BACKGROUND: Splenic Actinomycosis is a rare entity which usually presents as a difficult diagnostic case. It is a chronic granulomatous infectious disease, caused by Actinomyces which is commonly associated with history of abdominal surgery and manipulation. Majority of cases would present as an enlarging abdominal mass often mimicking malignant tumors.
CASE PRESENTATION: This paper presents a rare case of splenic actinomycosis in a 24-year-old Filipino female presenting as multiple splenic abscesses leading to gradual progressive ascites initially thought to be due to a malignant lymphoma. On physical examination, massive ascites and splenomegaly were the only abnormality appreciated. Initial radiologic imaging (x-ray, ultrasound, CT scan) revealed presence of multiple splenic nodules associated with extensive mediastinal and retroperitoneal lymphadenopathy as well as peritoneal extension/carcinomatosis (Figure 1 and 2). Splenic biopsy revealed presence of actinomyces (Figure 3).
TREATMENT AND OUTCOME: Patient was started on amoxicillin 2.0 g per day for 24 months which led to a significant resolution of her massive ascites. Subsequent abdominal ultrasound showed gradual reduction in the hepatic and splenic size with resolution of splenic foci. Patient is currently on frequent follow-up.
CONCLUSION: Splenic actinomycosis although extremely rare should be included as a differential diagnosis when presented with an unusual splenic mass or abscess on CT scan. Majority would mimic different forms of malignancy hence early histologic biopsy is usually needed to prevent unnecessary extensive and invasive surgical procedures. Radiologic and biochemical test are usually non-specific and not helpful with the establishment of the diagnosis. Although surgery remains to be the cornerstone for its management, prolonged antibiotic therapy might show promising results due to intensive closer follow up and accessibility to monitoring modalities for treatment response.

Human ; Female ; Adult ; Actinomyces ; Splenomegaly ; Amoxicillin ; Splenic Diseases ; Abscess ; Ascites ; Actinomycosis ; Lymphoma ; Neoplasms ; Anti-bacterial Agents ; Lymphadenopathy

BACKGROUND: Cushing's syndrome is a state of hypercortisolism manifesting non-specific clinical; features where its diagnosis entails biochemical confirmation of cortisol excess. this study aims to validate the efficacy of midnight salivary cortisol as a screening test for Filipino suspected with Cushing's syndrome and determine the cut-off value applicable in the local setting.

METHODS: This is a cross-sectional study of Filipinos suspected with endogenous Cushing's syndrome seen at a tertiary hospital. Modification of plasma cortisol measured by RIA was used to measure salivary cortisol. The sensitivity, specificity, positive predictive curve, negative predictive curve and area under the screening tests were estimated and compared using 48 hour low dose dexamethasone suppression test (LDDST) as the reference standard.

RESULTS: The determine cut-off value (? 7.0 nmol/L) for salivary cortisol showed a relatively high sensitivity (91.3%) and specificity (89.5%) in detecting cases suspected of Cushing's syndrome. One milligram (1mg) dexamethasone suppression test had the highest sensitivity (100%) but had the lowest specificity (68.4%) as a screening test. The area under the curve of the three diagnostic test appeared to be similar when compared with the low dose dexamethasone suppression test.

CONCLUSIONS: Using a cut-off value of 7nmol/L, local utility if late-night salivary cortisol has a high sensitivity and specificity in detecting Cushing's syndrome. It has a similar efficiency with 24-hour urine free cortisol and 1mg dexamethasone suppression test as a screening test for Cushing's syndrome. Salivary cortisol may be considered as a valid initial screening test for Filipinos suspected of cushing's syndrome.

