1. family and parenting
2. babies and toddlers

No. 8 | January 2015
A quarterly publication of the NUHS
PROSPECTS
FOR
GROWTH
WHAT A LONG-TERM STUDY OF
NEWBORNS & THEIR MOTHERS REVEALS
PAGE 02
CLINICAL CARE
THE HEART OF THE PROBLEM
Evidence+_Cover_Jan'15_FA.indd 1
GRAND ROUNDS
CLUELESS ABOUT STROKE
THE PROFESSIONS
A RARE BREED
15/12/14 11:05 am
No. 8 | January 2015
CONTENTS
FEATURE
Prospects for Growth
What a long-term study of
newborns & their mothers reveals
The ‘Growing Up in Singapore Towards
healthy Outcomes (GUSTO)’ longitudinal
survey involves 1,247 Singaporean mothers
and their children, born between Nov 2009
and May 2011.
Read about it on page
Happy New Year!
This year holds special significance for Singapore, which is marking
its 50th year as a sovereign and independent state. It is also the 110th
anniversary of the National University of Singapore (NUS) Yong Loo
Lin School of Medicine and the NUS that eventually arose from the
institution.
Just how large does the School’s shadow loom over Singapore
medicine? Available information suggests that six out of 10 doctors
practising in Singapore today are alumni. Of these, about 70% hold
senior leadership posts in our public hospitals. At its teaching hospital,
the National University Hospital (NUH), an overwhelming majority of
the clinical departments are headed by NUS Medicine graduates.
More pertinently, advances in healthcare that have led to a healthier
population over the decades are due in large part to the work of
generations of NUS Medicine graduates. They laid the foundations
and built a healthcare system that is one of the world’s best, and which
continues to evolve to meet the needs of a 21st-century Singaporean
population.
The School that’s been making medical history since 1905 continues
to do so, graduating 300 young doctors every year. These numbers will
go up, in response to the increased need for healthcare professionals.
The NUS brand of medical education is well recognised: the School
consistently places among the top three in Quacquarelli Symonds
international medical school rankings. Its graduates are welcome
additions to hospital staff ranks everywhere, while its students’
community health screening initiatives—both here and abroad—
are lauded for the civic-minded spirit that drives these enterprises.
Meanwhile, work by its scientists add to our understanding of human
diseases while introducing new and better ways of dealing with them.
The establishment and accumulation of institutional fame and glory
was not the mission of the NUS medical school when it was begun
through the generosity of Mr Tan Jiak Kim and members of the local
business community. Rather, the Straits Settlement and Federated
Malay States Government Medical School, as it was then called, was
established simply to train doctors to care for the local community. In
its 110th year, the School continues to fulfil the purpose for which it was
created; that Singapore’s first and foremost medical school is doing it
well and faithfully is cause for celebration as well as thanksgiving.
IFC_NUHS_Evidence+_TOC.indd 2
FYI
06
DISCOVERY
Fat? It’s Just a Big
Turn-off / Multitasking?
Forget About It!
08
CLINICAL CARE
The Heart of the Problem
02
Dear Reader,
The Editorial Committee
01
10
GRAND ROUNDS
Clueless About Stroke
12
SECOND OPINION
Help of the Helpless
IBC
ON
THE
BACK
THE PROFESSIONS
A Rare Breed
FAST FACTS
Once More,
With GUSTO
Evidence+ is published quarterly by the Communications
Office of the National University Health System,
1E Kent Ridge Road, Tower Block, L13, Singapore 119228.
Please address comments to evidence@nuhs.edu.sg.
Edited and designed by:
Copyright © is held by the publishers. All rights
reserved. Reproduction in whole or in part
without permission is prohibited. Printed in
Singapore by NPE Print Communications Pte Ltd.
MCI (P) 074/03/2014
WWW.NOVUSASIA.COM
15/12/14 11:31 am
FYI
BESTSELLING MEDICAL
TOME UPDATED
CHIEF EXECUTIVE
CONFERRED
PRESIDENTIAL
AWARD
THE National University Health System’s
(NUHS) Chief Executive, Professor John
Eu-Li Wong, has been awarded the 2014
President’s Science and Technology
Medal, part of the President’s Science and
Technology Awards (PSTA).
The PSTA are the highest honours
bestowed on exceptional research
scientists and engineers in Singapore
for their achievements in science and
technology, and outstanding contributions
to the development of the R&D landscape
here. The Awards were presented by
President Tony Tan at a ceremony held at
the Istana on 4 Nov 2014.
According to the Agency for Science,
Technology and Research, the Medal “is
awarded to outstanding individuals who
have made distinguished, sustained and
exceptional contributions, and played
a strategic role in the development of
Singapore through the promotion and
management of R&D. Recipients receive a
specially designed gold medal and a citation.”
