1.Challenges and experiences of young medical specialists in establishing private clinical practice.
Flordeluna Z. MESINA ; Ma. Theresa M. COLLANTE
Journal of Medicine University of Santo Tomas 2022;6(S1):39-49
Background:
The field of medicine is constantly changing. Notable changes occur in the patterns of clinical practice, business of medicine, shift in demographics/generation of the health care workforce, emergence of sub-specialization; and advances in research and technology. These changes can affect the way young physicians establish their practice and this is an area not addressed by the medical education and training.
Purpose:
There is little data in the literature regarding the experience of young physicians in establishing clinical practice. This study was undertaken to answer the central question: Among physicians in the field of Internal Medicine with or without subspecialty who graduated from training in 2013 to 2018, what were the issues and challenges that they faced as they established their clinical practice in the urban or mixed setting?
Methodology:
Qualitative research-case study; Key informant interview was conducted among junior Internal Medicine consultants who satisfied the inclusion criteria. Data analysis used thematic analysis consisting of reading, writing notes, describing, and classifying transcripts according to categories and themes.
Results:
After a comprehensive analysis of narratives, five emergent themes surfaced: “Tough Days” (Period of figuring out the system; Need for Self-introduction; Few patients and Feelings of frustration and depression); “Torn and Divided” (Unpredictable work schedule and workload; Lack of time for issues outside career); “Temporary Debt” (Large start-up cost; Expensive maintenance); “Difficult but Tolerable” (Family support; Call-a-colleague; Debt of gratitude to mentors) and lastly “Dreams and To-do’s”.
Conclusions
Our respondents have experienced substantial challenges in starting clinical practice. Learning the ways of the healthcare business, effectively promoting oneself to the community, dealing with the emotional turmoil of having few patients, coming up with a strategic schedule and area of practice, and looking for funds and paying it back, were the challenges and experiences of these young medical specialists as they establish their careers in the urban and/or rural setting.
Private Practice
2.Status of vitamin D-25 hydroxy ditamin D {25 (OH)} in patients with multiple myeloma
Donaryn V PASAMONTE ; Flordeluna Z MESINA
Journal of Medicine University of Santo Tomas 2019;3(1):277-281
Introduction :
Multiple myeloma (MM) causes generalized bone loss leading to lytic bone lesions and
pathologic fractures. The increased osteoclast activity and reduced osteoblast function favors bone
resorption and decreased bone formation. Vitamin
D is vital in regulating calcium homeostasis and
osteoclast-mediated bone resorption. Defi ciency
of Vitamin D among MM patients may complicate
bone mineralization problems and fractures.
Objective:
General Objective:To determine the status of Vitamin D in patients with multiple myeloma
Specific Objective: To determine the levels of Vitamin D, intact parathyroid hormone and ionized calcium among MM patients.
Methodology :
This is a prospective, cross-sectional study which included patients who were 18
years old and above, male or female, diagnosed
with MM at the University of Santo Tomas Hospital,
with or without treatment. Excluded in the study were
those with Vitamin D and calcium supplementation.
Eligible subjects were extracted blood for Vitamin D assay, intact parathyroid hormone and ionized calcium.
Results:
A total of 22 patients with MM were included in the study. Sixteen patients (72.7%) had
hypovitaminosis D. Among these sixteen patients,
seven (31.8%) had Vitamin D defi ciency (Vitamin
D levels <20 ng/mL [50 nmol/L]) and nine (40.9%)
had Vitamin D insuffi ciency (levels of 21-29 ng/
mL [52.5-72.5 nmol/L]). Only 6 (27.3%) of them
were found to have normal serum Vitamin D (levels of >29 ng/mL [>72.5 nmol/L]). The mean age
(p=0.069), intact PTH (p=0.062) and ionized calcium (p=0.188) of the three groups of patients did
not differ
Conclusion :
This study found a high incidence of
Vitamin D defi ciency among MM patients seen at
the University of Santo Tomas Hospital. Vitamin D
defi ciency was independent of age, intact PTH and
ionized calcium. It was more common in male subjects. Patients with hypovitaminosis D are at risk of
having secondary hyperparathyroidism.
Recommendation
Vitamin D status should be determined among patients with MM. Early recognition and treatment of hypovitaminosis D will prevent
the risk of having secondary hyperparathyroidism
that can complicate skeletal-related events.
