Insulin hypersensitivity reactions are rare, but cause significant complexity in the care of patients with diabetes mellitus. A 54-year-old Filipino male with type 2 diabetes mellitus and multiple co-morbidities developed delayed-type hypersensitivity reactions to biphasic isophane human insulin and glargine. Despite good glycemic control on oral hypoglycemic agents, his endocrinologist foresaw the need for future insulin therapy, particularly one basal and one short-acting insulin. Targeted skin tests demonstrated protamine allergy and negative reactions to regular insulin and detemir. Close coordination of care among endocrinologists, allergists, patients and patients' family is needed to optimize glucose control, prevent complications, and minimize the risk of future hypersensitivity reactions.

Key Words: drug hypersensitivity, insulin, diabetes mellitus

The Universal Health Care (UHC) Act of the Philippines, signed into law in 2019, aims to provide a full range of health services to all Filipinos.1 However, its planned implementation was derailed with the COVID-19 pandemic. We observed a large variation in the pandemic response across regions and countries, highlighting the complex interplay of political, structural, economic, and cultural factors on health. 2 The Philippine national government implemented varying levels of community quarantine, risk communication, travel restrictions, testing and monitoring of at-risk individuals, and vaccination policies to control the pandemic, while the local government units (LGUs) were tasked to adopt and coordinate these policies in their communities.

Key Findings There is currently no evidence to support the use of virgin coconut oil in the adjunctive treatment of COVID-19. • Virgin coconut oil is naturally extracted from fresh coconut kernel and is rich in medium chain triglycerides, with lauric acid as the predominant fatty acid. • Virgin coconut oil is currently explored as an adjunctive treatment for patients with COVID-19 due to its antiviral and immunomodulatory properties. • In vitro studies show that lauric acid or its derivative exert inhibitory activities against viruses with similar structure to coronavirus (enveloped ssRNA virus) such as Junin virus, vesicular stomatitis virus, human immunodeficiency virus type 1 (HIV-1), and Semliki Forest virus. • Animal studies demonstrate antiviral activity of monolaurin, the pharmacologically active metabolite of lauric acid, on avian influenza virus and Simean immunodeficiency virus, which are both enveloped ssRNA viruses. • Clinical trials among patients with HIV report that virgin coconut oil can increase CD4+ T lymphocyte counts and reduce viral load. • In vitro and animal studies demonstrate anti-inflammatory properties of virgin coconut oil. • At present, there are no studies that investigate the effectiveness of virgin coconut oil in the adjunctive treatment of COVID-19 infection. • There is currently one ongoing clinical trial in the Philippines evaluating the use of virgin coconut oil in the adjunctive treatment of COVID-19. • Nausea, vomiting, mild diarrhea, and abdominal pain have been reported, but no serious adverse events have been identified with the use of virgin coconut oil. • To date, there are no guidelines that mention virgin coconut oil as an option for the adjunctive treatment of COVID-19.
Coronavirus ; Covid-19

Key Findings At present, there are no studies that evaluate the efficacy or safety of dexmedetomidine with another sedative agent among coronavirus disease 2019 (COVID-19) patients. Possible adverse events should be carefully considered in the choice of an add-on sedative agent. • Adequate sedation is important among ventilated COVID-19 patients. Dexmedetomidine is an alpha2-adrenergic receptor agonist that produces sedation, analgesia and anxiolysis. It preserves respiratory function even when given in high doses; thus, it is commonly used for COVID-19 patients. • Due to the high cost of dexmedetomidine, a common clinical practice is to use dexmedetomidine in combination with other sedatives. • Co-administration of dexmedetomidine with other sedatives has an additive effect. Possible adverse effects of combination treatment include hypotension, bradycardia, and delirium. • There are no completed or ongoing clinical trials that evaluate the efficacy or safety of dexmedetomidine with another sedative agent among COVID-19 patients. • Currently, there are no guidelines that specifically mention the recommended add-on sedative agent to dexmedetomidine for sedation of COVID-19 patients. • The World Health Organization recommends light sedation and minimizing continuous or intermittent sedation among suspected COVID-19 patients with severe acute respiratory infection. • Consensus statements for mechanically ventilated COVID-19 patients recommend using dexmedetomidine, lidocaine or opioids during extubation to minimize coughing. • Clinical practice guidelines for sedation among critically ill, mechanically ventilated adult patients recommend the use of propofol or dexmedetomidine over benzodiazepines due to decreased time to extubation, duration of stay in the intensive care unit, and incidence of delirium.
Coronavirus ; Covid-19