Human ; Hydrocortisone ; Saliva ; Cushing Syndrome ; Urine ; Dexamethasone ; Serum

BACKGROUND: Differentiated thyroid cancer is a common endocrine malignancy with an indolent course and high overall survival rate. With more cases diagnosed early, survivors of this cancer live longer and hence are at risk of second primary cancers. In patients with known primary malignancy, work-up often focuses on the primary disease, so that coexistence of another primary malignant lesion can be missed.
CASE PRESENTATION: We report a case of a 78 year-old Filipino male diagnosed to have papillary thyroid cancer with nodal metastases presenting with an incidental rectosigmoid cancer on pre-operative workup.
TREATMENT AND OUTCOME: Patient eventually underwent complete surgical removal of both malignancies. He is currently on levothyroxine suppression therapy with no evidence of tumor recurrence for both malignancy and is on close follow-up for cancer recurrence surveillance.
CONCLUSION: Clinical vigilance for cancer screening and surveillance is mandatory for patients diagnosed with any type of primary malignancy to reduce the rate of missing secondary primary malignancy simultaneously present in the same patient , Early cancer detection might improve cancer patient's overall prognosis and eventually proved to be life-saving.

Human ; Male ; Aged ; Neoplasms ; Patients ; Prognosis ; Thyroxine

BACKGROUND: Providing sedation and analgesia for patients especially in the intensive care units remains difficult and controversial for clinicians and many institutions.
OBJECTIVE: The purpose of this study is to describe the knowledge, attitudes and practices on sedation and analgesia among medical residents and pulmonary fellows-in-training in a tertiary care hospital.
METHODS: The research design is a prospective descriptive survey of 67 participants.
RESULTS: Midazolam is the preferred sedative agent for continuous infusion. The top two reasons why sedation is used according to the knowledge of the study participants were agitation and patient comfort. Monitoring neurologic status is the primary reason why sedation is not used. Majority of the medical residents said that 50% of the mechanically ventilated patients require continuous intravenous sedation. On the other hand, pulmonary fellows-in-training said that 50-75% of mechanically ventilated patients require continuous intravenous sedation. Twenty three participants (34.32%) have used a sedation scale, of which majority uses Ramsay Sedation Scale. Morphine is the preferred analgesic agents of the study participants. Unavailability of analgesic agents is the top reason why analgesia is not used.
CONCLUSION AND RECOMMENDATION: The medical residents and pulmonary fellows-in-training showed differences in
knowledge, attitudes and practices with regard to use of sedation and analgesia. To increase their knowledge and improve their practice, they should be given medical education and training in sedation and analgesia.

Human ; Male ; Female ; Adult ; Hypnotics And Sedatives ; Midazolam ; Morphine ; Patient Comfort ; Analgesics ; Analgesia ; Pain Management ; Intensive Care Units ; Education, Medical ; Attitude

BACKGROUND: Anaplastic thyroid cancer (ATC) is a rare type of thyroid malignancy and one of the most aggressive solid tumors, responsible for between 14% and 50% of the total annual mortality associated with thyroid cancer. METHODS: A retrospective study was made of all ATC cases diagnosed by biopsy in the Philippine General Hospital between 2008 and 2013. RESULTS: A total of 15 patients were identified, with a median age at diagnosis of 63 years. All tumors were at least 6 cm in size upon diagnosis. All patients had a previous history of thyroid pathology, presenting with an average duration of 11 years. Eleven patients presented with cervical lymphadenopathies, whereas seven exhibited signs of distant metastases, for which the lungs appeared to be the most common site. More than 70% of the patients presented with a rapidly growing neck mass, leading to airway obstruction. Only three patients were treated using curative surgery; the majority received palliative and supportive forms of treatment. In addition, only three patients were offered radiotherapy. Chemotherapy was not offered to any patient. Only two patients were confirmed to still be alive during the study period. The median survival time for the other patients was 3 months; in the majority of cases the patient died within the first year following diagnosis. CONCLUSION: Our experience with ATC demonstrated concordance with other institutions with respect to current clinical profile, presentation, and prognosis. An absence of distant metastases and lymph node involvement was associated with improved survival outcomes, whereas age at diagnosis and tumor size did not affect survival. Curative surgery offers the most effective means of prolonging survival. Radiotherapy and chemotherapy in combination with surgery represents a promising treatment strategy.
Airway Obstruction ; Biopsy ; Diagnosis ; Drug Therapy ; Hospitals, General* ; Humans ; Lung ; Lymph Nodes ; Mortality ; Neck ; Neoplasm Metastasis ; Pathology ; Philippines ; Prognosis ; Radiotherapy ; Retrospective Studies ; Thyroid Gland ; Thyroid Neoplasms*

