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Successful reduction in thyroid and nodule volumes in large solitary and multinodular goiters with serial 131 iodine therapy

April Melody T. Abcede ; Sjoberg A. Kho ; Bien J. Matawaran ; Leilani B. Mercado-Asis

Philippine Journal of Internal Medicine.2017;55(4):1-5.

Introduction: 131Iodine therapy is effective in nodular nontoxic goiter with enhanced effects using recombinant thyroid stimulating hormone (rTSH). The eventual fibrosis of the thyroid tissue and blood vessels ligates the vascular supply of the nodule. The study aims to show the successful reduction of thyroid and nodule volumes in large solitary and multinodular goiters using serial low dose 131iodine therapy (10mCi) at three to six months interval. Methods: A retrospective analytical study was done from January 2010 to December 2012 and included twenty three patients with enlarged solitary and multinodular (nodule/s ≥2cm) non-toxic goiter (females: age range 35-65yrs) given serial 131iodine therapy (eight to10mCi) at three to six-month interval. Before each course, serum thyroid stimulating hormone (TSH) was done to document hypothyroidism while thyroid gland and nodule sizes were monitored by ultrasonographic measurements serially with each 131iodine therapy. Relief of compressive symptoms was monitored on follow-up at clinic. Results: Thyroid size reduced by 38-40% from baseline after first radioactive iodine (RAI) and by 33-39% after the second RAI. Thyroid nodules reduced by 63-69% and 11-25% serially. Significant reduction was noted after the first RAI. One subject underwent third RAI with 80-85% overall reduction in nodule size. All patients developed post-RAI hypothyroidism and overall had greater than 50% increase in levothyroxine replacement dose after the last RAI. Significant relief of compressive symptoms was noted by 91% post-therapy. Four thyroid nodules disappeared which resulted in reduced total number of thyroid nodules from 29 to 25 nodules post serial RAI. Conclusion Serial 131iodine therapy proved to have thyroid and nodule size reduction by more than 70% in this study. Among patients who do not consent or have contraindications to surgery, serial 131iodine therapy may be considered a safe and effective non-surgical alternative.
Goiter

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Development and validation of the Filipino Version of the Coronary Artery Disease Education Questionnaire Version 2 (FILIPINO CADE-Q II)

Lucky R. Cuenza ; Bernard Benjamin Albano ; Joseph Michael Ramirez ; Raphael Magbag ; Benjamin Jose Quito ; Edgardo Ebba ; Leandro Bongosia

Philippine Journal of Internal Medicine.2017;55(4):1-11.

Introduction: There is currently a lack of validated tools that measure knowledge level as an outcome of the educational component of cardiac rehabilitation programs in our local setting. The researchers aim to culturally adapt and validate a questionnaire that was designed to assess patients’ knowledge about coronary artery disease and participation in cardiac rehabilitation programs, the second version of the Coronary Artery Disease Education Questionnaire (CADE-Q II). Methods: Qualified translators did two independent translations of the questionnaire. After back translation, the questions were reviewed and modified by a committee of experts. The final Filipino version was tested in a pilot study. For psychometric validation the tool was administered to 109 patients enrolled in a cardiac rehabilitation program. Criterion validity was assessed with regards to differences in educational attainment and patient characteristics. Spearman rank was used to correlate patient’s level of knowledge with number of sessions attended. Internal consistency was assessed by use of cronbach’s alpha. Results: The final version of the questionnaire had 30 questions arranged in five domains consisting of medical condition, risk factors, exercise, nutrition, and psychosocial risk. Patients who were college graduates had significantly higher mean scores than non college graduates. The number of cardiac rehab sessions attended had a weak but statistically significant correlation with knowledge. (spearman rho 0.35, p=0.007). The overall internal consistency of the questionnaire was good (α=0.75) Conclusion The CADE-Q II questionnaire cross culturally adapted in Filipino is a valid and reliable tool which can be used to assess Filipino patients’ knowledge about their disease when participating in cardiac rehabilitation programs.
Coronary Artery Disease ; Patient Education as Topic

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Diagnosis of gestational diabetes mellitus using the international association of the diabetes and pregnancy study groups criteria and adverse pregnancy outcomes among a cohort of Filipino women: An association analysis

Kristine S. de Luna ; Elaine C. Cunanan

Philippine Journal of Internal Medicine.2017;55(4):1-8.

