September - November 2012

A quarterly publication of GP Liaison Centre, National University Hospital.MICA (P) No. 018/08/2012

Médico

2 - 3Medical Spotlight

4Medical Notes

5 - 6 Treatment Room

7 - 12 Insight

13 - 15 Doctor’s Heartbeat

A member of the NUHS

Diabetic Retinopathy

Bronchial Thermoplasty for

Severe Asthma

Approach to Thyroid

Nodules

Medical Sp tlight

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Medical Spotlight

A/Prof Lee Pyng, Senior Consultant, Division of Respiratory and Critical Care Medicine, University Medicine Cluster

OverviewAsthma afflicts millions of people in the world. Airway hyper-responsiveness (AHR) that characterises asthma is excessive bronchoconstriction to stimulus consequent to chronic airway inflammation, which leads to mucus production, airway remodeling and smooth muscle hypertrophy. In the last decade, treatment of asthma has focused on abating airway inflammation and most asthmatics achieve good disease control with inhaled corticosteroids. However 10% continue to experience symptoms despite high-dose inhaled corticosteroids often in combination with long-acting ß2-agonists and leukotriene inhibitors.1

About 250,000 people died of asthma in 20092 and 50 – 100 in Singapore. Autopsy studies suggest 2 phenotypes; one of intense airway inflammation and mucus plugging, and the other of severe bronchoconstriction without significant airway inflammation, and stratifying the severe asthmatics without bronchoscopy to optimise treatment is difficult. Although severe asthma comprises only 10% of asthma population, it accounts for significant amount of healthcare spending since these patients require expensive drugs and resources. Effective treatment of severe asthma is a major unmet medical need as these patients’ symptoms are not controlled despite on maximum inhaler therapy.

A novel approach that targets airway remodeling by reducing airway smooth muscle mass is recently approved by the United States Food and Drug Administration (FDA) to complement standard drug treatments for patients suffering from severe persistent asthma.

Bronchial thermoplasty (BT) is radiofrequency ablation of airway smooth muscle that is administered during bronchoscopy. This procedure can be performed in an outpatient setting with the patient under conscious sedation and studies have demonstrated safety, good symptom control without development of airway strictures and bronchiectasis.

ProcedureWth Alair™ system (Boston Scientific, USA), controlled thermal energy is administered to the patient’s airway walls via a radiofrequency catheter during flexible bronchoscopy. The distal tip of the radiofrequency catheter measures 1.5 mm, and can be applied through a 2mm working channel of the bronchoscope. Thermal energy at 65°C is circumferentially transmitted to the airway via 4-pronged expandable electrode array that has a 5mm area of contact with the airway wall (Figure 1).

A 10-second pulse of thermal energy is administered to the airway wall each time the footswitch is activated. All accessible airways measuring 3 to 10 mm in diameter are treated, with the exception of the right middle lobe due to

Bronchial Thermoplasty for Severe Asthma

concern about the middle lobe syndrome. Total procedural time is 30-45 minutes, and 3 procedures are scheduled 3 weeks apart. BT targets the right lower lobe first, followed by the left lower lobe and both upper lobes, and patients are prescribed 50 mg of prednisolone for 3 days to be consumed a day before, on the day of procedure and the day after BT.

Studies on Bronchial Thermoplasty and SafetyPre-clinical studies on canine airways have shown that airway recovery was complete after thermal injury and the only histological difference between treated and untreated airways 3 months after BT was the reduction of smooth muscle mass. At the treated sites smooth muscle was replaced by connective tissue, and even at 3 years there was persistent reduction of smooth muscle mass, which correlated with decrease in airway hyper-responsiveness to methacholine.3 The first human study involving BT to the airways of patients scheduled for lung cancer surgery confirmed a similar effect on human airway smooth muscle with resolution of inflammatory changes over 1-3 weeks.4

Four key clinical studies in patients with asthma were performed (Table 1). The first was a feasibility study consisting of 16 patients with mild to moderate asthma, and the results showed significant reduction in AHR associated with symptom improvement that lasted for more than 2 years.5 Asthma Intervention Research (AIR), a large multi-centre which conducted a randomised trial of 112 patients

Figure 1 - Bronchial thermoplasty procedure

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Medical Spotlight

Authors(Year)

Study Name (Asthma Severity)

Study Methods No of patients

Findings Complications (up to 6 weeks after last BT)

Cox et al5(2006)

Feasibility Study(Mild to severe)

MulticenterSingle armNon-randomised

16 BT Improvement in % symptom free days, symptom scores, PEF, FEV1 and Methacholine PC20

Cough, dypnea, chest pain

Pavord et al7(2007)

RISA(Severe refractory)

Randomised,controlled trial

15 BT17 C

Improvements in measures of asthma control, quality of life, symptom free days and rescue medication use

Wheeze, cough, chest pain and discolored sputum. Higher rate of hospitalisation

Cox et al6(2007)

AIR Trial(Moderate to severe)

Randomised, controlled trial

56 BT56 C

10 fewer exacerbations per year. Improvements in asthma control, quality of life, symptom free days and rescue medication use

Dyspnea, wheeze, cough, chest pain, night awakenings

Castro et al8(2011)

AIR 2 Trial(Severe)

Randomised, double-blind, sham controlled trial

196 BT101 C

Reduction in severe exacerbations, ER visits for respiratory symptoms, days lost from work/school/other daily activities due to asthma. Improvement in asthma QOL

Transient increase in peri-procedural respiratory events, higher rate of hospitalizations (atelectasis, LRTI, Low FEV1, hemoptysis, aspirated tooth)

with moderate to severe asthma, showed objective and subjective benefits of BT as early as 3 months after treatment and lasted up to 12 months. Those who received BT had 10 fewer mild exacerbations per year compared with controls, demonstrated improved peak flow rates, more symptom-free days, better symptom scores and Asthma Quality of Life (QoL) as well as less need for rescue medications.6

Research in Severe Asthma (RISA) trial of 32 patients with severe and refractory asthma, improvements were also observed in FEV1, QoL, asthma control and use of rescue medication.7 AIR2, a study with a sham arm to eliminate plausible placebo effect in previous studies, recruited 287 patients with severe asthma who remained symptomatic despite compliance to combination therapy (high dose inhaled corticosteroid and long-acting ß2-agonist). Patients who received BT reported improvements in Asthma QoL that persisted for a year; reductions in severe exacerbations, emergency room visits and hospitalisations as well as fewer days away from work, school or other daily activities.8 Efficacy of BT persisted for 2 years of follow up. AIR2 trial documented a short-term increase in wheezing, upper and lower respiratory tract infections, atelectasis and hemoptysis during the treatment period. No respiratory failure necessitating mechanical ventilation, pneumothorax, cardiac arrhythmias or death were encountered with BT, and high-resolution CT thorax at baseline, 12 and 24 months post-treatment did not reveal parenchymal abnormalities or airway stricture.

DiscussionHalf of patients with severe asthma do not experience good symptom control despite compliance to medications, and although asthma mortality seems low in Singapore, these represent younger individuals for whom effective medications exist and are readily accessible. BT complements anti-inflammatory therapy by targeting airway smooth muscle responsible for bronchoconstriction. As therapy for asthma becomes individualised guided by sputum analysis and radiological imaging, good symptom control and outcome can be achieved with BT through careful patient selection.

Associate Professor Lee PyngAssociate Professor Lee Pyng is competent in pulmonary and critical care medicine, interventional bronchoscopy and pleuroscopy.

Her training included attachments at the Cleveland Clinic, University of California Irvine, Universitat Llobret, Hiroshima City Hospital, Thoraxklinik and Vijre University Medical Center in interventional bronchoscopy, pleuroscopy, endobronchial ultrasonography and autofluorescence bronchoscopy.

