BACKGROUND

Diabetes mellitus (DM) is a significant and growing global health concern. Worldwide, 537 million adults have diabetes and 206 million of them are from the Western Pacific Region1. Local prevalence continues to remain high at 7.5%, with 4,303,899 adult Filipinos suffering from diabetes in 2021. DM significantly contributes to the growing burden of chronic kidney disease (CKD) worldwide with about 50% of end-stage renal disease (ESRD) being due to diabetic nephropathy alone. Likewise, 60% of Filipinos on maintenance dialysis have ESRD due to DM and hypertension. The primary care setting is the initial point of contact between healthcare providers and patients with type 2 diabetes, hence, the development of clinical practice guidelines that will provide guidance in caring for patients with stable complications of diabetes. The guideline is the first of 3 that are being developed by the Philippine Academy of Family Physicians for the diagnosis and management of adult patients with type 2 diabetes and stable microvascular complications – nephropathy, retinopathy and neuropathy.

This guideline aims to provide evidence-based recommendations on the diagnosis and management of adults with type 2 diabetes mellitus (T2DM) and early stage CKD and is divided into 5 main sections – Clinical Assessment, Diagnostic Tests, Pharmacologic Treatment, Non-pharmacologic Treatment and Patient Outcomes.

The method of guideline development followed the ADAPTE process. The Technical Working Group identified 19 key questions after consultation with colleagues and patients. Recommendations were adopted from high-quality clinical practice guidelines whenever applicable for most of the key clinical questions. On the other hand, the De Novo method of evidence review was used to answer key clinical questions for which recommendations from reviewed guidelines were not available. A modified GRADEPro was used in assessing the quality of evidence – high, moderate, low or very low. Following external review by a nephrologist, the draft recommendations were sent to the members of the consensus panel. Voting on whether to include or not by the consensus panel was facilitated to determine the strength of each recommendation – strong, moderate or weak.

After reviewing 3 high-quality clinical practice guidelines and the current evidence, the technical working group was able to develop 40 recommendations for the 19 key clinical questions.

BACKGROUND

This first clinical practice guideline (CPG) on osteoporosis prevention and management in the Philippines is the output of a shared undertaking by a multidisciplinary CPG development team spearheaded by the Osteoporosis Society of the Philippines Foundation, Inc. and joined by the Philippine Academy of Family Physicians; the Philippine College of Endocrinology, Diabetes, and Metabolism; the Philippine Orthopedic Association; the Philippine Obstetrics and Gynecological Society and the Philippine Rheumatology Association. This guideline seeks to augment and update the "Consensus statements on osteoporosis diagnosis, prevention and management in the Philippines," initially published in 2011, incorporating evidence-based practices developed in the last decade.

The steering committee formulated and prioritized clinical questions based on meetings and stakeholder consultations. A PICO (population, intervention, comparator, outcome) format was used to develop clinical questions and guide the systematic search for evidence. The development of guidelines followed the ADAPTE process. Once completed, panel discussions were done using the Evidence to Decision Framework. After the panel discussions, the final recommendations were revised.

Thirty-four recommendations were formulated to address 27 clinical questions related to screening, prevention, diagnosis, pharmacologic and nonpharmacologic treatment, surgical management, follow-up, and continuity of care. With these recommendations, the developers aim to establish a standard of care in the prevention, diagnosis and management of osteoporosis and fragility fractures in both in-patient and out-patient cases that are appropriate to the Philippine context. Specifically, the CPG development group aims to use these recommendations to define the standard of care for osteoporosis as part of universal healthcare services once the program is implemented nationally. Relevant stakeholders may also use the recommendations to inform public and private payor policies for patients with fragility fractures, as well as by local government units or private companies looking to establish orthogeriatric centers with fracture liaison services.

This guideline is helpful for physicians and other allied health personnel in screening, diagnosis, management and prevention of primary osteoporosis and fragility fractures among postmenopausal women and older men.

