Institute (NHGEI) organised a ‘Lo Hei’ appreciation lunch and interactive eye workshop for General Practice (GP) partners on Saturday, 25 January 2014. A/Prof. Chia Sing Joo, Divisional Chairman, Surgery of TTSH, gave a welcome address and spoke on partnering the GPs through the TTSH Community Right Siting Programme. Well-attended by 60 GPs, this event marks an auspicious beginning to stronger engagement with GPs in the community. In the interactive eye workshop, Dr Wong Hong Tym, Medical Director of NHGEI, Dr Vernon Yong, Deputy Director and eight consultants were also present to facilitate the eye workshop, where GPs were taught simple and useful procedures which they could safely perform in their clinics. Interactive eye workshop by NHGEI. ‘Lo Hei’ to a better year ahead. CME Schedule April – June 2014 CME POINTS DATE TIME VENUE REGISTRATION DETAILS CME POINTS DATE TIME VENUE REGISTRATION DETAILS Subject to approval by SMC* 26 April 2014 1:00pm – 5:00pm Theatrette, Tan Tock Seng Hospital, Level 1 Ms Chiang Han Fong Contact: 6357 7897 Email: han_fong_chiang@ttsh.com.sg Subject to approval by SMC* 24 May 2014 12:00pm – 5:00pm TBC Ms Mary Cheong Contact: 6357 3044 Email: mary_yl_cheong@ttsh.com.sg Liver Disease In General Practice – Some Useful Tips A Holistic Approach to Benign Urological Diseases * Subject to the approval of Singapore Medical Council. For an updated listing of CME and event schedule, please visit http://www.ttsh.com.sg/gp/. Information is correct at the time of publishing. Contact Heart Atrium at 6357 2668 (Mon – Fri: 8:00am – 5:30pm; Sat: 8:00am – 12:30pm) for an appointment and assessment by TTSH Cardiologist. 04 05
  4. 4. Improving Function for Elderly Fractures Mobility and the Ageing Population T he ageing population in Singapore has been on the rise and today, most elderly folks in our society lead healthy and active lifestyles. Trivial injuries are more likely to result in fractures among the elderly due to the presence of osteoporosis compared to the younger population. Common fractures that occur in the upper limb are fractures around the shoulder, elbow and wrist joints. In the lower limb, the most common fractures involve the hip joint. The incidence of hip fractures in particular has been on the rise in recent years. One of the major challenges for these patients is to regain their pre-fracture mobility or function. cover story cover story Maintaining Mobility In today’s society, cultural norms demand every individual to be independent and self-sufficient, particularly in carrying out activities of daily living. Although caregivers may be present to care for the aged in a family unit, the elderly would usually hope to remain active and be able to care for themselves. After sustaining a fracture, mobility is acutely lost, due to pain and loss of bodily function. Some fractures, particularly in the upper limb that are not displaced, may be treated conservatively with a cast or arm sling. Nevertheless, displaced fractures in the upper limb can benefit from a surgical procedure. Mobility among the elderly can be significantly affected when fractures are sustained. Depending on the fracture configuration and patient’s needs, timely surgery after consideration of options including minimally invasive approaches is of paramount importance. With specialised geriatric care available in Tan Tock Seng Hospital, our elderly patients are all set to enjoy better recovery and improved mobility. 06 07
  5. 5. cover story cover story Loss in mobility proves more of a concern in the lower limb, as the patient will not be able to sit up or even walk after sustaining a fracture. Being bed bound poses other complications of immobility, such as deep vein thrombosis, bed sores, urinary tract infection, chest infection and depression. Therefore, upon a decision for surgery with informed consent, surgery should be done as early as possible. Delays in surgery will significantly increase complications and impede commencement of rehabilitation. Figure 1: X-ray of the Elbow Figure 2: Patient with Dynamic Hip Screw (DHS) Figure 3: Patient with Proximal Femoral Nail (PFN) Figure 4: Total Replacement of the Hip Surgical Treatment Options The surgical options for a fragility fracture are either a surgical fixation or surgical replacement. • SURGicAL FIXATION Treatment of fragility fractures with surgical fixation aims to stabilise osteoporotic bones with the use of special plates designed for brittle bones. These plates have locking screws that make the fixation more stable. Furthermore, these newer plates are anatomical, as they are designed to conform to the bone with maximal options for screw purchase (Refer to Figure 1). Newer designs also provide an option for augmentation with bone cement to further enhance the anchorage of the screw in severe osteoporotic bone. This is crucial in ensuring optimal stability so that the patient can start immediate mobilisation and weight bearing. The surgical technique of applying the plate through a minimally invasive approach minimises skin incisions on fragile and thin skin. Furthermore, there will be less post-operative pain from smaller surgical wounds. • JOINT REPLACEMENT SURGERY Many types of fractures can benefit from joint replacement surgery. This is particularly so, when there is significant destruction of the joint surface that affects articulation (e.g. the shoulder joint, elbow joint, hip joint and knee joint). In some instances, the fracture may involve the region that supplies blood to the articulating surface (e.g. the neck of the femur or neck of the humerus). This will eventually result in necrosis and collapse of the articulating head, even if the bones are stabilised with screws. Hence, a replacement surgery is advisable in such fracture patterns. A joint replacement involves excising the damaged articulating surface and replacing it with a metal implant (prosthesis) that will allow for immediate articulation and weight bearing. This is considered a partial replacement. The replacement surgery may also involve the corresponding articulating surface, if required, and in this case, will be a total joint replacement. Newer designs of joint replacement implants provide a wide range of modularity and options to allow for maximum stability and mobility. The newer designs also accommodate instrumentation of the implant in a minimally invasive approach. EXAMPLES OF FRAGILITY FRACTURES • Typical Fracture in Lower Limb A typical fracture in the lower limb after a fall in the elderly is a hip