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 ;

Medical journals are meant to both reflect the science behind medical practice and facilitate the advancement of the discipline.1 They present newly generated knowledge in the field, with the general aim of improving health care. The effectiveness of a journal article to convey its messages can potentially affect the development of health care. Medical information from journals used to be designed for medical practitioners alone. Now, increasingly, publishers feel the need to package the same information to make it accessible to different types of readers. Almost always, readers go to journals to look for evidence that can support decisions about health. The common questions readers ask when looking for evidence in medical literature have something to do with incidence or prevalence of conditions, effectiveness of therapy or prevention, accuracy of diagnostic approaches, and associations of exposures and outcomes.

The Philippine COVID-19 Living Clinical Practice Guidelines (CPG) is a set of guidelines that provides up-to-date evidence-based recommendations on COVID-19 treatment, diagnosis, infection prevention and control. This living guideline follows the Department of Health’s Manual for Clinical Practice Guideline Development1 and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Approach.2 The diagram below is a summary of the treatment regimens gathered from the Philippine COVID-19 Living Recommendations website. The recommendation for each drug regimen is based on the assessment and literature review done by the Living CPG Task Force (LCTF).3 The LCTF follows the classification of quality of evidence enumerated and described in Box 1.
COVID-19

Hernia of the cord (HOC) is a rare condition that results from failure of the viscera to return to the abdominal cavity by the 10th week of fetal development. It sometimes presents together with a patent omphalomesenteric duct (POMD), another rare condition, which occurs earlier in fetal development. A proportion of POMD cases may also have ileal prolapse (IP) through the POMD lumen. Neonates diagnosed with the combination of these rare clinical conditions require immediate surgical intervention to resect the POMD and non-viable bowel segments, reduce the hernia, and repair the umbilical defect. In this case series, we report two neonates diagnosed with HOC with POMD and IP. One patient who had complete IP was not fit for immediate surgery and died of respiratory distress and sepsis. The other patient had a successful surgical correction of the congenital defects, but succumbed to sepsis postoperatively. Treatment of patients with this combination of clinical conditions should focus mainly on both surgical correction, and infection control and management.
Hernia, Umbilical ; Neonatal Sepsis

The prevalence of non-communicable diseases (NCDs) across the globe has reached epidemic proportions, with more than three quarters of NCD deaths now occurring in low- and middle-income countries (LMIC).1 NCDs encompass a broad range of chronic conditions, which include cardiovascular diseases, cancers, chronic respiratory diseases, diabetes, and mental disorders.2 To mitigate the growing global NCD burden and its associated challenges, upscaling high-impact essential interventions for the prevention and control of NCDs has remained a priority, especially in low-resource settings. One such intervention is strengthening self-care strategies or self-management of individuals living with NCDs.3 In the past few decades, the self-management approach to NCD has proven to be a cost-effective strategy to improve a patient’s quality of life by reducing symptom severity and decreasing pain. This approach has also encouraged patients to become key decision makers in the treatment process.4 Self-management includes both technological (e.g. smartphone applications, telemonitoring systems, or wearable devices) and non-technological interventions (social support, educational materials, or in-person training seminars).5 Telemedicine has played several important roles in the whole spectrum of care for patients with NCD. These include promotion of healthy behaviors, prevention of risk factors, prompt recognition and initiation of treatment, disease monitoring and follow-up, rehabilitation, and palliation. Telemedicine not only increases access to health care but also improves the quality of health care especially in rural areas.6 7 The unique challenges resulting from the COVID-19 pandemic has limited patient access to health care, especially in geographically isolated and disadvantaged areas. This literature review aims to determine the effectiveness of telemedicine on clinical and psychosocial outcomes of adult patients diagnosed with NCDs. We conducted a literature search on PubMed, EBSCOhost, ProQuest, Google Scholar, and Gale using the search words “telemedicine,” “adult,” “non-communicable disease,” “self-management,” and “teleconsultation.” We filtered the results to only include randomized controlled trials (RCT). To narrow down the scope of this literature review, only previous studies that compared telemedicine and usual care (non-telemedicine) among adults with non-communicable diseases, and those that report clinical and psychosocial outcomes—i.e., symptom outcomes, laboratory outcomes, knowledge on disease, or behavior outcomes that pertain to self-management of disease—were assessed. We excluded studies if they were done among patients <18 years old, if they included telemedicine that supplemented rather than replaced the usual (face-to-face) care, if they were not able to report outcomes between groups, or if they did not meet the criteria of a RCT. Two reviewers independently reviewed the abstracts yielded from the search strategy and assessed them based on the set criteria. If neither reviewer was able to rule out an article based on the abstract, the full text was retrieved and assessed to determine inclusion into the study. After the final assessment, a total of 9 RCT reports were included in this review. The general characteristics and key findings of the 9 studies included in this literature review are summarized in Table 1. The included studies, published in various journals between 2014 and 2021, were carried out in eight countries—two studies were done in Australia, and one each in Bangladesh, India, Italy, USA, Germany, China, and the Netherlands. The studies enrolled patients who were diagnosed with type 2 diabetes mellitus (DM) (n=3), chronic obstructive pulmonary disease (n=1), type 1 DM (n=1), congestive heart failure (n=1), stroke (n=1), osteoarthritis (n=1), and various non-specific chronic conditions, including type 2 DM, hypertension, coronary artery diseases, heart failure, chronic depression, and schizophrenia (n=1). The sample sizes of the studies included ranged from 29 to 10,815 participants. Follow-up periods ranged from 3 to 36 months. The telemedicine techniques that were used in the studies included mobile phone-based health interventions, telemedicine-based visits, and telephone-based health coaching. In general, most of the studies included in this review reported that telemedicine is as good as, if not better than, usual care approaches in achieving clinical and psychosocial outcomes.
