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.

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

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.

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.

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

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.

The Health Promotion Board (HPB) has developed the Clinical Practice Guidelines (CPG) on Falls Prevention among Older Adults Living in the Community to provide health professionals in Singapore with recommendations for evidence-based assessments and interventions for falls prevention. This article reproduces the introduction and executive summary of the key recommendations from the HPB-MOH CPG on Falls Prevention among Older Adults Living in the Community for the information of SMJ readers. The chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Health Promotion Board website: http://www.hpb.gov. sg/cpg-falls-prevention. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
Accidental Falls ; prevention & control ; Aged ; Environment ; Evidence-Based Medicine ; Geriatrics ; standards ; Health Promotion ; methods ; Housing ; Humans ; Incidence ; Middle Aged ; Practice Guidelines as Topic ; Risk Assessment ; methods ; Singapore ; Social Class

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

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