1.In-hospital outcomes of methylprednisolone pulse therapy in the treatment of systemic lupus erythematosus.
Magbitang Angeline-Therese D. ; Rubio Anna Kristina Gutierrez ; Salido Evelyn Osio
Philippine Journal of Internal Medicine 2014;52(1):1-7
BACKGROUND: Methylprednisolone Pulse Therapy (MPPT) is standard of care in the management of severe systemic lupus erythematosus (SLE). This treatment, though, is considered a double-edged sword due to its life-threatening adverse effects. Renal disease, liver disease and high dose of the drug are factors proposed to adversely affect outcomes of patients treated with MPPT. Despite the widely accepted use of MPPT, there are no reports describing the outcomes from its use among Filipinos with SLE.
OBJECTIVE: To determine the in-hospital outcomes of patients with SLE treated with MPPT and to identify factors associated with adverse outcomes.
GENERAL STUDY DESIGN: Retrospective
POPULATION: Adult patients with SLE who were admitted in Philippine General Hospital and underwent MPPT from January 2008 to December 2012.
METHODS: Patient demographics, disease characteristics on admission, indications for MPPT and in-hospital outcomes were extracted.
ANALYSIS: Chi-square test and Fisher's exact test were used to elicit association of population characteristics to outcomes.
RESULTS: Forty-two patients with SLE who underwent MPPT were included. Majority are females (98%) and most (60%) underwent MPPT within one year of SLE diagnosis. High disease activity is seen at the time
of MPPT with a mean Mex-SLEDAI score of 14.69. Infection (83%) is the most common comorbidity. Anemia, hypoalbuminemia and significant proteinuria are the most common laboratory abnormalities. The top indication for MPPT is nephritis (83.3%). The dose received by the majority (66.7%) is one gram/day for three days, which is a high dose.
Improvement rate is 76% but the in-hospital complication rate is 64% and mortality rate is 21%. Patients with in-hospital complications have significantly lower absolute lymphocyte count (p=0.013), serum albumin (p=0.04) and greater 24-hour proteinuria (p=0.04) at baseline. High-dose MPPT is significantly associated with in-hospital complications (p=0.04) but not mortality. Nephritis (p= 0.04) and low platelet counts at baseline (p=0.01) are associated with mortality.
CONCLUSION: In this population, there is a high rate of improvement of lupus disease activity when MPPT is used but there is a corresponding high rate of in-hospital complications and mortality. High dose of MPPT seems to be associated with increased in- hospital complication, while nephritis and low platelet count showed a probable association with mortality. Further studies on a larger cohort are needed. For now, the findings of this study may be helpful in developing guidelines on the use of MPPT among Filipino patients with SLE.
Human ; Male ; Female ; Adult ; Hypoalbuminemia ; Serum Albumin ; Lupus Erythematosus, Systemic ; Nephritis ; Kidney Diseases ; Proteinuria ; Anemia ; Liver Diseases ; Lymphocyte Count ; Methylprednisolone
3.The use of prognostic prediction models for mortality or clinical deterioration among hospitalized and non-hospitalized adults with COVID-19: A systematic review
Patricia Pauline M. Remalante-Rayco ; Evelyn Osio-Salido
Acta Medica Philippina 2020;54(Rapid Reviews on COVID19):1-12
Objective:
To assess the performance of prognostic models in predicting mortality or clinical deterioration among patients with COVID-19, both hospitalized and non-hospitalized
Methods:
We conducted a systematic review of the literature until March 8, 2021. We included models for the prediction of mortality or clinical deterioration in COVID-19 with external validation. We used the Prediction model Risk Of Bias ASsessment Tool (PROBAST) and the GRADEpro Guideline Development Tool (GDT) to assess the evidence obtained.