Prof Wong, who is also the Isabel
Chan Professor in M edical Sciences and
Senior Vice President (Health Affairs) at
the National University of Singapore, was
honoured for his sustained contributions
to Singapore’s healthcare and biomedical
sciences research. Besides being one of
the pioneers of the biomedical sciences
industry here, Prof Wong has also
championed translational clinical research
and helped to establish the Cancer
Therapeutics Research Group, which links
cancer centres in Singapore, Australia
and across Asia to better treat cancers
that affect Asians. As Chief Executive of
the NUHS, he leads ongoing initiatives
in research, health management and
education that aim to advance healthcare
in Singapore.
COMPILED by two National
University Hospital Emergency
Medicine doctors, a standard reference
for emergency doctors and nurses as
well as medical students here has been
updated.
The first edition of Guide to the
Essentials in Emergency Medicine,
co-edited by Associate Professor
Shirley Ooi and Associate Professor
Peter Manning, has sold 16,000 copies
since it was released a decade ago, with
more than half of the sales coming
from overseas. The second edition was
launched in Jun 2014 and has already
sold 4,000 copies. “It’s a textbook
that’s succinct enough to be read cover
to cover and used in real-time clinical
practice, but comprehensive enough
to avoid leaving gaps in knowledge
of key points,” says Professor Amal
Mattu from the University of Maryland
School of Medicine, in his foreword.
The new version is filled with
coloured images, hand-drawn
illustrations, ECGs, radiographs, CT
scans and ultrasound images, and
essential information is easily
retrievable. It contains extensive
and updated coverage of the types
of cases that present themselves
in emergency departments. It
also has 20 new chapters on
specific conditions (cardiovascular
and neurologic emergencies,
for example) and approaches
to certain ailments (such as
peripheral joint pain).
To help readers absorb
information, it contains
highlighted keywords and text
written in point form. It also
reaches out to different audiences.
For example, every chapter
contains a ‘special tips for GPs’
section, which are areas doctors
practising in pre-hospital settings
need to focus on.
“Writing and editing the book
helps me to sort out my thought
processes, and enables me to
become a better clinician and
teacher as well,” says Assoc Prof
Ooi of her experience.
01
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FEATURE
PROSPECTS FOR GROWTH
What can 1,247 mothers and their children teach Singapore
and the world? Plenty, as the initial findings from a longterm study of these mums and their newborn babies show.
02
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T
he past foretells
the future, whose
seemingly inevitable
unfolding may yet be
influenced through
knowledge of what is
to come.
That was the plot
of a recent Hollywood
movie. It’s also a
superficial summary of an ambitious
and groundbreaking study currently
underway at the National University
Health System (NUHS), KK Women’s
and Children’s Hospital, Singapore
Institute for Clinical Sciences (SICS)
and Agency for Science, Technology
and Research (A*STAR), led by an
obstetrics and gynaecology professor
who is also a clinician investigator.
The study, Growing Up in
Singapore Towards healthy Outcomes
(GUSTO), involves 1,247 Singaporean
mothers and their children, born
between Nov 2009 and May 2011. It
began recruitment of mothers and
children in Jun 2009, recalls Associate
Professor Chong Yap Seng.
DAYS OF FUTURE PAST
GUSTO’s hypothesis is that the
conditions in a child’s early life and
his or her mother’s pregnancy can
influence the risk of future disease for
the little one.
Operating from this understanding,
Assoc Prof Chong and his team are
studying epigenetic markers at birth.
“If we look at the epigenetic markers
at birth and take it in conjunction
with a child’s underlying genetics
and exposures, we can come up
with a projection of his or her future
trajectory for disease,” he explains.
So, if doctors had clear, advance
indicators about the likelihood of
Facial imitation test on the day of birth,
recorded on video for neurocognitive analysis.
disease development in a child’s
later or even adult years, they would
be able to intervene clinically.
IT ALL STARTS IN THE WOMB
But first, the team had to find and
recruit more than 1,000 expectant
mothers who were willing to be
put through hours of testing over
several years. And yet they managed,
marvels Assoc Prof Chong. “What’s
quite amazing about GUSTO is
we recruited 1,247 mothers and
put them through a very rigorous
protocol, and managed to convince
them to join the study within a
15-month time frame, so it was a
very fast recruitment,” he says.
Then the barrage of tests
began: detailed phenotyping of the
mother’s oral glucose tolerance
tests for diabetes, hair samples to
examine environmental exposures,
retinal photography, body
composition measures including
height and weight, blood pressure,
detailed questions about their
general health status, mood, sleep
quality, and so on. Some of this
information was collected in a
three-hour visit, and is all part of
collecting the broadest and deepest
range of high-quality biological
information possible.
GUSTO researchers also chose
their participants carefully to cover
Singapore’s major ethnic groups. “We
oversampled Malays and Indians
because we wanted to compare the
three ethnicities,” reveals Assoc Prof
Chong. “Singapore is 75% Chinese.
Our study has 55% Chinese, about 25%
Malays, and the rest were Indians.” It
is data that could be exported to other
governments interested in the health
of their people: together, these three
ethnicities make up more than 40% of
the world’s population.
While the team regularly collected
data from the expectant mothers and
their as yet unborn babies, the pace
stepped up after delivery, when both
test subjects were finally present. Assoc
Prof Chong cheerfully recalls, “We
were quite busy for the first day or two
following the birth.”
