Author: mwh-med56doc

Not all wheezing is asthma-related

Asthma is a common medical condition affecting the lower respiratory tract. It affects all age groups, genders and is seen globally. It has several causes – namely genetic and environmental factors. However, in the absence of an obvious precipitant, it is often idiopathic (when the cause is unknown). Asthma is characterised by breathing difficulty, often at night and associated with wheezing, shortness of breath (hence its name from the Greek “to pant”), chest tightness and coughing. There are however other medical conditions which present in a similar vein which are characterised by noisy breathing when the patient is awake, strained/rapid breathing (and in severe cases) leading to cessation of breathing and death. Some of these conditions manifest very early in life and others in adulthood.

The aim of this article is to provide the reader with a few causes of breathing problems affecting children and adults that may occasionally be treated as asthma but affect the upper airway as opposed to the lungs.

Anatomy

The airway can be divided into two broad parts – the upper and lower. The upper part provides a common passage for food, fluid and air to pass through the oral cavity (such as from the nose for air) and into the back of the mouth and thereafter into the throat (pharynx). It is at this crossroads that our physiological control mechanisms separate what enters the lungs and what enters the gullet (oesophagus). The upper airway descends into our voice box (larynx) through the windpipe (trachea) and into the lungs which are found within the chest (thorax).

The narrowest portion of the child’s upper airway is just below the vocal folds (level of the cricoid cartilage) and above the start of the trachea while the adult upper airway is narrowest at the level of the vocal folds. The vocal folds are found within the voice box which is a cartilaginous structure comprising a shield-like structure and a complete cartilaginous ring. The level at which the vocal folds are is described as the glottis and following on, the area above the supragottis and below – the subglottis before descending into the trachea (Figures 1 and 2).

Noisy breathing

Not all noisy breathing is wheeze. Narrowing of the lower air passages with a characteristic high-pitched noise due to the vibration of the walls of the partially obstructed “air tubes” is effectively wheeze. A frequently confused sound which arises from laryngeal obstruction is called stridor. This sound is also high-pitched, often higher pitched than a wheeze and can vary depending on the location of the obstruction in the larynx and trachea i.e. being present when breathing in (inspiration), out (expiration) or both.

Another noise which is low-pitched and related to obstruction of air above the voice box, at the level of the back of the tongue or tonsils, is called stertor. These noises are present when the patient is awake, unlike snoring which is low-pitched noisy breathing when asleep.

Childhood conditions

Paediatric causes of breathing difficulties can be congenital and present very early in life. Severe cases of upper airway obstruction can be due to the incomplete canalisation of the tubular structures that eventually become the larynx and trachea. These conditions are rare and the milder forms may not present that early in life and become more evident as the child becomes more active or starts to make noises or speaks. Other conditions affecting the child but not present at birth are acquired and can be due to a variety of causes including infections, tumours, foreign body inhalation and neurological conditions.

Laryngeal webs

Mild laryngeal webs in children may cause noisy breathing which can be confused for a wheeze. As the child grows, parents may notice that their child has a hoarse voice and on exertion starts to “wheeze”. Mild laryngeal webs can be asymptomatic and go unnoticed for years, while more severe ones will manifest earlier. Surgery in symptomatic cases is the treatment of choice and is generally successful.

Laryngeal papillomatosis

Recurrent respiratory papillomatosis (RRP) is a viral infection of the upper airway – most commonly involving the voice box but occasionally the trachea and rarely (but potentially fatally) – the bronchioles (lung air passages). It is caused by the human papilloma virus (HPV) which causes skin warts and other tumours such as the cancers of the female cervix and palatine tonsil. The condition affects both adults and children although the disease profile is somewhat different with remission generally a feature in the childhood form. Despite this, many children with this condition can be misdiagnosed for having noisy breathing commonly ascribed to wheezing and if associated with a hacking cough – to croup (laryngotracheobronchitis).

Recalcitrant “wheeze” with hoarseness in children should therefore be a consideration for specialist ENT referral to assess the airway. Treatment of RRP can be fraught with multiple operations to reduce the bulk of viral growths and restore the airway while making every effort not to cause damage to the vocal folds that are very delicate and scarring of the airway.

Adult conditions

Unlike childhood causes of laryngeal obstruction, most adult onset upper airway conditions are acquired. Throat cancer is often seen in smokers and when tumours of the larynx narrow the air passage, the ensuing “noise” can be mistaken for a lower airway pathology. Operations to the thyroid, carotid arteries and upper spine can affect the nerves (causing various degrees of paralysis) that control the movement of the vocal folds and may be subtle – only becoming evident if a co-existing problem such as a throat infection worsens the airway resulting in noisy breathing/stridor. Here are some other interesting causes that may be mistaken for asthma:

Exercise-induced laryngeal obstruction

This condition is seen in young adults who are usually involved in high intensity sporting activities or exercise. The attacks of noisy breathing and breathlessness only come on when performing certain tasks but otherwise the subject is well when not under such duress. The confusion with asthma is common and diagnosis in subjects who already have asthma – difficult. Special investigations including a real-time examination of the patient’s larynx (continuous laryngoscopy examination, CLE) with a flexible nasendoscope while performing the said exercise is indicative but, in many instances, impractical.

