Symmetrical polyarthritis is not uncommon as a presenting clinical problem in the primary care setting. The ability to differentiate inflammatory from non-inflammatory, articular from peri-articular joint pain will help the Family Physician (FP) to further narrow the diagnosis of joint pain, and provide early referral and effective treatment when necessary. Integrating clinical reasoning with the concept of likelihood ratios in the process of diagnosis, FPs can also easily differentiate the various diagnoses of symmetrical polyarthritis, including rheumatoid arthritis (RA). There is also increasing evidence that shared care of patients with rheumatoid arthritis can be done successfully and safely between FPs and rheumatologists.

Glucocorticoid-induced osteoporosis (GIOP) is a form of secondary osteoporosis caused by the intake of glucocorticoid medication. It is characterised by rapid bone loss and takes place soon after glucocorticoid therapy is initiated (three to six months). This results in increased fracture risk. The increased risk is observed in patients taking 5 mg/day prednisolone (or equivalent) for 3 months. Therefore, clinicians should use the lowest dose of glucocorticoid for the shortest duration of time to control or treat the disease and consider steroid-sparing agent when appropriate. Patients who appear cushingoid should be evaluated to exclude excess endogenous or exogenous source of glucocorticoid. They should be evaluated for complications of glucocorticoid, including GIOP. BMD Testing using DXA is recommended for assessment of fracture risk in patients who will be started on glucocorticoid for three months at 5 mg/day prednisolone or equivalent. Patients who are at moderate to high risk of fractures or rapid bone loss should be treated with bisphosphonate, denosumab or teriparatide therapy to reduce the risk of fractures.

Osteoporosis is a chronic disease that may require lifelong therapy. Therefore, evidence-based approach regarding the efficacy and safety of long‐term osteoporosis therapy and therapy discontinuation is important. The most important goals for osteoporosis and fragility fracture patients are the recovery of pre-fracture functional level and reduction of fracture risk. There has been increasing consensus that a treat-to-target (T2T) strategy is applicable to osteoporosis and that bone mineral density (BMD) is currently the most clinically appropriate target. However, there is no clear consensus with regard to the definition of a specific BMD treatment target and timeframes applicable to T2T in osteoporosis, and these would need to be individually determined. Treatment with bisphosphonates may be interrupted after 3-5 years, only in patients in whom fracture risk is low or lowered because of the treatment itself. It is recommended never to discontinue treatment in patients with one or more prevalent osteoporotic fractures or in whom the BMD values are still below -2.5 (T score). Recent reports imply that denosumab discontinuation may lead to an increased risk of multiple vertebral fractures. Patients considered at high fracture risk should either continue denosumab therapy for up to ten years or be switched to an alternative treatment. For patients at low-risk, a decision to discontinue denosumab could be made after five years, but bisphosphonate therapy should be considered to reduce or prevent the rebound increase in bone turnover.

fractures will affect one-third of women andone-fifth of men 50 years old and older worldwide.1 Toprevent the inevitable rise in hip fracture occurrences,early patient identification is of paramount importance.Patients with timely osteoporosis diagnosis andappropriate management can remain fracture free.Fracture Liaison Services (FLSs) arecare-coordinator-based secondary fracture preventionprogrammes that systematically identify fragilityfracture patients, then assess, investigate and treatthem for underlying osteoporosis as appropriate.2 Theyare promoted by the International OsteoporosisFoundation (IOF) as a cost-effective strategy forreducing the osteoporosis care gap, the refracture rate,and mortality.3,4 Identifying patients with high fracturerisk using the WHO fracture risk assessment tool(FRAX), and discussing the treatment thresholds basedon patient’s ideas, concerns, expectations and caregoals, using a shared decision-making approach, is apatient-centric and cost-effective way to manageosteoporosis and prevent fractures.