Introduction: Locally, there is no unified set of diagnostic criteria for gestational diabetes mellitus (GDM) and this can lead to potential confusion on the part of the physician and the patient as well. Moreover, whether the adoption of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) threshold values for GDM diagnosis among Filipino women is appropriate is still unclear. This study serves to give a clinically important insight whether utilizing the abovementioned diagnostic criteria is appropriate in the local setting or not. The study aims to determine the association of the threshold values set up by the IADPSG to diagnose GDM with adverse pregnancy outcomes among a cohort of Filipino women. Methods: A retrospective analysis of medical files of the women diagnosed with GDM using the IADPSG criteria from January 2013 to March 2016 was done. The results of seventyfive gram oral glucose tolerance test (75-g OGTT) were recorded. The association between each IADPSG threshold values (fasting blood glucose of ≥92 mg/dL, one-hour post glucose load of ≥180 mg/dL, two-hour post glucose load of ≥153 mg/dL) used to define GDM and maternal and perinatal outcomes were determined. Results: One hundred twenty women with GDM were included in the analysis. Each of IADPSG-defined cut-off values was not significantly associated with increased likelihood of having adverse maternal outcomes namely: hypertensive disorders of pregnancy, miscarriage, primary cesarean section, operative vaginal delivery, and maternal death. Similarly, the likelihood of perinatal outcomes namely: macrosomia, perinatal death, prematurity, birth injuries, congenital anomalies, neonatal hypoglycemia, jaundice, low APGAR score, acute respiratory distress syndrome, and infection were not significantly higher even if these cut-off values were met. Of note, high odds ratio was noted for neonatal hypoglycemia at FBS >92 mg/dL and <92 mg/dL and the low Apgar Score in first minute at >153 mg/dL and <153 mg/dL even though they were statistically not significant. Conclusion We did not find a statistically significant positive association between IADPSG threshold values and specified adverse maternal and perinatal outcomes.
Diabetes, Gestational

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Relationship of average daily glycemic index and glycemic load with body mass Index among Filipinos in the rural setting

Hderbert A. Arellano ; Mark Anthony S. Sandoval ; Elizabeth Paz-Pacheco ; Jundelle Romulo Jalique

Philippine Journal of Internal Medicine.2017;55(4):1-7.

Introduction: While the relationship between obesity and caloric intake is widely accepted, the role of glycemic index (GI) and glycemic load (GL) to body mass index (BMI) remains equivocal. This study seeks to determine the daily glycemic index (GI) and glycemic load (GL) of usual diet of rural-dwelling Filipinos, and their relationship with body mass index (BMI). Methods: This is a cross-sectional study reviewing the data of 139 adults from San Juan, Batangas. Average daily GI and GL were calculated from two-day food recall questionnaires. Spearman’s rank test was used to determine correlation of daily GI and GL with BMI; the mean BMI was compared among GI and GL tertiles using one-way ANOVA. Partial least squares regression was used to determine the contribution of food items to daily GI and GL. Results: No overall correlation was observed between daily GI or GL and BMI using Spearman’s rank. However, BMI was higher with increasing GI tertiles (p<0.0001) and GL tertiles (p=0.0108) among the males, but not females. Bread, coffeemix and sweets were major contributors to daily GI, while rice, bread/pastries and sweetened beverages were to daily GL. Leafy vegetables negatively contributed to both. Conclusion There is a positive relationship observed between daily GI and BMI, and daily GL and BMI among the men, but not women, in this population. Staple food with high GI like bread/pastries and sweetened beverages contributed most to both daily GI and GL, with the addition of rice for daily GL. Among Filipinos with marginal daily caloric intake, optimizing carbohydrate quality (low GI or GL) rather than limiting its quantity may be more appropriate. Future studies of prospective design and using objective methods of food intake reporting are recommended.
Glycemic Index ; Glycemic Load

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Disease characteristics of Behcet’s Disease among Filipino patients seen in Rheumatology Clinics

Juneth Ria R. Limgenco-Hipe ; Evelyn O. Salido ; Ester G. Penserga

Philippine Journal of Internal Medicine.2017;55(4):1-5.

