HEALTH DOSSIER

HEALTH IN THEBALANCEFrom third world to first, Singapore has garnered many accolades – the Republic is ranked by US-based research institute Business Environment Risk Intelligence as the top investment destination globally and is recognised by the World Economic Forum as the most competitive in Asia in terms of efficiency.

Rising standards of living, the availability of good housing, safe water supply and sanitation, and access to high-quality medical service have helped to significantly boost the health of Singapore residents. We are eating better, earning more and living well. Today, Singapore’s life expectancy is at an all-time high of 82 years, up from 72 years in 1980.

But much like other developed East Asian urbanised

Affluence brings better nutrition, greater awareness about health and better medical therapies. But it also brings lifestyles which are not all good for us. We speak with eight leading medical specialists from various disciplines, who share what’s happening and what we can do about it.

societies like Japan, Taiwan and Hong Kong, strong economic growth and increasing affluence have brought about a set of “first-world” issues. In addition, our declining birth rate – due to later marriages and married couples choosing to delay parenthood – coupled with a rapidly ageing population have created a unique class of health conditions that need to be tackled.

In fact, the available data tells a sobering tale of the state of Singaporeans’ health. According to the Health Promotion Board, one in four Singaporeans in their 40s has at least one or more of these chronic diseases: diabetes, hypertension and high blood cholesterol.

Even though the risk of contracting chronic illnesses increases with age, doctors agree that the rising rate is attributable to our increasingly stressful, sedentary and unhealthy lifestyles. A close

WORDS

QUINTELLA KOH

40

witness to this shift are specialists – from fields such as cardiology, ophthalmology, rheumatology, ENT, hand surgery, urology, obstetrics and gynaecology – who are noticing clear trends. They are almost unanimous in concluding that our diets and lifestyles are largely to blame.

Contracting chronic diseases is a serious matter as many of them, if unchecked and uncontrolled, lead to other major illnesses. Cardiologist Dr Ruth Kam notes that hypertension can lead to health complications such as heart attack, heart failure, stroke, kidney failure, atrial fibrillation and dementia. Cardiologist Dr Eric Hong, who specialises in multimodal imaging (MMI), echoes this, reporting that he is seeing more acute and chronic heart failures, arrhythmias (irregular heartbeat) and structural heart diseases.

Lifestyle choices The root of the problem? Singaporean residents simply exercise too little and eat too much. The National Health Survey (NHS) found that a staggering 54% of Singaporean residents aged 18 to 69 did not participate in any leisure-time physical activity, compared to countries like the US (41%) and France (33%).

As a renowned foodie heaven, Singapore is seeing the level of obesity rising. The NHS found that one in 10 Singaporeans were considered obese, more than twice the number in 1992. Obesity can not only lead to diabetes, hypertension and high cholesterol, it can also be a prelude to arthritis and certain classes of cancer.

For example, people who have hypertension or who are obese are more prone to developing bladder stones. Left untreated, these can cause discomfort, bacterial infections and prevent urine passing from the body, explains Urologist Dr Michael Wong.

Singapore has also seen a slight uptick in the number of people smoking, which has led to an increase in throat and tongue cancers – seen not only in the elderly but also the young and females, says A/Prof Luke Tan, Ear Nose Throat - Head and Neck Surgeon.

And while the serious hand injuries from use of heavy machines in the 70s and 80s have become less frequent as Singapore went high-tech, today’s hand injuries are mostly the result of lifestyle and recreational activities like sports and computer use, notes Hand Surgeon Dr Tan Soo Heong.

Stone treatment technology has leapt forward in the last five years, as have

techniques for tackling

male infertility along with IVF

capabilities.

DR MICHAEL WONGAssociate Editor of the

British Journal of Urology and Deputy Director of the Asian

School of Urology

54%OF

SINGAPOREANS AGED

DID NOT PARTICIPATE IN ANY LEISURE-TIME PHYSICAL ACTIVITY*

18-69

The bad news is that urinary stone incidence has risen in the past 20 years due to changes in diet and obesity, while male fertility is a larger concern due to delayed

marriage and more second marriages. Female

urinary incontinence has risen with an ageing

population, as have prostate enlargement and cancer. The good news? Technological

advancements in the form of better instrumentation,

use of lasers and robotics and more

targetted medication are, collectively, tackling these issues head-on, resulting in faster recovery, shorter

hospital stays and improved odds for fertility.

