OBJECTIVES

Clinical pathways (CPs) ensure adherence to heart failure (HF) management guidelines. To optimize quality care in a low resource setting, an evidence-based care pathway for the management of acute HF was implemented at the emergency department (ED) of the Philippine General Hospital (PGH), the designated national tertiary hospital and referral center. This study aimed to describe the characteristics of adults with acute HF admitted at the ED and evaluate the quality of care they received, measured using physician adherence to the hospital’s acute heart failure CP.

METHODS

This was a retrospective, descriptive cohort study. We reviewed the inpatient charts of all adult patients with acute HF admitted to the ED of the PGH and referred to the Division of Cardiovascular Medicine between December 1, 2022 and May 31, 2023. Quality of care was assessed based on adherence to quality indicators adapted from routine and conditional order sets detailed in the pathway. Descriptive statistics was utilized to describe patient characteristics, quality of care, and outcomes.

RESULTS

Two hundred thirty-six (236) patients were included, with a mean age of 51.8 years. Majority were male (53.4%); hypertension (61.4%) and ischemic heart disease (53.8%) were the most common comorbidities, and infection the most common precipitant of decompensation (60.6%). There were optimal adherence rates to routine orders, which included referrals to Internal Medicine and Cardiology, baseline vital signs monitoring, fluid intake and output monitoring, chest radiograph, complete blood count, blood urea nitrogen, sodium, potassium, prothrombin time, partial thromboplastin time, arterial blood gas, urinalysis, and N-terminal pro b-type natriuretic peptide. Conditional orders, such as oxygen support, focused echocardiography, thyroid - stimulating hormone, and the use of vasopressors, diuretics, and venous thromboembolism prophylactic agents, were optimally performed when warranted. However, we noted suboptimal adherence to certain resource-intensive conditional orders, such as hourly monitoring of urine output (61.4%), hooking to cardiac monitor (53.8%), and performance of 12-lead ECG within 10 minutes (56.8%). Further, only 43.9% of patients were referred to the intensive care unit. Troponin I, calcium, magnesium, and albumin were ordered in excess.

CONCLUSION

Overall adherence rate of physicians to the hospital’s Acute Heart Failure Pathway was satisfactory. Work is needed to improve adherence to hourly urine output monitoring, consistent hooking to cardiac monitor, and timely performance of 12-lead ECG – an effort that begins with expanding in-hospital diagnostic equipment and human resource supply. We recommend continuous pathway implementation with periodic evaluation and stakeholder feedback to further improve quality of care.

Human ; Male ; Female ; Middle Aged: 45-64 Yrs Old ; Adult ; Albumins ; Blood ; Blood Urea Nitrogen ; Calcium ; Cardiology ; Chart ; Charts ; Cohort Studies ; Critical Care ; Critical Pathways ; Diagnostic Equipment ; Disease ; Diuretics ; Echocardiography ; Electrocardiography ; Emergencies ; Emergency Service, Hospital ; Equipment And Supplies ; Evaluation Studies As Topic ; Feedback ; Heart ; Heart Diseases ; Heart Failure ; Hormones ; Hospitals ; Hospitals, General ; Humans ; Hypertension ; Indicators And Reagents ; Infection ; Infections ; Inpatients ; Intensive Care Units ; Internal Medicine ; Lead ; Magnesium ; Male ; Medicine ; Myocardial Ischemia ; Natriuretic Peptide, Brain ; Natriuretic Peptides ; Nitrogen ; Overall ; Oxygen ; Partial Thromboplastin Time ; Patients ; Peptides ; Philippines ; Physicians ; Potassium ; Prothrombin ; Prothrombin Time ; Quality Of Health Care ; Referral And Consultation ; Sodium ; Statistics ; Tertiary Care Centers ; Thorax ; Thromboembolism ; Thromboplastin ; Thyroid Gland ; Time ; Troponin ; Troponin I ; Universities ; Urea ; Urinalysis ; Urine ; Venous Thromboembolism ; Vital Signs ; Work ; Workforce

OBJECTIVES

In Asia, younger individuals (below age 45) are diagnosed to have type 2 diabetes with increased rates of obesity defined by lower BMI yet with greater visceral adiposity (waist circumference and waisthip ratios). The prevalence data on type 1 diabetes is not well established, considered to be low, but is seen to be increasing as well. This changing phenotype therefore, presents a clinical dilemma in terms of correctly classifying diabetes and deciding on the consequent appropriate treatment. Distinguishing type 1 from type 2 diabetes has become more difficult with type 2 diabetes dramatically increasing in young adults and children. This study aims to define the characteristics of diabetes among young adults in the Philippines to provide a basis for appropriate management amidst changes in diabetes phenotypes seen globally.

