BACKGROUND

Thirteen-and-a-half syndrome consists of a one-and-a half syndrome with an ipsilateral facial and trigeminal nerve palsy. This is due to lesions that affects the ipsilateral paramedian pontine reticular formation (PPRF) or the ipsilateral abducens nerve nucleus (VI), the contralateral medial longitudinal fasciculus (MLF), the facial nerve (VII), and the trigeminal nerve (V) .

This is a case of Thirteen-and-a-half syndrome and stress the importance of a proper neurologic exam to aid in the localization of lesions in the brain.

This patient was monitored during her admission. She underwent a plain cranial CT scan to confirm the suspected hemorrhage and supportive management was done to relieve her symptoms.

A 14-year-old female patient presented with a one day history of right-sided hemiparesis. There was associated binocular diplopia, dizziness, slurring of speech, dropping of the left lip, and three episodes of spontaneous projectile vomiting. Plain cranial CT scan showed a left-sided pontine hemorrhage, and she was then advised admission. There was exotropia of the right eye on primary gaze with -4 on adduction, abducting nystagmus on the right eye, horizontal gaze palsy on the left eye, no convergence, left facial weakness, and decreased left facial sensation with minimal improvement during her admission. On the 1-year follow up, there was significant improvement with full motility on the right eye and a -1 on abduction on the left eye.

This is a case of a Thirteen-and-a-half syndrome in a young female patient. A complete neuro-ophthalmological exam is paramount as it is both sight-saving and life saving.

Objective: To report the frequency of neuro-ophthalmologic cases seen over one working week by a senior neuro-ophthalmologist in Singapore and to determine a pattern in the incidence of neuro-ophthalmic diseases. Methods: A retrospective review of 57 consecutive neuro-ophthalmologic cases seen by one senior neuro-ophthalmologist from June 14 to 18, 2010 was done. All patients underwent a complete neuro-ophthalmologic examination. Demographic data and clinical diagnoses were gathered. Results: A total of 57 patients were seen. Thirty-one percent (18) of these patients were new consultations while the remaining 61% (39) were follow-up visits. Fifty-two percent were females (30) with a mean age of 53 years while 47% were males (27) with a mean age of 49 years. Nineteen cases involved disorders of the optic nerve followed by disorders of ocular motility (11), optic chiasm, visual pathways, and/or visual cortex (14). Among the cases involving the optic nerve, 5 were ischemic optic neuropathy. In respect to disorders of ocular motility, ocular myasthenia gravis (n=5) was the most common condition seen. Pituitary adenomas comprised the bulk of the disorders of the optic chiasm (4). The remaining neuro-ophthalmic cases were almost evenly distributed. A very rare case of Froin’s syndrome was also seen. Conclusion Overall, during the five-day neuro-ophthalmologic clinic, majority of cases were ischemic in nature, reminding readers that systemic diseases, such as hypertension, diabetes mellitus, hyperlipidemia, commonly manifest in the eye. Hence, better systemic control of these diseases is necessary.
Optic Nerve Diseases ; Visual Pathways ; Visual Cortex

Objective: We determined the frequency of refractive errors among Filipino patients undergoing refractive or cataract screening at an ambulatory eye-care center, correlated them with demographic and ophthalmic variables, and compared refractive and keratometric astigmatism. Methods Clinical records of 666 consecutive patients who had optical interferometry were reviewed and the demographic and clinical parameters obtained were subjected to statistical analyses.
Refractive Errors ; Astigmatism ; Myopia ; Hyperopia