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A/PROF LUKE TANEar, Nose & Throat – Head

and Neck Surgeon

The general state of ENT health has improved significantly over the past few decades as a result of education, access to primary healthcare and

improved medicines. Thyroid cancer and

thyroid nodular diseases are on the rise due to

early screening. On the flipside, the common

issues are predominantly allergy and sinus-related.

One common trend is the increased prevalence

of smoking among the young and in particular,

females. In the West, there is a

rising trend of sexually transmitted human

papilloma virus-related throat cancers, which

would probably reflect in some way here as

trends in smoking and sexual activities change

in tandem.

I recently diagnosed a 20-year-old

mother with late Stage 4 tongue

cancer. She had symptoms

for about six months.

* Finding from National Health Survey (NHS), a first of its kind which captured information on the prevalence of major non-communicable diseases and related risk factors. It also revealed information on chronic disease screening, use of primary healthcare services, mental health and self-rated overall health. It was conducted in 2010; the next NHS is due in 2016.

HEALTH DOSSIER

Age-related challenges Singapore also has to contend with the rising onset of age-related conditions such as infertility, osteoporosis and myopia.

It is well-known that Singaporeans are delaying parenthood – marrying later, pursuing career goals, treasuring freedom – but less well-known is how the ageing process affects fertility. Obstetrician and Gynaecologist Dr Ann Tan explains, “Fertility potential peaks in the 20s when desire (to have children) is low, and then reverses. Fertility potential is lower when desire is higher.”

Women may reach menopause on average at 51, but the deterioration starts in the late 20s. After 35, the female’s fertility drops dramatically with diminishing number and quality of eggs.

The spotlight tends to fall on female infertility, but it is also male pressing in males. Urologist Dr Wong says more people delaying marriage or entering second marriages mean that men are older and sperm quality poorer. Male infertility issues constitute about 60% of cases.

Like infertility, the incidence of osteoporosis is likely to increase dramatically as the city-state’s median age pushes towards 47 come 2030 (from 39 in 2011). Characterised by decreasing bone mass and density, osteoporosis is a progressive condition that results in weak, brittle bones. It is most common in post-menopausal

women following the decrease in estrogen, a female sex hormone that protects bones in women.

Rheumatologist A/Prof Leong Keng Hong points out that osteoporosis creeps into a person’s life undetected as there are often no symptoms until fractures occur. “If not treated, it can result in fractures, particularly of the wrist, spine or hip. These occur after little or no trauma, such as falling down while walking, and often result in life-changing disability, ” he explains.

Then there are the eyes. Myopia, according to Ophthalmologist Dr Leo Seo Wei, has reached “epidemic proportions” with 90% of adult Singaporeans facing it. “The earlier the onset of myopia, the higher the degree of it. The higher the degree, the higher the risk of developing complications leading to reduced vision and blindness. These risks are for life,” she says.

Young people, especially

women, are are susceptible to autoimmune

diseases such as lupus, psoriasis,

schleroderma and Sjogren’s

syndrome, with onset usually between 20

and 50.

A/PROF LEONG KENG HONG

Rheumatologist

In 2010, MOH did a study on disability adjusted life years

or DALYS. This measures years of life lost not just

due to premature death but also to living with disability.

Rheumatoid arthritis was No. 12 and osteoarthritis

was No. 16 on the list. Arthritis is due to

either wear and tear or inflammation. Left

untreated, the patient has disability such as being unable to walk or use

the hands. Autoimmune diseases arise when a trigger causes the

body’s immune system to attack the body’s

own tissue. There are treatments to control the underlying causes, and surgical replacement of hips and knees, but there are no specific

preventive measures we can take to reduce the

risk of contracting these conditions.

80%OF 18-YEAR-OLD SINGAPOREANS

ARE MYOPIC

28%OF ASIAN CHILDREN

ARE MYOPIC

SINGAPORE MYOPIA ALERT!

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Preventive measures, early detectionThe good news is that most of the conditions that affect our population are also among the most preventable.

In the case of chronic diseases such as diabetes, hypertension and high blood cholesterol, a few simple lifestyle tweaks can significantly decrease the risk of contracting these diseases. The Health Promotion Board recommends that the average adult Singapore resident gets 150 minutes of physical activity a week.