Results:
We reviewed 33 cohort studies. Two studies had a low risk of bias, four unclear risks, and 27 with a high risk of bias due to participant selection and analysis. For the outcome of mortality, the QCOVID model had excellent prediction with high certainty of evidence but was specific for use in England. The COVID Outcome Prediction in the Emergency Department (COPE) model, the 4C Mortality Score, the Age, BUN, number of comorbidities, CRP, SpO2/FiO2 ratio, platelet count, heart rate (ABC2-SPH) risk score, the Confusion Urea Respiration Blood Pressure (CURB-65) severity score, the Rapid Emergency Medicine Score (REMS), and the Risk Stratification in the Emergency Department in Acutely Ill Older Patients (RISE UP) score had fair to good prediction of death among inpatients, while the quick Sepsis-related Organ Failure Assessment (qSOFA) score had poor to fair prediction. The certainty of evidence for these models was very low to low. For the outcome of clinical deterioration, the 4C Deterioration Score had fair prediction, the National Early Warning Score 2 (NEWS2) score poor to good, and the Modified Early Warning Score (MEWS) had poor prediction. The certainty of evidence for these three models was also very low to low. None of these models had been validated in the Philippine setting.
Conclusion
The QCOVID, COPE, ABC2-SPH, 4C, CURB-65, REMS, RISE-UP models for prediction of mortality and the 4C Deterioration and NEWS2 models for prediction of clinical deterioration are potentially useful but need to be validated among patients with COVID-19 of varying severity in the Philippine setting.
COVID-19
;
Mortality
;
Clinical Deterioration
4.Calf pain as a prominent feature of Behçet's Disease
Grace G. Penserga ; Evelyn Osio-Salido
Acta Medica Philippina 2022;56(2):77-80
Objective:
This study aimed to present four cases of Behçet's disease (BD) wherein recurrent calf pain was the first and prominent symptom experienced by the patients.
Methodology:
The case series described the clinical features, disease development, management, and outcomes of these patients. Written consent was obtained from each participant for the review and publication of their case.
Results:
All cases presented with chronic and recurrent calf pain, three of whom were bilateral. All four had skin changes on the lower extremities that may have contributed to leg pain. Only probing was a history of oral ulcers reported in all four; none had genital ulcers, eye abnormality, or sensory or motor deficits. All presented with elevated acute phase reactants. Based on the 2013 International Criteria for Behçet’s Disease (ICBD), a diagnosis of possible BD was made due to the presence of oral ulcers, skin lesions, and absence of other findings pointing to another connective tissue disease or systemic vasculitides. All four cases were given oral corticosteroids and colchicine, but two required the addition of methotrexate and azathioprine for control of symptoms.
Conclusion
A complaint of recurrent calf pain warrants inquiry and examination of the skin lesions over the affected area and other areas like the oral cavity and genital area. It also warrants consideration of a vasculitic process, especially in the background of oral ulcers and skin changes. In such cases, BD is the right differential diagnosis to be considered.
Pain
5.Outcomes of patients newly-diagnosed with systemic lupus erythematosus managed in a Tertiary Training and Referral Hospital in the Philippines
Katrina Elys A. Suilan ; Evelyn Osio-Salido
Acta Medica Philippina 2024;58(3):15-22
Objective:
To determine the one-year outcomes of newly-diagnosed patients with systemic lupus erythematosus (SLE) in a tertiary government hospital in Manila, Philippines.
Methods:
After ethics approval, we reviewed the medical records of a cohort of 44 newly-diagnosed SLE patients at 6- and 12-months post-diagnosis in 2018-2019. The outcomes of interest were: modified lupus low disease activity state as defined (mLLDAS), remission, hospitalization, 30-day readmission, organ damage, and mortality.
Results:
The patients were predominantly young females (mean age of 29 ± 9.9 years). There was an average interval period of six months between onset of symptoms and diagnosis (6.4 ± 10.8 months). The most common manifestations were mucocutaneous (86.4%), hematologic (63.6%), musculoskeletal (61.4%), and renal disorder (47.7%). There was at least one positive serologic test in 88.7%. Five patients (11.4%) had comorbidity, usually hypertension (9.1%). The initial lupus treatment consisted of moderate to high doses of glucocorticoids and hydroxychloroquine. Patients with life-threatening or organ-threatening disease, usually nephritis, received cyclophosphamide, azathioprine, or mycophenolate mofetil. One patient received rituximab. Fewer patients with nephritis received cyclophosphamide infusions during the first six months compared to the later six months.
