An eye test can save your life

Modern medicine works by finding evidence to support one or more differential diagnosis at a particular point in time. Sometimes the evidence can come from seemingly unrelated parts of our body. The eye is unique in being the only organ in our body that allows a direct visualisation of its nerve and blood vessels. This offers a peephole view of the state of our health. As such, an eye test is a golden opportunity not to be missed, to gauge our overall physical wellbeing.

Starting from the eyelid and the internal content of the eyeball, all the way to the layers of its walls as well as the six muscles responsible for eye movements, all are closely connected to the rest of our body via their blood supply and innervations. One could say the eye is the “crystal ball” that can foretell our health, providing early clues that should be acted on with appropriate follow-up tests and actions, not just for sight, but also for life-preservation. Several recent examples come to my mind.

First is a very fit patient who had a persistent blurring of vision when reading in one eye and no obvious general health issues. I made a diagnosis of macula swelling secondary to blockage of a branch retina vein at the back of the eye, supported by a thorough eye examination and eye scans. Treatment with eye injections and laser was successful in restoring eyesight. Closing the case after eyesight restoration would be like missing the forest for the trees, as it is usually the underlying cardiovascular health that is the root cause of the eye disease. In fact, in a 2016 meta-analysis endorsed by the American Heart Association and American Stroke association, blockage of the retina vein was found to be associated with a 120 per cent to 450 per cent increase in the risk of stroke, depending on age.

The bigger picture

Recognising the possible bigger picture from a single problem of blurring of eyesight can indeed prompt health-seeking behaviour and ultimately save your life. In fact, my patient is contemplating a career switch from a very stressful job that is felt to be contributing to episodic blood pressure spikes, which almost certainly caused the vein occlusion in the eye.

Another is a patient with a complex intraocular lens problem who also suffered from intractable diabetes and severe diabetic eye disease. A previous cataract surgery in a neighbouring country many years ago could not stand the test of time and the inserted artificial lens implant had become wobbly, to the point of causing terrible visual distortions with every movement. After a rather “heroic” eye surgery lasting several hours, we treated both the dislocated lens implant and detached retina, but subsequent recovery of sight seemed slower than expected.

As a result of the severe diabetic eye disease, in this case, the optic nerve is no longer able to provide clues to possible brain diseases. However, due to complaints of headache and my impression that there could be more to the case, I ordered a brain magnetic resonance imaging (MRI). The result was a sizeable brain tumour that fortunately was still operable, and the final outcome of the case was thankfully a happy ending.

Many patients ask me why their eyes look “smaller” and their eye colour seems to become lighter as they age. The answer is a ring of deposit of oily (lipid) material around the cornea, which is the perceived “black of eye”. The scientific parlance is arcus senilis (pardon the language please) and may indicate a rise in the blood cholesterol level of the body, so it is highly recommended to undergo tests and treatment to manage the cholesterol level.

More than meets the eye

And if becoming senile and demented is a concern, new research also indicated that studying the retina blood vessels may give clues to early Alzheimer’s disease, although diagnosis still needs to be supplemented by neurological tests and brain imaging.

Dry eye disease can be associated with an underlying thyroid problem, and new research has also indicated an association with a lack of Vitamin D which is not rare even in sunny Singapore. I have sent many patients, some even pre-operatively before their planned cataract or laser refractive surgery for blood tests for the above, if suspicion index is high.

Sometimes these tests do turn out to be positive. Proper treatment can then improve their eye symptoms such as eye tiredness and irritation, and improve their general wellbeing too.

I always make it a point to inform young (and sometimes older) patients who sign up for Lasik surgeries which rid them of refractive errors like myopia and astigmatism, if I find any tell-tale signs suspicious of glaucoma, at the risk of sounding like nagging.

One of the associated causes for glaucoma is snoring (sleep apnoea). This may sound innocent enough, but if the end result of continuous neglect is the possibility of complete blindness, my sincere advice is to please get the snoring treated, by the ear nose and throat specialist, as believe me, blindness from glaucoma is real, irreversible and very terrible.

The English poet William Blake once wrote in his famous Auguries of Innocence: To see a world in a grain of sand, and heaven in a wild flower. So too, a quick check of the eyes can reveal more than, well, meets the eye. It may not be possible to hold infinity in the palm of the hand, but here’s wishing that we safely go through the world!

Getting a flu shot is a good idea right now

The year-end and the yuletide season will be soon upon us. Ordinarily we would be gearing to go travelling and some of us would be headed to cold temperatures in the northern part of the globe. However, this has been anything but an ordinary year. We have been beset by a once-in-a-centenary event of a pandemic. As we speak, the pandemic has claimed its one millionth victim and shows no signs of abating. We are all resigned to tracking with bated breath the progress of the 11 Covid-19 vaccines in Phase 3 human trials as there seems to be no other way to stop the onslaught of the coronavirus. Yet we should not be so helpless; we can still do our part by getting our influenza (flu) vaccines. The influenza vaccine is important at this juncture in our fight against the pandemic.

We should first understand that influenza attacks vulnerable groups especially in winter. We do not have a winter season but up to recently we have had a mobile population that travelled extensively for leisure and business; and we used to have 20 million visitors annually. Despite being at the Equator and having tropical climate, we are also an air-conditioned nation. All these factors can make us more susceptible to influenza and its spread. The more vulnerable among us include young children, those who are pregnant and seniors, especially those with chronic diseases and ailments.

Risk to vulnerable groups
Influenza vaccines are recommended for these groups and in the midst of the pandemic, it is imperative that we get them vaccinated to avoid the difficulty of telling apart the Covid-19 infection from the common cold or influenza when patients present with respiratory illnesses. We can also prevent hospitalisation or events related to flu that may increase the risk of the vulnerable groups to Covid-19. We are often asked which flu vaccine we need to take. There are two flu vaccines in a calendar year. The Northern Hemisphere vaccine is available around this time of the year while the Southern Hemisphere vaccine is available in March. The names of Northern and Southern refer to the winter seasons that are critical to patients who contract influenza. The winter season tends to exacerbate the influenza and lead to complications and ultimately the demise of the vulnerable patients. As a result we tend to vaccinate prior to the arrival of winter.

