INTRODUCTION. This 2021 paper is an update of the 2019 version. In this current update, two new items of information added. Firstly, the 2020 Consensus statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on HPDM, provided recommendations on additional medications to be considered in uncontrolled morning or night blood pressure (BP) are noted.9 Secondly, the nephroprotective properties of the SGLT-2 inhibitors are highlighted.19 Similar to the content of the 2019 version, four related areas are reviewed. They are (1) BP definition and classification; (2) Hypertension diagnosis; (3) Hypertension and proteinuria in non-diabetic patients; and (4) Proteinuria and hypertension in the patient with diabetes. METHODOLOGY. PubMed searches were done for papers to the above four topics published in the last five years (2014 to 2019). These were supplemented by papers from hand searches. RESULTS. For diagnosis of hypertension, the current cut off of 140/90 mmHg can be reduced to 130/80 to improve cardiovascular outcomes and all-cause mortality. Diagnosis of hypertension should not be based on office BP readings alone. Hypertension in older patients should be treated to prevent worse outcomes and should be individualised. In non-diabetic patients, both low grade and microalbuminuria needs to be treated; adequate BP control is needed to prevent cardiovascular outcomes and all-cause mortality. In the diabetic patient, a BP target of less than 140/90 mmHg applies to most patients, but individualisation of the BP goal is important. CONCLUSIONS. Much development in the management of proteinuria and hypertension has taken place in the last five years.

Singapore progressed to DORSCON Orange on 7 February 2020 when a local case with no history of travel out of Singapore was confirmed COVID-19 positive. With the impending lockdown, decision was made to move all postgraduate programs online. The objectives of this paper are to document early experiences and lessons learnt in the conversion of face-to-face to online teaching; and to conduct a literature search for tips on effective online teaching.

In this update four related areas are reviewed. They are: (1) Blood Pressure (BP) definition and classification; (2) Hypertension diagnosis; (3) Hypertension and proteinuria in non-diabetic patients; and (4) Proteinuria and hypertension in the patient with diabetes. METHODOLOGY. PubMed searches were done for papers to the above four topics published in the last five years (2014 to 2019). These were supplemented by papers from hand searches. RESULTS. For diagnosis of hypertension, the current cut off of 140/90 mmHg can be reduced to 130/80 mmHg to improve cardiovascular outcomes and all-cause mortality. Diagnosis of hypertension should not be based on office BP readings alone. Hypertension in older patients should be treated to prevent worse outcomes and should be individualised. In non-diabetic patients, both low grade and microalbuminuria needs to be treated; adequate BP control is needed to prevent cardiovascular outcomes and all-cause mortality. In the diabetic patient, a BP target of less than 140/90 mmHg applies to most patients but individualisation of the BP goal is important. CONCLUSIONS. Much development in the management of proteinuria and hypertension has taken place in the last five years.

Anorexia Nervosa is one of the eating disorders, as classified in the Diagnostic and Statistical Manual, the fifth edition. It is characterised by a pathological fear of weight gain associated with an overwhelming drive for thinness. Patients do present to primary care with vague, non-specific complaints. A heightened degree of suspicion is required for the diagnosis, as patients tend to hide symptoms and are often in denial. We present a case in an 11-year-old girl brought by her mother to the polyclinic with a history of restrictive eating and excessive exercise for three weeks. This case provided a learning opportunity on the assessment and management of an eating disorder, as well as the adverse effects of undernutrition.

Pneumonia is an important cause of mortality and morbidity worldwide including Singapore. It imposes heavy economic burdens on health care systems. S. pneumoniae is an important pathogen in community acquired pneumonia (CAP) in both developed and developing countries. Pneumococcal disease is importantly, vaccine preventable. The objectives of this review are to provide updates on: pneumococcal disease in adults; pneumococcal vaccines for adults; the need to increase uptake of pneumococcal vaccines; and recommendations on pneumococcal vaccinations in the current national adult immunization schedule. Pneumococcal disease in adults can be divided into invasive and non-invasive pneumococcal diseases. Two pneumococcal vaccines are currently available for adult vaccination in Singapore, namely, the 23-valent pneumococcal polysaccharide vaccine (PPSV23) and the 13-valent pneumococcal conjugate vaccine (PCV13). The current recommended pneumococcal vaccine immunization strategy is to administer the PCV13 first followed by PPSV23 a year later in pneumococcal vaccine naïve patients. In patients given PPSV23 before, PCV13 is given to complete the protection. Cost effectiveness studies in Singapore have shown that pneumococcal conjugate vaccines may confer protection against pneumococcal disease both directly and indirectly through herd effects, and reduction of nasal carriage. Uptake of pneumococcal vaccines in Singapore is currently low. Characteristics associated with increased pneumococcal vaccination uptake were higher monthly income, higher educational level, having a regular doctor, and good self-rated health. A research-guided educational intervention may be an effective model to improve the knowledge and attitudes of patients towards pneumococcal vaccinations. We need to find ways to use vaccination and other strategies to reduce the mortality and morbidity associated with pneumococcal disease in Singapore.

Prevention of disease is one of the key functions ofprimary care. Vaccines have earned their place inpreventing communicable diseases. The rate of uptake ofvaccines does not always match with knowledge.There are barriers which the healthcare professionalsneed to address. In the new era of IT, innovation andpolicy change, many ideas can be pursued to improvevaccination uptake in the community.There is a group of our population who will need ourspecial attention to vaccinate. They are the healthcareworkers, caregivers, the foreign domestic helpers, theimmunocompromised, and the pregnant mothers.There are many areas we need to work on to improve ourvaccination rate. Primary Care Research will provide theevidence and guide the refinement of these programmes.

A 20-day-old previously well neonate presented with a 3-day vesiculopapular rash and was admitted to the paediatrics ward. He received extensive workup and treatment with IV acyclovir. The disease ran a mild, uncomplicated course, and recovery. His mother was found to be immune to varicella, having had the disease as a child. However, her immunity had not transferred to the neonate, which was unexpected. A literature review revealed that maternal varicella antibodies do not necessarily prevent infection but may help the infant avoid severe or complicated disease. A review of the management of neonatal varicella in both the immune and the non-immune mother which put the child at risk is also done. Vaccination of all susceptible young females prior to pregnancy will help to reduce the incidence of neonatal varicella in infants and is strongly encouraged. Vaccination of household contacts especially siblings, is also encouraged. Family Physicians should remain open to the diagnosis of neonatal varicella, even when the mother has a history having chickenpox as a child.

A case study of a 76-year-old man with end-stage chronic obstructive pulmonary disease (COPD) with refractory breathlessness and the challenges in managing the dyspnoea he had been experiencing are described. A multi-modal approach is the mainstay of management, encompassing pharmacological agents, home oxygen therapy, and non-pharmacological approaches, namely, breathing techniques and smoking cessation. As this patient was at an advanced stage of disease, integration of palliative care with disease care was needed. Administering oxygen therapy for a patient who is still smoking and has household members who are current smokers need firm adherence to rules. The AIC HOME Programme is also briefly described.

Medical reports are required to support court applications to appoint a deputy to make decisions on behalf of a person who has lost mental capacity. The doctor writing such a medical report needs to be able to systematically assess the mental capacity of the person in question, in order to gather the necessary evidence for the court to make a decision. If the medical report is not adequate, the application will be rejected and the appointment of the deputy delayed. This article sets out best practices for performing the assessment and writing the medical report, common errors, and issues of concern.
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