fracture. Depending on the location of the fracture, the patient is either stabilised (intertrochanteric fractures) with a Dynamic Hip Screw (DHS) (Refer to Figure 2), a Proximal Femoral Nail (PFN) (Refer to Figure 3) or a replacement surgery (Refer to Figure 4). With regard to replacement surgery, an active elderly patient will benefit from a total replacement (as compared to a partial replacement) as it allows for better functional recovery, mobility and long-term outcomes. • Typical Fracture in Upper Limb A typical fracture involving the upper limb after a fall, is a fracture of the humeral neck or head. While most neck fractures can be stabilised with an anatomical plate, humeral head fractures with significant osteoporosis will benefit from a replacement surgery. Replacement surgery in such cases has the advantage of early mobilisation. In most situations, a partial replacement would suffice (Refer to Figure 5). Nevertheless, in cases where the shoulder cuff muscles are weak or torn, a total replacement 08 09
  6. 6. cover story cover story Dr. Hitendra K. Doshi Dr. Hitendra K. Doshi is a Consultant in the Department of Orthopaedic Surgery of Tan Tock Seng Hospital and a Clinical Lecturer in the National University of Singapore (NUS). Dr H.K. Doshi completed his Masters in Orthopaedic Surgery from NUS and his Fellowship Degree in Orthopaedics from the Royal College of Surgeon in Edinburgh and from the European Board of Ortopaedics and Traumatology. He has undergone further training in Switzerland, Germany and Austria in his specialised area of interest in advanced and complex trauma, joint replacement surgery and geriatric fracture management. (Reverse Shoulder) will be advantageous. For complex fractures involving the elbow joint that is not amenable to surgical fixation, a total elbow joint replacement is recommended (Refer to Figure 6). A Multidisciplinary Team Approach The involvement of multiple disciplines is often required to provide optimal patient care, especially for complex cases with pre-existing medical conditions (including osteoporosis and dementia). A multidisciplinary approach, which includes an Orthopaedic Surgeon, a Geriatric Physician, an Anaesthetist and a Physiotherapist, is required to ensure that all aspects of patient care and treatment are managed optimally pre-and-post surgery. In recent years, specialised care pathways have been established in many centres abroad to ensure optimal management of geriatric fractures. At Tan Tock Seng Hospital, we have a well established integrated care pathway for geriatric hip fractures. With a dedicated Ortho-Geriatric care model, patients have shown promising recovery with minimal complications. Under this care model, rehabilitation efforts and progress are followed through for one year to ensure optimal functional recovery. Furthermore, secondary fracture prevention is also practised by actively screening and treating osteoporosis. Patients are also assessed for ‘fall risk’, and both patients and caregivers are educated on ‘fall prevention’. This preventive effort is essential to minimise future falls and fractures. Patient’s Account: Up and Moving AgainFigure 5: Partial Replacement of the Shoulder Figure 6: Total Elbow Joint Replacement At 67 years of age, Mrs Koh Thiam Huat is a busy grandmother who considers caring for her grandchild one of her daily routines and a great joy in life. As a retired primary school teacher, Mrs Koh continues to maintain an active lifestyle as mobility is of the utmost importance to her. Arthritis did not deter her from getting about and managing her daily routines. A total knee replacement that she underwent in 2009 also improved her mobility. On a morning in early December 2013, Mrs Koh was already up and about, preparing her grandchild for kindergarten. In haste, she slipped and landed hard on her buttocks. On the third day of her fall, she found that she was unable to ambulate due to her fall and pain. An ambulance was called and she was sent to the Emergency Department of Tan Tock Seng Hospital (TTSH). At TTSH, Mrs Koh had her X-ray done and was diagnosed to have a hip fracture. She was quickly referred to Dr Hitendra K. Doshi, a Consultant from the Orthopaedic Surgery Department. Dr H.K. Doshi clearly evaluated and explained the condition to Mrs Koh and her family. A hip replacement surgery was recommended in view of the benefits of mobility and long-term outcomes. On 14 December 2013, Mrs Koh was operated by Dr. H.K. Doshi and on the second day of surgery, her rehabilitation journey began, assisted by TTSH’s Physiotherapist who got Mrs Koh to take her first step with a walking frame. “It was painful in the beginning, but I know I cannot give up. I had to walk,” Mrs Koh said when she recounted her recovery journey. While she was warded, Mrs Koh was encouraged to exercise daily. She had to attempt climbing stairs and to strengthen her hip muscles with the goal of regaining her pre-fall functional capacity. Nearly two months after her hip replacement surgery, Mrs Koh can now move around her house independently. When asked on the most important thing that she would like to share with patients with the same condition, Mrs Koh shared that mobilising the affected joints early after surgery is very important. Conclusion The quality of life after a fracture in the elderly is dependent on optimising function. This is certainly achievable with a stable fixation or a replacement surgery based on the fracture configuration and demands of the patient. To ensure optimal results, an integrated care pathway with a multidisciplinary approach provides comprehensive care to patients for better, safer and faster recovery. 10 11