We also need to understand the logistics of producing a flu vaccine. The initial research is to figure out what flu strains will be active in the winter ahead. This involves some degree of “crystal balling” to identify the strains the vaccine should be effective against. Sometimes the prediction is correct and sometimes it is not. It takes, on an average, five months for the pharmaceutical firms to produce, ship and have a vaccine made available. We will usually offer the vaccine that is currently available. Sometimes because the pharmaceutical firms have to make an educated guess as to which flu strains will be causing problems in the winter ahead, we have a situation where if one takes the prevailing vaccine, there is still a chance that we have to take the next vaccine that comes out six months later. So you may hear of people taking two flu vaccines within six months of each other. Fortunately we have guidance on this from our Ministry of Health.

While we are in the midst of a pandemic, we should look back at history. We had the infamous Spanish flu pandemic in 1918 that spawned the H1N1 virus that came from birds. There were smaller pandemics in 1957 (H2N2), 1968 (H3N2) and the recent H1N1 in 2009. I was fascinated by the stories of scientists who discovered the genome of the Spanish flu by exhuming the bodies of Inuit natives who died in 1918. The lung tissue of these bodies was well preserved by the permafrost in Alaska. The scientists managed to extract the RNA of the virus from the preserved lung tissue, decipher it and reconstruct the actual virus at the CDC Laboratories in Atlanta, Georgia. As for the 1957 flu pandemic, my Italian patient in his 70s recall contracting the flu in 1957 as a young boy and told me that he was so ill that he was in bed for three weeks.

Global fight
We are always faced with mutating flu strains and the latest is a swine flu strain in China. This strain is H1N1 and has been spreading since 2016 in the Chinese pig herd. They have found that about 10 per cent of swine workers have been exposed to the virus. So far there has been no human-to-human spread but the local and global authorities are watching this virus like a hawk. This siege is the reality in our global and united fight against viral threats. One of the key battles is the speed of a vaccine against a novel virus. The vaccines take a long time to be produced and in the H1N1 pandemic in 2009, it took 26 weeks for a vaccine to be produced and shipped. We can technically reduce this lead time to 12 weeks but that will need a lot of resources and international cooperation.

A universal flu vaccine is still light years away. The comparison is the ongoing vaccine race for the Covid-19 vaccine. We had the published genome of the Covid-19 virus on the weekend of Jan 11/12 this year. As of today we have 11 vaccines in Phase 3 trials and five approved for limited use. These five include four Chinese vaccines and one Russian vaccine. In the midst of this pandemic while we wait for the Covid-19 vaccine, we must act and mobilise the population to get vaccinated against influenza. The latest flu vaccine is now here and I myself have taken it. While the use of face masks has reduced the incidence of influenza, it is still a good idea to approach your family doctor for a flu shot for all the reasons I have outlined above.

One reason is that it can help in differentiating the Covid-19 infection from the common cold or influenza when patients show symptoms of respiratory illnesses.

Should cholesterol lowering medication be started in the young?

Earlier treatment of elevated cholesterol results, even for children when indicated, results in better outcomes

While the general perception is that strokes only occur in the elderly, over the years, there has been a gradual increase in the prevalence of strokes in the young. Recently, a young patient of mine, who is in his 20s with multiple risk factors for heart disease and stroke, was found to have near complete occlusion of one of his major arteries in the brain, the middle cerebral artery (MCA). The MCA provides blood supply to the part of the brain that controls power, sensation and speech. A stroke involving this artery will not only result in severe disability but can also be life threatening.

Stroke in the young

Severe narrowing of an artery within the skull is termed as intracranial stenosis and encompasses narrowing of the brain arteries. Intracranial stenosis is a common cause of stroke and is particularly prevalent in Asians. In a 2017 study on young Chinese with intracranial stenosis published in the Annals of Translational Research, it was found that in about 80 per cent of those with unilateral blockage of the MCA, the underlying cause was attributable to atherosclerosis. Atherosclerosis is the condition where there is narrowing of the arterial wall (plaque formation) due to the build-up of fat, cholesterol, calcium, and other substances found in the arterial wall. While atherosclerosis remains the main cause of blockage of brain arteries in the young, there are also other causes such as vessel malformation (Moyamoya disease), inflammation of vessels (vasculitis), abnormal arterial wall growth (fibromuscular dysplasia), tear of the artery (arterial dissection); however, these are more prevalent in young females.

Earlier studies showed that for those with significant intracranial stenosis, there was about a one-in-eight chance of getting a stroke or even death within a one- to two-year period even with medical treatment. A more recent publication on the Oxford Vascular Study in May 2020 in Lancet Neurology demonstrated that the risk of intracranial stenosis stroke for those on intensive medical therapy was lower when compared to previous studies, being 5.6 per cent one-year risk (compared to 9.4 per cent in VISSIT, a study on treatment of intracranial stenosis) and 5.6 per cent two-year risk (compared to 14.1 per cent in SAMMPRIS, a study on treatment of intracranial stenosis). The better outcomes in the Oxford Vascular Study may be explained by better medical treatment available in more recent years. In the Chinese Intracranial Atherosclerosis (CICAS) Study, the highest rate of recurrent stroke was seen in those with three or more risk factors.

The major risk factors include high cholesterol level, diabetes mellitus, smoking and high blood pressure. Hence, optimal control of risk factors is essential in those with intracranial stenosis.

Atherosclerosis in children and young adults

While it may come as a surprise to many that the young can develop significant blockage of arteries, the data proving that atherosclerosis is prevalent in the young has been around for some time. Autopsy data from young men with a mean age of 22 years who died during the Korean war showed that more than 70 per cent of them had atherosclerosis in their heart arteries. A similar study on young Americans who perished in the Vietnam war showed that 45 per cent had atherosclerosis and 5 per cent had severe heart artery atherosclerosis. Studies on younger cohorts showed evidence of early onset atherosclerosis in children. A study of young American motor accident victims showed that more than 50 per cent of children aged 10 to 14 years have evidence of early atherosclerosis. In the Bogalusa Heart Study, early atherosclerosis (presence of fatty streaks in the heart arteries) was present in about 50 per cent of those aged from two to 15 years.