Research agenda are identified following the process of research priority setting which generally serves to guide resource allocation, address the identified needs of the stakeholders, and reinforce the link between research and actions and policies. The 2023-2028 PAFP Research Agenda was developed in three (3) phases - preparation, implementation and dissemination. An online survey was sent to the general membership through the regions, chapters and training institutions to determine priority research topics based on the National Unified Health Research Agenda and World Organization of Family Doctors (NUHRA and WONCA) research themes. Responses were collated and categorized in the appropriate research themes through an iterative process. A research agenda setting workshop was held with participants from the different stakeholders, which was facilitated by members of the working committee on research agenda and grants. Research themes and research questions were generated and compiled. There were forty-four (44) sub themes generated which align with the research themes of the 2023-2028 NUHRA and with the goal of the universal healthcare act. Majority of these sub themes fall under the themes, disease management and health systems strengthening towards UHC and support information generation on topic areas that are pertinent to the PAFP’s organizational missions - use of clinical pathways and clinical practice guidelines, continuous quality improvement, Patient-centered, Family-focused and Community-oriented approach to care, patient education and counseling, primary care models, family and community practice, family medicine in basic medical education and the role of a Family Physician in UHC.

BACKGROUND

Type 2 DM is a chronic disease and is increasing in prevalence and incidence worldwide. In developing nations like the Philippines, it affects patients and their families. Family-oriented interventions, like family counseling, meetings, interviews, and home visits, can support commitment to change and enhance medication adherence, health behavior, and knowledge ensuring adherence to the multifaceted diabetes type 2 management. Patients and families should be permitted to make decisions about lifestyle modifications and medication interventions and finding the appropriate family-focused intervention that works for managing type 2 diabetes is essential. With this information, family physicians can provide more effective care to patients hence, improving their quality of life.

This review’s objective was to determine the effectiveness of family-focused intervention among patients with type 2 diabetes in terms of glycemic control (HbA1c and FBS) and in terms of improving the quality of life.

This is a meta-analysis that included clinical trials randomized involving adult participants that were diagnosed to have type 2 DM. The interventions tested was family-based interventions and the primary outcomes included are HbA1c and FBS. A systematic review was conducted for secondary outcome, patients’ quality of life. Reviewers used the RevMan5 software in the analysis of data.

Seven studies met the inclusion criterion. The overall mean difference in post-treatment HbA1c was −0.54%(95%CI [-0.82,-0.25];p=0.0003) for the 1,265 participants included, showing an overall significant benefit of reducing HbA1c favoring intervention, especially on the 3-month follow-up. On subgroup analysis, the results were as follows: 3-months, -0.45%(95%CI [-0.73,-0.16];p=0.002); 6-month, -0.15%(95%CI[-0.51,0.22];p=0.44), and 12-month, -0.77%(95%CI[-1.75,0.21], p=0.12). The overall difference in mean change in FBS showed a result of -7.8(95%CI[-17.52,1.92],p=0.12) showing benefit, though not statistically significant, favoring intervention in decreasing FBS.

Family-focused interventions among Type 2 DM patients shows significant benefit on improving glycemic control and QOL.

BACKGROUND

The COVID-19 pandemic had a profound impact on medical education, particularly in Family and Community Medicine training programs. This study aimed to assess the impact in the Philippines by comparing the number of cases and procedures before and during the pandemic, as well as the adaptations made by these programs.

The objective of this study was to determine the effect of the COVID-19 pandemic on Family and Community Medicine training in the Philippines by comparing the average number of cases and procedures done before and during the pandemic and the changes implemented by the different accredited training programs.

A cross-sectional study utilizing an explanatory sequential mixed methods approach was undertaken. The quantitative portion collected data on cases and procedures from the participating institutions’ residents using the standardized checklist of the Philippine Academy of Family Physicians. The qualitative portion was done through a focused group discussion (FGD) following a prepared set of FGD questions. Analysis of variation (ANOVA) was used to compare the average cases seen and procedures across the four years and content analysis for the qualitative data.