  7. 7. feature feature InGoodHandsA multi-disciplinary approach is adopted for many common hand and wrist conditions. The hand therapist is a valuable asset in this respect. Many of these conditions can be managed in the primary care setting. There have been recent advances in therapy modalities and surgical techniques available, to better care and advise our patients. S ingapore is one of two countries in the world where Hand Surgery exists as a specialty, recognising that hand and wrist conditions can be complicated. There is a need for the preservation of both form and function when it comes to the management of hand and wrist conditions. Our hands are the primary tools we use to interact with our surroundings, be it activities at work or play, or even activities of daily living (ADL). Managing Wrist and Hand Conditions In Primary Care Our primary care physicians will encounter in their daily practice many patients who present a multitude of hand and wrist conditions. Common conditions include: • Trigger Digits • De Quervain’s Tenosynovitis • Carpal Tunnel Syndrome • Ganglion Cysts • Osteoarthritis • Inflammatory Arthropathy • Paronychia • Simple Lacerations Primary care settings possessing adequate equipment and setups can usually deal with simple lacerations by careful cleaning and suturing the wound. Similarly, simple paronychia can be derided and treated through appropriate antibiotics and regular dressings. Enthesopathies and tendinopathies can be managed in the primary care setting with non-steroidal anti-inflammatory drugs (NSAIDs) and subsequent referral to the hand therapists TTSH Hand Procedure Suite - Fully equipped and certified operating theatre providing one-stop service for day surgery cases done under local anesthesia or regional block. X-ray films depicting a rheumatoid patient who has undergone total wrist replacement, which allowed the patient to retain motion, as opposed to the traditional option of fusing the wrist. View from inside the carpal tunnel during endoscopic carpal tunnel release. The transverse carpal tunnel has been released, revealing the subcutaneous fat from anterior to the ligament. The median nerve is on the right of the incision. in Tan Tock Seng Hospital (TTSH) for splints or other treatment modalities for pain management. Steroid based injections can also be carried out in the primary setting for these conditions. 12 13
  8. 8. Treatment Options And Medical Developments Recalcitrant, chronic or specialised cases requiring specific opinions should be referred to Hand Surgeons. We approach most conditions to do with hand and wrist complications in a multidisciplinary approach. We aim to provide a one-stop clinic experience, integrating the doctor’s consultation rooms, hand therapist room, x-ray imaging facilities and pharmacy within the same compound. This makes the management of the patient and condition seamless. In 2012, TTSH’s Hand Procedure Suite (HPS) was established. HPS is a certified operating theatre with similar sterile conditions as the main operating theatre, located within the clinic. This allows suitable operations to be carried out under local anesthesia, or regional blocks, within the compound. Sometimes, these operations may be carried out on the same day as the patient’s consultation visit to the clinic. Advances in Hand Surgery Hand Surgery has seen major advances in recent years. There is a move towards minimally invasive surgery, to allow for faster wound healing and for earlier rehabilitation to occur. In the HPS, we routinely perform endoscopic carpal tunnel release, which has been shown to cause lower pain intensity and yield shorter recovery times, as compared to traditional open carpal tunnel release. We have been offering patients, where possible, the option of a percutaneous release of their trigger digits as well. The patients start their rehabilitation immediately, post-operation, and there are no open surgical incisions to contend with. Other minimally invasive procedures that we perform in the major operating theatres include wrist arthroscopy for both diagnostic and therapeutic management of chronic wrist conditions. There are usually four to six small stab incisions to allow for instrumentation and camera placement. Our scopes range in diameters of 1.9mm to 2.4mm for the wrist, and there are conditions where we are able to perform entire operations through these multiple small incisions. Dr Yeo Chong Jin Dr Yeo Chong Jin is the Acting Head and Associate Consultant of the Hand and Microsurgery Section, Department of Orthopaedic Surgery at Tan Tock Seng Hospital. He completed his fellowship training with A/Prof Gregory Bain for Wrist Arthroscopy and Reconstruction at the Royal Adelaide Hospital, South Australia. His clinical interests lie in minimally invasive arthroscopic and open wrist reconstruction. Patient’sAccount: Endoscopic Carpal Tunnel Release A bubbly senior at 76 years of age, Ms Lee Chin Lan keeps herself busy caring for her six grandchildren and helps out in church. She professes that she inherited her active lifestyle from her hardworking mother and she started helping her mother with laborious chores at a very young age. She went on to complete nursing school and served as a senior nursing officer in Tan Tock Seng Hospital (TTSH) until her retirement at the age of 61 in May 2000. Carpal Tunnel Syndrome on her right hand did not slow her down and her busy schedule resumed after her carpal tunnel release surgery almost 20 years ago. Ms Lee shared that as surgical methods were not as developed as compared to current times, her surgical incision then was long. In recent years, she started experiencing numbness and trigger finger on the middle finger of her left hand. She knew that her situation had worsened about 6 months ago. She felt a tingling sensation on her middle finger when she held up newspapers for reading. The numbness had also extended to her left shoulder and down her arm. In one of her consultation sessions in the Orthopaedic Surgery Department of TTSH for her knees, she highlighted her problem to her consultant and was subsequently referred to Associate Professor Teoh Lam Chuan. A/Prof. Teoh, Senior Consultant of the Orthopaedic Surgery Department (Hand and Microsurgery), prescribed steroid injection into the carpal tunnel but it only provided temporary relief to Ms Lee. On January 2014, Ms Lee underwent an endoscopic carpal tunnel release surgery by A/Prof. Teoh in the Hand Procedure Suite of the outpatient clinic in TTSH. The minimally invasive surgery took about 30 minutes and Ms Lee felt little pain as she was under local anaesthesia during the day surgery. Unlike her previous carpal tunnel release surgery on her right hand 20 years ago, the endoscopic surgery on her left hand was a keyhole and hence the incision was not visible. In the first few days of her surgery, Ms Lee felt some stiffness in the operated hand. Pain levels were manageable. Ms Lee continued with usual daily activities carefully, innovating in her own way to keep her operated hand dry and injury free. Now, about 2 months after her surgical procedure, Ms Lee can now squeeze her left fingers together easily. She shared that this is a simple procedure and advised patients who have undergone the same procedure not to overexert their hands. feature feature Endoscopic decompression of other peripheral nerves in the upper limb are also becoming more commonplace. After carpal tunnel syndrome, ulnar nerve compression at the elbow is the next most common peripheral nerve to be compressed. Occasionally, the ulnar nerve will need to be transposed anteriorly after decompression, to prevent the recurrence of symptoms. This whole procedure can now be performed endoscopically. Total joint replacement in the finger and wrist are also available for patients with arthritic or dysfunctional joints. Silicone, pyrocarbon or metal-on- polyethylene implant types are now available. Each has specific indications, depending on the patient’s condition and requirements. With these advances, there are now more treatment options for patients to wave goodbye to hand and wrist pain. 14 15
