BACKGROUND

The Philippines has a wide variety of plant species with potential to produce allergenic pollen grains. Most of the study subjects which are residents in Manila tested positive to Fabaceae and Amaranthaceae. Weeds, especially the Amaranthaceae and Fabaceae families, are relevant triggers of allergy as they are highly adaptive and can grow despite adverse weather conditions. However, only a few allergens have been identified among these families and listed in the International Union of Immunological Societies allergen nomenclature database. Currently, local pollen grains are being processed at the Medical Research Laboratory of our institution to produce crude pollen extracts for use in specific diagnostic skin tests and in subcutaneous immunotherapy of patients with respiratory allergies all over the country. However, these extracts have not been characterized and data of cross-reactivity is limited.

This study aimed to evaluate the IgE binding activity of allergen extracts from Philippine weeds and trees, and determine their cross-reactive components.

Pollen extracts from Amaranthus spinosus (pigweed), Mimosa pudica (makahiya), Tridax procumbens (wild daisy), Albizia saman (acacia), Leucaena leucocephala (ipil-ipil), Mangifera indica (mango), and Cocos nucifera (coconut) were extracted and analyzed for crossreactivity using ELISA and Western blot. 

Cross-reaction was observed between ipil-ipil and coconut, and between makahiya and wild daisy. IgE bound to protein components at ~20, 18, and 15 kDa of the weeds, while for the trees, IgE bound to protein components at ~35 and ~15 kDa which may be responsible for the cross-inhibitions observed.

Data may contribute to the development of immunotherapeutic strategies and diagnostic applications for respiratory allergies, comprising the production of standardized panel of allergens thus eliminating unwanted side effects and providing patients with safer diagnosis and therapy.

BACKGROUND

The Philippines has a wide variety of plant species with potential to produce allergenic pollen grains. Most of the study subjects which are residents in Manila tested positive to Fabaceae and Amaranthaceae. Weeds, especially the Amaranthaceae and Fabaceae families, are relevant triggers of allergy as they are highly adaptive and can grow despite adverse weather conditions. However, only a few allergens have been identified among these families and listed in the International Union of Immunological Societies allergen nomenclature database. Currently, local pollen grains are being processed at the Medical Research Laboratory of our institution to produce crude pollen extracts for use in specific diagnostic skin tests and in subcutaneous immunotherapy of patients with respiratory allergies all over the country. However, these extracts have not been characterized and data of cross-reactivity is limited.

This study aimed to evaluate the IgE binding activity of allergen extracts from Philippine weeds and trees, and determine their cross-reactive components.

Pollen extracts from Amaranthus spinosus (pigweed), Mimosa pudica (makahiya), Tridax procumbens (wild daisy), Albizia saman (acacia), Leucaena leucocephala (ipil-ipil), Mangifera indica (mango), and Cocos nucifera (coconut) were extracted and analyzed for crossreactivity using ELISA and Western blot. 

Cross-reaction was observed between ipil-ipil and coconut, and between makahiya and wild daisy. IgE bound to protein components at ~20, 18, and 15 kDa of the weeds, while for the trees, IgE bound to protein components at ~35 and ~15 kDa which may be responsible for the cross-inhibitions observed.

Data may contribute to the development of immunotherapeutic strategies and diagnostic applications for respiratory allergies, comprising the production of standardized panel of allergens thus eliminating unwanted side effects and providing patients with safer diagnosis and therapy.

Cohort studies is an epidemiologic study that follows a group of individuals who share a common characteristic at the start of the study to observe the emergence of outcomes. Cohort studies are classified based on the population characteristics from where they were drawn, the way the data collection occurred or if its open or closed. This allows the computation of the absolute risk or the incidence of an outcome. There are several advantages in conducting a cohort study, such as clarity of temporal relationship of the exposure and outcome, permits the computation of incidence, permits multiple effects of a single exposure, and avoids selection bias on admission. While there are advantages, there are also disadvantages in doing this study, such as it requires long follow-up, need of large sample size, maybe costly, and may make it difficult to argue causation due to the presence of confounding. The statistical test that can be used to analyze the results will depend on the type of variable used. Statistical test such as T-test, Chi square test, and Regression can be used. Writing the final report follows the STROBE guidelines.