Key Findings There is currently no evidence to support the use of sanitation tents in the prevention of COVID-19 transmission. • Sanitation tents or disinfection tents have been installed in various areas of the Philippines as a measure to decontaminate individuals and prevent COVID-19 transmission. • The commonly used disinfectant in these tents is diluted household bleach. Others propose to use alcohol or diluted povidone iodine to decontaminate individuals in the tent. • Bleach is an irritant to mucous membranes and loses its antimicrobial effect over time or when exposed to heat and sunlight. • Alcohol is flammable and also causes irritation to mucous membranes. • Povidone iodine may cause skin irritation, chemical pneumonitis when inhaled, and acute kidney injury when systemically absorbed. • There are no completed or ongoing studies on the use of sanitation tents for the prevention of COVID-19 transmission. • To date, there are no guidelines that recommend the use of sanitation tents for prevention of COVID-19 transmission. • The World Health Organization explicitly recommends against spraying alcohol or chlorine all over a person's body due to adverse health effects and the lack of inhibitory activity against viruses that have already entered the body. • The Centers for Disease Control and Prevention note that most environmental protection agency-registered household disinfectants are effective against COVID-19. However, these products are approved for use only on surfaces and not on humans. • The Department of Health guidelines recommend the avoidance of spraying or misting for COVID-19 due to lack of evidence of its efficacy.
Coronavirus ; Covid-19

BACKGROUND

Remdesivir is an intravenously administered antiviral drug that inhibits RNA-dependent RNA polymerase. In vitro studies have shown that remdesivir can inhibit the growth of the COVID-19 virus in infected Vero cells and can inhibit infection in human cell lines.

To determine the efficacy and safety of remdesivir in treating patients with COVID-19 infection.

A systematic search of electronic medical literature databases was done from inception until September 4, 2022. Search for ongoing studies and preprints was also done. Risk of bias assessment was done using Cochrane risk of bias tool version 2.0. Measures of effect used were relative risk (RR) and 95% confidence interval (CI). Subgroup analysis by disease severity was preplanned. The estimates for efficacy and safety of remdesivir was calculated using Review Manager 5.4 software.

Nine randomized controlled trials with 13,085 participants were identified. Eight of the included studies recruited confirmed COVID-19 patients needing hospitalization, while one study limited recruitment to nonhospitalized patients. Remdesivir showed significant benefit for outpatients with mild to moderate disease with at least one risk factor for disease progression in terms of COVID 19-related hospitalization (RR 0.13 95% CI 0.03 to 0.59), all-cause hospitalization (RR 0.28, 95% CI 0.10 to 0.75), and need for medically-attended visits (RR 0.19, 95% CI 0.07 to 0.56). For hospitalized patients, remdesivir had a slight benefit in reducing all-cause mortality at day 28 (RR 0.90, 95% CI 0.83 to 0.98). Subgroup analysis by disease severity showed a trend towards reduction in mortality among those with severe disease (RR 0.61, 95% CI 0.35 to 1.07), with no effect on those with critical disease (RR 0.96, 95% CI 0.87 to 1.04), and inconclusive effect for those with mild-moderate disease (RR 0.74, 95% CI 0.49 to 1.11). Remdesivir showed benefit in decreasing clinical deterioration (RR 0.75, 95% CI 0.61 to 0.89), improving recovery rate (RR 1.07, 95% CI 1.01 to 1.13), and reducing the need for mechanical ventilation (RR 0.68, 95% CI 0.51 to 0.90). There was inconclusive effect on the need for ICU admission (RR 0.98, 95% CI 0.43 to 2.22). No increased risk of adverse events (RR 0.98, 95% CI 0.91 to 1.06), including serious adverse events (RR 0.77, 95% CI 0.57 to 1.03), was seen.

