2010 July Aug GP Buzz

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,A.pproachTo Co,mmon 'Gastroin'fes,final s.y'mt1oms

Orgcni~EU : De\pCI:ITmelnt of Oc5<lroentetrology Dale ;4 s.epiemb~r .2010 C:OJilt.act:Pe,~on: Ms·Ch,iclng Hen Ito:ng COIiI,tac:t !Nio : 6357 7897

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Eve, :Exam~nation In family :Prcct~c:,e!

Qrganirler: OepQrlmer'l~ or Op:hIMlmalogy Dale: Ul Septem~f 201 0

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UP NIEXT IN OUR -

INTRODUCIG THE 0, S PO R1TS'SHOULDER IN:JU'RJIES

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010

T'rig:e,minal N!e'ulll'a~gia I(llne! Symlpfoms .. TIl,e Severity clnd Ilhe .soh.,Jili~ons]1

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Organizer; PQil! Mgnt;lg!llm~nl Clinic Date: 9 October 20 1 Q Co:nfac:t ,Peirson: Ml!! llh~Ci Co:nklc'l HQ ; 63573041/9722 1715 iE"m,ail t I?MC@t~:sh.com.sg

R ISS,UE •••• T

UN ING ~ JURIES & BEDS~DE SSESSMENT Of RU J G 10 ECHANICS

NOIN-,SUIGIC,AL MANAGEMENT AP'pilOACH JO CEIVIC,Al RADI,CULO"ATHY

MANAGE F

CON JTlONS IN THE GP CUNIC

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FIGHlilN'GTHE SILENT EP'IDEMIIC

COMP UTER - ASSI SIE D

E

L CE

TENDINII'TIS IN THE HIANID

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T SURGERY

THIE IEVOLLmO:N OF MINIMALLY IWASIVIESURGERY IN ORTHOPA,EDICS,

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HEAD OF·DEPARTMENT-MESSAGE'.

t(lirhi~no.larylngdogy has come a long w,aiY ~n the la.s:~ t\!v0' (1Jecades. lit is no longer jusl( confil1ed'[o, th:e ear, nose and thma;t. ,~E:~rn. TIle uni:q:ue skill~ sets I~n mior-oscqpii:c" ,endoscopil(: as welill :8:S open sUllrgery a nd hers etX~endeid ou r Ifeach into rtthe alrrltelrriorand lat;eira~1 'skJu IIII baseto wmk jointilly witill our neur"OisUllwgi calli 0.01111 eagues. to pm1vi,d.e mare oplttiima I cawe fOr our pati,el1ID3.

The a~ea .of Ih,ead amd nec!t surg,ery has 8111:50 beeoma welill elstabl.ished wi~~hli n our s:pec:ila~ityfor boltthl beni'gn and mall@gnanr~ diseases. We IPro,vi,d'e a ,u.omplrehens~ve h.ead' and neck service w!1ii,ch i n:cl udes: n,o~~ust alb,lation of d iseaElle b!J~a lse reconstruction and lI'estoll'ation offunctmorJ.

Snoll'i ngl ~8:n(j] sillee'p surglery I~S no,w all!50' b;rea.ci and bUl~ersulr,ge ry as, we work j_o,ill1tlliy witih ou r respiratory and neurology 'uoll,ea,gu,esto Imanalge sl,eep diserders, .our sleep cll~nwc also irrvdves, dietJ]~ian,s, endocMino.le:9IisV3 ,aiF~,d ev'en balrialt1ric suw-gieons '~o Ipro.vid!e more Ih,olist:lc C8lrre.

Firr81l1y, macWa~1 plas~ics sUlI~gelry in ENTis, a new a rea we a Fe developl]ng wn Si ngapor,e. lit. is ,ailready very we'll~ establish,ed in p~!aces 111~lke tln,e 'US, UK, 'Europe as welill astop Asian a,esthetic 'centres I ikJe Southl KOrea. Ourstren.gthl is, i~n improllJi ng both aes,tlh,e[ic a nd ~unctional~ out.comes ..

I!n ttns issue, of (3P IBuzz, we woUlhl the refo~e ~Ii keto focus onthes!e 'newer su bspecmal~'~ies in ENT- h.ead land neck. surg,ery~. sll!eep slJIlrgemy and fa,ci8111PIas~ics.. I wou~dl alllsQi ~ii ke to~a k.e~h:is OppoftUlnl~ty to. wotre cI !Joe our young,er but eutstsnd ilngl consulta n~s:

• Dr Chong Yew KIh~allil is fu lIy Im:all'ly~ra i ne d and m 8!,rn;ag as. our sl;eep c[;i III i c. He has bra ught. tog,eU"er a. mu'ltid i sc:iipl i na.ry team to provide ,opti rna I and h o:listic ca re fo r sleep cI~sorder patients.

• Dr J eevend mil Kana'gall in;g am is, eu r head and neck SlWg eon" He grad u ated fmm O~x:~,ord a nd did :n jls post-g rad IJ ate train ~ng in the U1 K.. IH e was tih,€: Gold meda~11 wi nne r in the 2fl06 FRCS (ORt-lHINS) ,examlJnat:liOns .. He, did his feillowship in Head and INeck .s urg sryatth e PrirJ!(::ess Alexand ra IH osplta I ill B lii'slb,a.n.e I Austra lila ..

~ Dr Stephen La is au rfacia I plastics su rgeon. He 9 red ua~ed from the U 11 iversr;ty of London and won the pres~i,gIous European .Academy of F;aciel P'li;S"~ic Surgelry F:ellowshl:p (2007-08). He has singh3!-handedl!l.y set up the flrs~ fa'cial plastics sceNio€: ina n E NIT d epa rtm en! in S~ng,a.pofe. 'he service is fa.S:~ Ig r,ow! ng and he is busy tral n i n g anew generaUon of lENT resid ents in th is a rea,

II nqpe '~hat iIle articles in this issuie wilUI h,e~:p, you lID better understand tih,e s,ervi(:es. we! alre proovl]dmng flOr your IPst]ents .. Thank you for 'the OppoftUlnl~ty to. co-ma na,ge! your plat!iierJts!~

Dr. Vea:k. Chow Un, S,ii.lnl,lIIell H€1iId ,or [hlp!8:J'\Jr1lerd, Sel1iQr COIlsultant MBBS. F.RC$'{15dlO)I, !FRee (Gftasgi), :F'A!MS (ORl!.) ~asaJ&$mI;l5 ImSQf'(jIe~

&

10'·88,1

hroat (ENT)

About IUs

!h,e Ear, INose 8: ThroaJi (lENT) Olinic oompnises Cl;ff IE,NT speciia~1 iists ~Mt lTnclude 5SEl:flr~r cOIil,slllllilant8. 3: ooniSillll~alil:ts. 1a,SSOcial€i consultant and :2 reg,lisn rs, nu rses sind admi lIlis,tr-:a'Uve stalff and! IiIJnS severa'il sub...s:pecia'llity olink,s,.

The dHnlc IProv~des cOrl'i\PfieihePi'~~ve' .ENII serv,uoo'Si, fiiom diagn.ostic evaluation to, opemliive ma nag:ement aU'ld~heral:py.

Allied health services are run Iby' alUdiO:I'ogis~.s and Sipeoonll1era,pis'l.s,. A. fi..!II.;nooged illl!iCliolo9iV division ~ill ,aiia~gnostio and Ile.arin:gl aid dispemsing capabilities campli€milMIIs. the: ~NlT seNI!C€,A, ded'h::a,ted Sipeeio~~her-apy servii'e:e was es:tablisfn;ed fill 1997f;of management of patie.nm with: voice a,nel .swa'll:ow:ing p.rolJ:l!ems.

Overview

State of the art recnnol091Y in clinical €'X'amiirlht:lltiol1ls, includes file.xib:~e 91;'l,d[ riglidi

aog'l!ed eliLdoso~~es foir tne nose, !1i'Bsopl1aryniX an:dl phral rynlx. Patients. wli~hsll!!Sipectecl tul'il"l'OUI'8". gmWlh (rr aiMay na.!rliowiJlg can bs OI\€a~IIY and: 'liJrIoroug'hly e-XOll min8d1witi1 th~se endoscopes. Stroiboso~pic exa min8JUiOiIl ,0111 the Il:aryniX f'Or voice d'ilSOrdiers a nd real ti1iTIedigiiital IrecOIifCling of e:nclosoopicprrooec!uriE!s are alsO" avaiiallJ:~e. Miiorosco;pic examination 'Of the

ear riS pelifformed: mr all palt[:e.l1Its.

Investijgatlons like audtCiJogicail evah.!iEltiorfl,. skin prick testing ,sleep stycly and speech assessments are also av·ailiable. Vestibular re,habTilitati.ona:m::i 'Vo~i:oo thrsra,p'y are also ilQcatooWithin the dnnT:c.

D'lIrSe'rvices htlc~ude:

1'. General Otorhinolaryngology

Our :sipecia'llist teaml uleijlts common,simple p.robllems ,sil!charS sora throats,. nasa'll alll:,erg[y, ear bloCl~ge and lremo,val o~ fo.m:i9n bodiesro, i()Qmpl9()!:. complica~oo ,C8i8IElS stf:ohars he,adalild :neck cancer mqui~ili1g major Wide excision andilfeOOns,tfl.!llotive 'Qpera.lion.

2. Nose Clinic

No~e Cliinic, :i~s ~lim Iby a R!~i:nolog~i:st wl1io, sees pa"tiientswith oomplf:catedi nose pr-oblemsslI!!ah as :reCI!! l1Tentnas~l! polyps :andl failed: s:inusslJI rgEl~irY .•.

It :is affilfatecl williltlile .AJlergy Clinic run by a'llergis,tsil"rom 1I1e Department of RlheumaJoIogy, AlJleffi¥ and Immu!i!.oklg¥. gNIl sp€loT:aUsts screen pelie.iiI'ls b€iklre referral ~o~lhis clinic.

Our Services Include:

3, Voice Clinic,

Voioo cnnic IProiVid!es ;managlem:en!t 'for' pa1iemts wi!!h \lO~OO diso.rdelliS such as hcarseness OF v,o,lioo or diiicliliit voice problems,wno,wcn.!la: !benefit wom 1I1e comb'fnecleiXperlise.

4. Snori rlg/Sleep Apnoea Clinic,

S!ll€ep Clinh:::J)i'\ovfides mi!!magemelil~sO:I:l:jtiofiHS 'fm lPati€:nts :with severe obs.~ruc~ir\fie slee:P' apnoe,alproblemlS. SH\aep physilcia ns, 'cti\eiticianls~ ba'nattfJo surgeons~ elilidocr:lnologilsts, psydnolog1fst'S alild prosUmOdOI'!l~1i8ts WITiIi1 a, multidisciplljmary team IQf speci:alislts availab:lie 'for COfiFsl~,!ltatio:nifromtl1eclin'ic.

5 Giddi'n~ss Clinic

Giddlii1ess: Clinic: manag:9s dilicUl'I~ eases of gIddiness. Anaudicdbgi~t, IPtiysicaltl1l,e.raplsts, neu we>:1'ogists, ca ~io!ogiislts and IPsyd11ial1!'ists fo~m a :mli!'ltidisci~linary ream ,ofspeci;~lis,ts available fo,roonsul:lationlromlhe clinic,

Direct referrals an!!' accepted:.

6_ Otology C,linic

Otdl:Ogy' -Ol'inkl sees patieil1ts wi1ll1 oomp.!ElX. ear prob:liems. A Heacland Neck lRad.iollogist !1Ieil.!rol~ogislts and nEl'!llfOSlm'Q:€lonsform a m:ultidisciplin1i1:!i!iY team of spooiial,f:sts a'vai'liablefor cOlil5ults,ti:onwomllhe ann iiC.

I~N'" (Ear. r;r.J!ooo &Tlltlr'Oallt.) spooTIalli'sts S!OIr€!€'!I1 patii3'!I1ts befof'e lliefenal to U'lis clinic.

7. Head and Cancer Cllruc

IHead O:ncologiY Clinic proYid€:s or:lit:;ologjir.a~1 sUllN'eill;3IilIOEi end oonformHy lncaneer ms Iilagemel]:i.

I~N'" (Ear. r;r.J!OOO &Tlltlr'Oallt.) spoo]alli'sts S!OIr€!€:!I1 patii3'!I1ts before lliefenal to U'lis clinic.

IHei3ldalliliCI Nj~k,T'!llmour e;oardl m9;8:tingl heidi ev,euy forttnigiht wllth pa.mticipaitton 'of diagn.ostic radiologiJ5!:s, tl1,erapeuUc radiologiists, Iffied~cajl ,oncolog.1lsts, pal~ltlOlogtiS.ts, and pla:stilc andllffiOQ!I1stmc:tive S!lll~loons.

8. Facial PI.8Stic Clinic

The Facigll P;ll~astic Cil:~l'iIiiCde.als wiliJrl .alJl aspecl.s o~ "!facila II clefoIDlli~y, cll.l!lE! to oongleni~g~, tra,yma, POO:f facial sesr, a!nd diseaiSi€lS Imlalll8c1macia:11 problems<. Wed:€lal w,iftn poor rE'5!l!.Ilts 81l1d oompftcations8!ssociated wilt" previol,Jllsifiacia11 cosn'il!e,tic slil.!r,g~ry. We a'llsod:eal w:iilil Uli:e agTngfa.ce US!llI{ll va:nous reJ,llIvelil:ation procedllllres, amid ~aciia'l: s3(iolll lesions .8S welill as lurnpss nd bumps.

9. Noi se-l nd uced D eafoess eli n lc

'fthEl (Joea~l"ll;€!SS C!llinTlc alms to pro,viide a more h~l'iisl:r:C ,app.roa,oob lie diag!nosis andi manalgement of persons ii!illicted Wi~l1o.owpa~fona'~ Marfng p.ro!:lil:ems.

i o. AudIo logy .s 9 rviea s

W~ provide a comprehensive ralnge o:f S8'fr\fioos mar h.eanng and Iblalan!Ce di~oJde"s.

Our service,s: ineluaie':

• Pu re-ton:eAil!.ldiometry IIHea ring Assess1ment

• Cil'inliical lDiag.nosUc Servioes

• Heariing Aid E::vaIUl:8'ljonand FiUings

• Tinnilb.ls ~se.ss;menlt and Coul'lseillTng

11. V()i.ce The ra py

Our IE::NT Speeclill1iJ1,ltlerapist.manag:e:s: paltielilts wiml voic€! and: s\!Valiowingl problerns \lViUllilile help ota higl'il'liY s:pecial~i~ed com,puteir programme, Ule Computsirisedl Speech ILa:boralmry. Wealsol pirovid~sp€eclill iPatitlologTist ecunselsnd 'reach patients; the propei~ use of '!he voioe. Refe~fals Inave to, be w,om an lENT specialist

'Our serslees include:

• Assessment of vofoo uS~,ge and voicingl

performance

• Ed'uC8t.e paJtie.nil:s en envi[io.l1mein~al 81lld behtilJ'IrJo'umll ,oharlges in voice,

• r,ea!ch pa1rurients laryng:e:al rellia!X'ation exerol\S~;andl: voicing' lechniques.

Our specialists in Ear, Nose and Throat (Ofhorhinolarynqoloqy)

Dr .. Veal!!: :Chow ILin~SaJmlu:e~ HIl!sl,di m lJepirrtmel'1ll,. 8:enOClr COI'1lSlu1l:al'lt

MBSS" F:R,CCS (Edlin). F~CS (GaOlsg), FAMS (ORL) Nasal.& S,nus Disorder

IDr.Veo :Sengl EI.elfl:Q SiMiar Ca:l111ullant -

MeBS, F:R.C.s (Ediil1l}. IF.AMS (ORl.) Otolog-y &: ~el.ilro-ol,Olog¥

IDr. ILee' Cheow Yew~ ,JuUall1l S-enio:r CO:!'I$uUant

MBSS, FiRCS (Edlin). FRieS (GlaS/g). FMlJHINiS (!UISA), FAiMS to!R:L) Nasal & S1r1US [)i$o~der

lOr .. Jle1evendlra KanagalliilQ!all11 Coo.5Ulltanl

13M .8Ch:lQ.xlll'l), M~C;S(EiliIJ), D:LcO,(Eng),

DOHNSf(Eng)" !FRCS(ORL-HNS)1 -

Hea(ltll1c' Nee&:. CMce~

lOr. 00 KialllIKwalfli IK.elilne1ih il.ssoCia~fI' CG:rls.u~~ant

MB.eS, MMedi (ORl.~, MR.CS (!Edin) Facial P!ilSitiic: SUf:Qery .

I~ 'f..

C~iilil~caIA.sSlocjalte 'r,afessor Siow Jh, lK.eat

SJIl'l'Ii@lI' ComuUanl

MO, MBS'S, FRCS (Edln), !FAlMS (OiRiL) Nasal & S1ntls Disorder

A,djj UIi'I'Clt ASlsc<c~ate' IP:ro~eSSQr IKlh,QO U"C:I'illiilfilQ, IMark

S-e.niot!" CO'MiultaJ"!l

MeSS, PReS (Edlin). FR:CS (a~a$Q) Hlllld80 NecK CBJhce~

Dr. Cho:nig Yaw li!l]liall1 Cansunta!'lt

MBSS, F'R.CS (cd~n). MMed (ORL)", F AiMS ~Of'lJL)" FAAQHINS ~!USA)I, EA.O~O, A~NO ('I!i A)

lOr, •. Stepihern Lo Cafl!su~tanL

MD (l.and), MBA~Healt!h~ IBMedlSc, eMiSS, FRlCSEd ~ORiI.-HNS), MIRCS (Ed), IMRCS (Eng), DLO (Engl}, IPAIMS (ORL)

F.aCilall?la~;tlc Su~gely

EARI.NOSE & 'THHOAl.(EN'TT

I of ~

e

Has your patient got a head and neck cancer?

