Our Dr Ang Teng Soon Paul has written an article for Changi General Hospital’s Caring Magazine.
Patient Education
Gardasil 9
Gardasil 9 has been launched in Singapore since 1 April 2017.
We are one of the clinics to offer this cervical cancer vaccine in Punggol, Singapore.
What is all the hype about?
It is not just because it is new, but it has also shown to have improvement (Petrosky et al. 2015) in the protection against cervical cancer, anal cancer and genital warts. In fact, in the same research, it was also found that it can help to save money in the long run.
What is the difference between Gardasil 9, Gardasil and Cervarix?
| Gardasil 9 | Gardasil Quadrivalent | Cervarix | |
|---|---|---|---|
| Human Papillomavirus Types Covered | 6, 11, 16, 18, 31, 33, 45, 52, and 58 | 6, 11, 16, and 18 | 16, 18 |
| Price | $$$ | $$ | $ |
| Protection against Cancer | +++ | ++ | ++ |
| Protection against genital warts | +++ | ++ | + |
| Injection Timings | Three jabs: 0 months, 2 months and 6 months | Three jabs: 0 months, 2 months and 6 months | Three jabs: 0 months, 1 months and 6 months |
| Possible Side Effects | as below, SAME | as below, SAME | as below, SAME |
Update on 9 November 2018
Stocks are back in, come and get while it lasts!
Wait, hold on to all your medical terms! What in the world are we talking about?
If you look deep inside a woman’s below, there is a cone shaped thing (cervix) that leads into the womb (uterus). This part can get infected by the Human Papillomavirus (HPV) over time (when the woman starts to have partners), and this virus causes the body to react badly. Once you are infected with HPV, the virus doesn’t go away! It causes the body cells to keep growing and growing. When the body cells keeps “growing and growing”, there will be a point when some of them go berserk and decide to become cancerous.
So, when a Zenith doctor gives you a HPV vaccine, we are essentially going back to where it begun (almost :p). We are trying to prevent the cervix from even catching the virus in the first place.
How common is HPV infection?
A study conducted in Singapore found that 1 in 5 Singapore females have HPV infection and half of these females already carry the virus strains that are known to cause cancer (Tay et al. 2008).
How does the vaccine work out?
It gives your body some virus parts and makes your body detect and kill it the next time it meets this virus, instead of letting it fester and cause problems. Even if you have already caught one of the sub-types of virus, the vaccine will still be effective against the many other strains. That is why it is still effective even after sexual exposure.
When should I get it done?
This vaccine is approved for use in girls 9 to 26 years old. Truly, there are few things that can actually prevent cancer to this extent and this easily, but this is one of them.
So the short answer is: yes, you should get it done as early as possible.
What if I don’t belong to the above age and gender group?
Apparently, the HPV vaccine can still benefit older women, but not as much, and in Singapore, the government only allows Medisave claims up to and before your 27th birthday.
This vaccine has been highly recommended in males as well. It can reduce the risk of genital warts and cancer. It can also protect your spouse.
Another group for which this vaccine has been highly advocated is the MSM community. There are additional benefits of reducing warts and anal cancer. Unfortunately, the government does not subsidise this group of people yet.
What is the 2 dose regime about?
Good question, for boys and girls 9 to 14 years old, there is a recommendation to just take 2 doses 6 months apart instead of 3.
What if I am pregnant?
Hmm, the thing is NOT that this vaccine is dangerous to your unborn child. It is that we have NOT run tests on this group of patients, so the short answer is “we don’t know”. Hence, we tend to wait until the end of the pregnancy to complete the injections.
What if if you got pregnant after you got vaccinated? Fret not, it has not been shown to be dangerous so far.
What are the possible side effects?
- Pain, swelling and redness with any vaccination is common, but in my experience it should last only a few days
- Bruising, bleeding and having a lump over the area is quite common too. Try to apply an ice pack over the area after the injection
- Headache, fever and nausea are less common, but they are short-lived as well
- Dizziness with injections are common especially for some patients with fainting spells and “vasovagal syncope”. Please tell the Zenith doctors if you have such a problem!
- Severe allergies. However, these are extremely rare and can be treated, which is why vaccines are only approved to be given in clinics with the proper equipment to save you.