Subtle adjustments to diet are another way to stave off diseases. For instance, a moderately active male should only consume 2,590 calories each day, while a fairly active female only needs 2,035 calories. The tired adages hold true – more fruits and vegetables, whole grains instead of processed carbohydrates, smaller portions, less sugar and salt.

Explains Dr Leo: “Many eye diseases are linked to chronic diseases. Exercise can help keep them at bay or limit their impact if they do occur. Exercise has also been shown to lessen the risk of age-related eye diseases such as diabetic retinopathy, age-related

Singapore has one of the highest rates of myopia –

short-sightedness – in the world.

Child myopia is suspected when they can’t see things well in the distance. Other

signs include children going up close to the TV to watch shows. “Myopia is not just about wearing

glasses. LASIK or refractive surgery may get rid of the

need to wear glasses but it does not decrease the risk of blinding complications associated with myopia. A study of six-year-old

Chinese children shows that myopia rates are 29% in Singapore but only 3% in Sydney. The primary difference? Children in Sydney enjoy 14 hours

per week outdoors while Singapore children get by

with only three.Risk factors: excessive

reading, writing, computer use and lack of time

outdoors in sunlight, which causes the release of

dopamine in the retina and prevents excessive eye

growth and myopia.

Myopia has reached

epidemic proportions in

Singapore, with 90% of adults

facing it.

DR LEO SEO WEIOphthalmologist who sub-

specialises in paediatric ophthalmology

Good cardiac health results

from habits which must

be inculcated from childhood. Narrowing of the arteries occurs

over many years and bad dietary habits

are difficult to change

once they are ingrained.

DR RUTH KAMCardiologist

In stable coronary heart disease, the symptoms are predictable. They

occur only after a certain threshold of activity, such as exercise, after a meal,

after getting angry and so on. It is also relieved after

the activity stops. In unstable coronary heart disease, the

symptoms become unpredictable. They occur at rest or with increasing frequency and intensity

until they become persistent, unrelieved

by the usual rest or medication, culminating in a heart attack when a part of the heart muscle dies because its blood supply

is cut off.

macular degeneration and glaucoma.”

Consistency is key to maintaining an active lifestyle, and sudden intense spurts of physical activity should be avoided. “What has been popular in recent years are short-distance weekend triathlons which attract middle-aged working adults who tend to be ‘weekend warriors’,” Dr Hong notes. These amateur athletes can be prone to sudden cardiac death – a condition where seemingly fit individuals suddenly collapse and die. “In older athletes above 35, the main cause of sudden cardiac death is coronary artery disease.”

In addition to exercising moderately and regularly, Dr Hong advises individuals, especially those who are keen on endurance sports, to have a proper heart screening to avoid sudden cardiac death. “Be mindful of your heart,” he says. “The consequences of sudden cardiac death go beyond yourself; they affect your loved ones. Sudden cardiac arrest is not rare, but surviving it is.”

A multifaceted approach to healthy living not only comprises exercise and a healthy diet. Early detection of diseases and timely treatment can reduce the chances of complications.

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HEALTH DOSSIER

Early screening & detection

HEART: Frequent chest pain points to a likelihood of coronary heart disease, says Dr Kam. “Less common symptoms include abdominal pain, palpitations, giddiness, shoulder pain and jaw pain. These seem to be more frequent in women who also get it later, usually after menopause,” she adds.

Recent advancements in cardiac imaging technology have made it possible to diagnose more, earlier. “A decade ago, it was common to report as normal a scan with findings suggestive of ‘low likelihood for adverse cardiac events’. Today, we know that many patients with normal ECG could still have extensive coronary artery disease even though blood flow through the arteries has not been compromised yet,” explains Cardiologist Dr Hong. “Applying high-sensitivity CZT crystal cameras over gamma camera technology for heart scans reduces scanning time by 75%. And the 320-slice cardiac computed tomography reduces radiation in a heart scan by 90%.”

Says Dr Kam: “Stents have drugs in them that lower the risk of restenosis – narrowing at the same place – and some components are biodegradable and dissolve over time. The metal scaffolding remains, and becomes covered in cells so that it is inside the vessel wall.”

EYES: Adults at 40 should get a baseline eye disease screening which can detect abnormalities of the visual system and evidence of systemic diseases such as hypertension and diabetes. Says Dr Leo, “Several common eye diseases – diabetic retinopathy, age-related macular degeneration

In older athletes who are above 35 years old, the main cause of

sudden cardiac death is

coronary artery disease.