In ST~tilgapore, cancers o,ftbe ihead and neGk are pfedom[l11antly l'J!aJ50pharyl'll:geal cardn.oma (NIPC), OJtl\1'YI~.idJ cancer:. lili1ere sireappro,xI:mately 300 rlJiew fr'IIJPCcases amli 1i 65 new~hyr'Qi!d cancers ea;ch Y13:ar, This means UiN:3,tal gel1lie:ml p,lJaoUitiiO'Iler :malY e:<pect 'lo· see a n:ew ease o,f INIPiC ence ,every 5 years andsl new thyroid osneer ,every 9 years!

A neck hlJrlIlP' may be UU)I OInly p-IIeoontifllg complaint in a !panen~ wiiUl eilher canoer. Howev,er, cervica'll II¥mplihad€'nopa.~hy is exo€i€ding:liy common,. a !rid a 'lIil,y,iitQidl lIlod:I!I~:e :may bepalpe,b:I:e' In upt.o 5% of women" IHow does one pick IllJpthos:eell:usive oanoer cases ,amongst the wol"111ed w~lll?'

Ealfiy ,aetectio:n and cliag nosis: 'of ·~l1e.se C2!lrl,OOrs cont!1i'oute Imorelo a,ver.a!111 survival ~lfIal'lll adiVanooo in :sul;glery. ,mdi[artherapy ordnern1Otherapy. The GP lIS therefcre paramo!i,ln~ in the tii9hla.gairlkst these cancers.

What tOI do witn neck lumps?

''lJ.sten to the patient. He is lellillY §IOU UJe dlaglws},sl'_ Sir Wi:lliam Osler

Tallri~ng a good his~Q,ny is more imports IIltilia.1il perftmmingl8J thoroug:h lexamInation. TIM!iJToliowin,Q points willi lead YCII.IIJ lowarosa, di;agn.osis:

,i, Reactive! Iym ph a(l:eno patil1iY - IDid IDe Il'ump appear a'l3!f a u,ppe:~ r,eS)pir:alt'Ory tract li'lIlness?

Is 1iher-e a ll:ooolisedi ,dente'll, S~fll,1!.lS' er skin ifllireotian8'S a seu roe for lympl1adenoipall1y?

&

ancer

II thyrold mass ~ 'fiU:bercu lous I ympadenopatlil'll - IlHas~lhere besn any' e.xposur-eto TEl?

., M,eta staNe: la ry!1lg:eall or Ilungi cancer-Is the pati:enl a smdIKi€r1

~ Nhllta stat,ic 0 ral ,orr pha ryfilg eall eaneer - Doe's '~ne paUe!illi consume too muchl 2111001101 or OMw betel n:ut?

.' Lymphoma- Is,~h€!re fewr~weight 11:000 or d'I1'€!I1:oning n:ight swea~s CB' sy.mp~oms)?

Trea,t all,Qb¥ious 1~n:fieotiol1!s wi1ha,pprolpriaJte alliUbiotios and folliow-I.lI,p yOYf pa~i:enJt lynUl the ne"O~ lump, thas IrElsO:lived. Dia'o'@itics mat d€1velop absQ€<s'SiEiS or SiUPPUirnltf,ve nodes. Ilif 'the lump is wil1ilnthe~hyroid gliiilnd, perlio,1iT'I1 ~hyroliC1~ufll,clion te'Slt"s. lif tI\1JYlwoto!Xi~, refer~o an endoc~iinologiiS,t and! rtO,t a surgeon ~nmally.. 'Co:nsid€J a CIilI€:Sit ,x~rn'y in s:mcd~€:~ or p<,I!tierilitswitil pos~ible liB.

Wil 0 10 refer?

111e mollowing fef;},tuNls ifill a pati€l:l1[ witlilr a neck I'ump merit uwgent r-ei-elWal:

~ NrEliC:k:.lui1Il;p wilh h.oarsen9ss or stifidQr .' Neal:< lump ina smokeJ

., Nook [ympWfIh recenllt-O!1!S:et deathes:s or nasal sy,mploms (F>iJ PC)

~ Nelok lumprwith ora:111ulcel's, redlwhite paitc'hes or toose teelli

• Neck: Ilump with, ,ooynopha,gJIEI., dyspilhagial oOli mmm'1ld otalgial '~Le. nOlilTlaleal1drums on otosoopy)

line Minis~ry of Healttll (MO:FI) does lIIlot recomm:endl matS'S SCfieenin:gf;or NPC withl IE::BV' igA serology. There is m.erit. :fill pedcmming: these ser-ologiicall tests fill first-degree reillativesof pa!l!tents W1i,~tl INIPIC. IRefe:ra'lIIpatiel111:s with ,8 IEIE!V \leA Ilg'A. tli~lI'es o,f 1 :160a ncla'bove, anai IiOSil! wilhaJ posi~ive ltnres of EBV lEa IlgAfor nasals!1Idosco,PY.

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What can we offer?

- - - -

,~f1lI the IDepanitJil1lenil o~ OIDrhTnolalYllI1goihJ.g~fat Tan Tock Se:ng Hospite:ll, we. o,ier a direct access seMce fur your pallJi:ents wlilih suspecte'oll1ead and neck canoor .. Rere!1lfals are triaged by a speoi!all'i'stand paiUents ,otferecl early a:ppointments ..

.AII]I patiel1lits, recelves tl\1,orough EINT exa minaJlJ;an includTng nasa'il ,e.l11dosoo,PY. We have 'V,i:deo lalYngeell!slmbos,oopy~o h:e:tp' E!'x;amine, the Illa!fYnx Ifn grea~:er detail. Wea'llso' l1al'ife narJiow~banclimaging! ~oaiid eu r en.dosoOiP'Y·.

~f a neck II:urmpis jdientimoo, we ar-ea ole 101 !p,erform~n,e-needle aspir-aijof'll cytology' Ijll'1i th:eclinio. Acytol:agy 'leoolr:lliCian assists ~his procedure. Smears are s,t8:in,ecl :i:mme<lia~e!liy and alilaq~ql.l!'ate cell yieil:d: is ensured Ibe-fore iU1e pati~nt II!eavesWie cleiP·a.rtment linis enSllllr'€ts a rapid ,diragnos:is.

We are iinl~och"!ci!1!,gl IUII,1ra!so'llInd'scanni!1!Q :iin OYf lo~eiPiS!rlme:nt to allow surgeons to, better assess: these lumps,13M direct needll'e biClP'sies. SUf:Q€lol1lperfioiil1iled ultrasoumd scanningi is recommended bylihe Aimer:l,can lilhyrofd Associatiofill andl improves surgJ:cal Qul:cames.

SFOUGHT

IDr,J'e,even(lllfa KaJl1Iagallii!1lg:ai!1i Consultaru

8M BCh(O:x.U.I'I)i. IMRCS(EI'I:[I)., IDtLO(Eng}., DOHN5(Eng),. ,FRCSlORL4iNS)1 He.adand INeck Cancer

l~rJIEl€ve Kana,glalinga m tsa ConslJliltantWith tlilJl3: lJ'elparlm€:nt o~ O~o.minol:alliYlilgologiYa!t fanrock Si€ngl Hosipital (ITSIH) •. He studied ,pre-eli nital imed'~cil1l:e8iS a Chevenfng. $rooi:ar s.t,thie Un~versi~y of Oxford', and tnen oo:mpl'eted his 'olinica'l' s,t.ud'iIeSSilt the Uniwrsiity ,of 'O"X!wn:;I. .IHe spe1nt: 12y,ears wo~king in tl1ie rNJaltional Hleal~h SeN,iiOO tn lon,don - receiving Ihis sipecia'liisl rrailflingl .a~l!JiIe Roya~11 Nlai~iQli'laITtnl~ait rNJose and ~,u Hospita~ll. Gray's Illlilil'ill Road,and 1he Royal Marsden Hos:pital. IHis maim area o~s.ui'bSpeciaility inteiliest IS in hea/CI and I1leck surgicslll onooil~O:Qy8il1ld Uiyroid sUlr-gery. He has pub!llisl'lled e%!!el1!5~\I\ely., with 23 Ipel3iHeviewed pulJ!~ica,tionsa ncl2: [book ohapters to date. In 2006, Ine receivedltthe Gold Medal lor his 'Oy~s~'ndingl pe.!!'IDlima:nC€: in the ~ nterooll,egialli€ FRCS elKamiS" He oompil1eitedl 8i ol1e~year fellowship ifill h,eadall"iliCI '!11€:cksUi rgicail ofil:oologiy Bittle IPrinoess PtlI!exand ra Hospili:al., IBrisbalile~ Aus~ralia in .2~Q8 be:fore' joinil1l,gTlSH. He is ma:rriedi wiith two daughliefs, agied 7 and 110"

00 m

~

EAR,. NOSE, s THROAT.(ENTT

'Obstructive Sleep Apnea (OSA)

I~ Olbs~rUlctive S,leep ~pnea , ..... " '.'

. abs,tw,olive sleep apnea ,(O~.A), IS a sil!eep-rellls:tedi b,re8J~hlng

d,j.soroerU1at :Involv-es ,8 decrease Of complete. :stop in ar~ow d!l:lspite an or:J:QoinQI e,fIQmI: to bma~e. It OCC!iJ!1i'S w,hen the ml.ll!ool!es relao< du~ing sleep, causingl sojjttissl!I e lln ~he back of the Ll1roaJt~o oollapseand IYtock the I.l!.pPeli ai ~y. This leads to lParlial reQ:uotiol':!:S (h~{popn€'a:8) and compJlere stop (a,plIlea:s) 'in breathinglihat laslaJt least 10secoJilds ,d'li.!rirn.g slee;p .. T:ni:$ can leadl to reduC1ii'onsiin bloocl o.xyg~n sa:turalJon.Th€l blf3in l1espcmiGIs, tot.h:€l Illack of oXY'gJ€n by SI'liertir'lg '~he bodiY, 'Qausin@iSli brief ar-ousa'llfr-om slee:p'~hat res,t.ores normal breaWi~!1I,g .. 'i~lis PElJttern OCCli!rs r-epealteclly ,ouring sleep fn palilents Yjljiili!il e8A. Mos'~ people withl O!S#\' a'loo, saore II'oud liya,ndmreque,IIlUy.,wUh pe:riods ,0fs,iTelilce wl1enaJIfiHOW iiiS recluoedl or blocked •. Tiley men make choking, sl1IiOrting Qr gaspirng sounds when thekaYMraY reopens,

These .sleep disorders re.sil;,d~ 'iin poor slel3iP' ,q;yali~y, tmgmentedsleepo. inte:,mrIiitl.-ent nTghUume., la:ck: o~ oxyg,en and l~n,Qreased lrisk. 'of ea miovsls!Ql,lIar dise.aseand mortality, TheiS'e, ma!1liires~ iln thed:ay as day~i:me~iredl1eS's. manning h,€lad'8,~ltIes,. poo'r conce<ntr:altTon, me:mory loss, 'f,ru'stralti:On,. depression and even [mariltal disoord.

The ApneaAlypopnea inoe'x (AHlI), is aln irM:J!e'x.ofseveri~y ~ltIalt combin€lsap.ii1ea,s and hypopnS',as.TllH!l AHI is ca'iloulalte,(j bycHivh:ftlilg ~l1e oom'bined: nu mbew of arpneas and I1lyponeas Iby the"ftl.l! mber o~ IMl.I!fS· oil' silleap. A :score of '15, or m0l18 :rlS ,dTagnoSi€d as ObtS:trtll:ctiw 8!lleep Apn:sa. that would r1ieoossits~e treatmenit.

Mll~I'OSA!AHII0f5-·1S wi'th ~nvd[Uf1t\3£y' sleepill1ess dur'ihg a~ li1iat !leql.l!fre IliWealtentioo, such as \!V3"td1ing TV ,or lreading.

M,oder,a~e iQISA~AI9II o~ 15~30 wl~1i1 invoil:untary sleepflil€lSS d:Ufil"lQ . activities thSit. requilie" somesJi1oentiolil. stich as m.eet~l1Igs 'or presen,tationis.

Sellere OSA: AH~ of more thsn 3D, with in,voluf1IItary sleepiness d'l!.lring ac.tivirties 'that I'"EH:jI!!.lire more :aotive aJttelilitio n,S!,IIClhals talkingl or ,d'ri\!'in~l

I~Ril$k Fac.~cns. . _ ", _, . More tl'1l:an half of those will'll OSAa.re overwelgt'llt Fat

d:eposiils aroU!il!l:ltllJ,e l!!~per aM'way may obstn.u::t ~ne b:rea;~hinl'l Fat amuoo 'lhe a'bdomen (Ule so-calledia,pple shape».,. is a pamticulslr liis'k fa,otor for s!lleep apl1l,ea. How.eve'~, l1iiQitaJIl p.eopr:ewho 3..rE! obese halve sleep aprIH!!<a.

At large necJk (17' inches ,org'reaJter fn meriancl 116 il1hOneS or 'gmalt18r inwolilEln) iS2!lso a risk mcror mr sloop apn:s8 .. St~lJc.turill abnormali~ies :jln the fiaoosilildsklll'lll may con~!1itbl!Jte to' :smeep arpnea. eg reced ing oolin. o,ve~bi{e. and bulkyto.iilQule. A bulk.y aniCI low Ihang,[ng soH: p:ala~e: Tis a

slgnu~;cant r:lt8kfac~QlI' ~or sleep ,apnJ€03isinoe 'ilt collapsi€s ea!5!i'l:y durin g: sil!eepthlereby deoreasing; patency. En'llairgoo tontSi'l!s.a ncI adienoidis als welllliittS at'uonic nasaloQ.ngesti:o.n cam Ibea;ssociated wiU'l1 O!S#\',

Tihosew!1o smoke mQm thallli'wo, packs a dalY h<3JV€l a. liiisk 40 times greaterlhan liIlol1lsmokers. Alooholi:lUld s<edsi~tves malY be associalted wit!1I apn,ea.

press!.l! rizedl air to' paltents lI1~ugl1 ,ilIJ :mask ~Mt Ule~ 'WOOf 'd'uriIilIQ slroop. liltlis airflow ~oopsUi!:€JaTM3Y open, prevelill~jng pauses in bJl"~a~hinQl and reswrin,Q liIlolimal 'oxygen Illeveis. Newer OPAJP' rmOdJels are smalU!, liiight and virluallysilent Pa,tiel1lits can Choo5e from n,Ui'iIi1e'ffiIJlS mask siZl.es- s'nd styles to adhieve ·8 '@food 'fit

U'estyle M,odUiicatio:n:

We~g:l1t loss shol,Jilid be reoommendJecl~o all patients wino ~rIi€:O"v€'ii"I!Veight or obe(!j9 [1 l.fhisis lbasedl ('m€:Vtdel1loe~ltlat weigh,! 105:s improl,!ies Qve:l'all health, decreases the ap,I11,ea I1i'Yipopnea 1~l1Idex, iimproves ,q!l.!ali~ ,of lire, and prdb!ably (j\ecreases darylifme sleepJllless. Cha!11Hging~rom ba.ck.-sleepingl~osid:e.;.sleepingI8.nd 'misingtne ll7leaiCIoF ~he bed may l1e!l:p,U,.ose withl milel eases ,of OSA

Or,alll >appll~a:l"ilc~s:

An ,orala,Piplian:ooi:s another b'OObll~n~: option for psople withl ml:ldl to mooera:l.'e OS-A O~a'il appI1!al!i1C€ls look. much liRe' sports mouth;g,w:uds" land: they help maintain SIIil open >and I.I! nobsbl!ct,ed "ar~y by re:pOsitio.nirng or .stabilizing the 1OW€J,r ja,w i tong;ue,. :so~ palalt.e or IJIfViula.

Slyrgel'Y:

Surgery :~s a,~rea!tmel"lli~ optiQIiI for oaA w,hen paltienlt.are llI,nable ~.o tolerafe the conti nued use .of CPAP device. It is most effeotive when ·there is an obv,ious anatomIc ,a.e>fo!1mi~ 'liIh:a,tcalil be COl1i"€lcted to al!l!®viate:: 'U1e ibreathing pm!bleml.

Q,ne o~ the: moslt common smgical me~li1orJis is uV'lIlopa'llat:oplharyngopillast.y(tllP'PP j,whiclll ~rimsrn.esize or uru! soft paJlial~eil! nd may inl';folve Ule remov,al 'of IDe tonsils and uvula.

r! 'C'ompli,c,~tions..o1ff. u ntreat~dOSA ".

