BACKGROUND AND OBJECTIVE

Primary care providers are key players in providing quality care to patients and advancing Universal Health Care (UHC). However, effective and quality healthcare delivery may be affected by inadequate knowledge and failure to adhere to evidence-based guidelines among providers. The Philippine Primary Care Studies (PPCS) is a five-year program that pilot tested interventions aimed at strengthening the primary care system in the country. Evidence-based training modules for healthcare providers were administered in Sorsogon and Bataan from the years 2018 to 2021. Module topics were selected based on common health conditions encountered by providers in rural and remote settings. This program aimed to evaluate the effectiveness of training in increasing provider knowledge.

METHODS

A series of training workshops were conducted among 184 remote- and 210 rural-based primary care providers [nurses, midwives, barangay or village health workers (BHWs)]. They covered four modules: essential intrapartum and newborn care (EINC), integrated management of childhood illness (IMCI), non-communicable diseases (NCD), and geriatrics. A decision support system (UpToDate) was provided as a supplementary resource for all participants. We administered pre-tests and post-tests consisting of multiple-choice questions on common health conditions. Data was analyzed using paired one-tailed t-test, with an alpha of 0.05.

RESULTS

The knowledge of nurses, midwives, and BHWs improved after the training workshops were conducted. The largest increase from pre-test to post-test scores were observed among the midwives, with a mean difference (MD) of 32.9% (95% CI 23.9 to 41.9) on the EINC module, MD of 25.0% (95% CI 16.6 to 33.4) in the geriatrics module, and MD of 13.5% (95% CI 6.9 to 20.1) in the NCDs module. The nurses had the greatest improvement in the IMCI module (MD 10.8%, 95% CI 2.5 to 19.1). The knowledge of BHWs improved in all participated modules, with greatest improvement in the NCD module (MD 9.0%, 95% CI 5.77 to 12.14).

CONCLUSIONS

Primary care workshops, even if conducted as single-sessions and on a short-term basis, are effective in improving short-term knowledge of providers. However, this may not translate to long-term knowledge and application in practice. Furthermore, comparisons across provider categories cannot be made as participant composition for each training workshop varied. Ultimately, this study shows enhancing provider knowledge and competence in primary care will therefore require regular and diverse learning interventions and access to clinical decision support tools.

Capacity Building ; Health Workforce ; Philippines ; Primary Health Care

Background and Objective: Primary care providers are key players in providing quality care to patients and advancing Universal Health Care (UHC). However, effective and quality healthcare delivery may be affected by inadequate knowledge and failure to adhere to evidence-based guidelines among providers. The Philippine Primary Care Studies (PPCS) is a five-year program that pilot tested interventions aimed at strengthening the primary care system in the country. Evidence-based training modules for healthcare providers were administered in Sorsogon and Bataan from the years 2018 to 2021. Module topics were selected based on common health conditions encountered by providers in rural and remote settings. This program aimed to evaluate the effectiveness of training in increasing provider knowledge. Methods: A series of training workshops were conducted among 184 remote- and 210 rural-based primary care providers [nurses, midwives, barangay or village health workers (BHWs)]. They covered four modules: essential intrapartum and newborn care (EINC), integrated management of childhood illness (IMCI), non-communicable diseases (NCD), and geriatrics. A decision support system (UpToDate) was provided as a supplementary resource for all participants. We administered pre-tests and post-tests consisting of multiple-choice questions on common health conditions. Data was analyzed using paired one-tailed t-test, with an alpha of 0.05. Results: The knowledge of nurses, midwives, and BHWs improved after the training workshops were conducted. The largest increase from pre-test to post-test scores were observed among the midwives, with a mean difference (MD) of 32.9% (95% CI 23.9 to 41.9) on the EINC module, MD of 25.0% (95% CI 16.6 to 33.4) in the geriatrics module, and MD of 13.5% (95% CI 6.9 to 20.1) in the NCDs module. The nurses had the greatest improvement in the IMCI module (MD 10.8%, 95% CI 2.5 to 19.1). The knowledge of BHWs improved in all participated modules, with greatest improvement in the NCD module (MD 9.0%, 95% CI 5.77 to 12.14). Conclusions Primary care workshops, even if conducted as single-sessions and on a short-term basis, are effective in improving short-term knowledge of providers. However, this may not translate to long-term knowledge and application in practice. Furthermore, comparisons across provider categories cannot be made as participant composition for each training workshop varied. Ultimately, this study shows enhancing provider knowledge and competence in primary care will therefore require regular and diverse learning interventions and access to clinical decision support tools.
Capacity Building ; Health Workforce ; Philippines ; Primary Health Care

