June-september 2013A PUBLICATION FOR PRIMARY CARE PHYSICIANSMCI (P) 097/03/2013Scan the QR code usingyour iPhone or smart ...
editor’s notecontentsThe GP BUZZ editorial team:Jessie TayLee Wei KitCeline OngADVISORY PANEL:Associate Professor Thomas L...
in the newsin the newsIN-CLINICDIETETICSSERVICETan Tock Seng Hospital’s (TTSH’s) Clinic 2B (non-subsidised) offersone-stop...
cover storycover storyNowYou See It,Now youDon’tBioabsorbable CoronaryStents – A New Frontierin Treating Heart DiseaseBloc...
Coronary artery disease (CAD)is rampant in Asia. CAD leadsto limited blood flow to theheart culminating in, at its worst, ...
cover storycover storyDr Fahim H. JafaryDr Fahim H. Jafary is a Senior Consultant inthe Department of Cardiology at Tan To...
Here are some tips to help you reduce work stress:Tip 1: Recognise the differentmanifestations of work stressand how it im...
There are a variety of treatment methodsfor Erectile Dysfunction (ED), a commoncondition afflicting men today. Read onto u...
Viagra, Levitra and Cialis, which arepills prescribed for ED, more menand their partners have a greaterawareness of this i...
Dr Simon ChongDr Simon Chongis a Consultant inthe Department ofUrology at the TanTock Seng Hospital(TTSH). He obtainedhis ...
featurefeatureThe Journey toa Brighter SmileOral health plays a vital role in the overall well-being of a person.Many peop...
featurefeatureAn atypical extraction scheme wasdecided upon whereby her grosslydecayed upper left canine tooth wasremoved ...
featurefeatureWhat are you looking for in an effectiveweight loss programme?If you are looking for a quick fix ratherthan ...
FitnessfitnessCore, also known as the centre or‘powerhouse’ of the body, is whereJoseph Pilates, the founder of Pilatesexe...
3. Single Leg KickBegin with lying in prone, forehead resting onhands and legs together flat on the mat.1Herbal Recipesfor...
special recipesspecial recipesHERBAL AGAR AGAR (Serving: 32 pieces)IngredientsDang Shen	 15gmDang Gui Slices	 15gmRed Date...
Clinic B1B–	 Orthopaedic Surgery• Hand Procedure Suite–	 Rheumatology, Allergy and	Immunology• Intravenous Infusion Day Fa...
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GP Buzz (June - Sep 2013)

  1. 1. June-september 2013A PUBLICATION FOR PRIMARY CARE PHYSICIANSMCI (P) 097/03/2013Scan the QR code usingyour iPhone or smart phoneto view GP BUZZ on theTTSH website or visitwww.ttsh.com.sg/gp/.WorkYourStressAwayWhatelseisthereforErectileDysfunction?The Journey to aBrighterSmileBioabsorbableCoronary Stents
  2. 2. editor’s notecontentsThe GP BUZZ editorial team:Jessie TayLee Wei KitCeline OngADVISORY PANEL:Associate Professor Thomas LewAssociate Professor Chia Sing JooAssociate Professor Chin Jing JihAdjunct Assistant Professor Chong Yew LamDr Tan Kok LeongMr Joe HauGP Buzz is a magazine byTan Tock Seng Hospital, designed byWe value your feedback on how we can enhancethe content of GP Buzz. Please send in yourcomments and queries to gp@ttsh.com.sg.© All rights reserved.No part of this publication may be reproducedor transmitted in any form by any meanswithout prior consent from the publisher.in every issue030 editor’s note040 in the news260 fitness290 special recipesin this issue06 Now You See It, Now You Don’t12 Work Your Stress Away...15 After The Magic Pill, What Else Is There For Erectile Dysfunction?20 The Journey To A Brighter Smile24 Fad Diets: How Effective Are They For Weight Loss?June - september 201312062420t is said that wellness exists ona continuum. It is differentand distinct to everyindividual.To many, it is not just one thing butinvolving interconnected elementsthat can range from the spiritual,body and mind. It is not only howmuch you weigh, your cholesterollevel but also how well you managestress.The road to achieving wellness is achoice and it may begin with theconsciousness to build a healthylifestyle which could range fromdietary planning to engagement inphysical activities.In this ‘Wellness and Health’ issue ofGP BUZZ, we aim to look at theheart, mind, oral aesthetics andeven sexual well-being of anindividual. The cover storyshowcases bioabsorbable coronarystents, one of the latestadvancements in the field ofangioplasty. We cast the spotlight onpsychological and emotional well-being with tips on how to work yourstress away. Treatment options forerectile dysfunction, a common issuefacing men, are also detailed in thisedition of GP BUZZ. Let’s not forgetthe importance of oral health, thekey to a great smile for that addedesteem boost.We debunk the myth of fad diets forhealthier and wiser dietary choices.Specially for this issue, we bring youa special three-course herbal menucustomised in consultation with MsDora Ng, Principal Acupuncturist ofTan Tock Seng Hospital’s (TTSH’s)Complementary Integrative MedicineClinic and with the chefs from theHospitality & General Services team.Finally, we get physical with a seriesof pilates exercises which are used byTTSH Physiotherapists for patients totone up their abdominal muscles,manage their back pain, strengthenand improve the stabilisation of theirback.Now, where are you on the wellnesscontinuum?The GP BUZZ Editorial TeamIWhere Are You On TheWellness Continuum?03
  3. 3. in the newsin the newsIN-CLINICDIETETICSSERVICETan Tock Seng Hospital’s (TTSH’s) Clinic 2B (non-subsidised) offersone-stop dietetics service.Launched in October 2012, patients can now be referred by their doctorsto an in-clinic Dietitian to obtain pre- and post-surgery nutritionaladvice. Currently, this service is available for Urology patients everyTuesday to address general healthy eating matters.In each session, TTSH’s Dietitian conducts a detailed nutrition assessmentto determine the patient’s nutritional risk and status. This involvesgathering information including anthropometry (e.g. height, weight,weight changes), biochemistry data, clinical signs, dietary history (e.g.diet recalls, food frequency information, eating patterns). The Dietitianwill educate and advise the patient on dietary or nutrition plans based onthe patients’ nutritional requirements. CME Schedule June - September 2013CME POINTSDATETIMEVENUEREGISTRATIONDETAILSCME POINTSDATETIMEVENUEREGISTRATIONDETAILS1 CME point*06 July 20131.00pm - 2.30pmConference Room 1 & 2,Tan Tock Seng HospitalCheryl CheeContact: 6357 3242Email: cheryl_pl_chee@ttsh.com.sgTo be confirmed21 September 20131.00pm - 4.30pmCourt Yard 1 & 2, Basement 1,Oasia Hotel, Sinaran DriveHilary ChuaContact: 6357 3197Email: hilary_xm_chua@ttsh.com.sgLunch Symposium on Common