Idiopathic subglottic stenosis

This condition is characterised by a deposition of scar tissue in the region of the subglottis below the true vocal folds and above the start of the trachea. It is almost exclusively seen in Caucasian women and is, as the name implies, of unknown cause. Treatment options include minimally invasive “closed” techniques which are performed through the nose using flexible endoscopes.

Conclusion

Upper airway narrowing in the context of the voice box and windpipe can be confused with asthma and leads to delays in the diagnosis and subsequent management of the root cause. It is worthwhile reconsidering whether patients who have been erroneously diagnosed with asthma really suffer from this condition. Recalcitrant cases or cases where two or more co-existing pathologies are present should be referred on to ENT surgeons for the necessary investigations and management promptly.

Dr Vyas Prasad
Senior Consultant Otolaryngologist Head and Neck Surgeon
MB BCh BAO BA (Dublin), MSc DIC (London), DLO (England), MRCS (Edin), FRCS (ORL-HNS)(Edin), FICS

THE BUSINESS TIMES WEEKEND, OCTOBER 19-20, 2019

Safeguarding your eyes from the ‘thief of sight’

Glaucoma is a silent disease, and opportunistic screening and regular monitoring are recommended to detect it early

The recent haze ended as quickly as it began and the skies in Singapore are blue again. In medical parlance, such episodic problems are usually termed an “attack”, such as a heart attack, a gout attack or more relevant to my profession, a glaucoma attack. After each annual episode of “haze attack”, our region seems to bounce back, finger-pointing subsides and life returns to normalcy, until the attack repeats again the following year.

However, unlike the haze, human organs once “attacked” usually decline in function, causing ill-health that may become irreversible to the point of demise. A glaucoma attack is an acute disease that the eye may suffer from, which can be associated with irreparable damage. For the uninitiated, glaucoma is a group of eye diseases typically characterised by elevated eye pressure, loss of field of vision and a classic glaucomatous appearance of the eye nerve ending, visible only through an examination of the back of eye.

Field of vision is a concept that warrants explanation to many people. Each eye has its own field of view – the area that it can see – and in combination they provide comprehensive navigation of our environment. A minimum visual field criterion denoted as at least 120 degree of angle horizontally with either single or both eyes is legally required for driving.

Mixed bag of subtypes

As a disease, glaucoma comprises a mixed bag of subtypes, arising from various causes. These may be as innocent as being born with the genes for glaucoma whose effect manifests as one age, or simply being anatomically predisposed. It may arise as an association of general diseases such as diabetes or as a side effect of prolonged use of steroid medications. It may even be a result of other local eye diseases such as ischaemia (a lack of oxygen), inflammation or injury.

What ties these various subtypes together is the ultimate destiny of the eye nerve: that there is thinning and loss of the nerve cells as a result of the eye pressure, which in some cases may be deceptively normal on measurement but high for the individual eye nerve  (to each eye nerve its own eye pressure, so to speak). Unchecked, glaucoma can surreptitiously lead to irreversible blindness.

By year 2020, as the third leading eye disease, it will affect an estimated 80 million people worldwide. Of these, 3.2 million is estimated to be blind from glaucoma. Being the top irreversibly blinding eye disease, public education of glaucoma is one of the leading ophthalmic priorities. Nevertheless, compulsory glaucoma screening has not been deemed cost-effective in public health policies worldwide. Opportunistic screening is hence the usual approach.

In general, glaucoma is divided into two broad categories based on the shape of the outflow apparatus of the eye (yes, there is a plumbing system in the amazing design of the human eye). These two categories are the open angle type versus the closed angle type. Although the open angle variety is commoner worldwide, closed angle glaucoma has a higher incidence in East Asians and Caucasians compared to Africans, due to racial differences and anatomical features.

Both types are silent diseases, with few warning signs of the loss of field of vision, hence nicknamed “the thief of sight”. However, the closed angle variety of glaucoma is notorious for being associated with episodes of not-so-silent attacks during which the eye pressure becomes acutely elevated due to vicious cycles of outflow blockage within the eye. During an attack, one would experience a red, painful and blurry eye, often with severe accompanying headache, nausea and vomiting, so much so that confused sufferers had on occasions been misdirected to the gastroenterology department for the prominent symptoms suspicious of a stomach flu.

Disclaiming any intended ageism and sexism, the classic scenario of an attack of angle closure  glaucoma is of a little old lady watching television at night: advanced age, being female and in the dark are indeed risk factors, although televisions are commonly swapped for mobile phones these days. While the management of an acute attack of glaucoma is considered a gift question in the eye specialty board examinations, real life cases are not as straightforward.

After a glaucoma attack is “broken” or stopped, much else needs doing, including prevention of recurrence, repairing sight and safeguarding the fate of the fellow eye. Ramifications affect the front and back of the eye as the high pressure affects them all. Closely associated with vascular diseases, glaucoma has a higher incidence in those who suffer poor circulation in the extremities (cold hands and feet). A big drop in night-time blood pressure, snoring or sleep apnoea are possible contributors too.

