A unified consensus statement on medication-related osteonecrosis of the jaw (MRONJ) has not yet been established among the Asian member countries or regions of the Asian Federation of Osteoporosis Societies (AFOS). This study aimed to develop a consensus on MRONJ in patients with osteoporosis across these countries and regions. In this study, the term “Asia-Pacific” refers specifically to the Asian member countries and regions of AFOS. A structured survey consisting of nine MRONJ-related questions was distributed across 10 countries and regions to assess the level of agreement and summarize regional perspectives. In addition, a manual literature review and voting were conducted to evaluate the current evidence on MRONJ. The key aspects of MRONJ, including definition, staging, diagnosis, pathogenesis, risk factors, management, and prevention, were generally consistent among the AFOS countries and regions. The annual incidence and incidence rate of MRONJ associated with low-dose antiresorptive therapy in patients with osteoporosis ranged from 0.025% to 0.136% and 21 to 283 cases per 100,000 person-years, respectively. However, evidence regarding the benefits of drug discontinuation before dental surgery, such as tooth extraction, remains insufficient. Large-scale, multinational studies across AFOS countries and regions are warranted to determine the incidence of MRONJ better and evaluate the impact of antiresorptive drug discontinuation before dental procedures. These findings may contribute to the devel opment of effective evidence-based strategies for preventing MRONJ in patients with osteoporosis.

RATIONALE AND OBJECTIVES

The COVID- 19 pandemic and the subsequent designation of the Philippine General Hospital lead to necessary adjustments in internal medicine residency training. This study investigated the impact of the COVID-19 pandemic on internal medicine (IM) residents in the Philippine General Hospital.

A questionnaire was developed and distributed among internal medicine residents employed in the years 2020 and 2021. Qualitative data was then gathered through on line and face-to-face interviews.

A total of 43 Internal Medicine residents responded. This study found that the pandemic significantly affected internal medicine residents and their overall training. The participants reported changes in the number and profile of patients seen, the limited outpatient clinical exposure, the difficulties of telemedicine, and the reduced interactions with consultants and subspecialty fellows. Infection control protocols and workforce limitations also affected the number of procedures done by the residents. Resident participants reported that they were able to allot more time to studying from the textbook because of the skeletal schedules and decreased number of patients. Other learning avenues were shifted to online conferences and lectures.

The COVID-19 pandemic a lso brought about changes in residents' day-to-day routines, schedules, and rotations. Communicating with patients and relatives was also reported to be more difficult. Lifestyle changes varied among resident s. Socialization also shifted to online avenues and social messaging platforms. Having colleagues who test positive tor COVID and subsequently requiring quarantine lead to constant changes in workforce dynamics. This lead to feelings of anxiety and isolation among its trainees.

However, a number of participants still believed that the pandemic allowed them to become better physicians. This was brought about by a sense of service and pride, camaraderie among colleagues, commitment to finishing the program, financial stability, and administrative support. Still, the participants stated areas for improvement, including more consistent protocol measures, additional financial compensation, added workforce, and more transparent administrative support. All in all, participants felt that they were still able to meet the learning outcomes and minimum competencies. Majority of the participants believed the experiences brought about by the pandemic helped them become a better internist.

Ultimately, the new challenges from the pandemic strengthened the sense of service, resilience and clinical acumen of the residents.

Intracranial lipomas are benign tumors that may occasionally be found in the suprasellar cistern while pituitary adenomas are far more common brain tumors. Pituitary adenomas may rarely coexist with other intracranial tumors in the sellar-suprasellar region. We share a unique case of a patient with coexisting non-functioning pituitary adenoma and sellar-suprasellar lipoma presenting with blurring of vision.

We report a 55-year-old male presenting with a two-year history of blurring of vision with findings of a 2.7 x 3.0 x 3.2 cm homogeneously enhancing lobulated isointense mass on the sellar-suprasellar region. Hormonal workups revealed low cortisol and mildly elevated prolactin. He initially underwent endonasal transsphenoidal excision of the tumor which revealed to be a lipoma on histopathology. Due to minimal improvement of vision from the subtotal excision, he underwent repeat surgery through the transcranial approach which in turn showed a pituitary adenoma.