Abstract: Repetitive Transcranial Magnetic Stimulation is a non-invasive brain stimulation process popularly used to treat psychiatric disorders. Multiple evidence shows effectiveness of rTMS in treating addiction, particularly in tobacco or cigarette users. This study consisted of review of current published literatures on repetitive transcranial magnetic stimulation following predefined eligibility criteria. The studies included evaluated at least one of the epidemiological parameters: (i) the meaning of repetitive transcranial magnetic stimulation (ii) Effectiveness of the Repetitive Transcranial Magnetic Simulation Over Behavioral therapy (iii) rTMS-associated adverse events among tobacco users Methodology: We included published studies discussing rTMS in smoking cessation which examined if these interventions were effective and identified whether it has a severe negative effect on the patients. A total of 104 related studies were identified through database searches (Pubmed, Elsevier, Cochrane). Of which, 53 duplicate studies were removed. Five studies were then excluded with more than 10 years in publication. A total of 28 papers were then included in the study. Conclusion We conclude that rTMS is more effective in treating addiction in terms of smoking compared to behavioral therapy and rTMS affects triggered desired circuit which may be crucial among tobacco users. Individual neuronal excitability in the specific region’s subsequent induction may impact the therapeutic outcomes. With this, the high-frequency rTMS sequentially applied to the left superior medial frontal cortex and dorsolateral prefrontal cortex may be an effective tool for improving the cessation rate.
Transcranial Magnetic Stimulation ; Smoking Cessation