Most of the hospitalizations (34/36) occurred during the first six months and 22 of these were for diagnosis. Seven patients had more than one hospitalization and five (20%) had 30-day readmissions. mLLDAS was achieved by 15 (34.1%) and 30 (68.2%) patients at 6- and 12- months, respectively. Only one patient was in remission a year after diagnosis. Seven patients (15.9%) were assessed with organ damage, six (13.64%) of them at 6-months post-diagnosis. Organ damage was most commonly renal. Four (9.1%) patients died, all during their initial hospitalization.
Conclusion
In our population observed over a period of one year (2018-2019), there was a very low rate of
remission (1/44, 2.3%), mLLDAS in 68.2%, and organ damage in 15.9%. Most of the hospitalizations (65%) were for the diagnosis of lupus and all deaths (9.1%) occurred during this first hospital confinement. We must intensify our efforts to (1) achieve earlier diagnosis, (2) deliver optimal lupus treatment and supportive care during the first lupus hospitalization, and (3) initiate early and persistent immunosuppressive treatment for nephritis to improve outcomes for our patents with SLE.
Lupus Erythematosus, Systemic
;
Hospitalization
;
Philippines
6.Outcomes of seizures in patients with Systemic Lupus Erythematosus in a tertiary government hospital in the Philippines
Karen Joyce C. Cortez ; Evelyn Osio-Salido
Acta Medica Philippina 2022;56(2):26-31
Background:
Seizures in patients with systemic lupus erythematosus (SLE) are uncommon but life-threatening; mortality rate is 25-29%. Seizure in a person with lupus may be due to lupus itself or other conditions. There are no published studies describing the causes and outcomes of seizures in Filipino patients with lupus.
Objective:
To describe the causes and outcomes of seizure in a cohort of patients with lupus seen at Philippine General Hospital.
Methodology:
We reviewed the medical records of patients with SLE) with a documented seizure and admitted between January 2016 and April 2019. History, physical examination and laboratory findings, and clinical course were obtained.
Results:
We included 29 patients with 31 seizure events. They were all women, mostly single, of low socio-economic status, and had poor functional capacity. Lupus was active in 77.4% (24/31), commonly with mucocutaneous or hematologic manifestations. Seizures were generalized in 87 % (27/31). Prior to seizure, one-third had headache, fever, and vomiting. There were no neurologic localizing signs. Twenty-four seizure events (77%) occurred among patients with active lupus; 16 (67%) was attributed to neuropsychiatric systemic lupus erythematosus (NPSLE) and eight (33%) to other causes: infection (tuberculous meningitis and septic encephalopathy), posterior reversible encephalopathy syndrome (PRES), uremia, arrhythmia, and eclampsia. Seven seizures in inactive lupus were not SLE-related. Mortality rate was 28%; infection was the most common cause. Seizure resolved in 97%. Mean duration of hospitalization was 26.7 days. Patients were discharged improved from 19 seizure events (18 patients); 14 had follow-up consultations, three were readmitted. There was no seizure recurrence within 30 days of discharge. There was improvement in functional capacity.
Conclusion
The most common cause of seizure was NPSLE, followed by infection. Despite high rates of complete seizure resolution, poor outcomes were noted in almost half of the patients. Prolonged hospitalization was common. A high rate of mortality was observed. Infection was the most common cause of mortality.
Lupus Vasculitis, Central Nervous System
7.Should Mesenchymal Stem Cell Therapy be used in the treatment of COVID-19?
Namnama P. Villarta-De Dios ; Evelyn S. S. Osio-Salido
Acta Medica Philippina 2020;54(Rapid Reviews on COVID19):86-100
Key Findings
There is some short-term benefit from the use of mesenchymal stem cell therapy for severe COVID-19 in a lowquality, small randomized controlled trial (RCT). Further studies, ideally with good quality RCTs, are needed to
confirm benefit and safety.
