BACKGROUND

Patients with diabetes are vulnerable and highly susceptible to contracting COVID-19. Stress hyperglycemia ratio (SHR) may provide prognostic information in hospitalized patients. It is debatable whether stress hyperglycemia directly leads to poor outcomes, or is simply a marker of increased stress and inflammation.

This study investigates whether high SHR is associated with poor clinical outcomes among patients with type 2 diabetes mellitus (T2DM) and moderate to critical COVID-19 infection. Moreover, this study aims to compare high SHR versus absolute hyperglycemia as a predictor of poor outcomes.

A chart review was conducted on 146 COVID-19 patients with T2DM from March 2020 to December 2021. The area under the receiver operating curve was conducted to categorize SHR into low and high levels. The association of high SHR levels and absolute hyperglycemia with outcomes was analyzed using the regression analysis. Survival analysis was also utilized to allow differences in the time when in-hospital mortality occurred.

Patients with high SHR had a significantly higher proportion of mortality and invasive ventilation compared to those with low SHR. High SHR significantly increased the likelihood of invasive ventilation by 16.49 times and mortality hazards by 5.70 times compared to low SHR. Kaplan-Meier survival curves showed that those with high SHR had significantly lower survival rates than those with low SHR. In contrast, the survival estimates between those with and without absolute hyperglycemia were not statistically significant.

High SHR (>1.082) was associated with poorer outcomes, increased invasive mechanical ventilatory support and increased mortality.

BACKGROUND AND OBJECTIVE

Robotic surgery for rectal malignancies in the Philippines is emerging. Evidence has shown promising results for robot-assisted (R) rectal surgery when compared to the laparoscopic (L) and open (O) approach. This study discussed the clinicopathologic outcomes of the first robotic rectal resections versus laparoscopic and open rectal resections at the Philippine General Hospital (PGH).

This was a retrospective cohort of 45 consecutive surgical resections for rectal malignancy done at the PGH from March 2019 to October 2019 that compared the outcomes of the first 15 robotic procedures done at the institution versus laparoscopic (n=15) and open (n=15) operations performed during the same time period. One-way ANOVA was done to determine significant differences among variables, while Bonferonni multiple comparison test was done to analyze differences among means.

The 45 patients in the study had a mean age of 56.04 ± 13.45 years. The patients were mostly male (60%). Most of the tumors were located in the low rectum (27/45; 60%). Most of the patients had locally-advanced (at least Stage IIIB) disease (27/45; 60%), and warranted neoadjuvant treatment (41/45; 91.11%). Most patients underwent a sphincter-saving procedure (34/45; 75.56%). All three groups had comparable baseline characteristics. The R-group had the longest operative time (438.07 ± 124.57; p value < 0.0001). Blood loss was significantly highest in the R-group (399 ± 133.07 cc; p value - 0.0020) as well, while no statistical difference was observed between the Oand L-groups (p value – 0.75). No conversion to open was noted in the R- and L-groups. Most of the patients had well-differentiated adenocarcinoma (22/45; 48.49%). All patients in the L- and O-groups had an R0 resection There were two R1 resections in the R-group. All patients who underwent an open surgery had a negative circumferential resection margin (CRM); L-group 93.99%, R-group 69.23%. All patients had adequate proximal and distal resection margins. Those who underwent an open surgery had the shortest post-operative length of stay (LOS) (p value – 0.0002). Post-operative ileus (7/45; 15.56%) was the most commonly encountered morbidity, and was seen mostly in the R-group (3/15; 20%). One patient in the R-group underwent a transanal repair of an anastomotic dehiscence and was discharged three days after reoperation. There was no reported mortality.

Our institution with a beginning robotic colorectal surgery program showed promise as its initial outcomes for rectal cancer were compared to the more often-performed open and laparoscopic procedures. The authors expect more favorable clinicopathological outcomes as our staff overcome the prescribed learning curve for robotic surgery.

Objectives: COVID-19 exacerbates the long-standing, low-grade chronic inflammation observed in diabetes leading to heightened insulin resistance and hyperglycemia. Mortality increases with hyperglycemia and poor glycemic variability, hence, this study aims to identify the predictors associated with poor glycemic control and increased glucose variability among patients with COVID-19 and Type 2 Diabetes Mellitus (T2DM). Methodology: A retrospective chart review of 109 patients with moderate to severe COVID-19 and T2DM admitted from March 2020 to June 2021 was done. Logistic regression was done to determine predictors for hyperglycemia and poor variability. Results: Of the 109 patients, 78% had hyperglycemia and poor variability and 22% had no poor outcomes. Chronic kidney disease (eOR 2.83, CI [1.07-7.46], p=0.035) was associated with increased glycemic variability. In contrast, increasing eGFR level (eOR 0.97, CI [0.96-0.99], p=0.004) was associated with less likelihood of increased variability. Hs-CRP (eOR 1.01, CI [1.00-1.01], p=0.011), HbA1c (eOR 1.86, CI [1.23-2.82], p=0.003), severe COVID-19 (eOR 8.91, CI [1.77-44.94], p=0.008) and critical COVID-19 (eOR 4.42, CI [1.65-11.75], p=0.003) were associated with hyperglycemia. Steroid use (eOR 71.17, CI [8.53-593.54], p<0.001) showed the strongest association with hyperglycemia. Conclusion Potential clinical, laboratory and inflammatory profiles were identified as predictors for poor glycemic control and variability outcomes. HbA1c, hs-CRP, and COVID-19 severity are predictors of hyperglycemia. Likewise, chronic kidney disease is a predictor of increased glycemic variability.
COVID-19 ; Diabetes Mellitus, Type 2 ; Hyperglycemia ; Risk Factors