Background: Diarrhea is among the common causes of morbidity and mortality in children. It is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). It does not include frequent passing of formed stool and passing of loose, pasty stools by breastfed babies. It is usually a symptom of an infection in the intestinal tract, caused by variety of organisms, which is spread through contaminated food or drinking water, or from person-to-person as a result of poor hygiene. Diarrhea can last several days and can leave the body without the water and salts that are necessary for survival causing significant number of mortality and morbidity among children. At the level of primary care, diagnosis, management and treatment of food- and waterborne-diseases, which commonly present as diarrhea, lack the necessary protocols and standards, thus, the creation of this clinical pathway. Objective: The main goal of this clinical pathway was to provide guidance to family and community physicians, and other primary care physicians in managing acute diarrhea among immunocompetent pediatric patients. Methods: ADAPTE process was used in CPG development. Existing guidelines on acute diarrhea among pediatric patients were retrieved and appraised using the AGREE II tool. Recommendation statements from the guidelines that passed the AGREE II tool were reviewed. Recommendation statements that will help answer the clinical questions posed in the creation of the clinical pathway were adapted. For clinical questions were not answered by the available guideline recommendations, a de novo method was conducted. The adapted recommendation statements and the supporting summary of evidences were sent for external review prior to consensus development. Suggestions provided in both steps were discussed and incorporated in the final manuscript, as appropriate. Key Recommendation Statements: These key recommendation statements addressing the clinical assessment, diagnosis, interventions (pharmacologic and nonpharmacologic), and patient outcomes that are relevant in the outpatient or primary care setting in the Philippines were based on the summarized key evidences from the systematic review of literature conducted using the ADAPTE process. Clinical Assessment Recommendation 1. A focused medical history that includes questions on duration, frequency, characteristics, associated symptoms, consumption of raw, ill-prepared, or rotten food; intake of antibiotics, contaminated food or water; and history of travel should be obtained. (Strong recommendation, High quality evidence) Recommendation 2. Physical examination should be done to assess the nutritional status, degree of dehydration, severity of disease, and presence of complications and comorbid conditions. (Strong recommendation, High quality evidence) Recommendation 3. Degree of dehydration should be classified into No Dehydration, Mild to Moderate Dehydration, or Severe Dehydration. (Weak recommendation, Moderate quality evidence) Recommendation 4. Children with acute infectious diarrhea who have any of the following conditions should be admitted to the hospital: severe dehydration, inability to tolerate fluids orally, suspected electrolyte abnormalities, altered consciousness, abdominal distention, respiratory distress, pneumonia, meningitis/encephalitis, sepsis, moderate to severe malnutrition, suspected surgical condition, or conditions for safe follow-up and home management are not met. (Strong recommendation, High quality evidence) Diagnostic Tests Recommendation 5. Routine diagnostic tests are not necessary among children with acute diarrhea. (Strong recommendation, Low quality evidence) Recommendation 6. Stool examination may only be requested if the patient present with moderate to severe condition, bloody diarrhea, or amoebiasis and parasitism is being considered at time of epidemic. (Strong recommendation, High quality evidence) Recommendation 7. Diagnostic tests may be requested if concomitant conditions like pneumonia, urinary tract infection, sepsis or meningitis are suspected; or if abdominal distension is observed post-hydration. (Strong recommendation, High quality evidence) Recommendation 8. Stool culture, serologic test, rapid diagnostic test, PCR determination and serum biomarkers are not recommended in family and community practice. (Strong recommendation, High quality evidence) Pharmacologic Treatment Recommendation 9. Reduced osmolarity oral rehydration solution (ORS), commercial or home-made is recommended to replace previous and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 10. The volume and frequency of reduced osmolarity oral rehydration solution (ORS) should be dependent on patient’s age or weight, severity of dehydration and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 11. Severe dehydration should be managed in the hospital with intravenous hydration. (Strong recommendation, High quality of evidence) Recommendation 12. Routine empiric antibiotic treatment is not recommended in children with acute infectious diarrhea. (Strong recommendation, Very low quality evidence) Recommendation 13. Antibiotic treatment may be given to children with Cholera, Shigella, typhoidal Salmonella, amoebiasis, and giardiasis. The choice of antibiotic must be guided by the local Antibiotic Surveillance Program. (Strong recommendation, High quality evidence) Recommendation 14. In general, antibiotic treatment should not be given in children with non-typhoidal Salmonella. It may be given in children with underlying conditions i.e., immunodeficiency, corticosteroid or immunosuppressive therapy. (Strong recommendation, Very low quality evidence) Recommendation 15. Among children older than six months, zinc supplementation of 10-20 mg per day for 10-14 days may be offered to reduce the duration and severity of diarrhea, and recurrence in the next two to three months (Strong recommendation, High quality evidence) Recommendation 16. Racecadotril may be offered to reduce ongoing loss of water and electrolytes. (Strong recommendation, High quality evidence) Recommendation 17. Probiotics may be offered to reduce the duration of diarrhea. Lactobacillus rhamnosus GG (LGG), Saccharomyces boulardii and Lactobacillus reuteri are strains with evidence of effectiveness. (Strong recommendation, High quality evidence) Recommendation 18. Anti-emetics and antidiarrheal drugs are generally not recommended because of their side-effects. (Strong recommendation, High quality evidence) Non-pharmacologic Interventions Recommendation 19. Among children with acute diarrhea, age-appropriate feeding should be continued. There is no need to modify or restrict diet. (Strong recommendation, Moderate quality of evidence) Recommendation 20. Among infants with diarrhea, breastfeeding must be continued. (Strong recommendation, High quality evidence) Recommendation 21. If diet was restricted because of frequent vomiting, early refeeding must be done. (Strong recommendation, Moderate quality evidence) Recommendation 22. All members of the family must be encouraged regular hand washing with soap and water. (Strong recommendation, Moderate quality evidence) Recommendation 23. Family members must observe proper food handling, have access to safe drinking water, and observe proper waste disposal. (Strong recommendation, Low quality evidence) Recommendation 24. Community level intervention that encourages hand washing, proper food handling, appropriate waste disposal and ensuring safe drinking water must be done. (Strong recommendation, Low quality evidence) Expected Patient Outcomes Recommendation 25. After each encounter the patient or guardian must understand the nature of acute diarrhea, its management and potential complications. (Strong recommendation, Low quality evidence) Recommendation 26. The management plan must be a mutual agreement between the family physician and the guardian. (Strong recommendation, Low quality evidence) Recommendation 27. For the management of a child with acute diarrhea, the family physician must target for resolution of dehydration, resolution of diarrhea, prevention of relapse, hospitalization, complications and early detection of adverse events. (Strong recommendation, High quality evidence) Dissemination and Implementation This clinical pathway will be published in the “The Filipino Family Physician” journal, which is accessible in the PAFP journal website. PAFP’s Committee on Research will disseminate the clinical pathway through distribution to its subspecialty and affiliate societies, chapters, training programs, and primary care practitioners; and continuing development sessions of the PAFP. Monitoring of the uptake of the clinical pathway will be through the number of downloads at the website and requests for copies. This clinical pathway may be used as a guide by family and community physician and primary care physicians in a primary care setting. Tabular presentation of the clinical pathway was included as a tool for implementation. Monitoring of implementation will be via continuous quality improvements activities, which can be a self-initiated activity of the member as recommended in the Universal Healthcare, or as a chapter or group activity.

