BACKGROUND: In 2016, the Philippine Health Insurance Corporation (PhilHealth) introduced the Z-package to provide financial coverage for, among others, intramedullary nailing procedures and implant costs for eligible patients with femoral shaft fractures. OBJECTIVE: To compare health care durations and expenses between patients with closed femoral shaft fractures requiring intramedullary fixation who utilized the PhilHealth Z-package and those who did not. DESIGN: Retrospective cohort study. PARTICIPANTS: 66 male and female patients, aged 19 to 39 years, who underwent intramedullary nailing for closed femoral shaft fractures. SETTING: Orthopedic Ward, Southern Philippines Medical Center, Davao City, January to December 2018. MAIN OUTCOME PROCEDURE: Time to surgery, length of hospital stay, total hospital bill, total PhilHealth coverage, other funds for medical assistance (OFMA) coverage, and out-of-pocket (OOP) expenses. MAIN RESULTS: Among the 66 patients, 33 had the Z-package, while the remaining 33 did not. The median time to surgery (19 days vs 24 days; p=0.156), median length of hospital stay (24 days vs 29 days; p=0.546), and median total hospital bill (Php 62,392.00 vs Php 62,404.80; p=0.314) were comparable between those without the Z-package and those who had, respectively. However, patients without the Z-package had significantly lower total PhilHealth coverage (Php 30,740.00 vs Php 48,740.00; p<0.001) and higher OFMA coverage (Php 49,909.90 vs Php 34,409.20; p=0.024), and OOP expenses (Php 0.00; IQR: Php 0.00 to Php 20,000.00 vs Php 0.00; IQR: Php 0.00 to Php 0.00; p=0.004) compared to those with the Z-package. CONCLUSION Patients with the Z-package had a slightly longer time to surgery, although this difference was not statistically significant. However, they benefited from significantly lower remaining bills after PhilHealth coverage and reduced OOP expenses compared to patients without Z-package coverage.
PhilHealth coverage ; out-of-pocket expenses ; medical assistance ; length of stay

Urticaria pigmentosa (UP) is the most common form of cutaneous mastocytosis in children. It can be diagnosed clinically, based on the appearance of numerous brownish macules and papules that are symmetrically distributed, mostly on the trunk and the extremities. Skin biopsy is helpful in establishing the diagnosis. Treatment options generally include antihistamines and/or topical corticosteroids. In most cases, pediatric UP tends to disappear spontaneously before puberty. We present the case of a 9-month-old male with a history of multiple brownish patches and plaques, which started when he was four months old. He was diagnosed with UP based on clinical and histopathologic findings, and was prescribed oral antihistamines and emollients for symptomatic treatment.
cutaneous mastocytosis ; mast cell degranulation

BACKGROUND: Radiotherapy (RT) to the chest or other large areas of the body may cause bone marrow suppression, resulting in anemia and other changes in blood cell counts. OBJECTIVE: To compare the post­RT hemoglobin levels between patients who underwent forward­ planned intensitymodulated radiotherapy (FPIMRT) and those who underwent three­dimensional conformal radiotherapy (3D­CRT). DESIGN: Retrospective cohort study SETTING: Department of Radiological and Imaging Sciences, Southern Philippines Medical Center, Davao City, from October 2018 to March 2019. PARTICIPANTS: 94 women with invasive ductal carcinoma, aged 29 to 75 years, who received at least 28 fractions (with or without boost dose) of either 3D­CRT or FPIMRT. MAIN OUTCOME MEASURES: Mean hemoglobin counts and anemia within 4 weeks post­RT. MAIN RESULTS: Of the 94 women, 62 (65.96%) underwent 3D­CRT, and 32 (34.04%) underwent FPIMRT. The proportion of patients with left­sided tumors was significantly higher in the FPIMRT group than in the 3D­CRT group. The baseline hemoglobin levels (12.60 ± 1.04 g/dL for 3D­CRT vs 12.49 ± 0.80 g/dL for FPIMRT; p=0.5994) and the mean changes in hemoglobin count from baseline (­0.11 ± 0.72 g/dL for 3D­CRT vs ­0.18 ± 0.67 g/dL for FPIMRT; p=0.6707) were both comparable between the two groups. The proportions of patients with anemia within four weeks post­RT were also comparable between the two groups (13/62, 20.97% for 3D­CRT vs 8/32, 25.00% for FPIMRT; p=0.6565). Left­sided tumors were significantly associated with post­RT anemia (unadjusted OR 2.87; 95% CI 1.00 to 8.22; p=0.0498), even after controlling for type of RT technique (adjusted OR 3.15; 95% CI 1.01 to 9.87; p=0.0484). CONCLUSION After RT, the mean hemoglobin levels of patients with breast cancer who underwent 3D­CRT were comparable with those of patients who underwent IMRT. The type of RT technique was not significantly associated with the occurrence of post­RT anemia in these patients.