Never too young for prevention

Cholesterol remains the single most important risk factor for stroke and heart disease. While it is almost unthinkable in the past to consider starting children on cholesterol-lowering drugs (statins), there is now almost universal agreement that in those with familial hypercholesterolaemia (genetically high cholesterol levels), treatment should commence at a young age. The European Atherosclerosis Society (EAS) consensus panel and the latest American College of Cardiology-American Heart Association (ACC-AHA) guidelines for familial hypercholesterolemia recommend that statins be commenced from as young as eight years (EAS) to 10 years (ACC-AHA) of age. In October 2019, the New England Journal of Medicine published a 20-year follow-up study of children with familial hypercholesterolemia who were started on statin medication at an age of eight to 18 years.

Their results were compared with their affected parents with familial hypercholesterolemia who were only given statins much later in their lives. At the end of the follow-up period, 99 per cent of young patients receiving statins had cardiovascular disease-free survival compared to 74 per cent for their affected parents. This meant that earlier commencement of statin therapy in these at-risk young patients resulted in better long-term outcomes. The latest consensus from the EAS and the International Society of Atherosclerosis (ISA) is that it is not a hypothesis but a fact that LDL cholesterol (“bad” cholesterol) is a major determinant of atherosclerosis. The development of atherosclerosis in arteries is not just dependent on the absolute LDL cholesterol level but also by the cumulative exposure of the arterial wall to LDL cholesterol.

Hence, preventing the development of atherosclerosis not only embodies the concept of “the lower the better” with respect to the LDL cholesterol level, but also a newer concept that “the younger the better”, meaning earlier treatment of elevated cholesterol results in better outcomes.

Early detection

While prevention remains the cornerstone of management, there will be invariably some at-risk young people who may get a stroke. Understanding the symptoms is a key step in early detection and management. Patients with significant intracranial stenosis can present with symptoms of a transient insufficiency in blood flow to the brain (transient ischemic attack) or a stroke. While symptoms such as weakness of one side of the body, slurring of speech, and numbness of one side of the body are easily recognised as an evolving stroke, other symptoms such as severe headache, changes in vision and severe dizziness or a spinning sensation (vertigo) are less well recognised as symptoms of stroke. While ultrasound of the neck (carotid) arteries is commonly used to assess the risk of stroke, it has its limitations. In the CICAS Study, only 20 per cent of those with intracranial stenosis had co-existing neck carotid artery disease, which means that the absence of disease in the neck carotid arteries does not mean that there is no significant intracranial stenosis.

For patients with symptoms, an MRI of the brain and brain arteries can provide confirmation. In an acute stroke, a CT scan of the neck and brain arteries is usually performed at the Emergency Department to help the doctor make a decision on therapeutic choices. In summary, evolving lifestyle and dietary changes have resulted in the development of atherosclerosis in children and young adults. Elevated LDL cholesterol remains the key driver of atherosclerosis and early management, even for children when indicated, can lead to better cardiovascular disease-free outcomes.

The havoc wreaked by the pandemic across the world

Let’s hope that a vaccine will put an end to all this misery and Singapore will be among the first to launch it

It has been six months since the first imported case of Covid-19 virus landed on our shores. The first imported case was diagnosed on Jan 23, 2020, and the first local case was on Feb 4, 2020. We have since come far with 54,797 cases as of yesterday. The community cases have come down to a trickle, averaging about two cases daily in the last week. The migrant worker cases still average about 300-odd cases daily in the last week.

This is really due to the ongoing effort to achieve clearance of the dormitories so the workers can go back to work. There is a herculean effort going on to swab all migrant workers by the day we go to print. To get a better understanding of the situation, I turned to my medical colleagues. These colleagues had founded Crisis Relief Alliance, an NGO that usually does overseas relief missions but could not turn its back on the outbreak in our dormitories at home. My colleagues in full battle order had ventured into the smaller factory dormitories to see, assess and help out.

They had helped to assess the ground situation to feedback to the relevant authorities, distributed fruits regularly to boost morale of the workers and prior to Hari Raya Haji had handed out new clothes, prayer mats and dates obtained from generous donors. There are more than a thousand of these factory dormitories housing anywhere from 20 to 200 migrant workers on their premises. The best way to describe these premises is that if a floor in a factory is empty, you house your workers there. The conditions are basic and spartan with bunk beds and the proximity of these bunk beds has led to rapid transmission.

The toilets are common and the kitchen is shared. Most foreign media have decried them as squalid but I liken them to my bunk bed in the overseas army camps during my National Service days three decades ago. The NGO has visited more than a hundred factory dormitories and the conditions in their premises vary. I have found that the majority of the bosses of these premises have treated their staff well and most workers have been working for the same boss for five to 20 years. Their salaries are paid on time, they received three catered meals daily and all had Internet access or data cards that allowed them to communicate with their loved ones back home.

As for the workers’ fears, they were not worried about the virus as the medical care here is world class, but they were more concerned about the economic damage and the loss of their jobs. In a sense, their fears and emotions are very much aligned with the rest of the population. On the subject of the economic fallout, we have seen devastation to global economies, with our own economy savaged by the virus. The downturn has caused GDP to drop by more than 40 per cent quarter on quarter, and total trade figures contracted by 25 per cent in May 2020. This has prompted a rescue budget totalling 20 per cent of our GDP, probably one of the largest globally in percentage terms.

We have seen our 19 million tourist annual arrivals tumble to a trickle, our airport and our national airline suffer huge downturns. We have really taken for granted in the past that we are truly a global city. The rest of the world has not fared well; we have seen the experience of nations that have done well in the first wave, now felled by the ferocity of the pandemic. We are dismayed by what has happened in Hong Kong and Australia.

Hong Kong is now in the midst of a lockdown and Melbourne is in a state of nightly curfew. Even China, with its herculean efforts in containing the Wuhan/Hubei situation, is now experiencing fresh outbreaks in Beijing, Dalian and Xinjiang. The lessons learnt from these nations is that the virus is unforgiving and penetrates through loopholes created by exemptions from testing, breakdown in quarantine procedures and unexpected contamination of packaging of frozen foods.

As for other nations, we gape in amazement at the politicisation of wearing masks in the US, along with sidelining of experts like Dr Anthony Fauci, a giant figure in the field of medicine. In my weekly Zoom meetings with my Indian colleagues, I hear their struggles about fighting the pandemic without essential resources of Covid-19 swabs or antibody test kits. You can imagine trying to diagnose a Covid-19 patient clinically and telling it apart from other viral or bacteria infections.