BACKGROUND: The incidence of well-differentiated thyroid cancer (WDTC) has increased in recent years. Despite its excellent prognosis, increasing morbidity from recurrent diseases continues to affect long-term outcomes. Among at-risk populations, Filipinos have the highest incidence of thyroid cancer worldwide, characterized by a highly aggressive and recurrent form of disease. Here, we sought to identify risk factors associated with disease recurrence among Filipinos with WDTC. METHODS: This retrospective cohort study examined 723 patients diagnosed with WDTC seen at Philippine General Hospital. Affected individuals were classified based on the presence or absence of disease recurrence. Multivariate logistic regression analyses were used to determine significant predictors of recurrence. RESULTS: Multiple risk factors, including age >45 years (odds ratio [OR], 1.44), multifocality of cancer (OR, 1.43), nodal involvement (OR, 4.0), and distant metastases at presentation (OR, 2.78), were significantly associated with a recurrence of papillary thyroid cancer (PTC). In contrast, follicular variant histology (OR, 0.60) and postsurgical radioactive iodine therapy (OR, 0.31) were protective for PTC recurrence. Distant metastases at presentation (OR, 19.4) and postsurgical radioactive iodine therapy (OR, 0.41) were associated with follicular thyroid cancer (FTC) recurrence. CONCLUSION: Lymph node metastases at presentation was the strongest predictor of recurrence in PTC, whereas distant metastases at presentation was the strongest for FTC recurrence. Among Filipinos, stratification of WDTC patients based on recurrence risk factors identified in this study will be helpful in guiding the intensity of treatment strategies and long-term thyroid cancer surveillance.
Cohort Studies ; Hospitals, General ; Humans ; Incidence ; Iodine ; Logistic Models ; Lymph Nodes ; Neoplasm Metastasis ; Prognosis ; Recurrence* ; Retrospective Studies ; Risk Factors* ; Thyroid Gland* ; Thyroid Neoplasms*

BACKGROUND: Well-differentiated thyroid cancer (WDTC) is the most common form of thyroid malignancy. While it is typically associated with good prognosis, it may exhibit higher recurrence and mortality rates in selected groups, particularly Filipinos. This paper aims to describe the experience of a Philippine Hospital in managing patients with differentiated thyroid cancer. METHODS: We performed a retrospective cohort study of 723 patients with WDTC (649 papillary and 79 follicular), evaluating the clinicopathologic profiles, ultrasound features, management received, tumor recurrence, and eventual outcome over a mean follow-up period of 5 years. RESULTS: The mean age at diagnosis was 44±13 years (range, 18 to 82), with a majority of cases occurring in the younger age group (<45 years). Most tumors were between 2 and 4 cm in size. The majority of papillary thyroid cancers (PTCs, 63.2%) and follicular thyroid cancers (FTCs, 54.4%) initially presented as stage 1, with a greater proportion of FTC cases (12.7% vs. 3.7%) presenting with distant metastases. Nodal metastases at presentation were more frequent among patients with PTC (29.9% vs. 7.6%). A majority of cases were treated by complete thyroidectomy, followed by radioactive iodine therapy and thyroid stimulating hormone suppression, resulting in a disease-free state. Excluding patients with distant metastases at presentation, the recurrence rates for papillary and FTC were 30.1% and 18.8%, respectively. CONCLUSION: Overall, PTC among Filipinos was associated with a more aggressive and recurrent behavior. FTC among Filipinos appeared to behave similarly with other racial groups.
Cohort Studies ; Diagnosis ; Follow-Up Studies ; Hospitals, General* ; Humans ; Iodine ; Mortality ; Neoplasm Metastasis ; Prognosis ; Recurrence ; Retrospective Studies ; Thyroid Gland* ; Thyroid Neoplasms* ; Thyroidectomy ; Thyrotropin ; Ultrasonography