METHODS

In this cross-sectional analytic study, we characterized the demographic, metabolic, and autoimmune features of diabetes among young adult Filipinos aged 18 to 45 years old consulting at a tertiary referral center in Manila, Philippines. Baseline serum A1c, FBS, 75-g oral glucose tolerance test, insulin, serum C-peptide, insulin autoantibodies, leptin, adiponectin, lipid profile, and thyroid function tests were obtained from the participants and analyzed. The homeostasis model assessment (HOMA) was used to estimate the insulin sensitivity.

RESULTS

A total of 348 patients with diabetes were included, with females comprising two-thirds of the participants. The mean age at diagnosis of diabetes was 35.9±7.22 years. The mean BMI was 28.12 kg/m2, with median waist to hip ratio (WHR) of 0·93. Metabolic syndrome was found in 60% of participants and 67.82% were obese by body mass index. The mean A1c was 9.07±2.52%. Good glucose control (A1c less than 7.0%) was seen in 23% of participants  while nearly half (48%) had HbA1c which was >9.0%. The median levels of fasting insulin and C-peptide were 12.62 (range 1.33–90.42) mIU/L and 0.78 ng/mL (range 0–16.2), respectively. 

Included participants were diagnosed with diabetes within a year and as such, majority did not have any micro- or macrovascular complications. The most common diabetes complication was sensory neuropathy detected by monofilament testing, which was found in 28% of participants, followed by non-proliferative diabetic retinopathy in 13%. A history of previous diabetic ketoacidosis was found in 10 patients (2.87%). Glutamic acid decarboxylase (GAD) and insulin auto-antibodies were found in 3.2% and 19.3% of participants, respectively. Approximately half (51.73%) of the participants were insulin resistant by HOMA-IR.

CONCLUSION

In contrast with Caucasians and other Asians, diabetes among young Filipino adults is associated with lower BMI but with a similarly high visceral adiposity as shown by an elevated WHR. Metabolic syndrome with insulin resistance as defined by a variety of indices is predominant. Type 1 diabetes with autoantibodies occur in only a small fraction of this population. Data derived from this work can provide a framework for cluster analysis towards personalized management specific to this population.

Human ; Acids ; Adiponectin ; Adiposity ; Adult ; Aged ; Antibodies ; Asia ; Asian ; Asian Continental Ancestry Group ; Autoantibodies ; Body Mass Index ; C-peptide ; Carboxy-lyases ; Child ; Cluster Analysis ; Demography ; Diabetes Complications ; Diabetes Mellitus ; Diabetes Mellitus, Type 1 ; Diabetes Mellitus, Type 2 ; Diabetic Ketoacidosis ; Diabetic Retinopathy ; Diagnosis ; Fasting ; Female ; Glucose ; Glucose Tolerance Test ; Glutamate Decarboxylase ; Glutamic Acid ; Insulin ; Insulin Resistance ; Ketosis ; Leptin ; Lipids ; Metabolic Syndrome ; Obesity ; Patients ; Peptides ; Phenotype ; Philippines ; Population ; Prevalence ; Serum ; Therapeutics ; Thyroid Gland ; Thyroid Function Tests ; Young Adult