Acute epiglottitis (AE), an inflammation of the epiglottis and adjacent supraglottic structures, can lead to a fatal airway obstruction. We report the case of a 47­year­old male who developed AE after experiencing a sore throat, odynophagia, and high­grade fever for a week. The patient came in with late signs of AE, suggesting a poor prognosis. Laryngoscopy revealed a swollen epiglottis obstructing the patient’s tracheal opening. He had cardiopulmonary arrest due to the airway obstruction. The patient was successfully resuscitated but had several episodes of generalized seizure after the return of spontaneous circulation. He was discharged in a persistent vegetative state. Because AE is unusual in the adult population, a clinician's high index of suspicion for the diagnosis and the emergency team’s prompt intervention are crucial factors in the management approach to AE. Physicians working in the emergency room must be equipped with skills in establishing a definitive airway, especially in securing a surgical airway.
Epiglottitis ; Laryngoscopy ; Tracheostomy ;

In 2003, the secretaries of the Department of Health (DOH) and the Department of Science and Technology (DOST) signed a memorandum of understanding to institutionalize the Philippine National Health Research System (PNHRS) for the management of research in the country.1 One of the groups constituted under the PNHRS was the Technical Working Group (TWG) on Ethics, which created strategies that highlight the role of ethics in a responsible health research system. Among the recommendations of the Ethics TWG was the establishment of the Philippine Health Research Ethics Board (PHREB).2 In 2006, the PHREB was formally created through DOST Special Order 2006-91 “to ensure that all phases of health research shall adhere to universal ethical principles that value the protection and promotion of the dignity of health research participants.” Since then, PHREB has become the country’s policy making body on health research ethics.2 3 In 2013, the Republic Act 10532一or the PNHRS Law一was enacted.4 The Act strengthened the mandate of PHREB to ensure protection of the welfare, rights, and safety of human research participants, and the implementing rules and regulations (IRR) of the Act specified the policies that facilitate the achievement of the PHREB mandate.5 In 2017, through DOST Special Order 2017-248, DOST established research ethics monitoring boards (REMBs) in Region I, Region VI, and Region XI to assist in the comprehensive and consistent implementation of PHREB policies at the regional level.6 The creation of PHREB in 2006 initiated several other mandates from PHREB and other agencies that implement the PNHRS. These mandates一shown in the infographic一support human research participant protection through ethical reviews of research protocols, establishment of research ethics committees, and maintenance of quality standards of these committees through accreditation. Many of these mandates are national in scope, but a few are specific to Davao Region (Region XI).
Ethics Committees, Research

When communities were forced into lockdown due to the COVID-19 pandemic, governments across different countries globally also started to impose new social restrictions. In order to comply with these new rules and to meet the demands of an emerging disease, health facilities modified the structures and processes of health care services. 1 Teleconsultations—or medical consultations wherein patients and health care practitioners are away from each other, connected only by telecommunication devices —took the place of the traditional face-toface (FTF) consultations, especially in the outpatient clinics. The provision of remote clinical services or telemedicine—which frequently involves teleconsultations—has been practiced since the early 1960’s, 2 but its utilization has grown exponentially ever since this pandemic started. 3-5 A few studies have demonstrated a significant reduction, from to 60 to 80%, in in-person outpatient visits and a four-fold increase in telehealth outpatient visits in the United States during the early days of the pandemic. 6 7 Similarly, across Asia-Pacific countries, there has been a surge of activity in telemedicine platforms since the identification of the COVID-19 virus in January 2020. 8 In the Philippines, for example, a subscription-based teleconsultation service called KonsultaMD registered a 450% increase in the number of teleconsultations in April 2020. 9 Medgate, one of the country’s leading international telemedicine providers, reported a 170% increase in teleconsultations in 2020. 10 11 The aim of this article is to recommend policies for the delivery and reporting of outpatient care using telemedicine in a tertiary hospital.
Remote Consultation ; COVID-19

