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aha Issue 1: January-february 2019
a journey of mANY STEPS
The road to wellness at Yishun Health is paved with
MCI (P) 101/04/2018
constant improvements in all areas of a health system
What’s 12 “it’s good to know 16 a wealth of 26
cooking? someone cares” experience
AHA Jan-Feb 19 cover.indd 1 10/1/19 3:40 PM
ontents
4 HEALTH HIGHLIGHTS 24 5 THINGS ABOUT…
18 COVER STORY Healthcare news and updates Radiation and X-rays
A better understanding of
A journey of 6 WHAT’S UP this important diagnostic
many steps Community events, outreach tool
Part two of the Kaizen efforts, and more
26 LIVE WELL
series explores the 12 SPOTLIGHT A wealth of experience
many ways — big What’s cooking? Four veteran
and small — in Step inside Yishun Health’s anaesthesiologists share
kitchen for a glimpse of how what keeps them going in
which clinical care is safe, healthy, nutritious and the pursuit of their vocation
improved at tasty meals are prepared
Yishun Health. 28 MAKAN TIME
16 EVERYDAY HEROES Steamed
“It’s good to know seabass,
someone cares” Teochew
Sally Low shares how style
community support has made Learn to
a difference to alleviate her prepare this
caregiving struggles classic fish dish
The Kaizen mindset — a culture of constant improvement and continuous small
refinements — has shaped the way we enhance our care processes, develop
healthcare programmes, and even locate our services in the community. In this
THE KAIZEN second instalment of The Kaizen Series, we explore what’s been done across our
SERIES institutions at the clinical, process and community levels.
2 |
2-3 contents.indd 2 10/1/19 3:21 PM
PUBLISHER
Yishun Health is a network of
medical institutions and health facilities in
the north of Singapore, under the National
Healthcare Group. It comprises Admiralty
Medical Centre, Khoo Teck Puat Hospital
and Yishun Community Hospital. It also
16
includes community extensions such as
Wellness Kampung.
EDITORIAL TEAM
Hannah Wong
Sabrina Ng
Sharon Ng
Albert Foo
30 DAILY DOSE
Snack smart! EDITORIAL COMMITTEE
Choosing quality over quantity The editorial committee — made up of
means you can still indulge a clinical, nursing, allied health, population
little this festive season health & community transformation, and
administrative heads of department —
advises aha’s direction.
31 MIND & HEALTH
A/Prof Tan Kok Yang
Healthy habits planner
Angeline Tang
Set out your intentions for the Bastari Irwan
day, week, month or year — Chia Kwee Lee
Fatimah Moideen Kutty
and achieve your health goals!
Shirley Heng
ktph.com.sg/aha
aha@ktph.com.sg
PUBLISHING AGENT
THINKFARM PTE LTD
aha Issue 1: January-february 2019
www.thinkfarm.sg
M A N AG I N G D I R E C T O R
Christopher Tay
E D I TO R I A L D I R E C TO R
Chua Kim Beng
C O N T R I B U T I N G E D I TO R
Sheralyn Tay
E D I TO R
a journey of mANY STEPS
The road to wellness at Yishun Health is paved with Dang Hui Ling
MCI (P) 101/04/2018
constant improvements in all areas of a health system
What’s 12 “it’s good to know 16 a wealth of 26
cooking? someone cares” experience
A R T D I R E C TO R
Regina Wong
W
DESIGNER
Melissa Poon
hy aha?
S E N I O R M A N AG E R , C L I E N T R E L AT I O N S H I P
The name aha holds much Jessie Kek
significance for us at Yishun Health. C O N T R I B U TO R S
In part, it is a nod to our beginnings Justin Loh, Lee Lily
at Alexandra Hospital; it also stands for ‘Advocates aha is the official bi-monthly publication of Khoo Teck Puat Hospital
(Co. Reg. No. 200717564H) and is produced by ThinkFarm Pte Ltd. All
for Health in Action’. Through these pages, we hope rights to this publication are reserved and no part may be reproduced
without the expressed written consent of the publishers. While every
to empower you to take charge of your own health effort has been made to ensure that the information in this newsletter
is accurate and up to date, the editorial team will not be responsible
for errors due to information received. Opinions expressed are that of
and discover those ‘aha!’ moments that lead to a the writers and do not necessarily represent the views and opinions
of the publishers. Printed by Mainland Press Pte Ltd.
healthier, happier you. MCI (P) 101/04/2018
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2-3 contents.indd 3 10/1/19 3:21 PM
ealth Highlights
Better
Caregiver
Support
Being a caregiver can be taxing,
especially when the population
is ageing and families are small.
This is why the Ministry of Health
recently reviewed the system that
offers support and relief to people
providing this critical role.
T
he Ministry of Health (MOH) size is usually small, there is added The discussions included
conducted a series of burden on caregivers. consultations with caregivers, service
focus group discussions While steps have been taken providers, and various stakeholders,
in December 2018. The over the past few years towards all of whom were encouraged to
aim was to identify opportunities building up the range and quality of come together to co-create solutions.
to strengthen care navigation in eldercare services, MOH also aims An enhanced caregiver support
the community, improve caregiver to focus on providing more direct system will also be implemented,
support services, and find ways to and holistic assistance to complementing existing programmes
empower caregivers. caregivers and build a strong and assistance for caregivers, including
As Singapore’s population ages, caregiver support system. This is tax relief for caring for parents or
caregivers play an increasingly critical to ensure that the elderly handicapped family members, as well
important role. However, as family can age well in place. as grants to train caregivers.
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4-5 Health Highlights.indd 4 10/1/19 3:25 PM
MEDISHIELD LIFE EXTENDED TO COVER MORE NEEDS
In November 2018, national health insurance scheme MediShield Life was extended
to cover three more groups of patients:
1
Patients admitted directly from
emergency departments of public
hospitals to community hospitals
Eligible patients can claim up to
$350 per day from MediShield Life,
under the prevailing inpatient limit for
community hospitals.
2
3 Those who need long-term intravenous
nutrition for intestinal conditions
Eligible patients who need parenteral
nutrition for 90 days or more may claim
Children born with the rare congenital conditions of trisomy 18 up to $1,700 a month from MediShield
and alobar holoprosencephaly and who need surgery Life and withdraw up to $200 a month
Eligible patients may make a claim from MediShield Life for from Medisave for items necessary to
surgical interventions, up to the prevailing surgical claim limits of administer parenteral nutrition.