One of the first tests conducted
could quite possibly be the most
memorable for the watching parents:
the newborn would be cradled by a
research assistant, who would then
stick a tongue out, gawp and make odd
facial expressions at the baby. “We
wanted to see if the baby imitated the
researcher. It’s a good way to test how
aware the babies are and how able
they are to process visual stimulation,”
explains Assoc Prof Chong.
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LEARNING BY DOING
The ongoing success of the project
is due, in very large part, to the
commitment and cooperation of the
mothers and GUSTO families. To
make the process as easy as possible
for the family, the GUSTO team
went all out—literally. “In the first
15 months, we made home visits to
ensure it was more convenient for
mothers, and to make sure we had
a high retention rate,” says Assoc
Prof Chong. “You’ve just had a
baby, everything is a struggle, you
probably don’t want to come in to
the clinic for tests. So we went to
their homes to take measurements,
collect data and samples.”
When the babies were six months
old, they were tested to see what
they were looking at. “We did
computerised eye tracking, where
we showed pictures to the babies
while a camera tracked their eyes.
By examining what they’re looking
at, you can see what they’re learning
and remembering.”
A large part of GUSTO also
examines the role of environmental
factors compared to pre-determined
genetics—in essence, nature versus
nurture. In the custom-built
Neurocognitive Development Centre,
where much of the observation of
mothers and their babies is done,
the team records the women playing
with their children from behind a
one-way mirror. “Our researchers
score the videotapes while observing
how the mothers play with their
children—with and without the help
of toys. It’s to see how sensitive they
are to the child’s cues. We can also
see how the nurturing influences a
child’s development.”
A DISTURBING FIND
The study has also provided new
information about gestational
diabetes mellitus (GDM). During
pregnancy, a mother can develop
a form of diabetes that apparently
disappears after the baby is born.
It has traditionally been seen as
a self-resolving problem that, in
most cases, does not trigger serious
trouble and may be a blind spot to
doctors.
According to Assoc Prof Chong,
Above: A six-month-old GUSTO baby
fitted with an EEG net for tests in SICS
Neurodevelopment Research Centre.
Left: Video camera tracking the eye
movements of a child going through
the visual habituation test.
“We used to think it was only
present in 5–10% of cases, but in
GUSTO, we tested all the mothers
for GDM and found 19% had
diabetes during pregnancy. Had we
only tested mothers at high risk,
such as the overweight ones or those
with a family history of diabetes, we
would only have picked up 10%. So
we are systematically missing about
half the patients with GDM with
our current practice.” That is a big
insight, he insists. “What we’re doing
now is not good enough; we need to
test everybody.”
But why? “Children of mothers
who have gestational diabetes have
a five-fold increased risk of getting
diabetes themselves, and double the
risk of obesity. As for the mothers,
almost 20% will go on to become
diabetic themselves within 10 years.
So we’re really missing a big thing
because the women appear to recover
once they have delivered. We miss the
opportunity to pick up mothers who will
go on to develop frank diabetes, while
perhaps prudent lifestyle modifications
could prevent them from becoming
diabetic in the first place,” says Assoc
Prof Chong.
Another GUSTO discovery, thanks
to careful analysis of MRI scans, was
this: if mothers experienced depression
during pregnancy, the right amygdalas
of their babies were subsequently
affected. The amygdala is an area of
the brain associated with vulnerability
towards anxiety disorders. It could thus
be a mechanism of transmission of
anxiety from mother to child. “It proves
our point that, while the environment
can affect the baby’s brain, the genotype
makes a difference, too.”
Proof that this was a key discovery
came six weeks after the team
04
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“WHAT’S QUITE
AMAZING ABOUT
GUSTO IS WE
RECRUITED 1,247
MOTHERS AND PUT
THEM THROUGH A
VERY RIGOROUS
PROTOCOL, AND
MANAGED TO
CONVINCE THEM
TO JOIN THE STUDY
WITHIN A 15-MONTH
TIME FRAME, SO IT
WAS A VERY FAST
RECRUITMENT.”
— ASSOC PROF CHONG YAP SENG
submitted the results of this
particular study to the American
Journal of Psychiatry. The journal’s
editor wrote back, “We recognise the
monumental scope of the GUSTO
study and its unique potential and
importance,” and invited GUSTO
researchers to submit more papers.
PEOPLE POWER
Monumental scope and unique
potential—that sums up the
challenge and promise of GUSTO.
If Assoc Prof Chong seems like a
visionary who fervently believes in
this study, it’s because he feels it
can be a huge resource to Singapore
and, in his words, “enhance human
capacity.” He argues, “In Singapore,
we only have two natural resources.
One is the geographic position
and the other is people. We want
to produce the best and healthiest
Singaporeans we can.”
He shares another GUSTO finding:
“What we found is that babies who
came from households where they
were spoken to in two languages
actually have better visual habituation
and better learning function at six
months of age.” The baby isn’t just
learning two languages; it’s learning
to differentiate between two languages
and sort the words out. As adults, we
forget what monumental brainpower
this takes.