In Singapore, male osteoporosis is gaining greater importance due to our ageing population. Family physicians should screen for osteoporosis in elderly men and men with risk factors or secondary causes for the condition. A bone mineral density (BMD) test is used for diagnosis. FRAX® can be used to predict the absolute ten-year fracture risk. Management includes reduction of risk factors or secondary causes, fall prevention, appropriate physical activity and a diet adequate in calcium and vitamin D. Referrals to specialists for evaluation and therapy can be considered, particularly for younger men with more severe disease. Current first-line drug treatment includes bisphosphonates and teriparatide. Testosterone increases BMD of the spine, but data on fracture risk reduction is unavailable. Public and physician education with the involvement of health authorities can create greater awareness of this silent condition, which can lead to complications, morbidity and death, if left untreated.
Accidental Falls ; Aged ; Aged, 80 and over ; Aging ; Bone Density ; Calcium ; metabolism ; Diphosphonates ; therapeutic use ; Family Practice ; Female ; Fractures, Bone ; diagnosis ; Humans ; Male ; Middle Aged ; Osteoporosis ; diagnosis ; therapy ; Referral and Consultation ; Risk Factors ; Sex Factors ; Singapore ; Teriparatide ; therapeutic use ; Testosterone ; metabolism ; Vitamin D ; metabolism

INTRODUCTIONUndergraduate education in medical schools plays an important role in promoting patient safety. Medical students from different backgrounds may have different perceptions and attitudes toward issues concerning safety. This study aimed to investigate whether patient safety cultures differed between students from two Asian countries, and if they did, to find out how they differed. This study also aimed to identify the educational needs of these students.

METHODSA voluntary, cross-sectional and self-administered questionnaire survey was conducted on 259 students from two medical schools - one in Hong Kong and the other in Singapore. None of the students had received any formal teaching on patient safety. We used a validated survey instrument, the Attitudes to Patient Safety Questionnaire III (APSQ-III), which was designed specifically for students and covered nine key factors of patient safety culture.

RESULTSOf the 259 students, 81 (31.3%) were from Hong Kong and 178 (68.7%) were from Singapore. The overall response rate was 66.4%. Significant differences between the two groups of students were found for two key factors - 'patient safety training', with Hong Kong students being more likely to report having received more of such training (p = 0.007); and 'error reporting confidence', which Singapore students reported having less of (p < 0.001). Both groups considered medical errors as inevitable, and that long working hours and professional incompetence were important causes of medical errors. The importance of patient involvement and team functioning were ranked relatively lower by the students.

CONCLUSIONStudents from different countries with no prior teaching on patient safety may differ in their baseline patient safety cultures and educational needs. Our findings serve as a reference for future longitudinal studies on the effects of different teaching and healthcare development programmes.

Curriculum ; standards ; Education, Medical, Undergraduate ; methods ; Female ; Health Knowledge, Attitudes, Practice ; Hong Kong ; Humans ; Male ; Patient Safety ; Schools, Medical ; Singapore ; Students, Medical ; psychology ; Surveys and Questionnaires

The COVID-19 pandemic has significantly disrupted medical education, particularly affecting clinical-year students. Educational institutions often had to halt, shorten or impose significant restrictions on their hospital rotations due to strict infection control and social-distancing guidelines implemented in tertiary healthcare institutions, as well as manpower and logistical constraints amid the pandemic. Thus, distance-based learning platforms such as online lectures and case-based teaching were increasingly adopted in place of bedside and face-to-face tutorials. While interactive virtual case-based discussions are generally useful in imparting clinical reasoning skills to medical students, they are unfortunately not able to fully replicate the experience of clerking, examining and managing real patients in the wards, which is a quintessential process towards building clinical acumen and attaining core clinical competencies. Therefore, for final year medical students who are preparing for their Bachelor of Medicine and Bachelor of Surgery (MBBS) examinations, many are naturally concerned by how learning in this "new normal" may affect their ability to make the transition to become competent junior doctors. As such, we seek to share our learning experiences as the first batch of medical students to have completed our entire final year of clinical education amid the COVID-19 pandemic, and offer 4 practical suggestions to future batches of students on how to adapt and optimise clinical learning under these circumstances: actively engaging in virtual learning, making the most of every clinical encounter, learning how to construct peer teaching/practice sessions, and maintaining physical and psychological well-being.
COVID-19 ; Humans ; Pandemics ; SARS-CoV-2 ; Singapore/epidemiology* ; Students, Medical

INTRODUCTIONUp to 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional non-biologic disease modifying antirheumatic drugs (nbDMARDs), and may benefit from therapy with biologic DMARDs (bDMARDs). However, the high cost of bDMARDs limits their widespread use. The Chapter of Rheumatologists, College of Physicians, Academy of Medicine, Singapore aims to define clinical eligibility for government-assisted funding of bDMARDs for local RA patients.