Background: Chronic obstructive pulmonary disease (COPD) is one of the contributors to the burden of non-communicable disease. Health education is a key component in COPD management. Effective health education interventions directed to patient, family and community are necessary to prevent exacerbations, emergency room visits, hospitalizations and improve quality of life for patients with COPD. The general objective of the study was to determine effectiveness of health education interventions directed to patient, family and community. Specifically, to determine the effect on the number of acute exacerbations, COPD related emergency room visits and hospitalizations, improvement in the quality of life and patient satisfaction. Methods: This study only included comparative clinical trials randomized or non- randomized, parallel or cross-over clinical trial design, cohort study involving humans as the participants. It also includes published studies in peer reviewed journals of PubMed, clinical trials registered Cochrane Central Register of Controlled Trials, and the grey literature. There were no foreign language studies included relevant to this review. The non-comparative clinical trials, outcomes research or real-world data, animal experiments, reviews and case reports were excluded. The study population of reviewed literature has an established diagnosis of Chronic Obstructive Pulmonary Disease based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for diagnosis of COPD. Studies involving COPD patients who have other co morbidities were also included. The patients with COPD in the study were similar to patients consulting in family and community medicine practice clinics in the Philippines. Data synthesis was done separately for each type of intervention, i.e., patient directed, family directed, community directed health education intervention on Chronic Obstructive Pulmonary Disease. Quantitative analysis was only possible for studies reporting similar outcomes and units of measures such as number of COPD-related hospitalizations and emergency room visits for health education intervention directed to patient and improvement in the quality-of-life scores for health education intervention directed to family and community. Narrative synthesis was done when it was not feasible to include studies to do pooled analysis due to any of the following reasons such as different outcomes and when outcomes not reported as means with standard deviation. The Review Manager 5 software was used in the analysis of the data. Sensitivity analysis was done by restricting the analysis to published studies and with low risk of bias. Results: A total of ten studies were included. Health education interventions directed to patient has no benefit in decreasing the number of COPD related emergency room visits (1.84, 95% CI 0.94,2.74) and insufficient evidence to decrease the number of COPD related hospitalizations (4.33,95%CI-4.69,13.34). Health education intervention directed to family have insufficient evidence to improve the quality of life among patients with COPD (0.35,95% CI -0.49,1.19). Community directed health education intervention have significantly improved the quality of life among patients with COPD (-1.95,95% CI -3.37, -0.53).The studies had low risk for bias in terms of random sequence generation, allocation concealment and blinding of outcome assessment except for one study that was a non-randomized trial (Tabari et al, 2018). The highest risk for bias across the studies was the non-blinding of the participants. The withdrawals or dropouts in one study exceeded 20%. Three studies reported non possibility of blinding the assessor (Marques et al 2015, Nguyen et al 2019, Tabari et al 2018). Furthermore, five studies (Gallefos, 2004, Hernandez et al 2015, Tabari et al 2018, Van Wetering et al 2010, Marques et al, 2015) did not report the use of intention to treat analysis Discussion Effective health education interventions directed to patient, family and community in conjunction with standard of care may decrease exacerbations, hospitalizations, emergency visits, better quality of life and patient satisfaction. The studies included for this review were heath education interventions solely directed to patient, to family and to community and not a combination of the interventions directed to patient and family, or patient and community, or patient and family and community. Overall, health education interventions are integrated in a patient centered family focused community-oriented care for COPD. Health education is just one of the components of the integrated care on COPD. Better control of COPD is likely due to the combined effects of the different care components. Hence, there is a need for more randomized controlled trials on health education interventions directed to patient and family. Inclusion of COPD related hospitalizations, emergency room visits, acute exacerbations as outcome measures in health education interventions directed to patient, family and community is useful to provide evidence in effectiveness of the intervention. The authors declare no financial or funding involvement in the development and implementation of this study. This protocol was registered with Research Grants Administration Office (RGAO) with Registration No. RGAO-2020-1276, Research Implementation Development Office (RIDO) and to the Research Committee of the Philippine Academy of Family Physicians. The study was given Certification of Exemption from Ethical Review by the University of the Philippines Research Ethics Board (UPMREB CODE: UPMREB 2020-783-EX
Pulmonary Disease, Chronic Obstructive