Certain yoga postures involving inverse poses were documented to be associated with elevated eye pressures (particularly the sirsasana pose), hence glaucoma-sufferers should consider modifications to these poses. In terms of treatment of glaucoma, there are roles for topical eyedrops, laser   treatments and surgical therapies, with recent advances in minimally-invasive glaucoma surgery, all of which target lowering of the eye pressure to halt progression of visual field loss.

Preventive care

However, the mantra remains “prevention is the best medicine”. Opportunistic screening and regular monitoring are highly recommended particularly when there is a positive family history or significant risk factors. Detection of strong signs of suspicions of glaucoma is followed by management strategies unique to each subtype of disease. Preventive treatment involving lasers and surgeries such as early cataract extraction is recommended for closed angle glaucoma.

The latter represents a shift in management strategies as a result of large-scale multinational studies conducted in the recent years, and is believed to be a more cost-effective treatment to lower the risk of an attack. As I resign myself to the high probability of a repeat haze “attack” next September, I find solace in the thought that in healthcare, active steps can be taken by the individual to prevent acute phases by monitoring and managing chronic conditions, in an evidence-based manner, before devastating problems arise.

The best defence may indeed be a good offence, in the form of an eyecheck, for a start!

Dr Daphne Han
Senior Consultant Ophthalmologist
MBBS (Melbourne), MMed, MRCS, FRCS (Edinburgh), FAMS

THE BUSINESS TIMES WEEKEND, OCTOBER 12-13, 2019

Should I Eat More Fish?

Beyond just eating fish, it is also important to understand what fish to take, how it should be cooked and the quantity that should be consumed. Among the fatty acids that are present in seafood, the long-chain n-3 polyunsaturated fatty acids (P3UFAs), namely, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are the PUFAs most closely associated with heart health. The content of these 3PUFAs vary with the type of seafood, the highest content being seen in coldwater fatty fish such as salmon, anchovies, herring, mackerel, tuna and sardines. One fatty fish serving of about 100 gm per week provides the recommended daily intake of 3PUFAs. Other types of seafood such as shrimp, lobster, scallops, tilapia, and cod have lower levels of 3PUFA.

Currently, supermarkets stock a wide variety of foods enriched with 3PUFAs including eggs, peanut butter, orange juice, margarine, bread, yogurt, and milk. However, seafood remains the only class of food which has been researched extensively. Presently, the 2015-2020 Dietary Guidelines for Americans and the Scientific Report of the 2015 US Dietary Guidelines Advisory Committee recommend at least two servings per week to provide a daily average of 250 mg of 3PUFAs per day in place of other animal sources of protein.

Effect of 3PUFAS in studies

Ingested seafood-derived 3PUFAs eventually become part of the cell membranes and have been shown to have favourable physiological effects on the electrical activity of the heart cell membrane which make the cell “less irritable” and more electrically stable. Hence, adequate consumption of seafood has also been associated with positive clinical findings such as lower heart rate, slower conduction of electrical impulses between the upper and lower heart chambers, lower likelihood of abnormal recovery of the electrical activity of the heart muscle cell and less heart rate variability.

The combined effects contribute to more stable heart muscle cell electrical activity and have been associated with a lower risk of developing life-threatening heart rhythms and sudden heart-related deaths. Studies have shown that 3PUFA intake is associated with improvement in the elasticity of arterial walls and lower arterial stiffness. Seafood-derived 3PUFAs have been shown to reduce serum triglycerides (TG) concentrations in those with high serum triglycerides, most likely by increased liver removal of TG and reduced liver production of TG rich protein particles VLDL (or very low-density lipoprotein).

Preventing sudden heart death

Many studies including the Physicians’ Health Study have shown that while diets high in seafood 3PUFA have not been associated with prevention of heart attacks, there is a strong inverse association with sudden cardiac death. A possible explanation of this is the association of 3PUFA intake with reduction in life-threatening heart rhythms which can occur after a heart attack. Higher seafood intakes have been associated with greater electrical stability of the heart muscle cell, decreased risk of fatal and non-fatal ventricular arrhythmias (abnormal heart rhythm originating from the lower heart chambers), lower heart rate, and improved heart rate variability, each of which is a risk factor for sudden heart death.

It does not mean that the higher the intake of seafood 3PUFA, the lower the risk of sudden cardiac death. While there is an incremental risk reduction benefit seen in those with increasing intake of seafood, this risk reduction plateaus. Hence, while consuming up to 2 fatty fish meals per week is associated with a 50 per cent lower risk of sudden heart death compared with little or no seafood intake, no further reduction was seen with higher intake. Beyond the quantity of seafood consumed, the method of cooking also affects the benefits. While seafood 3 PUFA intake was associated with reduction in sudden cardiac death, this benefit was not seen when the fish was fried. While the studies showing a reduction of sudden heart death with seafood 3PUFA intake were mainly studies conducted in the United States, other studies done in Japanese populations have failed to demonstrate this benefit. One explanation could be that the baseline dietary seafood intake is much higher and 95 per cent of adults eat seafood more than once weekly.