MATERIALS AND METHODSEvidence synthesis was performed by reviewing 7 published guidelines on use of biologics for RA. Using the modified RAND/UCLA Appropriateness Method (RAM), rheumatologists rated indications for therapies for different clinical scenarios. Points reflecting the output from the formal group consensus were used to formulate the practice recommendations.

RESULTSTen recommendations including diagnosis of RA, choice of disease activity measure, initiation and continuation of bDMARD and option of first and second-line therapies were formulated. The panellists agreed that a bDMARD is indicated if a patient has (1) active RA with a Disease Activity Score in 28 joints (DAS28) score of ≥3.2, (2) a minimum of 6 swollen and tender joints, and (3) has failed a minimum of 2 nbDMARD combinations of adequate dose regimen for at least 3 months each. To qualify for continued biologic therapy, a patient must have (1) documentation of DAS28 every 3 months and (2) at least a European League Against Rheumatism (EULAR) moderate response by 6 months after commencement of therapy.

CONCLUSIONThe recommendations developed by a formal group consensus method may be useful for clinical practice and guiding funding decisions by relevant authorities in making bDMARDs usage accessible and equitable to eligible patients in Singapore.

Antirheumatic Agents ; economics ; therapeutic use ; Arthritis, Rheumatoid ; drug therapy ; Financing, Government ; Humans ; Practice Guidelines as Topic ; Singapore

INTRODUCTIONThis study aimed to assess the effectiveness of the use of a cardiopulmonary patient simulator in the teaching of second-year medical students. Effectiveness was measured in terms of the extent of knowledge retention and students' ability to apply the skills learned in subsequent real-life patient contact.

METHODSIn this study, ten third-year medical students who had previously undergone simulator training as part of their second-year curriculum underwent an objective structured clinical examination (OSCE) and a multiple-choice question (MCQ) test to assess their ability to apply the knowledge gained during the simulator training when dealing with real patients. The performance of this group of students was compared with that of a group of ten fourth-year medical students who did not undergo simulation training.

RESULTSAlthough the third-year medical students performed well in the OSCE, they were outperformed by the group of fourth-year medical students, who had an extra year of clinical exposure. The MCQ scores of the two groups of students were similar. Post-simulation training survey revealed that students were generally in favour of incorporating cardiopulmonary simulator training in the preclinical curriculum.

CONCLUSIONCardiopulmonary simulator training is a useful tool for the education of preclinical medical students. It aids the translation of preclinical knowledge into real-life clinical skills.

Cardiology ; education ; Clinical Clerkship ; Computer Simulation ; Curriculum ; Education, Medical ; organization & administration ; Educational Measurement ; Female ; Humans ; Learning ; Male ; Singapore ; Students, Medical ; Surveys and Questionnaires ; Universities

Traditional Chinese medicine (TCM)-based herbal therapies have gained increasing popularity worldwide, raising concerns of its efficacy, safety profile and potential interactions with Western medications. Antithrombotic agents are among the most common prescription drugs involved in herb-drug interactions, and this article focused on aspirin, one of the most widely used antiplatelet agents worldwide. We discussed herbs that have potential interactions by exploring Western and TCM approaches to thrombotic events. Common TCM indications for these herbs were also highlighted, including possible scenarios of their concurrent usage with aspirin. With greater awareness and understanding of potential herb-drug interactions, TCM and Western physicians may collaborate more closely to identify, treat and, most importantly, prevent adverse drug events.
Aspirin ; therapeutic use ; Carthamus ; Drug-Related Side Effects and Adverse Reactions ; Drugs, Chinese Herbal ; therapeutic use ; Herb-Drug Interactions ; Humans ; Medicine, Chinese Traditional ; Panax ; Physicians ; Platelet Aggregation Inhibitors ; therapeutic use ; Salvia ; Thrombosis ; drug therapy