Discovery work continues apace,
with data collected from GUSTO
amounting to about one to two
terabytes of text data alone, not
including MRI scans. A single terabyte
could hold the entire Encyclopaedia
Britannica a thousand times over!
WITH GUSTO
In practical terms, it’s a goldmine,
quips Assoc Prof Chong, “made
possible through the partnerships with
Assoc Prof Chong Yap Seng attending to a GUSTO baby
before its MRI scan in NUH—the little one snugly sleeping
through the procedure without any need for sedation.
colleagues and researchers from the
NUHS, KK Women’s and Children’s
Hospital, and A*STAR coming together
for a common goal—to improve the
health of Singaporeans tomorrow,
today. Together, we’ve collected
enough samples and data so that
analysis may be made in many areas of
research, from oral health to allergies,
from metabolism to neuro-disorders,
such as autism, and more.”
And this is just the beginning.
When people ask how long the
study will go on for, Assoc Prof
Chong’s response is to answer the
question with a question: how long
is a piece of rope? “You go on for as
long as the work is useful. To me,
this is a cohort I’d like to hand over
to my grandchildren. Quite literally,
it is cradle to grave. It is a wonderful
jewel for Singapore, a platform for
everybody to research on, and it just
needs to go on.”
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IT'S JUST A
BIG TURN-OFF
A new way of fighting fat has been
discovered—and no exercise or
diet is required at all!
A
team from the National
University of Singapore (NUS)
Yong Loo Lin School of Medicine
has discovered a molecular link
between diet and fat retention
that could lead to a way to reduce obesity
in humans. The novel method involves
interfering with a mechanism present in
all mammals—including humans—that
helps us resist starvation when food is
scarce. “This means depositing fat
whenever you can, because there may not
be breakfast, lunch and dinner every
day,” says Professor Carlos Ibanez, from
the School’s Department of Physiology,
explaining how the ancient mechanism
works.
The problem is that, these days, “we
have constant access to high-calorie
foods, and we have a sedentary life,”
Prof Ibanez reveals. Yet our bodies
today have not really evolved much
from the bodies of Stone Age humans,
as we have retained this primal, fatstoring mechanism.
There are several links between diet
and fat storage, but Prof Ibanez and his
team have discovered and learnt how
to shut down the link governed by a
receptor, called ALK7, found in fat cells.
Photo: The Straits Times © Singapore Press Holdings Limited. Reprinted with permission.
DISCOVERY
The team uncovered the ALK7 receptor
while looking for new brain receptors.
In Prof Ibanez’s research, mice
fed a high-fat diet but whose ALK7
receptors were shut down gained only
half as much weight as those mice
whose receptors were on. Prof Ibanez
theorised that the mice could actually
lose weight if placed on a lower fat
diet. His tests on human fat cells
showed that ALK7 worked in a
similar fashion.
The NUS Medicine team’s research
was done in collaboration with the
Karolinska Institutet in Sweden and
the Howard Hughes Medical Institute
in the United States. Their findings,
published in the online science journal
eLife, could one day help people
lose weight through suppression of
the human variant of ALK7. This
possibility is, however, still some time
away and depends in large part on the
ability of pharmaceutical companies
to translate this knowledge into
commercially viable solutions.
Prof Ibanez plans to study
this phenomenon further and
determine how the ALK7 in different
peoples around the world affect fat
PROF IBANEZ AND
HIS TEAM HAVE
DISCOVERED AND
LEARNT HOW TO
SHUT DOWN THE
LINK GOVERNED
BY A RECEPTOR,
CALLED ALK7,
FOUND IN FAT
CELLS.
accumulation. For example, does it
have a part to play in Asians’ tendency
to develop fatty livers?
The battle against the bulge is a
serious quest. The American Medical
Association has classified obesity as
a disease, and it is considered one
of the most serious public health
issues of the 21st century. How serious
is it? Consider these numbers: in
China, about 30% of its population
is considered obese (BMI > 25); in
the United States, that figure is about
70%; here in Singapore, 40% of our
residents are in that category, and
are at risk of developing a range of
health problems, from diabetes to
heart disease.
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MULTITASKING?
FORGET
ABOUT IT!
A recently published study here reveals that the much-lauded
ability to multitask could be detrimental to the formation of
long-term memories, leading to memory disorders.
P
eople who can multitask
are often referred to in
complimentary tones, but that
could soon change because of a
three-year study conducted by
scientists from the National University
of Singapore (NUS). They found that
multitasking may impair the formation
of long-term memories, which in turn
may increase the risk for Alzheimer’s
disease or early-onset dementia.
The study’s principal investigator,
Assistant Professor S Sajikumar, from
the Department of Physiology at the
NUS Yong Loo Lin School of Medicine,
explains that the capacity to form
memories is compromised if too
many memories compete for memory
proteins in the brain. “It’s like six
people trying to eat a cake made for
two. They will still be hungry,” he offers
by way of analogy.
