BACKGROUND: Radiotherapy (RT) to the chest or other large areas of the body may cause bone marrow suppression, resulting in anemia and other changes in blood cell counts. OBJECTIVE: To compare the post­RT hemoglobin levels between patients who underwent forward­ planned intensitymodulated radiotherapy (FPIMRT) and those who underwent three­dimensional conformal radiotherapy (3D­CRT). DESIGN: Retrospective cohort study SETTING: Department of Radiological and Imaging Sciences, Southern Philippines Medical Center, Davao City, from October 2018 to March 2019. PARTICIPANTS: 94 women with invasive ductal carcinoma, aged 29 to 75 years, who received at least 28 fractions (with or without boost dose) of either 3D­CRT or FPIMRT. MAIN OUTCOME MEASURES: Mean hemoglobin counts and anemia within 4 weeks post­RT. MAIN RESULTS: Of the 94 women, 62 (65.96%) underwent 3D­CRT, and 32 (34.04%) underwent FPIMRT. The proportion of patients with left­sided tumors was significantly higher in the FPIMRT group than in the 3D­CRT group. The baseline hemoglobin levels (12.60 ± 1.04 g/dL for 3D­CRT vs 12.49 ± 0.80 g/dL for FPIMRT; p=0.5994) and the mean changes in hemoglobin count from baseline (­0.11 ± 0.72 g/dL for 3D­CRT vs ­0.18 ± 0.67 g/dL for FPIMRT; p=0.6707) were both comparable between the two groups. The proportions of patients with anemia within four weeks post­RT were also comparable between the two groups (13/62, 20.97% for 3D­CRT vs 8/32, 25.00% for FPIMRT; p=0.6565). Left­sided tumors were significantly associated with post­RT anemia (unadjusted OR 2.87; 95% CI 1.00 to 8.22; p=0.0498), even after controlling for type of RT technique (adjusted OR 3.15; 95% CI 1.01 to 9.87; p=0.0484). CONCLUSION After RT, the mean hemoglobin levels of patients with breast cancer who underwent 3D­CRT were comparable with those of patients who underwent IMRT. The type of RT technique was not significantly associated with the occurrence of post­RT anemia in these patients.

Acute epiglottitis (AE), an inflammation of the epiglottis and adjacent supraglottic structures, can lead to a fatal airway obstruction. We report the case of a 47­year­old male who developed AE after experiencing a sore throat, odynophagia, and high­grade fever for a week. The patient came in with late signs of AE, suggesting a poor prognosis. Laryngoscopy revealed a swollen epiglottis obstructing the patient’s tracheal opening. He had cardiopulmonary arrest due to the airway obstruction. The patient was successfully resuscitated but had several episodes of generalized seizure after the return of spontaneous circulation. He was discharged in a persistent vegetative state. Because AE is unusual in the adult population, a clinician's high index of suspicion for the diagnosis and the emergency team’s prompt intervention are crucial factors in the management approach to AE. Physicians working in the emergency room must be equipped with skills in establishing a definitive airway, especially in securing a surgical airway.
Epiglottitis ; Laryngoscopy ; Tracheostomy ;

BACKGROUND: In 2016, the Philippine Health Insurance Corporation (PhilHealth) introduced the Z-package to provide financial coverage for, among others, intramedullary nailing procedures and implant costs for eligible patients with femoral shaft fractures. OBJECTIVE: To compare health care durations and expenses between patients with closed femoral shaft fractures requiring intramedullary fixation who utilized the PhilHealth Z-package and those who did not. DESIGN: Retrospective cohort study. PARTICIPANTS: 66 male and female patients, aged 19 to 39 years, who underwent intramedullary nailing for closed femoral shaft fractures. SETTING: Orthopedic Ward, Southern Philippines Medical Center, Davao City, January to December 2018. MAIN OUTCOME PROCEDURE: Time to surgery, length of hospital stay, total hospital bill, total PhilHealth coverage, other funds for medical assistance (OFMA) coverage, and out-of-pocket (OOP) expenses. MAIN RESULTS: Among the 66 patients, 33 had the Z-package, while the remaining 33 did not. The median time to surgery (19 days vs 24 days; p=0.156), median length of hospital stay (24 days vs 29 days; p=0.546), and median total hospital bill (Php 62,392.00 vs Php 62,404.80; p=0.314) were comparable between those without the Z-package and those who had, respectively. However, patients without the Z-package had significantly lower total PhilHealth coverage (Php 30,740.00 vs Php 48,740.00; p<0.001) and higher OFMA coverage (Php 49,909.90 vs Php 34,409.20; p=0.024), and OOP expenses (Php 0.00; IQR: Php 0.00 to Php 20,000.00 vs Php 0.00; IQR: Php 0.00 to Php 0.00; p=0.004) compared to those with the Z-package. CONCLUSION Patients with the Z-package had a slightly longer time to surgery, although this difference was not statistically significant. However, they benefited from significantly lower remaining bills after PhilHealth coverage and reduced OOP expenses compared to patients without Z-package coverage.
PhilHealth coverage ; out-of-pocket expenses ; medical assistance ; length of stay

