The Mental Capacity Act (MCA) addresses the need for authorised individuals (donees) to act on behalf of persons who are unable to make decisions for themselves. One of the consequences of Singapore’s rapidly ageing population is the rise in the number of patients suffering from stroke and age-related neurodegenerative diseases. As their cognitive function deteriorates, they also lose their ability to make independent decisions, which makes them at risk of potentially detrimental decisions made by them or others. Conflicts and uncertainty may come about because of a lack of clarity concerning the individual's wishes with mental incapacity. There is a growing concern amongst individuals that, on losing their mental capacity, they also lose their right to make decisions based on. The MCA has two mechanisms to address such issues, namely, (1) Lasting Power of Attorney (LPA) Certification and (2) Court-appointed Deputy Application for Patients. The former allows for cognitively intact persons to appoint one or more persons to act on their behalf should they lose their mental capacity in the future. The Court-appointed Deputy Application for Patients is required for persons who have not made an LPA before losing mental capacity. The court-appointed deputy can make certain decisions on their behalf. A deputy can be an individual or a licensed trust company under the Trust Companies Act (Cap.336). There are also five ethical issues related to the MCA of 2008 to be discussed.

The Mental Capacity Act (MCA) addresses the need to act on behalf of persons who are unable to make decisions for themselves.One of the consequences of Singapore’s rapidly aging population is the rise in the number of patients suffering from stroke and age-related neuro-degenerative diseases. As their cognitive function deteriorates, they also lose their ability to make independent decisions, and this makes them at risk of potentially detrimental decisions made by them or others. Conflicts and uncertainty may come about because of a lack of clarity concerning the wishes of the individual with mental incapacity. There is a growing concern amongst individuals that, on losing their mental capacity, they also lose their right to determine their preferences to choose. The MCA has mechanisms in place to address such issues.The Singapore Family Physician first published an article on the Mental Capacity Act in 2009, and its lessons and messages hold for family physicians today. This article further updates on two provisions of the MCA:1.Lasting Power of Attorney (LPA) Certification2.Court-appointed Deputy Application for PatientsThe former allows for persons who are cognitively intact to appoint one or more persons to act on their behalf should they lose their mental capacity in the future.Should a person not have made an LPA before losing mental capacity, a deputy is appointed by the court to make certain decisions on their behalf. A deputy can be an individual or a licensed trust company under the Trust Companies Act (Cap.336).This paper will explore the processes involved in certifying the LPA as well as the court-appointed deputies.

A rising prevalence of asthma in Singapore translates to a more considerable patient care burden for general practitioners. Along with diagnosing and managing the treatment of asthma, general practitioners must recognise when referral to a respiratory specialist is necessary. Although mild to moderate asthma is generally manageable in the primary care setting, patients with poorly controlled, difficult-to-treat, or severe asthma may benefit from referral to a specialist. Currently, many of these patients are not receiving optimal care, which places them at risk of asthma exacerbations and unnecessary systemic corticosteroid use. AsthmaID was developed as a tool for general practitioners to identify patients with asthma for whom a specialist evaluation could help improve asthma symptom control and optimise treatment strategies. Using four questions developed by asthma experts and rooted in the Global Initiative for Asthma report, AsthmaID quickly identifies patients who may benefit from a specialist referral without requiring additional patient assessments or testing modalities. Implementation of AsthmaID in clinical practice has the potential to transform the patient care pathway, thereby improving the quality of care for patients with asthma.

INTRODUCTION: We conducted a descriptive study to evaluate any changes in practice behaviour regarding the provision of hydrocortisone and lignocaine (H&L) injections among doctors and how an H&L injection is priced following a disciplinary proceeding decision. A doctor had been fined SGD 100,000 for failing to obtain informed consent before an H&L injection. METHODS: We performed a survey shortly after the disciplinary decision to ascertain: (a) the category of the respondent; (b) whether the respondent provided H&L injections and how much he charged before the decision; and (c) after the decision. All members of the Singapore Medical Association and College of Family Physicians Singapore are doctors and were invited to participate. RESULTS: 1,927 doctors responded to the survey. Prior to the decision, 804 doctors did not perform H&L injections; this increased by 20.4% to 968 after the decision. The number of doctors who gave H&L injections decreased by 164 (14.6%), from the previous 1,123. Pre-decision, doctors who determined their own price for H&L injections charged a median pricing ≤ SGD 100. Post-decision, the median charge rose to > SGD 100 to SGD 200. At higher price bands, the number of doctors who charged > SGD 1,000 increased eight-fold, from eight to 65. CONCLUSION The study demonstrated how a disciplinary decision can affect practice behaviour, and specifically how doctors may choose to not offer a service, an example of defensive medicine through avoidance behaviour. It also showed how prices for a service can rise following such a decision, which demonstrates the concept of negative general deterrence in sentencing.

Osteoporosis is commonly underdiagnosed and undertreated. We performed a clinical audit to assess the risk factors and clinical care for osteoporosis among older persons who attended medical clinic during a 4-week period in August 2013. There was a total of 128 patients with a mean age of 73.1±5.8 years, and 20.3%. had a history of fall. Fracture Risk Assessment Tool (FRAX) scores assessment showed 14.2% and 68.8% had a 10-year risk of major osteoporotic and hip fractures respectively. Only 6.3% underwent Dual-energy X-ray absorptiometry (DXA) and 73.4% did not receive any preventive treatment for osteoporosis. Older persons attending medical clinic at high risk of osteoporosis fractures did not receive appropriate screening and treatment. There is a need to improve the suboptimal care for bone health among older persons.

Purpose: Central venous stenosis is a recurring problem affecting dialysis access patency. Increasing evidence suggests that the use of drug-coated balloons (DCBs) improves target lesion primary patency (TLPP) in dialysis access. However, few studies have investigated the use of DCBs specifically in central venous stenosis. Thus, this study presents our initial experience with DCBs in the central vein of a dialysis access circuit. Materials and Methods: This is a retrospective cohort study of all hemodialysis patients who underwent central vein angioplasty with DCB between February 2017 and March 2018 at Singapore General Hospital. We compared the primary patency post DCB angioplasty to the primary patency of the patient’s previous plain old balloon angioplasty (POBA). Results: We observed a 100% anatomic and procedural success rate with no complications. The median follow-up period was 151 days (interquartile range, 85.5- 234 days) and no patients were lost to follow-up. The 30- and 90-day TLPPs after DCB were 93.3% and 75.7%, respectively. The mean primary patency in our study group post-DCB during the follow-up period was 164 days (vs. 140 days in the POBA group). However, no statistically significant difference was detected. Conclusion DCB showed a similar TLPP to that for POBA in treating central venous stenosis with a trend toward a longer re-intervention-free period for DCB. However, there were numerous confounding factors and a well-designed randomized controlled trial is warranted to assess the true utility of DCB in treating central venous stenosis.

The aim of this Biologic Advisory Group (BAG) Malaysia consensus guideline is to provide clinicians managing cutaneous diseases with biologics relevant parameters to consider prior to initiating or stopping or continuing any biologic treatment in the current landscape of the COVID-19 pandemic. Besides reviewing the medical literatures on COVID-19 and evidences related to other human coronavirus or influenza, expert opinions and clinical experiences are shared and debated in formulation of this biologic consensus guideline.