IDay1limlti! :sllooIPllliUlJSiS. It. IliS U'le m05:t iIloW::eable,ailld one o~ Ui1il3; mostsenous. It 'iiliilterliere.s withl mental alertness and qU1Jalfity of IlTifiEl. It fncmases Ute ~i:sik.~or accid€'iiI~~relatoo inJuries, Several studies ha.vesuggested th8!t lpeoplle wil~h sleE3iP' apr;H!!a. have two to lh rea Umesa!s many C9J aCCidents',

Efrf,e,clts ,of Sleep A,flea OlA Iliea!1aruJ Cir'ClI.!!~ati'OIlil. Hllg'n blood !piJ'i9!S'S,tlril:1' heartmailure~ str,akl€,a.iild heart aiirl'iltly"thmhas -- have as!Joflllgl as;oocia~iol1lwith o.bs1!lFUc~lve sle,e:pa;pnea,. tip to' ,a~hird of patf;enlts will'l heart failure a,lso harveslee,p apnea.

Other Adyerse IEfifec,ts ,o:n 1H1ea,ltlfl~ Sleep apnea may 'worsen asUilma symptoms andl in~s<~re W,iltltl tllHll effectiveness of asfhma medic8!tlons.

There mal)!' !be s.nassooiiation ibe,twele:n seiauresa nd OSA especially ln olele,f adults- Somesludiies, I~a\l'e sh,ow,r! ~mafment ,ofobs:Ull,otiv€ sl€ie:p apRea. Wh®'.!'1 ~:m€lS€n~, may' he:tp in the cOf1l11JiO:~ o~ refractory seil:ur-es,

eSA may be Hie undelrlyingl causes of some ,chro.ii1ic headach:es, eg .• C.luster headiad,ne ..

Silleep apfil:ea csnses hTgher ra,l:€s. of pregmmcy com plicatkms., ~ ndll!Jdil1lQ gie-s~milonal diabetes and! hiigh blood pressure,

IEye disorders, including gla~ioomal. n~ppy eyelidl s.ym~:rome and Op1!IIC neuropathy may h:t;vean assQoTatiITrn wil~1tI 08A,

IP':SYC:tllOI,og ieajl IEBe,c.ts. Slud'iies reporit an6l's'SociaUcm b€il'w€em oov"ereapli1e13: andi psychologica'il prriblel'l!ilS>.. Th~ risk fordepr-essicm: rise:s with increasing seveliiilyof sle:e:P' apnea.Sleep.rertateol breathifng clisordersca,n also worsen nig'li'Itma~li€:sa.iild post~tmu math::; s~m,SiS disorder.

IEfrf:e,cts, QI'\I Be(t Paliit!ller$. Beca~~se s:l!eep :ap!II:easo oft.en inch.ildles noisy smMingl,.~lfIe condiiHlOn can aliso advers€ly af'fiec,t ~he :slileep qualrirtyof'a peilJient.'\s bed partiller. lin some' cases, th,e snoring can g'iisrupt 1r€!latfonsh,ips,

If"" TTSH 'Com blned "Sleep C ~inic, . ~ ~

'The TTSHI lENT depsJilment 11!\llIIiI'Sa com'bined slee,p,seNICle ~Itl,a~ is ~iQintly nluri Iby an EINTslJI iigoon as well as a respira~:ory pl1ysioiam. rlu:~s is IUOiqu:e 'OCl' lTSH and it ensuresfhe paUent will have a. comprehensiveanel ba'iiance ~e'View fimml bQ'~h m.€ldica:1 and! ~sur,glic:al PEllfSp~C'Ii\fe, patiient: wll~n :5!lIspelCled ()iSA will be seen a~the ee:n1iest p(lssible date.

A sleep s~l!Idy ~polysomnog.li1'lIm)willll be armn9.iedr,orlihe paltient lIhis is a Illevel ,one ~sfudy in wl1i!cht~n! sil'eep t€d1nician wm~ mQliliiiIDr~he paltiernf's sleep via a mon i,tor 'liliwolll;Qhout~he night. The sleeip' s~l.Idy' wl'lll provide inform,a,tion ,on the AIH~ i'nclex as well as 91 llIyiliac.l of para.m~~€'.ifS eg ib~linwave" O;X.y:glElrl .saturatiofill" plJl11ee rate a.nd ar-ousa:11 index. ThJs is done at tbe Ihospiltal s!l~eep la'boratory durfng alll oy,emigllilt slel9\p,.

,.. Tr~atment~" f'o~ tile ptU:i.ent -,-C "_

- CornblilliiOIUS poslltave >a~nwy press,llIre (CPAIP):

Tlhis liis the-first II:i ne of treatment for moderate to, $,evere cases. of 0811... CI~'#\'P provides a. steady s'lr,ea,m o~

l1realtmerul: ,of OSA is [Mil/idualized. Trna:tment ,offered dEllP,endiso:nlhe severi~yof~ie OSA., 19M!, IM!o,tivatioJil, Agie and/or other cOfi!rect.~U'lea natomical obstruction in me u~per :aerodi.gl€'sti\l'l'I~rnct E:::achl pa~r:€:1i1~ is lCareirully counseled and a management plan is Iproposed! al1ld discLII!$:secl wilh the patiemlt

~r 1I1e patien~ is overweigl1lt,al referral to the weig:ht malllagl€m€!Ult ~:e,am (comprising o,f ~he dietician. phry.5!io:thempirst and s:urgieon),will be oiered.

n i,stMa.~mtof m,e Sleep Sel'V,i:ooclinic to proViI'diEl sn unbiased, oom,prehensive and permafil:elTU treatment OF pa~i:erd with OBA. AJIII avenues of bl!aitmenlt options, inclu:aiil'lgsUlrgica:lll1r1on 'sulil'gica'il OptiQUlS wi!lIllbee.>:lp!I'ore:. w~ also aim to edu)oat:elhe palille:lIlt, lreglsJding the conditio.1lI1 and em,powe:redi~nem withl 1M n:g'llt !ilUii~!.!deto IbeUer their lih~&t~I'e.

S@UGHT

D:f •. C'I1Icmgl Yaw IKlhlian CQl'l~'Ul~O!!'!t

MB13:S, FIReS {Edlin,), MiMed (OR.L), IFAMS (ORlo}, IF:AAOH NS (I!JSA),.IEAOt>40, AINO (FIlA)

Dr Cho!'lgl Yaw 1<h1li111'1 is a CO.IlsuUant ·Witih '!he DlljplIl'il:m!1lnt 'of Oll)rhi!'lo~lIYr;g!#logiY O!i~TanTod:. Sen'll' Hlospl~1 (lTS'H),. He gradiLlal!ed from Nati"ona'lIUnh.rersil¥Si!'i!ll<ljPQre m~i(;aI sctJ.ool In, 1993 aJ1C QIi,l~ameCl FRCS {Edlnbu.rg} ill'l :2000_ IflY€l~r 2003, 110: obt!lliFll!ild.~h€l MMai:! ~'ORq 31Fl1d F:I\!MS~ORq, Compl'e:~e(j 'f,ellawsl:llp' o.tolQg1jS,.;sl-;UI ba~e 're~CIN'$hl~ in IU,K& ltally.

His, maill'lElrea of silIbs.p.ilciaBiy inll8'res~. !sin ,o(alog,yana s!eep diso:rde;F_

IDr Chorlgruns 2: SJ~p CnniC: s!)s(;J!ons with !tie, I'l!e$p.lr,a!ory Medit;.o1ne cons:~~taJilt In. nSH. The 5peclflUi!'lof :$!ee;p d~5O:rde.r fro!!llls!mple '5f10riI'lQ to H'IB're O:b.slJua~i,lIe sre~,p .~rlIeai is SEte!'l il'l ~hE! cI~rllfc, i[l1eool!lm is, com:p-1eledl·wti1!h!Ole~:p ~~w(hn~i;l,!ni <!!nd G!eep d1evi~ personnel. He, ;aliSo '!NO:rk~ ,crO'sely 'witl1 weigN managem.el1l! teaJm, Wihr~n iF)clU:d:-e,$. trne sl'lr1geom. dio:fidansaf)Q plhysi.(j~llElro'3Jpisls.

A spooTlaliet fn 'OtD~hiIAOlail7f"'9~G~lo!iJy;~Hieadl&. ~i€lGk '9urge:rry fiSa' p:hysiGJal'll wlilostu(iJies an,a~omIY.1PhysiQI~gy. pa,1ililolo9iY and Sll!Iugt'Ca'l ~r1€8tmient'fer 1Me el'ltit~ head m'u:hleok ~rea wiUru e;xooption 0:1' the bmin& 'the eye. The oto1ary~Q.cdogtlSit. o:ftel'ldeals witt~·. ~l!n<i1iQna11 IP[!IO.bT.ems in '~hese 'ineas. Howevelr; tl1i.ese ;awe ,often \8iss:oQiat~ 'Wi.ti1StrnGtural wi~h -~ Wi~ilGY~,U easmeUc deftrml'lit~~" ~t is'lper'lif'nen~t tlil'a{ :Iilile OOfgilllOn improV®fffUlnCitiPIili whilst maJn~'ain]i1g o:r €)r\fen imp.ro\Iilifg tI1e Cb,sm®s:f,S ,m tlil~se .8l1eas, In the: USA. &.Euul'ope,l'l1oSEH:I~lal'¥'l1gQIi?giii5'ts Who Wjlts1h to, in'ijlertheilr sl!Jbspedal~y e;xpertise; inif:aieilSl~ pCSI!StiC S!1!J~i€,ry ~m und:er'g.a, ,Fulffiller atlva nce~1 na:inil'lQ lin ~nis ,e fsorpliine, ·suj::l1ilasUlf#·f:el~lowslni:p l~f'i)g.rammes 'of'~l1e American .AQa(lemy· or

~he EUlroPean Aea.diEll'i!llY o~ Facial Plaistic cSl!Irg~rY. . ,

Thf~ Fach3!11 'itas1icSlJlffilel'Y Q]TniQ; i~nllil're. DeparilmelrJ~ of IE~T at Taln lioo:l:l;, 'Sang H'otSpiltaJI is ll:ecllt),y an 9:~ol~ry!1lg0I.!!!g ilsi who, IMs lbe9'n n i.jiI'Eld ·~otusively infa'c!.al pla,sij~ an~j l:ii)~adl land ni8~surgelY. Hem y.tolll deal VII\~J!)II~ects'm fin:iall'di€ilfo~mi~y. ,o:lJjei to, CQlllgenitaTI. ~mU! ma,poor facial scar, an~ QliS'eiSses, r~lafildfia.cial prt.:lble:ms," we· dealll willih PQQ;W resutlils ancloomplicatinns .associated lfflill lpre\lji:ousfacial oosmetiosl.l! rge~:. We!a'loo, '~~al W:ii~~l the' a.gingl~oe wi~11I1 v8riiouS lrejllli'llenati'o:n :~r,ooeclures~ and! facial skil'ill II18sJol1l:8: as, well as lum,p's ~Iild blJllmps~

OO$Jmeliie nalSal ,d:eifiormity is oiliten (jiue tol Il;md:erlyingl sll1l1Job,,lI:ral abn,Cl:OlIa:ri,ty wll1l:d,h reQlJI:hi"eS S'lup,glh::a] corwec,ijOil1 to improV'e, .Im::djltl 'ftiillction (liIa:sal. hmaJli1tIing) antd coomes~s. We .ajlso deal wi1l'1.com:plfeatlil'iltS 'ef augmenrt~diol'i1l I!'hiiop:lasly as, well as • re~i$ionTimin.o:plaity f~f pauenij. J..!ni$a,tislliedl ~f1 ltTheir previOitJ§SUr9~ry elsewlil_@rE!i.

__ ....... . ~.... "'" - _ '" aU<.> ~ -.. ~ ,.:... .. _, _. "'""

F',ac~a:11 bone f~otUi re lrepair (IEincipsoopic &,o~en

We 'a,e~lwilh congenitalll, 'italUl maine ,(il;ndotlil,er ,dir~ease-.u~I8Jled derormiUes of the ,extemal ear.

toih:ls,t [acuallfmctUilies. are dl:Qsely asSooiia'te.dl with tm;portant rn~m!a!ljs1ruc~ulnes~slilidh 9tS naS2lJlsilil!.lIi$i!!S and 'ota'il ca\ii~. We" are! famillia rw,~1J '~reafme:n~ o(filJn6Hormal anatomy' ldf~h~8i8~a!reas" and: olff€:J€':ndosoo:l1iC MPalT wi1eirileVer PQS1ilITlbI~El~Q aChi€r'!le '~he' best .pooSiTble '[Ulnotiol'il'al and oosmeitic outcome .•

W€i WOJik clQS'E!~Jy w~~h OUlJ occUlI'ojplasticand maxinofEU::.I!a'~ coll€lag,lll.esin dlealingl w,111ilil lhese de,fO:mfIities~

As we MlllfineWy ,€/X'Of,s€'andllieccllil!S1ruct 18;S;[OiilS of tl1li9lhead andl n~cl<'l we are famiiliar with dea'l'hll9 with scsr Irelated pfclille,msin '~hese ana,wmioa11 areas ..

Facial loerve lpalsy 18 o~n mlalted 'k> ENI: paH1Qlog~.. w;=roulin€i,liy dle:al WiU~1 th>€c causes' an.dthe 'asso.eislted pf'O:blemsdlJ.lrinlgr the ln~ili\aIIP:nratSe)l''ai1d r:e-Sln~ma~i:o.n a~. a

laiJter stage~ '4i

NeH)k Sllngle1ry for IlI"emarval of be,nignglfoWltti!iS9.m:l eeneers are ImiUl!uililely pe:rt!olimed by Ile otdliaryngolog:iist andl no oll1ierspeaial[y' is llIoreamatq,mically ifamilifiar withl~nis areal.

uuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuu'<-

HJI

we ,Off'er ooin advaneemel'illt fur pa~h~I'iII1s'w,ir~h' 1'i~,li1athiawhich Imay be Ule"'Cause,

~~ ..""_ I~ • - ;;0.:.; .If J,:..

j)fU1!3'lrr Slnor!n.g. We,aJso')offer ;;!!!.l!gmen~tiono"'·chrn& ~Meil~;;s 'd~e'.t.o' oon,genital and

acq~ifi~d:'b8;'fiormTil:rIEis"

Facial fililers

Tempo:Il'~li!'yamd permanent. fiille:rnare oierec.l to paINer'l'!s wiUlI congiElnUajor aoqulred ~a.cTla'll defo.niit[>es.

SFQuGHT

011". S~e'P'en lo 'Oonsyll:ard:

MD (Wild). MB~Hea1ifJ~; BlMiedS~;, ~MOO. FIR-aBEd (ORIA·IN,S) •. MiR.CS (iid}~

MRCS (Eng). OLO (l!:l'iig~. FA!MiS tQJ~L.l

Facial Plasllo S:iililgSl'y

Or S~e:ph.'il!:nr La is: a .consultant: ana ~~£ls '1i11.e FO!.~fa] Pla5.~ic S • .ir-g:etY S!eiN[oe in ilie Oepartmen.t @W Q;temino~aryngor,OgIY' He undertook Orolil'1inolarynijology trainLr'l{l1 tnl london,aool wmp.1eled too presu~ioog; 'ane year E1J~!fJn A.ca,demy d Faciall P~asoo' Sl!ngery fe1lewship. He lis a. ShiooommiHee a't:'l.d TI~aili1in9 Supervisor af'!he S~in9apore' Special:iSit Training Comnnnlibee in Oto:lihinolaryngology. He selVes :as~he Na~ona~ E'r:>IT Fliesltwn:ell Progwm Facta'i Pl1li5'ruC M:OO:uLe le,ad, and a oomm'itleememoon:lfl!lae NHG Dom:ain Specific Review' Soard for ~e.s11!'aroh. lMe ils commlll1ee ml1ml~r land ~eaChrngl ra,c_iiJlty on many inlelin.a:t[Q.n:al 'rn.eiallpla5Jtfc SiUT{l.IE!iFli' SIOcreHes"co!Jrs.e~ and ool1l~eNlmce!;,. He ~elere!1fspeer-reVile'lNed lp.a:~rs on 11acial plastr:c S!Urg:eiry for sCieinIirlic jOYl1nals. He .MS OVer 100 medical pubri.oatkms and has le~uredl exien:sw.e~y 01'11 topics m~ated to tJ~·s-specially.

lOr. lOG Kia!!il IK.wan I IK.elilnetill AiSsociate CO:i'I~ult<lllt

MBBS. MMfld (ORL). MR.CS~Edil'1l) F<!~al F'las.fj" Surgery

Dr Kerme~h 00 has jIJst Ireturned l1rom his fellowship ~r11 F:a.da1Plasibics and ReoonstruoUtm, spon!So~d by~he Minis~ry of Heal~l Ilmde'rlhe! Heal!h Manpower developmel'li~ program (HMDP)., He 'grllidWl~ed from the f\lalic:ma~ UrniveFSilW of S!ingapore ~nH197 and comprieted tJiisOlorhinoli<!l)'J'lgorogry trniniln9 in

Singapore. Dr 00 wi!llllbe! dellr,g:hrted~o parit~r l{O!lJ [I'll managing p.a:ttents.

who, have: difficulr'l: scars 'Of ike:Toid~,. pmminJ!liint or derolimed ears requiring! otloip'lasly., orpiiil~ienl$ who may Ineed funOti!:ln:a'1 or aesthelic min.op.lasr:y.

~inj~fiies ,oflhe faooand neck unctuding l<aJoe:ralions ,f[actu:res and safil.~SS'ue defeds requiiFrn91 mconswciton can alse be S1lllEliril ,onarnemergel'llt basis ..

11

. . .

