1.Is high-flow nasal cannula oxygenation more effective than noninvasive ventilation or conventional oxygen therapy in treating acute hypoxemic respiratory failure in COVID-19 patients?
Cary Amiel G. Villanueva ; Marie Gene D. Cruz ; Lia M. Palileo-Villanueva
Acta Medica Philippina 2020;54(Rapid Reviews on COVID19):125-129
Key Findings
Very low-quality evidence suggests lower mortality (based on five observational studies) but higher failure
rate of respiratory support (based on two observational studies) in COVID-19 patients given high-flow nasal
cannula (HFNC) oxygen compared with noninvasive ventilation (NIV) and conventional oxygenation therapy.
Randomized controlled trials (RCT) are urgently needed in this area.
• Respiratory failure accounts for about half of deaths in patients with COVID-19.
• High-flow nasal cannula (HFNC) oxygen therapy reduces the need for escalating respiratory support and improves
patient comfort compared with conventional oxygen therapy among those with acute respiratory failure.
• Mortality was consistently lower in COVID-19 patients who received HFNC rather than NIV or conventional
oxygen therapy (COT) across 5 very low-quality retrospective observational studies from China.
• Several international guidelines recommend the use of HFNC oxygen therapy in COVID-19 patients who
develop acute hypoxemic respiratory failure. However, local guidelines from the Philippine Society for
Microbiology and Infectious Diseases (PSMID) and the Philippine College of Chest Physicians (PCCP) recommend
against HFNC due to risks of transmission and paucity of direct evidence for efficacy.
• Additional infection control precautions, i.e. wearing a surgical mask over the cannula, and locating in a negative
pressure room, are recommended whenever using HFNC or NIV.
• There are at least two ongoing trials due to be completed by the second quarter of 2021 comparing
HFNC oxygenation with NIV or COT in COVID-19 patients.
Cannula
;
Noninvasive Ventilation
;
COVID-19
;
Coronavirus
2.Update: Should Hydroxychloroquine (HCQ) or Chloroquine (CQ) be used in the treatment of COVID-19?
Lia M. Palileo-Villanueva ; Elenore Judy B. Uy
Acta Medica Philippina 2020;54(Rapid Reviews on COVID19):1-6
Key Findings
There is insufficient evidence to support the routine use of HCQ or CQ for the treatment of COVID-19. Results
from interim analyses of 2 large RCTs, the Recovery and the Solidarity trials, reportedly showed no clinical benefit
from HCQ for hospitalized patients with COVID-19.
There are 3 randomized controlled trials that investigated the efficacy and safety of HCQ compared to standard
therapy. Overall quality of evidence was very low.
Meta-analyses from the “COVID-19 Living Data” project suggests that the use of HCQ may increase the
incidence of adverse events at day 14 to day 28 (RR 2.49, 95% confidence interval: 1.04 to 5.98, moderate
quality of evidence); the most common adverse event across the two trials is diarrhea (n=8).
In a statement dated June 5, 2020, the investigators of the Recovery trial announced their decision to halt
further enrollment to the HCQ arm of the trial because an interim analysis showed no clinical benefit from
the use of HCQ in hospitalized patients with COVID.
On June 15, 2020, the US FDA revoked the emergency use authorization for HCQ and CQ as treatment for
COVID-19.
On June 18, 2020, the WHO announced that recruitment to the HCQ arm of the Solidarity trial has been halted.
Chloroquine
;
Hydroxychloroquine
;
COVID-19
3.Burnout and resilience of internal medicine physician trainees in a tertiary government hospital in the Philippines during the COVID-19 pandemic: A Mixed-method study.
Paula Isabel G. FRANCO ; Lia M. PALILEO-VILLANUEVA ; Patricia Maria Gregoria M. CUAÑ ; O ; Marvin E. MARQUEZ ; Ma. Rosario E. BAYAN ; Jhaki A. MENDOZA
Acta Medica Philippina 2022;56(6):7-16
Objectives: Internal Medicine physician trainees faced unique challenges as the primary frontline physicians at a tertiary COVID-19 government referral center during the COVID-19 pandemic. This study examined the prevalence of burnout and resilience of these physician trainees during the early period of the pandemic, the determinants of burnout, and their sources of anxiety and coping mechanisms.