JointConditions for GPsGP Forum – Updates on Prostateand urinary 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.and provide insights on how organisations can create acompetitive advantage through people.One of the nine organisations recognised as BestEmployers in Singapore and the first healthcareorganisation in Singapore to clinch the award, TTSH wasdeemed to have demonstrated high levels of employeeengagement, compelling employer branding, effectiveleadership and a high performance culture.In the recent Aon Hewitt Best Employers 2013 study,Tan Tock Seng Hospital (TTSH) was recognised asone of the Best Employers in Singapore.The Aon Hewitt Best Employers study is a regionalresearch study to identify best employer organisationsin each of the nine participating countries in AsiaPacific region. The study aims to identify a list of BestEmployers in Asia and their unique people practices,First inHealthcareProf Philip Choo, CEO of TTSH, receiving the award from Mr Kulshaan Singh, Managing Director,Aon Hewitt South East Asia and Ms Tan Su-Lin, Vice-President, CATS Classified, SingaporePress Holdings.04 05
  4. 4. cover storycover storyNowYou See It,Now youDon’tBioabsorbable CoronaryStents – A New Frontierin Treating Heart DiseaseBlocked heart arteries, also known ascoronary artery disease, is a major problem inAsia and leads to symptoms of a heart attackand angina. Coronary angioplasty andstenting is a widely accepted procedure toeffectively treat these blockages and involvesthe implantation of a permanent metallic tubecalled a stent in the artery which props thevessel open. A new generation ofbioabsorbable stents is now available whichdisappears after two years, leaving the vesselin its restored natural state. This ‘vascularreparative therapy’ represents a newadvancement in cardiology.Scan this QR code toread the article online.06 07
  5. 5. Coronary artery disease (CAD)is rampant in Asia. CAD leadsto limited blood flow to theheart culminating in, at its worst, aheart attack in which a portion ofthe heart muscle permanently dies,but also symptoms of angina whichcan range from mild to limiting chestpain or shortness of breath onexertion.A combination of increasingaffluence leading to unhealthydietary habits along with a generalageing of our population has madeCAD a widely prevalent disease thataffects not only longevity but alsoquality of life and productivity.Coronary angioplasty and stentingare widely accepted procedures toeffectively treat blockages in thecoronary arteries.This article will highlight a recentadvancement in the field and focuson the newest generation ofbiodegradable coronary stents.cover storycover storyAbout 50 years agoSurgeons performed the first coronary arterybypass graft surgery in which veins from theleg were harvested and implanted in order to‘bypass’ blockages in the patient’s ownnative arteries. This revolutionised thetreatment of heart disease but theextensiveness of the operation and risks(particularly for stroke or paralysis) was aphysical as well as psychological barrier formany patients.About 30 years agoCoronary angioplasty came into existence in which, underlocal anesthesia, a thin plastic tube called a ‘catheter’was introduced via the femoral artery in the groin andadvanced to the heart. Through this catheter, a smallballoon was introduced into the artery and the blockagepoint was opened up by inflating the balloon. Thecatheter was then removed and the patient went home afew days later with a small nick in the groin instead of ahuge incision in the middle of the patient’s chest.However, balloon angioplasty patients suffered from a 5%risk of emergency bypass surgery due to complicationsand a 30-50% risk of recurrence, termed ‘restenosis’.Restenosis results in the shrinking back of balloon-stretched artery at the site of the blockage, somewhatlike an elastic band slowly recoiling.Early 2000sCoronary procedures moved from the groin to a moreelegant approach via the radial artery in the wrist.Introduced in the mid-1990s, the radial approach is nowthe de facto standard-of-care and offers lowercomplication rates than a groin procedure. At the sametime, the next iteration of these stents came in the formof ‘drug-coated’ devices which slowly eluted a specialdrug that reduced the restenosis rate to less than 10%.Although these drug-eluting stents represent a markedimprovement over the previous generation of stents andhave an excellent long-term safety record, concernsabout leaving a permanent implant have remained – bothin the minds of cardiologists as well as patients. Thestent, a permanent irritant in the vessel, is always at riskof suddenly clotting (causing a heart attack) and requiresprolonged use of blood thinners.About 20 years agoThe procedure was modified with theimplantation of metallic stents afterballoon angioplasty at the site of theblockage, yielding much lower restenosisrates. These stents are metal tubes thatlook quite similar to the spring of aball-point pen and act like a metalscaffold that props the artery openthereby preventing the artery fromcollapsing back on itself.Stents reduced the need for emergencysurgery to less than 1% and althoughelastic recoil of the artery was eliminatedby the scaffolding effect, the stent itselfincited new tissue growth that resulted inre-narrowing of the vessel and arestenosis rate of about 15-20%. Thus,while procedural safety improvedmarkedly, there remained a one-in-fivechance of the blockage recurring.Past CAD Invasive TreatmentsA quick recap of how the invasive treatment of CAD has evolved over the last several decades is worthwhile.08 09