She is the past President of Singapore Thoracic Society, and serves on international scientific committees in Lung Cancer and Bronchology as well as American College of Chest Physician Steering Committees. She is the author of publications in peer-reviewed journals on lung cancer, interventional pulmonology and pleural diseases, and has written a manual and co-authored a book on pleuroscopy which is awarded British Medical Association Best Book 2011.She has received the Young Investigator’s award for work in asthma and another award at CHEST for research in talc and cancer cells.

Email address: pyng_lee@nuhs.edu.sg

References

1. Holgate ST, Polosa R. The mechanisms, diagnosis and management of severe asthma in adults. Lancet 2006;368:780-93.

2. Bergeron C, Boulet LP. Structural changes in airway diseases: characteristics, mechanisms, consequences and pharmacologic modulation. Chest 2006;129:1068–87.

3. Danek C, Lombard C, Dungworth D, et al. Reduction in airway hyperresponsiveness to methacholine by the application of RF energy in dogs. J Appl Physiol 2004;97:1946–53.

4. Miller P, Danek CJ, Cox G, et al. Development of a bronchoscopic technique for airway diameter measurement. Chest 2001;120:229S.

5. Cox G, Miller JD, McWilliams A, et al. Bronchial thermoplasty for asthma. Am J Respir Crit Care Med 2006 ;173:965–9.

6. Cox G, Thomson NC, Rubin AS, et al. AIR Study Group. Asthma control during the year after bronchial thermoplasty. N Engl J Med 2007;356:1327–37.

7. Pavord ID, Cox G, Thomson NC, et al.; RISA Trial Study Group. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med 2008;176:1185–91.

8. Castro M, Rubin A, Lavioletter M et al. Persistence of effectiveness of bronchial thermoplasty in patients with severe asthma. Ann Allergy Asthma Immunol 2011;107:65-70.

Table 1: Clinical Trials of Bronchial Thermoplasty

BT = Bronchial themopasty, C = control, PEF = peak expiratory flow rate, FEV1 = forced expiratory volume in the 1st second, PC20 = provocative concentration of methacholine causing a 20% drop in FEV1, LRTI = lower respiratory tract infection

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Ms Reshmi Karayan Kayanoth (Senior Psychologist), Dr Teng Jia Ying (Registrar), Dr Terence Leong (Consultant), Ms Joanne Chua Su Ann (Psychologist) and A/Prof Rathi Mahendran (Senior Consultant)

The Department of Psychological Medicine at NUH has started a Psycho-Oncology Service, incorporated into the Supportive and Palliative Group of the National University Cancer Institute, Singapore (NCIS).

Our team is led by A/Prof Rathi Mahendran (Senior Consultant). Team members include Dr Terence Leong (Consultant), Dr Teng Jia Ying (Registrar), Ms Joanne Chua (Clinical Psychologist) and Ms Reshmi Karayan Kayanoth (Clinical Psychologist).

This service has a tripartite mission:

Clinical CareWe aim to support NCIS patients and caregivers who experience emotional distress during their journey. Care is provided by our multi-disciplinary team of psychiatrists and psychologists to help cancer patients in distress and with psychiatric complications such as anxiety, depression and adjustment disorders. Caregivers and/or family members can also receive help.

Initial screening will be done by NCIS nurses in using instruments such as the Distress Thermometer (1-item and 5-item versions) and the Hospital Anxiety and Depression Scale. Patients or carers identified to be at risk will be surfaced to the primary NCIS clinician, who will assess and refer to our service accordingly.

We have started our outpatient clinics at the NCIS’ Cancer Centre on Monday and Thursday mornings from 2 July 2012. Inpatient referrals are also seen, with follow-up in these clinics after discharge. Various interventions are provided, from counselling to other psychological therapies and pharmacotherapy. In particular, we will also be starting a Mindfulness Based Cognitive Therapy programme in August 2012.

Currently, all referrals will be through NCIS oncologists, from the Divisions of Medical Oncology, Haematology-Oncology, Radiation Oncology and Surgical Oncology.

EducationOur team also aims to provide training for healthcare staff in the early detection and recognition of cancer patients’ distress and emotional needs. We have trained over 180 nurses since May 2012, providing an overview of common psychological conditions in oncology, use of the screening instruments, supportive counseling, communication skills, relaxation exercises and the fundamentals of how to identify and address unhelpful negative thinking habits.

Future workshops will be conducted in the identification and management of depression, anxiety, psychosis, delirium, cognitive impairment and the neuro-psychiatric complications of oncology treatment, etc.

ResearchClinical research has commenced. We are conducting a longitudinal cohort study on the effectiveness of the workshops in improving nursing confidence and ability in caring for the psychological needs of patients and carers. Our team will investigate the Factor Structure of the English and Mandarin Caregiver Quality of Life Index - Cancer (CQOLC) in Singapore.

We will build on these studies and continue to conduct quality research in psycho-oncology.

Dr Terence Leong, Consultant, Department of Psychological Medicine, University Medicine Cluster

Psycho-Oncology Service @ NUH

Medical Notes

Dr Terence LeongDr Terence Leong is a Consultant in the Department of Psychological Medicine, University Medicine Cluster, at the National University Hospital. He graduated from the medical school at the National University of Singapore (NUS) in 1999 and obtained his MMed (Psychiatry) from NUS in 2007. He then completed his Advanced Specialty training in Psychiatry in 2010.

In addition to being part of the team in the Psycho-Oncology Service, he is also the Clinical Director for his Department, Consultant-in-Charge of the Psychosis Outpatient Service, Deputy Head of the Consultation-Liaison Psychiatry Service, as well as a Lecturer with the Yong Loo Lin School of Medicine, NUS.

Email address: terence_sc_leong@nuhs.edu.sg

For more information, please contact:

Cancer Centre @ Level 3Kent Ridge Wing, Level 3, via South Entrance Appointment Line: +65 6773 7888 (Monday to Friday: 8.30am - 5.30pm)Fax: +65 6772 5829Email: CancerApptLine@nuhs.edu.sg

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Treatment Room

Dr Samantha Yang Peiling, Registrar and Dr Chionh Siok Bee, Senior Consultant, Division of Endocrinology, University Medicine Cluster

Approach to Thyroid Nodules

Thyroid nodules are a common clinical problem.

Epidemiologic studies have shown the prevalence of palpable thyroid nodules to be approximately 5% in women and 1% in men living in iodine-sufficient parts of the world.1 Furthermore, high-resolution ultrasound, often done for other reasons, can detect thyroid nodules in 19-67% of randomly selected individuals, with higher frequencies in women and the elderly.2

The key management issue in a patient with thyroid nodules relates to the need to exclude thyroid cancer which occurs in 5-15%, depending on the presence of risk factors for thyroid malignancy.3

What is the appropriate evaluation of clinically or incidentally discovered thyroid nodule(s)?With the discovery of a thyroid nodule, a complete history and physical examination focusing on the thyroid gland and adjacent cervical lymph nodes should be performed.

Risk factors for thyroid cancer would include:• Rapidgrowthofthyroidnodulesize• Hoarsevoicethatcouldindicatecompressionofrecurrent

laryngeal nerve•Childhoodhead&neckirradiation•Totalbodyirradiationforbonemarrowtransplant•Familyhistory,infirstdegreerelative,ofsporadicthyroid

cancer• Hereditary conditions like Multiple Endocrine Neoplasm

type 2 that is associated with medullary thyroid cancer•Age<20,or>60yrs•Male

Physical examination signs that could suggest thyroid cancer include:•Fixationofthyroidnoduletosurroundingtissues•Lateralcervicallymphadenopathy•Vocalcordparalysis•Pemberton’ssign

In addition, symptoms of stridor, dysphagia, and choking sensation in the setting of large goiters may indicate goiter compression of trachea, esophagus, and neck vessels.