Methods: Using a mixed-methods approach, we conducted an online cross-sectional survey to measure burnout and resilience among 196 Internal Medicine physician trainees using the Maslach Burnout Index Human Services Survey for Medical Personnel and the Connor-Davidson Resiliency questionnaires, respectively. We then conducted virtual focus group discussions and in-depth key informant interviews to explore the trainees' sources of anxiety and coping mechanisms until thematic saturation was satisfied.
Results: Out of 146 respondents (from 196 eligible participants, 74% response rate), four percent of physician trainees fit the frank burnout profile, 40% were engaged, while the majority had intermediate profiles (23% ineffective, 28% overextended, and 4% disengaged). The mean resilience score was 72.9 (SD 12.4). Resilience was a significant negative predictor for burnout (Beta Coefficient = -0.73, p<0.001). Its protective effect decreases in those with more exposure to patient deaths (Beta Coefficient = 6.767, p<0.05). Significant sources of anxiety included changes in the practice of medicine (changes in workflow, working in full personal protective equipment, telemedicine and zoom fatigue, constant threat of acquiring the infection) and having competing demands between service and training. Coping mechanisms included preserving a haven, maintaining social relationships, and self-care.
Conclusion: In the largest government hospital in the Philippines, four percent of Internal Medicine physician trainees had burnout, 40% were engaged, and the majority were at-risk for burnout a few months into the COVID-19 pandemic in 2020. Resilience reduces the risk for burnout. However, its protective effect decreased with exposure to a higher number of patient deaths per week.
Burnout, Psychological ; COVID-19 ; Physicians ; Pandemics
4.Which dialysis method should be used for patients with COVID-19?
Patricia Maria Gregoria Mina-Cuañ ; o ; Cary Amiel G. Villanueva ; John Jefferson V. Besa ; Andrew Rufino M. Villafuerte ; Jayson M. Villavicencio ; Vincent Anthony S. Tang ; Lia M. Palileo-Villanueva
Acta Medica Philippina 2020;54(Rapid Reviews on COVID19):120-124
Key Findings
• Very low-quality evidence from a single retrospective study suggests that continuous renal replacement
therapy (CRRT) may reduce mortality among COVID-19 patients on invasive mechanical ventilation. Guidelines
recommend CRRT for critically ill patients to minimize the risk of possible transmission, if this option is available.
• Although uncommon, acute kidney injury (AKI) can occur in association with coronavirus disease 2019
(COVID-19) and is associated with increased in-hospital mortality.
• There are currently no published or ongoing clinical trials directly comparing dialysis modalities for acute
kidney injury in COVID-19 patients.
• In reducing the risk of transmission during dialysis: currently, there are no studies comparing one dialysis
modality to another. The method of dialysis is still primarily determined by the clinical picture of the patient, the
expertise of the center, and the resources available. The American Society of Nephrology (ASN) recommends
CRRT over intermittent hemodialysis (IHD) for critically ill patients with COVID-19 to minimize patient contact
when it is available, and resources allow. Otherwise, intermittent hemodialysis may be done provided that,
infection control measures are strictly followed.
• Several international and local guidelines recommend strict adherence to infection prevention and control
measures (e.g. hand hygiene, physical distancing, proper use of personal protective equipment (PPE), and
cohorting of patients) who are undergoing dialysis.
Covid-19
5.Adherence of physicians to local guideline recommendations among patients with COVID-19 in two tertiary public hospitals in Metro Manila, Philippines: A rapid assessment study
Anton G. Elepañ ; o ; Cynthia P. Cordero ; Lia M. Palileo-Villanueva ; Nina T. Castillo-Carandang ; Maria Teresa B. Abola ; Jan Bendric C. Borbe ; Vincent Anthony S. Tang ; Jerahmeel Aleson L. Mapili ; Bryan F. Elvambuena ; Rogelio N. Velasco Jr. ; Leahdette O. Padua ; Carl Lawrence C. Arenos ; Leonila F. Dans ; Antonio Miguel L. Dans
Acta Medica Philippina 2020;54(Online):1-7
Objectives:
Adherence to clinical practice guidelines (CPG) has been shown to reduce inter-physician practice
variation and improve quality of care. This study evaluated guideline adherence of physicians in two tertiary public hospitals to local CPG on COVID-19.