HEAD OF· OEP._4RTM_ENT MESSA.GE;

. .

ntha last. th1ll'Iee decili.des s,ince wefi rst :s~al1ed tm:a!Ungl plaltl~ents; wi~h v,aruollLl:s conll1l,sdiv,e tJ]ss·ue disea;ses. and allrt!l1n]~id~s in Tan Tock, Sengi HosIP,jtal~. many n.ew· dmagnosUc moda~litliles, and: nov,el amlll :8ndbmo~og lc diselase~:modifY1]ng .a:nt!]-rheum8;~ic d nlLJg:s (O:MIA.RDs,) have emelr'ged in the di:agrno,sl's and tmatment. of valrlous. m-heum8!~olloglica~1 di:~ordellis. Gone are tirH3: days of melr,ely depelUldin:9 on l'11ol1.-steroid!al antil~inf\]ammat.ory dnlLJg:s :ii3J1'il(j predniso~!one a~lone~ with aUthek a:tterndant s .. ide-effects "Ea rI ler diagnolsis and ·~8,rg,mSid. therapies brt 11,9 the prornise o,f li,educlticH'i1 in pll',oglressive~Qmnt ~ndorgl~ln d'aJma9,e~jmpn:lv,ement in function and better qua I~[y of ~ifeJor our rh:eulma.to~logy pa~ient~s ..

lin the field of c~lini,ca~1 immunology/alll!ElII'9Y.,. the :a,vail~abilliU.y of a wide range afvaUfiated skin~e5~5 land blood ~ests for the wdlentl~fic~:~ion o,f8illerg ic~ruggern~ useof mmmiUnomod:u~iatolfY :ra:gl!1!lI1m, I ilkJe inli~a;ven,Qlus;i m m uln,og labul ins ~n '~'I1e~rei8.tJment (jb.xic epidermall l1ecmlysis., and ·~h.e :8!va!~~ab~1 ity of' specific lrn m urmtherapy for ~ns:ect venom ana:phyl,axis and allll,ergii,c rih iniUs in SinglalPore.~ 1n:(!Jlve widened our alrmamentalrium i n the d ia.grnosis and treatment o,f valfi~o:I!.J;5 :alle'rg~c dl~so>rde·rs;.

lin thws mssue~ we hsve chosen fcnJ r l~mponani~8Ire!8:s/dev,e.l!opme:nts in liheumakllogy and erni nli!ca~1 iJmJmunollogyla~I,ergIY' whi,ch we ~eel wUI be h ig hly re~evant to! your dai~y' plrac.ti,ce:

• R,€·valution in the mana'gem.eflt of rheumatoid i3lrthrlris. (RAJ - musQuloskel'etal ultrasotmd in the diagnosis and management of ear:ly RA

~ A practical approach to dmg allergy - diagnostic modla'liHesand drug crcss-hypsrsan sitiv,i tie s

• Th e facts a bo ut foo d a.1.1 ergy - tru th s a nod u~ Eli myt ns surround jng e pide m lo lo g y an d d 18'9 no stic tests in f'O ad ,SI lie rgy

~ Labmatory~€H?its - interp:reti n!g t h 9 eli n ioal releva ncs of a posi'tive ANA a nd rh'€lu m atold factor test, how arid when to' order laboratory tests 'in Irheumatology andl clinical i mmunologyfaU epgy.

We ~ootforvvalrd to! o·u r ,contJ]nueC! palrtn:ershmp ln IP'ro~id i ngl beHerquaUity of care to your patilents.

Dr .. lhon\!;J YUlHor, IBemnlard He:a:dl .of D€\P8IrmmMI:

Se'.!"!IO'f ConGI,II~.ml MEI'SS, MIRICP (liIK~, IFA!MS IRlh!!!:l]l1fl!a!tology, C3in:ic.al ImmY!'lo!ogy& AI!erm

IDEP'ARTMENT 'O'F RHIEUMATO~OGY, ALL,EIR,GY AND IIMM'UNOLOGY

. -.

The IDefllartmen.t of lUI eumatCl'loli"~ A!Uoergy and bnmuililology ii,sal nationa'ilancl l~gi'an;;M referml cenlieil"or paltierillts withl ~heuma~dl:ogic:. allergflc a;iiId l~mmliJnologicd iloor,dllllrs .. Apart firoml €"""XC€lIenoail1ll paili€lnt cam, ~Itis also;!ll rngionalUiY r-ecQgnized oentre for training, eduC8.Uonend resear-cll .. The cenillro sees morel the.1il 30.00001U~paJ~ilen~.8Jtl:end!amcesal year. withl more than 2,1000 new cases.

For '~he RhelUmatQ!I:ogyServjlce, paJ~telilts may' be refelllTed ~.o tiile il1ldi.vidua* (:"O.nsulta.IIl~.'s Pe.roon8J1 CIi11l1:c. The common ~neyma~o:rogical condiUorul treated. are' 1fhe'I!J!1I!'!iMOld arliMtis,Systemic:luPlLls erytnema,WSl;.!iS, goul, siPQna:y~oarliMtiS, Ilsoria~vo .alnthl'\il~f;s;, rsystemflc sclerosis, QS,18oarlilhlrriijs. andl ostifl0pOiwsis. Wht'il:m approp:lriallia, paUents may be [lfefsrred tOIil1€i rollowingl se:Nices aVSI.U(i.[ble w,llltii!l1 lTSH e,gl. di~e,ase"'SipeGific edu!osnon progr..ammes. I!j1JOUl,pr threra.p·y run by RiheUi ma~.otogy N'urse Olinicians. physiofl1!:sirapy, opCll!,patio:n,al~l1!eralpy, pocli;a,try, orllMpaedic sl!Jr'geMY. and. painsl3irvices.

The 1M IlilisclIIllQ'sk,eletal llUllrai5,ol!.illlildl :SelllVi>!::;ei:~ run Iby 41 OOf1tSiUIWl1Ilt riheUi matO:l.o,gis~s tmined rill mu~cUl'l:O;S!keletajl 1J!1~rasQJlGglraphy.. Ilit" l&Jrovidess:tate~of~tl1!e~aml: ·'d~,tgnoSills andl trea~men~ ,of r:uaU:en~s withl arilritis and soi lisSl"llit! rMuma,tisffiI indlludingl illlltra.ooulil.d~glJltdedl .aspir:13r1l,on 0.fjoililtsl, l:!iopsi:es. alil.d. inla.CIJJons,

The NiliJillfo~d V~dee £lapin liu·'ose,opy Servi'~\e prov:Ir:!esexam ina-lion lof'U~~e I1Ila_j"llfolcl eapill8fii:es wl1~ChIC;1.m beta1j·a.gnosUa il'lllpati8'iIltsM~hll certaIn disQiid8'1rS incllJl:tlrilg R:tlJy.lI1al.ll.d~'s pl1teillom€lnQiIl,syst€'mi.c ;scl~rosisamj dlerm!at:om:yosi~ls,

·The EJlay' Treatment & D iag nD"stic Cientf,e I~:rovhj:es anal! laiiY ou~pat~e:nl~ services in~l!.1!.d[ng inI1~i,IIe:n.oI"ll's cy.cl!Q,llhoSrphamlde" inrusioli!l, j,jll,fuis~on of IbiologJc agi3'JI~'~o.~ refi".adoi"y artlilliitis t s:pan:Sryiloal1hritis..andl minor Jl)rocecJ:liJre·~· in·.c!~udingr :minQ.~ saliVazy gla:Iil!J'bt~psy., .s,ofitissUI!e ~m:d-jjJint rnIee,tjor:'l!s ..

lI1e Clili lIIIieall ~ftlmtllul"l Dg" , Aile IDY SeNilc,D' Ji!S: run !Zl1l11l( Ib,y .consul~a iIl~.8~rnii1led ,11iI t I~! mlana;gel"jl'"lEjnt oHm",l1i1161

~ ndaller9,to: '~T~ro:e r.i. The' oone moli)ns,lJ;~led include aiNJIBiY allefgy, aner-gio IminOOQnjlJlll1l;ejlvitis. asUlma, ana,ph ,a:wp[Q d\!rm·· . iSs. I E!C@e.mct drum ,alilleg-gy. fOO(j' . lIergy and iI':IliQler.anoe, in;:!E!Jd v"6n,Qm,a'II'e'llilf. urliioorial andi eng i'O:~clm ... , antJl jlnma rry ii'inmul1l.o(jefjei~iIlCY diseases.

Skin rests for alieriQ,ens (e.,gl. cln,JQ, fOod, insellSt. aeIlQalller'g.ens). pr(Jvo.caltL"on I ehal:lenge tests: (e.g .. lQf:moo., ~rugl)!, dwg' d!€sel1ldriSa~ion, speeTlfii:G immliJru::ltlrleraIPr (fOr insent \1'el1l.oma:llie~[y. allergic ~hinitisat;ltl i3iSlD1ma), and mo~1hly i[l~rniV€lnQLl.s immuliloglobulill1 replaoemel'Tht (fOIl8!I'Thti!body defieI:enG~) are :a.v,ailable.

E-ducation and eGunse:lliillg is provided by the Clinical ImfillulilolQQY f.Alllerg¥ Nurse OHAidan" TheM incllJi:de allergen 8:VQid:r:moo, emefgelilcy mantil.gement. o~ afl8,p\hylaxis (iru::ludlfng epil1leph~rlile autol1l"1I~ctor use), use of lnha'l!errs and Mase'll sp.ray·s. an~ Sikitn CtU"E! f:Of ;;lJtopic denna~itis ..

Ou:r C~illliical Immunology LabomlQ,ry prceides d:iagno.sti.c~ests, fer m:eumatologi:c, a:llerg~e and immunologIc d.fseases. nlese i ncludeall!rtoaf~I1UJodY te$1s.serologi.cal tes,ls· forsy:philis, HLA.fI!2.7, 'total andl sp~ilc Ig:E 'lOI various aEiroalliElrg~ns andl mood aIl1eH'gens. It is accredited l)y the College ol American Patb.ologlsts (CAP) and: United Kingdom Natlomlll Extemall Quality Assessment: Serv[oo (UK. NIEQAS):.

Ourspeciallsts iln Rheurnatoloqy, AlIIergy and lrnmunoloqy

Dr. ThcHlIg'1.u Hor" Be'rnanl

Head of' Depilrh1n~fil; ,senior OonsilllltaJrli

MS'SS, MR:CP' (UK.)" FAiMS Rheum.a/to~ogV! CUfilieal

'-- "-_-' Imm.IJIIolog;y.& A1le;rg,)!

D:r"l(oh, Eie T;Ztlll1l :genlor COii!5'IJ1l<il'lt IM!I~IBS, MMe(1 (1m M!ld)" IM~CI?' (UK)\ FAMS

'"-- __"' Rit\elilmatolbg'l{

lOr. IKOJil!j1 Kolc 10:Oil Setll~f CO:ilSiUnan~

MBBS, MR.ep (UK;), :F.AMS .....,:::;~~ RI'I~umalcl'1gy

CUni,cal1 Professor Chllll:g ~l~ok Hoo S~nior CO!'ls'ulb;im Mass. MMed (If'll Med), IFRCP (GfaS,Q}" IF.A!MlS IRil'l,eul1ll!ltolog~. CliJ'lfical li!'lf!mu!'l·o109~ .& Alllefgy

Dli. IHlowe Hiwee: S~ew ,senior OonsilllltaJrli

MSISS" MiMed (~!'It Mea). FAMS

~=;",,;;,,:,,~~~ Rh~urllaltorcgy

D:r. Uong IKlhraii IPang S~nt9r Cons'lIltlill'\t

MBSS. FPlCPE. F AMS iRihel1imiltology. Cllllh:al ImrnunG:logi1' .& A1n~rijY

DIf,. UaIT!1H.U 'Vee Sen~or OO!1$il!M:a!rrli,

MB'SS, MRlCP (UK)' FAiMS, Rh~umlBItotogy

Dr. I!.aw Well1lg Gi:CliP CiO:llsilltant

IMBBS Hon~"(Syd!lley}, MFH'.lP (UiK)1 FAiMS ~_~~_",""I IRlheu!!n!ltQl'og,y

Dr. Yang ''Well'ilil H!l!Ii Assaeiata: PonsLlltan~ MElElS. MRCiP ~UIF\:) 'b"",,_~ __ 4..! I~~i:lmatolog~

CON'TACT' US

[lr. 'falw.e~ l,I, JI.stlnSI A~o1ate C'O,n$1JIf<!l'Yt

MBBS. MRPtf;l' ~,K}

DEPAR1'iMIENlf OIFRHEUMATOlOGiY ~ .ALJL.EIRGY ANII) IIMMUNOlOGY

cnnh:: 911 e'l lLevell B 1~nSIH MedicallOemtll'e l'e~ : 1635183621 8iD14 I aDO,S,

f,~x : IS851 1673

Opening IHoliJfS

M,on,day to, IFItiid!ay: 8amto, 5,:;310,m ·Saturtlary; 8:al!D to 12~3:0pm

114

LABORATORY TESTS IN

RHEUM TOLOG AND CLINJCAL

I U N·· 0.' LO. ' . G,·,· VIAL L, E R·· G. Y··- IEly Dr IBemOlfd'Thong;$

_ Dr ILeongIIKI:l!li lFi!iIlI'b{I

The Clil'iliicalll ~mml.il nol09iY L:abo.mto.ny '(Clil) canlfies out tesls:tnat are \I",j[:alror Wlemal1'agementof pa:tier:llts with lineu!'mato:i:ogic, aller'Q,iic ow immunol'ogic clisea:ses,. We offer tl1le 'OOlllip!l!ete r,angie of cHnically reilevanlt inves.uga~i'onsID!8it are Iperfoffiil,ecl 'accuraltely a nde'clo!!pe~t~tiously' ..

TI1"s Iliabcrmtcrrryse:Nice was inifiai'€d Iby ,clinicia ns to ~umlll a clinh::a1li :role and UilliS Ili1as immainoo our misS!ion. Th:El ra.l1ge of lests811'1l,d the wa:,y~hey8Ii'e nil,porl:edr:ue de5!i:gnedilo, aid the dl'i.lllliQi:an in hisOi~ her I~acti!oetllthe labomto;ry is undier tne mar'Qe 0;1' 211 pra,Qtii$:ing RtM!Uma~ologiis,twho Ii'S availa,bll:e f'Or disci!"l!tS:SliiOnsa'Dcu"Uit H1e tes~ irnterpret;::dion.

'Quality is veliY importa nt to us. We Sl.ll~oscribe to two leXilernal a!,l!di~ programs:lhe INaltO'nal !ExtemaIChll:aIHyAssessment Se.Nice ,(INIE:QAS) from UK aniCI the 'College o~ I\merica:f'ilI IP:athoil,ogists (CAP) SlJI.irvey t'roml~he lJSfA..

Our Service,s

• [J\liagnosUcA!utoimmuJiI€" Allergy and ,~fiI"Imul1liO!ltJgy Testing

• AUlto81'i1Iti'bodi,es in Rhe uma~ologry

• Or'9:an~~pecif!c Autoantibodies

• .Ane:lrgern~sp€:c]1ilic~g~ DetermJnation:s

• Syphilis $,erO:I:oQY

• Hiuman Leucocyte AnUgen. IB27 (H LA 827)

Thi6: latnlMloryoffers ~hes€i classes o,ff tests:

• AUlt081'i1lti'body testil1lg, im:ludflFlg: ~ 3,nthllJ,Jclear an'tioody

". ~nti~CCP (R~elJi matokl arltmrl~r;s)

,. anti-(h::uJIb:lie strand:ed DNA al1llti'bod,y ,(Systemic 1l,I!IpUl'ii ery~herll1atQsl.!Is) '·anti~Ro,.anti~Lal {Sjoglren's ,syndrome},

~ ,ant!ciiurdioil'lrpln,anilH;ltlliI:a2;gly'cop.rot€;T.n 1 Ig,G (AntipihQiSpliiiOlipid syndro.ffil5:)

• Orga'il1.,sp€ci~callJt~.oantjoodies, s:ucha:s:

• ,anti.;~hyrord pe:lI:oxid.lase (anlHPO), thyroglobuline'lilililbodry ,(tiillllIiloimmune thyroiditis} 11 asihimo1.o's thrymid'i:tiiS)

• TSIIH r'eooptor antibodiy (lRAB) (Grave':s ,(fiis,ease)

··anili·IN.ar and i4Jidney rmfuosomalantiOOd,y (anili"lKM),a nll-sfilil'Ooth Imuscle alil~i.bOOy ,(anIHliMA) (AutoimmllJl1l!8h€lplatitisj

• ,8rrthglomerutlar basement membKlfite anli'body(afil:~t~GBM) (Goodpasture's disease)

• ,anti~i\sil\et cell a nlHbody (PerniciclI.l!iS 3n6i:amia)

15

~ To,tal imm:un~II:O!)l:flli!1il E as well a~ foodt insect. venom am:Jiaten)alllle(i~en~peciilic immlln .. q,globuTfn E le)le!I's; (fri'g:g:ers ror rood! allllel'!9iY. ihs~ V~liIicfm alll~e.~y, aller'glc rhlilili~r's, ilslhma, aJ!.cipJ:c:.delimatli~r,s"l

~ SiP.eci01l'llisoo immun:aliogy te~ls::

• serum Il1lptase levelll (Mastooytosis. ali'ldalil:aphl~1I!axis. in slJlS\pecJede{plJivoca'll ease .. s)

•. antil'-el1ldomy:S!lal andl ,aJl~~~]sslue transglh.llltamTIII!18SeaJld arnitii"gliadTn Ipeptides tests (Ooeifiiao cliseaiS!E!' orgTuren

selili!$fr~lrV€l' emlel1o,pathiiY)' . .. .