McKittrick-Wheelock syndrome is a rare and life-threatening disease characterized by the triad of (1) chronic mucous diarrhea, (2) renal function impairment with hydroelectrolyte imbalance, and (3) a giant colorectal tumor. Often, the tumor is a rectal adenoma. With the mortality being certain, if left untreated, it is important to raise awareness on the presentation, diagnosis, and management of this disease entity. Here, we presented 3 cases of McKittrick-Wheelock syndrome that were successfully managed with surgical resection at the Philippine General Hospital from August 2018 to May 2019. Resolution of their symptoms, reversal of their renal impairment, and correction of their electrolyte depletion were noted after removal of the tumor with a sphincter-saving operation.

Objective: To determine the utility of a highly sensitive troponin assay when utilized in the emergency department. Methods The FAST-TRAC study prospectively enrolled >1,500 emergency department patients with suspected acute coronary syndrome within 6 hours of symptom onset and 2 hours of emergency department presentation. It has several unique features that are not found in the majority of studies evaluating troponin. These include a very early presenting population in whom prospective data collection of risk score parameters and the physician’s clinical impression of the probability of acute coronary syndrome before any troponin data were available. Furthermore, two gold standard diagnostic definitions were determined by a pair of cardiologists reviewing two separate data sets; one that included all local troponin testing results and a second that excluded troponin testing so that diagnosis was based solely on clinical grounds. By this method, a statistically valid head-to-head comparison of contemporary and high sensitivity troponin testing is obtainable. Finally, because of a significant delay in sample processing, a unique ability to define the molecular stability of various troponin assays is possible.Trial registration ClinicalTrials.gov Identifier NCT00880802

Background: and Purpose The Save ChildS Study demonstrated that endovascular thrombectomy (EVT) is a safe treatment option for pediatric stroke patients with large vessel occlusions (LVOs) with high recanalization rates. Our aim was to determine the long-term cost, health consequences and cost-effectiveness of EVT in this patient population. Methods: In this retrospective study, a decision-analytic Markov model estimated lifetime costs and quality-adjusted life years (QALYs). Early outcome parameters were based on the entire Save ChildS Study to model the EVT group. As no randomized data exist, the Save ChildS patient subgroup with unsuccessful recanalization was used to model the standard of care group. For modeling of lifetime estimates, pediatric and adult input parameters were obtained from the current literature. The analysis was conducted in a United States setting applying healthcare and societal perspectives. Probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set to $100,000 per QALY. Results: The model results yielded EVT as the dominant (cost-effective as well as cost-saving) strategy for pediatric stroke patients. The incremental effectiveness for the average age of 11.3 years at first stroke in the Save ChildS Study was determined as an additional 4.02 lifetime QALYs, with lifetime cost-savings that amounted to $169,982 from a healthcare perspective and $254,110 when applying a societal perspective. Acceptability rates for EVT were 96.60% and 96.66% for the healthcare and societal perspectives. Conclusions EVT for pediatric stroke patients with LVOs resulted in added QALY and reduced lifetime costs. Based on the available data in the Save ChildS Study, EVT is very likely to be a cost-effective treatment strategy for childhood stroke.

Purpose: This study aims to evaluate surgical outcomes (i.e. length of stay [LOS], 30-day morbidity, mortality, reoperation, and readmission rates) with the use of the Enhanced Recovery After Surgery (ERAS) pathway, and determine its association with the rate of compliance to the different ERAS components. Methods: This was a prospective cohort of patients, who underwent the following elective procedures: stoma reversal (SR), colon resection (CR), and rectal resection (RR). The primary endpoint was to determine the association of compliance to an ERAS pathway and surgical outcomes. These were then retrospectively compared to outcomes prior to the implementation of ERAS. Results: A total of 267 patients were included in the study. The overall compliance to the ERAS component was 92.0% (SR, 91.8%; CR, 93.1%; RR, 90.7%). There was an associated decrease in morbidity rates across all types of surgery, as compliance to ERAS increased. The average total LOS decreased in all groups but was only found to have statistical significance in SR (12.1±6.7 days vs. 10.0±5.4 days, P=0.002) and RR (19.9±11.4 days vs. 16.9±10.5 days, P=0.04) groups. Decreased postoperative LOS was noted in all groups. Morbidity rates were significantly higher after ERAS implementation, but reoperation and mortality rates were found to be similar. Conclusion Increased compliance to ERAS protocol is associated with a decrease in morbidity across all surgery types. The implementation of an ERAS protocol significantly decreased mean hospital LOS, without any increase in major surgical complications. Having your own hospital ERAS pathway improves documentation and accuracy of reporting surgical complications.