Based on the available evidence, remdesivir shows benefit in the treatment for patients with mild, moderate, and severe COVID-19 infection. However, there was no benefit in mortality noted among those with critical disease requiring mechanical ventilation. Remdesivir demonstrated a good safety profile, with no increased risk of adverse events compared to control. These results are consistent with the international agencies’ recommendations for the use of remdesivir among patients with mild, moderate or severe COVID-19 infection, but not for those with critical infection.

Current evidence supports the use of remdesivir as treatment for selected patients with COVID-19.

Executive Summary This Clinical Practice Guideline for the Periodic Health Examination (Pediatric Immunization) is an output from the joint undertaking of the Department of Health and National Institutes of Health-Institute of Clinical Epidemiology. This clinical practice guideline is a systematic synthesis of scientific evidence on immunization for the prevention of human papilloma virus (HPV) infection, influenza, typhoid fever, Japanese encephalitis, poliomyelitis, meningococcal infection, and Hepatitis A in the pediatric population. The CPG provides nine (9) recommendations on prioritized questions regarding the relevant vaccines for preventing these seven (7) diseases. Recommendations are based on the appraisal of the best available evidence on each of the eight identified clinical questions. The CPG is intended to be used by general practitioners and specialists in the primary care setting, policy makers, employers and administrators, allied health practitioners and even patients. The guideline development process followed the widely accepted Grading of Recommendations, Assessment, Development, and Evaluation or the GRADE approach including GRADE Adolopment, a systematic process of adapting evidence summaries and the GRADE Evidence to Decision (EtD) framework. 1,2 It includes 1) identification of critical questions and critical outcomes, 2) retrieval of current evidence, 3) assessment and synthesis of the evidence base for these critical questions, 4) formulation of draft recommendations, 5) convening of a multi-sectoral stakeholder panel to discuss values and preferences and assess the strength of the recommendations, and 6) planning for dissemination, implementation, impact evaluation and updating. The recommendations in this CPG shall hold and will be updated after 3 years or when new evidence arise.

Background. A 2017 situational analysis assessing Clinical Practice Guidelines (CPG) development in the Philippines revealed CPGs of inconsistent quality. In response, the Department of Health (DOH)-Philippine Health Insurance Corporation Manual for CPG Development was developed to outline the standardized steps of the CPG development process. To implement this, technically qualified institutions and individuals should be commissioned.

Objective. To identify qualified institutions and individuals and map out their technical skills and potential for capacit building in CPG development

Methods. Mixed methods were used in this cross-sectional study. A snowballing method identified specific institutions and individuals. Self-administered surveys and key informant interviews were conducted to determine competence, strengths, and gaps in the development of CPGs.

Results. A total of 74 individuals from 45 institutions with competencies in CPG development were identified. Of the 45 institutions, 72% were non-clinical, with roughly half working on formal research. Of the 74 individuals, 96% possessed relevant knowledge and skills and 85% already provided training on CPG development topics. Around half of the respondents have been part of a CPG development task force. Only about half were able to incorporate social concepts of equity, and only one-third had experience in managing conflicts of interest.

Conclusion. Qualified institutions and individuals identified in this capacity mapping can be tapped in future CPG development in the country. Incorporation of social concepts and management of conflicts of interest still need to be ensured.

Background: Physician burnout is a growing problem worldwide. Several interventions aimed at lowering burnout rates among physicians have been implemented. To date, there is no established structured program to combat burnout in the Philippine General Hospital. This study evaluated the effectiveness of the I-CARE program, a physician resilience and wellness program which adapted the different components of the international programs for the Philippine setting.

Objective: To evaluate the effectiveness of the I-CARE program in reducing medical residents' burnout level.

Methods: After key components of the I-CARE program were identified, the program was implemented in 2 phases. The first phase involved training of consultants to hone their facilitation skills. The second phase was a before-and-after study of the I-CARE program. The participants' burnout level was measured before and after the program using the Maslach Burnout Inventory.