Urticaria pigmentosa (UP) is the most common form of cutaneous mastocytosis in children. It can be diagnosed clinically, based on the appearance of numerous brownish macules and papules that are symmetrically distributed, mostly on the trunk and the extremities. Skin biopsy is helpful in establishing the diagnosis. Treatment options generally include antihistamines and/or topical corticosteroids. In most cases, pediatric UP tends to disappear spontaneously before puberty. We present the case of a 9-month-old male with a history of multiple brownish patches and plaques, which started when he was four months old. He was diagnosed with UP based on clinical and histopathologic findings, and was prescribed oral antihistamines and emollients for symptomatic treatment.
cutaneous mastocytosis ; mast cell degranulation

The patient-level experience of health care financing in the Philippines is complex and challenging. While almost all citizens of the Philippines are now covered by the Philippine Health Insurance Corporation (PhilHealth), in practice, not all health care expenses are covered during an episode of illness. Consequently, individuals facing illness might be compelled to seek alternative financial sources to pay for health care costs. This can result in high out-of-pocket (OOP) expenses for patients, which can be financially devastating, especially for those who are already struggling to make ends meet.1 In 2022, government schemes and compulsory contributory health care financing schemes accounted for 44.8% of the Philippines’ current health expenditure, while household OOP payments contributed a close 44.7%.2 Multiple studies evaluating PhilHealth coverage have highlighted the insufficiency of case rates to meet the complete cost of hospitalization.3 4 5 6 This is especially true for high-cost procedures and treatments. As a result, patients with large hospital bills may be left with a significant financial burden, even after they have received PhilHealth reimbursement. Beyond the OOP costs that admitted patients are required to settle, which are reflected in the hospital bill after applying discounts, PhilHealth coverage, and other financial aid, patients often incur additional health care expenses that are not included in the bill. These non-billed OOP costs can encompass a variety of expenses, such as those for medications and diagnostics that are not available in the hospital, and for living allowances, transportation fees, and salaries of private duty nurses, caregivers, and/or patient watchers. These costs are typically borne by the patients themselves and are not usually reimbursed by insurance or the hospital. To cope with these expenses, many patients seek financial aid from various government schemes designed to provide medical assistance. These include programs—such as the Malasakit Program7 and the Medical Assistance for Indigent Patients program8—and the services offered by medical social workers. However, these schemes often do not cover everything in the excess bill, and the distance between offices, coupled with extended waiting times, could discourage patients from pursuing financial aid. Moreover, the paperwork required for PhilHealth coverage and government assistance, especially for patients from outside the city, who must travel home to get the necessary documents, poses significant challenges. Despite seeking financial help, many patients continue to grapple with OOP expenses due to insufficient assistance. This can lead to financial hardship, debt, and even bankruptcy. In some cases, it can also push patients into poverty. In addition to the challenges of inadequate PhilHealth coverage and limited financial assistance, there is also the question of cost efficiency in health care delivery and the reasonableness of professional fees. Are the diagnostics requested really warranted? Is there judicious use of therapeutics? Are the professional fees fair and proportionate to the health care services provided, taking into account the complexity of the case, the time spent, the risks involved, the physician’s professional standing, and the patient’s financial capacity?9 Unwarranted or unjustified use of diagnostics and therapeutics, and disproportionate professional fees, increase health care spending and ultimately put the financial burden on patients. In practice, while the PhilHealth Z Benefit Packages do outline a list of acceptable diagnostic and therapeutic interventions, as well as professional fees for specific packages,10 11 12 much of the practice of determining diagnostics, therapeutics, and professional charges in health care is largely left to the discretion of the health care providers. There are a number of things that can be done to improve the patient-level experience of health care financing in the Philippines. First, there needs to be more research on the adequacy of PhilHealth case rates. These studies will help improve the financial protection that PhilHealth provides to patients. Second, interventions in clinical practice should be aimed at optimizing patient diagnostic and therapeutic management. These measures can both improve patient outcomes and reduce health care costs. Third, professional fees should be efficiently managed to ensure that they are balanced and equitable. A comprehensive and thoughtful approach to fee management can foster transparency in health care spending and greater public trust in the health care system. Fourth, the government should implement mechanisms to address the barriers in availing PhilHealth and other financial assistance schemes. These mechanisms should make it easier for patients to access the funds they need to pay for their health care. One such mechanism is the Malasakit Centers Act,7 13 which encourages public hospitals to establish one-stop shops within their premises, where patients and their families can seek medical assistance from various agencies. This law should be efficiently enforced, as it simplifies the process of obtaining medical assistance. Future interventions should be geared towards reducing OOP expenses. This can be done by making the diagnostic and therapeutic management of patients cost-efficient, ensuring that professional fees are justifiable, expanding the coverage of PhilHealth, and making it easier for patients to access affordable health care services. While PhilHealth and other government schemes have made strides towards universal health coverage, significant gaps in practice still exist. These need to be addressed in order to improve the experiences of patients procuring health care services and make health care truly universal and accessible to all.