Background: Coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, causing a pandemic. The Philippines ranks 3rd in Southeast Asia with more than 15,000 confirmed cases, and a case fatality rate of 6.01%, close to the global average of 6.33%. Objective: This clinical pathway was developed to guide family and community physicians on the diagnosis and initial management of COVID-19 in terms of 1) clinical history and physical examination; 2) laboratory and ancillary procedures to be requested; 3) pharmacologic interventions; 4) non-pharmacologic interventions, and 5) patient outcomes to expect. Method: The PAFP Clinical Pathways Group reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication on the management of patients with COVID-19 in family and community practice. Recommendations: The recommendations are time-bound tasks on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions. The recommendations are presented as a table and algorithm. Implementation At the clinic level, self-audit using the recommendations of this clinical pathway as the standard may be done. At the organizational level, the PAFP should establish a new model of quality improvement initiative where self-practice audits are included as part of the program.
COVID-19 ; Family Practice

Dear Editor: Time has proven that endoscopy is generally a safe and effective tool in the diagnosis and treatment of various conditions. It offers superior visualization with markedly decreased morbidity and mortality. In Otolaryngology, otoendoscopy has been gaining acceptance in providing improved otoscopic visualization and video recording of the tympanic membrane. We describe a technique of myringotomy and ventilation tube insertion under endoscopic visualization using a rigid Hopkins rod scope previously described by other authors based on their accepted clinical guidelines for myringotomy. 1,2 The use of rigid endoscopes provides visualization of the entire tympanic membrane with excellent resolution, better fidelity of color with a well-angled or side-to-side vision. The procedure is generally safe, convenient and can be performed in an out-patient setting. Correspondingly, the video recordings could improve disease documentation for baseline and post-myringotomy evaluation. They can also be a tool to enable better understanding for patients.
Anesthesia

Corneal blindness is a preventable disease among Filipinos.Review of hospital data from the Department of Ophthalmology and Visual Sciences, Philippine General hospital and the Ophthalmic Pathology Section, Institute of Ophthalmology, University of the Philippines Manila showed the following: 1.Corneal diseases is the third most common cause ; 2.Inflammation is the leading cause of corneal diseases up to now; 3.Regraft/failed PKP is the 3rd indication for corneal transplant;and 4.Corneal blindness accounted for 94/578 enucleation cases
Human ; BLINDING CORNEAL DISEASES ; BLINDNESS

Human ; OPHTHALMOLOGY ; CORNEAL DISEASES