Noncommunicable Diseases ; Chronic Disease

Life-threatening congenital anomalies, which constitute neonatal surgical emergencies, can result in death or severe disability if not treated immediately at birth. Prompt recognition and treatment of these emergencies, which include initial stabilization following birth, can lead to better patient outcomes.1 2 The perioperative period refers to the time interval encompassing the surgical procedure. This includes three stages: preoperative phase (from the time the patient arrives up to surgery), operative phase (the surgical period), and postoperative phase (until either the patient has expired or has been discharged).3 4 Optimizing patient flow is one of the greatest challenges facing health care today. Increased waiting time, delays, and cancellations are frequently encountered by patients, as well as health care workers, that they now believe that these problems are a part of the care process.5 6 Monitoring the perioperative duration, especially for life-saving procedures during neonatal emergencies, is the first step towards providing safe and efficient patient care while maximizing hospital resources.7 Southern Philippines Medical Center (SPMC) currently has a set of time-specific surgical protocols from admission to discharge. However, these protocols are not age-specific. Since SPMC is an end-referral institution in Mindanao for patients requiring neonatal surgery, it is imperative that surgeons gain a thorough understanding of patient flow from admission to discharge, and the occurrence of morbidity and mortality among these patients during admission, in order to effectively implement and possibly improve these protocols in the future. The aim of this study was to describe the perioperative clinical profile of newborn patients who underwent surgical management for congenital malformations of the gastrointestinal (GI) tract. In our institution, neonatal surgery is considered an emergency procedure that is managed accordingly by the Pediatrics, Pediatric Surgery, and Anesthesiology services as soon as the diagnosis is established. The Section of Pediatric Surgery at SPMC caters to an annual average of 89 patients with congenital malformations of the GI tract from 2017 to 2019. For this descriptive study, we collected data retrospectively from the medical records of patients admitted in the neonatal and pediatric intensive care units of SPMC who underwent surgery in the institution from 2015 to 2019 after being diagnosed with a congenital malformation of the GI tract. We excluded patients ≥29 days old, as well as those who were diagnosed with and/or who underwent surgery for multiple congenital anomalies. We were able to gather the data of a total of 60 patients—15 patients each for congenital diaphragmatic hernia (CDH), esophageal atresia (EA), gastroschisis (GS), and imperforate anus (IA)—for this study. From the medical records, we collected data on the patient’s sex, age upon admission, and preoperative diagnosis. We also collected data on the preoperative time (the time interval in hours from admission to surgical cutting), the operative time (the time interval in minutes from surgical cutting to last stitch), the postoperative time (the time interval in days from last stitch to discharge), and the total length of hospital stay (the time interval in days from admission to discharge). Further, we also gathered data on the occurrence of morbidities during admission (neonatal sepsis, health-care associated pneumonia, fungal infection, others) and/or death, as well as the patients’ disposition upon discharge. Among patients who died, we also determined the median time in days from end of surgery (last stitch) to death. Overall, there were 38 males and 22 females included in the study. Specifically, there were 6 males and 9 females in the CDH group, 13 males and 2 females in the EA group, 8 males and 7 females in the GS group, and 11 males and 4 females in the IA group. The overall median age of the 60 patients upon admission was 4.5 (range: 1–28) days. The median ages of the patient groups upon admission were 11 (2–25) days for CDH, 17 (4–28) days for EA, 1 (1–1) day for GS, and 2 (1–24) days for IA. Overall, the median preoperative time was 47.22 (6.27–582.72) hours, the median operative time was 95 (24–350) minutes, the median postoperative time was 9.94 (0.15–39.16) days, and the median total length of hospital stay was 17.16 (0.71–44.42) days. The median preoperative time was 242.25 (31.27–413.88) hours for CDH, 163.58 (39.48–444.77) hours for EA, 13.27 (6.27–30.17) hours for GS, and 32.1 (11.27–582.75) hours for IA. The median operative time was 100 (24–175) minutes for CDH, 140 (88–350) minutes for EA, 64 (35–120) minutes for GS, and 70 (35–133) minutes for IA. The median postoperative time was 8.40 (0.31–31.08) days for CDH, 9.92 (2.12–39.16) days for EA, 14.20 (0.15–38.69) days for GS, and 9.95 (2.85–24.77) for IA. The median total length of hospital stay was 17.30 (2.98–41.26) days for CDH, 22.09 (7.07–47.42) days for EA, 15.40 (0.71–39.72) days for GS, and 12.82 (4.32–29.86) days for IA. Of the 60 patients, 24 had at least one morbidity during admission, and 23 died. There were 5 patients who had morbidity during admission in the CDH group, 8 in the EA group, and 11 in the GS group. There were 5 deaths in the CDH group, 7 deaths in the EA group, and 11 deaths in the IA group. There was no morbidity or death