OBJECTIVE: To  report  a  case  of  tumoral  calcinosis  from  secondary hyperparathyroidism  and  to describe its surgical management.
METHODS:
 Design: Case Report
 Setting: Tertiary Public University Hospital
 Patient: One
RESULTS: A 34-year-old woman presented with progressively-enlarging bilateral upper extremity masses. Diagnostic tests revealed hyperfunctioning parathyroid glands. The patient underwent subtotal  parathyroidectomy,  right  thyroid  lobectomy  with  isthmusectomy,  and  transcervical thymectomy.    Follow-up  revealed  marked  decrease  in  parathyroid  hormone,  and  progressive resolution of the tumoral calcinosis.
CONCLUSION: Subtotal  parathyroidectomy  and  transcervical  thymectomy  have  a  role  in  the management  of  tumoral  calcinosis,  and  in  this  case  led  to  excellent  post-operative  results. The rare  presentation  of  secondary  hyperparathyroidism  and  intervention  in  this  patient  may  have potential lessons for future management of similar cases.

Human ; Female ; Adult ; Calcinosis ; Parathyroidectomy ; Thymectomy

BACKGROUND: Periodontitis affects more than half of patients with diabetes. In resource poor areas in the Philippines, access to routine dental visits may be difficult and thus, a selective approach might be needed to identify those who need dental evaluation and management. An easy-to-administer oral health self-report questionnaire was developed in order to predict serious (moderate to severe) periodontitis.
OBJECTIVE: The study aims to determine the validity of the Oral Health Screening Questionnaire for Persons with Diabetes (OHSQPD) in estimating the prevalence of serious periodontitis.
METHODOLOGY: A cross-sectional criterion-referenced study of 175 participants with T2DM were included in the study. They were asked to answer the questionnaire and then made to undergo a full dental examination to identify the presence and severity of periodontitis. The validity of the questionnaire was assessed by determining the sensitivity, specificity, positive predictive value, negative predictive value and area under the receiver-operating curve (AUROC) with the dental examination as the gold standard.
RESULTS: Using the questionnaire, the prevalence of serious periodontitis was 61% (106) based on an optimal cut-off score of ?12. At this score, the questionnaire yielded a sensitivity of 80.4% and a specificity of 70.6%, with an AUROC of 0.83.
CONCLUSION: The OHSQPD is a valid tool in detecting serious periodontitis

Human ; Male ; Female ; Aged 80 And Over ; Aged ; Middle Aged ; Adult ; Questionnaires ; Diabetes Mellitus ; Periodontitis ; Oral Health ; Philippines

Background: The likelihood of periodontitis among type 2 diabetes is thrice the non-diabetic population and progresses rapidly when uncontrolled. An inexpensive and easy way of dental assessment via self-reported oral health questionnaire has great potential as a screening tool. Objective: This study aims to validate self-reported oral health measures, socio-demographic and medical variables in predicting the severity of periodontitis in Filipino adults with type 2 diabetes. Methodology: The validated self-reported oral health questionnaires created by the CDC Periodontal Disease Surveillance Project was translated into Filipino and used. A cross-sectional study of 180 participants was conducted in a single institution. Multivariable logistic regression analyses were used to determine significant predictors of serious periodontitis. Results: Male sex [OR=2.17], low educational status [OR=2.98], poor glycemic control [OR=2.58], less frequent dental visits [OR=2.77] and teeth loss >6 [OR=5.02] were considered to be predictive of serious periodontitis. Self reported oral health variables like gum disease –Q1 [OR=8.33], state of gum health –Q2 [OR=0.39], loose teeth –Q3 [OR=63.0], brushing of teeth –Q4 [OR=0.65], use of mouthwash –Q4 [OR=0.69] and poor tooth appearance –Q5 [OR=48.42] were also shown to be significantly predictive of serious periodontitis. A recommended set of questions and proposed scoring system based on the logistic regression analysis of each predictor’s strength was then formulated. Conclusion The use of specific self-reported oral health questions, certain socio-demographic and medical variables appeared to be highly predictive of serious periodontitis among Filipinos with type 2 diabetes. This provides a cost-effective and rapid method of screening patients who are in need of immediate dental evaluation.
Periodontitis ; Diabetes Mellitus, Type 2 ; Dental Care