  6. 6. cover storycover storyDr Fahim H. JafaryDr Fahim H. Jafary is a Senior Consultant inthe Department of Cardiology at Tan TockSeng Hospital. He is a graduate of the AgaKhan University Medical College in Karachi.He was trained in Internal Medicine at theUniversity of Texas Health Sciences Centerin Houston and Cardiology at Tufts MedicalCenter in Boston. Dr Jafary is certified inCardiology & Interventional Cardiology bythe American Board of Internal Medicine, andNuclear Cardiology & Cardiovascular CT bythe Certification Boards of Nuclear Cardiologyand Cardiovascular CT. Dr Jafary has beenperforming coronary angioplasty and stentingfor close to 15 years.“Studies with the leadingbioabsorbable stent have shownthat indeed, the stent is largelygone by two years and the vesselis restored to its original healthyfunctional state…”A four-year follow-up of the currentstent demonstrates excellent resultswith very low restenosis rates and nosigns of a ‘late catch-up’ in terms ofproblems. The need for long-termblood thinners is significantly less.Furthermore, the bioabsorbablestent is substantially easier to imageusing non-invasive techniques likecardiac CT as compared to theirmetallic counterparts, an importantand welcome benefit.Drawbacks of BioabsorbableStentWhile the bioabsorbable stentrepresents an importantadvancement in stent technology,at present there are a fewlimitations.First, the stent has largely beentested in relatively simpler coronarylesions; more complicated blockagesmay not be suited to receive thisstent and, hence, not everyone is acandidate.Second, the stent is not as easilydeliverable to the blockage as themetallic stents are – it is a bit morebulky and sometimes that may makegetting the stent down the coronaryartery a challenge particularly if theartery has a very curved course.Third, these stents are substantiallymore expensive than the metallicdrug-eluting stents; this becomesparticularly important if a patientrequires multiple stents.Finally, the long-term follow up islimited to 4-5 years. While we don’tknow how these patients will behaveyears down the line, if the earlierstudies with PLLA stents are anyindication, there is no suggestionthat these stents have any long-termadverse effects.Bioabsorbable stents represent a newway forward and ‘vascular reparativetherapy’ may indeed be the future.Patients should consider abioabsorbable stent as an optionpreferably via the radial (wrist)approach. Patients should have anopen discussion about the pros andcons with their physicians prior toundergoing coronary procedures.Stents RenewedThis brings us to the most recent andexciting development in the field ofangioplasty – the bioabsorbablestent. The basic concept behindhaving a temporary scaffold in placeis quite simple.Studies show that after balloondilatation of a blockage you reallyneed a stent to prop up the artery for3-4 months after which the arterygets ‘set’ in its new, expanded shape.Therefore, if the stent coulddisappear after ‘doing its job’, thepatient benefits from the implant andfrom not having a permanentpresence in the artery. If this stentcan elute the same drug as metallicdrug-eluting stents, tissue regrowthand restenosis is prevented.Initial versions of bioabsorbablestents were made of magnesiumwhich degraded very quickly, within amonth or two and this rapiddisappearance of the scaffold Biodegradable Stentresulted in the blockage recurring ina large fraction of the patient’s heartdue to recoil of the artery.Another version of the bioabsorbablestent used poly-L-lactic acid (PLLA),a polymer similar in consistency toplastic. PLLA has a long history ofsafe use in medical implants (e.g.orthopedic screws, pins, soft tissueimplants) and degrades into lacticacid which is then broken down bythe body into water and carbondioxide. This stent had a muchslower degradation profile (12-24months) and hence the scaffoldingwas retained for the critical first fewmonths after stent implantation.The only problem was that the stentincited a similar tissue reaction asthe bare metal stents leading torestenosis.The next logical step was toimpregnate the PLLA with the samedrug that drug-eluting metallic stentsuse and the most recent generationof bioabsorbable stent is exactly that– a drug-eluting PLLA stent thatcombines the best of all worlds –a temporary scaffold that elutes adrug, expands the artery and thendisappears.Studies with the leadingbioabsorbable stent have shown thatindeed, the stent is largely gone bytwo years and the vessel is restoredto its original healthy functionalstate, giving rise to the term‘vascular reparative therapy’ for thecurrent generation bioabsorbablestents.10 11
  7. 7. Here are some tips to help you reduce work stress:Tip 1: Recognise the differentmanifestations of work stressand how it impact on us physically,psychologically as well asemotionally.• Physical impact: - Breathlessness - Fatigue - Headaches / Migraines - Insomnia - Loss of appetite - Numbness - Problems in digestion - Reduced immunity - Tensed muscles• Emotional impact: - Anxiety - Apathy - Depression - Frustration / Irritability - Restlessness• Psychological impact: - Difficulty concentrating - Diminished interest at work - Loss of confidence - Negativity - Poor judgment - Worrying - Increase drinking or smoking to cope at work - Social withdrawalfeaturefeatureEffective management ofpersonal and work stresscan allow you to exert apositive influence overthose around you...‘Work stress’ is something that we experiencecommonly in the work place. With theconstant threat of a possible economic crisislooming before us, there is always the pressure for us toimprove our work performance and increase ourproductivity.Work stress often occurs when our capabilities orneeds do not meet the requirements of our jobs.This could arise from a number of sources such as workoverload, time pressure to meet datelines, not likingthe job and having to deal with difficult people at work.WORKYOURSTRESSAWAY…Work stresses are present andcan lead to burnout if they arenot properly managed. Stressmanagement strategies areavailable for a healthier you –physically, psychologically andemotionally.Tip 2: Identify your sources of workstress.Work stress can come from one source or many sources.In order to deal with our stressors, we need to first knowwhat is stressing us. Below are some examples of sourcesof work stress:• Work conflicts• Work overload• Information gaps• Blocked career• Meaningless jobTip 3: Manage your stressors.• Resolve your conflicts at work. If you feel that youhave been unfairly treated at work, considerexpressing your grievances in an assertive, non-aggressive manner instead of suffering in silence. When you are faced with problems dealing with adifficult superior or co-worker, do bear in mind thatwe can only be in control of our own feelings andreactions, and not the behaviours of others.• Manage your time effectively. In order to achievework–life balance, you require good timemanagement skills. First, make a plan. Create a list where you identifyimportant tasks that you need complete within theday, including leisure activity. Next, work out your priorities by determining what ismost urgent or most important to you. Always targetthe difficult tasks at a time when you feel mostenergetic (such as in the morning) and leave thesimpler tasks for later. Procrastination is often the main cause for our lack oftime. Hence, self-discipline is very important.While some stress may be good in motivating us toperform better at our jobs and to increase ourproductivity, prolonged or excessive exposure to stresscan lead to burnout. Burnout is the state of physical,psychological and emotional exhaustion which leavesyou feeling overwhelmed or hopeless. When thishappens, your productivity is reduced.Effective management of personal and work stress canallow you to exert a positive influence over thosearound you and also prevent you from being affected bythe negativity from others.Scan this QR code toread the article online.12 13