Introduction: Type 2 diabetes mellitus (T2DM) and thyroid disorders are common endocrine conditions with a bidirectional relationship affecting glucose and lipid metabolism. Adiposity, particularly fat mass index (FMI), may influence thyroid function. but its association with thyroid dysfunction and glycemic control remains unclear, especially in Malaysia. This study aimed to determine the prevalence of thyroid dysfunction in T2DM and its association with glycemic control and FMI at Universiti Teknologi MARA (UiTM). Methodology: A cross-sectional study was conducted among patients with T2DM attending the Endocrine Clinic, UiTM, from December 2025 to March 2026. A total of 91 participants aged 18–70 years were recruited using convenience sampling. Demographic, clinical, anthropometric, and laboratory data were collected. Thyroid dysfunction was defined as thyroid-stimulating hormone (TSH) <0.38 or >5.33 mIU/L. Body composition was assessed using the InBody 380 to determine FMI. Data were analyzed using SPSS version 30 with descriptive statistics and Pearson correlation. Results: The prevalence of thyroid dysfunction among patients with T2DM was 7.7% (7/91), predominantly with low TSH levels. Mean hemoglobin A1c (HbA1c) in the overall study population was 7.59 ± 1.49%, and mean TSH was 1.42 ± 0.95 mIU/L, within the euthyroid range. Mean FMI was 11.95 ± 5.23 kg/m², exceeding normal ranges for both men (3–6 kg/m²) and women (5–9 kg/m²). FMI showed a positive correlation with TSH level (r = 0.379, p <0.001), indicating that higher adiposity was associated with higher TSH levels despite remaining within the euthyroid range. Pearson correlation showed a weak, non-significant negative correlation between HbA1c and TSH (r = −0.127, p = 0.229). Conclusion The prevalence of thyroid dysfunction among patients with T2DM in our cohort was relatively low at 7.7%. However, the significant correlation between FMI and TSH level, even within the euthyroid range, suggests that adiposity may exert a clinically relevant influence on thyroid function.
Diabetes Mellitus, Type 2 ; Prevalence ; Thyroid Gland ; Adipose Tissue

Introduction: Endocrine abnormalities are frequently observed in children with Down syndrome, with thyroid dysfunction being the most common. The distribution and patterns of thyroid disorders vary between populations. Methodology: Retrospective data were collected from the electronic medical records of children with Down syndrome who attended the paediatric clinic at University Malaya Medical Centre from the year 2000 to 2025. Data were analyzed to determine the frequency and distribution of thyroid disorders in this cohort. Results: The study included 57 patients, the majority of whom were identified through routine screening (n = 56, 98.2%). Only one child (1.8%) was diagnosed following a symptomatic presentation of diarrhea. Within the cohort, 51 patients were diagnosed with hypothyroidism and six with hyperthyroidism. Among those with hypothyroidism, the mean TSH was 22.5 mIU/L, with a median age at presentation of 61 days (IQR: 19–211.5). Notably, 25% of the cohort presented within the first 19 days, while the rest presented after 7 months of age. Of these, 24 cases (47.1%) were transient, with medications successfully discontinued at a mean age of 4.0 ± 2.13 years. Only 26 patients underwent thyroid scan, which was normal except for one case of thyroid agenesis. Imaging was not performed in others due to early discontinuation of therapy or loss to follow-up. All hyperthyroid patients had autoimmune thyroid disease (4 Graves’ disease, 2 Hashimoto’s thyroiditis) with positive autoantibodies. The median age at presentation was 5.4 years (IQR: 2.3–10.2). Conclusion Screening for thyroid dysfunction successfully identified almost all cases in patients with Down syndrome. Notably, patients which hyperthyroidism in this cohort had co-occurring autoimmune thyroid dysfunction and demonstrated a significantly earlier age of presentation compared to the general paediatric population.
Child ; Down Syndrome ; Thyroid Gland

BACKGROUND

Thyroid fine-needle aspiration biopsy (FNAB) is widely used for thyroid nodule characterization, with approximately 2.7% of samples classified as "inadequate." Non-diagnostic samples pose limitations, resulting in repeated procedures, and unnecessary diagnostic thyroidectomies. Conventional smear (CS) is commonly the method of choice for cytologic preparation of thyroid FNAB. The cell block technique is an alternative that concentrates cells providing additional material for better evaluation and ancillary testing. While conventional smears are commonly used, introducing routine complementary cell blocks could potentially lower costs associated with repeat procedures and improve patient management.

OBJECTIVE

The study aimed to investigate the diagnostic value of incorporating the cell block technique as adjunct to conventional smear technique in reducing nondiagnostic rates (Bethesda Category I) in thyroid-fine needle aspiration biopsies (FNAB) conducted in 2 private hospitals.