The presence of one or more of these features should prompt early referral for evaluation.

What investigations should be performed in a patient with goiter or thyroid nodules?Thyroid function test should be assessed. If primary hyperthyroidism is diagnosed with significant serum thyroid stimulating hormone (TSH) suppression, radionuclide thyroid

scan should be performed using either technetium 99mTc pertechnetate or 131I thyroid uptake scan, to assess for toxic thyroid nodules.

Non-functioning thyroid nodules need to be evaluated to exclude the presence of thyroid cancer. This relies on the imaging features and cytological examination.

All patients with a thyroid nodule or multinodular goiter should have a diagnostic ultrasound scan on the thyroid to document the number and size of the nodules. In addition, we look for features that might suggest that a nodule might be a thyroid cancer. These might include nodule hypoechogenicity with respect to normal thyroid parenchyma, microcalcifications, irregular infiltrative margins, absent halo, shape taller than wide, increased intra-nodular central vascularity, or suspicious cervical lymphadenopathy.

Fine needle aspiration (FNA) is done on nodules that are larger than 1cm or on smaller nodules if there are sinister ultrasonographic features suggestive of malignancy. Since hyperfunctioning nodules rarely harbour malignancy, if a nodule identified on ultrasound is found to be hyperfunctioning on a thyroid scan, no cytologic evaluation is usually necessary.3

FNA is the most accurate method for evaluating thyroid nodules for malignancy. It reduces the rate of unnecessary thyroid surgery for patients with benign nodules and appropriately triages patients with thyroid cancer to appropriate surgery.

Figure 1: Ultrasound-guided FNA of a left thyroid lobe nodule

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Treatment Room

What are the best methods for long-term follow-up of patients with thyroid nodules?Thyroid nodules diagnosed as benign require follow-up because of a low, but not negligible, false-negative rate of up to 5% with FNA, which may be even higher with nodules >4 cm. Occasionally, small nodules decreasein size or even disappear on follow up, but more often, benign thyroid nodules do increase slowly in size. Nodule growth is not. Nodule growth is not pathognomonic of malignancy, but growth is an indication for repeat biopsy. It is recommended that all benign thyroid nodules be followed with serial ultrasound examinations 6–18 months after the initial FNA, to detect clinically significant changes in size. If nodule size is stable, the interval before the next follow-up clinical examination or ultrasound may be longer. If there is evidence for nodule growth either by palpation or preferably sonographically (more than a 50% change in volume or a 20% increase in at least two nodule dimensions with a minimal increase of 2mm in solid nodules or in the solid portion of mixed cystic–solid nodules), the FNA should be repeated, preferably with US guidance.3

Before the routine use of thyroid FNA, the percentage of surgically resected thyroid nodules that were malignant was 14%.4 With current thyroid FNA practice, the percentage of resected nodules that are malignant surpasses 50%.5 Retrospective studies have reported lower rates of both non-diagnostic and false-negative cytology specimens from FNA procedures performed via US guidance compared to palpation.6 Therefore, US-guided FNA is preferred, especially for nodules with a higher likelihood of either a non-diagnostic cytology (>25–50% cystic component) or sampling error(difficult to palpate or posteriorly located nodules).3 (Figure 1)

The overall approach to patients with thyroid nodules and the relevant recommended investigations is summarised in Figure 2.

References:

1. Tunbridge WMG, Evered DC, Hall R, Appleton D, Brewis M, Clark F, Evans JG, Young E, Bird T, Smith PA. The spectrum of thyroid disease in a community: the Whickham Survey. Clin Endocrinol (Oxf ) 1977;7:481–493.

2. Tan GH, Gharib H. Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging. Ann Intern Med 1997;126:226–23.

3. David S. Cooper et al. Revised ATA management guidelines for pts with thyroid nodules&differentiatedthyroidCA.Thyroid2009;19(11):1167-1214

4. Hamberger B, Gharib H, Melton LJ, 3rd, Goellner JR, Zinsmeister AR. Fine-needle aspiration biopsy of thyroid nodules. Impact on thyroid practice and cost of care. Am J Med 1982;73:381–384.

5. Yassa L, Cibas ES, Benson CB, Frates MC, Doubilet PM, Gawande AA, Moore FD Jr., Kim BW, Nose V, Marqusee E, Larsen PR, Alexander EK. Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer 2007;111:508–516.

6. Danese D, Sciacchitano S, Farsetti A, Andreoli M, Pontecorvi A. Diagnostic accuracy of conventional versus sonography-guided fine-needle aspiration biopsy of thyroid nodules. Thyroid 1998;8:15–21.

Dr Chionh Siok Bee Dr Chionh Siok Bee is currently Senior Consultant and Director of Clinical Services in the Division of Endocrinology, National University Hospital. She is also an Assistant Professor at the Yong Loo Lin School of Medicine, National University of Singapore.

She is the Chair of the Chapter of Endocrinologists and Council Member, College of Physicians, Singapore, Academy of Medicine since 2009; Chair of the Joint Institutions Diabetic Foot Workgroup; Vice-President of the Osteoporosis Society; Past President of the Endocrine and Metabolic Society of Singapore and current Member of the International Osteoporosis Foundation (IOF) Asia-Pacific Regional Advisory Council.

Email address: siok_bee_chionh@nuhs.edu.sg

Figure 2: Adapted from David S. Cooper et al. Revised ATA management guidelines for pts with thyroid nodules & differentiated thyroid CA. Thyroid 2009;19(11):1167-1214.

The NUH Medicine clinic provides follow-up and ultrasound-guided FNA for thyroid nodule and thyroid cancer patients in the thyroid nodule clinic. FNA service is provided along with the pathology department who views the FNA slides for adequacy of cell yield at the same clinic session to improve FNA yield.

Dr Samantha Yang Peiling Dr Samantha Yang is currently a Registrar with NUH’s Division of Endocrinology, with a special interest in thyroidology.

She is a past committee member of the Endocrine and Metabolic Society of Singapore in 2010. Email address: peiling_yang@nuhs.edu.sg

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Insight

From Blindness to Vision – A Multi-disciplinary, Multi-modality ApproachDr Gangadhara Sundar,Head,Orbit&OculofacialSurgeryand Dr Clement Tan, Head, Neuro-Ophthalmology, Department of Ophthalmology

IntroductionCarotico-cavernous fistula (CCF) is an uncommon yet potentially blinding condition resulting from an abnormal communication between the carotid arterial system and the dural venous cavernous sinus system in the brain. Although uncommon, when it occurs, they are associated with significant neuro-ophthalmologic morbidity and mortality, as the cavernous sinus is the primary venous drainage conduit. They form about 10-15 % of all such brain (dural AV) fistulae and may originate either spontaneously or from varied secondary causes: trauma, cavernous carotid aneurysm, atherosclerosis with hypertension, venous thrombosis and genetic predisposition e.g. fibromuscular dysplasia, Ehlers-Danlos syndrome, pseudoxanthoma elasticum. Treatment decisions are made based on various considerations: the nature and severity of symptoms, location and type of drainage, complexity of angioarchitecture and the risk of visual and neurological morbidity.

