Vitamin D in COVID - 19: Dousing the fire or averting the storm? e A perspective from the Asia-Pacific

COVID-19, the acute respiratory tract infection (RTI) caused by the Coronavirus, Sars-CoV-2, has swept around the world. No country has been spared from its onslaught. Treatments that can reduce the risk of infection and mortality from the disease are desperately needed. Though high quality randomized controlled trials are lacking, some observational and interventional studies that explore the link between vitamin D and RTIs exist. Vitamin D modulates both innate as well as adaptive immunity and may potentially prevent or mitigate the complications associated with RTIs. Evidence linking vitamin D to COVID-19 include that the outbreak occurred in winter in the northern hemisphere at a time when vitamin D levels are lowest in resident populations, that blacks and minority ethnic individuals who are known to have lower levels of vitamin D appear to be disproportionately affected and have more severe complications from the disease, that vitamin D deficiency has been shown to contribute to acute respiratory distress syndrome and that case fatality rates increase with age and in populations with comorbid conditions such as diabetes, hypertension, and cardiovascular disease, all of which are associated with lower vitamin D levels. This narrative review summarizes the current knowledge about the epidemiology and pathophysiology of COVID-19, the evidence linking vitamin D and RTIs, especially COVID-19, the mechanistic reasons behind the possible protective effect of vitamin D in COVID-19, and the evidence with regard to vitamin D supplementation in RTIs. It concludes with some recommendations regarding supplementation of vitamin D in patients with COVID-19.

Ability of FRAX Sri Lanka adjusted for trabecular bone score to discriminate between postmenopausal women with a recent fracture and without a fracture

Objectives@#We evaluated the ability of fracture risk assessment tool (FRAX) Sri Lanka to discriminate between women with a recent fracture and without a fracture, when trabecular bone score (TBS) is added to the calculation. @*Methods@#We studied 394 women without previous fractures and 87 women who underwent dual energy X-ray absorptiometry within 3 months after the first fragility fracture. Fracture probabilities (FP) were estimated with and without TBS using Sri Lankan FRAX model and their ability to discriminate those with and without fracture was tested. @*Results@#Women without fractures had higher bone mineral densities (BMDs) and lower FPs, compared to those with a recent fracture. Area under curves of receiver operating characteristic for FPs unadjusted were not different from those adjusted for TBS. The odd ratios of FPs unadjusted were not different from those of adjusted. The FPs estimated with TBS were higher, hence the intervention thresholds (ITs) were higher compared to FPs estimated without TBS. Thirty-two percent of women without previous fracture were above the ITs and the inclusion of TBS increased this to 36%. The integrated discriminatory index analysis showed a 8% increase in the discriminatory slope. @*Conclusions@#The inclusion of TBS to Sri Lankan FRAX did not show an added advantage in discriminating between postmenopausal women with a recent fracture and without a fracture. TBS inclusion in fracture risk calculation among those without previous fractures, however, showed a marginal increase in the number of women above ITs.

Clinical aspects and management of osteoporosis and fragility fractures in patients with diabetes

Both diabetes and osteoporosis are assuming epidemic proportions throughout the world. Accumulating data suggest that both types 1 and 2 diabetes are associated with an increased risk of fragility fractures. This increased risk appears to be largely independent of bone mineral density (BMD) which is most often noted to be low in type 1 diabetes and normal or increased in type 2 diabetes. This review explores the clinical characteristics of bone fragility in patients with diabetes and highlights studies that have evaluated BMD and fracture prediction tools in these patients. It also briefly reviews the current management principles of osteoporosis in diabetes, with special emphasis on the impact of diabetes medications on bone health as well as explores the efficacy of currently available antiosteoporosis pharmacotherapy in the diabetic population.

A Retrospective Review of Imaging and Operative Modalities Performed in Patients with Primary Hyperparathyroidism at a Mid-Volume Surgical Centre in Southeast Asia

<p><b>INTRODUCTION</b>A paradigm shift appears to have occurred worldwide in surgery for primary hyperparathyroidism with the advent of sensitive preoperative imaging techniques. Preoperative imaging for parathyroid adenoma localisation was not found to be useful in a study conducted in Singapore in the 1990s. This study aimed to explore what the change has been in preoperative localisation tools compared to the previous study and if the ability of these tools to correctly localise pathologic parathyroid glands has improved.</p><p><b>MATERIALS AND METHODS</b>A retrospective review of patients who had surgery for primary hyperparathyroidism at our institution during the period 2005 to 2014 was carried out. Individuals with positive, as opposed to those with negative preoperative imaging, were compared with regard to whether they underwent limited focal or bilateral neck exploration. Length of hospital stay (LOHS) was also compared between patients who underwent limited versus bilateral exploration.</p><p><b>RESULTS</b>Fifty-eight patients who had preoperative imaging and surgery were evaluated. True positive rates of sestamibi, ultrasound and 4-dimensional (4D) computed tomography (CT) scans were 63.8%, 72.4% and 90%, respectively. Eighty percent of patients who had positive localisation had limited exploration. LOHS was 2.8 days (1.6, 4.8) and 4.3 days (2.1, 9.0) for limited and bilateral exploration respectively, P = 0.011.</p><p><b>CONCLUSION</b>Our study highlights the marked change in the surgical landscape for primary hyperparathyroidism in the last 2 decades in Singapore. Improved preoperative localisation has resulted in a swing from predominantly bilateral, to limited exploration in almost all cases of primary hyperparathyroidism due to solitary adenoma. LOHS was significantly shorter in patients who had limited as compared to those who had bilateral exploration.</p>

Secondary fracture prevention: plucking the low hanging fruit

It is well known that one fragility fracture begets another. Fracture Liaison Services have been shown to narrow the care gap that exists in the care of patients with fragility fractures. A secondary fracture prevention programme "OPTIMAL" (Osteoporosis Patient Targeted and Integrated Management for Active Living) has been in existence in the public restructured hospitals and polyclinics of Singapore since 2008 and this is beginning to show significant beneficial results in terms of identification and management of fragility fractures. However, significant obstacles in the path of appropriate management of the patient with a fragility fracture still exist. A concerted, multipronged and interdisciplinary approach is needed to overcome these barriers.