  8. 8. There are a variety of treatment methodsfor Erectile Dysfunction (ED), a commoncondition afflicting men today. Read onto understand the modes of treatmentand effectiveness of each of thetreatment options.Dr Jaswyn ChinDr Jaswyn Chin is a Clinical Psychologist fromthe Psychological Services Department inTan Tock Seng Hospital. She is a registeredPsychologist with the Singapore PsychologicalSociety and conducts stress management talks fororganisations on a regular basis.• Positively reframe your negative thoughts. Many ofus experience recurring self-defeating thoughtswhen we feel stressed. These thoughts often tell usthat we are ‘stupid’, ‘incompetent’ or ‘unable tocope’. Dwelling in these negative thoughts candeflate our morale and we become less motivated inour jobs. Therefore, it is important for us to reframethese thoughts in a more positive light. Consider what you would say to a friend who ishaving these thoughts. You will probably saysomething encouraging such as ‘Making one mistakedoes not mean that you are a failure.’ In the sameway, we need to encourage ourselves and not beatourselves up when we feel defeated.• Consider enhancing your skills and knowledge. Thework environment is constantly changing rapidly dueto advancing technology. Therefore, it is importantthat we upgrade our skills and fill up any knowledgegap in order to maintain our competitiveness. Weare happy workers when we feel competent in ourwork.• Inject new meaning into your job. Do you find yourjob meaningful? If no, perhaps it is now time for youto consider other job options. Ask yourself what is meaningful to you. Being able tohelp the less fortunate? Working with the elderly,maybe? Or, you may even consider expanding yourcurrent portfolio or develop your skills in anotherarea.• Seek professional help. Many a times, we keepthings to ourselves to avoid burdening our loved oneswith our problems. Therefore, it is sometimesadvisable to seek professional help by consultingwith a psychologist to help you manage yourstressors.After themagic pill,what elseis therefor ErectileDysfunction?Tip 4: Learn to relax.Remember the saying, ‘All work and no play makes Jacka dull boy’? It is important for us to engage inpleasurable activities in order to relax.• Have enough sleep• Eat healthily• Exercise• Confide in your spouse, a family member or closefriend. Do not bottle up your feelings• Schedule ‘me’ time. Set aside time to engage in yourhobby or favourite activities such as playing music,watching a movie or going for massages• Go for a vacationRemember, work stress can lead to adverse impact onour physical, psychological and emotional health if it isnot managed properly. So work, work, work thosestresses away!Scan this QR code toread the article online.feature feature14 15
  9. 9. Viagra, Levitra and Cialis, which arepills prescribed for ED, more menand their partners have a greaterawareness of this issue, and a largernumber of them are coming forth toseek treatment.It is not uncommon nowadays tosee a patient with ED in theUrology specialist clinic who hasalready tried one or more typesof the pills mentioned earlier,and the response was not ideal.In that situation, are there othermodes of treatment availableand how effective can they be,when the pills have failed?This article will address theseissues and I hope it will encouragemen with this problem to lookfurther for more effectivetreatment.Sexual Counseling& TherapyMajority of cases of ED arecaused by both medical andpsychological factors such asanxiety, depression, sexualnaiveness etc. If present,treatment should bemultipronged, involving both thedoctor and the sexual therapist.The doctor will perform themedical evaluation and initiatetreatment, while the sexualtherapist will supplement byproviding sexual counselling andtechniques to overcome thepsychological and behaviouralissues. Both of these services arenow available in Tan Tock SengHospital (TTSH).PillsThese pills are collectivelyknown as phosphodiesterase-5inhibitors (PDE5Is) and they areusually prescribed on anon-demand regime, that is, asand when the patient wants tohave sexual intercourse.The pill has to be taken at least30-45 minutes prior for it to beeffective, and stimulation willbe required to kick-start theeffect. For some people, theneed for planning andscheduling can be counter-productive and it can take thejoy of sex away.To overcome this, there is a newmethod of treatment where asmaller dose of Cialis, 5 mg, istaken on a daily basis. Thisallows for a constant presenceof the drug within the bloodstream so that erection and sexcan be more spontaneous.The common side-effectsexperienced include facialflushing, headache andmuscular ache while the moreserious adverse effects such asgiddiness and chest pain arerare. These PDE5Is cannot betaken together with nitrates.featurefeatureErectile Dysfunction (ED) is avery common condition thatafflicts men of all ages. It ispresent, in varying severity, inabout 30% to more than 50% of menabove the age of 40 years.With the widespread advertisementand marketing by the makers ofPenile InjectionsPenile injections have beenavailable even before theadvent of PDE5Is, and they area good alternative to the pills.The injectable drug commonlyused in Singapore is Alprostadil,and there are Papaverine andPhentolamine as well. Thesedrugs can be used singly or incombination, on an on-demandregime.The needle used is very shortand narrow, and the injection isperformed at the shaft of thepenis into the cavernosal tissue.The drug usually takes about15-30 minutes to work, andsexual stimulation is preferredto initiate the effect. The painexperienced is quite mild andthe side-effects, such asbleeding, penile pain, prolongederection etc. are uncommon.These drugs work via adifferent pathway from thePDE5Is, and they can beeffective even though theresponse to the pills has beenpoor.They should not be given topatients with a history ofprolonged erection, or bleedingtendency due to medications,coagulopathy and other causes.Vacuum Erection DeviceThe penile vacuum device caneffect an erection by placing itover the penis and activating agraduated pump to gently createa vacuum within the device,thereby drawing in blood to fillthe distensible cavernosal tissue.A medical grade silicon band isthen placed at the base of thepenis to maintain the erectionfor the duration of the sexualintercourse, and it should not beleft there for more than 30minutes.With some practice, it is afairly easy to use appliancethat does not rely on theeffect of a drug. Needless tosay, the man or his partnermust have the dexterity tomanipulate the device and thesilicon band.It should be avoided in menwho have bleeding tendencies.The adverse events due to thedevice is uncommon. Theyinclude bruising or bleedingbeneath the skin due toexcessive negative pressure16 17