Multiple Myeloma
;
Calcifediol
;
Vitamins
3.Infusion reaction to monoclonal antibodies in outpatient infusion units of a university hospital – A two-year retrospective study
Joanna Luisa Z SALVADOR ; Angelita T GARCIA ; Flordeluna Z MESINA
Journal of Medicine University of Santo Tomas 2019;3(1):282-289
Introduction :
Monoclonal antibodies have revolutionized the treatment of immune-mediated infl ammatory diseases (eg, rheumatoid arthritis [RA], Crohn’s
disease [CD], and psoriasis) as well as malignant
diseases. Currently, there are about 100 monoclonal
antibodies and even more are expected in the coming years. Knowledge of not only their mechanism
of action but also their adverse event profi le is tantamount. One of the distinctive side effects of these
drugs is the potential for non-allergic and allergic
infusion reactions caused by cytokine release. These
adverse reactions should be monitored and managed immediately for patient welfare and safety.
General Objective :
To determine the prevalence
of infusion reaction among patients given monoclonal antibodies at outpatient infusion units of a
University Hospital, from July 2015 to July 2017.
Methodology :
This is a two-year retrospective
study at the University of Santo Tomas Hospital
(USTH), a tertiary teaching hospital. A chart review
of patients seen at the USTH Benavides Cancer
Institute (BCI) and Joint and Bone Center (JBC) were
gathered. Patients who received monoclonal antibodies namely rituximab, infl iximab, bevacizumab,
tocilizumab, belimumab, brentuximab, pembrolizumab, trastuzumab, pertuzumab, nimotuzumab
and eculizumab from July 2015 to July 2017 were
included in the study.
Results :
Majority of patients were in the 61 to 70
years age group (25.7%); the median age of the
population was 53 years and the majority were
females (64.9%). The most common indication for
monoclonal antibody infusion is rheumatoid arthritis
(28.4%). More than one-fourth of the patients did not
receive premedications (28.4%) but a good number
(25.7%) received at least two drugs: paracetamol
plus diphenhydramine plus corticosteroids followed
by 17.6% who received paracetamol plus diphenhydramine. The authors found a signifi cant difference
in the occurrence of infusion reaction between those
that were given premedications compared to those
who were not given premedications (p=0.032). The
most common monoclonal antibodies administered
were rituximab (28.4%); tocilizumab (23%); and infl iximab (14.9%). However, only rituximab (9.5%),
infl iximab (2.7%) and bevacizumab (1.4%) had infusion reactions. The overall incidence rate of infusion
reaction to monoclonal antibodies was 14%. The onset was within 2 hours with most infusion reactions
occurring in the fi rst cycle. Ninety percent were classifi ed as grade 2 infusion reactions. Management
of these reactions included rescue medications and
brief interruption of infusion. No hospitalization nor
recurrence of infusion reaction on the resumption of
infusion occurred.
Conclusions
The prevalence rate of infusion reaction to monoclonal antibodies was 14% in this present single-center two-year retrospective study. All adverse events were graded mild to moderate (grade
2) in severity, and were all accordingly managed
successfully in the outpatient setting.
Antibodies, Monoclonal
;
Prevalence
4.Profile and treatment outcomes of Filipino multiple myeloma patients managed at a tertiary institution: A single center six-year retrospective study.
Joy Ann V. DE CASTRO ; Flordeluna Z. MESINA ; Priscilla B. CAGUIOA
Journal of Medicine University of Santo Tomas 2021;5(1):642-657
Introduction: Multiple myeloma remains to be an incurable hematologic entity, but with the advent of novel agents more patients experience significantly longer survival. In a third world country like the Philippines, autologous bone marrow transplant after chemotherapy for newly diagnosed cases which is the standard of care is difficult to comply. The management paradigm for myeloma has shifted over the years, hence this study.
Objective: Determine the clinical profile and treatment outcome of Filipino multiple myeloma patients diagnosed and managed at a tertiary institution from January 2013 to December 2018.
Methodology: Retrospective, observational and cross-sectional study of eligible symptomatic myeloma patients.
Results: Data for six years were retrospectively collected from a single tertiary institution. The clinical characteristics at diagnosis, treatment and survival rates of 109 active myeloma patients were described. The median age was 61 years (range, 28-83), with 51.4% being female. Median overall survival was 49.5 months (95% CI 42.7-56.2). The frontline treatments of patients were also analyzed. The combined deep response (complete and very good partial) of our patients at 31.7% was higher than of Asian Myeloma Network Study at 30.9%. None of them yet underwent autologous bone marrow transplantation as of date. Novel agents, especially bortezomib was used in 35.7% and significantly affected overall and progression-free survivals when used as a first line treatment.