in the IA group. The three most common morbidities during admission were neonatal sepsis 15/60 (25%), ventilator-associated pneumonia 6/60 (10%), and fungal infection 6/60 (10%). Among the patients who died, the median time from end of surgery to death was 6.94 (0.31–11.45) days for CDH, 8.78 (2.35–29.11) days for EA, and 14.56 (0.15–38.69) days for GS. All in all, there were 10 patients whose conditions improved upon discharge in the CDH group, 8 in the EA group, 4 in the GS group, and 15 in the IA group. In this study, we found out that patients with congenital malformations of the GI tract are usually admitted in our institution during their first week of life. Patients stayed in the hospital for 2.5 weeks, 27.84% of which was spent on preoperative care, 0.40% on operative care, and 71.76% on postoperative care. The data presented in this study happened before the WHO declaration of a COVID-19 pandemic in March 2020. During the height of the SARS-CoV-2 infection, and even today, more than two years after the start of the pandemic, the patient flow within our institution for non-COVID-19 cases changed several times to comply with the evolving mandates and regulations related to the pandemic. These changes included the addition of mandatory COVID-19 screening prior to admission or any procedure with patient contact, the mandatory isolation of patients presenting with COVID-19-like symptoms, and the capacity limitations in patient beds and operating theaters, to name a few. The same health care modifications could have affected the outcomes of patients with congenital GI malformations. In the future, a formal comparison of perioperative time intervals and patient outcomes in different health care contexts could point out specific aspects of patient flow that need action for improvement. Further studies focusing on the identification of specific risks and contributory factors affecting delays in perioperative care and patient outcomes would also be useful in addressing the health care needs of these patients. Ensuring an efficient health care pathway should be an essential part of a wider effort to improve the quality care for patients with life-threatening conditions, such as those with congenital anomalies of the GI tract.
Infant, Newborn ; Gastrointestinal Tract

Mental health has profound effects on an individual’s quality of life, and it can also affect the families and the communities of persons with mental illness. In early 2020, the World Health Organization (WHO) Special Initiative for Mental Health in the Philippines recorded at least 3.6 million Filipinos suffering from a mental, neurological, or substance abuse disorder.1 In 2015, schizophrenia was the top mental disorder in the Philippines,2 and it is estimated that 1 million Filipinos (1% of the population) suffer from schizophrenia.3 Schizophrenia, a debilitating mental health condition, is characterized by both positive (e.g., hallucinations, delusions, confused thoughts, etc.) and negative (e.g., lack of pleasure, flattening, withdrawal, etc.) symptoms.4 5 6 The condition can affect the individual’s personal and social aspects of daily life, such as self-care, interpersonal relationships, education, and employment.7 8 9 10 Hospitalization is generally indicated for patients who are actively experiencing delusions/hallucinations, those who pose a serious threat of harm to themselves or others, or those who are unable to care for themselves and need constant supervision and support. Other possible indications for hospitalization include the presence of general medical or psychiatric problems that may render outpatient treatment unsafe or ineffective.11 12 Recent therapeutic advances, especially the introduction of atypical antipsychotic medications that have demonstrated better efficacy rates compared to older generation oral antipsychotic drugs, have allowed the reintegration of persons with mental health disorders (e.g., schizophrenia, other psychotic disorders, major depression, mood disorder, or bipolar disorder) into the society.13 14 15 Yet, despite the availability of such medications, there still exists substantial gaps in the delivery of mental health services. In the Philippines, mental health has remained poorly-resourced, with only 3-5% of the total health budget spent on mental health care.16 Mental health specialists have been in shortage, and a large proportion of these specialists work in urban for-profit services or private practices. 16 Mental health care services are delivered largely in hospital and private clinic settings,16 18 while community-based services remain underdeveloped.17 19 Prohibitive economic conditions and stigma on mental illness20 21 are some of the factors that contribute to low diagnosis and treatment rates. These factors, as well as funding issues that limit patient access, especially to newer innovative drugs, have rendered mental health care relatively inaccessible, leaving many patients undiagnosed and untreated or undertreated.17 In 2015, the Davao Center for Development (DCHD) Mental Health Program facilitated the establishment of Community-Based Mental Health Programs (CBMHPs) and the implementation of the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) in several municipalities in the region. Since their launching, CBMHPs in Davao Region documented annual increases ranging from 10 to 13% in the number of patients availing mental health services in primary and tertiary care facilities from 2016 to 2019. 