  10. 10. Dr Simon ChongDr Simon Chongis a Consultant inthe Department ofUrology at the TanTock Seng Hospital(TTSH). He obtainedhis basic medicaldegree at theQueen’s Universityof Belfast in UK, and went on to obtainhis MRCS and MMed in Surgery beforecompleting his urology training.His subspecialty interest is in MaleSexual Dysfunction/Andrology andMale Infertility. He did his subspecialtytraining with Dr David Ralph in theUniversity College Hospital and theLondon Clinic in Harley Street, andhis team in the Institute of Urology inLondon, UK where he learnt proceduressuch as penile prosthesis implantation,various surgical techniques for Peyronie’sdisease, phalloplasty and organ-preserving procedures for penile cancer.He is actively involved in Men’s Healthand Andrology in Singapore where hehas organised and lectured in GP andpublic forums. He is also a Clinical SeniorLecturer of the Yong Loo Lin Schoolof Medicine of NUS, and ProgrammeDirector of the Urology ResidencyProgramme in TTSH.generated, a slightly cooler peniswhich may be unpleasant for thepartner, and prolonged erection.Penile ImplantsShould all else fail, penileprosthesis surgery is an alternativeworth considering. Again, anerection is effected by mechanicalmeans and is not reliant on theeffect of a drug. The sensation andfeaturefeaturewhich are inserted into the penis,the saline reservoir which isplaced in the retropubic spaceand the pump which is placedwithin the scrotum for easyaccess.To achieve an erection, the manjust has to locate and repeatedlysqueeze the pump in the scrotumto cycle the saline from thereservoir into the penilecylinders, thereby inflating them.After the sexual intercourse, hethen squeezes the deflationbutton in the pump to releasethe saline back to the reservoirand thereby deflating thecylinders.The surgery is slightly morecomplex and it takes a longertime to perform as compared tothe malleable implant. Thepatient usually stays for a nightand he goes home the next daywith the implant deflated. Hecan start cycling the implant twoweeks after surgery and startusing the implant after six weeks.These implants can be left withinthe body permanently. The twokey complications followingimplant surgery are infection andmechanical failure. Theincidences are in the region ofabout 2% and 5% respectively.Should either of these occur, theimplant can be easily changed.They do come with warranty.Low Testosterone StateBlood testosterone level shouldpreferably be checked in menwith ED, especially if they haveconcomitant lack of libido. Thistest should be performed in themorning between 7am and11am, as there is a diurnalvariation of the serumtestosterone level. Should thelevel be low, that is less than8 nmol/L, testosteronereplacement therapy can beoffered.In summary, the treatment of EDgoes beyond just pills. At times,a combined approachincorporating sexual therapy andtestosterone replacementtherapy can yield betteroutcomes. Should these measuresfail, there are other effectivealternatives such as penileinjections, vacuum erectiondevice and penile prosthesissurgery. These options should beactively discussed with patientsso that they do not lose hopewhen the pills fail them.the ability to achieve orgasm andejaculation remain the same afterthe surgery. There are two types ofpenile implants – malleable andinflatable.The malleable penile implant, asthe name suggests, can be bentand it can be straightened. Theimplant is surgically inserted intothe penis in a simple and shortoperation. The resultantoutcome is a constantly erectedpenis that can be straightenedfor sexual intercourse, or it canbe bent and tucked away in thetrousers at other times.The inflatable type of penileimplant is also surgicallyinserted and it consists of threecomponents – the cylindersInflatable Penile ImplantReservoir(shown inflated & deflated)Cylinder inflatedcreates erect penisCylinder deflatedin flaccid penisMomentary Squeeze (MS) PumpPicture Courtesy of Amercian Medical Systems, Inc.18 19
  11. 11. featurefeatureThe Journey toa Brighter SmileOral health plays a vital role in the overall well-being of a person.Many people may have the misconception that all forms of dentaltreatment are painful and will tend to neglect their oral health. Withnew approaches to dental treatment and multidisciplinary care, dentaltreatment has transformed the perception of many patients as thewhole experience can be made more comfortable and pleasant.Read on to find out more about a patient’s oral health journey.Scan this QR code toread the article online.Tooth decay can be prevented byreducing the frequency of sugarintake while proper tooth brushingtechnique with a daily flossingregimen may prevent guminflammation called gingivitis.Individuals with increased risk ofdental decay may supplement theirdaily oral hygiene routine with theuse of fluoride mouth rinses.FEARFUL NO MOREMs Elaine Ou was first presented tothe Tan Tock Seng Hospital (TTSH)Dental Clinic in early 2009 with thehope of realigning her teeth prior toher wedding day. She had beenreferred to Dr Vivien Tan Hui Ling,the Head and Senior Consultant ofDental Clinic by her familymembers.Oral health encompasses thedaily care and maintenanceof the oral tissues. Thiscomprises two components: thehard tissues and soft tissues. Teethand bone make up the hard tissuecomponent, while the lips, cheeks,gums and tongue make up the softtissue component.Teeth are made up of three mainlayers: enamel, dentine and pulp(Figure 1).Without proper care andmaintenance, oral neglect can leadto a myriad of problems such astooth decay and gum disease. Aroot canal infection will occur iftooth decay progresses