  9. 9. KNOWING YOUR DRUGSAND ALLERGIES featurefeature A dverse reactions to medications are common and may present themselves in a variety of ways, with varying severity across different individuals. Approximately 5% to 10% of these reactions are due to a true allergic reaction, that is an immunologically (Immunoglobulin E or non- Immunoglobulin E) mediated hypersensitive reaction. Examples of non-immunologically mediated hypersensitivity reactions include intolerance to non-steroidal anti- inflammatory drugs (as a result of increased leukotriene synthesis) and angioedema associated with the use of angiotensin-converting enzyme inhibitors. Drug-Induced Allergies Manifestations of Immunoglobulin E (IgE) mediated (immediate) hypersensitivity reactions include urticaria, angioedema around the eyes and lips, and anaphylaxis which is severe and life-threatening. Symptoms of anaphylaxis may include generalised erythema or urticaria, oropharyngeal or tongue angioedema, dyspnea and wheezing, nausea or diarrhoea, abdominal pain and syncope. In severe cases, a rapid fall in blood pressure may result in shock and loss of consciousness. The manifestations of non-IgE mediated (delayed) reactions are more variable, and may range from mild and self-limiting maculopapular eruptions to more severe reactions such as Stevens Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), or severe hepatitis or nephritis. Rarer presentations of delayed reactions include fixed drug eruptions, bullous, or pustular drug eruptions. The onset of a drug allergy may occur any time within an hour (for immediate reactions) to days or weeks (for delayed reactions) from consumption of the medication. Reactions after the first few doses of a medication usually occur in the setting of prior exposure to the same medication whereby sensitisation has occurred. Otherwise, de novo reactions to a new medication typically occur after a period of continued use. Hence, prior uneventful use of a drug does not preclude the development of an allergy later on. Drugs that commonly cause allergies include antibiotics – in particular, beta-lactams and trimethoprim-sulfamethoxazole; anti-epileptic drugs; anti- tuberculous medication; non- steroidal anti-inflammatory drugs; and allopurinol. Management of Drug Allergies The most important step in managing drug allergy is to stop the use of the affecting medication. Early recognition of a drug allergy and early cessation of the drug(s) enables quicker clinical recovery and minimises the risk of progression to a severe reaction. Drug allergies are not uncommon and may manifest in a variety of ways, ranging from mild to severe reactions. Certain drug allergies may occur days to weeks after starting on new medication. Where the allergy is not definite, an allergist will be able to provide an opinion, or arrange for further tests to determine the diagnosis. 16 17
  10. 10. featurefeature Danger signs of a severe drug allergy include: • Dyspnea or breathlessness; abdominal pain or diarrhoea; giddiness, syncope, or hypotension – these are signs of anaphylaxis • Red or painful eyes, oral or genital ulcers – these are signs of SJS • Skin epidermal detachment which may indicate TEN • Systemic involvement, such as fever, abnormal liver function tests; microscopic haematuria or casturia. Subsequent acute management depends on the type of reaction: • Urticaria and angioedema associated with IgE-mediated reactions can be treated with antihistamines. Systemic corticosteroids are usually not required. Severe immediate reactions such as anaphylaxis requires the administration of intramuscular epinephrine and such cases should be referred to an accident and emergency department for further stabilisation and monitoring for at least 24 hours. • Mild cutaneous drug eruptions (such as maculopapular rashes) are self-limiting, and should resolve once the offending drug is stopped; topical corticosteroids may be added to hasten recovery and anti- histamines for symptom relief. • A tapering course of systemic corticosteroids are required for SJS, or drug hypersensitivity reactions with systemic involvement (such as haematological, liver, or renal involvement). These cases would require hospitalisation for careful monitoring of the patient’s clinical progress and adjustive treatment. TEN is severe and associated with up to 30% to 50% mortality, thus warranting hospitalisation, close monitoring, and intensive supportive care. Patients may progress from SJS to TEN or have organ/systems manifestations of drug hypersensitivity syndrome. Diagnosis Usually, a detailed history and recognition of a drug rash is sufficient for diagnosis of a drug allergy. Significant points include: • Establishing the temporal relationship of the onset of the patient’s symptoms and signs in relation to exposure to the drug • Establishing if there has been prior exposure, and thus sensitisation to the drug • Excluding other conditions which may mimic a drug allergy. For example, viral infections themselves may cause urticaria, angioedema, or exanthems. If the diagnosis of a drug allergy can be established with reasonable confidence, then the patient should be counselled on avoidance of the offending drug in future, be given a drug alert/Medik Awas card, and need not be referred to a specialist. Investigations for drug allergies such as skin tests or drug provocation tests, can be used as an adjunct where the diagnosis is not definite, or where multiple drugs are implicated. These patients should be referred to an allergist for evaluation. With advances in medical research, there are specialised genetic tests that can now predict a patient’s risk of developing a severe cutaneous adverse reaction (SCAR) to specific high-risk drugs (to date, they