• Mesenchymal stem cells (MSCs) are non-hematopoietic adult stem cells that are able to self-renew and
differentiate into various cells of any cell lineage. MSCs have the ability to migrate (homing) to damaged tissue
for repair and regeneration, as well as signal other cells to help in tissue repair. It can effect cellular differentiation,
consequently shifting the immune system from Th1 to Th2 responses.1,2
• A recent review showed improved disease-associated parameters in experimental acute respiratory distress
syndrome (ARDS).3
• We found three studies (one case report, one prospective cohort, and one small randomized controlled trial)
reporting the effects of MSC on COVID-19. Based on low-quality evidence, it appeared that human umbilical
cord blood-derived MSC, given after failure to improve with standard treatment, had beneficial effects in terms
of earlier onset of clinical improvement among individuals with severe or critical COVID-19. However, 28-day
clinical improvement and mortality were not significantly different compared to standard treatment. There was
no reported adverse reaction.
• There are 52 registered and ongoing clinical trials to investigate the efficacy and safety of mesenchymal stem
cells as treatment for COVID-19.
• Mesenchymal stem cell therapy is not included in any of the existing guidelines for the treatment of COVID-19.
Covid-19
8.Use of Renin-Angiotensin System Antagonists in patients with hypertension and COVID-19 infection: A rapid review and meta-analysis
Rowena Natividad S. Flores-Genuino ; Charissa Mia Salud-Gnilo ; Evelyn Osio-Salido
Acta Medica Philippina 2020;54(Rapid Reviews on COVID19):102-118
Key Findings
Among patients with confirmed COVID-19 infection and hypertension, there is insufficient evidence that RAS
antagonists are associated with mortality or severe COVID-19 disease.
• There is uncertainty with regards to the safe use of renin-angiotensin system (RAS) antagonists, such as
angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), for COVID-19 patients
with hypertension and other comorbidities (heart failure, chronic kidney disease) because of two possible
contradictory mechanisms 1) upregulation of ACE2 receptors that may facilitate the virus entry into the lung.
and 2) control of unabated angiotensin II levels reducing acute lung injury.
• Based on very low-quality retrospective cohort studies, there is insufficient evidence that RAS antagonists are
associated with increased mortality (6 studies) or severe disease (10 studies) among patients with confirmed
COVID-19 infection and hypertension.
• There are 36 ongoing studies (21 RCTs, 1 single-arm trial, 4 prospective cohorts, 4 retrospective cohorts, 4 casecontrol, and 2 cross-sectional) on this topic.
• The European Society of Cardiology (ESC) Council on Hypertension, the International Society of Hypertension
(ISH) and the joint statement by the American College of Cardiology (ACC), American Heart Association (AHA),
and Heart Failure Society of America (HFSA) all caution against discontinuing RAS-related treatments in
patients with hypertension who become infected with COVID-19.
Covid-19
9.Disease knowledge and functional disability of a cohort of rheumatoid arthritis in a tertiary government hospital in Manila, Philippines
Karen Joyce C. Cortez ; Charo E. Filarca ; Evelyn Osio-Salido ; Grace G. Penserga ; Bernadette Heizel M. Reyes
Acta Medica Philippina 2022;56(2):37-45
Background:
Rheumatoid arthritis (RA) is a chronic and progressive disease resulting in disability and poor quality of life. Patients’ knowledge (PxK) of disease can contribute to better disease control, reduced disability, and improved quality of life.
Objective:
The objective of this study was to determine the disease knowledge and functional disability of a cohort of patients with RA.
Methods:
We conducted a cross-sectional study among patients with RA at the University of the Philippines - Philippine General Hospital Arthritis Clinic. The subjects were recruited using convenience sampling over three months in 2019. We obtained demographic and disease characteristics, clinic attendance, patient knowledge, and functional status through chart review, a questionnaire, and a disability index. Descriptive statistics, 2-sample T-test, Pearson’s correlation, analysis of variance (ANOVA), and multiple linear regression analysis were used for data analysis. Informed consent was obtained before participation in the study.