Long-term memories are stored
only after they ‘win’ proteins over
other memories in the brain. When
a person multitasks, the quest for
memory proteins intensifies to such a
point where “nobody wins,” Asst Prof
Sajikumar says. He discovered this
by artificially stimulating synapses by
simultaneously providing different
electrical stimuli to a group of neurons
in the brain tissues of mice. The group
of neurons that received multiple
electrical stimuli within a 60-minute
“DON’T DO THINGS
SIMULTANEOUSLY
BECAUSE CHRONIC
MULTITASKING IS
NOT AT ALL GOOD
FOR OUR NEURAL
SYSTEM.”
time period showed impaired memory
storing capacity, leading to a complete
wipeout of long-term memory.
This discovery has serious
implications for young children.
Those 12 years and younger should
avoid multitasking because their
neural networks are still developing
and are in need of more memory
proteins. “Multitasking will enhance
the competition for memory proteins.
They could be at greater risk of
attention deficit syndrome,” warns
Asst Prof Sajikumar. “Don’t do things
simultaneously because chronic
multitasking is not at all good for our
neural system.” He advises parents to
limit how much their children are made
to multitask; rather, they should guide
their children to devote their attention
to one activity—such as reading—at
a time. He also advises parents to let
their children take frequent breaks.
“Have a break. This break will help you
recall more information,” he reveals.
The study was done in collaboration
with the Technical University
Braunschweig and the University of
Edinburgh. It received $850,000 of
funding from the National Medical
Research Council. The findings were
published in the journal Proceedings
of the National Academy of Sciences
of the United States of America in
Aug 2014.
07
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CLINICAL
CARE
T H E
O F
T H E
PROBLEM
The National University Heart Centre, Singapore’s (NUHCS) new
clinic helps people find out if they have inherited cardiac conditions.
H
ow many people are at risk of
an inherited cardiac condition
(ICC)? Not many. Depending
on the form of ICC, the average
Singaporean has a one-in-500
to one-in-5,000 chance of being
diagnosed with one. That’s because ICC
stands for a gamut of conditions. There’s
hypertrophic cardiomyopathy, dilated
idiopathic cardiomyopathy, Marfan
syndrome, Loeys-Dietz syndrome,
inherited arrhythmias and more.
Combating these conditions—even
identifying them with testing—has been
a complex task in Singapore up until
now. In the past, cardiologists who
suspected their patients had a genetic
condition had to ship DNA samples to
laboratories in the US. As such, sighs,
Associate Professor Roger Foo, the
tests tended to be expensive, costing
around US$4,000, and getting results
back took weeks.
But those days are over, thanks to
the opening of Singapore’s first ICC
Clinic. It boasts fully integrated genetic
testing access and clinical support.
Better still, for the time being, patients
can receive the testing free of charge.
MUTATION ALARM
The process works like this, says Assoc
Prof Foo. A patient might come in
complaining of heart trouble. “If it is a
“IF IT IS A YOUNG
PERSON AND
THERE IS A
STRONG FAMILY
HISTORY, THEN
GENETICS WOULD
BE RINGING
ALARM BELLS.
IN THE PAST, IT
WOULDN’T BE
POSSIBLE TO DO
GENETIC TESTING,
BUT NOW IT IS.”
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young person and there is a strong
family history, then genetics would
be ringing alarm bells. In the past,
it wouldn’t be possible to do genetic
testing, but now it is, so now the
patient comes to our clinic. In our
clinic we do counselling, explaining
what genetic testing means, what
the meaning of inheritance is, then
we look at the family history.” A
blood sample is taken and promptly
sent to the lab for genetic testing.
If anything significant is found,
the team informs the patient
and investigates further, says Dr
Raymond Wong, Senior Consultant
at the Department of Cardiology.
“If we find a strong suspicion of
confirmed gene mutation, we test
every single first-degree relative,”
a move common in the US and
Europe.
While ICCs may not be common,
it can wreak havoc on affected
families. One family that has
benefited from the new clinic had
lost a son to a type of ICC. “It’s
very striking,” says Assoc Prof
Foo. “The patriarch had a son who
passed away. His brother also died
in his sleep. And the brother’s
daughter passed away”—all from
cardiomyopathy.
The patriarch’s young daughter
has the mutation, too, he adds, “so
genetic testing can be very useful
for families like this.” The daughter
says she is grateful that she is aware
of what she can and cannot do,
while her mother calls the diagnosis
“a blessing in disguise.”
KNOW YOUR ENEMY
How does genetic testing actually
help these stricken families,
though? “It confirms diagnosis,”
adds Assoc Prof Foo. “It changes
the management because you may
A portrait of the family that has benefited from NUHCS’ new genetic testing clinic,
which helps screen patients for inherited cardiac conditions.
choose to follow up more closely; it
can make you more sure it’s Marfan,
for example.” Medication can be
introduced, doctors know how closely
they need to monitor their patients,
while patients understand the need
for regular checkups.
The confirmation of an ICC can
even lead to a change of jobs and
careers for some people, he says,
noting the case of a footballer who
passed out during a game. “If children
test positive, you can be aware of
what you’re dealing with, so you
don’t have them thinking they’ll be a
fighter pilot one day, or they’re going
to be a professional athlete.” This
kind of predictive testing for younger
members of a family thus shields
them from activities that could spell
death.