• nitr"()b.II.lI:elle:tJ:~1i um .f.est, immuElcglldbulinG subcl8isses, )~~talli'llls toxoid Ig~aAill1body and S/HJpto~tlS pne.t!./l.wl1fae IgG"aul~iboclies "(P~iima!)(immode1iiiQ]ecy,

•. C,1 il1l'lrliltJimr qUla~I,r,t:ative all1d 'q.illJjinl~irtaltive·tes·ts (Her:e\litary ang~loedecm'ii)

A.uw·ardiibody t.ests: .A:NA., IRf and anti-COP

.Aiu~oanm:l(){.Iy ~~ .$Iho.u'lld only be' iilrderecl if~eroe :iiS a pre.ites~elinicall iSi!J$picion 1hat ~M pa~ielilJt Ihas ,;3 n 2ilil!l"Oimm:une

diS8'~,~e, They slirulutdi nO'll!)e 'lii~l9clais .. $cr,e:,eningl ~egts for Ima!iJIm~lltc ~!s~i3~es irlal gelil.el1"i1!'~ 1P.ep!!J'I!~li6)11. .

·~ntiniJrilie!lr :QIntibciclY (ANAj

~ ·D.th!€r~t1an sys~m~c ~:~pu.;; el'ljltlii'ematasliIls',(SlllE.)", AiNA Qallibe pO,si~ive ·mnr: • INormal :peopilie in eit"geoeral populaitron ~IUP 1'0' ~O~)'1

: l~ll~l9li1y p(f:Q'~:i:e .~UlP,~a3oWm)i1 . . . .

• Ilnd'iiV',lduals wrr~nm~m'ilrljy hist.o~ of o~h€iw 8li1ll:eimmune, dis.es!ses

• [[)ru:g~irlJ,(j:b!ced' Il:lJpll$

• Otl1l:erO:ii"Qan~~p8c:illic ·f,lutoiMlTil,une dise~$

• Gltn:er sy.p;temie Imelil maili\9" dise8tSl€sf 'o~li'l:neet~vei~issuef iClisea5.eSt,

•. nitesig:nirfioaftc:e Q"f a po:sij~ve testsl1ol!"dC! be inte:rpret~~i in lI1eo.llnwxt: Qflill~ 'Olil'i!l~11 P"(C~t:l2lI'.i'lli~ of ar speoiifiliCl . sy'Sle.[Ilit ~ne'i.!~a~ic cHrSeas_e. ~~€iMise: ~1:1'€i~u~ 're'~Q·en !~ 2: 1~6'40)a,nd 'ijiEl' p'.aalE:m~e.Q. J1,0mqg~l1ousi' spe.~ledl,

• 'nlil:ote~olanllr Imrjll(~,d~ are by 'irt'S,el~ 'oflm~H::lillraal sigrlifi~rioo.

~owe\ler, a sbJdy has show,n th!8~ 11'n ;e,o%. ef patr:en~§. wi~115LE, ialf It~a~t ~n:eal!.l!iI.a.ai!1litiltJ"ij~Jv was: cleteO~.~i b9ffjr'B"Qn:sEihj,f dr,stease; (l1\Iean 3.:3ye:rn~, mJl!xilll1JJ!m 9~4 YEl~rs) e:.:g" ANIA}."1 ;1::20, ~t!11\8 inll 7iBoAj" a:nti.cls JJNA 8nililbodIY ~S:% fj~Iie,.Q1ini~1 ~U::·V

~ Tine Jpm;PQrlii'oft 'eli' a~,ym$ltQnma!tj!3 !~~~F,)leWi~~ l(:.lQSi~ive~ANA WI1~ fiil~lll¥ ~evelai!lSlE iriS' pmba'flly !:ow ,g:rcven that loca11ly,U1e Ip~valliene8i.()~ ANA >11/4Q liS. 34% and ~[gva'llel1ce"m'SllE is ar0un;d 0.1'%,

~ IRhelllma:rold fador '~IRjF)

• The i.liliOtdence (;1f~F pGsiUv.ity' irtl,~a,.g with tie dur18tia.11I1 Gf disea;oo in mt:ieUi maroid ,mil1ri'MiSi (RA): al :3 mGl'lihJsi'i1e '~i~~nll'e ~i~ 33%1; at eRe 'l{e"aJ 1~ js 75'%,

· [Up to"~flI% .trff ~ Itlalfiern,tlS. f€lmalnrliJl'1lmatTv!€lror Ime umaltdi~ fact0:r (also !91@W1'li ,;:liS ~~€iooneqatj~,a meuh'ilaloidl 8I1hrm,s~)" ~lnQy~:hOUlirih~ course,of1ijeir JZlisea,&€,.

• Qt~~r Ulan RA. RiF '11:iIM J'il"iay·bej~Qslti~e'.in . .

NCll1mal jJ€OP!'e in a geneml rl'QplJllla(llf:Qn (~'~r)'

~ IEirdeliliy I~e.~~ll~! wU~:out Sll!.I'loimmul'I:e Cll~~ases, (i1LIp w' 18%)

• :Si~gren'~ s;~o.drome

• €hmniC' ii"i11r.e€,tjl.\'llll~ 8,91,. d]tlrlllliC h~atilis B, pulMliinal}' dh1LeaOO,s, tu~~mtllosis""!.

~ Amti~(;CP' ('€;~I:~c .elWllirratEJd ~1~i~ifJel

· AnUbooies~a GIr.:::P :alle ss s€rrliSitive gIS, alJldi msre slOOeiil'ie than RF ~~JiIIl in eady ,a.lfldfllllliY es,tall'ilTiS!hed RA

• IfI}llalV p1m~ ilet Un,e eventl:ilial(j:e'\.i'elo;pme:iIl~ iO,ro: R.A wl~ern. found il'i 'urroiiHeren~iatooai[iJj1i llltis - il'l Pili rr1Iioolarr' in(ljviGlua:liS pos:I1Jil\!!'s'for RIP' or wh,e 11000ve pa.l1ll'1lJdr'~.mie tJneuma~sm

• lIS a! mark.ef 6,FelliCsive di:s.e:ase ili'l ~

.. May 1m det~Oted in IlfIea'litl1Mi in~iilliliidr~2!ls yeers lc-eJore 'Ginset Qf clinieaT RA (Ipr,e-clinitilil RA) ..

.A~lergy Tests

,. AlII:ellgy is a h'Yp€iffienl5!~~ill!i~ly ~e.aGtian jni~ia~ed by spe.oiifJre imm.!J.Inalogio fllfremalni:s:ms: l!JSUSI'llly Ig:E.~J11II.eritialled (Iimmooiate !'elaGiiorHB.}or nOA~i,gIE mediaJ,tecl (no!1i,·immecli9rte.ide:ll.ayeor irEl"l1it:s1iioos).

.' .like' aUliroal1l.~i:bodyt.estitlgin riheumarotog¥.

alh!r;giOICiglica'~tesls siMlildi bee UllSeclto" con1inmthe ,dI:rniealslI5PucIon 'M allerglY IU.e. VIilt:ver'€:[h~OOl is; a. tem,pera1 IrelQj~:qili'lship lbeme€llll orise~: ,of. sympJoms an(jl '·si·gnIS . of alle'rgy~ ancl~he suspec{edl~llIergic t~lr'igg:€Jr, fh!~yshiOUld 'l11ot Itre Iillseljl a,s,scmaIilT!ilQ tests lOr alll!eI"Qry' iiri'a g.ene.n:al P:OPUl'~8J1jon ..

·,t:ot~l~gE

~ 'Genel]llly not -a VI@!y ulserul~estto, diagrnf;lse allergy

• May Ibe eleva~edl ~Ii'l. 60!·7'O% ,of' aro,pk: individuals,. trr patrilioular<alJer,,_ic rhiil1l'iiIi.Ls,aslhma 'and ~dopi-e denmatitl!s. M~y aJsoi)e €l1~\!'03Jm"d in nQn~all~ic oomfu~i)!;j.ns,e.g. pamsitie ~l'iIlrectio.n:5:", MmedglE SYIIlld)'OlffS (8 IJtiimary im m!Jn(ldM""liOi~ncy ,disorder)'

~ May be· rll!)mnIa:~ im Inrlmi~lgE-m~di*~a,fle;~9~, ,end IglE-mlecljat~CI allef9iY·~i) ,ijiru!il!S.alnd 'Wnrecft vel1lo:m stiing~.

., .sP:9C:i~C.IJg!E ~~'~ls.'fOlnr:i'rH'lalilil' allergel1is ·'(h~u~e,dliJsli . mife,; u~. d!Og. oooiWojiQ'Ii) are ul5,>e·ful tests.tll ide:gijlfrY ~bese.·.a'e.f'Qal~rg:erls.wi1iCh· are ,oomrnen W\ggers for :aller:I1]G"~lfIiniUs!! ':asth rna ,andaJtopi£; ,delilnati~l's in :$m:~afJofe." AlIfflli.damoo! measures '$re IiJJseflil.~8iS: sn adjulli.,rrltO dth.er. 1~[J[rarmaA'ID'ttlerapiE!!s in im.~ro\fl~g. syrmp:roms.

•. Spet:i~p

•. Si~cjil"ic Ig!~ ie~e!1~8 ~or il1liSSC,t W!l.iilOmli il~n.')l'lIieyb€e·.

WJfIife:-fiaood t::iomet, MelLOVII: h.cUili'let" ]paper W,a!5:~, :V!E!lIow ja,ek-e,t) 8're J!)'!seIJ.lIlr ~[] U1i,e, i(;le:mtifiootiom of '~rle lc:aUsa.~ir\J!18 il11ll*io'l in r~alie:n~ with insi30Cl: verne:m :afl~p:h~lallSis, wre.hm i.s common amQli'lgj mililtary ·servitemen in Sirig!al~Qre!.~

• Speolfllo IglE lev,e:lls ~r cfru~:s. <penicillbyl G arrld ipen f:eillO'ylI \I) h:av:e geljHllr:'allly IPfJerse<IrISi,tiviW oom~aJ1oo 1G' :sli;i'n tests, IJUlt gootl !!Si~ecifik;ily. it is US!Jiil'llly use6w1'ie:re sj~in t.e;s!ts eann0't be clo!1l11!' 6.9. dermatogFa,phism,. or whe'Fe Ipati8fi1!s aM UITiiii'bitte to sftlpantfoinirstamiAe.

ReW:er:en.C2'S:

1. Tali EM, Fe,W,ampTE.S'mOle~ JS, BWlmer B •. 0a~~6; R. PrillJer W', ~oo T, H<tmm .IA. Kald.m JR. l,l!ihila .lIiI'6. ~illi ~'lfil, MeDrJupt JS. Rothfi.elliJ ~F, Sm.9~nk' RiJ. Tah'a-sakJ y, Mk A, ~M MR. ~o~lol JA. f'ffinge of anrmUQle~r a\lit.riaodie:s!n "Iwaflh¥~ if'Jrlitfrll®a-/&. .!Iirtnm~ Rlte.lm]' H.l9r; 40:1001~1t

~, Te;o Sf'Ii. 5'001'1 PC. Ng S~. At!ltth;lntibod\l'9!> fn .111101' hO!$p(Ul!ls61d' Orisfflotl eld1NfIj. Sint@pOffl MtfdJ ~'9Q'$; 3!b500·1 '1.

3.1trb!!'c-kfe MR.MCCI~"'n M'f;R~e M'I1; :S"CO.ri{r1~.R_H,3Jen"f.$'·.r~,,1, James JA, Hartey JS.CeWiCpmelitl of!:l!l.tt,oan~llpd'~ ,l!;ieiQfe tHee cll.nical M.Set. 'oj l!iJfS1~fc lu{}.rJ'S e.ryth$aID~.uS', 1'1 &9i J Mied2OOJ,'

34,9tt5~3. '. , .,

'4', Ch~w FT, 1.1m,,sH, SIr1<Nijj1 HS, Qahll:a MD, Gcn Or:: Lee' aw,. ~liia ur. T!i'!i1 TK,EVafUaOO/i ,of tilll !!l:ffetfierndljy ,of tropiatIiJ/ ,Vr:ill~.fl illlcrJ .a!ill'om;!l :SPQji'S~ In Sill'9<Jpot:e> lUlerg!12rOOQ,: S5:3if~iX ..

'5: ,aeJ;e~ IF. Sbe~ LP. ClraQ HH, rLe:e' OW. Dfaglilo'5~" Ms:rlS for food

. MedJ'2li~Q.; 51;' 4,9: '.' .

rtfi!~ etmg HH: lI'1iSll:lC''l li>Mom lIypElrsemollh@y:

expe.cret:l~ 'lftiii' . ~ .:: 0'tarte~ ",eil\iJ'c;e in'S~~ap,Ql~.

~[Jgl'1f}r!J~":M(Mj ~ ml~~ 46,:53",,9-

The CIi:nical,llmmul1l.ology Lal\'loratOl;,f IproC€!3ses m.cJr.l3: '~lhal"'1l 36,000 ~.ests '8. yem. UsersofM1e se.l'l!lili'OOs of the- labem~o.ry iAGhJfde dOQtQFS foolflJafill'Clok Sengi H~spital~~ '$\~eciaUsts h~' .pliilva~:e p::mclioQ, dcmtorS il'l Polyclinics,. 'Qq]liltraot~riall or-g~lI'misa1ions~a1fld C!llil1lilaal ~¢ar-Oh"em.

Sf@UGHT

DJ" leo ng IKII'I:illi P1all1\g

IH@aIIi, tOnica! hlllf'llllln(]fQ~)i\ ltElOOWllll"ar),!

Semiorr C~ns(llla~, lOep.mm¢l'IlcJ RMJjnilil;to:l~. AIle~'i1iM'lniimUliliorogy AssriS~liIlilt qJ;taiim·hBJI. rMleQ~.GB.J BoaFcl:i ~iRlliS'llarc"')

Dr lJeong; IKNiT ~ang, ':is a Ge~ot- ~OliU~ll'll:ati~ rn Ibe< Oeps.ll1ll'fe::u 0<1' RelJmMOIOlYI AJ~erg)t aii'it! Immliiiflol09M.

&lr lerlilii.'lrd iflhlolllg, IH·NtI and S:elil~m 'OOnslllttilJrll

'De'par~liIiIeli'lt or ~liU!llImafo~~nl', A~e"9yaliltl Imml!lno.1pgi'l

Dr 8flmamd 'ifhmll ~s !i1li8lj:! Brut ;senjar (la~I.!Uali'll lin Ifl@ rDep,BImOllJt ,!if Rl\te1U'liO~~ogy, Aillergy am Imml:!n"o,1Gglli. 10liD lQiCk SeJ'lg' HJ!)Gpi1lal. H~ fMere.5it:5 ate Ins;~telfl'il!c lupw .. eF)fUlemi1~05Jij5, r,liretlllrl:a1toiCl ,aflhr:l!u~, d~!i.lg !lrie[gy aml' fOod flillerg!l'.; His ,miller passiOlils a~fl promalifillt::l paoolill flliID pfi!rrutJlI"'}' ,care e<lI(IQ~lo:n OD !ihs"'ma1il~<lIl1fd al1eJ'gjc. dise'acselO • .an~ r\I;I~w~gr ifIec ne.xt genemUen o,f' rl1euifnal~gMs and!ill~er.gls~srilil'l'i11\IiIiiiO!Qgl$_lS,

17

THIE REVOl

M,ANAG,E,M RHEUMATOID,

Tl1iere nas io,een a ma~l!;,ed paradigm sihiiITII: iiin the man'ag9m.enitQnn~ammatory alil1ritis. Wha~ used! to iDe the Ir!Olirn tOf uSingl theb':s.di!liona:ll IPyre mid~ppr-oach ofll1e last IMMMentiellilcenfury in tlli,e lffi~l:U'lagement ,of these oond u~lo!rls~ hais boon replaced byeaiiily aggressive: ~re-aIDlflent, with the aim o,f im;provl ng clini:aal 811l.dfu ntOtione~11 outoome.lhis IMs ibeen pal'UcllIl',91ly SOl in mel,Jma~oidl artlu'Uis (RA) where t!1Je booy of researchl hasbeen fn.

WHY IS IT IMPORiANT TO RECOGNIZE EARlV' RA 1

fill ere fisev,i:dience tha,t radiog.mphiuc diama,ge, II:05:S of f,ynCt1onand loss of !Mole mTnera:11 detlsityoooyr'S very ea(~;y I[nlhe ,dlise-aseaintd onCEl: started, i~ OCCliIJS at a aQn:si;smnI~ ifi'jte over time .1~ The :~mpa,c~ oif RAM n be deva;statingl and up to 50% ,of patients. with eaulliy RA alre uliNa:t:)le to do their j~baifl:er3 yealll'S (if disease. n also !I/€adis to IQ~her oo-morbitUties like 'os:leoporosilsand camiov.8'soular disesJ5e andi ~nese oomfIl iiQaltiO!1IS oonbWoume to, the [iilcf.l3',asedl mortality r.ates amongst RA pa.Uents..