DR ERIC HONGCardiologist

HEART

URINARY TRACT

EYES

In older athletes who are above 35, the main cause of sudden cardiac death (SCD)

is coronary artery disease (CAD). Greater attention

must be paid to individuals with a history of it, including those who have had heart attacks, stents, coronary

bypasses or a known history of reduced heart function

with chronic diseases such as diabetes or kidney disease. These conditions account for 75 to 80% of

SCD in this age group. It is very important to assess one’s fitness to exercise.

In the past few years, there have been tremendous advancements in non-

invasive cardiac imaging for more accurate

assessment of CAD. We live in exciting times, with rapid

advances in imaging and interventional cardiology,

which lead to better patient outcomes.

44

and glaucoma – can impact people above 40 without them knowing it. With intervention, these potentially blinding diseases often have a favourable outcome.”

URINARY TRACT: The occurrence of urinary stones in elderly people is high at around 10%. Symptoms are very obvious: abdominal pain, abnormally coloured urine, blood in the urine, frequent urge to urinate and inability to urinate. To detect urinary stones, CT scanning, ultrasound examination and urine cultures test are viable screening options, says Dr Wong. Tests can indicate urinary stones, their location and whether they are causing damage to the urinary tract.

THROAT: Conditions like throat cancer can be difficult to diagnose because the symptoms can be vague. They include change in voice, swallowing difficulties, throat soreness, persistent cough, swollen lymph nodes in the neck, ear pain and wheezing. Targeted screening methods such as a laryngoscopy (where a long flexible tube with a mirror and a light is inserted down the throat) are required. If abnormalities are found, a tissue sample is tested for cancer. “The focus is on screening and early detection as the treatment outcomes are dependant to a large extent on the stage at presentation,” explains A/Prof Tan.

REPRODUCTIVE SYSTEM: Those who have been trying for a baby for a long time can feel isolated and frustrated. As treatment options are wide-ranging – with timed sexual intercourse, ovulation induction, in vitro fertilisation (IVF) and surgery – a specialist is required so that the problem

can be identified and correct treatment recommended. Many delay this.

Says Dr Ann Tan: “I would like to see men and woman be more mindful of their fertility potential and to have the ability to safeguard their healthy gametes to be used when their situation allows them to actualise their desire to be parents. Then we will definitely have less fertility issues.”

Dr Michael Wong points out that people worry needlessly about success rates of treatment options. “Techniques for male fertility have improved along with IVF capabilities.”

BONES: Conditions like osteoporosis often go undetected until an episode occurs. Occasional symptoms are backache, loss of weight and a stooped posture. “Many people think that boosting one’s calcium intake will help prevent osteoporosis but calcium, vitamin D and exercise can enhance bone health but cannot arrest the disease once it is there,” says A/Prof Leong.

Regular health screening is still recommended; early detection improves the chances of treatment, reduces risk of premature death and improves quality of life.

HANDS: Patients often ignore symptoms until it is very late. “Delayed treatment can lead to severe consequences. Cat bite injuries, if not cleaned, dressed and accompanied by antibiotics, can lead to severe spreading infection affecting bones, joints and soft tissue. Numbness and weakness can be due to carpal tunnel syndrome which, with neglect, leads to unremitting pain, loss of finger sensation and loss of control of thumb movements,“ explains Dr S H Tan.

REPRODUCTIVE SYSTEM

BONES

THROAT

45

HEALTH DOSSIER

New frontiersThe boundaries of medicine have advanced dramatically in the last few years, making it possible for more people to receive treatment without fear of complications.

Multimodal Imaging (MMI)In the past, when considering a condition like coronary artery disease, the option was ultrasound of the heart followed by an invasive procedure such as a coronary angiogram.

With MMI, a technology that has matured rapidly over the last decade, specialists are able to assess the severity of blockages in the arteries non-invasively. Imaging techniques, when combined with anatomical and physiological data, can produce detailed feedback that can differentiate a 71% blockage from a 69% blockage.

“In some cases, the patient might be wheelchair bound or his functional status not very good. So the question is: do you really want to do the conventional steps – angiogram, diagnosis of multi-vessel disease and heart bypass surgery – when the patient cannot take that route? MMI allows us to individualise medicine,” notes Dr Hong.