$200 to $2,000, depending on the complexity of the procedure.
The broadening of coverage is
part of MOH’s continuing review of Have a question about MediShield Life?
MediShield Life to ensure that it provides Log on to the MediShield Life website at
protection for Singaporeans against
large hospital bills and selected costly
outpatient treatments, in keeping with
www.medishieldlife.sg
developments in medical care.
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4-5 Health Highlights.indd 5 10/1/19 3:25 PM
hat’s Up
Kampung Admiralty wins
Building of the Year Award!
K ampung Admiralty, which
encompasses Admiralty Medical
Centre, was crowned Building of
the Year at the World Architecture
Festival in Amsterdam in December
2018. The 11-storey complex was
picked from 535 other projects
spread across 57 countries.
As the first integrated kampung
in the world, the development
was recognised for its innovative
infrastructural design and ‘software’,
both coming together to enhance
social integration and elder-friendly
community, while giving easy
access to amenities. The mixed Yishun Health’s Admiralty Medical
development hosts public housing, Centre occupies levels 3 and 4
a mix of healthcare, eldercare and of Kampung Admiralty, giving the
childcare facilities, as well as retail community access to a suite of
and dining outlets. specialist outpatient services.
6 |
6-11 Whats up.indd 6 10/1/19 3:26 PM
For All Your Urology Needs
Dr Molly Eng, Head & Senior Consultant, Urology (third from right), Mrs Chew Kwee Tiang, CEO, KTPH & Yishun Health (middle), with the
rest of the Urology department at the opening ceremony (below)
Y ishun Health officially opened
the new KTPH Urology
Clinic on 29 November 2018. The
urological procedures in the days of
Alexandra Hospital.
Located at Tower C, C44, the
subspecialties. These include a
Haematuria Clinic, Ureteric/Colic
Clinic, Fast Tract Clinic, as well as
comprehensive clinic is a milestone Urology Clinic will provide one- services to address bone health,
for the service, which has come stop hassle-free service across andrology, women’s urology,
a long way from providing key a wide range of conditions and oncology, endourology and stones.
| 7
6-11 Whats up.indd 7 10/1/19 3:27 PM
hat’s Up
Raising Pressure Injury
Awareness
T o raise the level of skill and
awareness of pressure injury,
the Pressure Injury Workgroup
organised an in-depth event for
staff and community partners. STOP
Pressure Injury was a full-day event
held on 29 November 2018.
Aimed at bolstering the
proficiency of healthcare workers,
particularly in the community care
sector, the event included four
plenary sessions and three skills Our community partners participated in the lectures and workshops
workshops. to share the knowledge and skills with their organisations
There was also a keynote speech
by Mr Emilio Galea, International
Medical Director of URGO Medical, topic and shared useful ideas on learn wound-dressing methods, and
who addressed the prevention and good pressure wound care. use a pressure-mapping system to
management of pressure injuries. Workshop participants had the ensure proper seating position to
Other experts also expanded on the chance to try pressure injury devices, lower the risk of pressure wounds.
Diabetes Management:
It Takes a Village
U nderscoring the importance
of support, Yishun Health
commemorated World Diabetes
diabetes management and reminded
participants of the far-reaching
consequences of the chronic disease
diabetes-related eye complications.
Foot and footwear were also
assessed. There was even a cooking
Day with the theme ‘The Family & for both patients and their loved ones. demonstration, which emphasised
Diabetes’. Held on 3 November 2018 At the booths, participants that food need not be heavily
at the Kampung Admiralty Plaza, were asked to guess their blood seasoned to be delicious.
the event involved five interactive glucose ‘number’, and shown the Guest calligraphist Mr Jimmy Koh
multisensory booths. Each covered consequences of high blood sugar also presented a scroll of a Chinese
the multidisciplinary nature of via illustrations, and the impact of couplet, which translates to:
“A healthy body makes you feel
strong, so do not wait and worry
about your health in old age.”
Unveiling of Mr Jimmy Koh’s (third from
right) calligraphy couplet by Guest-
of-Honour Mr Amrin Amin and KTPH
& Yishun Health CEO Mrs Chew Kwee
Tiang (fifth and sixth from left)
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6-11 Whats up.indd 8 10/1/19 3:27 PM
‘X’ Marks
the Spot
I n celebration of World
Radiography Day, which falls
on 8 November, Yishun Health
radiographers set up informational
posters to celebrate the 123rd
anniversary of the discovery of
Learn more X-rays. The exhibition showcased the
about X-rays and evolution of medical technologies.
radiation in There were also posters highlighting
5 Things About the different medical imaging
on page 24 methods and interesting trivia aimed
Participants took the time to read informational posters
at dispelling myths and fears of
in order to find answers to a challenging quiz
radiation exposure from scans.
Combat
Sports
Comes to
KTPH
Our first Combat
O n 3 November 2018, Yishun
Health’s Sports Medicine
Centre, together with WAKO
of diet for optimal performance,
and tips for physical training
and rehabilitation.
Sports Public
Forum brought
together medical
Kickboxing Singapore, held their Apart from this, demonstrations and martial
arts experts in
first Combat Sports Public Forum at added an action-filled edge to the day.
an afternoon of
KTPH. More than 150 people signed Athletes showed off a range of pugilistic educational talks
up for the event, which included styles, from kickboxing and Brazilian jiu- and action-packed
enlightening talks from a sports jitsu to silat and savate (French boxing), demonstrations
doctor, dietitian and physiotherapist thrilling the audience with their dexterity
on common sport injuries, the impact and high-powered moves.
| 9
6-11 Whats up.indd 9 10/1/19 3:27 PM
hat’s Up
Turn to
Mental Wellness for page 12 to read
more about the
Food Services
the Family department
I n collaboration with various community partners,
the Family Mental Wellness Carnival was held on
20 October 2018 to cultivate a caring and inclusive
community, and promote mental wellness. Community
partners organised a range of fun activities designed to
highlight the signs and symptoms usually manifested by
persons with mental illness, and the effects of ageing on
cognitive skills.
These included informative exhibits on the five
languages of love, and how to connect with and show
appreciation for each other. Families bonded over
crafting, skin painting, and balloon sculptures. Chefs
from KTPH Food Services also conducted a live cooking
demonstration to encourage healthy eating, providing
Staff from KTPH Food Services giving a live cooking demonstration recipe cards so that participants can recreate the dishes
at home.