The co-occurrence of two sellar-suprasellar tumors with different histology is rare, as most of the evidence is based on only a handful of case series. Intracranial lipomas result from persistence and abnormal differentiation of the meninx primitiva during the development of the subarachnoid cisterns. On the other hand, pituitary tumorigenesis is still largely unclear but appears to involve multiple tumor suppressor genes, oncogenes, cell cycle deregulation factors, and miRNAs. Given the differing pathogenesis of each tumor type, the coexistence may only be coincidental. The best surgical approach in this situation is unknown but the focus is on complete excision of the adenoma.

Atypical femoral fractures (AFFs) are a rare but serious complication of prolonged anti-resorptive therapy for osteoporosis. This study aimed to develop consensus-based recommendations for the clinical management of AFFs across the Asian Federation of Osteoporosis Societies (AFOS), for harmonizing practice and improving patient outcomes.A structured questionnaire covering ten key domains related to AFFs was distributed to expert representatives from the 10 AFOS member countries or regions. Responses were analyzed to identify areas of consensus and variation in regional practice. A concurrent narrative review of the literature was conducted to inform evidencebased recommendations. Survey responses were obtained from 8 of 10 participating AFOS member nations or regions. Among these, Thailand, Malaysia, South Korea, and Hong Kong reported established national guidelines or position statements on AFFs. Contributing risk factors include extended anti-resorptive therapy, femoral geometry, comorbidities, and specific pharmacologic exposures. Diagnosis depends on clinical suspicion and multimodal imaging, with high concordance in diagnostic criteria across regions. Screening emphasizes full-length femoral imaging in highrisk individuals. Incomplete AFFs are managed conservatively or with prophylactic fixation, while complete AFFs typically require intramedullary nailing, tailored to anatomic variations such as femoral bowing. Post-fracture care involves discontinuation of anti-resorptives, assessment for secondary osteoporosis, and potential initia tion of anabolic therapy, including teriparatide, abaloparatide, and romosozumab.This AFOS-led initiative highlights the importance for early detection, individualized management, and region-specific strategies. A multidisciplinary, patient-centered approach—encompassing risk assessment, im aging surveillance, surgical intervention, and tailored pharmacologic treatment—is crucial to reduce AFFs impact and improve skeletal health outcomes across Asia.

Intracranial lipomas are benign tumors that may occasionally be found in the suprasellar cistern while pituitary adenomas are far more common brain tumors. Pituitary adenomas may rarely coexist with other intracranial tumors in the sellar-suprasellar region. We share a unique case of a patient with coexisting non-functioning pituitary adenoma and sellar-suprasellar lipoma presenting with blurring of vision. We report a 55-year-old male presenting with a two-year history of blurring of vision with findings of a 2.7 x 3.0 x 3.2 cm homogeneously enhancing lobulated isointense mass on the sellar-suprasellar region. Hormonal workups revealed low cortisol and mildly elevated prolactin. He initially underwent endonasal transsphenoidal excision of the tumor which revealed to be a lipoma on histopathology. Due to minimal improvement of vision from the subtotal excision, he underwent repeat surgery through the transcranial approach which in turn showed a pituitary adenoma. The co-occurrence of two sellar-suprasellar tumors with different histology is rare, as most of the evidence is based on only a handful of case series. Intracranial lipomas result from persistence and abnormal differentiation of the meninx primitiva during the development of the subarachnoid cisterns. On the other hand, pituitary tumorigenesis is still largely unclear but appears to involve multiple tumor suppressor genes, oncogenes, cell cycle deregulation factors, and miRNAs. Given the differing pathogenesis of each tumor type, the coexistence may only be coincidental. The best surgical approach in this situation is unknown but the focus is on complete excision of the adenoma.
Pituitary Neoplasms

OBJECTIVES

To compare the effectiveness of different exercise interventions on improving adiposity-related inflammatory markers of metabolically healthy obese (MHO) adults.