Barrow classified them into 4 major types (Figure 1). Type A (direct, high-flow) fistulae typically occurs in young adult males from head injuries resulting in direct communication between the intracavernous internal carotid artery and the cavernous sinus. Type B and Type C are indirect low flow fistulae that result from smaller abnormal feeder branches of the internal carotid artery or the external carotid artery respectively. Type D is a combination of fine branches of both the internal and the external carotid artery communicating with the cavernous sinus.

PresentationWhile the high flow Type A typically presents soon after a closed head injury, usually in young adult males and thus easily diagnosed, the other ‘slow flow’ types may be spontaneous and insidious in onset, more commonly in older women. Typical signs and symptoms include unilateral proptosis, diplopia, subjective bruit, headache, chemosis with conjunctival injection and ocular/orbital pain. If persistent and left untreated, especially in the high flow and chronic low flow fistulae, one third of the patients may suffer from visual loss from various factors. These include increased intraocular pressure secondary to venous congestion, angle closure glaucoma, venous stasis retinopathy, vitreous hemorrhage, ocular ischemia with proliferative retinopathy, ischemic optic neuropathy, choroidal effusion and, exudative retinal detachment.

Moreover, owing to the protean manifestations, CCF may be commonly misdiagnosed as chronic conjunctivitis, thyroid eye disease (Figure 2) or other forms of orbital or intracranial tumor. Neurological complications may also lead to misdiagnosis such as intracranial tumor, aneurysm, carotid dissection, cavernous sinus thrombosis, intracranial infection and infiltrative disorders. A delay in diagnosis not only results in suffering but may also result in delay in management and thus visual loss as well.

Figure 1 – Barrow’s classification of carotico-cavernous fistula

InvestigationsInitial investigations to confirm the diagnosis may include computerized tomography (CT), CT angiography (CTA), Magnetic Resonance Imaging (MRI), MR angiography (MRA) and orbital or transcranial ultrasound. While any of the above may be ordered as the preliminary study to rule out other causes and to confirm the diagnosis, the diagnostic procedure of choice is a conventional digital subtraction angiography (DSA) which not only confirms the diagnosis but also directs treatment (Figure 3).

Figure 2 – Varied presentations: patients treated as thyroid orbitopathy (left) and chronic conjunctivitis (right), prior to referral

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Insight

TreatmentUntreated high-flow fistulae are almost always blinding and urgent treatment is indicated once patient is medically stable. This is usually performed by an interventional radiologist through a transfemoral arterial puncture. The more common condition in older adults are the low-flow fistulae which, although may spontaneously improve over several months, can cause significant morbidity. In the era of limited interventional radiological techniques, they were left untreated awaiting spontaneous resolution which may take months or years with residual visual loss and disability as an acceptable complication. However, in this modern era of sophisticated interventional radiological endovascular techniques, patients with severe symptoms often benefit from various methods of sinus closure (balloons, coils, polyvinyl alcohol particulates, liquid adhesives, etc). Not infrequently, where a conventional transfemoral route fails to allow access to the cavernous sinus, a more direct transorbital approach through one of the ophthalmic veins may be used to achieve the same.

Case ReportA 56-year-old female who lives alone with a history of multiple medical problems including long-standing diabetes mellitus, hypertension, hyperlipidemia, coronary artery disease, congestive heart failure and end-stage renal disease on Chronic Ambulatory Peritoneal dialysis (CAPD) presented with a sudden deterioration of vision with severe chemosis and conjunctival prolapse.

Visual acuityatpresentationwas6/24&6/36 in the rightand left eyes respectively, which deteriorated over the next few weeks to bare light perception and ability to perceive hand movements in the right and left eyes respectively. Intraocular pressures were raised with global limitation of eye movements in both eyes (Figure 4).

MRI of the brain followed by 4-vessel digital subtraction cerebral arteriogram showed bilateral Carotico-cavernous fistula with small feeder vessels from both the external and internal carotid circulation to bilateral cavernous sinuses (i.e. Type D fistula). After obtaining informed consent, obliteration of the fistula was attempted through the conventional transfemoral route. However, owing to non-patency and inability to cannulate the proximal vessels, it was aborted. With progressive deterioration of her vision, poor quality of life and prolonged admission of more than 2 months, an alternative and unconventional treatment was planned. With multiple systemic co-morbidities and a cardiac ejection fraction of 25%, a high-risk consent was obtained after a multi-disciplinary discussion between the Departments of Ophthalmology, Diagnostic Imaging (Interventional Radiology) and Anaesthesiology. The service of the newly-established Hybrid OT was also sought.

Under general anaesthesia, a left antero-superior orbitotomy with cannulation of the medial orbital collateral vein was performed by the Orbital team to access the intracranial cavernous sinus (Figure 5a). The interventional radiologist then proceeded to perform an angiogram (Figure 5b) followed by coiling of the entire cavernous sinus with the closure of the fistula. The cardiac anaesthetic team ensured smooth induction and recovery. A similar procedure was performed on the contralateral side the following week (Figure 6). Post-operatively, the patient showed dramatic recovery with improvement of vision from bare light perception to 6/120 in the right eye and from hand motions to 6/12 in the left eye (Figure 7). With visual improvement and restoration of her confidence she was discharged within 10 days and continues to lead an independent and cheerful life on long-term follow up.

Figure 3 – Cerebral arteriorgram demonstrating dilated superior ophthalmic vein

Figure 4 – Presentation: Bilateral proptosis with severe chemosis

Figure 7 – 3 months after transorbital carotico-cavernous fistula closure

Figures 5a & 5b – Demonstration of transorbital cavernous sinus access

Figure 6 – Bilateral cavernous sinus post-platinum coiling

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Insight

This case was unique in several ways. 1. This was the first time a carotico-cavernous sinus fistula

was occluded through a trans-orbital approach in Singapore, to the authors’ best knowledge.

2. Unlike previously published case reports elsewhere, where such patients have the initial surgical access performed in the operating theatre (OT), then wheeled to the interventional suite under general anaesthesia for the coiling and finally returned to the operating theatre for completion of the procedure, this procedure was carried out at a single location with the availability of the hybrid OT and high-risk cardiac anaesthesia support.

3. A successful outcome was possible because of the understanding and cooperation among the various teams involved, a common goal being the patient’s best interest despite a high risk of visual loss and death given her numerous serious co-morbidities, and the ability to perform a delicate procedure in a facility that permits the above with least inconvenience and danger to the patient.

Dr Gangadhara SundarHaving graduated from the Madras Medical College and received his basic Ophthalmic training in Chennai, Dr Gangadhara Sundar went on to pursue his residency training in Ophthalmology and a 2-year fellowship inOphthalmicPlastic &ReconstructiveSurgery&OcularOncology fromHenry Ford Hospital in Detroit.

Heading the Orbit and Oculoplastic Services in NUH, he is a Fellow of e Royal College of Surgeons (Edinburgh) and also certified by the American Board of Opthalmology.

Dr Ganga is also active in furthering the cause of the subspecialty in the South and East-Asian region and is actively involved in undergraduate and postgraduate education in Singapore and the region. He has been a Visiting Professor to various universities internationally and is an examiner in Singapore and regional universities.

His special interests include aesthetic and functional reconstructive surgery of the upper and mid-face, orbital reconstruction, anophthalmic sockets, thyroid eye disease and paediatric oculoplastics.

Email address: gangadhara_sundar@nuhs.edu.sg

Figure 8 – The multi-disciplinary team (from left to right):

Dr Ong Cheng Kang (Interventional Radiologist, Department of Diagnostic Imaging), Dr Sophia Ang (Department of Anaesthesiology), Dr Gangadhara Sundar, Orbit & Oculofacial Surgery, and Dr Ko Ko Lin, Neuro-ophthalmology, Department of Ophthalmology

Dr Clement TanDr Clement Tan is a Senior Consultant and heads the Neuro-Ophthalmology Service at the National University Hospital. He holds the appointment of Assistant Professor at the National University of Singapore. He is also the Director of Education and Training for Ophthalmology, as well as the Director of the NUHS Residency Program in Ophthalmology.