Coronary heart disease

Many large studies reported that increased seafood and dietary 3PUFAs intake was associated with a lower risk of heart artery disease in a healthy cohort. In studies in which all participants in the study reported on their seafood intake, participants who consumed seafood at least four times a week had a 22 per cent lower risk of heart artery disease, compared with those who consumed seafood less than once a month. In addition, the risk reduction could potentially be greater if the seafood intake replaced processed meat. This is illustrated in two large US cohorts, where substitution of 3 per cent of total protein calories in processed meat with 3 per cent of total protein calories from seafood was associated with 31 per cent lower risk of cardiovascular death.

Stroke

Results from the various prospective studies which examined the relationship between seafood 3PUFA intake and stroke have shown that intake of seafood was associated with a lower risk of thrombotic (due to occlusion of artery) stroke but has no association with haemorrhagic (due to bleeding)  stroke. One study which examined the way the fish was cooked, Cardiovascular Health Study, found that while intake of broiled and baked fish was associated with a 40 per cent lower risk of ischaemic stroke, intake of fried fish or fish sandwiches was associated with a higher risk of ischemic stroke. Recent analysis of combined studies has suggested that consumption of one serving of seafood a week was associated with a 14 per cent lower risk of ischaemic stroke compared with no or infrequent consumption of seafood.

Mercury

Large fish such as shark, swordfish, golden bass, king mackerel, tuna, marlin, and orange roughy are a significant source of methylmercury. While current evidence does not show any adverse impact on heart disease, it is possible that high mercury levels can negate the effect of seafood 3PUFAs intake. In a Finnish study of 1,857 men, a 0.5 per cent increase in blood 3PUFAs was associated with a 23 per cent lower risk of sudden heart death among men with low hair mercury but this did not translate to any benefit for men with high hair mercury.

The current evidence suggests that the benefits of one to two servings a week outweigh the risks of methylmercury, especially if a variety of seafood is consumed. However, caution should be exercised against consuming multiple servings of seafood which may potentially contain mercury, as higher fish intake does not translate to further risk reduction as the benefits plateau and have a threshold beyond which there is no incremental benefit.

Conclusions

Current evidence supports the following conclusions:

* Consumption of non-fried seafood with high 3PUFA, one to two times per week is associated with a reduction in the risk of sudden heart death, heart artery disease and ischaemic stroke;

* The beneficial effects of seafood 3PUFA peaks at about 250mg of seafood intake per week and higher intakes are generally not beneficial or harmful.

* There may be further beneficial risk reduction if the seafood is substituted for unhealthy meats such as processed meats.

Coldwater fatty fish such as salmon, anchovies, herring, mackerel, tuna and sardines have distinct benefits Should I eat more fish? The long-chain n-3 polyunsaturated fatty acids (P3UFAs), namely, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are the PUFAs most closely associated with heart health.

 

Dr Michael Lim

Medical Director, MWH
Heart Stroke and Cancer Centre
MBBS, MRCP (UK), M Med (Int Med), FAMS (Cardiology), FRCP (Edin)

THE BUSINESS TIMES WEEKEND, SEPTEMBER 28-29, 2019

What you should know about the various types of vaccines

Travellers especially should take precautions and depending on their destinations, go for the relevant vaccinations

I am often asked about vaccines by my patients; most of the queries pertain to travel, dengue, pneumonia and shingles.

It is interesting to note that most of our childhood vaccines are not compulsory under our laws in Singapore. I had always assumed that vaccines like BCG, polio, hepatitis B, pertussis (whooping cough) are mandatory but only diphtheria and measles are compulsory by law. I believe most parents in Singapore are very compliant with the National Childhood Immunisation Schedule.

In fact, childhood vaccinations have a long history in Singapore. Most people don’t realise that Singapore was one of the first nations in the world to start mass polio vaccination in 1958. We were also one of the first nations to start a mass hepatitis B vaccination programme for all newborns in 1987. As a result, we have managed to cut transmission of Hepatitis B from mother to child by 80 per cent or more. Some of the vaccines are not in the National Immunisation schedule and I am often asked about them. The rotavirus vaccine is for diarrhoea in infants and it is an oral vaccine so there is ease of administering the vaccine. The cost maybe a little daunting though.

The chickenpox vaccine is also useful as chickenpox scars can be quite traumatic for teenagers and everyone does not realise that as an adult, getting shingles is no laughing matter. I am often also asked about the vaccine for cancer of the cervix for young girls. This vaccine is now recommended in the National Schedule. I encourage my patients to send their young daughters for the vaccine as that would prevent cancer of the cervix. The best age would be before they become sexually active; the recommended age would be from 9 years of age onwards. Another vaccine that is quite unusual in the local context – except for people going for the Haj – is the meningitis vaccine. Most of the time, I am asked about this by parents when their child is going to university abroad especially in Europe, USA or Australia/New Zealand. The usual vaccine is called MenAWCY that protects against four strains or serogroups of bacteria identified by the letters.

