Background: Diabetes mellitus type 2 (T2DM) is a chronic metabolic disease leading to target organ complications over time. The delays in treatment and glycemic control have significant implications in short and long-term health outcomes resulting in increased healthcare resource utilization thus timely insulin initiation and intensification is recommended Objective: This clinical pathway was developed to guide family and community physicians on how to intensify the treatment of Type 2 Diabetes Mellitus (T2DM) using insulin intended for patients who require insulin initiation or titration Methods: The PAFP Clinical Pathways Group reviewed published literature in order to identify, summarize and operationalize the evidence in the management of T2DM patients on insulin use in family and community practice. The recommendations are time bound tasks on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions and patient outcomes Summary of Recommendations The recommendations on clinical history and physical examination, laboratory, pharmacologic interventions, non-pharmacologic interventions subdivided into patient-centered, family-focused and community-oriented and patient outcomes are grouped into first visit and second visit, continuing visits
Diabetes Mellitus, Type 2 ; Insulin ; Family Practice

A case control study is a type of observational study. In this study design, participants are selected to participate depending on their outcome status. Cases are participants with outcome of interest whereas controls are participants who do not have the outcome of interest. These studies estimate the odds ratio or the odds between the exposure and health outcome, however they cannot prove causality. Advantages of case control studies include the following: inexpensive, easy to design and implement, and are used to study rare outcomes. Case control studies are prone to certain research bias but can be addressed by the investigator through careful designing and planning. This paper describes the case control studies, their advantages, bias in case control studies and how to address them, and discuss the steps in how to conduct this type of study design.

Human ; Physicians, Family ; Practice Guideline

Background: Dizziness is a commonly encountered symptom in the primary care which can be caused, most of the time by benign condition and rarely due to serious conditions needing higher level of care. Objective: To develop a clinical guideline and pathway that will serve as guide in the diagnosis and management of adult patients with dizziness in primary care and outpatient setting Methods: A guideline development team was formed which is composed of family and community medicine specialists from different institutions. Searching, selection and assessment of the latest evidence on dizziness diagnosis and management was done using the search terms: “dizziness”, “diagnosis”, “management”, and “primary care”. Formulation of the recommendation was done using Grade approach and graded with modified GRADEPro and expert panel consensus. External review was also done by an expert in otorhinolaryngology. Recommendations: Clinical Assessment •Recommendation1.Askforthepatient’sdescriptionofdizzinessandclassifythepatientintooneofthefourtypes: vertigo, presyncope, disequilibrium, and lightheadedness and classify as acute/episodic or chronic/sustained. (Strong Recommendation, Low Quality Evidence) •Recommendation2.Obtainamedicalhistoryfocusingonthetiming,triggers,associatedsymptoms,riskfactorsfor atherosclerotic vascular disease, and functional status or quality of life. (Strong Recommendation, High Quality Evidence) •Recommendation3.Performaphysicalexaminationfocusingonvitalsigns,HEENT(includingotoscopy),cardiovascular and neurologic examination. (Strong Recommendation, High Quality Evidence) •Recommendation4.PerformspecialphysicalexaminationslikeDix-Hallpikemaneuverforacuteepisodictriggeredvertigo to check for BPPV (most common cause of peripheral vertigo), HINTS plus test for spontaneous episodic vertigo to check for stroke and hyperventilation provocation test for patients suspected of anxiety (Strong Recommendation, High Quality Evidence) •Recommendation5.Elicitredflagsthatshouldwarrantreferrallikeseveredizzinessandassociated,alteredmentalstatus, loss of consciousness and abnormal vital signs. Other symptoms like chest pain, palpitations, dyspnea, neurologic deficit may warrant referral for evaluation and management. (Strong Recommendation, High Quality Evidence) •Recommendation6.Forpatientsconsultingviatelemedicine,obtainamedicalhistoryfocusingonthetiming,triggers, associated symptoms, risk factors for atherosclerotic vascular disease, and functional status or quality of life, and observe and conduct self-physical examination (vital signs, mental status, ocular and facial nerve) (Strong Recommendation, Low Quality Evidence) Diagnostic •Recommendation7.Laboratorytestingisnotroutinelyrecommendedamongpatientswithdizziness.However,testingmay be requested if there is a need to identify a definite etiology to guide treatment and should be guided by the classification of dizziness, possible etiology, and the medical history and physical examination. (Strong Recommendation, High Quality Evidence).Recommendation8.Forpatientswithvertigoandwithauditorysymptoms(i.e.,hearingloss,tinnitusandauralfullness, etc.), pure tone audiometry speech test may be requested if available. (Strong Recommendation, High Quality Evidence) •Recommendation9.Forpatientswithpresyncope/syncopeandachronicmedicalconditionisbeingconsidered,complete blood count may be requested for those with probable blood dyscrasia, serum blood glucose may be requested for those with diabetes, electrocardiogram and lipid profile may be requested for those with cardiovascular disease. (Strong Recommendation, High Quality Evidence) •Recommendation10.Forpatientswithdisequilibriumandwithanabnormalneurologicphysicalexaminationfinding,CT scan may be requested. (Strong Recommendation, High Quality Evidence) Pharmacologic •Recommendation11.Empirictrialofshortcourse(7days)pharmacologictreatmentforsymptomreliefshouldbeoffered. Referral should be considered if the dizziness become more severe or it did not improve in 7 days. (Strong Recommendation, High Quality Evidence) •Recommendation12.Forpatientswithmildtomoderatevertigo,offerhistamineanalogue(betahistine)orantihistamine (meclizine, diphenhydramine, dimenhydrinate or cinnarizine) for symptom relief. (Strong Recommendation, High Quality Evidence) •Recommendation13.Forpatientswithmildtomoderatevertigoassociatedwithmigraine(vestibularmigraine),aside from symptom relief, offer any of the triptans as preventive medication. (Strong Recommendation, High Quality Evidence) •Recommendation14.Forpatientswhosedizzinessisdescribedasdisequilibrium(gaitimbalance)orpresyncope(near faintness) or dizziness with anxiety attack, offer symptomatic treatment and intervention based on the underlying cause or consider referral to appropriate specialist. (Strong Recommendation, High Quality Evidence) Non-pharmacologic •Recommendation15.Allpatientsshouldbeprovidedwithhealtheducationoncauses,triggersandfollowup.(Strong Recommendation, Low Quality Evidence) •Recommendation16.Allpatientsshouldbeadvisedonappropriatedietandlifestylemodification.(StrongRecommendation, Low Quality Evidence) •Recommendation17.Dependingonthenatureofvertigo,educateandtrainthepatientoncanalrepositioningmaneuver and vestibular rehabilitation. Referral to rehabilitation medicine may be considered. (Strong Recommendation, High Quality Evidence) •Recommendation18.Thepatient’sfamilymustalsobeprovidedwithhealtheducationandidentifyacaregivertoassist and promote compliance to management. (Strong Recommendation, Low Quality Evidence) •Recommendation19.Encouragecommunity-basedvestibularrehabilitationactivitiessuchasgroupbalancetraining exercise. (Strong Recommendation, Low Quality Evidence) Patient Outcomes •Recommendation20.Thepatientshouldknowthenatureofdizziness,causesandpotentialcomplicationsanddevelop skills in postural exercises. (Strong Recommendation, Moderate Quality Evidence) •Recommendation21.Decreaseinfrequencyandseverityshouldexpectedwithin48hoursandresolutionisexpectedwithin a month. (Strong Recommendation, Moderate Quality Evidence) •Recommendation22.Improvedqualityoflifeshouldalsobeelicited.(StrongRecommendation,ModerateQualityEvidence) •Recommendation23.Referraltoappropriatespecialtyshouldbedoneifnoresolutionorprogressionofsymptomsor impaired quality of life for more than a month. (Strong Recommendation, Expert Opinion) Implementation The committee shall disseminate the guidelines through presentations and via journal publications. The QA committee shall be in charge of implementation of the guideline and pathway.
Community Health Services ; Dizziness ; Partnership Practice