There was a significant decrease in the average number of adult and pediatric cases during the pandemic years (2020-2021) compared to before (2018-2019). Various organ systems cases such as neurology, ophthalmology, dermatology, and gastrointestinal, showed significant differences (p-value<0.05) were found for several organ system cases when comparing the years before (2018-2019) and during the pandemic (2020-2021), including neurology, ophthalmology, ENT, dermatology, cardiology, gastrointestinal, genitourinary, reproductive health, musculoskeletal, and endocrinology cases. The trainers adjusted training activities to support the hospital's COVID-19 response and that prompted an abrupt shift to online strategies for patient consultations, teaching sessions, and examinations.

The COVID-19 pandemic led to a reduction in the variety of cases and procedures in Family and Community Medicine training, impacting the fulfillment of specialty training requirements. However, it also drove innovation through the integration of technology, including online teaching methods. These experiences underscore the importance of resilience and adaptability in medical education and offer valuable lessons for future training programs, potentially leading to improvements in training and patient care through innovative methodologies.

Differential diagnosis is the method of limiting the possible causes of the patient’s symptoms before making a final diagnosis. For experienced clinicians, it is the process of using clinical experience alongside the patient’s symptoms and test results to prioritize the list of possibilities until the diagnosis can be identified with confidence.
Diagnosis, Differential

Background: Since its surfacing in 2019, COVID-19 has spread all over the world and became an international concern. Vaccines against COVID-19 are expected to be the key in controlling this pandemic. To achieve this, studying factors that affect COVID-19 vaccine acceptance is crucial in order to increase the vaccine uptake rate of Filipinos to attain herd immunity. Objective: The study aimed to determine the factors affecting COVID-19 vaccine acceptance among adult patients in primary care clinics in Laguna, Las Piñas and Parañaque. Methods: This cross-sectional study was conducted last June 2021 with 137 adult patients from 6 clinics. The participants were given self-administered questionnaires containing items on sociodemographic profile and perception on vaccines. MS Excel and IBM SPSS were used for statistical analysis. Categorical variables were summarized as frequencies and percentages and continuous variables as means and standard deviations. Chi square was used to compare outcomes. Variables with statistically significant differences (p-value of <0.05) were included in multinomial regression analysis to determine association with vaccine acceptance. Results: Residence (p=0.0166), educational level (p=0.017), perceived effectiveness of vaccines to prevent and control COVID-19 (p=0.001), safety (p=0.001), doctor’s recommendation (p=0.039), risk of being infected (p=0.025) and refusal of any type of vaccine in the past (p=0.003) were associated with COVID-19 vaccine acceptance. Conclusion Through this study, the authors found that most of the respondents are willing to get vaccinated regardless of their sociodemographic characteristics. Concerns about vaccine availability and accessibility can hinder the promotion of vaccine uptake in the future. This study can be used as a basis for development and planning of COVID -19 vaccination programs.
COVID-19 ; COVID-19 Vaccines

Background: According to the American Heart Association, post- stroke patients often have neurologic deficits which can lead to a variety of complications. Patient-centered approach to care promotes shared decision-making between physicians and patients regarding treatment plan and may lead to better health outcomes for these post-stroke patients Objective: The effectiveness of patient-centered intervention in improving physical functioning among adult post-stroke patients with residual neurologic deficit was determined. Secondary outcomes such as improvement in social functioning, activities of daily living, quality of life and prevention of negative events such as death, re-hospitalization and depression were also evaluated Method: This systematic review included comparative randomized clinical trials involving humans as the clinical subjects, diagnosed to have had a stroke and appropriately evaluated to be in recovery with residual neurologic deficit, with the intervention described labeled as ‘patient-centered care’, and reporting an outcome on the improvement of physical functioning. Online search was done in Pubmed, CENTRAL, NICE, and the grey literature. Three reviewers independently conducted the search, appraisal and data extraction Results: Results varied depending on the outcome measurement tool utilized by the included studies. There was no difference between groups in terms of overall physical functioning and ADL as measured by SIS 16 and SIS 3.0. However, significant improvement was noted in the following subscales of SIS 3.0: hand movement (0.45,3.18, p=0.009, I2=0%), communication (0.86,2.16, p<0.00001, I2= 0%), and memory and thinking (0.13, 1.74, p=.02, I2= 33%). Physical function, ADL and social functioning using RNLI as an outcome (1.44-3.70] p<0.00001, I2= 0%), and physical functioning, social functioning, ADL and QOL as measured by participation (1.48, 3.74, p<0.00001, I2= 0%) and perception of recovery (2.22, 4.00, p<0.00001, I2=0%) also showed significant improvement Conclusion Patient-centered approaches have potential benefit in improving specific components of physical and social functioning, ADL and quality of life. However, differences in the type of patient-centered intervention and outcome measurement tools warrant further investigation into the specific interventions which will provide the most benefit to post-stroke patients
Meta-Analysis ; Stroke