A Nurse Leader
in the Making
S abrina Tan, Staff Nurse, Acute
& Emergency (A&E), KTPH,
was conferred the Ngee Ann Kongsi
Sabrina’s first taste of
nursing occurred in
secondary school when
Gold Award on her graduation on she joined the St John’s
19 October 2018. She was recognised Ambulance Brigade
by the Singapore Institute of uniformed group.
Technology (SIT) not only for her “You’re there for the
excellent academic achievements, patients most of the time,
but also her active involvement in especially when they’re
community projects. sick. They can be angry and
She topped SIT’s inaugural batch frustrated sometimes, but
of 52 nursing degree students. The there is a sense of satisfaction
Bachelor of Science in Nursing is a to see them recover and go home, ”
joint degree awarded by SIT and the she recalls.
University of Glasgow. As part of SIT’s Today, Sabrina continues to show
Sabrina Tan’s passion for nursing started
Community Service Club, she led care for people in the wards as she when she joined the St John Ambulance
projects to benefit underprivileged equips herself with the skills required Brigade in secondary school
children in Laos and Myanmar. in the rigorous nature of A&E.
10 |
6-11 Whats up.indd 10 10/1/19 3:27 PMPledging Support
for an Inclusive Society
Y ishun Health was part of the
10,000 people who turned up
for the Purple Parade on 27 October
Within the Yishun Health campus
itself, there are efforts to build
an inclusive workforce through a
2018. Staff were there to pledge their partnership with SG Enable, an agency
support for the movement, which dedicated to enabling persons with
seeks equal access to education, disabilities. Every year, we provide a
employment, transport and social batch of students from SG Enable with
networks for people with special on-the-job training, equipping them
needs. with useful skills for the future.
| 11
6-11 Whats up.indd 11 10/1/19 3:27 PMpotlight
Ghazali (left) and Chef Simon, Executive Sous Chef,
lead the KTPH Food Services team behind the scenes
What’s Cooking? C
ooking 2,700 meals a day
is quite a feat. But consider
that not all these meals are
the same and, in fact, can
involve anywhere between 80 and
A complex choreography of planning goes 90 permutations, and the complexity
into each nutritionally balanced and becomes even more apparent.
carefully plated meal served across Yishun According to Ghazali bin
Mohamad, Head and Manager,
Health, from inpatient dishes to staff meals. Food Services, KTPH, putting
Here’s a look at what it takes. together these many variation
of meals entails comprehensive
planning behind the scenes. Not
only does the department provide
meal services for patients, it is also
12 |
12-15 Spotlight - kitchen.indd 12 10/1/19 3:28 PMTHE KAIZEN
SERIES
a supporting department for the PART 2 OF 3
whole organisation and caters for
1
internal and special events as well as
provides meals for staff. “Our area
of coverage is wide because we
cover outpatient clinics, Emergency
Department patients, and even
support frontline staff so that they Quality control
can focus on their jobs in caring for begins at
patients,” he shares. the door
Then there are also fresh fruits, Purchasers do stringent
coffee and tea provided for patients checks, acting as
who come for early morning ‘bouncers’ to ensure
appointments, and special treats that food items meet
during festive periods. “We do it minimum quality and
all,” Ghazali stresses. He emphasises temperature standards.
2
that the department’s key role is to
“provide healthy meals and support
therapeutic eating plans, and also
ensure that the food we provide is
safe and good enough for our own
families”. This means a high level of Safe storage and
care is exercised to ensure that all organisation
foods — raw, dried, fresh or cooked After passing inspection,
— are kept at safe temperatures, food items are stored
handled with care, and tested in respective areas and
for quality. organised under the
“It all begins at the planning, first-in-first-out and
purchasing and preparation stages,” first-expiry-first-out
explains Ghazali, “and takes up principles to reduce
almost three-quarters of the work.” food waste.
AVOIDING THE DANGER ZONE
100oC
• The temperature danger zone is between
5oC and 60oC — harmful bacteria grow in
Hot food zone
food easily at these temperatures
• Minimise the time that food spends at these
temperatures in order to keep food safe 60oC
• Refrigerated food needs to be kept at 5oC
or below Temperature Bacteria grow
danger zone quickly
• Hot food needs to be kept at 60oC or above
5oC
Food should be kept out of the danger zone,
Cold food zone 0oC
i.e. between 5oC and 60oC. The goal of the
kitchen’s hot and cold chain is thus to keep
food temperatures below or above this zone. Frozen food -18oC
zone Bacteria do not
grow
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12-15 Spotlight - kitchen.indd 13 10/1/19 3:28 PMpotlight
3 Preparation
To raise productivity and
speed of cooking, various raw
ingredients are cleaned and
prepared in advance. Some
items are given a quick blanch
to par-cook before being
blast-chilled to preserve their
freshness and flavour. Soups,
gravies and base sauces are
also made ahead of time.
MEALS IN NUMBERS
4
cuisines:
Chinese,
Malay, Indian
and Western
5
meals: breakfast,
lunch, afternoon
tea, dinner and
supper
6
rice options: white
rice, brown rice, mixed
white/brown rice, soft
rice, plain porridge and
pureed porridge
22
therapeutic
250kg diets
6
vegetables for 1,800
4
main meals daily allergy-
avoidance diets Fire it up!
Closer to meal times, the burners in the kitchen are
100kg
meat for 1,100
4
modified
fired up and chefs pull out the prepared ingredients
to cook up a variety of stir-fries, curries and soups.
texture diets:
main meals daily regular, soft, Each day, about 11 meal options are made available.
minced, pureed Some of the cooked food may have its texture
100kg
rice for 1,450
modified — pureed or mashed — in accordance
to the speech therapist’s texture guidelines. This
main meals daily ensures that people with swallowing difficulties can
eat safely without choking. To do this, foods may
be modified with special thickeners.
14 |
12-15 Spotlight - kitchen.indd 14 10/1/19 3:28 PMTHE KAIZEN
SERIES
PART 2 OF 3
5 Testing, plating and
temperature checks
Each meal prepared is developed in
6
collaboration with Yishun Health’s dietitians and
is checked to be low in fat, salt and sugar, but Load it up!
high in nutrition, variety, taste and texture. Once The plated food is plated according to the
a dish is cooked, it is loaded into warmers for patient’s diet order. It is then loaded into the
plating. Taste and temperature tests are done pre-heated food cart. The food cart will then be
before plating to ensure that the food meets all programmed and transported to the wards via
safety (and taste) requirements. Automated Guided Vehicles.