to the pulpchamber and swellings can developwith abscess formation (Figure 2).EnamelDentinPulp ChamberRoot CanalInfected PulpAbscessFigure 1 – Tooth with three layers.Figure 2 – Tooth with caries extendingto the pulp.She had been reluctant to seekdental treatment earlier as she hadan innate fear of the dentist from herprimary school days. She hadovercome her fear for the initial visitwith the encouragement of her sister,who had also undergone treatmentwith Dr Vivien several years earlier.INITIAL FINDINGSElaine had scheduled a weddingphoto shoot in July 2009 prior to herwedding day, which was to be heldin January 2010. She was found tohave several teeth with prior rootcanal treatment and dental fillings.Dr Vivien sought to understandElaine’s hopes and expectations bythe end of the dental treatmentcourse.Relevant radiographs were obtainedand diagnostic casts were prepared.The treatment options availablewere discussed with Elaine toprovide her with a betterunderstanding of the commitmentrequired for treatment to proceed.Although the timeline waschallenging, both Elaine and DrVivien decided to embark upon theproposed plan.DECISION-MAKINGCircumstances were compounded bythe fact that Elaine was at a higherrisk of developing dental caries.20 21
  12. 12. featurefeatureAn atypical extraction scheme wasdecided upon whereby her grosslydecayed upper left canine tooth wasremoved as very little toothstructure was remaining for thetooth to function even withprosthetic restoration.Three other premolar teeth and herwisdom teeth were also removedunder general anaesthesia.Concurrent removal of the teethunder general anaesthesia expeditedthe commencement of braceswithout compromising Elaine’scomfort levels.CLINICAL COURSEThe molars were banded andactivation began.Elaine was compliant with hersix-weekly reviews as her weddingday drew closer. On 8 January 2010,the eve of Elaine’s wedding, she hadthe orthodontic brackets removedand tooth-coloured composite resinrestorations placed on her upperfront teeth to achieve desiredaesthetics for her special day. Thebride was, without a doubt, themost beautiful person at thewedding.Dr Tan Hui Ling, VivienDr Vivien Tan Hui Ling is the Head and SeniorConsultant of the Dental Clinic in Tan TockSeng Hospital. She graduated from theUniversity of Singapore in 1980 and obtainedher Masters in Dental Surgery (Oral Surgery)from the National University of Singapore in1984. She embarked on further specialisationin Orthodontics from the Oregon ScienceHealth Sciences University in 1986. She wasawarded the Health Manpower DevelopmentPlan fellowship to the University of NorthCarolina, Chapel Hill in 1991 to subspecialisein the management of dentofacial and cranio-facial deformities. Since then, she has beenpracticing orthodontics exclusively for thepast 27 years. Her current interest has beencentred on adult orthodontics especially inthe field of corrective jaw surgery.Dr Yap Wai YanDr Yap Wai Yan is the Senior Dental Associateat the Dental Clinic in Tan Tock Seng Hospital(TTSH). She received her Bachelor ofDental Surgery from the National Universityof Singapore in 2002. She has had workexperiences from Alexandra Hospital andJurong Medical Centre. Her current practicein General Dentistry here allows her toincrease her scope in patient managementwith a multidisciplinary approach.Elaine Ou in her annual review session with Dr Vivien Tan.Elaine had returned on 22 January2010, after her honeymoon, to haveher orthodontic brackets replacedand treatment continued.Upon completion of her bracestreatment in April 2011, Elaine hadfurther tooth-coloured compositeresin restorations placed beforecommencing on definitive crowns onher upper teeth.Dr Ang Kok Yang, the dental officerin-charge of Elaine’s case togetherwith Dr Vivien, had prepared fiveupper teeth to receive crowns toprovide adequate protection againstfracture during function. Retainerswere subsequently fabricated to holdthe teeth in their new positions.Elaine’s new smile had warmed manyhearts at the end of treatment. Herwhole outlook on dentistry had beenchanged for the better.When she returned for an annualreview in December 2012, she hadprogressed to the next stage in life:motherhood. The arrival of her littlebundle of joy, a new baby girl, madeher smile even wider than ever. Thistime, she no longer dreads herdental visits.22 23
  13. 13. featurefeatureWhat are you looking for in an effectiveweight loss programme?If you are looking for a quick fix ratherthan a gradual and sustainable weightloss, you may be falling into the trap of faddiets. Fad diets promise quick fix andpromote ‘magic’ foods. Some diets haverigid rules that focus on weight loss.Claims of the effectiveness of such dietsare based mostly on single studies ortestimonials only.Fad diets commonly refers toidiosyncratic diets and eatingpatterns that provide short-term weight loss, with little or noemphasis on long-term weightmanagement. These diets usuallyenjoy temporary popularity.*Fad diets usually have catchy namesthat focus on single nutrients.Examples of fad diets include theSouth Beach Diet, Zone Diet,Dr Atkins’s New Diet Revolution,Cabbage Soup Diet, Grapefruit Diet,The Good Carbohydrate Revolution,Paleo Diet, to name a few.While the South Beach Diet drawsattention for its switch from ‘bad’fats to ‘good’ fats, the Zone Dietencourages the consumption ofcalories from carbohydrate, proteinand fat in a balanced ratio. TheAtkins’s Diet has been made popularfor its limited carbohydrate intakethat has reportedly resulted insignificant weight loss for its dieters.How it worksAnyone hoping to achieve quickweight loss usually looks to fad dietsas miracle eating programmes.These diets are usually madepopular by testimonials by itsdieters, who generally make claimsof the diet’s success in weight loss.Fad diets often omit certain foods orentire foods groups from its menu.Though fast and significant weightloss can be achieved if you followthese diets religiously, the resultsare usually temporary. Losingexcessive amount of weight in ashort period of time is usually theresult of water weight loss insteadof fat loss. Thus, this is notpermanent.The PitfallsHow long can one stay on such a rigiddiet? Being on such a diet requires agreat level of motivation and selfdetermination from the dieter. Oncepositive results of weight loss areachieved, the dieter often forgoesthe diet plan and falls back into oldeating habits, hence regaining thelost weight if not more.Inappropriate dieting can also lead tonutrient deficiencies, constipation,dehydration, fatigue and result inlow mood as well. Fad diets put thepressure on the dieter to makechoices guided by the diet plan. Attimes, the diet can be excessivelyrestrictive. For example, theCabbage Soup Diet limits intake to alarge amounts of cabbage soup overseven days.Healthier Strategiesfor Weight LossInstead of getting yourselfdisappointed by the non-sustainableresults, adopt healthier weight lossapproaches.Start by devoting yourself to ahealthier lifestyle that includeseating a balanced and healthy diet.Exercise is still the best approachto gradually shed off the extrapounds and maintain your desiredweight.Some strategies for weight lossinclude:• Eating a variety of foods• Minimising the intake ofsaturated and trans fats• Eating two servings of fruits and two servings of vegetables daily• Avoiding empty calories such assweetened beverages, sweets,etc.