Apart from general clinical ophthalmology and general neuro-ophthalmology, he has special interests in eye movement and pupil disorders and receives referrals for neuro-ophthalmology from fellow ophthalmologists, neurologists and neurosurgeons.

After completing his basic and advanced Ophthalmology training in Singapore, Dr Tan completed a fellowship in Neuro-Ophthalmology at King’s College Hospital and the National Hospital for Neurology and Neurosurgery in London, under the supervision of Drs Paul Riordan-Eva and Fion Bremner.

Dr Tan’s research interest is in the field of neuro-ophthalmology.

Email address: clement_wt_tan@nuhs.edu.sg

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Insight

IntroductionDiabetes mellitus has become a major epidemiological problem across the world. Considering the micro-vascular complications that affect almost all organs in the body, the management of these patients can involve multiple specialties1. The eye is affected in a significant percentage of the patients and along with the kidney is an important cause of morbidity.

EpidemiologyIt is estimated that there are about 135 million diabetics in the world in 1995. What is scary is the estimation that this number is likely to go up to 300 million by the year 20252. Nearly a third of the patients are ignorant of their diabetic status. In Singapore the incidence of diabetes was 8.2% in 2004 and rose to 11.3% in 20103. There seems to be significant difference among the ethnic races in Singapore, with Indians having the highest incidence4.

In a pooled data analysis, global prevalence for any diabetic retinopathy was found to be 34.96%, that for proliferative disease 6.96% and for diabetic macular edema 6.81% - accounting for a prevalence of 10.2% of vision-threatening diabetic retinopathy5. Zheng et al have shown that among the migrant Indian population in Singapore, the risk of diabetes is 1 in 3 and that of retinopathy is 1 in 106. They have also shown that 1 in 20 cases of bilateral blindness is due to diabetic retinopathy in this subset of Singapore population7. Similarly, 1 in 10 adult Malay diabetics were found to be at risk of vision-threatening diabetic retinopathy8.

Pathogenesis and pathologyNon enzymatic glycation of sugars leads to formation of advanced glycation end products (AGEs). Increased polyol metabolism of glucose leads to altered signaling of pathways involving protein kinase C, nuclear factor kappa-B (NFK-B) and MAP kinase. These changes result in damage to retinal endothelial cells, pericytes, retinal pigment epithelial cells and neurons. Capillary basement membrane thickening and loss of pericytes takes place in the retinal vascular endothelium as the initial changes. The initial changes are characterized by the break down in blood retinal barrier, formation of microaneurysms etc. This is followed by closure of retinal capillaries leading to variable extent of ischemia. Proliferative retinopathy is characterized by formation of new blood vessels and fibrous proliferation.

The most important growth factor liberated is the vascular endothelial growth factor (VEGF) that has been found to be raised in both proliferative diabetic retinopathy as well as in diabetic macular edema. Other factors that may have a role to play in the causation of the diabetic retinopathy and its sequelae are the connective tissue growth factor (CTGF)9, angioprotein (ang-2)10, erythropoietin (Epo)11, pigment

epitheilium derived growth factor (PEDF)12, Matrix metallic proteinases, Intercellular adhesion molecules (ICAM 1), Insulin like growth factor (IGF 1), etc.

Clinical featuresDiabetic retinopathy can be divided into background or non proliferative phase (NPDR) and proliferative phase (PDR). Macular edema can complicate both the non proliferative as well as proliferative phase. NPDR is characterized by presence of microaneurysms, retinal hemorrhages, dilated retinal veins, soft exudates (nerve fibre layer infarcts), intra retinal microvascular abnormalities (IRMA) and hard exudates (extra cellular lipid). The NPDR is sub divided into mild, moderate or severe. Mild NPDR is characterized by presence of only microaneurysms. The severe variety is characterized by the 4-2-1 rule i.e 4 quadrants of severe hemorrhages and microaneurysms, at least 2 quadrants of venous beading, and at least one quadrant of IRMA. Moderate NPDR falls between the two – more than just microaneurysms but less than the severe variety.

Macular edemaMacular edema is caused by leak from the incompetent retinal capillaries, microaneurysms, and IRMAs. Clinically it is characterized by retinal thickening with or without lipid exudation. Macular edema is classified into mild (some retinal thickening or hard exudates in posterior pole but distant from the centre of the macula); moderate (retinal thickening or hard exudates in posterior pole approaching the centre of the macula but not actually involving the centre) and Severe (Retinal thickening or hard exudates involving the centre of macula).

PDRProliferative diabetic retinopathy is characterized by proliferation of new vessels from retina (NVE) or from the optic disc (NVD). The onset of fibrosis and posterior vitreous detachment herald events such as pre retinal and vitreous hemorrhage, traction retinal detachment and sometimes combined traction and rhegmatogenous retinal detachment. The location and extent of the fibrovascular proliferation dictates the pathoanatomy.

Investigations

Fundus photographyPhotographic documentation of the retina is done using standard fields. This not only serves as documentation but is an excellent way of screening large populations without the ophthalmologist having to visit the patients. Photography can be done at primary / family physician level and these pictures can be read by a centralized reading centre. Digital transmission of the photographs makes it easy to give the report in a few hours. Once abnormality is found, the patient can be referred to an ophthalmologist for physical evaluation.

A/Prof Lingam Gopal, Senior Consultant, Department of Ophthalmology

Diabetic Retinopathy

11

Figure 2 – Fundus picture showing advanced proliferative diabetic retinopathy with traction retinal detachment.

Fundus fluorescein angiography (FFA):In this investigation, sodium fluorescein is injected intravenously and serial pictures of the retina are taken at close intervals. Normally this dye does not leak out of the retinal vessels. However in diabetic retinopathy, the dye leaks out of abnormal areas such as microaneurysms, IRMA, and new vessels and makes their presence easily detectable. The extent of retinal circulation can also be assessed and areas of capillary closure can be mapped. Presence of macular ischemia can be identified and this may have a bearing on the visual recovery following treatment for macular edema.

Optical coherence tomography (OCT):OCT permits microscopic evaluation of the macula- almost to 3-4 micron resolution. It enables quantification of the amount of macular thickness and delineates subtle features such as foveal detachment, epimacular traction etc and is an excellent tool for follow up, after administering treatment for macular edema13.

Ultrasonography: In eyes with vitreous hemorrhage, ultrasonography permits the identification of any underlying retinal detachment. This evaluation would be important in deciding on when to operate.

Symptoms:Sudden onset black spots are caused by mild to moderate vitreous hemorrhage while massive hemorrhage causes total loss of vision. Retinal detachment causes vision or field loss depending on its location. Macular edema produces more of visual acuity disturbance and difficulty in near activities. It must be stressed that diabetic retinopathy may remain asymptomatic till an advanced state is reached and hence the importance of screening.

Management:

Laser photocoagulation:Laser photocoagulation is performed usually with green laser, although infra red laser can also be used for this purpose. The indications for laser photocoagulation are presence of new vessels (PDR) and macular edema. For new vessels, the treatment is administered as scatter treatment covering all quadrants of the peripheral fundus from the arcades up to equator and sometimes beyond. The burns are spaced one burn width apart and the treatment is usually delivered in 2

or more sessions. Macular edema is treated by focal laser to the leaky microaneurysms or IRMA within the macular area or as a grid pattern avoiding the central 300 microns of the retina around the fovea.