In Brazil, the leadership continues to pillory the use of masks, social distancing and promoting the use of hydroxychloroquine without merit; all in a defiant show of maschismo. As the sideshow continues in a desperate spiral of death and misery, this pandemic has really sharply outlined the differences between the first world nations and the rest. The cost of a Covid PCR swab test is estimated to be a hundred US dollars. That has already put a lot of countries out of the league of massive testing.

The next is the much-vaunted vaccine. At the last count we have more than a hundred vaccines in the race with four entering the Phase 3 clinical trials. There are many ways to make a vaccine and the tried and tested method is to use a dead virus or a weakened but live virus. Other ways involved the use of an innocuous virus like a common cold virus to carry the viral genes into the body of the host as in the Oxford vaccine.

The new methods include using messenger RNA or DNA fragments. The messenger RNA is interesting as seen in the Modena vaccine. The DNA is our genetic code and stays in the cell nucleus as it is important to the survival of our species. The DNA sequences when deciphered are able to transcribe proteins. After the DNA helix structure unravels itself to allow messenger RNA to dock alongside to copy the sequences, the messenger RNA then leaves the nucleus to arrive at the protein making sites in the cell cytoplasm.

The vaccine approach is to embed messenger RNA with viral sequences. However, the thought of messenger RNA being able to travel into every cell nucleus in the body gives me some discomfort. In a rush to market, there is talk of reduced liability of vaccine manufacturers for side effects and complications. The regulatory bar may have to be raised higher for novel vaccine approaches as opposed to traditional methods. As for the economics of the vaccine, the US and EU have already put down their interest in the Big Pharma vaccine race. The Chinese, on the other hand, is taking the approach of the vaccine as a global common good.

We all wait in anticipation of the latest trials in the hope that a vaccine will put an end to all this misery. The last vaccine that was only 50 per cent effective did indeed wipe out polio. Interestingly, Singapore was one of the first countries in the world to launch the polio vaccine for all of her children in 1959. We were also one of the first countries in the world to launch Hepatitis B vaccination in 1987. It is with cautious optimism that I hope we will once again take the lead in such an endeavour.

10 ways to lower your blood pressure without medication

Making changes to your lifestyle will help give you a healthy head start in life

Can you lower your blood pressure without taking medication? The answer is yes. If you have abnormally elevated blood pressure (BP) or hypertension, you may want to consider non-pharmacological measures initially rather than commencing on drug therapy immediately. Here are 10 ways to lower your BP without taking medication.

  1. Exercise

It has been shown that after a single session of moderate intensity aerobic exercise of a duration of 10 minutes or more, the BP can be reduced by 5 to 7 mmHg in people with high blood pressure. The good news is that this BP reduction can be sustained for up to 24 hours after the exercise session. This BP reduction is termed as post-exercise hypotension or PEH. The exercise should preferably be 30 minutes a day or a total of 150 minutes or more of exercise per week. Evidence shows that PEH benefits occur more with aerobic exercises such as walking, jogging, cycling or swimming as compared to dynamic resistance training using weights or resistance machines. In terms of exercise intensity, it should be at least be the equivalent of brisk walking which would increase your heart rate and breathing but does not make you feel out of breath.

  1. Cut salt intake

There is strong evidence that reduction of salt or sodium intake will result in a reduction of blood pressure. For those with high BP, they should not take more than 2,400 mg of salt per day which is equivalent to about 1 teaspoon of table salt. If the salt intake can be further reduced to 1,500 mg per day, there can be as much as 7 mmHg reduction in the systolic blood pressure and 3 mmHg in the diastolic blood pressure. The reduction in salt intake not only decreases the blood pressure but it is also associated with reduction in cardiovascular morbidity and mortality.

  1. Weight reduction

Studies in diverse populations have consistently shown a nearly linear relationship between body mass index and systolic and diastolic BP. Data from the long term US Framingham Heart Study estimated that about three-quarters of high BP in men and two-thirds of high BP in women can be ascribed to excess weight gain. The increased fat accumulation in the abdomen in obese individuals can result in an increase in the pressure within the abdomen to as high as 40 mm Hg. This not only results in compression on the kidney but also increases the pressure within the kidney and the kidney vessels. These changes have been associated with the development of high blood pressure and chronic kidney disease. It has been shown that keeping your BMI below 25 kg/m2 is effective in preventing the development of high blood pressure. It is estimated that a weight reduction of about 10 kg can potentially reduce the systolic blood pressure by 5 to 20 mmHg.

  1. Stop smoking

There is some controversy about the impact of smoking in blood pressure. Nevertheless, it is known that smoking causes various adverse cardiovascular problems and acts synergistically with high blood pressure to increase the risk of heart artery disease, heart attacks, sudden cardiac death, and stroke. Hence, for those with hypertension, smoking cessation is advocated.

  1. Treat obstructive sleep apnoea

In recent years it has been shown that obstruction of the upper airway during sleep, a condition termed as obstructive sleep apnoea or OSA, may actually contribute to elevation in BP, poor control of hypertension and even hypertension that is resistant to drug therapy. OSA leads to poor sleep quality and a sleep duration of less than or equal to five hours per night has been shown to significantly increase risk for hypertension in patients 60 years of age or younger. Treatment of OSA may improve the blood pressure control.

  1. Eat potassium-rich foods

It has been shown that potassium can decrease both the systolic and diastolic BP possibly by causing the body to remove more salt in the urine and by relaxing the walls of the blood vessels. However excessive potassium supplements can be harmful and is generally not encouraged by doctors. Hence, instead of taking potassium supplements, the American Heart Association advises that eating potassium rich foods may help to manage the blood pressure. These foods may include dried apricots, spinach, tomatoes, avocados, mushrooms, prunes or a fat-free yoghurt or milk.

  1. Eat magnesium-rich foods

Review of trials on magnesium supplementation concluded that consumption of 300 mg of magnesium a day can cause a modest reduction of diastolic BP but has no significant impact on the systolic BP. However, excessive consumption of magnesium from supplements may cause diarrhoea. There are currently no known adverse effects of magnesium intake from food. It is best to get magnesium from foods that include dark leafy green vegetables, nuts, unrefined grains and legumes.