Genetic testing is not without its
emotional issues, however. For some
anxious families, the news can be
devastating. If you know you carry
a certain gene, it impacts family
planning, explains Assoc Prof Foo.
TREASURE GENES
The NUHCS and Cardiovascular
Research Institute have a specific vision
for the clinic—that it obtains and holds
up to 10,000 gene specimens from
healthy octogenarians in the database.
The genomes would act as a gold
standard reference, as he explains: “Why
octogenarians? Because if they live to be
this old and don’t have any diseases, you
can be pretty sure they don’t have the
genetic basis for the condition.” Every
time a mutation presents itself that
puzzles cardiologists, they can compare
it to healthy genes in the database.
And the genes wouldn’t just be a boon
for solving problems of the heart, he
adds. Neurological diseases, rheumatoid
arthritis—the hope is that, eventually,
solutions can be found to better the
lives of people with countless inherited
diseases.
It would cost a lot to build the
database, sure—but it would be worth
it. “This would be Singapore’s treasure
chest, you know, for future generations,”
Assoc Prof Foo smiles.
09
8-9_NUHS_Evidence+_CC_Cardiac_2.indd 2
15/12/14 11:29 am
GRAND
ROUNDS
CLUELESS
ABOUT
STROKE
Stroke is one of the top killers in Singapore, but a new
study indicates that most people are in the dark about it.
T
his fact has come to light
because of a study by
students at the National
University of Singapore
(NUS) Yong Loo Lin School
of Medicine. They looked at the
degree of awareness and knowledge
of issues revolving around stroke
here. The study found poor levels
of stroke literacy among the sample
population of 687 Singaporeans
who were surveyed in Feb and
Mar 2013. One of the questions
that stumped 20% of the
respondents was the number to
dial for an ambulance.
STROKE LITERACY
When it comes to health, ignorance
is definitely not bliss.
The fact that stroke is now the
fourth most common cause of death
in Singapore makes the lack of
stroke knowledge here all the more
worrying. Knowing and addressing
its risk factors can reduce the
incidence of the event, and
recognising its symptoms can help
a patient receive timely treatment.
“Earlier treatment of stroke is
associated with better outcomes,”
says Associate Professor Deidre
Anne De Silva, a senior consultant
from the Department of Neurology
at the National Neuroscience
Institute and an advisor of the
student-led study.
However, an earlier local study
published in the 2010 issue of the
Annals of the Academy of Medicine
Singapore has shown that the average
time taken by a stroke patient to arrive
at the hospital is more than 20 hours.
Published in the 2014 issue of the
same Annals, the study by the medical
students points to some possible insights
as to why this is so.
STARTLING FINDINGS
One striking statistic from the study
was the low awareness of what
constitutes stroke.
The acronym used by public health
institutions and campaigns for stroke
awareness in Singapore and in many
other parts of world is FAST: Facial
drooping, Arm weakness (one side in
particular), Slurring of speech, and
Time (calling for medical attention as
soon as possible). However, the study
showed that less than half of the survey
pool was able to cite at least one out of
FAST’s three symptoms of stroke. Even
though nearly 70% said they would call
emergency ambulatory services when
witnessing a stroke onset, the actual
figures may be much lower, given the
lack of knowledge of these symptoms.
“This is the first survey that
comprehensively looks at the knowledge
of stroke symptoms and risk factors
here, and it gives us a baseline idea of
where we stand now,” says Assoc Prof
De Silva. “Compared to other developed
countries, we fare very poorly in getting
people to come to the hospital early
when they have a stroke. Less than 20%
of patients here come in by ambulance,
but the figure is 80% in many developed
countries,” she states.
RISKY BUSINESS
It wasn’t just the symptoms of stroke
that the participants were clueless
about: about one-third of them could
not name any of the seven established
risk factors of stroke, such as diabetes,
high blood pressure, high cholesterol,
and smoking.
“It’s important for people to know
their risk factors, because stroke risk
reduction strategies are effective. If
people control their blood pressure and
cholesterol, stop smoking and have
a healthy lifestyle, they can reduce
their risk of stroke,” explains Assoc
Prof De Silva. This piece of advice
can be particularly useful for people
10
10-11_NUHS_Evidence+_Grand Rounds_Ignorance.indd 1
17/12/14 11:03 am
L–R: Assoc Prof Deidre Anne De Silva, Asst Prof Lim Wei-Yen
Answers from
respondents
when asked what
immediate action
they would take if a
colleague or friend
were to exhibit stroke
symptoms.
Call an ambulance
67.1% (461)
Send to A&E
department by car/taxi
12.4% (85)
Bring the person
to a GP
7.9% (54)
Prick finger and let the
blood drain
0.9% (6)
in the higher-risk demographic,
such as the elderly and those with
medical conditions predisposing
them to stroke. The student
researchers observed that these
groups demonstrated a poor overall
awareness of stroke symptoms and
risk factors.