HEALTHY, SAFE, TASTY Even the water used to wash fruits and vegetables is not
AND SUSTAINABLE immediately disposed of; rather, it is recycled and used
Apart from the many considerations to ensure that meals for the first round of floor washing.
are balanced, delicious and safe to eat, the department This underscores the Food Services department’s
goes the extra mile to be environmentally conscious holistic approach to food, health and wellness, assures
through many small process improvements. For example, Ghazali. “The Food Services team strives to provide
food waste is reduced at the production level. Vegetable the best food and care for our patients because we
and meat scraps are used to make richly flavoured stocks, believe eating well also plays a pivotal role in their
and fruit trimmings are used for desserts such as pies. healing process.”
| 15
12-15 Spotlight - kitchen.indd 15 10/1/19 3:28 PMveryday Heroes
“It’s good to know
someone cares”
Life has been hard for Ms Sally Low, 47, who has been a caregiver to both her
parents and is now in need of some care herself. Recently diagnosed with
cancer, Sally nevertheless finds joy in the simple pleasures of life and urges
people in need to open themselves up to self-care and social support.
As a caregiver, Sally receives free hand
massages at the sensory bay. This offers
her relief from the numbness in her
hands due to chemotherapy
S
ally was only in her 20s caregiving at home was too much for her mother, whose condition
when her father, then in for her mum and herself, and made was quite severe and resulted in a
his 70s, was diagnosed the difficult decision to move her number of behavioural adjustments.
with a brain tumour. As father to a nursing home. Back in the role of caregiver —
the only child of elderly parents, When he passed away in 2003, this time on her own — Sally was
Sally had to shoulder a lot of the Sally thought that her caregiving often overwhelmed. She became
responsibilities as breadwinner duties were over. But a few years depressed, stressed and isolated,
and co-caregiver. She even had to ago, her mother had a fall and, constantly worrying about her
hold down two jobs to support the during her stay in hospital, was mother, work and finances. She
household financially. After some diagnosed with dementia. Sally experienced one of her lowest
time, Sally realised that the strain of decided to leave her job to care points when her mother fell and was
16 |
16-17 Everyday Heroes.indd 16 10/1/19 3:30 PMwarded at Khoo Teck Puat Hospital. burden of treatment.
Recognising the immense Aside from this,
pressures that Sally was facing, Sally has benefited
her mother’s doctor, A/Prof Philip from receiving
Yap, Senior Consultant, Geriatric aromatherapy and
Medicine, connected her with massage sessions
Montfort Care, a network of social that helped improve
and community programmes her quality of sleep
committed to improving the lives (see sidebar). This has
of individuals, families and the helped her overcome
community facing transitional insomnia and manage
challenges. It was also during this her stress levels, so she can
time that Sally decided to find a focus on getting better.
new job as a Student Care Officer to By opening up about her
support both her mother and herself. experiences and illness, Sally hopes to Over time, Sally found herself
opening up to Jayne about her
encourage others to do the same —
problems and concerns
SOMEONE TO LEAN ON and know that there is help out there.
IN DARK TIMES Services such as Montfort Care, and
It was then that Sally met Jayne social workers such as Jayne, have will be conducive to helping others
Leong, Lead Social Worker at had a huge impact on her life. “I wish “open up to a circle of social support”
Montfort Care. “Somehow we we had this help when my dad was and know that there is hope and
connected,” says Sally, who found sick. It would have made such a big care out there. “I want to dedicate
herself opening up about her difference to us,” Sally shares. my life to help whoever comes my
problems and concerns. Through Though she still has her own way,” she says. “I used to be very
these chats, Sally made another battles to fight, Sally wishes to make a negative, but I have seen the light
difficult decision to opt for nursing difference to others, and pay forward at the end of the tunnel. It’s good to
home care at All Saints Home in the good she has received. In fact, she know someone cares, so I want to
Yishun, where her mother would have is looking forward to volunteering at people to know that there is help out
more supervision and professional GoodLife@Yishun, and is training to there. I have struggled before, but
care. “I felt very guilty about it but be a listening ear and friend to others. now with support, I know I do not
talking with Jayne helped me to see She hopes the environment of care struggle alone.”
things from a different perspective.”
Having someone to talk to
and a support system became
even more crucial when Sally was HEALING HANDS, CARING HEARTS
diagnosed with Stage 4 rectal cancer GoodLife@Yishun, a one-stop wellness hub and resource centre, was
launched on 25 November 2018. Run by Montfort Care and supported
in early 2018. Sally had surgery
by the Nee Soon South community, the space features a drop-in café
in April, followed by eight rounds for residents and a sensory bay that offers free hand massage therapy
of chemotherapy. Despite this, and mindful tea drinking sessions for caregivers.
Sally faces the next phase of her Apart from conducting wellness activities for seniors, the centre
treatment with quiet courage. “I am also runs case management, counselling, caregivers’ support groups,
dementia and mental health screenings, and active ageing and
no longer as worried as I used to be
befriending programmes.
because I know I have someone I can For Sally, these hand massages offer some relief as her
talk to and there is help,” she affirms. chemotherapy causes numbness in her hands. The sessions are
Jayne has helped her to apply for relaxing and help her feel better. Sally encourages caregivers to stop
subsidies, reducing the financial by to engage in some self-care and, perhaps, open up to others about
what they are going through. This is the first step to seeking help, she
says. “I would like to raise awareness of such spaces and services, and
GOODLIFE@YISHUN my hope is for others to come out of their shell to share their problems
838 Yishun Street 81 and seek help. If you do, will find that you are not alone and there are
Singapore 760838 many resources and help available.”
Tel: 6484 8040
| 17
16-17 Everyday Heroes.indd 17 10/1/19 3:30 PMCover Story
A JOURNEY
OF MANY
STEPS
From ground-up approaches that
engage the community to changing
behaviours, this article explores
the novel ways that Yishun Health
improves the delivery of healthcare.