include Allopurinol, Carbamazepine, and Abacavir). However, these tests are not meant to be used for diagnostic purposes and require special laboratory facilities. Hence, they have not been introduced as a standard of care in Singapore. There is no single investigation that is 100% diagnostic or that can be used to “screen” for drug allergies, hence these should not be offered to the patient. The Clinical Immunology and Allergy Service The Clinical Immunology and Allergy service in Tan Tock Seng Hospital comprises a team of clinicians and nurses who evaluate and manage patients with drug allergies. Our services include: • Consultation with an Allergist, who will evaluate the patient’s history, symptoms and signs; • Skin prick or intradermal tests to help in evaluation of immediate hypersensitivity reactions (where relevant); • Drug provocation tests which can be useful in eliminating drugs with a low probability of causing the reaction where multiple drugs are involved, or where patients may have inappropriately been labelled allergic to multiple drugs; • Appropriate counselling on avoidance and cross-reactivity of medications. In summary, previous uneventful consumption of a drug does not preclude developing an allergy subsequently. Once a drug allergy has been identified, the affecting drug should be avoided in future. Some of the prevention measures include patient education on drug management and giving a pocket- sized drug alert card for patients. Dr Grace Chan Yin Lai Dr Grace Chan Yin Lai is a Consultant in the Department of Rheumatology, Allergy and Immunology at Tan Tock Seng Hospital (TTSH). She graduated from University Malaysia Sarawak, Malaysia in 2000 and passed the MRCP (UK) in 2006. Subsequently, she completed the Advanced Subspecialty Training in Rheumatology, Allergy and Immunology at TTSH in 2010. Dr Tan Sze Chin Dr Tan Sze Chin is an Associate Consultant in the Department of Rheumatology, Allergy and Immunology at Tan Tock Seng Hospital (TTSH). He completed his Advanced Subspecialty Training in Rheumatology, Allergy and Immunology at TTSH in 2012. 18 19
  11. 11. feature With old age comes inevitable forms of physical limitations. These include reduced vision, hearing, body balance, energy level, body agility and/or physical strength. With the right strategies and early intervention by an Occupational Therapist, seniors with physical limitations can be empowered to live a fulfilling life with active engagement and participation in daily activities. feature Healthy Living in Your Golden Age - Enhancing Daily Living for Seniors with Physical Limitations Enhancing Daily Living for Seniors with Physical Limitations Introduction As one ages, the likelihood of physical limitations increases. Reduced vision, hearing, body balance, energy level, body agility and/ or physical strength may be experienced. In addition, the increased prevalence of chronic diseases has also become a significant cause of illness and death in Singapore. This also leads to the further reduction of one’s mobility and ability to function independently in everyday life. With higher standards of living in our society, and an ever improving healthcare system, the life expectancy of Singaporeans has increased from 73 years in 1990, to 82 years in 2012. Our first batch of baby boomers has also reached their retirement age by now. These baby boomers are equipped with a higher literacy rate, armed with higher- skilled jobs and are living a better quality of life. However, living longer may not equate to a healthy and active lifestyle. With the impending silver tsunami, it is essential to ensure that our seniors remain in the pink of health and continue their active lifestyles. Thus, promoting independence and keeping the seniors active in the community have become the crucial aims of quality living. Here are some suggestions on how Occupational Therapists can empower seniors with physical limitations to be actively participating in daily activities happily and with great ease: 1) Redesigning their Daily Routines In order to help our seniors remain active and independent, it is essential to make healthy changes in one’s daily life. This includes planning each day with a focus on completing tasks of a higher priority. This helps them retain a strong sense of control in their lives. In our busy world, there are often too many things to accomplish within the limits of a day. Time should be set aside, to list the tasks one wants to achieve and prioritise them accordingly. This helps to reduce mental stress as well as celebrate the accomplishment. For instance, important tasks should be completed early in the morning, when one’s energy is at a prime level. This is followed by less important tasks. Incorporating frequent breaks in the daily schedule also helps to ensure that energy levels go a longer way. 2) Promoting an Easier Daily Life There are many ways to encourage seniors with physical limitations through engaging in daily activities. Using built-up handles or universal cuffs on eating utensils can help those with grip difficulty feed themselves. Items such as the long handled sponge, buttoner and shoe horn can be used in showering and dressing. These equipments allow seniors with trunk or upper limb stiffness to 20 21
  12. 12. feature feature perform daily tasks in a seated position safely. Front load washing machines and portable low height laundry racks encourage ease of laundry management. Repositioning of microwaves and induction cookers to a lower height also promotes simple meal preparation for seniors in wheelchairs. 3) Enhancing Vision With reduced vision, it is essential that larger fonts are used to help our seniors read better. This includes relabelling and enlarging the expiry dates on food items and medication, as well as using phones or light switches with enlarged numbers or buttons. The use of magnifiers can help them with reading newspapers and other labels. Good lighting throughout the house, such as night lights along the stairways, bedrooms and toilets allow our loved ones to move safely and independently through their living spaces. Appropriate use of contrast, such as highlighting the edges of kerbs and steps with fluorescent tape or paint, can also heighten their awareness of possible hazards. 