IMPLICATIONS & LESSONS
Interestingly, however, it was the
caregivers of patients with these
risk factors who knew more about
stroke. One possible explanation for
this could be the way healthcare is
disseminated from doctor to patient
here, according to Assistant Professor
Lim Wei-Yen from the NUS Saw
Swee Hock School of Public Health,
who supervised the study, as relevant
information is often passed on to
family members and caregivers rather
than the patients.
The study can thus help to pave
the way for better-informed public
awareness and education initiatives to
increase stroke literacy, a need that is
now more pressing due to Singapore’s
ageing population and the common
incidence of risk factors such as
diabetes.
Meanwhile, the study may also serve
as a starting point for follow-up studies
that can better serve such initiatives
to increase stroke awareness. “A more
in-depth qualitative study would be
useful—to ask people who have had
stroke whether they knew what a stroke
was before they had it, or to probe their
circumstances around the stroke event,
such as what thoughts they had at that
point in time,” says Asst Prof Lim.
“This might be useful because it can
give us information about what actually
happens when people suffer a stroke,
and this can help us to craft a more
meaningful and helpful message or even
an education campaign,” he adds.
Encourage person to
exercise/change diet
0.7% (5)
Bring the person to a
traditional physician
0.3% (2)
Initiate cardiopulmonary
resuscitation
0.3% (2)
Send the patient for
acupuncture
0.3% (2)
Do not know what to do/
will not do anything
0.3% (2)
Apply medicated oil
0.3% (2)
11
10-11_NUHS_Evidence+_Grand Rounds_Ignorance.indd 2
17/12/14 11:03 am
Ms Yip Jia Hui is a Senior Medical Social Worker at the National University Hospital.
SECOND
OPINION
HELP OF THE
HELPLESS
To cure sometimes, relieve often, comfort always. Besides expressing the ideals of medical
practice, this aphorism is also an apt summary of the work done by medical social workers, who
help patients and their families deal with the stress of illness. While some clients may be difficult,
the satisfaction of seeing patients recover makes the jouney worthwhile, says Ms Yip Jia Hui.
O
n a typical day, a medical social
worker (MSW) has to attend to
various cases, with issues such
as care arrangements, financial
assistance, counselling and crises.
These cases can come from wards
or specialist clinics, where our doctors,
nurses or allied health professionals
identify potential social issues that
could affect patient care, safety or his/
her ability to cope. Patients could also
seek help by walking in or calling our
department. We work with patients
with all sorts of medical conditions,
including strokes, neurological and
cardiac conditions. We also help
patients suffering from the loss of
functions and abilities to perform
activities of daily living, those who
require long-term care due to acquired
disabilities (either at home or in a
nursing home), and those referred to us
for care arrangement.
We also support patients and families
to help them cope with grief and loss.
Some medical conditions may give rise
to severe side effects that require
long-term bedridden care, which can
be difficult to manage. That’s why
we work with the patients and their
families to link them up with various
aid programmes.
GIVING FACE TIME
MSWs often join doctors, nurses
and other allied health professionals
in multi-disciplinary meetings that
are aimed at rendering holistic care
for our patients. Then there are also
meetings with other agencies and
partners to maintain, support and
develop programmes and services.
These meetings are important
because they bridge service gaps and
aim to provide a seamless system for
patients.
Furthermore, MSWs need to be
cared for as well. I am thus fortunate
to have colleagues who look out for
one another. We hold weekly case
conferences to share knowledge,
skills and experience. We also have
team-based case discussions and offer
support to one another, if need be.
HITTING AN EMOTIONAL NOTE
Many patients have left lasting
impressions. I have encountered patients
or families who are in intense grief
or in a state of denial and anger, and
communicating with them about care
plans was very challenging. I had to
maintain my composure and remind
myself of my role as a social worker.
These situations tested my patience,
knowledge, skills and even values such as
respect for dignity, compassion and selfawareness; I needed to be aware of how
my own feelings affected my professional
response to these patients and families.
Other patients inspired me with their
perseverance, resilience and positive
spirit. I remember one particular
patient very well because of the way he
and his family exhibited grit and grace
in the midst of hardship.
There were numerous times when I
was deeply moved by my clients or their
families (the tears have to be controlled).
These are families who fight to care for
their loved ones despite difficulties,
and they have to hide their tears and
fears. I am grateful to these brave souls
because their fortitude and resilience
serve to rally and encourage me.
Ultimately, the greatest satisfaction
comes from the journey with the
patients, from their initial admission to
seeing them recover, being discharged
and being able to cope well on their
own. I think that’s the greatest gift
of all.
12
12_NUHS_Evidence+_Second Opinion_JiaHui_2.indd 1
15/12/14 11:30 am
Asst Prof Joanne Yoong is the only health economist at the Saw Swee Hock School of Public Health.
THE
PROFESSIONS
treatment programmes.
“It’s really cool, especially if your
Chinese is really lousy, like mine is,” she
jokes. “You have all these flash cards you
use when talking to the locals. I never
thought I’d learn how to say ‘sputum
test’ in Mandarin!”