Increasingly I am also asked by concerned parents about the meningitis B vaccine. At the moment on the CDC Atlanta website, there are three universities in the US that have outbreaks of meningitis B. Apparently there are quite sizeable populations in Western countries carrying the meningitis B strain especially in the varsity age groups. Approximately half of the meningitis cases in the Western world are now caused by this strain.

Another big group of patients are business travellers. A well-paying job in Singapore these days involves a lot of travelling in the region as companies expand overseas. I encourage business travellers to get the influenza vaccine annually. Sometimes the whole family shows up for vaccination prior to a holiday at year end to a winter destination.

This is sadly because they previously had a whole vacation ruined because they caught the flu bug.

Yet other travellers are encouraged to update their Hepatitis A and typhoid vaccines. They are both oralfecal in transmission. Hepatitis A can be quite debilitating, and the natural course may run for up to eight weeks.

Some patients may feel very fatigued for up to six months thereafter. Typhoid fever can be persistent and sometimes diagnosis is delayed; ultimately typhoid can be life threatening. The vaccines are tolerable and there is an oral and injectable typhoid vaccine.

Some of my patients get a fever with the typhoid injectable vaccine but it is usually resolved quickly with paracetamol. As for Hepatitis A, we can also test if the patient is protected against the virus with a simple blood test. About half of those aged 50 and above have natural immunity.

Some of my travellers ask me about tetanus. Most of us have been vaccinated against tetanus in childhood, hence the protection is good enough for a decade till the age of 21 years old. We are actually not worried about stepping on a rusty nail, but whether a wound is dirty. Animal bites are probably the worst and if one fell into a filthy drain, one should get a booster too. A good alternative to the tetanus vaccine is the combined tetanus, diphtheria and pertussis (whooping cough) Tdap vaccine. There is a resurgence of pertussis which is responsible for 10 per cent of emergency room patients presenting with cough.

As for animal bites, I caution travellers not to play with cats, dogs or monkeys when abroad. Singapore is rabies free but the surrounding countries are still endemic for rabies. When bitten abroad, the rabies vaccines and antibody shots should be administered immediately and are both costly and involve multiple injections.

Sometimes, patients ask me about Japanese B encephalitis. This is a disease with high fatality, but you need a mosquito to bite an infected pig and then transmit it to man. Since we have phased out pig farms in Singapore, it is very rare. We would recommend vaccination if one is travelling to certain endemic countries and staying for more than a month in a rural setting. In our local context, there is always the threat of dengue despite our world class mosquito control programme. In dengue infections, we are very concerned if there is a huge viral load coupled with an overwhelming response from the immune system of the patient. This often leads to severe dengue or dengue shock.

The current thinking is that we should vaccinate patients who had dengue previously. The data shows that if we vaccinate dengue-naïve patients; the body becomes primed for severe dengue illness when the infection does occur. In my older patients, I am often asked about pneumonia vaccines and shingles vaccine. The pneumonia vaccines are very useful. There are two available: one covers 13 strains (conjugate PCV13) and the other covers 23 strains (polysaccharide PPV23) of the bacteria that causes pneumonia. We recommend that all above the age of 65 years be vaccinated with both vaccines.

We usually advise that the patient be vaccinated with the conjugate vaccine first followed by the other vaccine a year later. This is to avoid the two vaccines affecting each other’s efficacy. Incidentally the conjugate vaccine is given to children under our national immunisation schedule.

Finally, we have shingles, which is a painful ordeal for patients. Some patients have it on their face and suffer a great deal. There is always the risk of post-shingles pain (post-herpetic neuralgia) that can go on for years. The pain has been known to drive patients to suicide.  The current single dose vaccine is available to those 50 years and older. A newer two-dose shingles vaccine offers very high efficacy, but it is not available yet.

A final word about the naysayers of vaccines; this is also known as vaccine hesitancy. There are many complex reasons for vaccine hesitancy; and social media and Dr Google have not been helpful. There are also the controversies such as Hepatitis B vaccine and multiple sclerosis in France in the 90s and the association of the MMR (measles, mumps and rubella) vaccine and autism. These have been found to be false but the damage has been done. There has been a drop in the coverage of the MMR vaccine in the US and UK with a rise in measles cases worldwide. There is an ongoing measles outbreak in the US originating in the orthodox Jewish communities in New York since October last year. The city has passed a law that prohibits exemptions from vaccines on non-medical grounds. This law will affect 26,000 school-going children in New York. Thankfully in Singapore, vaccine hesitancy has not been a big issue as our population believes that vaccines are safe, effective and necessary.

Dr Chong Yeh Woei
Senior Physician (Internal Medicine)
Singapore Medical Specialists Centre
MBBS (S’pore), MRCP (UK) (Internal Medicine)

The Business Times Weekend, 21 September 2019

Boosting collagen production for younger-looking skin

Boosting collagen production for younger-looking skin

A new skin product called Rejuran, which contains PolyNucleotides, has delivered impressive results

In recent years, bio-active molecules derived from multi-potential cells, such as stem cells or germ cells, extracted either from human or animal sources has been at the fore-front of research and medical cuse.