T
he pursuit of delivering its various touchpoints and Over the last three years, some
better healthcare can take institutions. This stems from a 20,000 people — students, retailers,
many forms. It could be mindset that first acknowledges business-owners, and members of
making access to care challenges. religious organisations — have been
more convenient for patients, trained to spot people with dementia,
collaborating with partners to A CARING-VILLAGE how to interact with them, and help
improve efficiency, or educating the APPROACH TOWARDS or refer them to suitable agencies.
public to raise awareness. In some DEMENTIA This awareness is aimed at better
cases, it may involve transforming Recognising that our population is addressing dementia, de-medicalising
processes completely. ageing rapidly, Yishun Health has it, and offering greater empathy
Yishun Health embraces all made improvements to build a and support to those with dementia
these moves as part of an ethos more aged- and dementia-friendly as well as their caregivers. Instead
of constant improvement across community in northern Singapore. of treating them as patients, the
18 |
18-23 Cover Story.indd 18 10/1/19 4:09 PMTHE KAIZEN
SERIES
PART 2 OF 3
Members of the CARITAS team
having a discussion led by
A/Prof Yap (fourth from right)
dementia-friendly initiative aims to about the newest GoodLife! eldercare Yap, Senior Consultant, Geriatric
help people with dementia to live centre in Yishun on page 17]. Medicine. When patients are
at home rather than in hospitals or Another partnership to improve discharged from the hospital and
nursing homes. the care for frail older persons with head home, or to a nursing home or
Today, there are more than 13 dementia as well as support ageing a day care centre, the CARITAS team
dementia go-to points in Yishun. These in place is CARITAS iCommunity@ continues to be part of the care.
‘safe return’ spots are places where North. Started in 2012, the goals of “This extends dementia care into the
members of the public can bring lost this integrated care model is spelt community,” explains A/Prof Yap.
and wandering people with dementia. out in its name. “CARITAS stands The transdisciplinary team of
Yishun Health has also partnered for Comprehensive, Accessible, Yishun Health doctors, nurses,
organisations such as Montfort Care Responsive, Individualised, physiotherapists, occupational
to provide longer-term support for Transdisciplinary, Accountable and therapists, speech therapists,
patients and caregivers [read more Seamless care,” says A/Prof Philip psychologists, pharmacists, and
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18-23 Cover Story.indd 19 10/1/19 4:09 PMCover Story
medical social workers — all dementia
specialists — meet weekly with
PATIENT-CENTRED DEMENTIA CARE community partners to discuss
Within the hospital setting, Yishun Health has made improvements care plans, provide updates, and
to the way dementia is cared for. Since 2003, it has run the only share recommendations to offer
specialised inpatient dementia care unit in a tertiary acute care setting in
timely and proactive care. This
Singapore.
The 16-bed CAMIE (Care for the Acute Mentally Infirm Elderly) ward means no patient falls through the
in KTPH adopts person-centred care that prioritises the needs of each cracks even after they have left the
patient. A sister ward in YCH, CARMIE (Comprehensive Assessment hospital. Patients and their families
& Rehabilitation of the Mentally Infirm Elder), cares for patients with are also holistically supported with
dementia who have less acute medical conditions or who need physical
individualised, person-centred care.
rehabilitation.
As of December 2018, CAMIE and CARMIE have recorded 2,078 and There is even a patient care manager
220 restraint-free days respectively. whom caregivers can readily contact
According to A/Prof Yap, elderly patients with dementia in hospitals if they need help. This heightens the
have been found to have better health outcomes if they are not tied responsiveness to ad hoc as well as
down with physical restraints, and if their autonomy is respected.
long-term needs.
He leads a study that proves that the restraint-free system is both
cost-effective and scalable. Instead of using restraints, nurses find other Today, CARITAS serves more
ways to gain the cooperation of patients. One way is to build rapport than 800 patients with dementia
and gain their trust. Another is to use technology such as pressure- and differing levels of frailty and co-
sensor mats so staff are alerted when the patient attempts to get out of morbidities in the North.
bed. Compared to conventional care, restraint-free care sees a:
Dementia awareness is nurtured
• 32% improvement in well-being
• 15% improvement in mobility and function through an intervention programme
• 45% reduction in challenging behaviour called New You. This started in
• No increase in the rate of falls 2007, back in the days of Alexandra
Hospital, and has been based
Dr Ng Chong Jin, Consultant,
Geriatric Medicine, works with
A/Prof Philip Yap in the Dementia
team to care for their patients
20 |
18-23 Cover Story.indd 20 10/1/19 4:09 PMTHE KAIZEN
SERIES
PART 2 OF 3
All dementia this culture of community-led care
is making its mark. A group of
diabetes nurses, podiatrists and
dietitians work not only on their
specialists meet residents has even begun to use specific areas, but across specialties
weekly with brochures on dementia as part of
their hanyu pinyin teaching material!
to ensure well-coordinated patient
care. “We realised our own gaps and
community partners “They are also doing Sudoku the need to train ourselves in the
to discuss care
puzzles as a group so that they can specialised knowledge and skill sets
support one of their friends who of our colleagues to move towards
plans, provide was recently diagnosed with early transdisciplinary care [see diagram
dementia,” shares Evon. on page 23],” he explains.
updates, and share While state-of-the-art research
recommendations EMPOWERING
DIABETES SELF-CARE
plays an important role in treating
disease, it is just as essential to go
to offer timely and Yishun Health has adapted its care back to the basics, emphasises
proactive care. This platforms to make care more integrated
as well as improve patient compliance.
A/Prof Tavintharan, who researches
in the area of diabetes and other
means no patient One of these is in the ongoing metabolic diseases. “We have good
improvements to diabetes drugs, surgical advancements, and
falls through the management. The disease is not only high-tech equipment, but as medical
cracks, even after about managing blood sugar through
medication, but also through long-
professionals, we must not neglect
bread-and-butter issues,” he notes.
they have left the term lifestyle and dietary changes. “Lifestyle choices and daily habits
hospital. And because the disease can lead to
many other complications, such as
make a big — if not more important —
difference in sustaining good health
heart disease, foot problems, poor and managing disease.”
A/PROF PHILIP YAP wound healing, and eye conditions, So, while he researches
SENIOR CONSULTANT, many specialists need to be involved. extensively in the field, A/Prof
GERIATRIC MEDICINE, KTPH This can result in confusion, frustration Tavintharan is just as involved in
and inconvenience for patients. ‘simpler’ innovations on the ground,
in KTPH’s Geriatric Clinic. The According to A/Prof Subramaniam particularly in novel ways to move
programme has been implemented Tavintharan, Director and Senior care away from the hospital and
in the Wellness Kampungs since Consultant, Diabetes Centre, into the community, and manage
2017, and more than 50 sessions Admiralty Medical Centre (AdMC), diabetes in the earlier stages of the
have been held. It combines exercise, Yishun Health has been building and disease pathway. “We are
cognitive training and stimulation, refining its diabetes care model since enhancing our collaborations
and social interaction for patients its days as Alexandra Hospital. “The with general practitioners (GPs),
with early dementia. This programme Diabetes Centre has been around polyclinics, and our own
for early dementia patients combines for some time, but care has evolved community nurses to influence
exercise, cognitive training and to better treat patients beyond diabetes care and improve
stimulation, and social interaction. their medical well-being,” he shares. outcomes,” he reveals.
