Osteoporosis-related fractures are increasing at a rapid rate, especially in Asia due to the ageing population. This would result in increased morbidity and mortality of the seniors as well as creating a strain on the healthcare system. Efforts should be made to prevent osteoporosis, screen for osteoporosis early and timely treatment to reduce the risk of fractures. As falls are a major risk factor for fracture in osteoporotic patients, management of osteoporosis should include efforts to reduce falls. Using a population-wide strategy for women 65 years old couple with high-risk population screening using a combination of tools such as FRAX® and OSTA as well as clinical risk factors for women below 65 years old can detect osteoporosis early for intervention. Treatment options for osteoporosis include bisphosphonates, denosumab, teriparatide, raloxifene, menopausal hormone therapy and tibolone. Drug choices should be individualised to the patient, balancing the risk/benefit ratio.

With an ageing population, the incidence of osteoporoticfractures leading to deaths and impairment in quality oflife. However, despite the availability of effectivetreatments, osteoporosis is often under-diagnosed andunder-treated. Primary fracture prevention meansdetection of osteoporosis early with timely appropriatetreatment to improve the bone and lifestyle andenvironment optimisation to reduce falls. We propose apopulation-based combined with high-risk prescreeningfor measurement of bone mineral density (BMD) toreduce the incidence of fractures in the population.

Aims:This study aim to gain insights into attitudes,acceptance and knowledge levels among family physicians toward homosexual people,which are important as they may affect care among this at-risk group.Methods:An anonymized self-administered questionnaire in English was posted with the assistance of the College of Family Physicians Singapore in February 2015 to its 1529 members with self-addressed,pre-stamped envelopes for replies.The questionnaire included demographic questions such as age group,gender,religion,ethnicity,marital status and place of practice.Questions and scales that measured attitude,acceptance,knowledge and perception of colleagues who are homosexual were also included in the questionnaire.Results:451 responses (29.5％) were obtained,of which 441 were valid (28.84％).About 52.8％ of participants were found to have negative,8.9％ neutral and 38.3％ positive attitudes toward homosexuality.Most (75.6％)were accepting of homosexuals,with 9.3％ neutral and 15.1％ not accepting.Knowledge levels were poor,with a mean score of 6.9 out of a maximum of 13.A strong correlation was found between the attitudes towards lesbians and gay men (ATLG) and acceptance of homosexuals scales (r =0.69,P ＜ 0.001),with moderate correlations between acceptance and knowledge (r =0.54,P ＜ 0.001) and ATLG and Knowledge (r =0.54,P ＜ 0.001).Conclusion:Despite majority of family physicians having negative attitudes towards homosexuality,most are able to accept homosexuality.With better education in sexual orientation in the medical educational curriculum,the increase in knowledge will lead to better care for people with homosexuality.

Menopause, a natural process in a woman's life, is defined as the cessation of menstrual period for 12 consecutive months. In Singapore, the average age of natural menopause is 49 years of age. We discuss the challenges faced by menopausal women and provide an example of a holistic approach to the management of women during this important stage of their lives.
Adult ; Age Factors ; Aged ; Female ; Holistic Health ; Humans ; Menopause ; Menstruation ; Middle Aged ; Reproductive Health ; Women ; Women's Health

INTRODUCTION: Practice guidelines advise caution on the use of metformin in patients with type 2 diabetes mellitus with chronic kidney disease (CKD). This review aims to examine the evidence for the benefits and risks of metformin use in patients with T2DM and CKD. METHODS: The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and PubMed were searched; the references of selected papers were hand searched. Systematic reviews, randomised controlled trials, cohort studies, case series and case-control studies were included. The full text of selected articles was reviewed. The outcomes studied were all-cause mortality, cardiovascular complications, lactic acidosis and worsening of renal function. Recommendations were graded according to the Scottish Intercollegiate Guidelines Network system. RESULTS: A total of 139 unique articles were identified, 14 of which met the inclusion criteria and were selected for full-text review. Four cohort studies reported an association between metformin use and improved all-cause mortality in CKD stage 4 and better. Two cohort studies reported improved cardiovascular outcomes with metformin use. Four cohort studies, 1 case series and 1 case-control study reported no significant association between metformin use and an increased risk of lactic acidosis in CKD. There is a moderate level of evidence to support reduced mortality, improved cardiovascular outcomes and a low risk of lactic acidosis with metformin use in patients with T2DM and with CKD stage 4 and above. CONCLUSION Existing recommendations to restrict metformin use in diabetes patients with CKD need to be reviewed in light of emerging evidence supporting its overall benefits in these patients.