IS fHfRE: ~IDENCE: TO SUP~oRt I::ARL'Y iFU!ATMr:Nl OFRA?'

laniCIma,l'k l~afH~rs goIng bajck b)liI1e mid 11990'\5: showedi ~hat del(ilLy in fnsmuti:OIllOf dliseasEl-imod iilYing anti-:meumaJti)c drugs (DMARI)S) led! to impaired ,clil1llicall, radiograph:i,o andl JuncUoiilal cnJltcome. Meta,~alil!alliy;8es of large paltiient. odhmts Ihav.e also IlFevealed 1hat Fe5iponse toDMAR.DS and :retenUo!ill lrates o:JT~i1e DMARDs alr'e m!!Jch better li:n earlliy smgEl'sof (j'jlsaase as oppo~edi ~o stalrting DIM!A!RIDS la:b~ in ~he disease course, S:ince~he results of these pa,pers: ill tne 1990's, more swdiles "Nave proven~l1e,eu:lvanltage, '01 ~ffla!Uiiilg RA ea~I,y I.e .. cwilhin the filifSt.3 mOil1~lhs of Sytm;pIDffiI onset with [JiMAJRDS. AJlilhough we will filot be~olJJ.chin;gl on DMARDiS inl UlJvsaltiticle,~I1e;re has been significant lresearchl andi fmproiVem,ent tin nill€ m,€dical treailment .[)f RA allowing me,umslli:Ologlists< to suppr-ess joint hlfiammaJ~iolll much more electlrvelytl1!anberore. ij • "I

HOW 10 MAKE .AN E,o,RL Y' OE,o,GNOSIS OF EARLY RA

!Jiiagno.s:f:s, of RA ~iS Imade by cam~ul hlslory and e:>::amlnatiolil andihe· e:<.cIusion of othelr diag,noses. laJ:Jomtory tests a re i~elpfi!,ll ltm~ notd'ia_gnostics:s [n.vestigia~hlli!'S likle rn.elJl matold fac,tor(IRIF). ar~ p.~~eiilt not only [n other mediics'~ OOJ1ldi~ofils (e .. g. chrlOnic hepa:tnis 8, s:uba:cl:.de· baoterial endacarditis,tubE!rclllTosis., sypl1iiliis. maliglf'hancy, sarooidosis to nalm:€ a ferw) bUlit als'O ina. snnalill lpen:::entage 'of nOllma11 healthy individ'lIJals.

From ciinica'il l11]story, botht.li!e duralJonof 'Ill1e sympl:omis and momingstliffiness (wh~dh lals~a!t leaJs~aili1 hour before malXiimaJ rmproV!ement) Inave va'J:l!Je in ea~liy arthrUls b;r predict

118

UTIION II,N

E N T a F ,ARTHRITIS

WHAT"S NEW .ABOUT Muse U LOSK.ELETAl ULTRASOUND AN[Jt HOW DOES rr HELP ~N AA '"I

The cun-entstandard imiaginr,;J1 teelim1.que iilS plain radiography tal sssess ter s~rucfl!Jra1! Ibone-d:amagealllCl e:rosiv.flj cha nges.fhes'8 struc:tu ml changi1lsa:m IlJ'lot only important in the diagnosis of RA, bUil.a'lool illi1~he 'Outoome as joiini ,(jiametge II!eads [0 poor ifyn:cti'ona~11 o!..!iloome. Hcweye:r, pliafrrl r;adi'O~rnphy is not the Ibest ~magi~l1li9 ~oo11 as :

al) erosive oMnges. are seen later intlile diisease b) the senSmiviTlly to cnang:9 m03iY be, :llow arlid!

0) ,the assessment ~s seen lnone pJlane.

Sinc€l:~lt1e 1980's" mlllsooloskElll!e<t:al ullrasound (MSlHS,) Inas ,evolved Siiijnificall1llly and iii: has many aOlvantages:1I

a!) pa!tienlflnendl.y

I)), salf€.~ n:olil irrvaiSilveWith :no' iOI'llJ!Ziillg radiatioirl

,e) multiple J~ints can be assecss-edalt ser:f:al time points Icll), struet~lres can be vliiewed :rn muJ'litiple p!1!anes

€I}' examination es n be dyn'amicaM real lime:

f) lesse)()'pel1's.~\fieU~'ali1 other mod'allitiese.g .. M RI

g!) compai(i,son with contrralalterall sfde 'or ot~'J!I!!r j,orn~s is possible.

MSUS IMs been s.flown~o detect very ,eallfly sligns of syniOiVial in~l!ammation compan~drosl~Ui1darda~.€lssm:ent toonniqll.les. 'With the use ,of Do:p,plerte,ahnologjl',~he seHlsitivitYelJnd .speci~ici~y in inflammajjon assessment ls impr,Qv€!d. Wh ille gmysca'l~a'II!QWs measurem€nt a'f synovial thic~e:nilng as in Ifigure (A.),Do;pple'~ detects a nd mleas~res the cha nges in vascula.lfity 'of joiints and sol tissues due to ~1ilifl.ammatiol1ll (8).. Wise-arly (j\~tectiQIil of SYfil.oviUs rlS: cniti:call: in makiing a diiagnos,tosai5: i~: allows~he promlP.t initia~i:on o.ff~eatment.1i1ne cletecltion of ong)Oing sYliliO,vi~is aiar ililli~i'ation of ~h€:mpy slJI:ggests inadequate OOEl~f\o],. I1lecessit8!Nng escali81Uon OF treatment to ImpJove long terrm ou~:come.

RA. From ~hysical ,ex.aminaJtion, i~t is som:e,times cliiffh:::I,ii'I:tto ,(j€ltelimin€l flf a paitienIt Ihas synovitis o]lil1l:~caIIIJy. HOWllt\ll€f;

MSIJ S also has~he ad~vantSige of asse:ssing images in ,~'iiffere,n[ planes, n,ence. :i~ pro\lli'des more ,9ccurare aiSioossmeiiltof€:rosive:cl1lang~S's (IFiig,lllr'lll! C WI1;B!ii88i possible ,cyst on plalim lradiographis as~essedto ibe am lerosion on l!I'lr1raSOl[m~i).. Olinically tI1iiis Ii's. relevant1llJS erlos[o:IlS lead fa ,d1amage., 11i,€nce: aleC'~f:iilgf1llncltIon o~m'le pa.'Ilent.

(11) i!1lvolvemen~: o,f 3j;oint ,grol.l!,pS or more wiii~n swelling of joiinll.s.,ffsipecially if

(2) hand joints are ~nvdl;ved:: wrists, rnetaca npophala:ngeal joints ,(MCPJ)aoo iPliOxrmal,inwphah:~ngealljoints(PIPJI) wUh (3) pain ,Oiil cOil1lpmSS:[lilg th:€ IMlCPJ ,Oli mma~alfSoplrlalaililgeall (MTP) joints ,{msq,ueezetest" posi!live)

MSU S has O1iher clinieeiil 8p:pl:icaHolIiS irnolil.l!dingl gl.l!i'ding ai8iPiral~[onsaliid dilicliI'l:i ~f1l.Ji€oti(m:s or ing,lllliclingl piliacement fOi needles iM bio,psies o~ lI.e sY,lIlovium (mer example in c-oo:eswinere If'n!lieclfrve aetidl!ogy is oonsideregjl).lt is Inighly lJliSiIFIlful in d'~a,gn08iiHc dill~mm:as.,a,n €lxam,ple beirng situati;ans where theclinicialn is lunsure if a: patilent has very early .synovi~is ..

are S8:.mlOitive 51go:s ~h;a,l [rtlfilammaticm Is, pmsefllt. a lihe symmeby o.ff:in\!'olvemellifa:I:~o has some di8jgnostilo valu,e for RA~

AIUiI,oughiiil1lvestigations ,8re net diag:nostie, if perfo:mted, basic Ifnvestigiationi$ like ErythlrocyleSiedim!3'n~ationRa~:e (C:SR) li3if1!,d I 'or ,C9ReacliiiV€ Pro.rein (CRP), cl1€atinil1l.i1land liverfu nc,tion tests ar-e very hlelpiu'll. mirier investrga~ior1l!s lik.e lil%rasoyn~! ,or m6tginetic resonance imagingl (Mlfill:~) lIi'ave made gr,ealt inroadis [iiltolil1e mana,9€m8;iIlt ,of fiilmlamma!tmy amthri1is.. AIlhough MRI is '~he mos:lsensitive imsgi:ng m.ocla.Tiity. iiltis moreexP'E!nsive. a,nd If,ess· accessii~l!e, In ~ne fo!Uloi!Mngs:ediofill. we will be: roCUiS]filg on ul~rasouf'td.

A1thoughliher-e is ifll.orealSilng 'evi:denoeih(iil~ MStlS ls a Va'11!J8ble tool in RA, mere alfe its illimiitafion:s. me :mai!1illones b~i,ng~hat U is lJI~r dep€,illde<illt~ iIld mqliliiffisai c~rlain amol!l nt: of training. rMone~heless, given~he increasingllllJse of' I.l!JtmISiQ'uno: in many rheumatology centres, Ute role of liI'li~msoiiJnd w,TIiI um::lQubtooly COr:l~rirluel'Ol eVQIiv€l .•

SUMMAR.Y

1 ) Tn.e ig~al of man:a.gement o~ RA is to rn;cogn~e: fit eaiily to enable 'early oonrr-ol of disease activity

2) liI1ereis no sii,ngle diagnostic testror IRA

3) Clinical S:lllspicio.n ,of eaiily inl~:almmat:ory arlhliliHis is sup,porl:ed by e~1I111y mOl1llling stilffhess for ;::. '1 hO!.!lf." preS811hoo 'ot 3 or more swollen ~:Oint$,especially if hamd joints1!lffi i ovolvoo and i~ :squeeze [est i ,~"comp!ressi.on aercss MCP.JI or MTPJ is positive

4} Cumenl! Iparadigm, in pl1a:nmaootl1erapy fOr RAifocu:s.es on €la~~y andl aggressive control ()f disea;stEl acttvily

5) MSUS is lliapi:dl,y becomil1lg an important. fma~~J.~liIg modality in diagnosis 9Jld ma_na,geme'ntof eMy arti1!ritist

FIGUREI'.

.' ,~ '" Increase Tn pO'Wer Doppl"er &~glla'l ooFll1rm~ngl aclwe sYflO\l\iIi5

119

.. - -- - --" - -'-' - , -. - - ~l' - - .,

i i_fU~J~·q M-~~T9_l.;2gX·'

.

n,e Depamtment,of R:I1eU!ma~ol:ogy. Allergy andllmmun~logystallflj.ed its lMiusculoske:I'etal Ultrasol,llncl Serv:foo in ,2004. Thel.re ;f!re :2 mlllsculosk.€lletallllllllilra;SO'!llndi dHilicswee:lk:liy ,and: :abo!llt4(JO ultrasotll nds a.1i€: lPerrormedanntll1alJliy,

Remiere noes:

f, PIn.\l;tUS r, C~ll'akaJ'l .LF,Safe WG", :Bi"Qot~ M,PafiI'W LE; 1I<l~1I I~, Severe' (I;f!1~<l:l declines, 1INOl'k df~b.IIIl:Y ,and'/~Soed mQrla-IJ~y

in seveflW rNo€' ,iVleJ,lma!o.id artRn'tis pa,rieJWssWdI~d o-ve.r .nine ¥.~~. ,MM!l:S ,aii:td RheUm.1Jism 19B4.: 27:864'-12, .

2. Stoff D( Symlrmfls .DP. C-auI/Ol! 8L, Po:pt1rtAJ_ .lOJ"lg la-1m OufoomB wh.atf,tJ'!1 ,mllumB11O.il1 <N11ffltisaftftF,2,O' years_

Lano!:lf 1981; 1;UoOa-11, - - .

:1 FeltS W. ¥eJln E.TIlee~onomic: impaG'l Qlfhe li'ooU1:natic di~iM~$ in me Ul'INedStaloo.. J Rlleumato.1 t,989; 11!t

4 .. ViSsl~f H: .Eadr D~'1I1Q$.fS' o:1'rlla-l.l\l1i!itC!.idla;fhdUsc .. Bil:stlPrBGU{IB ana! iRB'Hi!irol:l Gliflfual Rh!i!.I)'fJB1klJagll" 2-005 1.9;1:5a;'72:

5, Mlk!.!i.Ii: 'Tri'" Sa-ag KG. Crls~~ LA,,~rJll~ U, KO!~Jow RI!. Shell~:&II; C~m;m JR'. Marlalfly rf$~ associafl3d with rh9umalok/ attMtis ina plfO-spec,tiv,e cohOI'tO(·o1defliNOnM~tl,:re~uN5 .from' tire .lowOl ~menl~ H~alm SIiJ.dy.

Afl~ Rh8um Dis 2002; fn: 004-9_

6,Ander$Q)'1 JJ. FiM~ Dr; F!ao.to.rs predicl1flg ,:espom:e tOo hali!1lem tn me!:!'mOltoidarfljrili'S: .the .1:mpoffOj!l1'(:s' at

diS~iilse auralloJl. MMtis Rilecl:l'm 2000; 43":22""9" .

7. Al'fI,tb!l 0, Si1<JOlfl.n ,J:S. Tlre rll~rJm"/j/ojt1Brl/l'nlis p!itifl.nt fn tile dinic: compatil'J,g mare ,t:Ili!i1i1 1.300 OOn'sf!-w,IJl.I;B DMARD ~Ollrllle.s. Rh911mlOl~r (Ox{~ :2'002,,: 41:1367-7'4.

e, Soubtie.r M, Doagados M, How i~a.$$e.:;'S ie.arty .m~umi1tQid attlmWs III cml'1y crtmoal ptacti¢e. ,198'51 F\I'!lC1WB' ,i!itJio' R;i;'Slfl3rfl::'h Ciinir::!.!11 Rhflum!itbmgy 200:5 19; 1]3·!l~l -

9; S!"QWl'1AK. ,U$/ng ,Uil;IOI'$Olllld.to f<l~llli~ tlesr tHiil~a In ~n~~t; and .lm!na~ment al

1M, Nat Rev Rh~umOlir,W 2002,: 5:698·1aO'.

S.GHT

O:r. lialn! 'l':sui Vee! Senior CQn!!!yllarn

MBEIS. MRCiP ~U:K).FAM:S _ _,_----"' IRiIlgt:.um3;tologlY

D:r lien 'Jsui Y'ee is a $enio~ consU!Uanl in lilliE! Depalll1tment of RMumatol:Ogy. A![I€r,glya:m::! [~rmmunology, 'l,an Took ,Being [lFIosp1taL Her' ililt:er-ests erejn inrnlammat:ory amthlrilis, 'muSCl!n:Osk.eletal im~gingailld :s:ys1temiic II'upUlIS eryllemalWSl.lliS.

,.Ai"bE.R~GiANb,'~M·MUN{)LoGV

1 -_ .-J- :.:0 - - - ' .. ". - --: .• -.- ', -_~_': ~ ~ .. --.- .-: I _-

PRACTIICAAPPR A TO DRUG

ALLE

A!1Ii oif uswolJ!lid. have: b€lElifill 'faoodi w~tn pati:8lillts who report <one or mom ~,d\Ngl aUief'gtes". rn most cases, thiEl diagnosis '01 '~he adverse dlilJg r-eacti:on is fairly s~raig'ht,fol"W'ardiWith acleav r-eac~i:olll ~.Q one druglnat maiY ioe a tliue .drug allewgy, cr oocaisii:orullilly an adverrse drug reaction (e .. g. vomi~ing will1@ry~l1romydiln)'. However, levery now and; ~hen there willl[ b@ a palliiient where q,lllesticlIi1ing reveals a v.ague: fEHxlllecl:ion (iUf aJt all) of a ipossibil~ rash Tne:arly childl1lood, or a. number 'of ,events mar~ewew m'allll 'the nu mbell of drlll~s listed by' the pal1J~ent..

1llesesituiaHons can [be mru'Si:tra!l![ng for [bOtl1l1 'Iih.e patient andl ~lrIeir 'd'oc:t:or, and mla.y [Ilead] to a.li1xiely about flJil.ur~ dlru,9i Imadi{)ns, UIliTleceSsa'~ avoidsmae o~ .a rug'S or choroo 'of dl1ug '~hat. lis inapPIU,prialte, less effective" or needlessly mor-ecos~liy. line mollowing are someoemmo nly 'en!oolUlltered sib.l!!ations and lhow tl1.ey sholi.lld be ap,proaone~l

THE PATIENT W1TH IMUL frWJU:, DRUG ALLERG~ES

A ipa~ie.n~ may en.d Ii.Ipwitl1 'm~!litiiple drug allergies Wiroug:ij ooM~labellingl. ,or physiicia.II1's indiisoriminate or inappropriate lab8!l.I]ngof druf:Q allergies .. The patient: wh:Ottrtllliy has :multipl:e druga:lII€!irgies riB o;1it€-1fI tie e~(:€tPtion Irattlter ~han Ule norm.