Conclusion: This retrospective analysis demonstrated the paradigm shift in the treatment modality of myeloma and the survival outcomes has significantly improved, especially on the best response to chemotherapy. Short of the ideal management in a third world country like the Philippines, we can now set our new standard of care based on the treatments available including novel agents like bortezomib, and the best practices that our institution offers.
Multiple Myeloma ;
5.Effectiveness and safety of Therapeutic Plasma exchange as an adjunctive treatment for Coronavirus Disease 2019 (COVID-19) patients: A systematic review
Charles Eryll S. Sy ; Jomell C. Julian ; Flordeluna Z. Mesina
Philippine Journal of Internal Medicine 2021;59(4):272-282
Rationale:
COVID-19 is a new, rapidly emerging zoonotic infectious disease. Addressing the cytokine storm and
coagulopathy associated with this disease can minimize its severity and complications. Therapeutic plasma exchange (TPE) can be potentially used to remove these deleterious cytokines and procoagulant proteins.
Objective:
This study aims to assess the effectiveness and safety of TPE as an adjunctive treatment for COVID-19 patients.
Research Design and Methodology:
A systematic search of databases was conducted utilizing PubMed and Cochrane databases to identify relevant literature until December 31, 2020. All publications were included if they use TPE in COVID-
19 patients. The exclusion was applied in publications written in language other than English, review papers, or on-going clinical trials. No restrictions on age, sex, or clinical setting were applied. The eligible studies were reviewed in full text independently by two authors. Methodological quality and risk of bias assessment were done. The findings from the individual studies were summarized.
Results:
A total of 21 studies were included. Overall risk of bias was high within and across the studies. All studies reported marked improvement of clinical status and laboratory results after receiving the TPE. The use of TPE among COVID-19 patients resulted in no serious or life-threatening adverse events.
Conclusion
The available studies on the use of TPE for COVID-19 patients is still limited and evidence is of low certainty.
However, based on the available data, it has an encouraging result to be used as effective and safe adjunctive treatment in COVID-19 patients.
COVID-19
;
Cytokine Release Syndrome
6.Bumps of blood cells: Blastic Plasmacytoid Dendritic Cell Neoplasm in an elderly Filipino
Christian Bernard T. Cheng ; Ellen M. Gatchalian ; Flordeluna Z. Mesina ; Alejandro Arevalo
Philippine Journal of Internal Medicine 2019;57(1):34-38
Introduction:
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare and aggressive hematologic malignancy derived from the precursors of plasmacytoid dendritic cells. This malignancy presents with various noticeable cutaneous lesions and usually occurs in elderly males. Cutaneous manifestations usually precede leukemic dissemination to the lymph nodes, bone marrow, and peripheral blood which is associated with poor prognosis.
Case presentation:
We present a case of a 60-year-old Filipino male with a four-month history of multiple hyperpigmented, reddish brown, firm, fixed, non-tender cutaneous nodules on the extremities, trunk, chest, and face. Two large masses was also noted on the left arm and left upper back..Tissue biopsy of the cutaneous mass showed Immunohistochemical stain findings positive for LCA, CD68, CD4, CD56, and CD123 which are compatible with BPDCN. Patient was initially asymptomatic with relatively normal blood count and was treated supportively but serial blood count monitoring showed worsening with progression to acute myelogenous leukemia. Patient was then started on the 7+3 protocol of cytarabine and idarubicine which provided flattening of the cutaneous nodules and improvement of blood counts. However, due to complications of the disease and the treatment, the patient succumbed to severe pulmonary infection and sepsis.
Discussion:
Due to the varied, non-specific cutaneous manifestations and the similarity in the morphology of the skin lesions with other cutaneous conditions along with the rarity of this disease, there is difficulty in establishing the diagnosis of BPDCN as well as standardizing its treatment. Immunohistochemical stains play an important role in confirming the diagnosis as well as ruling out other differential diagnoses to tailor appropriate treatment.
Conclusion
Blastic plasmacytoid dendritic cell neoplasm (BPDCN) generally has a poor prognosis owing to the rapidity of its spread to the bone marrow and peripheral blood. Early diagnosis is essential to initiate early therapy and prevent progression.
Leukemia, Myeloid, Acute
7.Burden of symptoms and symptom experience of Filipino patients with myeloproliferative neoplasm: A qualitative phenomenological approach.