A RARE BREED
Assistant Professor Joanne Yoong is one of the few health
economists at the National University of Singapore; she is also a
faculty member of the Saw Swee Hock School of Public Health.
A
ssistant Professor Joanne
Yoong is a rare breed indeed:
she is the only economist
specialising in healthcare in
the public health school.
Health economics is a branch of
economics concerned with issues
related to efficiency, effectiveness,
value and behaviour in the production
and consumption of health and
healthcare. One of the many projects
that she is working on is determining
how resources can be allocated
to increase the uptake rate of flu
vaccines in Singapore. “It’s about
people having scarce resources and
unlimited wants, and how we make
decisions to allocate those scarce
resources across unlimited wants.
Essentially, it is the study of the
human condition.”
IBC_NUHS_Evidence+_Professions_Rare.indd 1
THE TRAVELLING ECONOMIST
A big part of Asst Prof Yoong’s job
involves talking to people in and beyond
Singapore.
One such project currently takes
her to the Mekong Delta in Myanmar
and Yunnan, China, where there are
high incidences of multi-drug resistant
tuberculosis (MDR-TB). “When people
with tuberculosis stop taking their
antibiotics, this leads not only to failed
cures, but also the development of MDRTB, which ultimately costs significantly
more to control,” she explains.
There, she is involved in talking to
patients, conducting surveys, “digging
through small offices at the local centre
of disease control to find out why
the local TB patients are not taking
their medications,” and how best to
redistribute resources to improve
THE TURNING POINT
The reason why Asst Prof Yoong decided
on this particular line of work is—
surprisingly—rooted in tragedy.
She was working at Goldman Sachs
in New York City when the first plane hit
the World Trade Center on 11 Sep 2001.
Her subway train came to a grinding halt
in the tunnel, and chaos and confusion
ensued. “I thought, this is the end, and
I’d not even tried to do anything with
my life outside finance,” she recalls. “My
roommate was in the tower, actually,
working for Lehman Brothers. So when
she got out, we both quit our jobs.”
But that was not the only reason why
Asst Prof Yoong decided to study health
economics: there was also the shock
of that roommate’s passing after a late
diagnosis of liver cancer due to Hepatitis
B. “By the time she knew she had it, it
was too late. So at that point, I decided
to understand why health systems fail
and why they fail certain people.”
MAKING BETTER CHOICES
These days, between talking to local
grassroots leaders and liaising with
representatives from the World Health
Organization, she is evaluating hospital
finance reforms in India, measuring
influenza vaccine uptake in three major
hospitals in Singapore, among a slew of
other projects.
Despite being the sole health
economist at the public health school,
Asst Prof Yoong is unfazed: “The idea
of health economics is that we’re trying
to help people use the limited resources
that we have to do the best that we can
for people’s health. That’s why health
economics is the best, because what’s
more important than people’s actual
lives and wellbeing? Nothing!”
Nothing, indeed.
15/12/14 11:30 am
FAST FACTS
,
E
R
O
M
E
C
N
O
!
O
T
S
U
G
H
T
WI
GROWING UP IN SINGAPORE
TOWARDS HEALTHY OUTCOMES
((GUSTO) IS A LONG-TERM STUDY
INVOLVING 1,247 MOTHERS
AND THEIR CHILDREN. HERE
ARE SOME FIGURES FROM
SINGAPORE’S LARGEST AND
MOST COMPREHENSIVE BIRTH
COHORT STUDY.
9,558
NUMBER OF FOLLOW-UPS
WITH GUSTO PARTICIPANTS
VER THE PAST FIVE YEARS
OVER
189,567
NUMBER OF
SAMPLES
COLLECTED
Genetic
differences
ALONE ACCOUNT
FOR ONLY 25%
OF EPIGENETIC
VARIATION; THE
REMAINING 75% IS
INFLUENCED BY
THE INTERACTION
OF GENETIC
DIFFERENCES
AND PRENATAL
ENVIRONMENT.
EPIGENETIC
VARIATION
IS WHAT
INFLUENCES
HOW MUCH A
PARTICULAR
GENE IS
EXPRESSED
OBC_NUHS_Evidence+_Fast Facts_v2.indd 1
21.0%
CHINESE
MALAY
INDIAN
12.1%
22.3%
PERCENTAGE OF CHINESE, MALAY AND INDIAN MOTHERS WHO
DEVELOPED DIABETES DURING THEIR PREGNANCY
5.4mm
AVERAGE TRICEPS
SKIN FOLD
MEASUREMENT
OF A NEWBORN
About 200
NUMBER OF MRI BRAIN SCANS
OF INFANTS RESEARCHERS
ANALYSED TO FIND THAT NEGATIVE
MATERNAL MOOD ALTERS INUTERO NEURODEVELOPMENT AND
INFLUENCES BRAIN GROWTH AND
FUNCTION IN INFANCY
Babies exposed to
2 languages
EXHIBITED
BETTER
LEARNING
AND RECALL
THAN BABIES
WHO WERE
EXPOSED TO ONE
LANGUAGE ONLY
11/12/14 1:41 pm