Results: The I-CARE program was implemented in the Department of Pediatrics from March to August 2020. There was no significant change in the overall burnout levels of 59 pediatric residents after the I-CARE implementation (p=0.32). This may be due to several challenges encountered during the implementation, such as time constraints, the increased workload caused by the COVID-19 pandemic, and the lack of physical meetings due to the restrictions of the pandemic. However, the feedback of the administrators, facilitators and residents was generally positive. All the interviewed participants recommended the continuation of the I-CARE program in the Department of Pediatrics.

Conclusion: The I-CARE program shows potential in promoting mental health and emotional wellness among physicians in training.

Objective: Phenobarbital is an inductor of microsomal hepatic enzyme and used as choleretic for cholestatic liver disease to enhance bile flow. It is also used as a premedication for hepatobiliary scintigraphy (HIDA) scan to improve diagnostic accuracy for an obstructive liver disease. We reviewed the available literature on the use of Phenobarbital for treatment of cholestasis and its utility as a premedication for HIDA scan. Methods: All published studies before June 30, 2023 that investigated the efficacy, effectiveness or safety of Phenobarbital in cholestatic jaundice and its effect on the accuracy of hepatobiliary scintigraphy in diagnosis of obstructive jaundice were included. Electronic databases were searched including MEDLINE via PubMed, Cochrane Library, medRxIV, BioRxIV, as well as the following registries for ongoing and completed trials: ClinicalTrials.gov (USA); ChiCTR.org. (China); and the WHO International Clinical Trials Registry Platform. We screened abstracts, reviewed full texts, and extracted relevant information on study design, settings, population and outcomes. There was no age and language restriction. Two reviewers independently rated the quality of included studies using: Joanna Briggs Institute critical appraisal tool for case reports, case series, and diagnostic accuracy; Newcastle – Ottawa Quality Assessment Scale for cohort studies, and Cochrane Risk of Bias for Randomized Trials. Risk of bias was appraised and GRADE certainty of evidence was judged. Pooled analysis was done using Stata 14 and reported as sensitivity and specificity. Results: Included were nine reports on Phenobarbital as treatment for cholestasis (one case report, five case series, one cohort and two randomized studies) and seven studies (four diagnostics, two cohorts, one randomized trial) on its use as a premedication for HIDA scan. The quality of case report and case series were considered fair; cohort studies as good; and diagnostic studies were included based on overall assessment. The randomized studies had some or high risk for bias due to concerns in randomization process, measurement of outcome, and risk in the selection of reported results. There were 31 patients (16 adults and 15 children) from case reports and case series. Of the 16 adults, serum total bilirubin concentrations declined from 4 to 70% from baseline in 13 of 15 (87%) patients after Phenobarbital was given at 120 to 250 mg per day from 22 days to f ive months. Eleven of 14 with pruritus at onset also had improvement in intensity of itching. Of the 15 pediatric patients, ten (67%) showed a decrease from 10 to 60% of the baseline total bilirubin but not a normalization with Phenobarbital intake at a dose of 3 to 12 mg/kg/day from one to 21 months. Five of 14 children also had relief of itching after treatment. Phenobarbital compared to Ursodeoxycholic acid had limited efficacy in reducing the bilirubin levels in neonates and young infants with cholestasis. Phenobarbital compared to Ursodeoxycholic acid had limited efficacy in reducing the bilirubin levels in neonates and young infants with cholestasis. Moderate certainty evidence showed that with Phenobarbital pretreatment, the hepatobiliary scan done on patients with neonatal cholestasis had 100% (CI 99.2, 100; I2 = 0.0%) sensitivity and 80.2% (CI 65.4, 92.1; I2 = 76.6%) specificity while no Phenobarbital pretreatment had 100% (94.9, 100; I2 = 0.0%) sensitivity and 89.5% (CI 77.0, 98.1; I2 = 11.4%) specificity. Adverse effects of Phenobarbital were drowsiness, lethargy, poor feeding, and irritability. Conclusion There was limited effectiveness of Phenobarbital in decreasing bilirubin levels in cholestatic liver disease. Moderate certainty evidence demonstrated that premedication with Phenobarbital did not improve the specificity of HIDA scan in the diagnosis of obstructive jaundice of infancy. Neurologic symptoms were observed with Phenobarbital intake.
phenobarbital ; cholestasis ; scintigraphy ; radionuclide imaging ; pruritus