Purpose: To determine the effectiveness of lid scrub with petroleum jelly versus lid scrub with tea tree oil and tea tree facial wash in patients with symptomatic blepharitis associated with above-normal Demodex counts Methods: Patients with symptomatic anterior blepharitis (AB), meibomian gland dysfunction (MGD), or mixed blepharitis (MB) were recruited into the study. Pertinent data, including ocular symptoms and findings, were recorded. Digital photographs of the lid margins were taken. Lash sampling was done using the modified Coston method for lash epilation. Patients with below-normal Demodex counts (DC <5) were excluded while those with DC ≥5 were randomly assigned to one of either treatment regimen: (1) lid scrub with tea tree oil and tea tree facial wash (The Body Wash®, control group), or (2) lid scrub with petroleum jelly (Apollo Pure Petroleum Jelly®, study drug). Lid scrub with the tea tree oil (TTO) or petroleum jelly was administered at the clinic during the initial visit and at 2-week intervals thereafter for 6 weeks. Patients were instructed to apply tea tree (TT) facial wash or petroleum jelly at home on specified intervals daily. DC posttreatment was recorded, and digital photographs of the eyelids were taken at the end of treatment. Results: Thirteen patients were included in the study; 5 in the TTO and 8 petroleum jelly. In the TTO group, 3 patients had decrease in DC and 2 an increase, but all patients reported decrease in the severity and frequency of ocular symptoms. In the petroleum jelly group, 5 patients had decrease in DC after 6 weeks, while the remaining 3 had opposite results. All reported a general improvement in their symptoms. No adverse reactions were observed in either treatment groups. Conclusion Lid scrub with petroleum jelly caused a significant reduction (p<0.05) in Demodex counts compared to lid scrub with tea tree oil and tea tree facial wash. Petroleum jelly may have some effect in the eradication of Demodex mites in cases of Demodex-induced blepharitis. Although lid scrub with petroleum jelly and tea tree oil and tea tree facial wash both produced a decrease in Demodex counts and a decrease in the frequency and severity of ocular symptoms after 6 weeks of treatment, the presence of some conflicting results suggests that further studies with more patients should be initiated.
Meibomian Gland Dysfunction ; Petrolatum ; Tea Tree Oil

Objectives: To evaluate and compare ectasia and pseudoectasia in post-myopic LASIK patients presenting with corneal topographic changes indicative of ectasia using the Ectasia Risk Factor Score System (ERFSS). Methods: Single-center retrospective comparative case series of a consecutive chart review of cases in 18 years who underwent bilateral myopic-LASIK and showed topographic changes indicative of ectasia. Results: Four patients were included. Group 1: pseudoectasia eyes, consisting of two patients with bilateral pseudoectasia, and Group 2: ectasia eyes, consisting of two patients with unilateral ectasia. The clinical course of the cases was discussed and compared based on the ERFSS parameters: topography pattern, residual stromal bed thickness, age, preop thinnest cornea, and pre-operative spherical equivalent (SE) manifest refraction (MR). Group 1 scored zero to low risk for developing ectasia while Group 2-eyes with ectasia scored moderate risk. The predictive value of the ERFSS was 1 in this study. Conclusion The ERFSS is a good measure in deciding the suited treatment plan for patient undergoing refractive procedure. Knowing the clinical course of ectasia and pseudoectasia is helpful in the therapeutic approach since pseudoectasia is reversible when identified and managed early as seen in this study.
Dilatation, Pathologic

