Urethral strictures in females are very uncommon. In selected populations of women who underwent urodynamic studies for obstructive symptoms, female urethral strictures represent 4-13% of the causes of bladder outlet obstruction. Literature is limited regarding surgical treatment for near-obliterative urethral strictures in female patients. In this paper, the authors aimed to report a novel technique of double-faced inlay buccal mucosal graft (BMG) urethroplasty, first described by Joshi in 2020. This is a case of a 35-year-old female with progressively worsening lower urinary tract symptoms, several months after undergoing cesarean section despite multiple internal urethrotomies. Grafts were placed both the anterior and posterior urethral walls with noted good urine flow with mild lower urinary tract symptoms on follow-up after 6 months. The combined dorsal and ventral inlay BMG urethroplasty is a feasible technique with good results for female patients with urethral strictures. To the authors’ knowledge, this is the first-ever reported case, for this novel technique, in the Philippines.

BACKGROUND: Patients with acute ischemic stroke are susceptible  to  cardiac  arrhythmias  however,fatal arrhythmias  are  rare  in  the  absence  of  cardiac  disease.Cardiac arrhythmias can develop in lesions at the right side of the brain specifically the insular,frontal and parietal area.Data that show the direct relationship of ischemic stroke and arrhythmia are scarce but they are indirectly attributed to an imbalance in the autonomic nervous system.This paper aims to present a rare case of an association between a fatal arrhythmia and right thalamic infarct.  
CASE: Presenting a case of a 39-year-old admitted as a survivor of sudden cardiac death from ventricular fibrillation.She presented with a history of left sided weakness a week prior but no work-up was done. Baseline serum electrolytes and  cardiac markers were all normal.Electrocardiogram (ECG) post-cardioversion showed sinus tachycardia.Echocardiogram   and cardiac computed tomography (CT) angiography were normal.  Magnetic resonance imaging (MRI) and angiography (MRA) of the brain showed an acute infarct at the right thalamus and an absent left internal carotid artery (ICA).Electroencephalogram (EEG) was negative.Bisoprolol was given and an Automatic Implantable Cardioverter Defibrillator (AICD) was subsequently placed.No recurrence of cardiac arrhythmia was noted on continuous cardiac telemetry monitoring during her hospitalization and on six months of follow-up.
CONCLUSION: Fatal cardiac arrhythmias, can occur in patients with  acute  thalamic  infarct  even  beyond  24  hours  in  the presence of other confounding factors despite the absence of cardiac pathology. This case showed the association of heightened  autonomic  imbalance  caused  by  an  acute stroke, decreased cerebral flow, and fatal arrhythmia. This elucidates the importance of cardiac monitoring in acute ischemic stroke. With the paucity of information on serious cardiac arrhythmia and ischemic stroke, a future study on this correlation will be useful.

Human ; Female ; Adult ; Bisoprolol ; Tachycardia, Sinus ; Ventricular Fibrillation ; Carotid Artery, Internal ; Defibrillators, Implantable ; Electric Countershock ; Arrhythmias, Cardiac ; Electrocardiography ; Death, Sudden, Cardiac ; Heart Conduction System ; Stroke ; Thalamus ; Brain ; Autonomic Nervous System ; Telemetry ; Angiography ; Hospitalization ; Survivors ; Electrolytes

INTRODUCTION: Advance directives are documents by which a person makes provisions for health care decisions in the event that, in the future, that person becomes unable to make those decisions. There is a lack of studies on the knowledge and understanding towards advance directives among patients and their families. The purpose of this study is to address this lack of research regarding advance directives by measuring the level of knowledge and attitudes of families of hospitalized patients. METHODS: A descriptive, cross-sectional study design was used to describe the attitudes and the level of knowledge on advance directives of the families of patients. Data were collected directly by the researchers via assisted questionnaires. Descriptive statistics and frequencies were reported. RESULTS: A total of 79 participants consisting of immediate family members of patients from UERMMMCI were enrolled. Only 24% reported having discussed advance directives with the patient's physician. Those respondents whose families had no discussion with their physician about advance directives had the same score as those who had. Overall, 61% of participants have only medium to low knowledge of advance directives, while 70% have positive attitudes regarding advance directives. CONCLUSION The study showed that the family members of patients had a reasonable understanding of advance directives in terms of basic knowledge, and positive attitudes on advance directives. Those who denied having discussed advance directives were comparable in the knowledge of advance directives with those who did.