The Psoriasis Foundation of the Philippines, Inc. (PFPI), is a non-profit organization in Davao City. The organization was founded in 1997 by dermatologists from Mindanao, with Dr. Carlos Pacheco as the founding president. In the same year, the PFPI was registered at the Securities and Exchange Commission (SEC). The foundation was established with the goal of improving the quality of life of patients with psoriasis. Its founders believed that they can achieve these goals by: 1. facilitating patient access to medical consultations and medications for psoriasis; 2. carrying out activities that provide social and financial support to patients and their families, and 3. promoting the conduct of research that can be used to improve the management of psoriasis. In order to do this, the PFPI partnered with the Southern Philippines Medical Center (SPMC) Department of Dermatology as it caters to numerous dermatological patients covering the Visayas and Mindanao region. With this, the PFPI was able to garner a wider grasp of psoriasis patients as well as the opportunity to work closely with their health care providers and aid patients not only medically but also in addressing various aspects of their well-being. This led to the establishment of the Psoriasis Club. The Psoriasis Club currently has at least 30 members, composed of patients who have been diagnosed with psoriasis in the SPMC Department of Dermatology Clinic. The club holds monthly meetings and functions as a support group for patients and their family members, along with their healthcare providers. This has led to better monitoring of patients, increase in compliance to treatment, and stronger patient-doctor relationships. Further, the club has been able to build and strengthen relationships among psoriasis patients and their families, thereby increasing the size of their social support team. The club also implemented livelihood programs such as soap-, candle-, and Christmas decor-making in order to provide patients with skills and offer them financial security. In addition, the SPMC Department of Dermatology organizes fundraising events (e.g. postgraduate courses or conferences, advance movie screenings, pop-up thrift shops) every year to raise funds for psoriasis patients in order to generate revenue for their livelihood and medications. The PFPI, together with the Philippine Dermatological Society, celebrates World Psoriasis Day every October. This annual event is attended by patients with psoriasis, family members, and healthcare workers. It is a time when patients are given an opportunity to share their personal health experiences to dispel stigma and myths regarding psoriasis. It also impels the lay people to partner with them as they lobby for better access to health care and affordable treatments. The event also provides entertaining activities and offers free dermatological consultations. In 2015, the PFPI, in partnership with the SPMC Department of Dermatology, also started the Psoriasis Registry (PsoReg) in Davao City to keep track of psoriasis patients’ disease progression or improvement. This registry contains the sociodemographic information, clinical profiles, efficacy or failure of treatment, and quality of life among patients with psoriasis in a tertiary government hospital and private dermatology clinics. The PsoReg also aims to facilitate further studies in the disease, influence health policies, and promote the creation of a unified national registry for the country. Currently, the PFPI is under the leadership of Dr. Victoria P. Guillano. As a partner institution of PFPI, the SPMC Department of Dermatology provides support to the foundation, especially in terms of human resources, financial assistance, and technical expertise from its pool of consultants, residents and health staff. Since the establishment of the PFPI, efforts toward improving psoriasis healthcare have been geared towards lobbying for the inclusion of psoriasis in the list of subsidized medical cases by the Philippine Health Insurance Corporation (PhilHealth). This is done with the help of Rep. Scott Davies Lanete, MD, who principally authored the House Resolution 1818 that would make treatment readily available for patients with psoriasis. In 2019, the PFPI received a pharmaceutical company-funded grant that enabled the foundation to implement project Psoriasis Health Innovations (Psor-HI). This project aims to link the patients, healthcare providers, and policy makers to develop and strengthen dermatologic care for psoriasis patients. Through this project, the PFPI was able to easily reach patients and their families in Davao City, Zamboanga City, Tagum City, and Cebu City. Psor-HI was able to connect with municipal health workers, allied medical professionals, and general practitioners in these areas and connect them to the PFPI where they were able to provide vital information on psoriasis and its appropriate management. In addition, health workers with limited access to specialized dermatologic care were properly guided and enhanced their capacities to provide the best care for their psoriasis patients. The PFPI plans to engage local partners in the community in the future to strengthen patient engagement. Since psoriasis is currently not included in the health programs of the Department of Health (DOH), the PFPI envisions the integration of psoriasis education in the list of non-communicable diseases being addressed and monitored by the DOH. The PFPI will continue to be an active advocate in the achievement of accessible and affordable health services for patients with psoriasis.