4) Creating a Safe Home Falls may threaten the health and independence of seniors. Hence, creating a safe living environment can enhance their ability to remain independent. To reduce accidental falls, we can remove clutter around the house, as well as rearrange furniture to widen walkways. Loose wires and cables should be tied or taped to the wall or floor. Consider placing non-slip mats in wet areas around the home, installing grab bars in toilets, and using shower chairs or bedside commodes, to enhance the safety of seniors with physical limitations. Through the appropriate use of suitable adaptive equipment, we can greatly reduce the risk of falls at home. 5) Developing a Positive Social Well-being Keeping an open mind to exploring new and meaningful activities can create a positive impact on our senior’s physical and mental well-being. Encourage them to learn a new skill or pick up a new leisure activity such as granny ballet, folkdance, calligraphy or even tea appreciation. Studies have shown that continuous and lifelong learning helps maintain mental alertness. With the availability of the Internet and social media, seniors can also easily access electronic services, grow their social network and actively participate in new social activities. They can also make new friends and renew their relationships with old ones. This can further strengthen their social network and enhance their quality of life. In conclusion, physical limitations in old age may be inevitable. However, creating successful participation in daily life can enhance their experience of old age and self- confidence. The ideas outlined above are a few of the many other recommendations that can aid in promoting independence of seniors with physical limitations. Occupational Therapists have a unique professional skill base of holistic assessment and enhancement of an individual’s performance through relevant interventions, consistent with promoting the experience of active and successful ageing. Ms Madeleine Tay Ms Madeleine Tay is a Principal Occupational Therapist at Tan Tock Seng Hospital. She received her Bachelor and Masters of Health Science (Occupational Therapy) from Australia and underwent Geriatric Attachment in Barnes-Jewish Hospital, St Louis, USA. She is also a Certified Specialist in Assessment of Motor and Process Skills (AMPS). 22 23
  13. 13. featurefeature Fixingthe LeakyTap- Incontinence inElderly Urinary incontinence is a prevalent problem among the elderly. We evaluate the contributing factors leading to incontinence which help in determining targetted and individualised treatment for better care and results. U rinary incontinence, which involves the involuntary discharging of urine, is a major problem among the elderly, affecting up to one third of community-dwelling or acutely hospitalised elderly people and half of the elderly in nursing homes. Although the prevalence of incontinence increases with age, urinary incontinence is abnormal and not part of the ageing process. There are treatment options available, and management may differ from those for a younger person. Evaluating Causes of Incontinence Among the elderly, incontinence may be transient and often multifactorial. The mnemonic “DIAPPERS” is useful in evaluating possible causes of transient incontinence. There are several types of urinary incontinence. Among the elderly, urinary leakage is a common occurrence due to underlying involuntary detrusor contractions. These abnormal bladder contractions may be secondary to normal ageing or central nervous system lesions (i.e., old strokes). Patients with this type of incontinence often report the need to rush to the bathroom, and among the elderly, the patient wets himself/herself, sometimes unknowingly. Stress urinary incontinence, is leakage of urine on straining such as with coughing or sneezing. It is a common cause of incontinence especially among older women. It can also occur with elderly men who have previously had prostate surgery. Some people have mixed urinary incontinence, with a combination of both symptoms mentioned. Overflow incontinence is a term to describe urine leakage associated with urinary retention. In some patients with neurological conditions or poorly controlled diabetes mellitus, neurological control in bladder storage and emptying is affected, hence resulting in “overflow” incontinence, in which bladder distension of the stored urine leaks out beyond a certain capacity. This type of leakage may also occur in older men with bladder outlet obstruction, often due to an enlarged prostate. Among the elderly, cognitive impairment and/or physical immobility can contribute to The mnemonic DIAPPERS represents: • Delirium, • Infection (symptomatic), • Atrophic vaginitis, • Pharmaceuticals (long-acting sedative, calcium channel blockers, ACE-inhibitors etc), • Psychological, • Excess urine output (diuretics, diabetes mellitus), • Reduced mobility (hip fractures, deconditioning), and • Stool impaction (opioid medication). Care should be taken to avoid any overtreatment of asymptomatic bacteriuria. If incontinence persists despite the elimination of possible transient causes, other established causes of urinary incontinence, similar to younger individuals, have to be evaluated and managed. incontinence, but incontinence is not inevitable with dementia or impaired physical function. The aim of evaluation should be to identify and treat any serious underlying cause, assess the patient’s clinical state, environment and support, and plan realistic individualised treatment targets. Targeted physical and neurological examination is essential, as well as functional status and existing medical conditions. Evidence of dementia, delirium, stroke, Parkinson’s disease and neuropathy have important impact on the course of management. Fecal impaction and anal tone are useful, although many neurologically intact elderly people are unable to volitionally contract the anal sphincter. Presence of atrophic vaginitis or pelvic organ prolapse among elderly women, and prostate size for men are relevant clinical findings that can help to guide effective management. The range of contributing factors to incontinence in an older patient are broader. A bladder diary is a useful tool in symptom evaluation. A typical bladder diary records the 24 hour, daytime and night-time frequency and amount of voided volumes, leakages and fluid intake over a period of three days. This provides information on the functional bladder capacity and severity of symptoms. It can also indicate possible systemic conditions (i.e., predominantly nocturia in a patient with congestive cardiac failure). Some elderly patients, especially those with cognitive or visual impairment may not be able to keep a bladder diary, and caregiver assistance will be required. Urinalysis, renal function, electrolytes and post-void residual volume are useful points for investigation among the elderly exhibiting incontinence, and will 24 25