This programme is “First, we tackled the many facets of For instance, patients coming to
complemented with other ground- care by developing multidisciplinary the Diabetes Centre are greeted by a
up initiatives from the community, services around the patient.” The large installation highlighting the Five
such as Age Well Everyday, where approach shifted the idea of ‘illness Pillars of Diabetes Care:
residents are trained to conduct care’ to ‘holistic healthcare’, viewing • Diet
programmes on health education, each patient as a whole rather than • Exercise
exercise and mindfulness. According a combination of body parts or • Support
to Evon Chua, Manager, Population medical conditions. • Monitoring
Health & Community Transformation, Together as a team, doctors, • Medication
| 21
18-23 Cover Story.indd 21 10/1/19 4:09 PMCover Story
The DESMM message is
reinforced throughout the clinic in
autonomy and agency improves
care compliance. “It is well known
Lifestyle choices
the form of visible cues, such as that patients who are more involved and daily habits
posters and self-monitoring booths.
“In every corner, the patient is
in decision-making regarding their
healthcare are more motivated.
make a big — if not
made aware of the steps they This translates to better outcomes.” more important
— difference
can take in their own self-care,” To drive patients to participate
A/Prof Tavintharan highlights. in their own care, his department
developed a mobile app for patients in sustaining
CO-CREATING to do their own eye tests at home.
A CULTURE OF Regular eye checks at the hospital can good health and
COMMUNITY CARE
A/Prof Yip Chee Chew, Medical
be inconvenient for patients, and could
lead to missed appointments that
managing disease.
Director, AdMC, and Head and result in eye problems going unnoticed.
Senior Consultant, Ophthalmology To improve the rate of eye screening, A/PROF SUBRAMANIAM TAVINTHARAN
and Visual Sciences Department, the Macular Amsler Testing Application DIRECTOR & SENIOR CONSULTANT,
echoes the point about self- (MATA) mobile app was developed. DIABETES CENTRE, ADMC
management as a way to improve This allows patients to easily screen
patient outcomes in the long themselves at home to accurately
term, and notes that a sense of monitor their eye conditions. It also
22 |
18-23 Cover Story.indd 22 10/1/19 4:09 PMTHE KAIZEN
SERIES
PART 2 OF 3
how they interact, their needs, and participants in their own care, creating
how the community can play a role. a more conducive place that supports
In some ways, AdMC, located the idea of self-care.
within Kampung Admiralty, moves Reflecting on these moves,
management of diabetes and eye which enormously widens the idea
conditions away from hospital-based of medical care from curing illness
treatment and shifts the perception to caring for the whole patient,
of care, he notes. “The environment is his family and even his community,
friendly and more community-based.” A/Prof Tavintharan points to his own
The specialist centre offers the range care motto, which is premised on
of services in a more convenient a foundation of “caring and learning”.
location that integrates both the He stresses, “While these innovations,
medical and social aspects of health. improvements and realignment of care
Apart from changing the place take more time and effort to put into
where care is delivered, AdMC also place, it is worth it if we really want to
shapes its spaces to encourage achieve integrated, hassle-free and
patients to be more active patient-centred care.”
The transdisciplinary approach sees the team coming together from the
beginning to jointly communicate, exchange ideas, and work together to
develop a holistic care plan. A multidisciplinary team involves individual
experts who come together with individually developed ideas to
formulate a solution. At Yishun Health, the medical teams explore ways
to move upstream to address the diseases in the early stages, so that
At the AdMC Diabetes Centre, complications can be prevented, delayed or reduced in severity.
patients are treated by the
transdisciplinary team led by A/Prof
Tavintharan (third from right) TRANSDISCIPLINARY CARE
enables them to spot any changes so
that they can seek help early.
But beyond the individual,
healthcare engagement and
education should also be widened.
A/Prof Yip believes that involving
PATIENT
the community will play an important
role in the management of not just
eye disease and diabetes but also
other lifestyle-related diseases,
which he terms ‘medical social MULTIDISCIPLINARY CARE
conditions’. “Medical treatment
cannot be as effective if the social or
familial setting does not permit
a change in lifestyle,” he explains.
After all, he adds, “what one person
does is a habit, what many people do
is a culture”. To truly manage health
holistically, healthcare innovations PATIENT
must consider where people live,
| 23
18-23 Cover Story.indd 23 10/1/19 4:09 PMThings About...
5 Things About
RADIATION
AND X-RAYS
You may undergo an X-ray as part of a regular
health screening or receive radiation therapy as
a form of medical treatment, but what exactly
are these ‘rays’ and how safe are they?
In consultation with Muhammad Azhar bin Samsudin and Jasmine Lee,
Senior Radiographers, Diagnostic Radiology, KTPH
24 |
24-25 5 Things About....indd 24 10/1/19 3:35 PM1
RADIATION IS ALL
AROUND US
We often think of radiation
as a man-made phenomenon,
but low-dose radiation is natural.
We are surrounded by naturally
occurring radioactive elements in
the environment, and cosmic rays
are constantly penetrating the
atmosphere from space. We have
radioactive elements (Potassium 40,
Carbon 14, Radium 226) in our blood
and bones, while man-made devices,
such as wrist watches and ionisation
smoke detectors, emit small amounts
of radiation. However, according to
studies done by the United Nations
Scientific Committee, the risk
associated with low-dose radiation
from natural and man-made sources
is extremely small.