Minimally invasive surgery MIS is now routine. Take urinary stones, for instance. “No matter how big or hard the stones, we now have the tools to not only remove them safely but to even prevent them reccurring. With increasing incidence in urinary stones arising from age-related changes, increased uric acid levels related to obesity and a dropping urine PH, technology and techniques have improved and offer MIS to remove them,” says Dr Wong.

Today’s hand injuries result from lifestyle

and recreational activities, strain from repetitive

tasks, and degenerative

hand conditions related to

ageing.

DR TAN SOO HEONGHand Surgeon

Chronic disease is looming large in Singapore. Not only are more people suffering from ailments linked to diabetes and high cholesterol, they are also getting younger.

Figures from the Ministry of Health show that two in five Singaporeans aged 20 years and above are suffering from at least one chronic condition, the most common being high blood pressure, high cholesterol and diabetes. These three illnesses increase the risk of heart problems and strokes.

CHRONIC DISEASES & THE YOUNG2

5SINGAPOREANS AGED 20 YEARS

AND ABOVE ARE SUFFERING FROM AT LEAST ONE CHRONIC

CONDITION

MINISTRY OF HEALTH

Hand lacerations with cut tendons and nerves during culinary classes,

tendon and pulley injuries during rock-climbing or rugby games, torn

ligaments during gym or yoga classes and hand,

wrist and finger fractures during cycling, mountain biking skateboarding or

running are common. Repetititve strain is also

more common, attributed to sedentary lifestyles and our keyboard and

gadget use. With ageing come osteoarthritis of the

thumb and finger joints, tendon inflammation

and progressive sensory loss and muscle wasting.

Neuropathic pain and loss of function are also to be expected. These occur so slowly and so commonly

that people attribute them to “normal ageing”

and don’t get them treated early.

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IN

3D printingRobotics and 3D printing have revolutionised many areas of medicine including hand therapy and limb retraining and replacement. “Robotics-assisted devices can help in rehabilitation to monitor and assist in hand therapy and upper limb retraining. They can be programmed to perform specific functions for the patient’s rehabilitation and to train patients in daily life activities,” notes Dr S H Tan.

3D printing technology works like MMI. In 3D printing, the patient’s body part is scanned and the data used to obtain the normal dimensions. Implants are then crafted to fit the patient’s specific profile. “In the old days, implants came in standard sizes and lengths, which meant that during during surgery, the body was altered to fit the implants. 3D printing allows for personalisation, done much more quickly and at a much lower cost,” he explains. Regulatory changes There are encouraging changes on the regulatory front with, for instance, rising acceptance of social egg freezing as a recognised form of preserving eggs before they are damaged or depleted. From 2012, the American Society of Reproductive Medicine declared that egg freezing is no longer an experimental procedure. Improvements in freezing methods and culture media have given many labs an almost 100% freeze and post-thawing survival rate.

In Singapore, egg freezing is only available in the context of those suffering from cancer and desiring to store their eggs before undergoing chemotherapy. Egg freezing is also an option at the post-chemotherapy stage if they are not able to consider pregnancy

The most urgent issue facing

our population would be the

dichotomy between their fertility wants

and potential. I would like to see

both men and woman be more mindful of their

fertility potential.

DR ANN TANObstetrician and

Gynaecologist

at that time. But with countries such as the US, Belgium and the Netherlands already permitting social egg freezing, it is a matter of time before Singapore must decide on her stance for egg freezing. “For childless women in their 40s and beyond, the option will be to have IVF performed with their own eggs. They can also use donor eggs if the former procedure is not possible.If unable to carry the pregnancy, then there will be cause to consider surrogacy,” Dr Ann Tan points out.

Regulatory changes have also made it easier for Singaporean residents to effect treatment for chronic conditions as outpatients. The Medisave Use for Chronic Disease

Many chemotherapy agents whilst having the

ability to battle the cancer, also have the ability to

impair the fertility of the patient. Currently, when

treatments have improved quality of life and life

expectancy, the notion of being a parent has become

increasingly desired and possible. It has been shown that when fertility has been

preserved, the patient’s prognosis improves. Fertility

preservtion can be in the form of egg freezing for

single or embryo freezing for couples. With breast cancer, there is often a window of opportunity between diagnosis and

surgery/treatments. This can be used to stimulate the patient and have her

eggs retrieved prior to any chemotherapy and its

harmful effects.

