Growth hormone - secreting pituitary adenomas are the cause of acromegaly in 95% of patients. In rare circumstances, a pituitary adenoma on magnetic resonance imaging cannot be found; hence, a search for an ectopic source of GH production is done. Even rarer is an acromegalic patient without an ectopic source and without imaging evidence of pituitary adenoma. We report a case of acromegaly with no evidence of a pituitary adenoma and no evidence of an ectopic source after imaging studies; who underwent medical therapy with improving biochemical and clinical parameters.
Acromegaly ; Pituitary Neoplasms ; Adenoma ; Magnetic Resonance Imaging ; Octreotide ; Cabergoline

Cardiovascular disease is a leading cause of mortality in the Philippines with an upward trend in the prevalence of atherosclerosis-related risk factors. In the national survey done in 2008, the prevalence of dyslipidemia is also increasing. As such, there is a need to increase awareness of the risk factors for cardiovascular disease among health care professionals. The development of Philippine guidelines were part of the strategy to improve overall cardiovascular risk and dyslipidemia management that is relevant to the Philippine setting. This article summarizes the 2005 Dyslipidemia guidelines, discusses some updates since its release and emphasizes equity issues when considering management of dyslipidemia in a Filipino patient.
Dyslipidemias ; Practice Guideline ; Philippines ; Cardiovascular Diseases ; Asia

Background: Studies show that healthcare workers from previous pandemics have experienced high levels of stress, anxiety with negative psychological impacts. This paper aims to identify factors affecting mental health outcomes of healthcare workers during Coronavirus Disease (COVID-19) pandemic. Methods: A cross-sectional design was used to determine factors affecting mental health outcome of healthcare workers with direct contact to patients with COVID-19. Depression, anxiety and distress were measured by the nine-item Patient Health Questionnaire, seven-item Generalized Anxiety Disorder scale, and 22-item Impact of Event Scale–Revised, respectively. Binomial multiple logistic regression model was used to identify the factors associated with mental health outcome. Results: 172 healthcare workers were included. Prevalence of depression, anxiety and distress symptoms among all healthcare workers were 57%, 47.7%, 65.1%, respectively. Age and living with a family with comorbidities are significantly associated with depression and anxiety. Healthcare workers aged 31 years and above are 70% less likely to have depression symptoms (OR 0.278, CI 95%, 0.11-0.72 p=0.008 and OR 0.273, CI 95%, 0.12-0.61, p=0.002). Those living with relatives with comorbidities are 2.7 times more likely to experience depression symptoms (OR 2.731, CI 95%, 1.36-5.5, p=0.005). Healthcare workers age 31-40 years has 80% less likely to experience anxiety symptoms (OR 0.212, CI 95%, 0.09-0.5, p<0.001), and those age 41 and above have 73% less likely to have anxiety symptoms (OR 0.37, CI 95%, 0.14-0.98, p<0.045). Those living with relatives with comorbidities are 2.9 times more likely to have anxiety symptoms (OR 2.889, CI 95%, 1.46-5.73, p=0.002). Level of knowledge on COVID-19 among health care workers significantly differs across severity but has no significant association with prevalence of depression. No factors were associated with distress symptom. Conclusion Cognizant of high rates of depression, anxiety and distress among our younger healthcare workers living with relatives with comorbidities will be a challenge to establish and/or improve existing programs to promote and address mental health needs. Psychological stress can accumulate over time and have an impact later in the outbreak which should be investigated in future studies.
Health Personnel ; COVID-19