  1. Consume cocoa

An analysis of more than 30 studies on cocoa have shown that consumption of cocoa was associated with about 2 mm Hg lowering of both systolic and diastolic BP. Hence the consumption of dark chocolate or cocoa products can be beneficial and this benefit is mediated through chemical compounds in the cocoa products called flavanols and it is believed that the blood pressure lowering of these chemicals are related to their ability to widen the blood vessels through a chemical called nitrate oxide.

  1. Take folate supplement

Studies have shown that the intake of folate, which is a type of Vitamin B, among patients with high blood pressure or hypertension may reduce the risk of stroke and aid in stroke prevention in patients with hypertension. Hence, for those with high blood pressure, consumption of folic acid may help to reduce the risk of stroke.

  1. Reduce stress

While researchers are not certain about the relationship between stress and the development of hypertension, they are clear that stress can cause significant transient elevation of blood pressure. It is possible that long-term stress can result in frequent, temporary spikes in blood pressure that can damage the blood vessels, heart and kidneys. Stress management includes getting sufficient sleep, adopting relaxation techniques such as meditation or yoga, widening your social circle by participating in support groups or classes, improving on time management, resolving stressful situations amicably, caring for yourself by doing the things you enjoy and asking for help when you need it.

These 10 ways to lower your blood pressure can make a difference to your life. Research has shown that a reduction in systolic blood pressure of 5 mmHg can reduce death from stroke by about 14 per cent, death from heart disease by 9 per cent and death from all causes by 7 per cent. Recent data show that lowering blood pressure to ideal targets reduced the risk of heart attack, stroke, heart failure, and cardiovascular death by 25 per cent. So, if your blood pressure is high, these lifestyle measures can help you to lower your blood pressure and give you a healthy head start in life.

The ABCs of high blood pressure

In most cases, diagnosis of high BP and hypertension should be made only after a period of evaluation

I recently saw a gentleman, Mr A, who had a history of frequent dizzy spells which were so severe that it made him unsteady when he was performing his activities of daily living. Mr A has been on high blood pressure (BP) medication for more than 20 years. After evaluation, his BP medicine was stopped, his dizziness resolved and his blood pressure remained normal.

Criteria for diagnosis

How should one determine that a person truly has high BP? According to the latest guidelines, an upper or systolic blood pressure (SBP) of 140 mmHg, and/ or a lower or diastolic blood pressure (DBP) of 90 mmHg on repeated examination in the clinic would meet the criteria of a diagnosis of high blood pressure or hypertension. In some patients with isolated systolic hypertension, only the SBP is elevated (140 mmHg) and the DBP is 90 mmHg.

This is more commonly seen in the elderly where there is decreased elasticity of the major arterial vessels due to age-related changes. The BP value that is used by doctors to determine whether someone has hypertension is based on the measurement of the BP while the patient is in the clinic. It is recommended that there should be two to three clinic visits between one and four weeks’ interval before a person is determined to have high BP and the diagnosis of hypertension should not be made solely on the basis of one single visit to the clinic.

However, the exception to this is when the BP on a single visit is 180/110 mmHg and there is also evidence from other evaluation that there is underlying heart disease, then the diagnosis of hypertension can also be made on a single visit. Should you be considered to have high BP, it is recommended that this should also be confirmed by repeated BP measurements at home.

The correct way of measuring blood pressure

The BP recording used by doctors is measured in a manner which is consistently observed so that it will be comparable. The optimal way to measure BP is to have a person seated with his back supported, his feet firmly on the floor, using a validated BP measurement machine or device on a table with his arm resting, and with the device at the mid arm at about the level of the heart. In addition, the cuff size must not be too big or too small and must be able to fit comfortably over the arm.

The room should be quiet and there should be no talking during and between the measurements. The person should be relaxed for three to five minutes and should have the bladder emptied before measuring the BP. In addition, there should be no smoking or consumption of coffee or caffeinated foods or exercise for 30 minutes prior to the measurement of BP. Once all these conditions are met, the BP levels can be taken and there should be an average of three measurements taken at one-minute intervals. It is advised that the average of the last two measurements be used as the BP recorded.

In the initial evaluation, it will be ideal to measure the BP in both arms. If there is a consistent difference between the two arms of more than 10 mmHg in repeated measurements, use the arm with the higher BP as the arm for routine BP measurement. If the difference is more than 20 mmHg, further investigation should be considered to look for an underlying cause. Generally, out-of-clinic BP measurements by patients at home or 24-hour ambulatory BP recordings prescribed by the doctors are more reproducible than the routine clinic measurements and are more closely associated with organ damage and related to high BP.

Hence, if your BP is elevated upon the visit to the clinic, it does not mean that you definitely have hypertension. Before a diagnosis of hypertension is made, it is advised that repeated BP measurements should be performed, done in a manner as described above and the BP validated with home measurements.

Types of hypertension

In addition to sustained hypertension which is the elevation of BP throughout the day, there are also individuals who have elevated BP values in the clinic but have normal BP values when they are measured out of the office or at home. This is termed white coat hypertension. These patients routinely present with high BP values at the clinic and if they are prescribed BP lowering medication, they may feel light-headed or dizzy at home as the blood pressure values can drop very low with the medication.

If their risk factor profile is low and there is no evidence of organ damage related to hypertension, medication is not necessary. However, they should be advised to manage this white coat hypertension with lifestyle modification. There is another category of patients with normal BP values in the clinic but the BP values are elevated at home. This condition is called masked hypertension. Unlike white coat hypertension, those with masked hypertension are at similar risk of complications as those with sustained hypertension and hence, they may need drug treatment to normalise the home BP readings.

Echocardiogram

One of the most useful tests to determine whether there is evidence of organ damage by hypertension is the echocardiogram, an ultrasound assessment of the heart. In patients with hypertension, the presence of high pressure in the heart chambers can result in a dilatation of the left upper heart chamber as the thinned walled chamber gradually distends as the BP increases. In addition, the muscular left lower chamber has to work harder to pump the blood out of the heart chamber to the aorta.