Background: Due to the COVID-19 pandemic, health care for patients who experienced out-of-hospital cardiac arrest (OHCA) has been suboptimal. Objective: To describe the demographic, clinical, and logistical characteristics of patients who experienced OHCA during the peak of the COVID-19 pandemic. Design: Descriptive study. Participants: 136 males and 58 females, aged 8 days to 89 years old, who experienced OHCA and were subsequently sent to the emergency department of Southern Philippines Medical Center (SPMC). Setting: Southern Philippines Medical Center, Davao City, March 15 to December 31, 2020. Main outcome measures: Demographic, clinical, and logistical characteristics of patients. Main results: Of the 194 patients, 149 (76.80%) experienced OHCA at home. Among them, 42 (21.65%) received initial CPR at the scene, with 36 (85.71%) of these procedures performed by ambulance crews. Only one (0.52%) patient received automated extracorporeal defibrillation performed by a bystander. There were 147 (75.77%) patients who were transported by private vehicles. The average times for dispatch, response and turnaround of the emergency medical services (EMS) were 8 minutes, 19 minutes, and 56 minutes, respectively. Of the 194 patients, 176 (90.72%) were transported without ongoing resuscitation. Upon arrival at the emergency department, 184 (94.84%) patients had unknown arrest rhythm. Only one (0.52%) patient had a return of spontaneous circulation and was admitted to the ICU. All the other patients expired within 10 to 15 minutes upon arriving at the emergency department. Conclusion In this study, most OHCAs happened at home, with few receiving CPR at the scene, primarily from ambulance crews. The average EMS response time was 19 minutes. Most patients were transported from the scene without ongoing resuscitation, and had an unknown arrest rhythm upon arrival at the emergency department. All patients expired shortly after arriving at the emergency department.
Resuscitation ; Ambulances

Extraskeletal Ewing sarcoma (EES) is a rare tumor that primarily affects children and lacks specific clinical signs. Diagnosis is confirmed through imaging techniques, histology, and molecular diagnostics. Treatment typically involves surgical intervention and chemotherapy. We present the case of a 15-year-old female with a history of abnormal mass enlargement in the right flank area. An initial diagnosis of Wilms tumor was made, and the patient underwent a right open radical nephrectomy. However, the tumor recurred eight months after nephrectomy, necessitating a metastasectomy. Chemotherapy was started to immediately target the tumor recurrence. Next-generation sequencing done on the open radical nephrectomy and metastasectomy samples revealed the presence of the EWSR1-FLI1 fusion gene in both specimens, confirming the final diagnosis to be primary renal Ewing sarcoma. Despite undergoing a right open radical nephrectomy for the primary tumor site, a metastasectomy during tumor recurrence, and chemotherapy, the patient’s prognosis remained poor.
Immunohistochemistry ; Drug Therapy

Pemphigus foliaceus (PF) is a chronic, benign, acquired autoimmune blistering disease characterized by fragile, superficial blisters and bullae.1 2 3 Patients commonly report blister formation on the skin, followed by localized lesions that typically begin on the trunk, face, or scalp.2 PF is a rare disease with a very low worldwide incidence and prevalence. However, it has a high incidence in endemic areas located in North Africa, Brazil, Colombia, and Peru.2 3 4 The disease affects both sexes equally, with symptoms typically appearing between the ages of 50 and 60 years.2 4 The universal type of PF that occurs sporadically is idiopathic, while the endemic type is linked exclusively to geographically-related environmental factors.
Pemphigus

Polymorphic eruption in pregnancy (PEP), formerly known as pruritic urticarial papules and plaques of pregnancy, is a common gestational dermatosis. It rarely manifests in the early trimester of pregnancy and hardly persists in the postpartum period especially in multigravid patients. PEP usually appears late in the third trimester of a first pregnancy, and less frequently in the immediate postpartum period. It occurs almost exclusively in primigravid mothers and is more common in multiple pregnancies.1 2 3 Recurrence in subsequent pregnancies is extremely rare.3 4 The cause of PEP is still unknown, although various theories have been proposed, including increased skin distention, deposition of fetal DNA in skin lesions, high levels of progesterone, and increased progesterone receptor immunoreactivity in patients with PEP.
Pruritic urticarial papules plaques of pregnancy ; Postpartum Period

Medical assistance programs are government-funded programs that provide financial assistance to low-income individuals and families. These programs aim to reduce financial burdens and improve health care access. Coverage may include outpatient visits, hospital care, mental health services, diagnostic work-ups, prescriptions, and other services. This increases the detection of health conditions and improves drug utilization.1 2 3 Even though government health schemes and compulsory contributory health care financing schemes (e.g., PhilHealth) accounted for the majority of health expenditures in the Philippines, household out-of-pocket (OOP) payment still remains high. In 2022, the country’s total health expenditure (THE) was Php 1.12 trillion, with government health schemes and compulsory contributory health care financing schemes accounting for 44.8% of the THE and household OOP payment accounting for 44.7%. Thus, every Filipino spent an average amount of Php 10,059.49 for health care goods and services in 2022
Medical Assistance ; Health Services Accessibility ; Mental Health Services