Results:
Eighty percent (57/71) of recruited patients participated in the study. All were female, and the mean age was 51.6 years (±12.9). Most participants completed secondary education, were employed, had an average duration of RA of 8 (±6.8) years, had been consulting at the Arthritis Clinic for an average of 4.8 years (±3.8), and had moderate disease activity (49.1%). Most patients had American College of Rheumatology (ACR) class I or II functional status (50/57, 88%). The usual source of the patients' knowledge about RA was their physician. The mean knowledge score was 5.10 (±0.93) out of a perfect score of 9. Most patients were aware of their disease diagnosis and the non-communicable nature of RA. There was low awareness of the need for self-monitoring for disease flares or treatment adverse events and the extra-articular involvement in RA. The mean functional disability score was 6.65 ± 5.33, and the mean functional disability index (FDI) was 0.83 (±0.66). These correspond to mild functional disability (FD). There was no significant relationship between the total knowledge score and age, duration of disease, number of consultations in the past year, level of education, employment status, perceived level of disease knowledge, or the practice of asking their physician about illness. Perception of overall health status was associated with functional disability (p=0.001).
Conclusion
Most of the patients in our cohort of RA patients had a mild functional disability and low knowledge scores. The study identified the gaps in our patients’ knowledge of disease and its management. A re-evaluation of existing educational and treatment strategies will be beneficial to enhance disease knowledge and improve health outcomes.
Functional Status
;
Arthritis, Rheumatoid
10.Clinical profile of Filipino patients with young-onset gout
Evelyn Osio-Salido ; Michael L. Tee ; Kenneth D. Tee ; Ana Teresa S. Hernandez ; Angeline-Therese M. Santiago
Acta Medica Philippina 2022;56(2):63-65
Objectives:
Recent studies show that patients with young-onset gout present with visible tophi or nephrolithiasis on diagnosis. In the Philippines, where gout is prevalent, there is no published work on this subset of patients. This study presents the clinical characteristics of a cohort of Filipino patients with gout whose symptoms started at 30 years of age or younger.
Methods:
The case records of all patients who fulfilled the 1977 American College of Rheumatology (ACR) criteria for gout seen in four adult rheumatology services were reviewed. We selected those whose age of onset of gout was at 30 years or younger. The demographic characteristics, medical history, laboratory parameters, and presenting manifestations were described.
Results:
Six hundred sixty-nine records of patients with gout were reviewed; 101 (15%) fulfilled the young-onset gout criteria. The mean age of onset was 25±4.40 years (range 14-30), and the mean disease duration before diagnosis was 12.64±11.91 years. All of the patients were male and most were married; 76% were alcoholic beverage drinkers and 38% were smokers. A family history of gout was noted in 47%. Most patients (66%) were already on nonsteroidal anti-inflammatory drugs (NSAIDs), 24% on colchicine, and 14% on urate-lowering therapy before consult at the rheumatology clinic. By history, at onset, the most common pattern of joint involvement was monoarthritis (95%), affecting the ankles (60%), knees (52%), and 1st metatarsophalangeal (MTP) joint (51%). However, on the first rheumatology clinic visit, 34% of arthritis was polyarticular, more than 68% had more than three arthritis attacks per year, and there were tophi in 35%. The mean duration before visible tophi formation was 2.81±6.75 years. Around 21% had nephrolithiasis or a history thereof. The mean serum uric acid (SUA) was 9.18 mg/dL and the mean serum creatinine was 1.5 mg/dL. Thirty-seven percent had estimated glomerular filtration rate (GFR) <60 mL/min.
Conclusion
Young-onset gout was present in 15% of our patients and gout was familial in 47%. There was a delay in diagnosis of as long as ten years in most of the patients. On presentation at the rheumatology clinic, more than 34% had polyarticular arthritis, 35% had tophi, and 37% had low estimated GFR. This emphasizes the importance of awareness and prompt diagnosis to ensure correct treatment and prevention of complications
Gout