As a result of constant stress on the muscular left lower chamber, the muscles will become thickened. This is analogous to the increase in your arm muscle if you have to carry heavier and heavier weights. If the BP is very high in the clinic and the echocardiogram is normal, it is very likely that this patient has white coat hypertension and medication is unnecessary in the majority of these patients. In Mr A’s case, his persistently elevated clinic BP as a result of white coat hypertension prompted his doctor to keep increasing his BP-lowering medication till he was on multiple drugs. At home, the BP-lowering drugs resulted in a low BP causing him to have severe dizzy spells whenever he tried to change his posture.

Despite being diagnosed to have hypertension and having been put on BP lowering drugs for more than 20 years, his echocardiogram did not support the diagnosis of long-standing hypertension. Hence, the decision to stop all his BP medication “cured” him of his symptoms and yet allowed his BP to remain normal.

The take-home message here is that if you are suspected to have high BP, measure your home BP according to the optimal protocols described above before you resign yourself to a fate of taking medication for the rest of your life.

Our Eyes, Our First Defence

As Singapore emerges from the “circuit breaker”, a measured approach and long-term plan for eye care to better prepare for possible future outbreaks should be considered

SGSecure, a national campaign launched in Singapore four years ago for crisis preparedness has been a success in informing residents of the need to be vigilant against terrorist attacks and other civic emergencies. It has a catchy tagline of “Our eyes are our first defence”, with eyeball mascots keeping an eye out for signs of trouble. I cannot agree more, since our sense of sight comprises 80 per cent of our senses.

2020, the year for good vision, has quickly degenerated into the worst public health and financial crisis in a generation, no thanks to Covid-19. As the world hunkers down to avoid what seems to be a threat worse than terrorism, local essential services like healthcare, transport, food supply and infrastructure have soldiered on these two months, including my specialist eye clinic, albeit on a much smaller scale.

Eye diseases are rarely life-threatening, even though they can blind one and affect one’s independence and livelihood. Yet the trickle of patients with eye problems, significant enough to leave home to see a doctor for, has told a sobering story of how prevention is truly many times better than cure. Apart from symptoms like seeing floaters and flashes which may be due to unavoidable retina tears that can cause detachment, most other acute eye diseases are arguably avoidable, either by early detection and preventive treatment, or careful management of general health problems that may give rise to eye diseases as a complication.

Flattening the curve
Very few would have predicted that a viral pandemic could bring human activities to such an abrupt halt. Deriving Singapore’s coping strategies from our Sars-hardened political leaders, public health and infectious diseases experts, themselves on a steep learning curve, we do our best to flatten the Covid-19 curve by staying home as much as possible.

Meanwhile, life goes on, and the usual urgent and emergent health problems happen as they normally would, with some exceptions such as reduction in influenza and air pollution-related allergies. On the other hand, as a result of the stay-home campaigns, health-seeking behaviours, other than pandemic-related, are altered and delayed by the healthcare bottlenecks worldwide. As such, there are emerging signs of increased disease severity at presentation in affected specialties, with possibly higher morbidity and mortality.

Even though I fully agree with and have operated by the Ministry of Health’s guidelines on appointments and social distancing during the past crucial weeks, my heart aches when I see otherwise able-bodied patients lose their vision. Chronic diseases like cataracts can sometimes progress faster than what conservative treatment plans for. This has resulted in some patients going from doctor to doctor, seeking surgical relief for functional restoration.

Furthermore, delays in seeking medical attention can cause one’s vision to be permanently damaged from common eye diseases like glaucoma, macular degeneration and diabetic retinopathy, all of which are usually symptomless in the early to moderate stages, where commencement of treatment to preserve sight is effective and strongly advised. In the worst scenarios, patients are unaware until they reach advanced stages of these eye diseases. By then, extensive treatment is indicated, unfortunately often unsuccessful in fully restoring vision. The consequent vision loss can render one unable to adequately manage activities of daily living and to work. It is my sincere wish that the eye care profession can satisfactorily manage the backlog of cases in the coming weeks.

As Singapore emerges from the “circuit breaker” and gradually resumes life as we knew it, my personal opinion is that a measured approach and long-term plan for eye care to better prepare for possible future outbreaks be considered. Ongoing management of acute cases aside, and while safe distancing and all applicable infection control measures are followed for protection of patients and doctors, emphasis should be on eye treatment to restore function as soon as possible for affected patients, so that breadwinners and families can get on with their lives.

Further to that, monitoring of previously diagnosed chronic eye diseases, particularly unstable cases, and eye screening for patients with risk factors should not be long-delayed, so that treatment outcome can be optimised. Efficient use of downtime As food for thought, in Hong Kong and South Korea where pandemic measures are reportedly balanced and infection control generally good, ophthalmologists, particularly those in non-hospital or privately-run settings, had continued to provide “compartmentalised” services for eye care including cataract and refractive laser surgeries.

Such practices, to my knowledge, had reportedly not contributed to a spread of Covid-19, is openly accepted locally and deemed an efficient use of enforced downtime, particularly by patients seeking laser refractive correction, who are typically young adults and more resilient to the pandemic. In other countries, Covid-19 swab tests are carried out as a screening prior to surgeries. In Hong Kong, eye specialists in different sectors seem to close ranks, with counterparts in the private sector proactively contributing to the care of public sector patients.

While practices differ from place to place, I opine that a universal principle should be to improve clinic infection control and time-efficiency so that eye service quality is not compromised. While we wait for sustained stabilization of the pandemic, clinical research, particularly commercial and unrelated to the pandemic, should continue to be scaled back. Certainly, in my practice, tests and procedures that are potentially aerosol-generating such as the airpuff eye pressure test, and that are invasive or prolonged, are currently avoided in favour of those that can achieve similar aims without the downsides.

Similar to how the pandemic forces us to hasten trends at the workplace, in retail and information technology, I believe in time to come, it will shape and perpetuate practice trends in healthcare and ophthalmology too. These trends may be the adoption of telemedicine, increasing use of non-invasive and contact-less diagnostic devices and embracing newer surgical approaches to reduce risks and improve long-term post-operative results, like using laser cataract and refractive laser lenticule techniques.