OBJECTIVE: To evaluate the benefits of surgical repair acute type A aortic dissection (ATAAD) on survival of octogenarians. METHODS: Patients who underwent surgery for acute ATAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD) were the subjects of the present analysis. RESULTS: 326 (8.4%) patients were aged ≥ 80 years. Among 280 propensity score matched pairs, in-hospital mortality was 30.0% in patients aged ≥ 80 years and 20.0% in younger patients (P = 0.006), while 10-year mortality were 93.2% and 48.0%, respectively (P < 0.001). The hazard of mortality was higher among octogenarians up to two years after surgery, but it became comparable to that of younger patients up to 5 years. Among patients who survived 3 months after surgery, 10-year relative survival was 0.77 in patients aged < 80 years, and 0.46 in patients aged ≥ 80 years. Relative survival of octogenarians decreased markedly 5 years after surgery. Age ≥ 85 years, glomerular filtration rate, preoperative invasive ventilation, preoperative mesenteric mal-perfusion and aortic root replacement were independent predictors of in-hospital mortality among octogenarians (AUC = 0.792; E:O ratio = 0.991; CITL = 0.016; slope = 1.096). An additive score was developed. A risk score ≤ 1 was observed in 68.4% of patients, and their in-hospital mortality was 20.9%. CONCLUSIONS Provided a thoughtful patient selection, surgery may provide a survival benefit in patients aged ≥ 80 years with ATAAD that, when compared to younger patients and the general population, may last up to 5 years after the procedure. These findings have significant epidemiologic and clinical relevance because of the increasing longevity of the population of the Western countries.

Methods: Patients undergoing lumbar decompression with or without fusion at a single tertiary care center were grouped based on the presence of a durotomy. Multivariate analysis was performed for length of stay (LOS), hospital readmissions, and changes in PROMs. To identify surgical risk factors for durotomy, 3:1 propensity matching was performed using stepwise logistic regression. The sensitivity and specificity of the International Classification of Disease, 10th revision (ICD-10) codes (G96.11 and G97.41) were also assessed. Results: Of the 3,684 consecutive patients who underwent lumbar decompressions, 533 (14.5%) had durotomies, and a complete set of PROMs (preoperative and 1-year postoperative) were available for 737 patients (20.0%). Incidental durotomy was an independent predictor of increased LOS but not hospital readmission or worse PROMs. The durotomy repair method was not associated with hospital readmission or LOS. However, repair with collagen graft and suture predicted reduced improvement in Visual Analog Scale back (β =2.56, p=0.004). Independent risk factors for incidental durotomies included revisions (odds ratio [OR], 1.73; p<0.001), levels decompressed (OR, 1.11; p=0.005), and preoperative diagnosis of spondylolisthesis or thoracolumbar kyphosis. The sensitivity and specificity of ICD-10 codes were 5.4% and 99.9%, respectively, for identifying durotomies. Conclusions The durotomy rate for lumbar decompressions was 14.5%. No differences in outcomes were detected except for increased LOS. Database studies relying on ICD codes should be interpreted with caution due to the limited sensitivity in identifying incidental durotomies.