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Management Programme, launched in 2006, now includes diabetes, hypertension, stroke, osteoarthritis, osteoporosis and rheumatoid arthritis.

Affluence alone clearly does not guarantee one a healthy life. What is needed is a conscious combination of good lifestyle and eating habits and regular screening and treatment. It also helps to keep abreast of medical advancements and regulatory changes.

HEALTH DOSSIER

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SPECIALIST ADVISORS

DR RUTH KAMCardiologist

RUTH KAM HEART AND ARRHYTHMIA CLINIC 290 Orchard Road

#14-10 Paragon Medical Singapore 238859

Tel: 6333 6866 www.arrhythmia.com.sg

Dr Ruth Kam provides general and specialised services in cardiac

arrhythmias, while lecturing and consulting for various hospitals

and medical institutions here and overseas. She has a keen interest

in cardiology in women and sportsmen.

DR TAN SOO HEONGHand Surgeon

HAND, WRIST & UPPER LIMB SURGERY

3 Mount Elizabeth #07-01 Mount Elizabeth

Medical Centre Singapore 228510

Tel: 6737 0177 www.hand.com.sg

Dr Tan Soo Heong is one of a small number of hand surgeons in Singapore and has a special

interest in the possibilities of robotics-assisted devices

and 3D printing’s potential for personalising surgery.

DR ANN TAN Obstetrician & GynaecologistWOMEN & FETAL CENTRE

 290 Orchard Road#20-01 Paragon Medical                                                                                 

Singapore 238859                                                                                             Tel: 6887 1103                                                                                                        

www.anntan.com.sg

Dr Ann Tan provides services in prenatal diagnosis & care of

mother and foetus, and has a deep interest in assisted fertility and

related issues. In her commitment to raising awareness, she is

a regular contributor to local publications.

A/PROF LEONG KENG HONG Rheumatologist

LEONG KENG HONG ARTHRITIS & MEDICAL CLINIC

6 Napier Road #04-18 Gleneagles

Medical CentreSingapore 258499

Tel: 6472 4337 www.leongkenghong.com

A/Prof Leong Keng Hong is a consultant and lecturer with an

active interest in research. He has a special interest in autoimmune

diseases such as arthritis and lupus, and degenerative diseases such as

osteoporosis and osteoarthritis.

DR LEO SEO WEIOphthalmologist

DR LEO ADULT & PAEDIATRIC EYE SPECIALIST PTE LTD

3 Mount Elizabeth #10-04 Mount Elizabeth

Medical Centre Singapore 228510

Tel: 6737 8366 www.drleoeyespecialist.com

Dr Leo Seo Wei treats all aspects of ophthalmology, with a special interest in strabismus surgery and paediatric ophthalmology. She is one of a few eye specialists here

performing bladeless, laser-assisted cataract operations.

DR ERIC HONG Cardiologist

EH HEART SPECIALIST PTE LTD3 Mount Elizabeth

#03-09 Mount Elizabeth Medical Centre

Singapore 228510Tel: 6736 1068

www.eheartspecialist.com

Dr Eric Hong is an interventional and nuclear cardiologist who

specialises in minimally and non-invasive procedures and methods

to diagnose and treat diseases of the heart.

DR MICHAEL WONGUrologist

INTERNATIONAL UROLOGY, FERTILITY & GYNAECOLOGY

CENTRE3 Mount Elizabeth

#10-09 Mount Elizabeth Medical Centre

Singapore 228510Tel: 68381212

www.drmichaelwong.com

Dr Michael Wong, currently Associate Editor of British

Journal of Urology International, is recognised for expertise and

contribution to the field of Urology, in particular minimally invasive

Endourology.

A/PROF LUKE TANEar, Nose & Throat – Head and

Neck SurgeonLUKE TAN ENT-HEAD & NECK CENTER & THYROID SURGERY

CENTRE 3 Mount Elizabeth

#14-17 Mount Elizabeth Medical Centre

Singapore 228510 Tel: 6474 6116

www.thyroidsurgery.com.sg

A/Prof Luke Tan is credited with building up the first ENT teams

in some Singapore hospitals and has a special interest in minimally invasive thyroid surgery, and head

and neck cancers.