Among the plethora of bio-active molecules, PolyNucleotides (PN) have recently been highly talked about. It is a germ cells of humans and animals. PN has a scaffold-like 3-dimensional structure that can be easily and more cheaply obtained from its sources, as compared to stem cells.

PN has near-miraculous tissue repair, anti-ischaemic and anti-inflammatory capabilities. Recent trials have shown promising results in treatments of severe burns, diabetes-impaired hard-to-heal wounds, chronic inflammatory diseases and many more.

Recent application in Aesthetic Medicine and Plastic Surgery have also shown promising results in stimulation of fibroblast function (collagen production) along with synthesis of scaffolding proteins to keep collagen in place. These effects will subsequently result in significant improvement in skin texture and reduction in wrinkle depth. PN also triggers many other processes of renewal, restoration and growth, making the cells that they affect become more resilient to damage that can cause premature ageing of skin. PN imparts the skin with much enhanced healing time and protection from damage.

About PolyNucleotides

For those who are savvy in the latest aesthetic treatments, Rejuran has become a buzzword among fans of dewy skin and flawless complexions. Rejuran, or its name in full glory: Rejuran PolyNucleotides, is a brand name of an anti-ageing, micro-injectable containing ultra-purified salmon-germ-cell-derived PolyNucloetides.

Its biological effects include:

  • Anti-inflammatory effects on sensitive, inflamed skin;
  • Induction of growth factors for fibroblasts (collagen-making cells) to build collagen; and
  • Improves skin micro-circulation through increased vascular growth factors (VEGF).

With these effects, doctors can treat patients with reactive skin that often occurs post-acne, treat damaged skin and acne scars, and improve fine lines and skin that has become dehydrated and wrinkly. As PN has high affinity for water, skin hydration is much improved – resulting in better skin hydration and reduced wrinkles and large pores. It signals a paradigm shift in the way patients want to be treated aesthetically. Instead of getting themselves makeovers with Botox and fillers, many of them have, instead, requested for Rejuran. Think of the combined effects of the hydrating power of Skin Booster, wrinkle-busting Botox and stem-cell-growth-factor treatments all packed into one syringe.

Are PN injections safe?

Rejuran PolyNucleotide is proven to be safe for injections into the skin. The composition of Rejuran products is 2 percent PolyNucleotide and 98 percent highly purified water and PH-regulators. Unlike fillers, Rejuran injections do not cause unintended tissue necrosis (tissue death) or blindness.

Furthermore, Rejuran PolyNucloetide products are manufactured under extremely strict and sterile CGMP processes to ensure safety and purity of their products. It is manufactured in South Korea – the Korean FDA ensures the quality of drug products by carefully monitoring drug manufacturers’ compliance with its Current Good Manufacturing Practice (CGMP) regulations.

How can PN be delivered into the skin?

The best results can be seen when PN is injected, by hand, into the sub-dermal layers of the skin. This allows larger doses of PN to be deposited into areas of concern such as to treat acne-scarred tissues, damaged or aged skin. However, this method of injection will have transient, tiny bumps on the skin that will last for 2-3 days.

Some patients who are averse to pain may prefer an automated injector gun that delivers small but even doses of PN into the superficial layer of the skin. This method of delivery has very minimal discomfort and less downtime – usually small, red spots that disappear within hours of injection. As an added benefit, the skin micro-needling also stimulates collagen production and repair. For the comfort of patients, application of a numbing cream for a good 30 minutes is done prior to the treatment. In most cases, the treatment time may range from 10 minutes to 30 minutes, depending on the technique used and areas treated. As with most injectable treatments, their side effects will be:

  • Tiny spots of induration (hardening) immediately after treatement – usually resolved within hours after treatment;
  • Transient appearance of swelling at injection sites, which may resolve within two or three days;
  • Mild bruising from injections that resolves within a few days.

Who will benefit most from PN treatment?

Treatment with PN is suitable for almost anyone of any age and gender, who may have the following skin issues or aesthetic requirement:

Thin and damaged skin due to ageing, frequent sun-exposure, dehydration and poor skin-care;
Fine lines on the face or on specific areas such as areas under the eyes;
Moderate to severe acne resulting in fatigued, atrophic acne-scarred skin (done in conjunction with a laser to resurface the skin);
Oily or dry skin with large, visible pores (re-balances oil-sebum level) and
Want to improve skin quality and skin hydration, in the absence of any skin problems.

What are the expected effects from PN treatment?

In my counselling of patients receiving this treatment, expectations need to be managed. Most patients expect immediate results and lasting dewy hydrating effects from a single session of this treatment – this is not always the case.

Patients receiving Rejuran PolyNucleotide treatments should understand the following:

  • It is NOT meant for augmentation of the face (unlike fillers) – hence, there will not be any drastic, alteration to the appearance of the face.
    It is a healer of damaged skin – hence, it will take four to six weeks of healing processes to take effect.
  • For optimal repair and rejuvenation of the skin, a loading course of three to four treatments in three-week intervals, followed by three to six monthly maintenance treatments. This will impart a sustained and long-lasting healing effect.