One thing is for sure, Zoom and webinars have resulted in unprecedentedly large participation in both public education and professional meetings I attended in the past two months, a trend that hopefully will stay for good. As for our first defence against the pandemic in the coming weeks, in addition to face masks, may I please suggest the anti-terrorist mentality of including eye protection, particularly in crowded places, since catching the virus through our eyes is not impossible – be it a wraparound eye shield, face shield or large-framed, close-fitting spectacles, all to be washed regularly. After all, Covid-19 is the most lethal terrorist to date!

How to live to 100

FROM 1960 till 2020, there has been a 28-fold increase in the number of centenarians. The path to longevity is strewn with false promises of expensive elixirs, exotic supplements, and stem cell rejuvenation. Human longevity is a complex interplay between the genes, the environment and lifestyle.

Genes and longevity
The study of human longevity genes is a developing science. Scientists estimate that between 15 and 30 per cent of the variation in human life span is determined by genes, but it is not clearly understood which genes are relevant, and how they contribute to longevity. In 2015, Ancestry, a genealogy and genetics company, partnered Calico, a Google spinoff, to study data from more than 54 million families and their family trees representing six billion ancestors, and were able to tease out a set of pedigrees that included over 400 million people. These individuals were connected to one another by either a parent-child or a spouse-spouse relationship.

In 2018, they published their results in Genetics, a journal of the Genetics Society of America. The study found that the lifespan of spouses were more similar and better correlated than in siblings of opposite gender. The study concluded that life span heritability is likely 7 per cent or less, and hence the contribution of genes to longevity is even lower.

Although genes seem to have only a small influence on lifespan, they appear to play a larger role in centenarians. Hence, there are a few genetic
factors that do give you a headstart in the journey to longevity. Being a first-degree relative of a centenarian makes it more likely for you to remain healthy longer and to live to an older age than your peers. First-degree relatives are less likely at age 70 years to have the age-related diseases that are common among older adults.

Women generally live longer than men, and the number of female centenarians is more than fourfold higher than that of male centenarians. It is
thought that this is due to a combination of social and biological factors. Studies on mammals and Korean eunuchs have shown that the removal of
testosterone at a young age was correlated with an increase in lifespan. Genetic studies show that centenarians have a lower genetic risk of having
heart disease, stroke, high blood pressure, high cholesterol, Alzheimer’s disease and decreased bone mineral density.

A study on Chinese centenarians published in 2013 showed that 55 per cent have normal systolic blood pressure, 82 per cent had normal diastolic blood pressure and less than 20 per cent were on long term medication. Hence, centenarians appear to have genes that reduce that risk of age-related chronic illnesses.

Biological clock
Epigenetics is the study of changes in organisms caused by modification of gene expression rather than alteration of the genetic code itself. One of the major mechanisms in which epigenetics manifest itself is by the process of DNA methylation, which involves the chemical modification of the DNA, thereby modifying the gene function and expression. Through this process, certain genes can be silenced or activated and potentially impact age-related diseases such as cancer, osteoarthritis, and neurodegeneration.

The biological or epigenetic lock in centenarians show a decrease in DNA methylation age, indicating that they are biologically younger than their chronological age. There is also data to suggest that although circadian rhythms deteriorate during ageing, they seem to be well preserved in centenarians, including preserved sleep quality.

Environment and longevity
Environmental factors have a large impact on longevity. Better living environment, clean food, clean water, good sanitation, reduction of infectious diseases, and access to better healthcare have resulted in significant improvement in human longevity. Using Italy as an example of the impact of a better living environment, the average life expectancy went up from 29 years in 1861 to 84 years in 2020.

The number of centenarians in Italy increased from 165 in 1951 to more than 15,000 in 2011, and the incidence of deaths occurring in those less than 60 years of age, decreased from 74 per cent in 1872 to less than 10 per cent in 2011. The continuous increase in lifespan in recent decades is mainly due to the advances in medical science. It is estimated that medical advances have allowed an increase in lifespan of five years in the last two decades and additional two years in the last decade.

When comparing two countries at different stages of development in 1950, the average life expectancy increase of 11 years from 68 years in 1950 to 79 years in 2020 in the USA, which was more developed in 1950, was much less remarkable than the increase of 3114 years in average life expectancy from 43 years in 1950 to 77  years in 2020 in China, which was less developed in 1950. The significant improvement in the living environment in China has contributed to the narrowing in the average life expectancy between those living in the US and China.

Lifestyle and longevity
In addition to environmental factors, lifestyle factors have an important impact on longevity. A study of more than 300,000 individuals over 7.5 years showed that individuals with social relationships have more than 50 per cent greater probability of survival compared with those with few and poor social interactions. A study on centenarians in Utah in the US between 2008 and 2015 suggested that sleep, life satisfaction and social attachment were significant predictors of days lived. There is an extricable linkage between lifestyle and socioeconomic status. The term  socioeconomic status as used in longevity studies encompass all the factors that can impact longevity including wealth, geography, education, occupation, ethnicity, cultural environment, neighbourhood environment, quality of healthcare and quality of diet. It is well established that the socioeconomic status of an individual will have a major impact on health and longevity.

A study on more than 120, 000 individuals by researchers from Harvard, published in the Circulation journal in April 2018, identified five low-risk lifestyle factors for increased life expectancy. They were: no smoking, non-obese ( body mass index of 18.5 to 24.9 kg/m2), exercise (at least 30 minutes per day of moderate to vigorous physical activity, including brisk walking), low-risk alcohol consumption (5 to 15 gm/day for women and 5 to 30 gm/day for men), and a high score for healthy diet.

In this study, the projected life expectancy at age 50 years was on average 14.0 years longer among female Americans with five low-risk factors
compared with those with zero low risk factors; for men, the difference was 12.2 years. These findings are consistent with a study on Chinese centenarians in which less than 20 per cent were smokers and less than 40 per cent drank alcohol. Hence, in general, most centenarians do not smoke, do not drink alcohol or are low-risk alcohol drinkers, are sociable, friendly, cope well with stress, are satisfied with life, have healthy diets and sleep well. In summary, the main drivers of longevity in the first eight decades of life are the socioeconomic environment and lifestyle choices.

Beyond the eighties, the inheritance of genes that defer age-related chronic diseases and a younger biological clock will help to propel these individuals beyond a hundred years.