Additional (repeat) treatment may sometimes be done depending on the response. PASCAL laser is a recent innovation that permits more rapid scatter laser photocoagulation with relatively less pain and discomfort to the patient.

Treatment reduces the risk of severe visual loss in a majority of the cases14.

Anti VEGF drugs:The introduction of anti VEGF drugs such as Ranibizumab, Bevacizumab, and Pegaptanib sodium have revolutionized the approach to the treatment of diabetic complication of the eye. The intra vitreal administration of these drugs have become the preferred modality of treatment for macular edema with or without the laser photocoagulation15,16,17. Unfortunately the treatment efficacy is short lived (about 2-3 months) and hence there is need for repetition. These drugs have also been used for neovascularization of anterior segment and to reduce the vascularity of the fibrovascular tissue before surgery18.

Intra vitreal steroid:Triamcinolone acetonide is a drug that was found useful for macular edema when administered intra vitreally19. Recently long acting slow release devises (of dexamethasone) are available. These devices act for up to 6 months and hence eliminate the need for frequent injection as with anti VEGF drugs. However steroids in general have increased risk of glaucoma and cataract formation.

Vitreo retinal surgery:Vitreo retinal surgery is recommended in cases with non resolving vitreous hemorrhage, traction retinal detachment involving the macula, traction- combined retinal detachment, pre macular fibrosis etc.

Follow up:The first eye examination is recommended within 5 yrs of diagnosis if the patient is below 30 yrs of age, and when diagnosis of diabetes is made in patients over 30 yrs of age. Pregnant diabetics must have their eye examined within the first trimester.

If on first examination, there is minimal or no retinopathy, annual examination is recommended. In case of mild to moderate NPDR with no macular edema, a follow up after 6 months is recommended. In the presence of macular edema, severe NPDR, and PDR, the follow up is at about 3-4 month intervals.

Figure 1 – Fundus picture of the left eye, revealing large areas of pre-retinal haemorrhage secondary to proliferative diabetic retinopathy.

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Community health issues:Control of blood glucose has been shown to delay the onset or progression of diabetic retinopathy in several studies20,21,22. Control of associated hypertension also has a beneficial effect23. In the treatment of diabetic macular edema, control of hyperlipidemia has been shown to have a beneficial effect24,25. Relevant to these facts is the observation of poor control of glycemia and blood pressure in the Malay population of Singapore 26.

Two studies from Singapore have shown the extent of negative impact that diabetic retinopathy has on the population, and specifically, the substantial difficulty in performing vision specific tasks on a daily basis27,28.

Community health issues include increasing the awareness of this potential vision-threatening complication of diabetes, routine screening measures to facilitate early detection and timely management of diabetic retinopathy. Concurrently the importance of control of diabetes, hypertension and serum lipids should be highlighted to the population at large.

Insight

References:

1. Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet. 2010 Jul10;376(9735):124-36. Epub 2010 Jun 26. Review.

2. King H, Aubert RW, Herman WH. Global burden of diabetes, 1995-2025: Prevalence, numerical estimates and projections. Diabetes care 1998;21:1414-1431.

3. Information paper on diabetes in Singapore November 14, 2011. Health promotion board. Web site address: http://www.hpb.gov.sg/diseases/article.aspx?id=680

4. Chiang PP, Lamoureux EL, Cheung CY, Sabanayagam C, Wong W, Tai ES, Lee J, Wong TY. Racial differences in the prevalence of diabetes but not diabetic retinopathy in a multi-ethnic Asian population. Invest Ophthalmol Vis Sci. 2011 Sep 29;52(10):7586-92. Print 2011 Sep. PubMed PMID: 21862647.

5. Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, Chen SJ, Dekker JM, Fletcher A, Grauslund J, Haffner S, Hamman RF, Ikram MK, Kayama T, Klein BE, Klein R, Krishnaiah S, Mayurasakorn K, O’Hare JP, Orchard TJ, Porta M, Rema M, Roy MS, Sharma T, Shaw J, Taylor H, Tielsch JM, Varma R, Wang JJ, Wang N, West S, Xu L, Yasuda M, Zhang X, Mitchell P, Wong TY; Meta-Analysis for Eye Disease (META-EYE) Study Group. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012 Mar;35(3):556-64. Epub 2012 Feb 1. Review.

6. Zheng Y, Lamoureux EL, Lavanya R, Wu R, Ikram MK, Wang JJ, Mitchell P, Cheung N, Aung T, Saw SM, Wong TY. Prevalence and Risk Factors of Diabetic Retinopathy in Migrant Indians in an Urbanized Society in Asia: The Singapore Indian Eye Study. Ophthalmology. 2012 Jun 16. [Epub ahead of print]

7. Zheng Y, Lavanya R, Wu R, Wong WL, Wang JJ, Mitchell P, Cheung N, Cajucom- Uy H, Lamoureux E, Aung T, Saw SM, Wong TY. Prevalence and causes of visual impairment and blindness in an urban Indian population: the Singapore Indian Eye Study. Ophthalmology. 2011 Sep;118(9):1798-804.

8. Wong TY, Cheung N, Tay WT, Wang JJ, Aung T, Saw SM, Lim SC, Tai ES, Mitchell P. Prevalence and risk factors for diabetic retinopathy: the Singapore Malay Eye Study. Ophthalmology. 2008 Nov;115(11):1869-75. Epub 2008 Jun 26. PubMed PMID: 18584872.

9. Kuiper E J, Van Nieuwenhoven F A, desmet M D, van Meurs JC, Tankck MW, Oliver N et al . The angio- fibrotic switch of VEGF and CTGF in proliferative diabetic retinopathy. PLoS one. 2008;3:2675

10. Lip PL, Chatterjee S, Caine GJ, Hope- Ross M, Gibson J, Blann AD et al . Plasma vascular endothelial growth factor, angiopoietin-2 and soluble angiopoietin receptor Tie-2 in diabetic retinopathy: effects of laser photocoagulation and angiotpoietin receptor blockade. Br J Ophthalmol. 2004;88:1543-1546.

11. Watanabe D. Erythropoietin as a retinal angiogenic factor in proliferative diabetic retinopathy. Nippon Ganka Gakkai Zasshi. 2007; 111:892-898

12. Ogata N, Matsuoka M, Matsuyama K, Shima C, Tjika A, Nishiyama T. et al . Plasma concentration of pigment epithelium derived factor in patients with diabetic retinopathy. J Clin Endocrinol Metab. 2007;92:1176-1179

13. Buabbud JC, Al-latyfeh MM, Sun JK. Optical coherence tomography imaging for diabetic retinopathy and macular edema. Curr Diab Rep. 2010;10:264-269

Associate Professor Lingam GopalAssociate Professor Lingam Gopal is a senior consultant at the National University Hospital and an associate professor at the National University of Singapore. He is also the senior investigator at the Singapore Eye Research Institute.

A/Prof Gopal completed his basic medical education from Andhra Medical College and did his postgraduate studies in ophthalmology from Postgraduate Institute of Medical Education and Research, Chandigarh, India. He did his fellowship in vitreoretinal surgery from Medical Research Foundation, Chennai and obtained the Fellowship of Royal College of Surgeons, Edinburgh.

His research interests include coloboma of choroid, retinopathy of prematurity, internal tamponading agents, vitreolysis and newer instrumentation.