Introduction: It is important to wean mechanically-ventilated patients as early as possible to avoid complications such as ventilator-associated pneumonia. Supplementing the diet with additional protein may help to stimulate muscle protein synthesis which may enhance respiratory muscle function and ventilator drive. This study aims to determine the effect of whey protein supplementation on the duration of mechanical ventilation in intensive care unit patients of Ospital ng Makati. Methods: We enrolled forty eligible patients in this openlabel randomized controlled trial and were assigned into two groups: Group A (N=20): patients were given enteral feeding using commercial formula with added whey protein, given as one serving every eight hours (equivalent to 18 g of additional protein per day) and Group B (N=20): patients were given enteral feeding using commercial formula alone. Weaning was started as soon as the patient fulfilled the criteria of spontaneous breathing trial and was considered successful if the patient maintained these criteria for 48 hours after extubation. Results: Our study’s results showed that the mechanically intubated patients in Group A have lesser ventilatordependent days with an average of 5.4 days as compared to those in Group B with an average of 7.45 days (p=0.00). Patients in Group A were also noted to have statistically significant higher increase in serum albumin, mid-arm circumference and triceps skin fold from baseline. Twentyfive percent of patients in Group B developed ventilator acquired pneumonia and none in Group A. No mortality was noted in both groups. Conclusion Whey protein supplementation in mechanically ventilated patients can be recommended to facilitate early weaning because of its effect on early muscle protein synthesis leading to improvement of lung function and ventilator drive. It can also help in preventing malnutrition and nosocomial infections during critical illness. With all these benefits of whey protein, its use can potentially lead to shorter duration of mechanical ventilation and hospital stay which can also mean less cost of care delivery.
Whey Proteins ; Weaning ; Respiration, Artificial ; Intensive Care Units ; Randomized Controlled Trial

This is a case report of a 22-year-old Filipino male, morbidly obese, not known to have diabetes mellitus (DM) who presented with diabetic ketoacidosis on initial diagnosis. He had a phenotype of type 2 DM (T2D) but an initial presentation consistent with type 1 DM (T1D). Insulin therapy was eventually discontinued but he maintained good glycemic control with diet alone. C-peptide showed adequate increase after a mixed-meal diet and GAD65Ab was negative, thus he was diagnosed with ketosis-prone DM (KPDM). The increasing prevalence of obesity challenges the classic phenotype of patients with DM, with many patients presenting as an obese type T1D, and being diagnosed with T2D at a younger age. This complicates how to classify the patient’s diabetes, and the clinical profile is sometimes insufficient to make the proper diagnosis. In these cases, immunologic markers and assessment of β-cell function are important tools to differentiate between T1D and T2D, to direct management plans and to anticipate complications.
Diabetes Mellitus, Type 1 ; C-Peptide

Objective: The main objective of this study is to determine if epicardial fat thickness can be an early marker of insulin resistance. The specific objectives are to determine the specific thickness of epicardial fat that will correlate with insulin resistance and to correlate epicardial fat thickness with co-morbidities, anthropometric measurements and other clinical variables. Methodology: Patients were enrolled into the study by purposive sampling. Insulin assay, fasting blood sugar (FBS) and 2D echocardiogram measuring the epicardial fat were requested. HOMA-IR was computed and correlated with epicardial fat thickness. SPSS version 19 and Epi info v3.5.1 were used for statistical analysis. Linear regression analysis was performed on all variables to identify correlates with epicardial fat thickness. Results: A total of 22 subjects were included in the study. Insulin resistance determined using HOMA-IR, as well as BMI and fasting insulin level showed significant correlation with epicardial fat thickness (p-value <0.01). Based on the analysis, 9.5 mm was found to be the most sensitive and specific measurement for epicardial fat thickness that is correlated to insulin resistance with sensitivity of 100% and specificity of 86%. Conclusions Epicardial fat thickness through routine 2D echocardiogram is significantly directly correlated with insulin resistance and 9.5 mm is the cut–off value for predicting insulin resistance.
Echocardiography ; Pericardium ; Insulin Resistance