Introduction: Behcet's disease (BD) sometimes called behcet's syndrome or silk road disease is an immunemediated systemic vasculitis. This condition remains a clinical challenge for physicians. There are many reports, mostly case series and nationwide surveys, on clinical manifestations of BD from different parts of the world. In the Philippines where BD is rare and underreported, physicians might not be familiar with the clinical manifestations of this disease. The aim of this research is to describe the disease presentation of BD among Filipinos to increase awareness and avoid delay in diagnosis which might pose a threat for the development of irreversible, sometimes fatal complications. Methods: A manual search was done for medical records with diagnosis of BD in the clinics of rheumatology staff of PGH. The diagnosis of BD was based on the 2006 International Criteria for BD. We noted the demographic data, clinical manifestations, results of ancillary procedures, treatment and outcomes. The study follows a descriptive design. Results: There were 31 patients with the diagnosis of BD found from the manual search. Most of them were female (77%). The mean age at diagnosis was 38.6 years ± 10.4 (SD) and the mean time duration from onset of first symptom to diagnosis was 41 months (range three to 180 months). Three patients had a family member who also had BD (10%). The most common features of the disease were oral ulcers (94%), ocular manifestation (68%), and cutaneous disease (65%). The pathergy test was positive in 17%.The most common treatments prescribed were oral steroids (74%), colchicine (58%), and NSAIDs (48%). There was symptom control or improvement in a third of patients but there were still symptom recurrence in some. Thirteen patients (42%) had recurrent oral ulcerations while 23% had recurrence of skin lesions. Two of the patients (six percent) developed blindness. There was no death recorded. Conclusion There is an average delay of three years in the diagnosis of BD that hinders appropriate early treatment. Moreover, BD remains to be a clinical challenge for physicians. While a third of the cohort had good outcomes, half still had symptom recurrences and the occurrence of blindness in two patients underlines the potential of the disease to disable. We recommend expansion of the cohort to include the BD patients of other rheumatologists in the Philippines to have an idea on the actual prevalence and incidence of how this uncommon disease in our locality, and to have a better understanding of its clinical presentation and disease management in our country.
Behcet Syndrome ; Rheumatology

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The effect of a single-session diabetes education on the knowledge, and attitudes of patients with type 2 Diabetes Mellitus seen at out-patient clinics in Chinese General Hospital: A prospective cohort study

Michelle U. Cornel ; Lora May T. Tin Hay

Philippine Journal of Internal Medicine.2017;55(4):1-17.

Introduction: With the increasing prevalence of diabetes mellitus (DM) in the Philippines, Diabetes Self-Management Education (DSME) remains to play a vital role in diabetes care. It is important in optimizing metabolic control, preventing and managing complications, and maximizing quality of life in a cost-effective manner. This study aimed to determine the effect of diabetes education on the knowledge and attitudes of type 2 DM patients. It also aimed to determine the topics that needed more emphasis during education. Methods: A prospective study, which included 75 patients: 38 patients in the education group and 37 patients in the noneducation group, was conducted. A single session diabetes education was given to the patients in the education group. Baseline and follow-up knowledge and attitude scores by using the modified, validated, Filipino versions of American Association of Clinical Endocrinologists (AACE) Knowledge Evaluation Form and Diabetes Attitude Scale–3 (DAS–3), respectively, were compared between the education and non-education groups. The changes in weight and body mass index (BMI) for both groups were also compared. Results: Results showed that on follow-up, there was a significant increase in the mean percentage scores for knowledge in the education group. There was no significant increase in mean frequency of correct answers for questions on precautions prior to exercise, monitoring, nutrition and medication adjustment during ill days. Questions on psychosocial impact, and value of tight glucose control showed significant improvement in the education group, while one question on seriousness of diabetes did not improve significantly. Conclusion Diabetes education generally improved the knowledge and attitudes of patients towards their disease.
Knowledge ; Attitude ; Diabetes Mellitus, Type 2

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The correlation of Body Mass Index with fasting C-peptide Levels of newly diagnosed Type 2 Diabetes Mellitus Filipino patients

Patrick Y. Siy ; Oliver Allan C. Dampil ; Joselynna A. Quimpo

Philippine Journal of Internal Medicine.2017;55(4):1-5.