Living through a once-in-a-lifetime event

It has been 14 weeks or so since the first case of Covid-19 virus landed on our shores. A lot has happened since, with a wave of returning citizens bringing home the virus from epicentres in the United Kingdom, Europe and the United States. These 579 imported cases unfortunately spawned community spread and the outbreak in our migrant worker dormitories.

The community spread led to unlinked cases that started from nine daily to as high as 31 daily before we had to impose “circuit breaker” measures. With the initial and further stricter measures, we have now brought the unlinked cases down to an average of 11 daily in the last week.

To date, Singapore has reported 21,707 Covid-19 cases in total, with more than 19,000 of those being migrant workers in the big dormitories and smaller factory converted dormitories. There are 200,000 workers in the big dormitories that can house up to 20,000 workers each, and 100,000 workers in the smaller factory dormitories that house as few as 20 workers.

The dormitory outbreak has challenged our nation in many ways. The logistics challenges are huge; agencies have had to deploy medical posts in the 43 big dormitories, impose restrictions on movements within these dormitories, swab huge numbers of sick migrant workers, move and house them in communal facilities to monitor them through their illness, and as they are recovering, move them to recovery facilities. The numbers in communal facilities total 10,000, a tally that is steadily rising and could soon double.

The agencies involved in such herculean efforts comprise both private organisations and public agencies. This private-public cooperation is heartwarming to see, as Singapore Inc mobilises under threat from this invisible enemy.  There has been criticism of the living conditions of the dormitories but I cannot think of any other nation that has mobilised in such a manner to look after their migrant-worker population.

The other challenge is the healthcare system and the effort to protect it from being overwhelmed. All the herculean effort on the dormitory scene is really to flatten the curve of the epidemic to prevent a massive surge of cases that may overwhelm the ICUs, high dependency units and oxygen points.

Though we have reduced the number of unlinked cases in the community, we are concerned that an outbreak in nursing homes will mimic that in the dormitories. The migrant workers are young and fit due to the nature of their job. The data shows that of those who are 30 years old and below, less than one per cent will need oxygen of any sort.

Hence the huge numbers of migrant workers who have caught the virus have not translated into huge demand on our ICU beds. But a sizeable outbreak in nursing homes will be of a different nature. On the testing front, the number of swabs has increased from 3,000 daily to 8,000 daily currently, and the number of swabs will be further increased five-fold. This is a huge ramp-up, with laboratory workers working non-stop at breakneck speed since January, and the shortage of reagents and disposables as there are limited suppliers globally.

The swab processing is a laborious process; it involves extracting and amplifying minute amounts of viral RNA and takes six to eight hours to execute. The antibody test that can be rapidly deployed and which is as simple as a pregnancy kit has been disappointing. The antibody test detects the viral antibody effectively only after 11 to 14 days of symptoms.

Good ICU care

On the ICU beds front, we have the capacity to double or triple the number needed. Our ICU care is good and we have a low mortality rate so far, although the 20 patients that have perished is one too many. Hence for a drug treatment to be effective, the drug has to perform much better than our ICU care or stop patients from entering ICU. There is a lot of hype around remdesivir.

Trials failed to show that it reduced mortality, but it did reduce the recovery period from 15 to 11 days. To find a drug off the shelf and then to repurpose it for a novel virus is a difficult ask. It is likely that we need to develop a new drug from scratch. As for the vaccine, there are three phases: the first involves 10 to 30 patients and you are looking for immune response and safety; the second phase is with larger numbers of 100 to 300 patients and you are still looking for safety and immune response. The third phase is real-world deployment with placebo-controlled randomised trials.

Realistically, this will take 12 to 18 months, and anything can go wrong during the three phases; then it is back to the drawing board. The race is on between the US and China for a vaccine, making this a geo-political race for prestige and prowess. This pandemic is a combination of health, economic and psychological crises all rolled into one. I would leave the economic aftermath to the economists and have a word about the psychological state of our globe. I like what author and public speaker David Kessler has said about this crisis – that it is a grief reaction.

Mr Kessler and his late collaborator Kubler Ross gave us the definitive stages of grief reaction.

The grief we feel is that of loss of normalcy, fear of economic loss and loss of connection to our social circles. The nature of the fear we feel is somewhat in the future; we dread the fear in anticipation. It is sort of like when a loved one is diagnosed with cancer – we dread the future of the disease and what it brings for us.

The stages of grief starts with denial, where we are sure the virus will never reach our shores and will go away. The next phase of anger results in us blaming that person for coming too close to us, or blaming another nation for the pandemic.  Bargaining makes us think if we take pills or supplements, it will not infect us. Sadness permeates us as we wonder when it will all end. The penultimate stage is acceptance where we decide we have to take control of the situation; we have to execute a series of actions of washing our hands, masking universally and working from home.

When we have a plan and execute it, we regain control and fulfil acceptance. There is an ultimate phase of grief reaction and that is to find meaning. We have encountered a once-in-a-lifetime event that has disrupted our lives, halted the economy dead in its tracks and left us hiding in our homes in a curfew-like situation. The virus has infected millions globally, killing a quarter of a million, decimated mighty economies and left the world in fear, grief and resignation.

Positive aspects

Yet there are silver linings. The skies are blue, the local PSI has halved, the dust on surfaces has reduced and wildlife and migratory birds have re-emerged. Our family life has become central, there is daily bonding over family meals, young children are amazed that parents are home daily, and exercising with children is a norm. Working from home has made workplace hierarchies less relevant, savings have accrued from reduction in transportation, meals and clothing; staff may actually need less renumeration with reduced costs, office space may shrink as most work can be done from home with today’s technology enablers. The need for helpers and the disincentive of the helper’s levy should be revisited.

That work is also a social need is important; offices may well become meeting places rather than workplaces. With the gradual reopening of the economy and the new normality we have to accept that there will be pain and loss of jobs, assets and destruction of value. This is a time to rally the nation round to face the hardships and the uncertainties the future holds. We have to form alliances, and we have to seek other nations to rebuild our economies together. Our leadership has to pull this off and navigate us through these uncharted waters.

The old adage is true – in the midst of crisis, there is opportunity to re-examine, realign and re-energise our values, our priorities and our prowess.

The race is on to seize the day.