  14. 14. Fitness Protect YourJoints withthese Strengthening Workouts O ur joints are meant to last a lifetime. Due to sedentary lifestyles, the muscles which provide support and stability to our joints may not be as conditioned to protect them. The increasing rates of obesity contribute to this problem, as an increase in body weight adds extra loading to the joints, hence causing accelerated wear and tear. Other causes of early joint degeneration include previous injuries, such as cartilage injuries. Joint degeneration or osteoarthritis is one of the leading causes of disability in Singapore. As these conditions affect activities of daily living, such as walking, standing, climbing stairs and squatting, a person suffering from osteoarthritis of a joint may be severely affected at work or play. guide subsequent tests. Interpretation of creatinine levels has to take into account the age-related reduction of muscle mass. Treatment Options Treatment of incontinence among the elderly has to be individualised, and the successful treatment is often multifactorial, addressing factors beyond the urinary tract. Contributing factors should be treated first (e.g. urinary tract infection, fecal impaction, atrophic vaginitis, heart failure), with appropriate fluid management and review of current medications. For urgency incontinence due to underlying detrusor overactivity, anticholinergics may be tried, with careful monitoring of potentially decreased bladder emptying leading to acute urinary retention, blurring of vision and cognitive impairment. Although the elderly are more vulnerable to any potential side effects of medication, many controlled trials have shown that anticholinergics prove effective and can be safely used with the elderly, with care for early review, and monitoring of post-void residual volumes. The most common cause of stress incontinence in older women is urethral hypermobility. Healthy weight loss if obese, and pelvic floor muscle exercise for the cognitively in-tact and motivated can be helpful for this condition. Age per se is not a contraindication to surgery for treatment of urinary incontinence. In well-selected patients, many incontinence surgical procedures can be done as day surgery, under regional anaesthesia. These include periurethral bulking injections, mid-urethral sling or artificial urinary sphincter for stress incontinence, and intravesical botulinium toxin A injections for detrusor overactivity incontinence. For men with incontinence due to an enlarged prostate causing bladder outlet obstruction, treatment options range from medication to transurethral resection of prostate (TURP) which can be done under regional anaesthesia. If surgery is contemplated, urodynamic testing should be considered pre-operatively after empirical treatment has failed. For frail patients possessing overflow incontinence and who are unfit for surgery, the option of intermittent catheterisation or long-term indwelling catheter with regular changes are realistic options. It is important that the principles of catheter care be taught to both patients and caregivers. Geriatric urinary incontinence can be treated or managed satisfactorily, with careful evaluation and monitoring of treatment effects. Dr Sharon Yeo Dr Sharon Yeo is a Consultant in the Department of Urology in Tan Tock Seng Hospital (TTSH) and a Clinical Lecturer with the Yong Loo Lin School of Medicine at the National University of Singapore (NUS). Dr Yeo obtained her medical degree and Master of Medicine (Surgery) at NUS and is a member of the Royal College of Physicians and Surgeons of Glasgow, UK. She received the Ministry of Health Manpower Development Plan (HMDP) award and completed a Fellowship in Female Urology, Neuro-urology, Urodynamics and Reconstructive Surgery at the Bristol Urological Institute, UK. Dr Yeo leads the new multidisciplinary Pelvic Floor Service in TTSH for Voiding Dysfunction and Incontinence and the Urology service at AMK- Thye Hua Kwan Hospital. feature 26 27
  15. 15. fITNESS Fitness Joints get lubricated by movement, and modern conveniences are depriving us of the much needed stimulation. For instance, the advent of sitting toilets has diminished the need for us to squat, hence the mobility and range of motion of our hip, knee and ankle joints are less stimulated. Escalators and lifts reduce the effort of muscles required for us to get to higher ground. Muscles of the hip and knee, over time, would have reduced strength and endurance to manage simple tasks such as climbing up and down the stairs. In Singapore, the knee joint is most commonly affected by osteoarthritis. Physiotherapists play an important role in assessing various impairments and correcting biomechanical factors that contribute to osteoarthritis. The impairments and factors include the following: 1) Reduced muscular strength and endurance 2) Reduced muscle flexibility 3) Restricted or stiff joint range of movement 4) Poor balance 5) Excessive body weight Therapeutic exercises are often prescribed to individuals with these knee impairments. The commonly affected muscles are the core muscles, gluteal muscles, quadriceps, hamstrings, and calves; hence the following exercises will target them. Instructions: 1) Stand with both feet apart, one foot in front of the other with both feet pointing forward. 2) While maintaining a stable trunk, lower the body and return to the starting position. 3) Go as low as you can while maintaining a stable trunk. 4) Perform 3 sets of 10 repetitions. What is it good for? This exercise not only works on the strength of lower limb muscles, but also maintains a smooth and stable movement that helps to improve balance. Split squats What is it good for? The sit to stand exercise is a modified squatting movement that trains strength and endurance. It also encourages range of motion of the hip, knee and ankle, and is a fundamental motion in daily living. Sit to Stand Instructions: 1) Begin by standing with both feet at hip width, toes pointing forward. 2) Lower yourself towards the chair. 3) Try to imagine the seat is far away as you reach back with your hips. This will encourage proper squatting mechanics and activate the gluteal muscles. 4) Once you have gained competence performing this movement, practice squatting without the chair behind you, and gradually increase the depth of the squat. 