Background: Flavonoids from Emblica officinalis effectively reduced serum and tissue lipid levels through their inhibitory effect on the hepatic β-hydroxy-β-methylglutaryl coenzyme A reductase activity. This study aimed to determine the efficacy and safety of E. officinalis extract in adults with dyslipidemia. Methods: We searched the following electronic databases: MEDLINE (PubMed), MEDLINE (Ovid), Google Scholar, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science, and ClinicalTrials.gov from inception until January 31, 2022. Two reviewers independently screened the abstracts, reviewed full-text papers, and critically appraised the quality of included studies. Meta-analysis was performed using the random-effects model. Our primary outcomes were total cholesterol, LDL-C, serum triglycerides, and HDL-C levels, while secondary outcomes included adverse events. Results: A total of four randomized trials (N = 227) were included in the final analysis. There were statistically significant decreases in total cholesterol levels (SMD = -21.23 mg/dL, 95% CI: -34.22, -8.25; P = 0.001) and LDL-C levels (SMD = -25.12 mg/dL, 95% CI: -40.24, -10.00; P = 0.001) and significant increase in HDL-C levels (SMD = 4.74 mg/dL, 95% CI: 0.40, 9.07; P = 0.03) after 12 weeks of intervention favoring the use of the Emblica extract over placebo. However, there were no statistically significant difference in the serum triglycerides levels following 12 weeks of treatment (SMD = -22.28 mg/dL, 95% CI: -53.33, 8.76; P = 0.16). There was high heterogeneity noted across all outcomes: total cholesterol (P = 0.01, I2 = 72%), LDL-C (P = 0.0004, I2 = 83%), HDL-C (P < 0.00001, I2 = 91%) and serum triglycerides (P < 0.00001, I2 = 93 %). The intervention was well tolerated and adverse events reported in the three of four studies were all mild: dyspepsia (7 events – treatment), mild diarrhea (3 events – placebo), fever (1 event – placebo), headache (1 event – placebo). Conclusion Compared to placebo, Emblica officinalis fruit extract resulted in lower total cholesterol and LDL-C levels and increased HDL-C levels but with no effect on serum triglyceride levels based on low certainty of evidence. Trials with a larger sample size that directly compare E. officinalis extract to statins, preferably local data, are needed to support its use in patients with dyslipidemia further.
dyslipidemia ; Emblica officinalis ; Phyllanthus emblica ; meta-analysis

Metastatic calcinosis cutis of the penis and scrotum seen in a patient with End Stage Renal Disease (ESRD) on hemodialysis is a case not usually encounter in urology clinics. Review of the available literature mostly showed compromised erectile function of patients with metastatic calcinosis cutis of the penis. Presented is a case of a patient with ESRD on hemodialysis for five years who developed metastatic calcinosis of the penis and scrotum causing dysmorphic changes, however maintaining full erectile function. Preserving the erectile function after successful excision of the penile and scrotal calcification is imperative to maintain good quality of life.
Erectile Dysfunction ; Hyperparathyroidism, Secondary

Objectives: The objectives of this study were to present maternal and perinatal health indicators for the years 2019–2022. Methodology: This is a cross-sectional review that analyzed data on maternal and perinatal health indicators, generated from submissions of POGS-accredited hospitals (training and service) from January 2019 to December 2022. The data were compared to the national data obtained from official public documents published by the Philippine Statistics Authority in 2022 and 2023. Results: The number of member hospitals has steadily increased over the years, and compliance rates have been consistently over 85%. The total number of registered cases and live births declined in 2020 and 2021, but has increased to prepandemic levels in 2022. The primary cesarean section (CS) rates remained above 20%, with the highest rate noted in 2021 (25.5%). The top three-most common indications for primary CS were dysfunctional labor, fetal distress, and malpresentation. Stillbirth, perinatal, and maternal mortality rates showed an increase from 2019 to 2022, with peak rates registered for the year 2021. The top five causes of maternal death are: medical complications, hemorrhage, hypertension, infection, and others (unspecified). The case fatality rate among pregnant patients with confirmed COVID-19 infection was 1.18%. Conclusion From 2019 to 2021, there was a decline in the number of registered cases and live births, and an increase in the primary CS rates, maternal mortality ratio, perinatal death rates, and stillbirth rates. This may be explained by the prevailing social, health, and economic impact of the COVID-19 pandemic during these years.
Censuses ; COVID‑19

Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.
papillary thyroid cancer

Sheehan’s syndrome is characterized by hypopituitarism following ischemic necrosis of the pituitary gland caused by postpartum hemorrhage and impaired blood supply to the enlarged pituitary gland during pregnancy. The worldwide prevalence has since decreased due to improvements in obstetric care. Behavioral change is a rare presentation and is often misdiagnosed and managed as psychosis. We report a 42-year-old woman presenting with behavioral changes associated with postpartum failure of lactation and amenorrhea. Hormonal work-up revealed panhypopituitarism; serum cortisol, 98.93 (NV: 138–690 nmol/L); free T4, less than 5.15 (NV: 11.5–23.00 pmol/L); free T3, less than 2.30 (NV: 2.89–4.88 pmol/L); FSH, 3.63 (NV: 30–135 mIU/mL); LH, 3.88 (NV: 13–80 mIU/mL); serum estradiol, 3.89 (NV: 10.41–35.0 pg/mL); IGF-1, 13.13 (NV: 56–194 ng/mL); and serum prolactin, 1.8 (NV: 2.6–24.8 ng/mL). Cranial MRI with contrast revealed an atrophic pituitary gland consistent with Sheehan's syndrome. The symptoms improved substantially upon replacement with steroids and thyroid hormones and she was able to resume her routine activities. The psychiatric features of hypopituitarism can be attributed to a combination of hypothyroidism, hypoglycemia, and hypocortisolism and have been shown to reverse with adequate hormone replacement.
Hypopituitarism ; Psychotic Disorders ; Hypopituitarism

Rationale: Coronary artery disease (CAD) is the leading cause of death worldwide and coronary angiography (CA) remains the gold standard for its diagnosis. However, proper patient selection for CA is important to avoid unnecessary risks and expense. The American College of Cardiology (ACC), with other major organizations, developed Appropriate Use Criteria (AUC) for CA. AUC assist clinicians in decision making on whether to use the tests according to indications and objectively assess if these tests are appropriately utilized. This is the first study to determine the appropriateness of CA performed and the clinical and angiographic profile among adult service patients in UP-PGH. Objectives: To determine (1) the indications for CA and its appropriateness based on 2012 AUC for Diagnostic Catheterization by the ACC, (2) the clinical profile of patients who underwent CA among adult service patients at UP-PGH and (3) the angiographic profile of these patients. Methods: This cross-sectional study included all CA studies performed on adult service patients from January to December 2019. Demographic and clinical profiles, non-invasive tests, and angiographic findings were collected. The primary outcome determined was the appropriateness of the indications for each CA performed based on AUC scores. Descriptive analysis using frequencies and mean values with standard deviations were used. Results: Among the 515 patients included, majority were males, above 50 years of age, with normal eGFR, presented initially with chest pain, and with a presenting diagnosis of chronic coronary syndrome. Majority of these patients had obstructive CAD (75%), with left anterior descending artery as the most frequently involved vessel. Non-obstructive CAD was found in 11% while normal coronaries were noted in 14% of these patients. Our findings showed that 99.8% of the CA performed were appropriate, of which majority (54%) had an AUC score of A9. STEMI or a suspicion of STEMI, with an A9 score, was the most frequently encountered indication at 33% of the time. Conclusion Majority (99%) of the CA studies performed in the PGH cardiac catheterization laboratory for the year 2019 were executed based on highly appropriate indications (AUC scores A7 to A9) and followed Class I and II recommendations from guidelines. The allocation of resources is deemed to be well-utilized based on the data generated from this study.
Coronary Angiography ; Cardiac Catheterization

Background and Objectives: The immediate post-discharge period of COVID-19 patients is a vulnerable state due to several complications that may arise during this time. Some patients get readmitted shortly after being discharged while others report persistence of symptoms, develop specialized needs, or observe a decline from their baseline functional capacity. Information on the outcomes of post-COVID discharge patients in our institution is currently lacking. This study described the outcomes of patients with COVID-19 after their discharge from the service areas of Philippine General Hospital. Methods: This study is a retrospective chart review involving charts of all adult patients discharged from the PGH COVID service areas last August 2021 to October 2021. Data from their follow up consults at 1 week, 1 month, and 3 months post-discharge were reviewed. Baseline characteristics and post-discharge outcomes including post-COVID symptoms, special care needs, mortality, rehospitalization, emergency consult, level of dependence, and ability to return to work were assessed. Results: A total of 171 patient charts were included. The mean age of patients was 53.7 years. Most were male (60.2%), unemployed (59.7%), non-smoker (55%), hypertensive (57.9%), diabetic (50.2%), and obese (50.2%). Most of them were oxygen requiring (80%) and with severe to critical COVID infection (72.5%) during admission. At 3 months post-discharge, 113 (66%) were stable and able to complete the follow up, 8 (4.6%) died, 9 (5.2%) got readmitted, and 41 (23.9%) were lost to follow up. Among those who were able to follow up after 3 months, 84 (74%) were asymptomatic. Among those who remained symptomatic, the most common symptoms were dyspnea, fatigue, and cough. After 3 months, 100 (88%) did not require special care needs, 100 (88%) were fully independent, and 45 (39.8%) were able to return to baseline work. Conclusions Despite the majority of patients having severe to critical COVID infection during admission, most were asymptomatic within 3 months post-discharge. In those who developed persistent symptoms, dyspnea, cough, and fatigue were the most common symptoms identified regardless of COVID severity. Majority did not require special care needs.
COVID-19