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The worldwide prevalence of smoking has been estimated at about 50% in men, and 10% in women, with larger variations among different populations studied. Smoking has been shown to affect many organ systems resulting in severe morbidity and increased mortality. In addition, smoking has been identified as a predictor of ten-year fracture risk in men and women, largely independent of an individual's bone mineral density. This finding has eventually lead to incorporation of this risk factor into FRAX®, an algorithm that has been developed to calculate an individual's ten-year fracture risk. However, only little, or conflicting data is available on a possible association between smoking dose, duration, length of time after cessation, type of tobacco and fracture risk, limiting this risk factor's applicability in the context of FRAX®. © 2011 The International Society for Clinical Densitometry. Source

Kwok B.C.,Singapore General Hospital | Mamun K.,Singapore General Hospital | Chandran M.,Osteoporosis and Bone Metabolism Unit | Wong C.H.,Khoo Teck Puat Hospital

Background: Falls are common in frail older adults and often result in injuries and hospitalisation. The Nintendo®Wii™ is an easily available exercise modality in the community which has been shown to improve lower limb strength and balance. However, not much is known on the effectiveness of the Nintendo®Wii™ to improve fall efficacy and reduce falls in a moderately frail older adult. Fall efficacy is the measure of fear of falling in performing various daily activities. Fear contributes to avoidance of activities and functional decline.Methods: This randomised active-control trial is a comparison between the Nintendo WiiActive programme against standard gym-based rehabilitation of the older population. Eighty subjects aged above 60, fallers and non-fallers, will be recruited from the hospital outpatient clinic. The primary outcome measure is the Modified Falls Efficacy Scale and the secondary outcome measures are self-reported falls, quadriceps strength, walking agility, dynamic balance and quality of life assessments.Discussions: The study is the first randomised control trial using the Nintendo Wii as a rehabilitation modality investigating a change in fall efficacy and self-reported falls. Longitudinally, the study will investigate if the interventions can successfully reduce falls and analyse the cost-effectiveness of the programme.Trial registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000576022. © 2011 Kwok et al; licensee BioMed Central Ltd. Source

Chiam P.,Singapore General Hospital | Tan H.C.,Singapore General Hospital | Bee Y.M.,Singapore General Hospital | Chandran M.,Osteoporosis and Bone Metabolism Unit

Though case reports and case series about oncogenic osteomalacia due to benign mesenchymal tumours and much more rarely, secondary to malignant ones exist in the literature, there has not been any series reported from a single department spanning the gamut of causes from benign to malignant. We present 3 patients who were seen at the department of endocrinology of our hospital between 2010 and 2012 with hypophosphataemia and severe skeletal complications. All of them were found to have oncogenic osteomalacia otherwise known as tumour induced osteomalacia (TIO) - a paraneoplastic syndrome characterised by renal phosphate wasting and severe hypophosphataemia. The implicating tumours in our patients ranged from a subcutaneous mesenchymal tumour in the heel to a mixed connective tissue variant within the nasal cavity to metastatic prostate cancer. All our patients had protracted periods before the diagnosis was made, during which time the burden of their metabolic and skeletal pathology had increased. A timely recognition of the clinical features and biochemical findings of this rare but potentially debilitating disease is critical. Physicians should be cognizant of the presence of the disease and its localising and treatment strategies. © 2012 Elsevier Inc. Source

Chandran M.,Osteoporosis and Bone Metabolism Unit | Hoeck H.C.,Center for Clinical and Basic Research | Wong H.C.,National University of Singapore | Zhang R.F.,Singapore General Hospital | Dimai H.P.,Medical University of Graz
Endocrine Practice

Objective: To investigate the vitamin D sufficiency status and the relationships among serum 25-hydroxyvitamin D [25(OH)D] levels, intact parathyroid hormone (iPTH) levels, and bone mineral density (BMD) in patients attending an osteoporosis clinic in Singapore.Methods: In total, 193 adults with or without prevalent fragility fractures and with low BMD at the femoral neck, total hip, or lumbar spine underwent assessment. Multivariate regression models were used to investigate the relationships among serum 25(OH)D, iPTH, and BMD.Results: The mean values (standard deviation) for age of the patients and serum 25(OH)D level were 61 (14) years and 26.05 (7.97) ng/mL, respectively. In 72% of patients, serum 25(OH)D levels were below 30 ng/mL. There was no association between 25(OH)D levels and BMD at the femoral neck, total hip, or lumbar spine (P =.568,.461, and.312, respectively). Serum iPTH levels were negatively associated with BMD at the total hip (P =.035) and the lumbar spine (P =.019). At levels <30 ng/mL, 25(OH)D was negatively associated with iPTH (P =.036).Conclusion: Among this Southeast Asian population of patients with low BMD, no direct relationship between serum 25(OH)D levels and BMD was observed. A negative correlation existed, however, between iPTH and 25(OH)D at serum 25(OH)D concentrations <30 ng/mL, and serum iPTH levels showed a significant negative association with BMD at the total hip and lumbar spine. These significant negative associations between iPTH levels and BMD at the total hip and lumbar spine underscore the critical role of this hormone in bone metabolism and health. Copyright © 2011 AACE. Source

Yung C.K.,Osteoporosis and Bone Metabolism Unit | Fook-Chong S.,Singapore General Hospital | Chandran M.,Osteoporosis and Bone Metabolism Unit
Archives of Osteoporosis

The prevalence of secondary contributors to osteoporosis in our population of SE Asian patients is high. Though various low thresholds Z score values have been proposed as suggestive of a high likelihood of secondary osteoporosis, they appear to have only limited discriminatory value in identifying a secondary cause. Introduction: Many patients with osteoporosis have significant secondary contributors towards their bone loss. The sensitivity and diagnostic utility of using Z score thresholds to screen for secondary osteoporosis have not yet been convincingly demonstrated nor has there been any previous attempt to estimate the prevalence of secondary osteoporosis in South East Asia. We aimed to study the prevalence of commonly recognized contributors and to determine the discriminatory ability of Z score thresholds in screening for them in Singaporean men and post-menopausal women with osteoporosis. Method: Three hundred thirty-two consecutive patients seen at the osteoporosis clinic of the largest hospital in Singapore were evaluated. The frequencies of the different contributors were determined and sensitivities, specificities, and positive and negative predictive values (PPV and NPV) of pre-specified Z score cut-off values calculated. Results: Vitamin D deficiency was present in 18.5% of the patients, hyperthyroidism in 10.11%, primary hyperparathyroidism in 1%, secondary hyperparathyroidism in 6%, hypercalciuria in 21.63%, glucocorticoid use in 8.43%, and hypogonadism in 9.4% of males. A Z score value of <-1 had a sensitivity of 71.7 % and NPV of 66.2 % in identifying the presence of a secondary contributor in post-menopausal women. The sensitivity and NPV of a similar threshold in men was 59.1 and 40 %, respectively. ROC curves used to investigate various Z score diagnostic thresholds for sensitivity and specificity showed that they provided poor predictive value for the presence of secondary osteoporosis. Conclusion: Secondary contributors are common in our patients with osteoporosis. Z score diagnostic thresholds have only limited value in discriminating between primary and secondary osteoporosis. © 2012 International Osteoporosis Foundation and National Osteoporosis Foundation. Source

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