Objective: The mandible is the most common fractured craniofacial bone of all craniofacial fractures in the Philippines, with the mandibular body as the most involved segment of all mandibular fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and management of mandibular body fractures in particular. General guidelines include the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic Review on interventions for the management of mandibular fractures. On the other hand, a very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and management, this clinical practice guideline focuses on the management of isolated mandibular body fractures in adults. Purpose: This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as well as primary care and specialist physicians, nurses and nurse practitioners, midwives and community health workers, dentists, and emergency first-responders) who may provide care to adults aged 18 years and above that may present with an acute history and physical and/or laboratory examination findings that may lead to a diagnosis of isolated mandibular body fracture and its subsequent medical and surgical management, including health promotion and disease prevention. It is applicable in any setting (including urban and rural primary-care, community centers, treatment units, hospital emergency rooms, operating rooms) in which adults with isolated mandibular body fractures would be identified, diagnosed, or managed. Outcomes are functional resolution of isolated mandibular body fractures; achieving premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing use of ineffective interventions; avoiding co-morbid infections, conditions, complications and adverse events; minimizing cost; maximizing health-related quality of life of individuals with isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in patients and occurrence in others. Action Statements The guideline development group made strong recommendationsfor the following key action statements: (6) pain management- clinicians should routinely evaluate pain in patients with isolated mandibular body fractures using a numerical rating scale (NRS) or visual analog scale (VAS); analgesics should be routinely offered to patients with a numerical rating pain scale score or VAS of at least 4/10 (paracetamol and a mild opioid with or without an adjuvant analgesic) until the numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- prophylactic antibiotics should be given to adult patients with isolated mandibular body fractures with concomitant mucosal or skin opening with or without direct visualization of bone fragments; penicillin is the drug of choice while clindamycin may be used as an alternative; and (14) prevention- clinicians should advocate for compliance with road traffic safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor vehicle, cycling and pedestrian accidents and maxillofacial injuries.The guideline development group made recommendations for the following key action statements: (1) history, clinical presentation, and diagnosis - clinicians should consider a presumptive diagnosis of mandibular fracture in adults presenting with a history of traumatic injury to the jaw plus a positive tongue blade test, and any of the following: malocclusion, trismus, tenderness on jaw closure and broken tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray as the initial imaging tool in evaluating patients with a presumptive clinical diagnosis; (3) radiographs - where panoramic radiography is not available, clinicians may recommend plain mandibular radiography; (4) computed tomography - if available, non-contrast facial CT Scan may be obtained; (5) immobilization - fractures should be temporarily immobilized/splinted with a figure-of-eight bandage until definitive surgical management can be performed or while initiating transport during emergency situations; (8) anesthesia - nasotracheal intubation is the preferred route of anesthesia; in the presence of contraindications, submental intubation or tracheostomy may be performed; (9) observation - with a soft diet may serve as management for favorable isolated nondisplaced and nonmobile mandibular body fractures with unchanged pre - traumatic occlusion; (10) closed reduction - with immobilization by maxillomandibular fixation for 4-6 weeks may be considered for minimally displaced favorable isolated mandibular body fractures with stable dentition, good nutrition and willingness to comply with post-procedure care that may affect oral hygiene, diet modifications, appearance, oral health and functional concerns (eating, swallowing and speech); (11) open reduction with transosseous wiring - with MMF is an option for isolated displaced unfavorable and unstable mandibular body fracture patients who cannot afford or avail of titanium plates; (12) open reduction with titanium plates - ORIF using titanium plates and screws should be performed in isolated displaced unfavorable and unstable mandibular body fracture; (13) maxillomandibular fixation - intraoperative MMF may not be routinely needed prior to reduction and internal fixation; and (15) promotion - clinicians should play a positive role in the prevention of interpersonal and collective violence as well as the settings in which violence occurs in order to avoid injuries in general and mandibular fractures in particular.
Mandibular Fractures ; Jaw Fractures ; Classification ; History ; Diagnosis ; Diagnostic Imaging ; Therapeutics ; Diet Therapy ; Drug Therapy ; Rehabilitation ; General Surgery

BACKGROUND

Coronary artery disease is the leading cause of death in the Philippines and can present as acute coronary syndrome. Hospitalization for ACS has epidemiologic and economic burden. In fact, last 2017, there were 1.52% or 152 admissions for every 10,000 hospitalized patients for medical conditions in PhilHealth-accredited hospitals locally. However, coronary angioplasty was performed in only less than 1% of these cases mainly because of its cost and the out-of-pocket expense that the treatment entail, when primary percutaneous intervention has been proven to be effective in reducing mortality in STEMI and early invasive intervention performed during index hospitalization for NSTEMI is likewise recommended. Moreover, there is a big disparity between the current case rates for ACS for medical therapy alone and for invasive intervention compared to the actual ACS hospitalization cost.

1) To propose revisions to the current PhilHealth case rates for acute coronary syndrome (ACS); and 2) To determine the budget impact of the proposed ACS case rates.

The Philippine Heart Association with the assistance of a technical working group undertook the study. A panel of experts composed of general and invasive cardiologists from Luzon, Visayas, and Mindanao was formed. The ACS hospitalization costs based on the recent study by Mendoza were presented and discussed during the focus group discussions with the panelists. Issues pertinent to their localities that may affect the costs were discussed. The proposed revised costs on the particular ACS conditions and therapeutic regimens were then voted and agreed upon. A budget impact analysis of the proposed case rates was then performed.

