Objectives: To explore the current experiences and perspectives of patients with chronic obstructive pulmonary disease (COPD) with advance care planning (ACP). Methods: A cross-sectional survey was conducted among patients diagnosed with COPD in the Philippine General Hospital. Results were illustrated using descriptive statistics. Results: A total of 90 patients were interviewed and included in the analysis. Nearly all patients were unfamiliar with the terms ACP (95.55%), end-of-life care (99.89%), and do-not-resuscitate order (100%). The majority expressed a desire to have ACP discussions (94.44%) which were not viewed as distressing and were deemed beneficial (96.67%). Patients who were employed were more likely to express readiness to sign legal papers. Patients living with their nuclear family or living alone, and those with higher COPD assessment test (CAT) scores were more likely to relegate health care decisions to their doctors. Conclusion Most patients with COPD in our cohort are unfamiliar with ACP and have not received ACP discussions. Most think that it will improve healthcare and quality of life. Some demographic and clinical factors may make patients more likely to engage in ACP-related activities.
advance care planning ; chronic obstructive pulmonary disease ; palliative medicine

Thyroid storm and thionamide-induced agranulocytosis are both rare and serious medical emergencies. We report a case of a patient in which these two rare events simultaneously occurred. A 33-year-old male, maintained on Methimazole for Graves’ Disease, presented with fever, throat pain, and uncontrolled thyrotoxic symptoms. Methimazole was promptly discontinued. Thyroid storm was alternatively treated with lithium, hydrocortisone, and propranolol. Agranulocytosis was managed supportively with GCSF and empiric antibiotics. Lithium was maintained until after radioablation. When thionamides are contraindicated, lithium is a viable option for the acute management of thyroid storm and a bridge to definitive therapy.
Methimazole ; Lithium

Objectives: To determine the overall diagnostic yield of bronchoscopy-guided sampling methods in detecting lung cancer at the University of the Philippines, Philippine General Hospital. The diagnostic yield, equivalent to sensitivity, is defined as the number of bronchoscopic sampling or biopsy procedures with a diagnosis of malignancy divided by the total number of confirmed malignant cases. Methods: This is a cross-sectional, retrospective sensitivity study involving bronchoscopy procedures from January 2014 to December 2018. Surgical Pathology and Cytology Reports of eligible cases were accessed through the institutional Laboratory Information System. Sensitive patient information was omitted, and each case was assigned a unique code. The overall diagnostic yield/sensitivity of bronchoscopy and the diagnostic yield/sensitivity of each technique were calculated. Results: A total of 100 patients satisfied the inclusion and exclusion criteria. Primary lung malignancies are more common in males and the elderly. The most common primary lung cancer is adenocarcinoma (33%). Bronchoscopy, regardless of whether single or multiple techniques were used, has a diagnostic yield of 86% (CI: 77.6-92.1%). Of the individual techniques, those that obtain solid tissues (endobronchial and transbronchial biopsies; 88.2% [CI: 78.1-94.8%] and 80.0% [CI: 28.4-99.5%], respectively) have higher yields compared to techniques that obtain cytologic samples (bronchial washing and brushing; 54.2% [43.7-64.4%] and 70.1% [58.6-80%], respectively). Conclusion Bronchoscopy, as a diagnostic procedure for pulmonary malignancies, has relatively high sensitivity and may be used for lesions located centrally and can be inspected visually. A multidisciplinary approach to patient selection for bronchoscopy helps improve the utility of the various bronchoscopic techniques.
Lung Neoplasms ; Bronchoscopy ; Cytodiagnosis ; Pathology, Surgical

BACKGROUND: Septic shock causes life threatening organ dysfunction needing vasopressor despite adequate fluid resuscitation. Numerous studies and meta-analysis have proven norepinephrine as the initial vasopressor of choice in septic shock with vasopressin as add-on. Although guidelines have established the goal monitoring response in septic shock, optimal approach in discontinuation of the vasopressors in the recovery phase of septic shock remains limited. METHODS: A systematic review and meta-analysis was performed on randomized controlled trials (RCTs) and nonrandomized studies comparing incidence of hypotension within 24 hours of discontinuing norepinephrine first versus vasopressin. Three reviewers independently selected studies, assessed their quality, and extracted the following data: the number and characteristics of patients enrolled, inclusion and exclusion criteria for each study, the description of interventions (discontinuing norepinephrine first versus discontinuing vasopressin first) and outcomes (incidence of hypotension within 24 hours). RESULTS: Seven retrospective cohort studies and one prospective randomized control trial were included. Compared with norepinephrine, risk of hypotension is higher when vasopressin is discontinued first among patients in the recovery phase of septic shock (RR 2.06; 95% CI [1.11,3.82]; I 2 91%). Results were consistent in the subgroup analysis after excluding abstract-only and poor-quality studies (RR 1.73; 95% CI [0.74, 4.03]; I 2 93%). There is no difference in ICU (RR 0.97; 95% CI [0.71, 1.32]; I 2 38%) and in-hospital mortality (RR 0.88; 95% CI [0.66, 1.16]; I 2 41%) between the two vasopressor weaning strategies. Finally ICU length of stay was reported on 5 studies with no significant difference between the two strategies. CONCLUSION: Based on the results, there is increased risk of hypotension when vasopressin is discontinued first versus norepinephrine.
Norepinephrine ; Shock, Septic ; AVP protein, human ; Vasopressins ; Vasoconstrictor Agents ; Neurophysins

INTRODUCTION: Contrast-induced nephropathy (CIN) is a serious but preventable complication of coronary procedures. Trimetazidine (TMZ) has recently been explored for use in preventing post-procedural CIN due to its cellular anti-ischemic and antioxidant properties. The objective is to assess the efficacy of oral TMZ in the prevention of contrast induced nephropathy during elective coronary angiography and PCI among patients with renal impairment.

METHODS: We conducted a systematic search of the Cochrane Central Register of Controlled Trials, Pubmed/ MEDLINE, EMBASE, clinicaltrials.gov for articles published until June 2016 for randomized controlled trials examining the effects of adding oral TMZ to standard therapy in preventing CIN. Outcome measures were incidence of CIN, defined as a 0.5 mg/dl or ?25% increase in serum creatinine 48-72 hours after contrast exposure, and incidence of dialysisrequiring CIN. Validity of studies was assessed through a risk assessment tool available from Cochrane. Treatment effect was estimated by calculating the Mantel-Haenszelweighted risk ratio (RR) using a fixed-effects model available from RevMan 5.3.

RESULTS: A total of four studies comprising 714 patients (TMZ group=352, Control group=362) were included in the final analysis. Pooled results revealed the TMZ group was associated with significantly fewer incidences of CIN compared to control (RR 0.33, 95% confidence interval [CI], 0.20, 0.53; P<.00001), with a relative risk reduction of 67% and an absolute risk reduction of 11.04% (NNT=nine). No dialysis-requiring CIN was observed in the included studies.

CONCLUSION: The addition of oral TMZ to standard hydration confers a significant benefit in preventing CIN after coronary procedures among patients with mild to moderate renal impairment. We recommend the addition of TMZ to standard prevention strategies. However, a large well-designed trial should be conducted to determine its effect on other outcomes such as prevention of dialysis-requiring CIN and mortality. 

Human ; Trimetazidine ; Coronary Angiography ; Medline ; Creatinine ; Pubmed ; Risk Assessment ; Renal Insufficiency ; Kidney Function Tests