5) Perform 3 sets of 10 repetitions. Instructions: 1) Lie on your back with your knees bent and feet facing forward. 2) Lift your hips upwards and lower it down slowly. 3) Maintain a normal breathing pattern. 4) Perform 3 sets of 10 repetitions. What is it good for? This is a simple exercise that works the gluteal muscles that are often weak in individuals with knee degeneration. Individuals with poor balance may benefit from this exercise when they have difficulties exercising in a standing position. Bridging What is it good for? This exercise trains single leg balance, which is important in activities of daily living, such as walking and going up stairs. Moving the arms while maintaining single leg balance trains rotational stability of the trunk. Single Leg Standing Instructions: 1) Stand on one leg while maintaining alignment of hips and knees. 2) If you are confident with this movement, try placing both hands together and rotating to the left and right while maintaining stability. 3) Perform 3 to 5 sets of one minute holds. Instructions: 1) Begin by placing one foot on the step. 2) Ensure proper alignment of the foot and knee. 3) Keeping a stable trunk, lean forward and step-up. 4) As you reach the top, straighten your trunk. 5) Perform 3 sets of 10 repetitions. What is it good for? This movement works the muscles of the lower limb, while demanding a considerable amount of balance during the phase of stepping up. Practising the step up will often ensure that your muscles will be conditioned to manage going over an overhead bridge, or going up a flight of stairs when the need arises. Step-ups Therapeutic exercises 28 29
  16. 16. Cantonese Stir Fry Kailan Cantonese Stir Fry Kailan (Serve 4) Ingredients Minced chicken breast 200g Kailan, chopped 3 cups Tau Kwa, diced 2 blocks Carrots, julienned 1 medium Garlic, minced 1 clove Oil, canola 1 tbsp Oyster sauce 1 tbsp Rice 4 bowls Methods 1. Heat non-stick wok and add oil. 2. Add garlic and fry till aromatic. 3. Add minced meat and sauté until half done. 4. Add kailan stems and sauté for 30 secs. 5. Add remaining ingredients and drizzle oyster sauce. 6. Cover the wok for 30 secs. 7. Serve on a plate with rice. Nutrition Information Panel Per Serve Energy (kcal) 410 Protein (g) 27 Total lipid (fat) (g) 11 Carbohydrate (g) 50 Fibre, total dietary (g) 10 Sodium (mg) 248 Calcium (mg) 262 healthy recipe In conclusion, an active lifestyle will condition our muscles and joints so that we can perform our daily activities. Regular exercises may protect our joints and add years of active living for our enjoyment. Mr Justin Wee Mr Justin Wee is a Senior Physiotherapist at Tan Tock Seng Hospital. He has completed his Masters in High Performance Science at Bond University, Australia. His area of interest includes sports and musculoskeletal rehabilitation, strength and condition and functional training. fITNESS Recipe was designed by the Nutrition & Dietetics Department and Hospitality & General Services of Tan Tock Seng Hospital. Photo courtesy of Mr Henry Lim, Photographer, Tan Tock Seng Hospital. High Calcium Dish for Stronger Bones What is it good for? The quadricep muscles (thigh muscles) link directly to the knee cap. Tightness in these muscles may cause increased compressive forces to the knee cap that may lead to excessive wear and tear. Quadriceps Stretch Instructions: 1) Begin by standing upright. 2) Lift one knee while holding just above the ankle. 3) Ensure that both thighs are inline and trunk is upright. 4) Hold for 20 to 30 seconds and repeat 5 times. Instructions: 1) Stand with one foot in front of the other. 2) Ensure both toes are pointing forward with heels flat on the ground. 3) Hold for 20 to 30 seconds and repeat 5 times. What is it good for? Reduced calf muscle length may cause reduced flexibility in the ankle, which would affect the normal range of motion. Calf Stretch Caution Some exercises may not be suitable for certain individuals. Please consult a trained Physiotherapist if pain is present during or after the exercise, or when in doubt. 30 31
  17. 17. Clinic B1B – Orthopaedic Surgery • Hand Procedure Suite – Rheumatology, Allergy and Immunology • Intravenous Infusion Day Facility Clinic 2B – Gastroenterology and Hepatology Our sub-specialties include: • General Gastroenterology • Hepatology (Liver) Service • Inflammatory Bowel Disease • Gastrointestinal Endoscopy • Pancreato-Biliary Diseases • Upper Gastrointestinal Motility • Nutrition – General Surgery Our sub-specialties include: • General Surgery • Colorectal Service • Bariatric and Weight Management Services • Upper Gastrointestinal Service • Head and Neck Surgical Services • Endocrine Service • Liver, Pancreas and Biliary Services • Vascular Service • Veins Service • Thoracic Service • Plastics, Reconstructive and Aesthetics Services – Urology Our sub-specialties include: • General Urology • Andrology and Men’s Health • Adrenal Surgery • Continence and Voiding Dysfunction • Endo-Urology and Stone Surgery • Female Urology • Minimally Invasive Surgery and Laparoscopic Surgery • Neuro-Urology • Prostate Surgery • Reconstructive Urology • Robotic Surgery • Subfertility and Sexual Dysfunction • Urologic Cancer Surgery – Endoscopy • Colonoscopy • Flexible Cystoscopy • Gastroscopy Clinic 4B – Diabetes and Endocrinology – General Medicine – Haematology – Infectious Disease – Pain Management – Psychological Medicine – Renal Medicine – Respiratory and Critical Care Medicine CLINIC 6B - Complementary Integrative Medicine • Acupuncture • Cupping • Dietary Advice • Pain-relief Physiotherapy - Dental Our specialist services include: • Braces • Root Canal Treatment • Wisdom Tooth Surgery • Dental Implants Multi-Disciplinary Specialist Care TTSH PEARL’s suite of clinics and services is guided by the four pillars of care through Evidence Care, Destination Care, Team Care and Personalised Care. We remain committed to delivering a higher level of patient care as we value our patients most. Clinic B1B Orthopaedic Surgery Tel: (65) 6889 4055 Email: ClinicB1B@ttsh.com.sg Rheumatology, Allergy and Immunology Tel: (65) 6889 4027 Email: ClinicB1B@ttsh.com.sg Clinic 2B Tel: (65) 1800-PEARL-00 (65) 1800-73275-00 Email: Clinic2B@ttsh.com.sg Clinic 4B Tel: (65) 1800-PEARL-00 (65) 1800-73275-00 Email: Clinic4B@ttsh.com.sg CLINIC 6B Complementary Integrative Medicine Tel: (65) 6889 4628 Email: Clinic6B@ttsh.com.sg Dental Tel: (65) 6889 4627 Email: Clinic6B@ttsh.com.sg

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