- Reference: (Markowitz et al. 2014)
I want to get vaccinated now!
As this is a new vaccine, stocks are limited and running out fast. Please call in (64433678) to reserve your jab now, or drop us your contact details for us to get back to you.
References
Markowitz, Lauri E., Eileen F. Dunne, Mona Saraiya, Harrell W. Chesson, C. Robinette Curtis, Julianne Gee, Joseph A. Bocchini Jr, Elizabeth R. Unger, Centers for Disease Control, and Prevention (CDC). 2014. “Human Papillomavirus Vaccination: Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR Recomm Rep 63 (RR-05): 1–30.
Petrosky, Emiko, Joseph A. Bocchini Jr, Susan Hariri, Harrell Chesson, C. Robinette Curtis, Mona Saraiya, Elizabeth R. Unger, Lauri E. Markowitz, Centers for Disease Control, and Prevention (CDC). 2015. “Use of 9-Valent Human Papillomavirus (HPV) Vaccine: Updated HPV Vaccination Recommendations of the Advisory Committee on Immunization Practices.” MMWR Morb Mortal Wkly Rep 64 (11): 300–304.
Tay, Sun Kuie, Hextan Y. S. Ngan, Tang-Yuan Chu, Annie N. Y. Cheung, and Eng Hseon Tay. 2008. “Epidemiology of Human Papillomavirus Infection and Cervical Cancer and Future Perspectives in Hong Kong, Singapore and Taiwan.” Vaccine, Prevention of Cervical Cancer in the Asia Pacific Region: Progress and Challenges on HPV Vaccination and Screening, 26 (Supplement 12): M60–70. https://doi.org/10.1016/j.vaccine.2008.05.042.
Dementia Care in a Clinic Setting
This is the main article about dementia care in a clinic (ambulatory setting).
What is dementia?
It is a disease related to the degeneration (accelerated ageing) of the brain cells, causing the patient to lose function. This can be very hard to detect in the early stages. Overtime, the loss of function would be obvious, and the disease would probably have been there for a while.
Screening tests done at Zenith Medical Clinic:
- MoCA screening
Screening Form
Instructions
- We run it FREE OF CHARGE for our patients, but strictly by appointment only.
- If need be, patient will be referred to the doctor or sometimes specialists for further assessment.
Getting the ball rolling
As dementia can be quite a complex problem, especially when it happens in the elderly, doctors will usually take look at the full medical history, medications, social history and a lot of other information about the patient.
We will also start the conversation rolling by covering some care planning components:
- Advanced care planning (ACP), see our other article here
- Lasting power of attorney (LPA), see our other article here
- Advanced medical directive (AMD). Generally will be signed after we have covered the ACP conversation with the patient
- Medical insurance. We will help you fill some forms if the patient happens to be covered.
- Functional assessments such as ElderShield assessment or Pioneer Generation Disability Assessment, see here
It can take a long time sometimes, and we may have to see the patient over a few sessions.
Community Resources
Alzheimer’s Disease Association (ADA)
Key services provided by Alzheimer’s Disease Association:
- Day Care Services
- ‘Family of Wisdom’ Programme
- Modelled after a programme in Taiwan
- 3 hours
- “Shared caregiving”
- Eldersit Respite Care Services
- Person-Centred Home-Based Intervention
- Caregiver Support Centre
- Family Caregiver Training Programme
- Caregiver Support Groups
- Foreign Domestic Workers Training Workshop
- FDWs are hired to do your housework, but what if you want them to also take care of your grandparents with dementia?
- At least equip them with some basic skills on how to cope with their incessant demands
- Possible to get subsidies from AIC and only pay $10
Services offered by ADA’s Caregiver Support Centre:
- Dementia Helpline: 6377 0700 (weekdays, office hours only)
- Information and referral (financial schemes, grant)
- Phone or face-to-face counselling
- Caregiver support groups
- Safe Return Card (by NCSS)
- Caregiver Respite Programme (Memories Café)
- Training centre to support Young Onset Dementia patients continue employability (ADA Café)
References
- Alzheimer’s Disease Association (ADA)
Constipation in Adults
Constipation is a common problem. It refers to either increased hardness of stools or reduced frequency of motion.