METHODOLOGY

This is a multi-center, retrospective cross-sectional study with 701 samples from 528 adult patients, who underwent thyroid FNAB between January 2020 - September 2022. The primary outcome of interest is the reduction in non-diagnostic rates with the combined use of conventional smears and cell block.

RESULTS

The non-diagnostic rates were significantly higher with cell block technique (28.10%) as compared to conventional smears (16.26%), p-value < .01. The results show that conventional smears have lower non-diagnostic rates. With smear cytology alone, 114 (16.3%) of all samples were nondiagnostic. With the addition of cell block technique, 15 of these samples were reclassified as benign (n = 13), Bethesda III (n = 1) or Bethesda IV (n = 1). The rest of the non-diagnostic samples (n = 99) remained Bethesda I. Overall, the equivalent decrease in non-diagnostic rate was 2.1%.

CONCLUSION

The combined use of cell block and conventional smears did not significantly decrease nondiagnostic rates in thyroid FNAB. In general, conventional smears demonstrated superior diagnostic efficacy across all Bethesda categories, establishing it as the preferred sampling preparation method for thyroid FNAB. Cell blocks should be considered a supplementary technique, particularly in cases where ancillary methods like immunohistochemistry or molecular testing are needed.

Biopsy, Fine-needle ; Thyroid Nodule ; Thyroid Gland ; Thyroid Diseases

OBJECTIVES

To discuss a case of papillary thyroid carcinoma with concomitant thyroid tuberculosisin terms of clinical presentation and treatment.

METHODS

Design:Case Report

Setting:Tertiary Government Training Hospital

Patient:One

RESULTS

A 19-year-old Filipina consulted with a four-year history of a left thyroid nodule. She was clinically euthyroid with unremarkable systemic examination. Fine needle aspiration cytology (FNAC) was suspicious for malignancy and she underwent total thyroidectomy. Histopathology revealed papillary thyroid carcinoma of the left lobe, microcarcinoma of the isthmus and incidental note of tuberculosis (TB) of the right lobe. Management included oral anti-TB medications and surveillance.

CONCLUSION

A 19-year-old Filipina consulted with a four-year history of a left thyroid nodule. She was clinically euthyroid with unremarkable systemic examination. Fine needle aspiration cytology (FNAC) was suspicious for malignancy and she underwent total thyroidectomy. Histopathology revealed papillary thyroid carcinoma of the left lobe, microcarcinoma of the isthmus and incidental note of tuberculosis (TB) of the right lobe. Management included oral anti-TB medications and surveillance.

Human ; Female ; Young Adult: 19-24 Yrs Old ; Carcinoma ; Thyroid Cancer, Papillary ; Thyroid Neoplasms ; Thyroid Gland ; Thyroidectomy ; Thyroid Nodule ; Government ; Needles ; Hospitals ; Research Report

OBJECTIVES

To report a case of triple primary malignant neoplasms in a 70-year-old woman diagnosed with follicular and papillary thyroid carcinoma and diffuse B-cell lymphoma of the right submandibular gland and cervical lymph nodes.

METHODS

Design:Case Report

Setting:Tertiary Government Training Hospital

Patient: One

RESULTS

A 70- year-old woman presented with a four-year history of gradually enlarging anterior neck mass, associated with a right submandibular mass and neck nodes for one year. The gradual progression of her symptoms made the patient think that it was a benign condition. This led to a delay in medical consultation. The patient underwent total thyroidectomy with functional neck dissection of the ipsilateral right neck. Histopathology revealed simultaneous follicular and papillary thyroid carcinoma, and diffuse B-cell lymphoma of the cervical lymph nodes. The patient was referred to medical oncology and nuclear medicine for further management.

CONCLUSION

Our patient was incidentally diagnosed with follicular and papillary thyroid carcinoma and diffuse B cell lymphoma of the cervical lymph nodes after surgery. Such triple primary malignant neoplasms in a single individual are rare, and as in our case, may only be diagnosed in hindsight.