2
RADIATION HAS ITS
3 4
PROS AND CONS SAFETY COMES X-RAYS ARE NOT
The use of radiation and FIRST UNDER THE ONLY USED FOR
nuclear imaging techniques in ALARA PRINCIPLE MEDICAL PURPOSES
medicine is one of the most important ALARA stands for As Low As While X-rays are used for diagnostic
ways we diagnose and treat disease Reasonably Achievable, and is or treatment purposes, they are
and injury. Small amounts of radiation how patients and professionals also very useful for security, and
are used to obtain X-ray images and working with radiation are protected. are extensively deployed in air
larger amounts are used to treat It consists of three principles: time, and sea ports as part of screening
cancers and tumours. Certainly, distance and shielding. The idea procedures. The usefulness of seeing
prolonged exposure can be harmful is to minimise the amount of time through the surface also means
and, in rare cases, lethal. This is why one is exposed to radiation, keep X-rays are used to analyse fossils
the risks and benefits are all weighed a distance of at least 2m from the and even artworks. In fact, historians
carefully by medical professionals radiation source, and use shielding have used X-rays to examine
and explained to patients who are to reduce unnecessary exposure underpaintings in ancient artefacts
undergoing medical procedures of body parts that are not being and famous works of art.
5
involving radiation. examined or treated.
THE ‘X’ IN X-RAY
MEANS ‘UNKNOWN’
TAKING CLEAR X-RAYS X-rays were discovered by
X-rays can be taken in a Wilhelm Röntgen, a German physicist
hospital’s radiology department, be asked to lie or sit on a plate, and mechanical engineer, in 1895
a clinic specialising in diagnostic while a camera on an arm is moved
during an experiment with electrical
procedures, or even while you’re over your body.
seated in a dentist’s chair! conduction through low-pressure
As with any kind of photography, gases. He named them ‘X-strahlen’.
Usually, you stand in front of a you need to remain still while the ‘Strahlen’ means ‘beams’ or ‘ray’
plate containing X-ray film or X-rays are emitted so that clear in German, while the ‘X’ was pulled
detectors. Sometimes, you may images can be obtained.
from algebra’s use of the letter as an
unknown quantity in an equation.
| 25
24-25 5 Things About....indd 25 10/1/19 3:35 PMive Well
A Wealth of
Experience
With a combined experience spanning
more than 150 years, these four veteran
anaesthesiologists aged 70 and above are still
passionately pursuing their vocation, which
helps them keep active in mind, body and spirit.
T
here is more to to see patients from across the age
anaesthesiology than spectrum and medical conditions.”
putting people to sleep. Another attractive aspect of the
For Dr Low Tut Choon, job, adds Dr Low, is that the work
Dr Lim Kim Seong, Dr Subhashini d/o can span the surgical, intensive care,
Anandan and Prof Chandra Mohan emergency, and pain management (L–R, standing): Dr Subhashini d/o
Kumar, it is about making challenging fields, which gives doctors many Anandan, Dr Lim Kim Seong,
Prof Chandra Mohan Kumar
medical conditions easier to bear, avenues to choose from. “There are (Seated): Dr Low Tut Choon
surgeries safer and more effective, various modes of anaesthesia, from
and giving patients a better quality general to regional, as well as mild
of life. After all, says Dr Subhashini, sedation. The work also involves
better known as Dr Subha, “Any airway and pain management,” BETTER WITH AGE
illness is tolerable if there is no pain. Dr Lim explains. With their breadth of experience,
And there is a lot of satisfaction in This variety keeps the job these four physicians are also
helping to alleviate pain and reassure interesting and offers many paths respected educators and mentors.
patients when they are afraid.” for professional development. “It feels good to be able to still be an
Prof Chandra, in particular, has active and appreciated member of
THE VARIETY WITHIN embraced this wholeheartedly: the medical profession,” says Dr Lim.
While they have each spent more he even has a Masters in Computing, They have continued to learn,
than 40 years in anaesthesiology, in addition to his medical grow and adapt with the profession,
they readily admit that it was qualifications. “I love this work!” he attending weekly lectures and poring
not their first choice as a medical enthuses. “Doing anaesthesiology over journals. One of the biggest
specialty, and never thought that — whether in the operating theatre, changes has been the incredible
it would become a lifelong career. writing papers, or as an educator — advancements in technology.
Most of them joined for practical keeps me mentally active.” Dr Low recalls that much of the
reasons — they were posted to the Just as active is Dr Subha. “I will management of patients was done
department during their houseman keep on working for as long as I am manually in the early days. “We had
rotation. But the year-long training able; it is something I really enjoy,” to take blood pressure with our hands
grew on them, so they stayed. Says she says with a laugh. “Working in the while ventilating the patient with our
Dr Lim, “It is a specialty that requires operating room keeps me active, and knees,” he shares. “Electrocardiograms
lots of focus, precision, and keeping I am known to move very fast — but were recorded not using electrodes
up with technology. You also get only in short bursts.” but with needles inserted under
26 |
26-27 Live Well.indd 26 10/1/19 3:36 PMthe skin.” Digital technologies, less This mindset of learning, and He frequently conducts lectures on
invasive methods, and automation embracing change and challenges is the role of anaesthesiology in eye
have changed the practice of medicine a common characteristic among the surgery for the elderly.
tremendously. “Anaesthesia drugs other members of this quartet. While Dr Low has spent several
and technology are now safer, more Dr Lim believes this is essential as years heading the Anaesthesia
precise, and the outcomes are better,” patient profiles change; illnesses are department, one of his areas of
assures Prof Chandra. getting more complex and doctors interest these days is chronic pain
It has not always been easy to have to account for complications management. Beyond just treating
keep up with technology, especially such as chronic illness, obesity and an the pain, he believes in supporting
when it comes to computers, admits ageing population. Dr Lim, who has an patients. “Some patients suffer for
Dr Subha. “But we just need to keep interest in bariatric surgery, works with a long time with chronic pain but
learning and not be afraid to ask for his peers to ensure that overweight may not be taken seriously by their
help.” It is all part of the collaborative patients optimise their health status family and friends,” he reveals.
aspect of medicine, she surmises. before surgery. He finds that listening to his
“I enjoy working with my team very Prof Chandra is an advocate patients supports them more
much. We need and support each for making eye surgeries safer holistically. “It is therapeutic
other.” For this reason, she is keen for elderly patients with dementia somehow to simply be there for
to work in the operating theatre, through regional rather than general them,” he shares. “All medicine is
where there is a strong sense anaesthesia. This, he advises, limits fulfilling; being able to be there to
of teamwork and camaraderie, the risks of respiratory, liver and ensure that patients are safe and
especially under pressure. kidney issues, and cognitive decline. taken care of is what matters.”
| 27
26-27 Live Well.indd 27 10/1/19 3:36 PMakan Time
Steamed Seabass,
cut
& keep
Teochew Style
Fresh fish, best served steamed, is a deliciously
simple addition to the dinner table. It’s high in
protein and omega-3, and low in fat.