• Watching your food portion sizes• Practising mindful eating andexercise• Incorporating regular physicalactivity into your daily lifeA balanced, healthy diet allows youto enjoy a variety of foods inmoderation whilst controlling yourcalories intake. Incorporatingexercise as part of your everydayroutine helps burns calories andcontributes to weight reduction.Thus, the best diet is simply alifestyle that includes food you enjoy,exercise and healthy habits.* Source: Wikipedia http://en.wikipedia.org/wiki/Food_faddismMs KavitaMs Kavita is the Senior Dietitian in theNutrition & Dietetics Department of TanTock Seng Hospital. She completed herBachelor Degree in Nutrition and Dieteticsfrom the University of Newcastle, Australiain 2005. Kavita specialises in the nutritionalconsultation of gastrointestinal and weightmanagement patients.how effective arethey for weight loss?Scan this QR code toread the article online.24 25
  14. 14. FitnessfitnessCore, also known as the centre or‘powerhouse’ of the body, is whereJoseph Pilates, the founder of Pilatesexercises, placed his main focus when hedeveloped his method of exercises in the1940s.Pilates exercises, when done correctly, will recruitthe deep core muscles such as transversusabdominus, diaphragm, pelvic floor muscles andmultifidus; align, stabilise and protect the spinefrom injury. In addition, Joseph designed hisexercises holistically by including simultaneousinvolvement of both leg and arm movements forease in transference to functional activities.Apart from the ‘core’, pilates also places emphasison precision, flow, control, concentration andproper breathing during the exercise with ultimateaim to achieve good posture and movement withoutthinking.People of any age or level can benefit from pilates.Therefore, it is common to see pilates beingincorporated in rehabilitation regime to treatpatients with low back pain due to conditions suchas degenerative changes in the spine, slipped discsand spinal instability.Pilates exercises can be performed either withequipment such as the reformer (picture on theleft) or on the mat. The benefit of using a reformeris that it is able to alter the level of difficulty of amovement based on the resistance of the springs.In Tan Tock Seng Hospital, physiotherapists withclinical pilates training will incorporate suitablepilates exercises for the patient to tone up theirabdominal muscles, manage their back pain,strengthen and improve their back. Some studieshave shown that when pilates exercises arepracticed over a period of time, it is able toreduce frequency, duration and intensity of lowback pain.Targetingthe ‘Core’issuePilates: Basic Pilates Mat Exercises for Beginners1. Hundreds 2. Knee to ChestBegin with lying in supine, knees bent and hands onthe side.Inhale and slowly lift your head and shoulders offthe floor and try to reach your fingers towards yourfeet while keeping the hands a few inches above themat. Keep your chin close towards your chest toprevent neck strain.Exhale and return back to resting position. Repeatthree sets of 10 repetitions or up to point of fatigue.12Scan this QR code toread the article online.Begin with four-point kneeling, hands and knees on themat. Hands and knees should be shoulder and hip widthapart respectively. Maintain a slight curve in the lowerback.1Inhale and slowly straighten one leg back whilebalancing on both hands and opposite knee.Exhale and draw the leg back while still maintainingthe curve in the lower back. Repeat three sets of 10repetitions or up to point of fatigue.226 27
  15. 15. 3. Single Leg KickBegin with lying in prone, forehead resting onhands and legs together flat on the mat.1Herbal Recipesfor WellnessScan this QR code toread the article online.special recipesfitnessBasic Pilates Mat Exercises for BeginnersInhale and bend one knee towards the buttockuntil the foot points towards the ceiling.2Lower the leg down on the mat once the kneeis fully straightened. Repeat three sets of 10repetitions or up to point of fatigue.5Exhale and straighten the knee with the thighstill lifted.4Ms Vernetta WongVernetta Wong is the Senior Physiotherapist and acertified clinical pilates instructor in the PhysiotherapyDepartment of Tan Tock Seng Hospital. She hadcompleted her Master of Musculoskeletal Physiotherapyin University of Queensland, Australia in 2012. Her areaof interest is neck and back conditions and she worksclosely with this group of patients.The use of chinese herbs for cookingexists since ancient times.Chinese herbs are not only used inenhancing the flavour of the dish butthey could also possess properties toimprove overall health and may at timesaid healing.In this special edition of ‘HealthyRecipes’, we bring you three herbalrecipes created with both CodonopsisPilosula Root (Dang Shen 党参) andAngelica Sinensis Root (Dang Gui 当归).4. Clams1Begin with lying on the side, knees bent and feet placedtogether inline with the torso.2Inhale and lift the knee on the top while keeping your feettogether at all times. Make sure that your torso is straightand not rotated backwards as you lift your knee.Exhale and return to resting position. Repeat three sets of10 repetitions or up to point of fatigue.Lift the thigh 3 inches off the mat whilekeeping the knee bent.3Codonopsis Pilosula or Dang Shenis a perennial flowering plantnative to northeast Asia and Korea.Its root is widely used as aningredient in Chinese cuisine tomake nutritional herbal soup aswell as a tonic beverage whenused on its own.Its health benefits are similar tothat of Ginseng. It is sold at a moreaffordable price, thus it is alsoknown as the ‘poor man’s Ginseng’.28 29