The proposed case rates for ACS ranged from Php 80,000 (for low risk unstable angina given medical treatment) to Php 530,000 (for ST-elevation myocardial infarction initially given a thrombolytic agent then underwent PCI which necessitated the use of three stents). The budget impact analysis showed that the proposed ACS rates would require an additional PHP 1.5 billion to 2.3 billion during the first year of a 3- versus 5-year implementation period, respectively. The period of implementation will be affected by budgetary constraints as well as the availability of cardiac catheterization facilities in the country.

The proposed revised PhilHealth hospitalization coverage for ACS is more reflective or realistic of the ACS hospitalization costs in contrast with the current PhilHealth case rates. The corresponding budget impact analysis of these proposed case rates showed that PHP 7.6 billion is needed for full implementation. However, given the budget constraints, the percentage of the total costs for the first and subsequent years of implementation may be modified.

BACKGROUND

Hospitalization for acute coronary syndrome (ACS) has epidemiologic and economic burden. The coverage for hospitalization in the local setting is much less than the actual costs. Many patients do not consent to or avail of the optimal and timely management because of financial challenges.

The paper aimed to propose revised PhilHealth case rates/packages for ACS, namely: 1) unstable angina (UA), 2) non-ST-elevation myocardial infarction (NSTEMI), and 3) STelevation myocardial infarction (STEMI).

A consensus panel was organized to provide inputs such as cost and other matters pertaining to the revision of the PhilHealth ACS case rates/packages. The results of the cost of hospitalization of the different ACS conditions derived from a study on hospitalization cost for ACS were presented to the panel. Several focused group discussions were held afterward for propositioning new case rates through votation and by nominal group technique, using the costs from the study as the bases of rate adjustment.

Final costs agreed upon by the consensus panel for medical management alone for UA, NSTEMI, and STEMI were adjusted or amended in increments of Php 20,000, (80,000, 100,000, and 120,000, respectively). Thrombolysis of a patient admitted for STEMI increased the cost to Php 140,000. An additional cost of Php 150,000 was added on top of the cost for medical management and coronary angiogram for NSTE- ACS for PCI with use of a single stent. For STEMI, the same category had an additional cost of Php 180,000. For each additional stent used for all clinical scenarios undergoing PCI, Php 65,000 was added, to cover up to a total of 3 stents.

Based on the consensus process with Philippine Heart Association ACS panelists, the cost proposed ranges from 80,000 pesos to 530,000 pesos depending on the clinical scenarios.

OBJECTIVE

This study aimed to determine the budget impact of the proposed revised PhilHealth case rate packages for acute coronary syndrome (ACS).

This budget impact analysis used the static approach or cost calculator modeling method. The prevalence of hospitalization for coronary artery disease in all PhilHealth-accredited hospitals in the country in 2017 and the data from the ACS registry project of the Philippine Heart Association were used in this study. The study multiplied the present PhilHealth coverage with the number of ACS hospitalization claims to come up with the total cost of ACS hospitalization in the next three years with the assumptions that the eligible population and the ACS PhilHealth case rates will remain constant for these years. The future ACS hospitalization costs were also determined if the proposed case rates were used rather than the current PhilHealth case rates. The cost of re-admissions was considered as savings in hospitalization cost (due to prevention of admissions if the appropriate interventions were given) and were deducted from the future total cost of ACS hospitalizations.

The annual total ACS hospitalization cost using the current case rates was Php 1,134,683,000. Using the proposed case rates, the total hospitalization costs over five years was Php 2,653,019,000 in the first year (proposed case rates implemented to only 20% of the ACS patients) and increased to Php 8,726,364,000 by year 5 (full implementation of the proposed case rates or to 100% of ACS patients). This resulted in a lower incremental cost in the first year of implementation compared with a less gradual implementation over 3 years. The total incremental costs would amount to PHP7.6 billion for full implementation.

The study provided the budget impact of the proposed revised ACS case rates. The incremental cost is relatively huge, however the benefits of providing coverage of guidelinedirected therapy including invasive strategies for ACS must be considered.