Lifestyle advice
- Eat foods with a lot of fibre (e.g. fruits, vegetables, cereal)
- Prune juice appears to be helpful to some patients
- Drink lots of water and fluids
- Exercising has been shown to help
- Maintain a daily routine, make sure there is a “protected time” to pass motion daily
Why?
Our gut has specific timings daily that will “move”. If you miss the timing where you have the “feel”, it will be hard to try to pass motion.
Medications
The number of medications that are used for constipation can be quite bewildering, even for doctors!
When all the above fails, you might have to use some of these.
First line
- Bulking agents
- Hydrophilic colloids
- Stool softeners
- Osmotic laxatives
- PEG
- Lactulose
- Sorbitol
Second line
- Stimulants (cause intestinal muscle contraction and secretion)
- Prucalopride (Resolor), is a 5HT4 prokinetic agent, 1mg daily (>65 years old) or 2mg daily. But $$$. Possible side effects: diarrhea, headache, abdominal pain, nausea.
- Lubricants
- Soften stool and make passage of faeces easier
- Irritant Suppositories
- Stimulate defacatory muscles to promote defacation
- Enema
- Injection of fluid into distal rectum via rectum) : elderly/immobile patients or neurological disorders
References
- Lectures given by Dr Aileen Seah from Colorectal Associates on 14 November 2015.
- Management of chronic constipation in adults. Uptodate.com. Topic 2636 Version 24.0. Accessed 6 March 2017.
Acid Reflux
Gastrointestinal Reflux Disease
This is an extremely common disease. Normally, a diagnosis is made after serious diseases are considered and ruled out by your doctor.
Unfortunately, if you are diagnosed with this disease, you must understand that it is a chronic disease (AKA long term). It tends to wax and wane with time, and will be triggered when the lifestyle factors are overlooked again.
Some of the information in this article is meant for family physicians. Patients can try to read the top portion only.
Main symptoms
- Burning sensation behind the chest. Can sometimes be a dull or even pulling sensation (heartburn)
- Perception or feeling of stomach contents in the throat (regurgitation)
- Painful or abnormal swallowing sensation (dysphagia)
Other possible symptoms
- Unusual chest pain sensation (make sure it’s not due to a heart problem first)
- Lump or the feeling of something in the throat (globus). Rather common symptom in the local setting
- Unexplained nausea
- Chronic persistent cough that cannot be explained by other symptoms
Red flags
The doctor must make sure that there is none of the following red flags that can be a sign of something more dangerous.
- Loss of weight
- Bleeding from stools, malena (black tarry stools) or hematochezia (red stools)
- Low blood count (anaemia)
- Painful swallowing (dysphagia)
- Chest pain (make sure it is not due to a lung or heart problem first)
Lifestyle factors
There are numerous lifestyle factors that are associated with this condition.
- Obesity
- Poor quality of sleep/insufficient sleep
- Irregular eating habits
Duty To Warn and Confidentiality
Confidentiality is of utmost importance in a therapist and client relationship. The sacred relationship formed between the therapist and client forms the bedrock of psychotherapy; the trust that all the client’s and therapist’s secrets will be kept within our 4 walls. Without this trust, no real work can be done.
However, there are cases when we have to breach this sacred relationship to follow what the law mandates us to do.
The few exceptions are:
- Impending harm to the client, like suicide
- Impending harm to other people, like the client having intention to harm another person
Why?
In 1976 in America, there was a man named Prosenjit Poddar who met a girl, Tatiana Tarasoff, in university and had a brief romantic relationship with her. The man interpreted this relationship as serious but the same view was not shared by the girl.
He felt rejected and went into deep depression. At that point in time, he was seeing a therapist and disclosed his intention to harm her during the course of therapy.
Eventually, he managed to brutally murder the girl after a period of detailed planning. During the time prior to the murder, he had stopped seeing the therapist and was probably well enough to escape detection by people around him.
The judge deemed that the health professionals did not carry out their due diligence in warning the potential victim of the death threats.
Ever since
Ever since then, mental health professionals have become more vigilant in trying to pick up risk factors for behaviour that may cause harm to the patient and/or to others.
Reference:
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