Email address: gopal_lingam@nuhs.edu.sg

14 Kaiser RS, Maguire MG, Grunwald JE, Lie D, Jani B, Brucker AJ, Maguire AM, Ho AC, Fine Sl. One year outcomes of pan retinal photocoagulation in proliferative diabetic retinopathy. Am J Ophthalmol. 2000;129:178-185

15. Kotsolis AI, Tsianta E, Niskipoulou M, Masaoutis P, Baltatzis S, Ladas ID. Ranibizumab for diabetic macular edema difficult to treat with focal/ grid laser. Graefes Arch Clin Exp Ophthalmol 2010; Jun 29 (Epub)

16. Arevalo JF, Sanchez JG, Lasave AF, Wu L, Mala M, BOnafonte S, Brito M et al: The Pan –American collaborative retina study group ( PACORES). Intravitreal Bevacizumab ( Avastin) for diabetic retinopathy at 24 months: The Juan Vedagures- Planas Lecture. Curr Diabetes Rev. 2010; Jul 1 ( Epub)

17. Querques G, Bux AV, Martinelli D, Laculli C, Noci ND. Intravitreal pegaptanib sodium ( Macugen) for diabetic macular edema. Acta Ophthalmol. 2009; 87:623-630

18. Hattori T, Shimada H, Nakashizuka H, Mizutani Y, Mori R, Yuzawa M. Dose of intra vitreal bevacizumab (avastin) used as preoperative adjunct therapy for proliferative diabetic retinopathy. Retina 2010;30:761-764

19. Jonas JB, Harder B, Kamppeter BA. Inter-eye difference in diabetic macular edema after unilateral intravitreal injection of triamcinolone acetonide. Am J Ophthalmol 2004;138:970-977

20. DCCT research group. The effect of intensive treatment of diabetes in the development and progression of long-term complication in insulin dependent diabetes .N. Engl J med 1993;329:977-986

21. UK prospective diabetes study group. Intensive blood-glucose control with sulphonyl ureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS33). Lancet 1998;352:837-853

22. Mohamed Q, Gillies MC, Wong TY. Management of diabetic retinopathy: a systematic review. JAMA. 2007 Aug 22;298(8):902-16. Review. PubMed PMID: 17712074.

23. UK prospective diabetes study group. Tight blood pressure control and risk of macro vascular and micro vascular complication in type 2 diabetes. UKPDS 38. Br Med J 1998;317:703-713

24. Gupta A, Gupta V, Thapar S, Bhansali A. Lipid-lowering drug atorvastatin as an adjunct in the management of diabetic macular edema. Am J Ophthalmol. 2004;137:675-682

25. Lim LS, Wong TY. Lipids and diabetic retinopathy. Expert Opin Biol Ther. 2012 Jan;12(1):93-105. Epub 2011 Nov 28. Review.

26. Huang OS, Lamoureux EL, Tay WT, Tai ES, Wang JJ, Wong TY. Glycemic and blood pressure control in an asian malay population with diabetes and diabetic retinopathy. Arch Ophthalmol. 2010 Sep;128(9):1185-90. Epub 2010 Jul 12.PubMed PMID: 20625039.

27. Fenwick EK, Pesudovs K, Rees G, Dirani M, Kawasaki R, Wong TY, Lamoureux EL. The impact of diabetic retinopathy: understanding the patient’s perspective. Br J Ophthalmol. 2011 Jun;95(6):774-82. Epub 2010 Oct 12. Review.

28. Lamoureux EL, Tai ES, Thumboo J, Kawasaki R, Saw SM, Mitchell P, Wong TY. Impact of diabetic retinopathy on vision- specific function. Ophthalmology. 2012 Apr:117:757-65.E pub 2012 Feb 12

13

Senior Resident PhysicianDivision of General MedicineUniversity Medicine Cluster

Doctor’s Heartbeat

Dr Goh Wei-Ping Specialist in Focus:

Winning the Accolade

1. Congratulations on winning the Outstanding Young Achiever Award, Dr Goh! Could you share with us your thoughts about winning this accolade?

It was a great honour! It is one thing to be enjoying what I am doing, but another that the institution recognises the work that I do. It really serves as an encouragement for me to continue to do my best, and to challenge the boundaries and ensure that I do my best and that our patients will always be the focus in all that we do.

2. How was your learning journey like? It certainly was not easy. I cannot use the “long, long ago,

during my time…” analogy, because it really has not been that long ago.

I graduated ten years ago, and the infancy years as a junior doctor were not easy. Junior doctors were kept very busy with the heavy patient load, as we had to see to almost everything ourselves. Now, with the empowerment of our nursing colleagues to help us with certain tasks, and the expansion of roles like phlebotomists and Advanced Practice Nurses, work in the wards is certainly more meaningful and enjoyable.

There was a lot of opportunistic learning and self-motivation needed to catch up on all the learning. I was fortunate to have met a few encouraging mentors along the arduous journey making the process much more palatable. I realised the importance of mentorship and guidance, and I try to apply that to the way I work now.

Experience of a Physician-Administrator at NUH

3. Of the many other possible careers that you could have chosen, what made you decide to become a doctor?

My parents had discouraged me initially when I told them I was applying for medical school! They saw how our family physician was working long hours and compromising on family time.

I remember I had 2 options then, to be a doctor or a teacher.

I was very inspired by one of my primary school teachers, who really went all the way out for her students. Besides the many excursions she organised, she also took us out in small groups for meals and movies.

The NUHS Leadership Awards recognise and honour the best of our NUHS community, who demonstrate innovative and motivational leadership with an impact on our tripartite mission of clinical care, research and education.

It is our privilege to honour outstanding individuals from our fraternity who have contributed significantly in clinical work, research, clinical quality improvement, and/or mentoring of young doctors. Their contributions to healthcare have greatly benefited patients, the healthcare community and have gained recognition from their peers. They stand as role models for the next generation.

In this issue, we have a chat with Dr Goh Wei-Ping, who won the “Outstanding Young Achiever Award 2011”. This award recognises young individuals who display outstanding leadership and professional excellence in their area of expertise.

As the first-appointed Chief Resident in NUH and now the mentor to new Chief Residents, Dr Goh is an important link between the hospital, senior and junior staff. He can be considered the architect for the transformation of the Medical Officers and Residency Programme in the University Medicine Cluster.

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Doctor’s Heartbeat

On the other hand, the imagery of a doctor lending a helping hand, always the heroic figure so well personified on television shows and movies, also had me spellbound. My family doctor was a soft-spoken elderly gentleman who always managed to comfort and heal no matter how distressed I was.

After my “A” levels results came out, I spent a long time deliberating. My results were probably good enough for medical school. I thought that if I became a doctor, I could still teach as part of my job; but if I became a teacher, I would not be able to practice medicine at all.

Hence to have the best of both worlds, I chose to be a doctor. It was a decision I am glad I took, and I have not looked back since.

4. How has the experience been at NUHS? NUHS is full of opportunities! There is something for

everyone here, be it clinical work, education, or research.

I especially appreciate the hands-on approach of the senior management as they “walk the talk”. They listen to feedback, review the processes and implement changes. The senior leadership takes a special interest in the grooming of the young doctors with the right values. Their support provides the perfect milieu for training the next generation of clinicians.

Teamwork is one of the NUHS TRICE values (others being

Respect, Integrity, Compassion and Excellence), and it is especially apparent in many areas of work within NUHS. The whole working environment is like a closely-knit family working together.

The ongoing expansion (services and infrastructure) within NUHS also means there are many more exciting opportunities to come.

5. You used to be the Chief Resident of the University Medicine Cluster. What were some of your responsibilities then?

I had to dig up my appointment letter for this one! The role of Chief Resident now has evolved so much and the current title-holder has so many additional responsibilities compared to what I was doing before.