Methods:
This was a multicenter, retrospective chart review, rapid assessment method study. Guideline adherence and non-adherence (overuse and underuse) to 15 strong recommendations in the prevailing Philippine COVID-19 Living Recommendations were assessed among a sample of patients admitted in two centers from July to October 2021. Differences in adherence across COVID-19 disease severities and managing hospital units were analyzed.
Results:
A total of 723 patient charts from two centers were reviewed. Guideline adherence to dexamethasone use among patients with hypoxemia is 91.4% (95% CI 88.6 to 93.6) with 9.2% overuse. Tocilizumab was underused in 52.2% of patients with indications to receive the drug. There was overuse of empiric antibiotics in 43.6% of patients without suspicion of bacterial coinfection. Lowest adherence to antibiotic use was seen among patients with critical disease severity and those managed in the intensive care unit. None of the other non-recommended treatment modalities were given.
Conclusion
Management of COVID-19 in both centers was generally adherent to guideline recommendations. We detected high underuse of tocilizumab probably related to the global supply shortage during the study period and high overuse of antibiotics in patients without suspicion of bacterial coinfection. While the results of this study cannot be generalized in other healthcare settings, we recommend the application of similar rapid assessment studies in guideline adherence evaluation as a quality improvement tool and to identify issues with resource utilization especially during public health emergencies
Guideline Adherence
;
COVID-19
;
Quality Improvement
6.Adherence of physicians to local guideline recommendations among patients with COVID-19 in two Tertiary Public Hospitals in Metro Manila, Philippines: A rapid assessment study
Anton G. Elepañ ; o ; Cynthia P. Cordero ; Lia M. Palileo-Villanueva ; Nina T. Castillo-Carandang ; Maria Teresa B. Abola ; Jan Bendric C. Borbe ; Vincent Anthony S. Tang ; Jerahmeel Aleson L. Mapili ; Bryan F. Elvambuena ; Rogelio N. Velasco Jr ; Leahdette O. Padua ; Carl Lawrence C. Arenos ; Leonila F. Dans ; Antonio Miguel L. Dans
Acta Medica Philippina 2023;57(11):34-40
Objectives:
Adherence to clinical practice guidelines (CPG) has been shown to reduce inter-physician practice
variation and improve quality of care. This study evaluated guideline adherence of physicians in two tertiary public hospitals to local CPG on COVID-19.
Methods:
This was a multicenter, retrospective chart review, rapid assessment method study. Guideline adherence and non-adherence (overuse and underuse) to 15 strong recommendations in the prevailing Philippine COVID-19 Living Recommendations were assessed among a sample of patients admitted in two centers from July to October 2021. Differences in adherence across COVID-19 disease severities and managing hospital units were analyzed.
Results:
A total of 723 patient charts from two centers were reviewed. Guideline adherence to dexamethasone use among patients with hypoxemia is 91.4% (95% CI 88.6 to 93.6) with 9.2% overuse. Tocilizumab was underused in 52.2% of patients with indications to receive the drug. There was overuse of empiric antibiotics in 43.6% of patients without suspicion of bacterial coinfection. Lowest adherence to antibiotic use was seen among patients with critical disease severity and those managed in the intensive care unit. None of the other non-recommended treatment modalities were given.
Conclusion
Management of COVID-19 in both centers was generally adherent to guideline recommendations.
We detected high underuse of tocilizumab probably related to the global supply shortage during the study
period and high overuse of antibiotics in patients without suspicion of bacterial coinfection. While the results of this study cannot be generalized in other healthcare settings, we recommend the application of similar rapid assessment studies in guideline adherence evaluation as a quality improvement tool and to identify issues with resource utilization especially during public health emergencies.
Guideline Adherence
;
COVID-19
;
Quality Improvement