Research—or the production of new knowledge—needs to be done ethically. Why is it important to factor ethics into the practice of producing new knowledge? The word “ethics” refers to “moral principles that govern a person’s behavior or the conducting of an activity.”1 Moral principles are “principles of right and wrong that are accepted by an individual or a social group.”2 If we add “research” into the term “ethics,” the phrase “research ethics” would now refer to the principles of right and wrong that govern a researcher’s behavior or the conducting of research. “Research ethics” is the principles of right and wrong in action, in practice, or in the actual implementation of knowledge production. When we conduct human research, we produce new knowledge, often with development goals in mind, for instance—to be more efficient in work, to make clients more satisfied, to diagnose more accurately, to treat more effectively, to prevent illness, to predict outcomes, or to save lives. We ask questions and answer them to produce new knowledge, which we hope will eventually inform the actions that we take in order to meet our development goals. This is a very human pattern of behavior: question-answer-knowledge-action, to strive towards development. It is human nature to work towards development—towards making existence a better experience. This is the reason why we have the propensity to marvel and to introspect, and then to question and look for answers to our questions. This is the most fundamental reason for generating more and more knowledge, for doing research. And this is good—the intention is noble because it benefits us, the people around us, and even those who will exist after us. Generating new knowledge is a conscious effort to do something that gives benefit to oneself and to others. The problem with knowledge production is that it can cause harm, especially to research participants. Harm within the context of research can either be physical, psychological, economic, sociocultural, or legal. Many researches in the past have caused direct, indirect, intentional, or unintentional harm to the participants, or even to the public.3 Asking questions, collecting and analyzing data to answer these questions, and communicating findings and interpretations to others all involve harm. That is why we have international and national guidelines, state laws, and research implementation standards that support human protection systems in research. In the Philippines, many mandates pertaining to health research order the establishment of research ethics committees, the review of all researches involving humans or human data by these committees, and the accreditation of these committees by the Philippine Health Research Ethics Board, the policy-making body in health research ethics in the country.4 These mandates should guide academic and health institutions, as well as agencies that conduct researches involving humans or human data, in providing human protection in research. Deciding to do research is an ethical act. If we decide to pursue knowledge, we affirm and celebrate the human features of introspection, examination of our actions, and pursuit of excellence in the things we do as a society. Actually doing research—i.e., asking questions, recruiting participants, giving interventions, gathering and analyzing data, to reporting findings—offers several opportunities for more ethical acts because, when we perform the tasks involved in research, we are presented with opportunities to do good for others, to prevent harm from coming their way, to show respect for and to acknowledge others as fellow humans, to actively participate in restoring or maintaining justice, and to practice professionalism, honesty, and integrity. By properly applying ethical principles in doing research, and by ensuring that a system for the oversight and guidance of research implementation is in place, we can prevent harm, minimize the risk of harm, and avoid misconduct in research. From there on, we can pursue the ethical act of doing research and positively gain from seizing the opportunities that the act offers. That is why it is important to factor ethics into the practice of producing new knowledge.
Ethics, Research

Background: Fluid management is crucial during the first 24 hours after a burn injury due to different systemic responses of the body Objective: To compare the outcomes of patients with partial- or full-thickness burns initially managed using the Parkland (PRK) formula with those initially managed using the Rizal D. Aportadera (RDA) formula, a fluid resuscitation formula with added sodium bicarbonate. Design: Cohort study. Participants: 181 male and female patients, aged 7 months to 78 years, with partial- or full-thickness burns. Setting: RDA Burn Unit of Southern Philippines Medical Center, Davao City, from January 2008 to December 2018. Main outcome measures: Proportions of patients with prolonged hospital stay, sepsis, and death; odds ratio of having the outcomes for selected factors. Main results: Of the 126 males and 55 females, with overall mean age 25.70 ± 20.92 years, included in this study, 175 (96.69%) had partial-thickness burns and 6 (3.31%) had full-thickness burns. Among the patients, 108/181; 59.67% were managed with the PRK formula, while 73/181 (40.33%) were managed with the RDA formula during fluid resuscitation. Compared to the PRK group, the RDA group had significantly lower mean length of hospital stay (11.67 ± 9.69 days vs 17.22 ± 20.45 days; p=0.0317) and lower proportion of patients with prolonged hospital stay (2/73, 2.74% vs 13/108, 12.04%; p=0.0287). Full-thickness burns had independent association with prolonged hospital stay, while major burns had independent association with death. Conclusion Compared to patients in the PRK group, those in the RDA group had significantly shorter hospital stay. Full-thickness burns and major burns were independently associated with prolonged hospital stay and death, respectively.

Neuroretinitis (NR) is an inflammation of the optic nerve and the neural retina. NR is diagnosed clinically, and it is characterized by blurring of vision (BOV), optic disc swelling, and macular star exudates. Spontaneous resolution of NR is possible, but corticosteroids help in hastening recovery. Rarely, Salmonella typhi infection may produce an immune-mediated reaction that can cause NR. Immune-mediated retinitis occurs 3 to 6 weeks after the febrile period of a typhoid infection. We present the case of a 55-year-old female with a two-week history of painless, unilateral BOV occurring five weeks after the initial febrile episode of a typhoid infection. A diagnosis of NR was made after fundus examination on the affected eye showed optic disc edema and macular star exudates. An eight-week course of corticosteroid treatment afforded partial resolution of the disc edema and significant reduction in the macular exudates, and improved the patient’s vision after six months.
Salmonella typhi ; Tomography, Optical Coherence