Objectives: This study explores the potential of the HeLe Service Delivery Model, a community-based newborn hearing screening (NHS) program supported by a web-based referral system, in improving provision of hearing care services. Methods: This prospective observational study evaluated the HeLe Service Delivery Model based on records review and user perspectives. We collected system usage logs from July to October 2018 and data on patient outcomes. Semi-structured interviews and review of field reports were conducted to identify implementation challenges and facilitating factors. Descriptive statistics and content analysis were used to analyze quantitative and qualitative data, respectively. Results: Six hundred ninety-two (692) babies were screened: 110 in the RHUs and 582 in the Category A NHS hospital. Mean age at screening was 1.4±1.05 months for those screened in the RHU and 0.46±0.74 month for those in the Category A site. 47.3% of babies screened at the RHU were ≤1 month old in contrast to 86.6% in the Category A hospital. A total of 10 babies (1.4%) received a positive NHS result. Eight of these ten patients were referred via the NHS Appointment and Referral System; seven were confirmed to have bilateral profound hearing loss, while one patient missed his confirmatory testing appointment. The average wait time between screening and confirmatory testing was 17.1±14.5 days. Facilitating factors for NHS implementation include the presence of champions, early technology adopters, legislations, and capacity-building programs. Challenges identified include perceived inconvenience in using information systems, cost concerns for the patients, costly hearing screening equipment, and unstable internet connectivity. The lack of nearby facilities providing NHS diagnostic and intervention services remains a major block in ensuring early diagnosis and management of hearing loss in the community. Conclusion The eHealth-enabled HeLe Service Delivery Model for NHS is promising. It addresses the challenges and needs of community-based NHS by establishing a healthcare provider network for NHS in the locale, providing a capacity-building program to train NHS screeners, and deploying health information systems that allows for documentation, web-based referral and tracking of NHS patients. The model has the potential to be implemented on a larger scale — a deliberate step towards universal hearing health for all Filipinos.
Neonatal Screening ; Hearing Loss ; Health Information Systems ; Community Health Services ; Delivery of Health Care

OBJECTIVES: This study is a retrospective cohort that aims to describe the profile of orthopedic geriatric patients aged 60 years old and above with acute hip fractures occurring within one month of admission in the Philippine General Hospital managed by a multidisciplinary team approach. METHODS: Data collection from the database was done to gather information regarding the patient profile, time to surgery, causes for delay in consultation, length of hospital stay, and follow-up rate, since this model was implemented. RESULTS: Overall, we saw a decrease in the time from admission to surgery and a decrease in the length of hospital stay, when compared to previous data. Follow-up rates and compliance to maintenance medication are at 96% and 72% respectively. CONCLUSION: The implementation of a multidisciplinary approach and fracture liaison service presents us with favorable results in addressing hip fractures and osteoporosis.
Orthopedics ; Osteoporotic Fractures ; Geriatrics ; Interdisciplinary Research ; Osteoporosis ; Orthopedic Procedures

Objective. To determine the diagnostic accuracy of self-collected snorted and spit saliva in detecting COVID-19 using RT-PCR (ssRT-PCR) and lateral flow antigen test (ssLFA) versus nasopharyngeal swab RT-PCR (npRT-PCR). Methods. One hundred ninety-seven symptomatic subjects for COVID-19 testing in a tertiary hospital underwent snort-spit saliva self-collection for RT-PCR and antigen testing and nasopharyngeal swab for RT-PCR as reference. Positivity rates, agreement, sensitivity, specificity, and likelihood ratios were estimated. Results. Estimated prevalence of COVID-19 using npRT-PCR was 9% (exact 95% CI of 5.5% - 14.1%). A higher positivity rate of 13% in the ssRT-PCR assay suggested possible higher viral RNA in the snort-spit samples. There was 92.9% agreement between ssRT-PCR and npRT-PCR (exact 95% CI of 88.4% to 96.1%; Cohen’s Kappa of 0.6435). If npRT-PCR will be assumed as reference standard, the estimated Sensitivity was 83.3% (exact 95% CI of 60.8% to 94.2%), Specificity 93.9% (exact 95% CI of 89.3% to 96.5%), Positive predictive value of 57.7% (exact 95% CI of 38.9% to 74.5%), Negative predictive value of 98.2% (exact 95% CI of 95% to 99.4%), positive likelihood ratio of 3.65 (95% CI of 7.37 to 24.9), negative likelihood ratio of 0.178 (95% CI of 0.063 to 0.499). There was 84.84% agreement (95% exact CI of 79.1% to 89.5%; Cohen’s Kappa of 0.2356) between ssLFAvs npRT-PCR, sensitivity of 38.9% (exact 95% CI of 20.3% to 61.4%), specificity of 89.4% (exact 95% CI of 84.1% to 93.1%), PPV of 26.9% (95% CI of 13.7% to 46.1%), NPV of 93.6% (exact 95% CI of 88.8% to 96.4%), LR+ of 3.67 (95% CI of 1.79 - 7.51), LR – of 0.68 (95% CI of 0.47 - 0.99). Conclusion. Our data showed that snort-spit saliva RT-PCR testing had acceptable diagnostic performance characteristics and can potentially be used as an alternative to the standard nasopharyngeal/oropharyngeal swab RT-PCR test for COVID-19 in certain situations. However, our data also showed that snort-spit saliva antigen testing using lateral flow assay did not offer acceptable performance.
Saliva ; SARS-CoV-2 ; Reverse Transcription ; Reverse Transcriptase Polymerase Chain Reaction