Clinical111istory is kley to, approachingl apatiiE!n~ willil mul~iple drug allergies to assess os usality and m,e [I iktely mednanTsm, of ~h€: reacHori ,I TheilillOOlrview WOti'lid !be geared! Wwards €luCid;llltlngthe liIatum o~ eMh rmaction, the l€mporall relationship be'tween ingies~ion otthe s!uspeoled dliug and onset of reaction, coneurreet drugs and other conditions thalt might ha.ve ca~i$ecl ltllie symptoms 3.sMoocJ to,the dru.g reaction. Asidelfrom sp.eakingl to ltn:e paJti!en~: a nel family., tnlistary may' aJlso lbe obtained] m[\o.m IiL08!Pci~:a1 reecrds aM tl1l.rolJlgh. ()oJi1~ad~l\g olll1€ir :presoirib.ingl phy&teianS~0Ji mo.re mfilJrorm;tjt!oirl,

Adl,1er~H! lfes!ctions: tl'nlill are cllearly ncm",a'I!leNrgic (@.g. ep:iig:ta$~rftt:; pain wi:tI1 aspi~in) should be well dooumente(t Skin p,ncR tests and in~lI"adi€rmal 'hlls,ts :m<3{Y be tMli€!~ul {or immecH!ate allergfic I1€03ICtioIflS, such as IIllrti,GaIlfia aliliGI a rlgioedema, and! halve [o,eern well st.u:d ted ~flltthie pe'niciillhl '9lr-aUP of antibi:olics.~ ~n V,ii~1Ii.Q tests such as 'n:uol'esoont ellizyme fmmul1108!5:Says (FE ~A) aim also .eern meroially ,9vailalll'e, b~t: are less $e!11iSi~ti:ve and speiQi~i\o ttliJ6In skin tests.. [for nO!1lFimmedialtE! ,rescfions suchl as a ma:o!lllopa:pular Imsli!l, delayoo lreadings ,o'flil1e intraderma'l[ te--st can be d.one" Patdlrll1l'1lstlngl may algo bEl luseful] but i's. not \!Videly aVililatllle locallyfo:llevaluation of druiQ aller-gy.ll

As: nat all reaotionls or mBdlica;1joflsare :amefilable to this aoofvetes'l:s. (j'l1Illg provoca~ion tests arlll: also uiSi€~ul in '~he mal118igremelllt o~ a patienlt wirth mlilllt~p!lle dru,Q aller-gies. lhey should be' used mainly~o e:<:cIude an aller-gy in the S!e,tUng o:fa nO$l~sl,llgges~ilve ihis1tory ,ro evalua~.e fOf 0('006 Irea.elj'Vii:ty of re:I!ated 'd~gls or provide salfe al~e:maJtJi;ves,. and occasio.nally to estaiblish a. dJagnoslsaf aU®irgy rna; pa.tient.Wno81€:hiistory f;s slJIggesUiViEl buthas n'8ga;~irV€s'k!lntes.l.so.r mn VimJ, Wisfs formutum ~Vlotdance.4

A!n skin tl€s!ts and: pro,voca:l!liOnl:ests must be dOI1!,e irnspecTal:liood cJiini<C$ wiUii esta'tjllshedl protocolls, lHilder medical supervision, 8ndwith r-esu5cita1ion facillilties, 8illldshouid not be eene in patielliitswitl severe ll'iife.-th rearening reacth:ms or pregna.rilt patUents.

211

THE PATIENT W~rH PENIC~lL.IN AllERGV WHO REQUIRES, A Ce'HAlOSPO RIN

Although eaflly ~tud'ues r'Elipo.rl:ed a cross: mac,tivity between oop'E1aloSiporin'S and penii;Ci!tl:~fiI in p.a~iel1rt~ willi IglE :medliated re'acUons of aboi!.!t 5~1 O%,~nese were based on ea~rly generatron cephalospolfins whicl1lco:nltai!1l,ecl ~faoos o~ peni!oiHfln. The inc~d:€lnDS wili~hthird or ,roul1l1 gelllera~ionr OEl,pha'liaisponns is proba'b'liy Imuch lilower, andll!l1e jlilic:f;d~nc81 o;f cr~macti;,rjt.y in l'iIon-lgll1:, :me<:Hated: r~8icUons ltower sUI II. is

A IPra,c~rical ,a;pprOif3chl,iVOuldl ba to p€iii!"olim slk!i.1iI 'les,ting!~o P€li1'iiOi'lI ~rJl Q"tlii18 major d9/1:€rmlnant p€li1icilll'o~1 polylysine (Pr'€i'penf®) 80dWne ooptH:ilosporin :in q,uestio]1" to, de.t:elimine'Whellher the roeacl:iol1l WSI,S ~gE Imediiated. ilif s;kin tests are negativ,e,.an i!1!,oremrentall drug ~Mllen.ge to' U1N! ce:pl1alloiSpo~in may Itl<i!! done.~f s.kin tests are pos,itirve, ce:pl1all~oiSpo~indleserH3,i:ti\Z:aUon maJl' be carrted out IPcr'OV,i:dedllihe belile,fits. ,of UiSJiilQ n~,8 oepliNllloiSpoliin outw>€lighi~lh€l risks, .. ~ iildth,ere is IiI,O'alt.elil1atil,l,e:irntibi~LC whIch can !be usedtetreat the infedlion. ~

TH.E PATIENT WITH ANorOEO£M'A OR URTrCll.RIA ro MUll. TlPLE NON""STERO~DAL ANTII-lNFlAMMA lORY DRUGS (NSA~DS)'

THE FACTS ABOUT fOOD AllERGY

O.n.e of Wile m~lIIl1imestaltio.l"J,s o~ Ih.ypersensillilvity~:o NSAllDs is a.cute urlioof.ia allid/or 8ng:ioed:ema. This may sometimes also ooour in Ipatients wlitlil dhroni[io !.iIltiticariia or chronic iPers:~~tent asthma Wi~11 rh~nosim.i!,sli~i:s. The reac,uon uS!.iIlEdly 'oocum wiU1,in an l1iourof ing;€G~ionr af Ui!€l NISAllr.l, and! often occurs witI'lIl more tl:i'ilUl one tYP91 ,of NISAIID. This is an exam,plt€l off a liIorhaller,gi:C dru.91 :~eacti:on causedi Iby inhi olDon ,of the cyclo-()\X.ygenase (COX)-lI el1l!zy,me with resuilitant. fm::reased Ite:uk.olrr'iene prod.li.!otjonr •. ~ Patients wiWl, NISAID I1I}/ipersensitivity tend to report r,eactions li!.!ponflir:s1t e'xposure~o ,each dru~,;h but may Ibe able to to~~ralte C!Q:X:~2 selecJjfi\l€ liililhibi~lJir.ll :such as eto!iicoXib (Af\ooxia*). Wes'S patiemlscan iDe aUe:rred; an ~1';h0li'9mer:utal ,drugl pllJ.lvocatiom rest k), 'etorioo.'!<!ib cr cele>co~ibto, prx:wide 1hemwith an efil'ectilve.altematii\l'earnili-Plr~etic and analg)esic': jp'atiel'llits wh.o, l1:ave N&A~ID hly:pers1ensitivity and! coronaJyarlte:rydflsease in whom the use of aspirlin is iil!1i.dica~ed wOi!.!ld atso beneflit from a dliuQ provoc81tiolilr test t'(" low[j'o~e~ls,pirin or ,Cj:eserrliS.iIU!Za,tiol1li if necessary. e

Flood piliaiYs an irmpo:rtamt: role in II'life" in particular ~l1e Singapo.rea.n il'ite,~n recent. 'Years,~hel1e: [has been increased: illlt:elles,t and heightened public a\i!lareness of adverse faodi rea!cti:ons, wl:ii:ctill may bee:iltner (jli,le to ill imml.!!lne lre.sponse t'O atcod pfiOt'ein (e.g. "~rue~ IDodallierrrgy). :~aJctionsto phsmI1ac:ologic or IDxicmooo oomponents.(e.9. can:e~n.e or foodl iPoi~onifng). lntolem,11!t)e to fooel (e .• QI. Ila.QtosEll"in~dl€ralilce) or flood aV"erSion, However. PUtll'iiC perception and! wh:at is IPQrlrayed in~hemed'i:a lis o,f:!:en exagiger:elJte~l Here are a few oommon'l~ l1I,eld Ibeliefsa'Ml.!!'t food! allergy U1a:~ you mEli!! €lrlaQUntBr.

REFERENCES:

'1. Schnlyder B. ,Aprpr,08ch to, the€! pallitent. withl drtlliQ allS'rrgy. I mmlJllilol Allergy Clin NI Am 200;9; 29:40~1 8.

2.Brookow K, lR.om:ano A, Blafil:CiiI M"Riing J, Pichler W, IDemaly p, 'Gefll,eral cOI1l!5!tdera1ions ~orskim tes1: prooodure:s in the diiagnooiis, of ,arugllhypersen:$ii~~!;j!iity. A!11~er:giY 200,2: 57: 45..ti1

3 .. lhol1iQ IBY. Upda,ffion ~h€: mal1lgBm€lnt ();f an~ibiGti(; .a:Uie:rgy. A!I!Ie:rrgy Asth rna IlmrnnUllOl Res 2010; .2:77,,66. 4'.Thien Fe. Drug IhyperrensiUivity. MJIA20ID6: 1185::333-38.

5.Mh,l!nez C, Bhi!['!.ca~Lo;pez IN, Tor,res MJ, Mal.yQlffil6J C, Pere:z~lnestrosaJ IE, MontaiITiez MI, IFemaJlclez. T, Blancal M. Immediate allergic Irea:c1ions to cep!halosporin,s:evaluat[Q.ii1 o,f()ross"l"ea,C'~vity W,li~h a pane!11 of penicilll'fns a.nd cephalosporins.

JAllerflY Clin ~mmlJmol.2D06;. 4117:404;,-10. .

6"8z~ei~llik A. Niizan'k'O·VllSka E, Sanal M, Swierczy:nska M. As,PTrin.,ii'nduced rhinitis ana: asthma. Curr Qpin Allergy C[~in

ImmuJloI2~m1; 11 :27~33. .

7.'W'eib,erschqclk. TB, MUI'lllell SM. Bioehncke S, IBoehn:cke WHo Toler,ance~oooo!i'bs. :~11Ii paijef!lliS with inltiOler!lme to non-ste'widia<11 a,lfIti~intl!ammlawry drugs: a sys,~ematicstllUc~ii.llrE!(!j: revii:ew of~e lIteratl,J!rE!. ArC:h De~matQ11IRes2.001; 1169675.

8. Go!.] IlapurdTi€ RJR, T,€irsteflil I~S, Stevelil!so,iIl IDID, Simon IRA. Aspirin 'SI.ensilivity: Irmplica~rons fo;r pa.Uents Wii1llil coronary artery

di!5ease. JAMA 2004;2.9i2:: 3'lH7~23. .

YTHI 1:

COM 0

LLE .GY I VE V

Fact;

Alm.Qs~ 25% o~ hOlJJsehQI\::Is rl1~he Unite-d Sta,ies have al,t.er1.;)d ~he,ir diets because OF iii perceived fboola11!ei[QIY ime; famiily member. However.~he tro,e inctolenoe of[ood alll:erglY is rdlia~er tOI 6% In YOUlilg childmn,a.nd 3~% [iii adulits;l ~1iI Singapore, a Slimil8!F p81ltel1n h,BS been demol1l,s~m~ed where ~he re,$:li.!lfs o~ a self-ilfepol1eci Cjues1i.onnafre survey on ~l1e pfii3;valenoe offioodl al:l\er,gry I:n s®conda,uysclilOolch Hd'lr€:l1li over-es~ilmate,rj '~he prevalence jb,y at, least 5 to, 110mQld.~ This serves to Ihigtil'llig:ht the (;;:l,m mat tIiJ,ere is great subjectivity to 'reporting fomjla'llieFg'!i€'S, w,nich maiy Illead 'to IJ! nn€O€~s,ary ,elimin8JtLondiiets .. This may l1Iiegatllveilly !impact theg,romh slldJdevelo,pmeni o~ 0111 iild1ren :ancl adults,. a ncI adiverseiliy alect ~h8 quallUl.yof Iliim ,af .a;ffec!t~d indJiv~d:ua,s 8liild their faml:Ues:.

YTH 2: FOOD .ALLE OlE. AR NOT DANG 'ROU

fac'e

Food aller-gfes may result in BfiliaphylaiX:l:s whi!c!h Ii'S. II ife.;tl1reaJteni!1l,9 . In Westem E!~r'o,pe 811IJd ~he Ur1lited States, roodl ;311 re~lyisU1:e ~:eadiiil,gl causeofa ii1a~y[axis am.onglst IP~tie'lilts tr~at.ed i n~he: emei[g:e1ncy delparlimePlrt. 3 The experienoein oUf centre is lsii:Milar, Will!l1if1oocl~i!1J:,j'ucedl

ana:p~hylBJ<is aoeounting fur M.8,%of cases of anaphyla!)()ilS IrefelfTied to US"~

D[,agnosf:s o~ 'food alll'efgry: and iden'~nf,r:caUofill o~ Ule putative food Ii'S t1erebre im,porl:ant as pSrHelllts I"lleed' 1'0, be ,oouriHlieleclallol,Jlil Sbicit9~void8n:oo measl.lroes" rOO.dingl fbod: ~labels. safety' ipr8{;~utioJils w,Mn eating Qut,ilUil.d a.cute mil1ll'ilagemel1lrt includfnglM use of anelpiinep'n,nne au~o-injector lilf n~ssary. n [IS; not uncommon to, enceunter piSU8!nts, who have hadithe]r seCQIiId ,011' e:ve:n th]rd B:piioode>s 6:fiHlaphyil:axis~r()mfood! anergies because ·Of poor undiE!,f$tanclingl Q,f their ,af'sease.

"Y1'H 3: FOO ER I ES

C ,u _ E. HYlPERA'CTlVE

ANDPROBLE S, TH

CA BEHIA IOU E a Y

Fact;

1"'1000 allergiesarffi lilrtediated by immulil:oiliagicall paUyw,ays and can bel classified fn:to ~glE mediated or non-lgiE. mec'f[ralted:. IgiE mediated roootio!1ls IrElSI.l!Trt Tn ul1f!Oari9J, anglf:oede,ma,. acute rlilTnocoliljunctivilis, a.cut€: asthma! and, an8,p:hylaxis. These USUI:ally OCCIJ rwi,thirn 1i houlr of ecnsu mptio.n of tn,efuoct INoni"l~gE. meelia~ed reaotions, ~nclud€: cO.nditions such as[ood~prote:iil1~in:dlJJcedl en~e'moo:l'il~iIS or IP.mcto-ool'ii~~s and! ooliacd'~sease. ~

YTIiI FDO~I_ CAUSED

Fact:

PesJ1l)1;ts and tree nuts a rrea.mong:st ~he top ca:usesof fbodl allt€lf'glY in W€!stern coulillbies. Howm,tS'r ,Utl~iS. is much .1€'SiS common in Sfngapore. The most common oauseof foodl~ind!l.:!ceda.napl1ly!llaxis in Sing!8,pOrean cnii'liClren is binji':S; :nesL~ In adu ~tSi the causes :n€: slifghtly ,d:iifferent withr crustaceans. (pmWTilr, amb, lobster) and mollUl!sks (abalone andl IimpeJf)aocoounlti:ng~or o,ver flal~ of the cases 'of food~ind:lJI!ood.~mapl1lryil:,axis.~ A moont ~slfjjdy pe:iiifmmedl fn our cenlresh,awedlil1at. 5:3.8% of fmmediate food Ilrlypersens]i~i;v,~ty in a,ol!.dts wa!s clue to crustaceans, fOlloweci: loy ITli"L'Olil:lll~Rs (18.9%) .and Ibird's iiilest ,[9.5'%) .. A!lTemgIY to fish, lPeanlfiJt~tree IlFlutS, vegetables and f1~U!it were 'unoommon:~

I YTH 5: T NEE!! TWAY TO DI MOE F OD ALLE G' TlESTS LIKE FOOD ECIFIC IGG IJ THE ALe _T TEO'

I TH - aUG" l.OOD

Fact:

The ,evalr~ation off fbodi a'Ulef'giY begins 'Wi~h al'oetailM m,eclica'li history and physicall examination. Numerl)YS, di~g:nostitt.ests I1have been !prqposedl: as ;lH:iJ'uncts toclimica'lllltlistory~Dr conriiimrlin,g ~he diagli1losis ()froocl allergy .. ~

Tests~hat are wellstucliedl in,ol!ude skin prick testing (SPT), in~vli~ro speci,f,jiC ~:g!E tests ai!il!l:l om:~ cl1aJlI'enges .. 8FT's are u:serul~o rapidliyd!eIflCllI1S,tr,aoo 'th~ p.r€S€:fil:OO o,t ~ 9i~selrlsiti2ati0l1ltosp€ciilicklOOs, liMy are hig'hly SeI!lISTit~V€ but less sipecific,and :80 Iitlas a high fil,eg8JUve predictive valtiJe. Comrlll:eroia,lly prepered e:<ltr>aotsalre often used, a,nd whe,n ul1lavailabll!e, ml'esih~ood malY he . ll!secl in a prl'dk:=prick" test l In vitflo testsmor fbodi Sp.eCiiflcllgE an'(iibf:odies may be u,sed in patiEM1~Swho tilt9v.e SeV'E!ire skind'irso;r:(j'ems; am an anti.JJrll's:tamJnes or who have elliiquJ;s:He S~U!lsiitlvi,W to oolJita.tn loads. Aglain, a. pasi~ive test nas i[oW sp.eci~dty'" and Ibetwtlll€;n "10":.2:5% (lif partTents Wu~ ne:@~tiveliests may' still have a positive ellinii:cal reaction. S ~ n gene,ii:arl U'le r-eperl.Qire Qwre's<ts ava~!able ulSing tll~oocl tests for foocl...siDeciflc ~.gE [is fewer~han Uliatif:or skin prick. tests"

Thedouble-blindi, pla.cel:Jo-controll!edoral roodichalleng:e :i!s~hegol:d sml1l,Q!ardi for ilire diagnosis offfiood allergies .. IHowever, these ca.n be oompliootooand Ume-oonsl.I!ming to .aliTange, 811l,din dli1ni1oal practice an opeHl cl1laUlange or a .siingle·lbl:incl dnallenge is otten don~ in~tead"' All tl1esJ8tests must be done ifill a ooiiltroliliedselilingl IbjlEl',xp€:ririSnCfldi p€!lfSonl'll>€ll, ,otYristanlt l1IOO,nitcnili1ga~nd li€suscitaUon equipmel'llit 8vatila'blears i~hey [pose a risk of iii r-eacliK:llil,

Te&ts suchla;s Jood-s:pecific :~gG test'S, cyl.Q~lY}(;lc tes,tlng (wIilTit€l blfoodl cell chalntQe in Il1um:bersand S!~€, or Ulta ALCAr [f\rilltT:g:en Leukocyte CellulsJAililtibooy Test] 8ndilintra,dermal provocation tests are inappro,p:riate andllli.llilrel'i:able 'fOil the diagl"llosis of food aHargy. AiJithoug:h some ,of 1he!se tests are pub!I'i]Qii.;red as ibeh'l91l1or food irn[O!~aran:c~'. the, scientfilic clatalFor the!se are not n:libusL

Refel'1enaes:

1. S~Ch9lW ~,.SO!mp$¢!')HA. FoOO A'wl[Iy,J AIl'~)' CNn lmmunof 2006;' H'l: :5470-475.

2, G>erez IF, SohSE, Sofl JYe~ ,Oll, Prevalmr,ce olpe.anul ililld tme-llut ,anergy Jrj' Singapore teenageR£" -ed"males Item a q!.rel'liicnnaife 5U1'11fe]K,al/eim'

~stitlg"'ndfGOO ahi!ill~.n{1€ts. World Alfe~y OIgtirJI,Z J .2007; 3296 ' ,

3, CJ~ntj;lroi'llA, SpetS!~ JM. ~ Al~l[IY,: Rl3'vfew, Clasi;#icOiii'b!l1 'OfM Ct~gn.o~J$, AIr~J hlt 2QOO'; 58:' t -10.