Background: Mental Health Literacy (MHL) is considered a vital determinant of mental health and has the ability to benefit both individual and public mental health. To thoroughly measure the different aspects of mental health literacy and determine level of knowledge in the community, a MHLS-Filipino version is required. Objective: This study aimed to validate the Mental Health Literacy Scale – Filipino (MHLS-F) version among Community Health Workers in a rural and an urban health center in CaLaBaRZon. Study Design: This is a methodological study that was conducted among rural and urban health workers Patients and Methods: The guidelines provided by Beaton was used as template for the process of translation and crosscultural adaptation. The first phase involved Translation and Cross- cultural Adaptation of the Mental Health Literacy Scale from English to Filipino Version (MHLS-F). The instrument was simultaneously forward translated from English to Filipino by two independent translators from the Sentro ng Wikang Filipino. Back translations into English were done by two independent translators. The expert review committee discussed discrepancies found between the original items and the back-translated version of the questionnaire through a small group discussion and evaluated the content validity. Judgement on each item was made based on the computed i- CVI. The pre-final translated questionnaire was pre-tested on 5 rural and 5 urban community health workers with similar characteristics to the study population. Suggestions or alternative wording were documented and forwarded to Sentro ng Wikang Filipino for editing and proofreading. After synthesis of all reviews, the Mental Health Literacy Scale – Filipino Version was finalized. The final version was administered to 220 Community Health Workers from the Santa Rosa CHO and San Juan MHO. Psychometric properties on internal reliability using Cronbach’s Alpha was used as complementary procedure for determining the final structure of the instrument. Results: All six domains of MHLS were translated into Filipino without any major problems. The Final Mental Health Literacy Scale- Filipino Version has 26 items under 3 subscales. It has an acceptable content validity and satisfactory internal consistency (Cronbach’s alpha 0.730). Conclusion MHLS was successfully cross-culturally adapted into Filipino. The MHLS-F has good validity and reliability in assessing knowledge and attitude in mental health among community healthcare workers
Community Health Workers

Cutaneous tuberculosis (TB) occurs rarely, comprising only approximately 1% of all extrapulmonary TB cases worldwide. This report presents an atypical clinical manifestation of Lupus vulgaris, the most common form of cutaneous TB. Typically, Lupus vulgaris presents as chronic erythematous plaques over the head and neck area. The patient, a 24-year-old male with limited support and financial resources, presented with chronic painful, non-healing ulcerated lesions on his left upper extremity. Diagnostic tests specific to TB infection, including culture, all turned out negative for TB. No improvement in the lesions was noted with antibacterial and antifungal therapies. Clinical course of the condition and histopathologic findings, though non-specific to TB, became the basis for diagnosis and treatment. Patient currently is on the 3rd month of anti-Koch’s treatment with noted gradual improvement in the character and appearance of the lesions. Lupus vulgaris could appear as ulcers and over the extremities though much less common, posing challenges in both diagnosis and treatment. Malignant transformation could develop if left untreated. Thus, careful and thorough examination of the patient and diligent follow-up and re-evaluation of lesions while considering the patient’s values, concerns and financial capacity, were necessary in successfully addressing both the biomedical and psychosocial aspect of the illness.
Skin Diseases ; Lupus Vulgaris