Objective: The mandible is the most common fractured craniofacial bone of all craniofacial fractures in the Philippines, with the mandibular body as the most involved segment of all mandibular fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and management of mandibular body fractures in particular. General guidelines include the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic Review on interventions for the management of mandibular fractures. On the other hand, a very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and management, this clinical practice guideline focuses on the management of isolated mandibular body fractures in adults. Purpose: This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as well as primary care and specialist physicians, nurses and nurse practitioners, midwives and community health workers, dentists, and emergency first-responders) who may provide care to adults aged 18 years and above that may present with an acute history and physical and/or laboratory examination findings that may lead to a diagnosis of isolated mandibular body fracture and its subsequent medical and surgical management, including health promotion and disease prevention. It is applicable in any setting (including urban and rural primary-care, community centers, treatment units, hospital emergency rooms, operating rooms) in which adults with isolated mandibular body fractures would be identified, diagnosed, or managed. Outcomes are functional resolution of isolated mandibular body fractures; achieving premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing use of ineffective interventions; avoiding co-morbid infections, conditions, complications and adverse events; minimizing cost; maximizing health-related quality of life of individuals with isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in patients and occurrence in others. Action Statements The guideline development group made strong recommendationsfor the following key action statements: (6) pain management- clinicians should routinely evaluate pain in patients with isolated mandibular body fractures using a numerical rating scale (NRS) or visual analog scale (VAS); analgesics should be routinely offered to patients with a numerical rating pain scale score or VAS of at least 4/10 (paracetamol and a mild opioid with or without an adjuvant analgesic) until the numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- prophylactic antibiotics should be given to adult patients with isolated mandibular body fractures with concomitant mucosal or skin opening with or without direct visualization of bone fragments; penicillin is the drug of choice while clindamycin may be used as an alternative; and (14) prevention- clinicians should advocate for compliance with road traffic safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor vehicle, cycling and pedestrian accidents and maxillofacial injuries.The guideline development group made recommendations for the following key action statements: (1) history, clinical presentation, and diagnosis - clinicians should consider a presumptive diagnosis of mandibular fracture in adults presenting with a history of traumatic injury to the jaw plus a positive tongue blade test, and any of the following: malocclusion, trismus, tenderness on jaw closure and broken tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray as the initial imaging tool in evaluating patients with a presumptive clinical diagnosis; (3) radiographs - where panoramic radiography is not available, clinicians may recommend plain mandibular radiography; (4) computed tomography - if available, non-contrast facial CT Scan may be obtained; (5) immobilization - fractures should be temporarily immobilized/splinted with a figure-of-eight bandage until definitive surgical management can be performed or while initiating transport during emergency situations; (8) anesthesia - nasotracheal intubation is the preferred route of anesthesia; in the presence of contraindications, submental intubation or tracheostomy may be performed; (9) observation - with a soft diet may serve as management for favorable isolated nondisplaced and nonmobile mandibular body fractures with unchanged pre - traumatic occlusion; (10) closed reduction - with immobilization by maxillomandibular fixation for 4-6 weeks may be considered for minimally displaced favorable isolated mandibular body fractures with stable dentition, good nutrition and willingness to comply with post-procedure care that may affect oral hygiene, diet modifications, appearance, oral health and functional concerns (eating, swallowing and speech); (11) open reduction with transosseous wiring - with MMF is an option for isolated displaced unfavorable and unstable mandibular body fracture patients who cannot afford or avail of titanium plates; (12) open reduction with titanium plates - ORIF using titanium plates and screws should be performed in isolated displaced unfavorable and unstable mandibular body fracture; (13) maxillomandibular fixation - intraoperative MMF may not be routinely needed prior to reduction and internal fixation; and (15) promotion - clinicians should play a positive role in the prevention of interpersonal and collective violence as well as the settings in which violence occurs in order to avoid injuries in general and mandibular fractures in particular.
Mandibular Fractures ; Jaw Fractures ; Classification ; History ; Diagnosis ; Diagnostic Imaging ; Therapeutics ; Diet Therapy ; Drug Therapy ; Rehabilitation ; General Surgery