  16. 16. special recipesspecial recipesHERBAL AGAR AGAR (Serving: 32 pieces)IngredientsDang Shen 15gmDang Gui Slices 15gmRed Dates 15gmWolfberry 15gmLow Calorie Sweetener 15gm(e.g. Equal™)Agar Agar Powder 10gLongan 1 canWater 1 litreMethod1. Add water and the herbs (i.e. dang shen, dang gui, red dates andwolfberry) into a pot.2. Steam the herbal mixture for 3 hours.3. When it is ready, set aside the herbal stock by straining the mixture.4. Add the herbal stock, sweetener, agar agar powder in a pot and bringto boil.5. Pour the mixture into the agar agar mould and add in the wolfberry andlongan.6. Let it set and it is ready to be served chilled.HERBAL CHICKEN SOUP (Serving: 300ml x 6 bowls)IngredientsDang Shen 30gmDang Gui Slices 15gmRed Dates 15gmWolfberry 15gmSkinless Boneless 45gmChicken LegsSalt 2.5gmWater 2 litresMethod1. Bring a pot of water to boil.2. Add in the chicken and poach for 10 mins.3. After 10 mins remove the chicken and set aside.4. Take a pot, add in the 2 litres of water, chicken and the herbs (i.e. dang shen, dang gui, red dates and wolfberry).5. Steam the chicken and herbal mixture for 3 hours.6. When it is ready, add in salt for flavour.7. Scoop and serve.HERBAL TEA (Serving: 220ml x 23 cups)IngredientsDang Shen 30gmDang Gui Slices 15gmRed Dates 30gmWolfberry 30gmHoney 300gmWater 5 litresMethod1. Add water and all the herbs (i.e. dang shen, dang gui, red dates andwolfberry) into a pot.2. Steam the herbal mixture for 3 hours.3. When it is ready, remove or strain the herbs.4. Add honey and let it boil.5. Ready to be served hot or chilled.Recipes were designed by Ms Dora Ng from CIM Clinic and chefsfrom the Hospitality & General Services, Tan Tock SengHospital.Nutritional information provided by the Nutrition & DieteticsDepartment of Tan Tock Seng Hospital.Photo Courtesy of Mr Henry Lim, Photographer,Tan Tock Seng Hospital.Herbal Agar Agar(32 pieces)Ingredients Per servingCalories (kcal) 8.9Carbohydrate (g) 2.1Protein (g) <0.1Total fat (g) 0Saturated fat (g) 0Cholesterol (mg) 0Dietary fibre (g) <0.1Sodium (mg) 0.9Herbal Tea(220ml x 23 cups)Ingredients Per servingCalories (kcal) 40.4Carbohydrate (g) 10.6Protein (g) <0.1Total fat (g) 0Saturated fat (g) 0Cholesterol (mg) 0Dietary fibre (g) 0Sodium (mg) 1.8Herbal Chicken Soup(300ml x 6 bowls)Ingredients Per servingCalories (kcal) 9.0Carbohydrate (g) 0Protein (g) 1.5Total fat (g) 0.3Saturated fat (g) <0.1Cholesterol (mg) 6.2Dietary fibre (g) 0Sodium (mg) 170NutritionalInformationDang Shen is commonly used inTraditional Chinese Medicine(TCM) to correct ‘Qi’ (气)deficiency and improve bloodcirculation to revitalise thebody.Dang Shen also possesses otherhealth benefits such as:• Stimulates appetite• Improves blood circulation• Stimulates the central nervoussystem and increasesendurance• Boosts immunity by increasingwhite blood cells, activatingmacrophages and other keycomponents of the immunesystem• Treatment of chronic upperrespiratory tract infection• Reduces fatigue and increaseswhite blood count in patientswho are undergoingchemotherapyHowever, if Dang Shen is usedexcessively, it may interferewith blood clotting and is bestto be avoided prior to surgery.Angelica Sinensis or Dang Guiis a perennial fragrant plant ofthe Apiaceae family which isindigenous to China. The stemcan grow to three metres talland has a purplish hue.Its root is widely used in TCM totreat gynaecological symptoms,giving rise to its reputation as‘female Ginseng’.Dang Gui is also found to haveoestrogen-like property thatnourishes the uterus and helpsregulate female hormones. It is oneof the essential herbal items oftenprescribed by TCM physicians totreat pre-menstrual as well asmenopausal symptoms.Dang Gui possesses other healthbenefits such as:• Relieves constipation• Helps correct mild cases ofanaemia• Counters chronic fatigue syndromeMs Dora NgMs Dora Ng is the Principal Acupuncturist ofthe Complementary Integrative Medicine(CIM) Clinic of Tan Tock Seng Hospital (TTSH).She is a Registered Traditional ChineseMedicine (TCM) Physician with the TCMPractitioners Board, Singapore. She hasspecial interest in the treatment of chronicpain and TCM-based dietary counselling.Dishes prepared by the Hospitality & General Services, Tan Tock Seng Hospital.30 31
  17. 17. Clinic B1B– Orthopaedic Surgery• Hand Procedure Suite– Rheumatology, Allergy and Immunology• Intravenous Infusion Day FacilityClinic 2B– Gastroenterology andHepatologyOur sub-specialties include:• General Gastroenterology• Hepatology (Liver) Service• Inflammatory Bowel Disease• Gastrointestinal Endoscopy• Pancreato-Biliary Diseases• Upper Gastrointestinal Motility• Nutrition– General SurgeryOur sub-specialties include:• General Surgery• Colorectal Service• Bariatric and WeightManagement Services• Upper Gastrointestinal Service• Head and Neck SurgicalServices• Endocrine Service• Liver, Pancreas and BiliaryServices• Vascular Service• Veins Service• Thoracic Service• Plastics, Reconstructive andAesthetics Services– UrologyOur sub-specialties include:• General Urology• Andrology and Men’s Health• Adrenal Surgery• Continence and VoidingDysfunction• Endo-Urology and StoneSurgery• Female Urology• Minimally Invasive Surgery and Laparoscopic Surgery• Neuro-Urology• Prostate Surgery• Reconstructive Urology• Robotic Surgery• Subfertility and SexualDysfunction• Urologic Cancer Surgery– Endocrinology• Colonoscopy• Flexible Cystoscopy• GastroscopyClinic 4B– Diabetes and Endocrinology– General Medicine– Haematology– Infectious Disease– Pain Management– Psychological Medicine– Renal Medicine– Respiratory and CriticalCare MedicineCLINIC 6B- Complementary IntegrativeMedicine• Acupuncture• Cupping• Dietary Advice• Pain-relief Physiotherapy- DentalOur specialist services include:• Braces• Root Canal Treatment• Wisdom Tooth Surgery• Dental ImplantsMulti-DisciplinarySpecialistCareTTSH PEARL’s suite of clinicsand services is guidedby the four pillars ofcare through EvidenceCare, DestinationCare, Team Care andPersonalised Care. Weremain committed todelivering a higher levelof patient care as wevalue our patients most.Clinic B1BOrthopaedic SurgeryTel: (65) 6889 4055 Email: ClinicB1B@ttsh.com.sgRheumatology, Allergyand ImmunologyTel: (65) 6889 4027 Email: ClinicB1B@ttsh.com.sgClinic 2BTel: (65) 1800-PEARL-00 (65) 1800-73275-00 Email: Clinic2B@ttsh.com.sgClinic 4BTel: (65) 1800-PEARL-00 (65) 1800-73275-00 Email: Clinic4B@ttsh.com.sgCLINIC 6BComplementary IntegrativeMedicineTel: (65) 6889 4628 Email: Clinic6B@ttsh.com.sgDentalTel: (65) 6889 4627 Email: Clinic6B@ttsh.com.sg