Introduction: Type 2 diabetes mellitus (DM) is one of the leading non-communicable causes of death in the Philippines with a prevalence of 5.4% and its pathogenesis includes insulin resistance correlated with excess weight and BMI. Asian-based studies have shown that serum C-peptide is strongly associated with newly diagnosed diabetes and has a linear increasing trend with BMI, hence, this study aimed to determine the correlation of body mass index (BMI) with fasting C-peptide levels in Filipino patients with newly diagnosed type 2 DM. Also, to determine the correlation of fasting C-peptide, markers of insulin secretion and sensitivity (Homeostasis Model Assessment of beta cell function and insulin resistance: HOMA-IR, HOMA-B) with other metabolic parameters in newly diagnosed diabetics: waist circumference, HbA1C, fasting blood sugar (FBS), lipid profile. Methods: This cross-sectional study included 35 treatment naïve, newly diagnosed type 2 DM Filipino patients evaluated with anthropometric measurements, fasting C-peptide, and other metabolic parameters. The correlations among fasting C-peptide, BMI, waist circumference, FBS, HbA1c, lipid profile, HOMA-IR, and HOMA-B were determined using Pearson correlation. Results: A significant positive relationship were observed between BMI and HOMA-IR(r=0.335); C-peptide and waist circumference (r=0.363); C-peptide and HOMA-B(r=0.357); HOMA-IR and C-peptide (r=0.892); HOMA-IR and waist circumference (r=0.438); HOMA-IR and triglycerides (r=0.543). HOMA-B was negatively correlated with FBS and HbA1C (r=- 0.771, and r=-0.641, respectively). No correlation was seen between BMI and C-peptide (p=0.61). Conclusion Body mass index (BMI) is not correlated with fasting C-peptide levels in newly diagnosed type 2 DM Filipino patients. The positive relationship between C-peptide, waist circumference, and HOMA-IR merits further evaluation with larger studies.
C-Peptide ; Diabetes Mellitus, Type 2 ; Body Mass Index ; Insulin Resistance

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The incidence of in-hospital hypoglycemia and its associated risk factors among adult Filipino patients with Diabetes Mellitus in Chong Hua Hospital

Ma. Vircel Duyongco-Tiu ; Imelda Lagula-Bilocura

Philippine Journal of Internal Medicine.2017;55(4):1-8.

Introduction: Hypoglycemia is a burdensome complication in the management of diabetes mellitus (DM), and has been noted to be increasing. This study evaluated the occurrence of hypoglycemia and identified its risk factors among diabetic Filipino patients. Methods: Census of Filipino non-pregnant adults with type 2 DM of Chong Hua Hospital, admitted and discharged from January 2015 to June 2015 was taken. This study determined the incidence rate of hypoglycemia (capillary blood glucose <70 mg/dL), its severity, patients’ dietary status, medication, and the common hospital areas where hypoglycemia occurred. The clinical profiles of these patients were analyzed and associated risk factors of hypoglycemia were identified. Also, the incidence of congestive heart failure, myocardial infarction, cerebrovascular disease, and allcause mortality among patients with hypoglycemia were determined. Results: Among 1,676 subjects, 8.9% had hypoglycemia predominantly non-severe type (blood glucose 51-69 mg/dL). The identified risk factors for the development of hypoglycemia were the following, age >65 years old (52.7% vs 36.2%, p<0.001), diabetes duration of 8.56 years (± 10.34 years), the presence of cardiovascular disease (62.7% vs 48.6%, p<0.001), congestive heart failure (8.7% vs 4.4%, p=0.009) and stage III, IV, V kidney disease (32.7% vs 25.1%, p=0.043, 12% vs 5.5%, p=0.002, 12% vs 4.1%, p<0.001, respectively), and the use of insulin whether combined with oral therapy (25.3% vs 16.5%, p<0.006) or used alone (34.7% vs 12.1%, p<0.001). Hypoglycemia occurred more frequently in the non-ICU ward (82.7%). Only one patient developed non-fatal myocardial infarction, one had nonfatal cerebrovascular disease and one had congestive heart failure. All-cause mortality rate was 4.7% Conclusion The notable incidence of in-hospital hypoglycemia of 8.9% among diabetic patients should be addressed to decrease the associated morbidity and mortality.
Hypoglycemia ; Diabetes Mellitus

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Accuracy of blood glucose measurements using capillary and arterial line of extracorporeal circuit of hemodialysis among diabetic patients undergoing outpatient hemodialysis at The Medical City

Genevieve F. Sia ; Christy S. Yao

Philippine Journal of Internal Medicine.2017;55(4):1-5.