Background: The interpretation of thyroid hormone function during pregnancy is difficult due to its physiologic changes. Differences in iodine status in previous studies led to different intervals; therefore the use of trimester-specific, method-specific and probably country-specific reference values is advocated. Objective: To establish trimester-specific reference interval for thyroid function tests in pregnant Filipino women. Methodology: Six hundred sixteen pregnant patients (5–40 weeks gestation) attending a tertiary center were recruited. Level of serum thyroid stimulating hormone (TSH) was measured using immunoradiometric assay while free thyroxine (FT4), free triiodothyronine (FT3) and thyroid peroxidase antibodies (TPOAb) were measured by radioimmunoassay method. Main outcome measures are trimester-specific reference interval based on 2.5th and 97.5th percentiles for TSH, FT4 and FT3 among TPOAb-negative pregnant patients. Results: The reference intervals for each trimester were as follows: TSH (0.05-4.24, 0.13-3.95, and 0.20-3.00 uIU/mL); FT4 (9.80-21.88, 9.10-18.95 and 9.16-18.64 pmol/L) and FT3 (2.40-6.20, 2.77-5.00 and 2.09-3.70 pmol/L). FT4 and FT3 are strongly and negatively correlated with age of gestation (p=<0.01and <0.01 respectively). No correlation is found with TSH and age of gestation (p=0.52). Conclusions Trimester-specific intervals among pregnant Filipino women are different from their non-pregnant counterparts and laboratory cutoffs. Thus, these reference values should be used in the country.
Thyroid Function Tests

BACKGROUND: Pregnancy has been associated with differences in thyroid function.1 Maternal thyroid dysfunction has been shown to be associated with fetal and obstetric complications and prompt management is of importance. It has thus been recommended by the British and American Thyroid Association11,12 that trimester-specific thyroid function test reference ranges be used in the assessment of thyroid dysfunction. Normative values across the trimesters of pregnancy have been conducted in several countries13,17,19 and in the Philippines. Reference ranges
in the first and second trimesters of pregnancy were conducted by Patal and Hamin et al. which showed values of TSH 0.14-3.84 uIU/mL, FT4 10.44-21.58 pmol/L, FT3 2.4-5.82 pmol/L in the first trimester and TSH 0.10-4.30 uIU/mL, FT4 9.10-19.40 pmol/L, FT3 2.70- 5.190 pmol/L in the second trimester, respectively.
OBJECTIVE: To establish third trimester reference intervals for free thyroid hormones (free triiodothyronine [FT3], free thyroxine [FT4]) and thyrotropin [TSH] from thyroid peroxidase antibody [TPOAb]-negative Filipino
pregnant women.
DESIGN: This is a prospective, cross-sectional study which included consecutive 200 healthy third-trimester pregnant Filipino women attending Philippine General Hospital (PGH) out-patient services. Serum TSH, FT4, FT3, and TPOAb were measured.
MAIN OUTCOME MEASURES: Reference intervals are based on 2.5th and 97.5th percentiles for TSH, FT4, and FT3 among TPOAb-negative third-trimester pregnant Filipino patients.
ANALYSIS: All numerical data were entered in MS Excel and analyzed using STATA 12. FT3, FT4 and TSH were expressed as mean ±SD, range at 2.5th to 97.5th percentiles.
RESULTS: The reference ranges for TSH, FT4 and FT3 in TPOAb-negative third-trimester pregnant population are as follows: TSH= 0.2-3.0 uIU/mL; FT4 = 9.16-18.64 pmol/L and FT3= 2.09-3.7 pmol/L.
CONCLUSION: Reference ranges for thyroid function tests for the third trimester of TPOAb-negative pregnant Filipino women were determined in this study and are as follows: TSH= 0.2-3.0uIU/mL; FT4 = 9.16-18.64pmol/L and FT3= 2.09-3.7pmol/L.

Human ; Female ; Adult ; Thyrotropin ; Thyroxine ; Triiodothyronine ; Iodide Peroxidase ; Thyroid Function Tests ; Pregnancy Trimesters ; Thyroid Diseases ; Thyroid Hormones