This is a systematic review with meta-analysis of randomized controlled trials (RCTs) and quasi-experimental studies on the effects of exercise interventions in the inflammatory markers of sedentary adults with MHO phenotype. Systematic searches were performed in PubMed, Cochrane, CINAHL, and OVID from January 2021 to January 2022. The included studies were from 2000 to 2021. The inclusion criteria included: a) adults with obese phenotype, b) has physical activity or exercise as intervention, and c) inflammatory markers as outcome measure. Exclusion criteria included: a) pregnant women, b) adults with cardiovascular conditions or taking medications, c) participants having central obesity. The review was registered on PROSPERO (CRD42021249661). Risk of bias (RoB) assessment was performed using Revised Cochrane RoB tool for RCTs, and ROBINS-I tool for quasi-experimental studies. A metaanalysis was performed for inflammatory markers and body composition measurements using random effects model with forest plots presenting mean differences (MD) of outcome measures with 95% CI.

Twenty-one RCTs and seven quasi-experimental studies with 1,117 participants were included in the review. For short-term intervention, aerobic exercises showed an increased trend in IL-6 levels, and both resistance and aerobic exercises reduced TNF-alpha and CRP levels, respectively. For long-term exercises, aerobic exercises showed a significant reduction in CRP (MD= -0.33, 95%CI, -0.57 to -0.09, p=0.006). Long-term concurrent training also showed a significant reduction in TNF-alpha (MD= -2.65, 95%CI, -4.13 to -1.18; p=0.0004). Meta-regression also found no direct association between body weight and fat mass, and changes in inflammatory markers.

Concurrent and aerobic exercises were both effective in reducing pro-inflammatory markers. Concurrent training was more effective in reducing BMI, body fat composition, and CRP compared to aerobic and resistance exercises. Furthermore, middle-aged women benefited from aerobic exercises to reduce IL-6 levels. These results indicate the need for both resistance and aerobic exercise in improving inflammatory levels of the body. This review has limitations in terms of degree of heterogeneity brought by different exercise protocol and assessment of inflammatory markers. More research is needed to identify possible outcome measures that can predict chronic inflammation in MHO people.

Background: Teachers in medicine do not only teach scientific facts about health and disease to their learners but they are also looked up to as role models. Little is known about the qualities of consultant-faculty members who are regarded as role models by Filipino internal medicine residents. Objective: This study aimed to determine the reasons why consultant-faculty members are considered role models by Filipino internal medicine residents. Methods: A cross-sectional survey was conducted among internal medicine residents at a tertiary national university hospital in the Philippines. Participants were asked to give the reasons for citing consultant-faculty members who they consider as role models. Results: There were 81 residents who participated (93% response rate) who gave a total of 332 qualities as reasons for citing them as role models. The most commonly cited quality category was those of personal qualities (35.84% of all responses). This was followed by academic, clinical, teaching, leadership and research qualities. Physical qualities were the least cited (0.30% of all responses). Across the four batches of residents, personal qualities were consistently cited the most number of times, while physical qualities were consistently cited the least. Conclusion Filipino internal medicine residents identified personal qualities as the most frequent reason for considering their consultant-faculty as role models.
Internal Medicine