Max was treated with SABA using an MDI and spacer with facemask and responded well to the initial treatment. You explained to the parents that nebulisers are neither required nor recommended in the treatment of wheezing in their child's situation. You advised the parents on the proper technique of MDI use with spacer and facemask, as well as care of the equipment. You also gave them a clearly written action plan regarding the efficient management of the next episode of wheeze with MDI and spacer. You further explained the side effects of oral bronchodilators and nebulisers, and why you refrained from using them. Max was given a follow-up appointment to assess his progress, and his parents were advised on the situations when they should go to a doctor or the emergency department.
Asthma ; drug therapy ; Child ; Cough ; Drug Delivery Systems ; Humans ; Inhalation Spacers ; Nebulizers and Vaporizers ; Respiratory Sounds

Combined oral contraceptive pills (COCs) remain one of the most popular forms of contraception to prevent unwanted pregnancy in women. While it is known that COCs can cause sexual dysfunction in women, there is currently no recommendation to screen for sexual function before and after initiation of COCs. We propose that, based on the evidence available, assessment of sexual function should be done at initiation of COCs, as well as at regular intervals thereafter. This would allow COC-related sexual dysfunction to be managed early, such as by switching the patient to newer-generation COCs or other forms of contraception.

Bone Density Conservation Agents ; Diphosphonates ; Humans ; Osteonecrosis

Osteoporosis is a major, growing healthcare issue. This is especially of concern in an ageing population like that of Singapore. Osteoporotic patients are at risk of fractures, which can result in increased morbidity and mortality. The use of antiresorptive therapy with bisphosphonates or denosumab has been proven to reduce fracture risk. However, the use of these medications has rarely been associated with the development of osteonecrosis of the jaw, a potentially debilitating condition affecting one or both jaws. Appropriate understanding of the patient's antiresorptive therapy regime, as well as early institution of preventive dental measures, can play an important role in preventing medication-related osteonecrosis of the jaw (MRONJ). Regular monitoring and prompt referral to specialist care is warranted for patients with established MRONJ.
Aged ; Bone Density Conservation Agents ; adverse effects ; therapeutic use ; Denosumab ; adverse effects ; therapeutic use ; Diphosphonates ; adverse effects ; therapeutic use ; Humans ; Jaw Diseases ; chemically induced ; prevention & control ; Osteonecrosis ; chemically induced ; prevention & control ; Osteoporosis ; complications ; drug therapy ; Osteoporotic Fractures ; complications ; drug therapy ; Risk Factors ; Singapore ; Treatment Outcome

INTRODUCTIONGenetic predisposition to clear cell renal cell carcinoma (ccRCC) has been linked to disorders such as von Hippel-Lindau (VHL) syndrome. While twin research is a classic approach for elucidating genetic and environmental contributions to disease, no monozygotic twin-pair concordant for ccRCC in the absence of VHL syndrome has been previously reported in the literature or in major twin registries.

CLINICAL PICTUREWe describe a unique monozygotic twin-pair concordant for ccRCC, with discordant but early ages of onset of 25 and 38 respectively. Cytogenetic studies and direct sequencing for VHL gene mutations in the second twin proved unremarkable.

CONCLUSIONSThis is the fi rst reported case of monozygotic twins concordant for ccRCC in the absence of VHL gene mutation. The early yet discordant, age of onset of disease in both twins suggests both genetic and environmental contributions to ccRCC.

Adult ; Carcinoma, Renal Cell ; genetics ; pathology ; Diseases in Twins ; genetics ; pathology ; Humans ; Kidney Neoplasms ; genetics ; pathology ; Male ; Twins, Monozygotic ; von Hippel-Lindau Disease ; genetics