Human ; Female ; Aged: 65-79 Yrs Old ; Carcinoma ; B-lymphocytes ; Adenocarcinoma, Follicular ; Neoplasms ; Submandibular Gland ; Lymph Nodes ; Lymphoma, B-cell ; Thyroid Gland ; Thyroid Cancer, Papillary ; Thyroidectomy

OBJECTIVE

To determine the predictive value of ACR-TIRADS in detecting malignancy in thyroid nodules.

METHODS

This is a retrospective, multi-center, cross-sectional analysis of patients who underwent ultrasound and thyroidectomy at three Cordillera Consortium hospitals between January 2019 and December 2021. Ultrasound reports were reviewed and correlated with histopathology reports to determine features associated with malignancy.

RESULTS

A study of 117 patients with thyroid nodules found significant differences in ACR-TIRADS subcategories. The risk of malignancy for TIRADS categories 1, 2, 3, 4, and 5 were 10%, 9.5%, 21.9%, 43.9%, and 76.97%, respectively. ACR-TIRADS demonstrated a high sensitivity of 92.1% and negative predictive value (NPV) of 90.3% as a rule-out test, and a specificity of 96.2% with a positive predictive value (PPV) of 76.9% as a rule-in test using TIRADS 5 as malignant. Correct classification of malignant nodules increased by cut-off value with the highest at 73.5% at the ≥5 cut-off value. Discussion: Thyroid nodules were more common in females under 55 years old. Certain sonographic features of thyroid nodules, such as being solid or predominantly solid, hypoechoic, lobulated/irregular, and having punctate echogenic foci, were associated with malignancy. The risk of malignancy at Cordillera Consortium hospitals was notably higher in this study. The ACR-TIRADS test yielded results consistent with previous studies, with TR 1 and 2 indicating benign nodules and TIRAD 3-5 indicating malignant nodules.

CONCLUSION

Due to a higher risk of malignancy, it is recommended to be more aggressive in performing biopsies for thyroid nodules at Cordillera Consortium hospitals. ACR-TIRADS is a reliable screening tool and is recommended as a confirmatory test (TIRADS 5) for thyroid malignancy. Biopsies are still recommended for TIRADS 3, 4, and 5 nodules to avoid unnecessary procedures and confusion among surgeons.

Human ; Thyroid Nodule ; Thyroid Gland ; Thyroidectomy ; Radiology

Thyroglossal duct cyst carcinoma is rare with majority being Papillary thyroid carcinoma. This is diagnosed after the final histopathology report following a Sistrunk procedure. Though with a good prognosis, surgical management has been controversial. Reported here is a case of a 30-year-old female who presented with an anterior neck mass. Pre-operative diagnosis was a thyroglossal duct cyst and patient underwent Sistrunk procedure with no untoward events. Final histopathology report of the excised mass revealed papillary thyroid carcinoma. This report draws attention to the rarity of papillary carcinoma in thyroglossal duct cyst and highlights the surgical options for such cases.

Human ; Female ; Adult: 25-44 Yrs Old ; Thyroid Cancer, Papillary ; Thyroid Neoplasms ; Thyroid Gland ; Thyroglossal Cyst ; Carcinoma, Papillary ; Cysts

OBJECTIVE

To determine the predictive values of the TIRADS and Bethesda Scoring Systems in diagnosing thyroid malignancy at the Quezon City General Hospital.

METHODS

Design: Retrospective Review of Records

Setting: Tertiary Government Training Hospital

Participants: Records of patients aged 18 years old and above who were admitted and underwent thyroidectomy under the Department of Otorhinolaryngology-Head and Neck Surgery from 2018 to 2023

RESULTS

A total of 47 patient records were included, 16 had thyroid malignancy while 31 had benign histopathology results. The Bethesda system showed 60% sensitivity, 94% specificity, 82% positive predictive value and 83% accuracy while the TIRADS system showed 53% sensitivity, 50% specificity, 33% positive predictive value,and 51% accuracy. Using Chi-Square tests, the Bethesda system had a strong association (p value < .0001), while the TIRADS system had no significant association (p value 1.000) with thyroid malignancy [odds ratios 24.2 and 1.00] respectively.

CONCLUSION

Our study showed that the Bethesda classification had good specificity, positive predictive value, accuracy and fair sensitivity while the TIRADS system had poor predictive value

Human ; Thyroid Gland ; Thyroid ; Cell Biology ; Cytology ; Biopsy