Objective: A diabetes prevention program is being proposed in the rural agricultural town of San Juan, Batangas, Philippines. This study aims to determine the prevailing level of food intake, physical activity, and health beliefs prior to any intervention. Methodology: Adults were recruited via random sampling with proportional allocation. Interviews were done to determine food intake and physical activity. Small group discussions were held to determine prevailing health beliefs. Results: The average energy intake (1,547 kcal/d) is only 72% of the recommended values for Filipinos. Only 12% of the respondents achieved the recommended energy intake. Carbohydrates comprise a large part (71%) of calorie intake. A majority (91%) already have moderate to high levels of physical activity. There are prevailing health beliefs that need to be considered when dietary modifications and physical activity interventions are to be done. Conclusion Internationally recommended diabetes prevention interventions such as reducing calorie intake and increasing physical activity may not be directly applicable here. We recommend that the features of a diabetes prevention program for this locale must include the following: 1) introduction of affordable plant sources of proteins; 2) decreasing the proportion of rice as a source of carbohydrates in the diet; 3) maintaining the level of physical activity; and 4) being sensitive to the prevailing health beliefs.
Culture ; Diet ; Life Style ; Prediabetic State ; Rural Population

Objective: This meta-analysis aimed to evaluate the association of neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) with the presence of diabetic kidney disease (DKD) among adult patients with Type 2 diabetes mellitus (T2DM).

Methods: A systematic search of articles was performed in various databases. Studies must have fulfilled the following criteria for inclusion: 1) Randomized controlled trial or observational study; 2) Included adults diagnosed with T2DM; 3) Reported data associating NLR or PLR with the presence of DKD; and 4) Controlled for confounders using logistic regression. Data analysis was performed using Review Manager 5.4 software. The estimates were derived using the generic inverse variance method and pooled using the random effects model. Results were presented as odds ratios (OR) and standard errors (SE) with 95% confidence intervals (CI), and graphically shown as forest plots. The I2 value and Chi-square test were used to assess heterogeneity across studies.

Results: Seven studies were included in the review, totaling 1,486 patients. All were cross-sectional studies and had satisfactory methodological quality as evaluated using the Newcastle-Ottawa Quality Assessment Scale. Pooled analysis from six studies showed a statistically significant association between increased NLR and the presence of DKD, defined as either the presence of albuminuria (95% CI, OR 1.68 [1.28, 2.19], p<0.01); or an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73m2 (95% CI, OR 1.56 [1.09, 2.23], p=0.01). In both analyses, there was no significant heterogeneity across studies (I2=0%, Chi2=3.54; and I2=28%, Chi2=2.76 respectively). On the other hand, pooled analysis from two studies did not show a statistically significant association between PLR and albuminuria (95% CI, OR 1.75 [0.85, 3.60], p=0.13), although both studies were homogeneous (I2=0%, Chi2=0.57).

Conclusion: We found a statistically significant association between increased NLR and the presence of DKD. However, a similar association was not found with PLR. Larger studies with more robust designs are recommended.

Objective: The sources of diabetes distress, defined as hidden negative emotions from the demands of daily self-management, are unknown to Filipinos with type 2 diabetes mellitus in the outpatient department. Therefore, we aimed to 1) explore the sources of distress in the perspective of Filipinos with type 2 diabetes mellitus and 2) create a conceptual framework of diabetes distress for Filipinos with T2DM.

Methods: Focus group discussions were done and audiotaped among Filipinos with type 2 diabetes (n=17). The transcript underwent content analysis to generate themes and subthemes. Relationships were determined between codes, categories, and themes elicited in the study to create a conceptual framework unique to Filipinos.

Results: The content analysis revealed five themes of diabetes distress: caregiver factor, socio-economic factor, psycho-emotional factor, medication-related factor, and health care service delivery factor. The socio-economic factor was a distinct theme missing in the prevailing validated questionnaires. Therefore, an adapted conceptual framework was created, as approved by the expert panel.

Conclusion: In conclusion, Filipinos with type 2 diabetes mellitus in the outpatient department have multiple sources of diabetes distress, namely, caregiver factor, socio-economic factor, psycho-emotional factor, medication-related factor, and health care service delivery factor. The socio-economic factor is a unique theme identified among Filipinos. Recognizing the sources of diabetes distress is vital to accurately screen Filipinos with type 2 diabetes mellitus and optimize management outcomes. The study findings will help develop and validate the questionnaire to screen diabetes distress unique to Filipinos.