Recipe contributed by Chef Terry Wan Sau Ann, Food Services, KTPH,
and in consultation with Nutrition and Dietetics, KTPH
INGREDIENTS
Serves 4
• 500g seabass, whole
• 20g tomato, thinly sliced
• 15g red chilli, thinly sliced
• 10g salted vegetable, thinly sliced
• 20g dried Chinese mushroom, soaked
and thinly sliced NUTRITIONAL
• 10g ginger, thinly sliced INFORMATION (1 SERVING)
• 30g silken tofu, cut into strips
Energy 128kcal
• 10g salted plum, seed removed
Carbohydrates 2g
METHOD Protein 25g
1. Wash and clean the seabass with water,
Fat 2g
pat dry, then place on a steaming plate
2. In a bowl, combine all other ingredients • Saturated 1g
and spoon on top of the fish • Polyunsaturated 0.5g
3. Pour ¼ bowl of water over the fish
• Monounsaturated 0.4g
4. Bring the water in your steamer to a
rolling boil Cholesterol 68mg
5. Steam the fish for 8 minutes Fibre 1g
6. Remove from steamer
Sodium 229mg
7. Add salt and pepper to taste; serve hot
28
28 |
28-29 Recipe.indd 28 10/1/19 3:37 PM| 29 28-29 Recipe.indd 29 10/1/19 3:37 PM
aily Dose
Snack smart!
Ring in the new year with a healthier
approach to traditional snacks and dishes of
festive occasions. Enjoy in moderation, and
exercise a little extra to burn off the excess.
In consultation with Chow Pek Yee, Principal Dietitian,
Nutrition and Dietetics, KTPH
E
ating healthily does not mean to sodas, packet drinks (even the
depriving yourself of all things ‘less sweet’ varieties), and fruit juices, that have lower sugar content.
delicious. It simply means all of which contain lots of sugar. Go Fat should form no more than
making informed choices and for water, Chinese tea, or sugar-free 25–30% of your daily caloric intake;
eating in moderation. It also means green tea instead. You can then this translates to 14–16 teaspoons
choosing quality over quantity, and allocate your sugar quota (the Health of fat (55–65g). To achieve this, try
mindfully enjoying each mouthful. Promotion Board recommends no forgoing items that are deep fried,
One simple way to reduce your more than 8–11 teaspoons a day; and be mindful of any hidden fat and
intake of extra calories is to say “no” that’s 40–55g) on cookies and snacks gravy served with dishes.
SUGAR
Soda (330ml): 7tsp sugar, 133kcal Chinese tea,
Green tea, Water
‘Less Sweet’ Chrysanthemum tea
0tsp sugar, 0kcal
(330ml): 4tsp sugar, 70kcal
Pineapple tart (1 piece) Love letter (1 piece)
3tsp sugar, 93kcal 1tsp sugar, 17kcal
FAT
Deep-fried nian gao (35g) Steamed nian gao (20g)
2tsp fat, 160kcal 1tsp fat, 46kcal
Traditional yu sheng with half
Traditional yu sheng (387g) the amount of oil dressing and
8.5tsp fat, 561kcal deep fried items (450g)
5tsp fat, 354kcal
Deep-fried chicken breast Deep-fried chicken breast
(with skin) (without skin)
4tsp fat, 364kcal 1tsp fat, 224kcal
30 |
30 Daily Dose.indd 30 11/1/19 5:27 PMind & Health
Healthy Habits Planner
Set out your intentions for the day, week,
month or year — and achieve your health goals!
EXERCISE REGULARLY: EAT HEALTHILY:
A weekly exercise routine I would like to try out Cups of water I would
like to drink daily
MONDAY 1 2 3 4
TUESDAY 5 6 7 8
Fruits and vegetables that I
WEDNESDAY would like to include in my meals
THURSDAY
FRIDAY
How many times a week
I would like to include
SATURDAY brown rice into my meals
1 2 3 4 5 6 7
SUNDAY
8 9 10 11 12 13 14
BE HAPPY: PRACTISE
3 things I am grateful HEALTHY HABITS:
PERSONAL HYGIENE: 2 bad habits I would
for in 2018 and 3 things Good hygiene practices
I look forward to in 2019 like to overcome
I would like to maintain
1 1
2 2
3
| 31
31 Mind & Health.indd 31 10/1/19 3:40 PMCommunity
Nurse Post
Wellness Kampung
Wellness Kampung is an initiative comprising three wellness and care centres for residents in the north. They
provide a suite of health and social programmes, creating a support network for residents to inspire each other to
adopt healthier lifestyles in a close-knit 'kampung' setting.
Opening hours: Mondays to Fridays, 8.30am to 5.30pm (closed on Saturdays, Sundays and all Public Holidays)
115 Chong Pang 260 Nee Soon East 765 Nee Soon
Blk 115 Yishun Ring Road Blk 260 Yishun Street 22 Blk 765 Yishun Street 72
#01-495, Singapore 760115 #01-87, Singapore 760260 #01-366, Singapore 760765
6257 4702 6257 4802 6257 4842
C
M
Y
CM
MY
CY
CMY
K
Admiralty Medical Khoo Teck Puat Yishun Community
Centre (AdMC) Hospital (KTPH) Hospital (YCH)
AdMC is a one-stop medical centre for KTPH is a 659-bed general and acute YCH provides intermediate care for
specialist outpatient consultation, day care hospital serving more than 800,000 recuperating patients who do not require
surgery, rehabilitation and diagnostic people living in the north of Singapore. the intensive services of an acute care
services, as well as community health It combines medical expertise with high hospital. Situated beside KTPH, the two
outreach activities. standards of personalised care in a hospitals provide an integrated care
healing environment, to provide care experience for patients.
good enough for our own loved ones.
676 Woodlands Drive 71, #03-01 90 Yishun Central 2 Yishun Central 2
Kampung Admiralty, Singapore 730676 Singapore 768828 Singapore 768024
6807 8000 6555 8000 6807 8800
www.admiraltymedicalcentre.com.sg www.ktph.com.sg www.yishuncommunityhospital.com.sg
www.fb.com/admiraltymedicalcentre www.fb.com/khooteckpuathospital www.fb.com/yishuncommunityhospitalYou can also read