Speak to your doctor above this treatment – I would advise seeking treatment from trusted, experienced doctors who have been trained to inject Rejuran PolyNucleotide. Treatments involving injections required doctors to perform – hence Rejuran treatments should never be offered at beauty centre or at a spa.

Disclaimer: Dr Looi has written this article independently, without any association with or financial support from Rejuran or its manufacturer.

Business Times
10-11 August 2019

ST Podcast: Forget about raising your good cholesterol?

ST Podcast: Forget about raising your good cholesterol?

In this episode, ST correspondent Joyce Teo and podcasting head Ernest Luis host Dr Michael Lim, the medical director of MWH Heart, Stroke & Cancer Centre, who’s also the honorary president of the Asian Society of Cardiology.

They ask him for tips on how to change lifestyles to prevent cardiovascular disease, like heart attacks or strokes.

Dr Lim answers the following questions:

1. Why is it hard for us to get a heart attack or stroke, when these conditions are common? (0:40 mins)

2. What is the simplest and cheapest way to prevent a heart attack? Drink enough water (4:04)

3. Why is good cholesterol obsolete today? (5:18)

4. Diabetes is a key risk factor, and Singapore is waging war against it. What else can we do to address this risk? (10:10)

5. Why it is better to have more and smaller meals daily (11:40)

6. How do we monitor our blood pressure levels, and what to look out for when doing so? (12:37)

Produced by: Joyce Teo and Ernest Luis

Edited by: Adam Azlee

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HEART TRUTHS

HEART TRUTHS

Changing your lifestyle to a healtl1ier one not only prevents diseases, but can also stave off a major health event such as a heart attack.

Cardiovascular diseases cause more than 17 million deaths worldwide, half of which are in Asia. In Singapore, one in three deaths is due to heart diseases or stroke.

As Singapore’s population ages, more people will likely develop such diseases, given that age is a risk factor and unhealthy behaviours are common.

Recently, a new report called for a shift away from an acute care model to a preventive one to reduce the incidence of cardiovascular diseases. These include heart attacks, strokes and peripheral artery disease which can cause limb loss.

The Healthy Hearts, Healthy Ageing Asia Pacific Report, released by pharmaceutical company Bayer and the entrepreneurial arm of the National University of Singapore (NUS), NUS Enterprise, also recommended better access to innovative therapies and technologies towards this aim.

While many are aware they should lead healthy lifestyles to prevent diseases, not all know that doing so can stave off a major health event like a heart attack. And, certainly, too few have adopted such a lifestyle.

Professor Tan Huay Cheem, director of the National University Heart Centre Singapore, who was a key contributor of the report, said: “Preventive care is not new and, yet, when we look at the adoption of healthier behaviours, it is not ideal.”

One in three diabetics may not know he has the condition while one in three diabetics has poor control of his disease, he said.

“And half the hypertension patients do not have their blood pressure lowered to the target level despite taking medicines.”

Prof Tan said the access to new preventive drugs that are more powerful and safer but costlier than current options, such as blood thinning medications, can be improved by lessening the time to market as well as subsidising them.

He said the report also highlighted the need for education and it is “not just for the public, but for primary care physicians and policymakers”.

Dr Michael Lim, medical director of MWH Heart Stroke & Cancer Centre, said preventive care is the future.

“I think the future of medicine is one where patients will be empowered with more knowledge and they will be able to change their lifestyles to reduce the development of diseases,” said the senior consultant physician and cardiologist.

“There will be less need for doctors to do any procedures on the heart.”

Heart attacks and strokes are mainly caused by a blockage that prevents blood from flowing to the heart or brain. Plaque, made up of cholesterol, fat and other substances, can build up in the inner walls of arteries.

When there is a tear in the plaque, the body will react by repairing the tear with the formation of a blood clot to seal it, said Dr Lim. If the blood clot is large enough, it will cause complete occlusion of the artery and result in a heart attack or stroke.

“Cardiovascular diseases are mostly caused by unhealthy lifestyles. If you can change lifestyles, you can almost prevent any heart attacks and strokes,” said Dr Lim.

Indeed, more than 90 per cent of such diseases can be prevented, said Prof Tan.

Straits Times Life
Mind your Body
8 July 2019
by Joyce Teo

Corporate Lunch Health Talk – Singapore Institute Management (SIM)

Corporate Lunch Health Talk

Date: 5 Jul 2019
Corporate Company: Singapore Institute Management (SIM)
Time: 12pm – 2pm

Topic: Insomnia
Speaker: Dr Vyas M.N. Prasad, Senior Consultant Otolaryngologist – Head & Neck Surgeon

The evolving vision of cataract surgery

Intraocular Lens Surgery: Then and Now

Many years ago, during a clinical Observership in Cataracts and Anterior Segment Reconstruction with Drs Osher and Snyder at the Cincinnati Eye Institute, one of America’s largest private eye centers, I was invited to co-author a chapter in the Textbook of Intraocular Lens Surgery (an Ophthalmology textbook eventually published in 2017 by Thieme, available on Amazon and Kindle).  As part of my research for writing this chapter, I acquired a vintage book titled “Intraocular Lenses and Implants”, widely regarded as the first ever textbook on the subject, written and hand-signed by Dr Peter Choyce.