Introduction: Accurate and reliable glucose level measurements are essential for ensuring safe and effective glycemic control among diabetic patients undergoing hemodialysis (HD). Capillary blood glucose (CBG) monitoring is the standard of care of glycemic control assessment in patients with diabetes on maintenance HD. In the Philippines, glucose monitoring during HD involves either standard finger stick (CBG) or blood sample from the arterial line (AL) of extracorporeal circuit of HD machine. However, anecdotal observations noted over the years have shown discrepancies in the glucose values from the two sites. This study aimed to determine the accuracy of blood glucose measurements of capillary and AL of extracorporeal circuit of HD machine using point-of-care (POC) glucose meter in comparison to central laboratory venous plasma among diabetic patients undergoing outpatient HD in a private tertiary hospital in the Philippines. Determining the most accurate and reliable method of glucose level measurement is vital in helping patients attain glycemic control. To date, there is limited published data regarding the accuracy of blood glucose values obtained through CBG and AL of extracorporeal circuit of HD machine while patients are undergoing dialysis. Methods: This is a prospective, cross-sectional, analytical study involving thirty patients. Forty blood samples from 30 patients obtained through CBG, AL and the peripheral venous plasma of the opposite arm were simultaneously analyzed. Specifically, StatStrip was utilized as the POC glucose meter. Accuracy of AL of extracorporeal circuit and CBG were determined and assessed in accordance with International Organization for Standardization (ISO) 15197:2013 minimum accuracy criteria for glucose meters. Regression analysis was used to determine whether AL and CBG significantly predict peripheral venous blood glucose levels. Results: Analysis showed that there is a statistically significant difference in the glucose values obtained from AL and CBG (p-values 0.005 and <0.0001) when compared to venous plasma glucose. However, this may not pose clinical significance in routine practice. It is noteworthy that both AL (concordance rate (CR)=100%) and CBG (CR=96.5%) satisfied the revised ISO 15197:2013 accuracy criteria for glucose value greater than or equal to 100mg/dL. Conclusion Both CBG and AL blood glucose measurement significantly predict venous plasma blood glucose level. POC blood glucose value from both AL of extracorporeal circuit during HD and CBG satisfied the accuracy criteria set by ISO 15197: 2013 for glucose value greater than or equal to 100mg/dL. Thus, confirming the glucose level by CBG monitoring is not necessary in patients with arterial glucose value of greater than or equal to 100 mg/dL during HD.
Vascular Access Devices ; Renal Dialysis

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Hemodialysis patients’ compliance and adherence behaviors to renal replacement therapy in two dialysis centers in Iloilo City

Renato C. Ong Jr. ; Agnes Jean M. Villaflor ; Patricio P. Palmes

Philippine Journal of Internal Medicine.2017;55(4):1-9.

Introduction: Approximately 120 per million population develop kidney failure, translating to about 10,000 Filipinos needing to replace their kidney function per year. If without the appropriate intervention, those having kidney failure will surely die. The study aims to evaluate the compliance of hemodialysis (HD) patients to renal replacement therapy (RRT) in two dialysis centers in Iloilo City, and to compare the prevalence of non-adherence in between groups. Methods: A cross-sectional study where subjects answered the End-Stage Renal Disease–Adherence Questionnaire (ESRD-AQ). Results: Of the 102 patients, 59.8% (n=61) were enrolled. The mean age was 47 years with average HD vintage of 30 months. More females were non-adherent to HD treatment, 17.1% vs.15.4%; whereas more males were non-adherent to the remainder descriptors (medications, 11.5% vs. 8.6%; fluid restriction, 23.1% vs. 17.1%; and diet recommendations 30.8% vs. 25.7%). There were less non-adherent patients than adherent ones (HD attendance, 9,803.92 vs. 50,000; medications, 5,882.35 vs. 53,921.57; fluid restriction, 11,764.71 vs. 48,039.22; and diet, 16,666.67 vs. 43,137.25 per 100,000). There were significant differences in their behaviors toward HD attendance (p=0.000); shortening of HD treatment (p=0.000); duration of shortening HD (p=0.000); adherence to medications (p=0.000); to fluid (p=0.000); and to diet (p=0.000). Both groups demonstrated the same level of perception and understanding towards the importance of HD (p=0.306 and 0.096, respectively). There was no significant difference in their perception to medications (p=0.427); however, figures illustrate a significant difference in their levels of understanding towards its importance (p=0.001). Adherent subjects have better perception and understanding in fluid restriction regimen and dietary recommendations as data show significant differences in between groups (p=0.000 and 0.000; and p=0.001 and 0.004, respectively). Conclusion The compliance of adherent subjects to HD treatment, medications, fluid restriction protocol and dietary recommendations was more adequate. The non-adherent subjects were less prevalent than adherent subjects.
Renal Replacement Therapy

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