Background: Among the various glycemic indices in current use, glycemic variability has the greatest contribution in the development of microvascular and macrovascular complications in Type 2 Diabetes mellitus (T2DM). Most metrics that are currently used to measure glycemic variability are derived from continuous glucose monitoring (CGM) data. However, CGM is burdensome to the patient due to its relatively high cost as well as the need for multiple visits with the health care provider. With the use of serum 1,5-anhydroglucitol (1,5-AG) as a biomarker of glucose fluctuations, physicians and patients alike could have an easier surrogate measure of glycemic variability thus aiding in achieving target glucose control. This study aims to determine the diagnostic accuracy of 1,5-AG as compared to the glycemic variability metrics derived from CGM as a surrogate measure of glycemic variability among adult Filipinos with T2DM. Methods: Retrospective analysis of data of adult patients aged 20 years old and above diagnosed with T2DM referred for CGM at the Diabetes, Endocrine, Metabolic, and Nutrition Center of Cardinal Santos Medical Center from January 2017 to October 2021 who underwent serum 1,5-AG level determination within 2 weeks of CGM were collected. Diagnostic accuracy was obtained by computing the sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and Youden index. Pearson correlation coefficient was used to determine the correlation of 1,5-AG and the different metrics. Analysis of variance (ANOVA) was used to check for statistical significance with 99% confidence interval and a p < 0.05 considered as statistically significant. Results: This study involving 37 subjects showed a good diagnostic accuracy of serum 1,5-AG levels with the different measures of glycemic variability derived from CGM namely mean amplitude of glycemic excursion (MAGE), continuous overlapping net glycemic action at 1-hour intervals (CONGA-1), and mean of daily differences (MODD) with significant correlation among patients with HbA1c ≤ 7%. Subjects were on CGM for approximately 6 ± 1 day with statistically significant difference between the good and poor glucose control group (p<0.05). Determination of diagnostic accuracy between 1,5- AG and MAGE showed good accuracy (Sensitivity = 95.3%, Specificity = 100%, PPV = 100%, NPV = 75.43%, Diagnostic accuracy 96%, and a Youden Index of 92.3) with a statistically significant correlation among subjects with HbA1c level ≤ 7% (p=0.021). There is likewise good diagnostic accuracy between CONGA-1 and 1,5-AG level (Sensitivity = 99%, Specificity = 75.29%, PPV = 89.1%, NPV = 97%, Accuracy = 89.50% and Youden index of 58.41) with a statistically significant correlation among subjects with HbA1c ≤ 7% (p=0.038). Comparison with interday glycemic variability showed fair diagnostic accuracy between MODD and 1,5-AG (Sensitivity = 79.17%, Specificity = 78%, PPV = 97%, NPV = 32%, Accuracy = 76.89%, and Youden index of 49.07) and a statistically significant correlation among subjects with HbA1c ≤ 7% (p=0.009). Conclusion There is good diagnostic accuracy of serum 1,5-AG levels with the different measures of glycemic variability derived from CGM namely MAGE, CONGA-1, and MODD with significant correlation among patients with HbA1c ≤ 7%. Among diabetics with HbA1c ≤7%, 1,5-AG could be used as a surrogate measure of glycemic variability and excursions.
Diabetes Mellitus, Type 2

Objective: To present the results from the Philippine cohort of the A1chieve study receiving insulin detemir (IDet) ± oral antidiabetic drugs. Methodology: A1chieve is a multinational, 6-month, observational study of 66,726 people with type 2 diabetes mellitus (T2DM), both insulin users and non-insulin users, started on IDet, insulin aspart or biphasic insulin aspart in 28 countries across four continents. This subgroup analysis evaluates the safety and effectiveness of IDet in 988 subjects from the Philippines. Results: At baseline the mean age, duration of diabetes and mean BMI were found to be 57±11.9 yrs, 6.9±5.3 yrs and 26±4.8 kg/m2 respectively. Majority of subjects were insulin-naive (84.3%) and glycemic control was poor in all the groups at baseline. At the end of 24 weeks, there were significant improvements following IDet initiation with a 2.1% reduction in mean HbA1c. The HbA1c target of <7% was achieved by 46.8% subjects at the study end. Although not statistically significant, there was a modest decrease in body weight in all the groups. There was no increase in the incidence of hypoglycemia among baseline insulin-naive subjects, while a significant reduction in hypoglycemia was seen among prior insulin users. Conclusions IDet appears to be an effective and safe option for individuals with T2DM in the Philippines. HbA1C was lowered to target, and there was no increase in incidence of hypoglycemia and body weight with IDet.
Diabetes Mellitus, Type 2 ; Insulin Detemir ; Philippines