For the uninitiated, cataracts are opacification of the lens in our eyes, arising from aging and accelerated by certain diseases, medications and trauma.  Choyce, along with his more famous mentor Sir Harold Ridley, were pioneers of the intraocular lens (IOL) for the use in cataract extractions in the 1940s.  They recognized the shortfalls of conservative management with thick spectacles and unwieldy contact lenses to “replace” the focusing power of the extracted lens after cataract surgeries.  That their inventions are by now a staple in cataract surgeries, the commonest operation in the world, belies the struggle for acceptance, complete with disdain and discourteous actions from many colleagues that they had to endure back in those early days.

Inspired by pieces of perspex from shattered warplane canopy that lodged inertly in the eyes of World War II fighter pilots which he treated as an army doctor, Ridley designed the first IOL and implanted the first case at St Thomas’ Hospital, London in 1949.  It wasn’t until significant improvements in designs were made and 20 years since, before the IOL became mainstream and recognitions streamed in for the inventors in the 1970s, culminating in the Gonin medal, the highest award in Ophthalmology for Ridley. The rest, as they say, is history.

In my eyes, Dr Choyce’s IOL designs illustrated in the musty book published in 1964 are remarkable.  Some were for lens replacement in traumatized eyes, iris replacement and routine cataract operations.  Now seeming “retro”, these ideas fathered the current generations of IOLs, and may continue to do so.  In fact, some novel creations in the current IOL market echo these first designs, such as the IC8 pinhole IOL which may have been inspired by the Choyce stenopaeic aperture IOL, and the telescopic IOL, with the difference being the IOL shape and locations within the eye had changed.

Fast forward to 2019, generations of IOL designs had come and gone, and millions implanted into human eyes, the vast majority to the recipients’ benefit. IOL materials improved, sometimes arising from mistakes in the past.  Together with advances in lens extraction techniques using ultrasound (phacoemulsification) and nowadays with a touch of femtosecond laser, modern surgical incision sizes are much smaller, and safety and efficacy approaching perfect.  In fact, IOL surgeries have evolved to become highly refractive, often bettering the pre-operative eye power.  From my experience as a cataract and refractive surgeon, this contributed to a significant shift in our mindset, even leading to refractive lens exchange without significant cataracts. It seems de rigueur for many resourceful patients to expect no less than perfect eyesight AND eye power from their IOL operations, thanks to the sophisticated IOL designs and variety, meticulous pre-operative measurement and surgical planning, which together can and often successfully meet these heightened expectations.  A version of the IOL, called the implantable collamer lens (ICL) can be implanted into eyes without lens extraction, a solely refractive operation, which I also perform as a premium alternative to laser in-situ keratomileusis surgery (LASIK).

New designs continue to pour into the IOL market almost every year. Suffice to say that currently, in general the simpler IOLs correct basic eye powers, while more advanced IOLs, which cost more, can also manage additional errors such as astigmatism, sphericity and presbyopia (e.g. multi focal and extended range lenses).  Competition amongst IOL companies produces some unique differentiating features, whose merits the companies work to substantiate, and ophthalmologists critically assess and responsibly peruse to benefit their patients’ IOL surgery visual outcome.

As a result of the plethora of IOL designs, it behoves any potential cataract surgery candidate to take a moment to understand their choices, as the surgery should ideally be done just once in a lifetime.  Apart from IOL, vision and visual quality results, technique of surgery such as with or without laser should be discussed, as these choices may affect short or long term outcome.  The final option depends on the activities and lifestyle of the individual, and other aspects of the eye and health.  While cost is a factor in the choice of implant and technique, there are alternative strategies that fall not far behind and sometimes arguably better, including glasses or the popular LASIK, for instance, for further refinement after cataract and IOL operations.  Personally, I find calculating for my patients an accurate IOL power a rewarding part of my clinic’s services.  I currently employ a ray tracing software based on a Swiss-made eye scanner, and regularly audit the results, which I find excellent and had shared at the recent congress of the Asia Pacific Academy of Ophthalmologists.

As such, with the increased IOL choices, increased “chair time” is expected, and a clear and thorough conversation should be sought between doctor and patient, since these surgeries are rarely emergencies.  For me, all individuals are unique and so are their eyes, hence a customized approach to the IOL choice is called for.  Occasionally, true suitability for some of the more complex IOL designs e.g multifocals (bi- or trifocals) can only be fully ascertained after a period of post-surgical adaptation, making clear and open communication even more important.

As for my two precious textbooks of Intraocular Lens Implants (the first and the latest published to date, to my knowledge), I may just read them side by side, for my fascination, perspective and gratitude. Indeed, we see further when standing on shoulders of giants!

Dr. Daphne Han
Senior Consultant, Ophthalmologist
Singapore Medical Specialists Centre

The Business Times, Saturday, 15 June 2019