4,TliOl'lg sy, Chl>'l'l.Q' "II<, LeWlg KP, Ti>l1:Ig C'Y, Chlit9 11ft. Anap.fly/~is Jrj adtiltS ,~le~ci t,ti<l' r;!inicaJ imlnlJnG'logy!alJergy oeJlfj'E) in Sin.gapom, Sil),gapore Med J 2()05; 46; :5:2'9-34.

5, Sh9k I.P, tee BW. FOod <l'~y III chJl~wrr the Slnga~ st~ry. As~nPOlC J AfJelfgY }.\'t!m!!ft9i1999; 17:'203;:6.

6.rPJOI'lg :l3Y, CIleng'Y"K, L,eoJ'lg KP, Taflg ey,. Chli'9 HH . .frnmedi'iite .fcoa llypeP.l&nsilMlyam.on.g ad1J~ antemiing iii clinical rmrnlJ1lG'logylalJeI'9Y oentffe ftl SinJ]litpo!fl,S\ing:!i;pw"€! MoM J 2007; 48; 236-4ll:

7, Scheirie.r Chafl3n JJ, Nl),Wl,!.s:ffY ·SJ;RIMt Mfliet 01:1, D&l.gno.slll9.md' Mal'1agil1!1 Comm~n hJ,orJ A{f!!mf.e.~, JAMA 20'10; l03; 1 M!l{l6. S, G>erez IF, Silef< lP, C/m.,g HH. Lee SW. DiagIl05!TC .tests {:br {:bod a1fetgl/, Singapore .Med· J 20'10; 51;' 4.9.

lheD:epall1lment: ,of IRheumaIDloglil{! .AJII!ergry andilimmunoil:ogy started. ils Clhlical ImmunQlogilf/~ll~eugy Se Mce as ·81 s!.l!.b.,special~ service in lf~68. mlnere are pres:E!ntly 3 seniorconsulta,n~s. 811ld :2 assoolate COnl$rl!.!ltants "l.~necl in tl1 iis 61] ~speclalty.

SF@UGHT

Dr. Chl~a U Ann" Fai.t!hi J\i$$Ociate CiOrlSiyll:;l;ni, MEIBS. MflCIP (UK) I~LiI1ii8,tolagy. Clinije!i1 Ilmmu.!!1Qlog,y' &. AI~e~gy

Df Fai~h (;!hia u.·;\nn, [isa.n assoch3llte oonsuU:ant im lillie D:epalltment: of RJIh€:urmatollogy, AlU!€r'91Y a.nd ~mmuno:I!ogy, fan Tocl( Se.ng HospiitaL HJ8r ~nterest.sare in dn!Fg and mood ~lIeugy, and musclJIllOl5ikeleta'llrima;ging.

NEWS

UBT & H2 TESTING

.A)I Urea S'retil1l'est I(UBT] B)I 'Gllllu;:os,e IBreldhl 'Test e)1 lactolSe Breatlhr Test:

Management ,of gasrrointest[nalkalct, disealSi.ElS is cOl'llstantly evolvingalfilld especially so in lliil!s elm, ,of lrapid 'rechnoIQgljca~11 adV8IliOOme!lIIt. He'nOO'i these selVliroosoffer an alt.elinative route far '~he management o,ff your !pa~i:ent.s wilhg8!s~lji()il'llltestina'll idilsord'ers.

(A) Ulrea .,reattll T'ast (UST)

The~3C Ureal Breaith Ter5:t(UIBT) is one Qflil1e :most important and accur"8~e. nOrl-inva'sli;ve methodswr deteclflllg IHelioobaO'l.er pyiliOri irnfection •. S:ym,ptoms.ex;pe~iienood: by patien~ may include e:piga's,tric pain, abdominlal pain. ~oose stool:$, nl9,USeelJi· less ()f' appElitite:, vomii~lngalfilld ha~rilrosis.

Any Jpanen~ who, nas .any ,of tt~!e' 1~II~tW,jng cUagnoses $ili1o!.l!Tdl be t.esteclfOr H pYI:o.ri if not previously doneso: gals,bie ulcer, ,di!llod8:l1al uloEl'[,g1a:stritis,. dlllodiElnitis, gastroH1t.estiJ'fllal mmaplasia:, gasllJric carcfiiloma andl MALTama,. P.atl~ntsa't)out to bEl: oommemcedi om long term warmril1lmSA~ D tli1'erapy should be checked for H IPil/tI:Ori. We wO·l!dd. reoern mend post eradilo.a~iol1li thiBra,py testi ng to, ensu:re $!uccessfliJl eradication;

(IB) GII!uCJose Bre:iJlth Test ,&. I(,e) Lactose Breattll Test.

The Gll!IOOJSe ,(small ifllil:estina'l: baote(;ial over'Q:K)Wtn) and! Lac!tose Br-eatlm Tests ere ifn'l.ended~Drthe evailuiBitiofli ,of 'g!astHii:n~esUil1l'al disorders such as bloatingl, (l~!ucm:jiO diarrhoea, cO!1Lsti:palion. Patientse~perlienciritgthefoillowing symptom!$; may 00 rmerl1Eld for t!he .a:oo,,..e tests;

ill Ab d!om,ilnallf'a iIIn for illilvesUgatio:n

3), BII!upliing Ilfll!aluilenee,ior illlivest!iigaUoll11 5)1 IDljiallil'ihoea in IIIBS patients

ill Halliiws:il$: (B,ad B!reath)

'9)1 p'O$,'t Alnti bione D'.ia rrheea

Appoillltilflellll1S:

Rease ~I OU, Ap,pGi(LlIrnffit IiWtll,[JE!: <lit ,6357 80001 finom ft.olOCl&l~~:o IFrid~$, 8;,.OOam to 5,.3,Opm, dlmld 5:!wma¥S. 8.'Oij~m liIllll 12.JO,prri.

:ClrIoo appoil1tw'u~<i1!t has bWIii! oor1!flrm'ed, lPr,e~ tcmp~~Ure appriopl1~le !\'e!cpJest mrmf'l' 011:11]] MlmJd,iU.o 'YOUi' p1abi:ent

Rease brief your tle'bl'erJ!t ~I tihe regll.!lre;I p~aratlof'llij" IlfiiOir to his I he.l:e5t.

'iIl1e patilerlt lis reqW!&'ed ltJ !~i~Elr Wiij'J1 Uli~ Test Req~est: Form- at: litIe fi\l:!gl~~ttcn ,Ctiuiilte;r.

l?atient pf#OmlS Ute ties!; at C~ir!i(; '2A, !Level 2, Noo1cal Block. ian 'fCIltk Sermg HQsp:JWI.

2)1 IB~oa.ti Dig fo:r illl1vlesligSi~jiollil 4)1 Cllil romie Dial1rhoela

6)1 Diil311i'rlIi1oea in IDiiiabetiilcs

8)1 Illrritable IBoiwe,ISyndrolme

'·For B' c.opy of the R€tqu~ Fo rmsarr<J ,pffiparatlon Ins,tructian~ p.~fiJ: (:(Jnt~d Clink: 2A 81' 6357 BOOB I &157 8009 from Mondays to Fridays, 8 . .J.C\a m IitJ 5.3Opm and Saturdays. ,13', 3aam UIJ 1.2.3Gpm

Rilltien'l:'!S.1iest RH;~$±

LiiXll!ll m!mpletion of~e Iid,the r;Jiiltlent'S results wil Ilefll!l!lECI Ii:) you Mbh~!i'li 45· haucs, fo~~ed bo/ 'time maiWill1Q ,of ~lme test resuUs to U~ ad~ess ss stawd

11'11 time Requ~t Fom'il.

f'i):r mq;uhie>, please 'W:rl~dt C~i1lc 2Aat

Tel: 6357 8008 / 163157 8009 from _Mcnd~s 00 fridays,s;, J{).am tin 5~3011mand '5aeuroayS, ac30~ UI 12.l0pm: '

stop TB. start with T -SPO

lJ'iJ,ill' majolill'ly ()f peoplie wliJ~) oocom.e trrlmected wi~1h ~!i.!be\lrClllosis (TI3) do not delle:llop diseasesyropwl'ills .. R~Uler:. theTe, iMcilli are oon1ro111.ed by Ule body's immune sys·tem, liiesid,~r:lg ,rna stalt~ of ~la\t'ency!·.,This is i~nOWI1li as latent TB fn~ectiQn (ILTS!) .. Individl!lals: with LTIBlcan go 0111 to deve1io;p active 1B ej'isease :if'thei~r immune· sys~em becomes compmmTs!€de.g.. by ~lhe l:i'S'€ o.f immunosuPPiiessiV,e dmgs orUil.ed"sve.lopme.llit ofoo~morbj:~,:t~1iliesi.

W!hilllS:~ ibact€l,lfial cult!lliWEl: isa,lili €lll€:d~Vi€l ~GiCilicl Standaiid" for tl1l\L5 diagnosisofeJcl:j:ve TlB disease, 11110 suchstaflldarx:! ,e:xji:sts 'for the diagnosjs of tIS!. Until the development of modern ~i~lillterf€:ronGiamma R!€lea;8€ .AS;8:alfS~ (l'GIRA:s.)., thEl: oirlly me~hod ~Qrili.e diagnosis ,of L TIEII was the tu:berx:luU n s!~rnte'5,t nSr),.sometim,es calledi "Mantol.i!!X". llneskin tes~ is :nolo:noullsliy IfnfJIcclii m~e, lead'rrrlgto false positive ImsUiUs ~,n BCG,_'vaccil1ha~ed ~lrldividLTials and fatse negB~ives ~lrl Tmml.ilnooompromised patients. lin addition the test is 1ir1coniV€lnient andl dimifiicliI'lit to peiifoffill.

lGilRA tests ,offer a. slgnificanlt adlvance! in~ne, ,~j'iiagnosrs o~ liBL IIIGRA,s ,d'liagn08!E: infection in :fndividLJ,als witllli bo~t1 L 'f1B'~ and activefB by detectingl the presence of' sensitised elector Teeilis $ipecific to Mj;cObaclerium tll/)'e·TCI.!/osi$ '(MIl1B,~,.. In ~Iile t'eslt,an i[ru:lividual'g whTite ce:ll!s aresfim!lliatoo wjl~n anltigens ttl:at. ere very sipeciflc tp MTB.8I'ltd, if MT6"si~ecific elfe,otorl ·cell:s are Ipresent Uley release tiM!! :cyI..ok;in,e [lilterfe'i'\Iln gammal {mFNV} which 'e'nabl€'s diagnosis off infeotion.

Sinloo the appeara1l1ceof these ~estsaroundl .8 yea:r.5. ag()'~ one of lI.echa!llien9ieS fur thle innovaltol's; of ~he new tectmolo.giyll]!8S Ibeelln to, accLWralt~lly ,estimate sensitivity aUld Sipecificity for lnu in !he aloseno9 of a gold s~i'3lndard.

F'or :s,pecificity,. thl.€llbest i'3iPproach is to sell!€ot a p0\pulati:oii'l ~hat has a very low ,Chanoo of being infected. wli~h MyccIJacleriunJ tuberci.lfo.sJ's; and: to, then calcl.I!'I'ate the lPerO€ntagethai~ are n€gatiivEl:.The study by Bienil!:. i!1lllild Cihamg~ is Dillie of th.e most. oomprehiensivel!o, dat.e an8'liy~iln,g Ine speciWicRy ofth,E! r..:s:POT. TB testTll1:e p~pulationtested W<€lr:e am.ong:st tlill~ lea;st IikJe1liy adilillil adhor!: to be: i IrIfec1.:ed w:ii~1h Mycob.acterium t-uberoulosis, comprisingl tI$~bom. US I1Hii!VY Irecru.its91$:sfgnedl as ~I~ow lrisk.~ on thll! bas/iis of ~rgorol!Js €xclusiOilil cl1i,i:eria, .. Amongst :218 ~Low Risk~ slJIibji€ds, only :3 were IPositive with T-SPOT. TSalss:ay providing! a value of T~SPOr. TB test spooiifiilQity of' 918 :9%.

96.,9%3

This is potenlia'lllythe rnest accurate rneasu re of the si,pecincity ,of me l~SPOT _ "8~est avai!a~lie to ,diail.e.. Some sipecificily 8;~!ijdie~~ conducted in int:effi1l,ediait!€. pr€"v"3lef1l:C€l se,~iHg:S Sll.lch as South IKorear poientia'll:y IJI ndelresUmate the Sipecificity o.f~l1e test. lJnfOrlil!.!naJtely moontly py_blished :meta~al'ilialyses have Inot b:;I:uded tliIe: stu dry mrom Bienek alilrd Changl, whioh was ofil'lly lP.ubT~shedifili NOivem'ber 200lfl

Re'fer€ ness:

1. Meier ~clJr J Cfin Miorobiol In'fecl.Di'S (,goa,oj 24-; 5l2'~:53\6

2. Ze.llweger~ ar .tNTJ TUBERC .LUNG DIS .(200:5)9 (11)': 1242-t2'47

3. .~/en~,I( tNT J TU~~RC .LUNG DJ.'S .(2Q091)' 1:3(,11):14:16-1421-

4. Lee JY,e{ at Eur Re5jJif J (2o,O~J 2'8:: ,24-30'

FirS'~I:Y ,s~udies have l:ii8.€d acUve 1"8 dise.ase as, a Slurwgail:e of LIBI, wneJe' [ndividllLills wiilih cultlJl:Jie ool1lullrmJed disease ere tested willen IGRit Stuelies II:Jsinglle T~SPOT. TB IGiRA ii n ~his way' ihaveshQw,nliltlalt up to 91%~ of culture confimfloo

active lIB easels a'fie posiliive: by '~nlii5;~GRA. lillllM

Second,liY ,some studies h:aveoompa[redl U'le cOl1relaticm !between 1S1 and T -,sPOT.. TB positivitY81lll.d levelll of e·xpOSil!.!re oiIT lindivicll,;!ali!s~g an lindex case o~ aotive TB. ~non)e stich :!ii:wdiy, Zellwege;r ,eta:l?aonclud!ed;"TiI1€\ r~SIIFOT, rs tlElstoon~laltedi significa:nHy' with the history ar erxposUife of each subjeotto the lnde.x case anol was !'i:a,telJffecled by Iprior BeGi vaccina.~fon..1i11€;TST did not show a slta:tiistf:cal eorrelatlon t~)exposUi we history and was :5li;gnificalUllIy affect.ed Iby BOG vaooTnation status_ ~

The Xpert. ant'i'h'iistamine fair aUergies

!I. ~'Ii',o·elillrJIII'l:i ::11:'1 Nil ~t!~~!l!tI;.~IItII!!I!'~!!I:

GIIlI)IIoSm ith I< ~i Pile

'G'lllxoSrmr,till(lln~ ~o U_CI 'MB.KIl~GaI1rMJy~m.oo.~ f~ leb{I!i~'~ Fm:: ..e.5moo4B25

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