Chief Residency was a brand new concept back then in Singapore in 2008. In the United States, where post-graduate training takes the form of Residency Programmes, Chief Residents are appointed into leadership roles, and their work include administrative and education responsibilities.

The Medicine Department recognised the need for a

medical officer in an intermediary position to link senior staff and junior doctors and hence imported the concept. My leadership role included planning of rosters and helping to revamp and co-ordinate teaching activities within the Department. I was involved in work-groups that were formed to review currency and efficacy of existing training programs.

As the Chief Resident, I was able to provide a mentoring role to junior doctors. On a few occasions, I had to act as mediator in work related and interpersonal conflicts and discontentment amongst house staff.

Junior doctor welfare was also a priority then for me, as the system required long and harsh hours. Together with my associates, we planned many activities to improve morale and promote camaraderie amongst our juniors. I find these get-togethers especially useful for me to get a feel of issues on the ground.

My team recognised the potential pitfalls in the traditional night call system and that the long hours can compromise patient care and safety. We were the first in Singapore to propose radical yet bold changes to the on-call system. The Night Float System was implemented in 2008 and is now adopted in many other Departments in Singapore.

The increased interest generated then of looking at workflows (that can be improved) culminated in the formation of JUICE (Junior Unit Against Inefficiencies) in the same year. The committee looks at work inefficiencies faced by junior doctors, as well as ways to improve patient safety. Some of our proposals have since been implemented hospital-wide.

I am fortunate that the Department in return, supported me for leadership courses aimed at helping me hone my leadership skills. I was also given the opportunity to provide input from the house staff’s perspective in the monthly Divisional Heads meeting and yearly Department Strategic Retreat.

6. What does your current role as a Resident Physician entail?

Many people see the role of a Resident Physician as merely that of providing clinical service, typically in Departments where manpower is deficient. I will say that is only partly true, because I get to do a lot of other things I really enjoy doing! I am really thankful for the support of the Hospital and Department in shaping the work I do now.

My clinical work includes inpatient service under Division of General Medicine. The Division is one of the busiest within the Department in terms of patient load. I find this a challenging Division to work in due to the patient numbers, but it is also where I get to hone my clinical skills as a general internist. The Division is also one that is very receptive to initiatives aimed at improving patient care and experience. With strong leadership and the many driven colleagues, it is certainly a fulfilling experience working here.

As a Resident Physician, my work also includes teaching responsibilities. In line with my initial career option of becoming a teacher, I am glad to be able to teach. My students include medical undergraduates, nurses and pharmacists. Besides bedside teaching, I also do lectures and teach in courses such as Advanced Cardiac Life Support.

15

Doctor’s Heartbeat

Postgraduate education is one exciting area I am involved in. Since the nationwide inception of residency in 2010, I have been actively involved in the planning of the curriculum and postings that our Internal Medicine residents go through.

I also provide mentorship to the current batch of Chief Residents. It is heartening to see how the position has evolved over the years. The Chief Residents share the immense pressure and challenge of shaping the current climate and experience our residents go through with us. Always full of challenges, it is also a satisfying commitment I enjoy.

Besides clinical service and education, I am also involved in a variety of other work as well.

I sit in the Graduate Medical Education Committee as Chair of Resident Welfare Subcommittee, where I get to work with a group of residents in discussing issues related to their training and experience within our institution. I work

with them to organise activities to bring the NUHS spirit and family together, and promote collegiality amongst junior staff and senior management. One such activity is Teacher’s Day Celebration, where we get junior doctors to show their appreciation to their teachers by serving them breakfast and writing thank you cards. This has since been extended to other members of the family including nurses and allied health colleagues, and has become a yearly tradition.

Appointed as a Manager in Medical Affairs, I oversee the Epidemiology Unit within the hospital. The unit oversees the tracking and surveillance of diseases of epidemiological significance.

Quality Improvement projects also interest me, and I get opportunities to work with various units as well as participate in Rapid Improvement Events that ultimately look at how we can improve workflows within the institution.

As you can see, there can be a lot more to just clinical service as a Resident Physician. I expressed my interests and was given the opportunity to contribute in other ways as well. I was able to define my own job scope in addition to the clinical service I provide to the institution. There are ample opportunities for growth and development and the institution is extremely supportive of this.

7. Tell us more about the exciting projects you are now working on. How does each initiative benefit / contribute to patient care ultimately?

Handover of sick patients as part of shift change has always been challenging in my Department, mainly because of the huge number of inpatients we see. I have seen several failed initiatives aimed at resolving this concern. At a recent Rapid Improvement Event (RIE) I led, a multi-disciplinary team looked at the issues and we proposed a systemised handover round.

The changes include senior clinician involvement, and a patient acuity-based Tiering System. A post-

implementation survey showed very encouraging results, as junior doctors felt safer and more confident of managing sick patients on their night calls. We are now looking at the next phase of spreading the workflow to other Departments in the institution, and also looking at developing an electronic handover platform. Part of my work in Epidemiology requires disease tracking and monitoring. The work can be labour intensive, repetitive and slow. I am currently working with my team to enhance our existing IT system to automate disease surveillance and reporting; and aid contact tracing as well. I hope to complete the enhancement by the end of this year.

8. What areas do you hope to focus on in your future career? Any particular reasons?

I like to maintain the uniqueness of my work now as a Physician-Administrator. Being involved on the ground allows me to understand issues better, be it from a clinical or systems perspective.

Clinical medicine is a continuous learning process and I need to continue to maintain currency. I will like to continue to be involved in postgraduate education and teaching, in line with my dreams when I was young.

I will also like to continue to improve the working environment for doctors and I hope to achieve this by reviewing systems wastes and improving workflows.

Dr Goh Wei-Ping leading his team of ex-Chief Residents to share their experiences in a workshop at the 2011 ACGME Educational Conference held in Tennesse, USA.

Médico

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A Publication of NUH GP Liaison Centre (GPLC)Advisors A/Prof Goh Lee GanEditor Esther LimEditorial Team Lisa Ang We will love to hear your feedback on Médico. Please direct all feedback to:The Editor, MédicoGP Liaison Centre, National University Hospital1E Kent Ridge Road, NUHS Tower Block, Level 6, Singapore 119228Tel: 6772 5079 Fax: 6777 8065Email: gp@nuhs.edu.sg Website: www.nuh.com.sg/nuh_gplcCo. Reg. No. 198500843R

The information in this publication is meant for educational purposes and should not be used as a substitute, or relied solely upon, for medical diagnosis or treatment. Please seek further medical advice if you have questions related to any medical condition. Although great effort has been made in compiling and checking the accuracy of the information given in this publication, the authors, publisher and National University Hospital shall not be responsible, or in any way liable, for the continued currency of the information, or for any errors, omissions or inaccuracies, whether arising from negligence or otherwise, or for any consequences arising therefrom. Contents in this newsletter are not to be quoted or reproduced in any form without the prior permission of National University Hospital.

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National UniversityCancer Institute, Singapore

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Upcoming Events NUH GP CME Programme 2012 Please refer to our GPLC website for online registration.

Date Clinical Specialty / Topic

15 Sep National University Cancer Institute, Singapore (NCIS)

Oncology Updates for GPs and Family Physicians

29 Sep Gastroenterology&Hepatology

The Good, The Bad and The Ugly of Hepatitis B Carrier

13 Oct Otolaryngology-Head&NeckSurgery

Common ENT Problems - A Relook and An Update on the Latest Offering

20 Oct Ophthalmology

Cancer and the Eye

27 Oct Orthopaedic Surgery

Case Studies and Presentations on Spinal Problems

10 Nov National University Cancer Institute, Singapore (NCIS)

Oncology Updates for GPs and Family Physicians