Flordeluna Z. Mesina ; Teresita E. Dumagay ; Marissa M. Alejandria ; Nina T. Castillo-Carandang
Acta Medica Philippina 2024;58(18):35-48
BACKGROUND
Myeloproliferative neoplasms (MPN) are a heterogeneous group of disorders characterized by the cellular proliferation of one or more hematologic cell lines. Patients with MPN who are Philadelphia-negative such as those with Polycythemia Vera (PV), Essential Thrombocytosis (ET), or Myelofibrosis (MF) experience a cluster of symptoms related to the disease activity which can affect their quality of life.
OBJECTIVESThis study aimed to explore the symptoms and symptom experience as well as lived experience of Filipino patients with MPN using a qualitative phenomenological approach to get a deeper understanding of the disease symptomatology.
METHODSTwenty-three patients with myeloproliferative neoplasms were purposively selected according to: 1) type of MPN (PV, ET, MF) 2) status of MPN disease (newly diagnosed vs. chronic) 3) age (≤50 years old; >50 years) and 4) sex (male vs. female). The investigators conducted key informant interviews using a semi-structured interview guide. Interview scripts and narratives were transcribed and analyzed using categorical aggregation and thematic analysis.
RESULTSTwenty patients proceeded with the interview (8 PV, 6 ET, 6 MF). The meta-themes identified were 1) symptom experience and 2) disease perception. Three sub-themes under symptom experience were a) heterogenous and complex symptomatology; b) dynamic nature of symptoms; c) living and coping with symptoms. Three sub-themes under disease perception were a) struggle with the concept of the disease; b) anxiety and uncertainty; c) acceptance and hope. The most common symptoms experienced by the patients were fatigue, bone pain, and abdominal discomfort. Vascular symptoms specifically headache, numbness, and problems in concentration were commonly reported by patients with PV. Fever and weight loss were the least common. Sources of anxiety/uncertainty include the unpredictability of symptom occurrence and blood counts, the burden of taking maintenance medications, the financial burden of living with MPN, and the unpredictability of disease and complications.
CONCLUSIONPatients with MPN had heterogenous, co-occurring, and dynamic symptoms which affected their overall productivity both at home and at work. Patients with MF had the most symptom burden while patients with ET had the least. This study provided valuable insights on disease perceptions, sources of anxiety, and coping mechanisms of patients with MPN. A deeper understanding of the symptom experience and disease perceptions of the patients will enhance the physician-patient interaction especially when discussing management options.
Human ; Symptom Burden ; Quality Of Life
8.Use of Convalescent Plasma Therapy among Hospitalized Coronavirus Disease 2019 (COVID-19) Patients: A Single-Center Experience
Flordeluna Z. Mesina ; Claudette G. Mangahas ; Ellen M. Gatchalian ; Mary Sheila Ariola-Ramos ; Rosalio P. Torres
Philippine Journal of Internal Medicine 2020;59(2):107-112
BACKGROUND: COVID-19 disease has strained our healthcare system. Convalescent plasma is an adjunct treatment used in emerging infectious diseases in past epidemics.
OBJECTIVE: This study aims to determine the outcome and clinical course of COVID-19 patients who received convalescent plasma (CP) transfusion at Cardinal Santos Medical Center.
METHODS: This is a retrospective cohort analytical study of 75 patients who received convalescent plasma.
RESULTS: Median time from admission to CP transfusion was 3 days. Majority of patients received additional therapies including dexamethasone (100%), antibiotics (100%), remdesivir (95%), hemoperfusion (88%), tocilizumab (65%), or combinations of these. Among the survivors, the median length of stay (LOS) was 15 days while non-survivors had a median LOS of 6 days. One patient (1.33%) had a mild transfusion reaction. Four patients (5.33%) developed deep vein thrombosis despite anticoagulation. There was improvement in the inflammatory markers (LDH p value 0.04, CRP p value 0.00, Ferritin p value 0.0001). There was improvement in the pulmonary parameters - increase in mean PaO2, mean SaO2, and mean PFR; and decrease in mean FiO2 and mean RR post-treatment. Median LOS is 14 days for the CP group vs 11 days for the non- CP group. Mortality rate among the CP group was 25.33% while the non-CP group was 26.67%. LOS and mortality rate did not reach statistical significance.
CONCLUSIONS: There was no significant difference in mortality and length of hospital stay in patients given CP vs controls. CP when combined with other treatment modalities might have a role in the improvement of inflammatory markers and pulmonary status.
COVID-19
;
Plasma