22 During the program implementation review conducted by the National Mental Health Program in 2019, two Centers for Health Development (CHD)—those in Davao and in CaLaBaRZon—planned to implement a common project for patients with schizophrenia in some areas with CBMHPs in their respective regions.22 This is in accordance with the Republic Act 11036, also known as the Philippine Mental Health Act, which mandates that basic mental health services be provided in community settings.23 The Schizophrenia Project was designed to make mental health services accessible and antipsychotic medications readily available in municipalities with the highest burden of schizophrenia, the most common mental health condition in the region. The project involves community-level assessment, management, and follow up of patients with schizophrenia through the process described in the mhGAP-IG. In Davao, the ongoing Schizophrenia Project implementation has been made possible by the collaboration of primary care providers in rural health units (RHU) with psychiatrist consultants. Johnson & Johnson Philippines, the marketing authorization holder of paliperidone palmitate in the country, conducts training of health care workers involved in the project. DCHD finances the project and provides technical assistance to the RHUs. A pilot phase of the project was planned to run for one year in four implementation sites—Boston in Davao Oriental, Santo Tomas in Davao del Norte, Sta. Cruz in Davao del Sur, and Jose Abad Santos in Davao Occidental—which have been identified by DOH DCHD as having the highest numbers of patients diagnosed with schizophrenia in Davao Region. DCHD purchased paliperidone palmitate needed for project implementation in December 2019. In March 2020, Johnson & Johnson conducted the first training for health workers. Patient enrollment into the pilot phase started in July 2020 and was completed in October 2020. RHUs in the four implementation sites identified patients with probable schizophrenia through a community-based case-finding and referral strategy patterned after the mhGAP-IG. Among the four municipalities, a total of 49 patients—9 from Boston, 10 from Santo Tomas, 11 from Sta. Cruz, and 19 from Jose Abad Santos—were enrolled into the program. The enrolled patients were diagnosed, treated, and monitored at least every six months by the collaborating psychiatrists and RHU physicians. The RHUs were also tasked with setting-up communication lines for emergency consultations with the collaborating psychiatrists during crisis, providing counseling to the patients’ families, and conducting health promotion events to raise awareness on schizophrenia. After the one-year implementation of the pilot phase, health care providers were highly satisfied with the project. After initiation of treatment, most of the patients demonstrated improved symptoms, and some of them were able to perform household chores or return to work within a few months. None of the patients experienced hospitalization or relapse during the pilot phase. Health workers involved in drug dispensing and patient monitoring observed that the intravenous preparation of paliperidone palmitate used in this project facilitates easier supply inventory and patient tracking. DCHD also noted cost savings in expenditure on antipsychotic drugs when paliperidone palmitate was used in this project instead of the oral and conventional depot antipsychotic drugs used in the past. Health workers involved in the project also encountered some challenges during implementation. Many caregivers and families of patients in the project were not very cooperative in complying with the demands of the treatment sessions and social reintegration. After initiation of antipsychotic treatment, many patients could not comply with the regular follow up sessions, mostly because they live very far from the RHUs and could not afford the transportation costs of the visits. The Schizophrenia Project did not have a structured reintegration program, so many patients who were already in remission after a few months of treatment could not be properly reintegrated into their respective families and communities. During the project review after the pilot phase, stakeholders pointed out several good practices of individual municipalities that can possibly be scaled up or replicated by other CBMHPs implementing similar projects in the future. In Boston, the municipal health officer conducted a series of lectures on the social dimensions of mental health disorders to the caregivers and families of patients in the project. Those who attended the lectures have expressed an increased understanding of the nature of their patients’ condition. In Sta. Cruz, the RHU provided food (rice and snacks) and fare reimbursements to the families of patients who came during follow up checkups. The RHUs of Santo Tomas and Sta. Cruz involved the social welfare service units of their respective municipalities in the process of family and community reintegration of patients on remission. The pilot phase implementation of the Schizophrenia Project in the four municipalities in Davao has demonstrated that it is highly possible to integrate mental health services at the primary care and community settings, and achieve positive outcomes for patients, caregivers, health care providers, and the health system.
Quality of Life ; Schizophrenia