Case reports remain to be an essential part of knowledge generation in health care. It is a research design that involves writing about a patient’s illness with either an unusual, new, unexpected, or unique characteristic. It can be about new findings, a novel diagnostic test, unfamiliar adverse events or innovative medical and surgical interventions. It is a detailed description of a patient’s course of illness including symptoms, physical examination findings, laboratory results, treatment modalities and outcomes. The essential element of writing a case report or series is to contribute to the generation of new knowledge. Wellwritten manuscripts have a valuable purpose in medicine as they present new illness, unexpected effects of treatment, novel diagnostic exams or unforeseen patients’ outcomes. The sections of a case report include an Abstract, Introduction or Background, Case Presentation [history, physical examinations, investigations or laboratories, differential diagnosis (if relevant), treatment (if relevant), outcome/follow-up, Discussion, Learning points/Take home messages, Patients perspectives and References. Manuscripts written as case reports or case series by nature of their design are not required to get approval from an Ethics Review Board (ERB). However, there should be an institutional process to clear and register papers. Case reports or a case series has its own distinctive writing components and features as not all single or series of clinical cases are reportable. This article aimed to define case reports/series, describe the different parts, how to write and evaluate a case report manuscript using the CARE guidelines.

Background: Bypass, is a pattern of seeking health care outside the local community where primary health care facilities are not efficiently utilized. It is common practice for patients to go directly to secondary or tertiary health facilities for primary health concerns, causing heavy traffic at the higher level facilities and corresponding over-utilization of resources. Objective: This study aimed to determine factors associated in the bypass of health care facilities among outpatient department patients and to identify health care facility factors perceived important among patients. Method: The study employed self-administered questionnaire with the assistance of trained research assistants among patients who sought consult at the Baguio General Hospital and Medical Center Outpatient Department during the study period of August 2018 – October 2018. Respondents were asked about demographic characteristics, health insurance status, referral status, health care facility factors and answer the Personal Satisfaction Questionnaire 18 (PSQ 18) survey. Results: The questionnaire survey included 251 patients. The total rate bypassing of local health care facilities was 37.8%. Pearson chi square test revealed that educational attainment was associated with increased bypass of health care facilities (p=0.013). Factors such as age, sex, civil status, employment status, monthly income and health insurance status were significantly associated with bypass. Availability of medical doctors was the most prevelant factor in choosing a health care facility in both bypassers (36%) and non bypassers (46%). PSQ 18 survey revealed that patients are generally satisfied on the availment of health services in both bypassers (mean 3.78) and non bypassers (mean 3.89). The subscales in communication, time spent with doctor and accessibility and convenience were scored highest while technical quality was scored lowest on both groups. Conclusion Bypass of local health care facilities is a major health concern. Travelling longer distances for health care imposes unnecessary shift of direct health care costs into indirect costs such as transport. Increasing awareness of available local health care facilities and services together with its improvement might help decrease bypass especially on patients with lower educational attainment. The referral system and network of health care providers should be reinforced for better health care service delivery, patient satisfaction and lower health care cost.
Referral and Consultation ; Surveys and Questionnaires