INTRODUCTION: This review aims to provide evidence-based recommendations for an enhanced primary series (third dose) coronavirus disease 2019 (COVID-19) vaccination in people with rheumatic diseases (PRDs) in the local and regional context. METHODS: Literature reviews were performed regarding the necessity, efficacy, safety and strategies for enhanced primary series COVID-19 vaccination in PRDs. Recommendations were developed based on evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence was synthesised by eight working group members, and the consensus was achieved by a Delphi method with nine members of an expert task force panel. RESULTS: Two graded recommendations and one ungraded position statement were developed. PRDs have impaired immunogenicity from the COVID-19 vaccine and are at an increased risk of postvaccine breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and poor clinical outcomes, compared to the general population. We strongly recommend that PRDs on immunomodulatory drugs be offered a third dose of the messenger RNA (mRNA) vaccine as part of an enhanced primary series, after the standard two-dose regimen. We conditionally recommend that the third dose of mRNA vaccine against SARS-CoV-2 be given at least 4 weeks after the second dose or as soon as possible thereafter. There is insufficient data to inform whether the third mRNA vaccine should be homologous or heterologous in PRDs. CONCLUSION These recommendations that were developed through evidence synthesis and formal consensus process provide guidance for an enhanced primary series COVID-19 vaccination in PRDs.
Humans ; COVID-19/prevention & control* ; COVID-19 Vaccines/administration & dosage* ; Rheumatic Diseases/immunology* ; Singapore ; SARS-CoV-2 ; Vaccination/methods* ; Delphi Technique ; Immunization, Secondary

INTRODUCTION: Pregnancy-associated breast cancer (PABC) is described as breast cancer diagnosed within pregnancy or within 1 year postpartum. PABC is becoming more common due to delayed childbearing, with older maternal age increasing the likelihood of tumorigenesis coinciding with pregnancy. Our review aims to outline the important principles of managing PABC, and discusses future fertility implications, genetic testing and postnatal considera-tions that are not often considered in other existing reviews. METHOD: A literature search was conducted using PubMed, Cochrane and Google Scholar databases. RESULTS: A persistent breast mass in pregnant women should be evaluated with a breast ultrasound. Total mastectomy is the standard treatment in the first trimester. Chemotherapy is contraindicated in the first trimesters, but can be given in the second and third trimester, and stopped before 35 weeks. Radiotherapy should be delayed until delivery, and hormone receptor therapy is contraindicated in pregnancy. A multidisciplinary team involving an obstetrician, medical oncologist and other allied health professionals is crucial. Delivery should be planned as close to 37 weeks as possible, and at least 3 weeks after the last chemotherapy cycle. Vaginal delivery is preferred, and breastfeeding can resume 14 days after the last chemotherapy regime. CONCLUSION A breast mass in a pregnant woman should not be dismissed. PABC must be managed by multidisciplinary teams at tertiary medical centres with access to surgery and chemoradiation therapies. Management strategies must include safe manage-ment and delivery of the fetus, contraception and future fertility planning.
Humans ; Female ; Pregnancy ; Breast Neoplasms/diagnosis* ; Pregnancy Complications, Neoplastic/diagnosis* ; Mastectomy ; Delivery, Obstetric

BACKGROUND

Appropriate use of medication is an important indicator of quality healthcare delivery among children. Previously published studies on drug utilization involved Filipino households in general and were conducted in the 1990s. No recent Philippine studies have been conducted that focus on drug utilization in children.

To describe the current prescribing patterns in one primary care service in a rural site in the Philippines using the World Health Organization (WHO) prescribing indicators.

A cross-sectional study was conducted by review of electronic medical records of patients seen at the primary care facility under the Philippine Primary Care Studies (PPCS) rural site from April 2019 to March 2020. Out of 9,930 total encounters, 623 patient encounters with prescriptions for pediatric patients were included in the study through systematic sampling. The average number of drugs per encounter, percentage of drugs prescribed by their generic names, percentage of encounters with prescribed antibiotics, percentage of encounters with prescribed injections, and percentage of drugs prescribed from the Philippine Drug Formulary were calculated. Values were compared to the cut-offs considered “good practice” for outpatient care in the WHO manual: (1) an average number of less than two drugs per encounter; (2) less than 30% of encounters are prescribed with antibiotics; (3) less than 20% of encounters are prescribed with injections; (4) 100% of drugs are prescribed by generic name; and (5) 100% of drugs are from the formulary.

On the average, three drugs were prescribed per encounter. Most patient encounters (80.9%) involved antibiotics prescription — higher than the WHO standard value of 30%. All drugs were prescribed by generic name and were prescribed from the formulary. Only 0.5% of encounters were prescribed injections, all of which were administered through the intramuscular route. Of the 1,962 prescriptions generated, antibiotics was the most prescribed medication (25.7%). The most common diagnosis was infectious in nature (88.8%).

The primary care service achieved the WHO standard values in terms of prescribing by injections and by generic names. There was a high rate of antibiotic prescriptions at 83%, and a high average number of drugs prescribed per encounter, exceeding the WHO standard value.

Background: and Purpose The management of acute ischemic stroke (AIS) due to distal medium vessel occlusion (DMVO) remains uncertain, particularly in comparing the effectiveness of intravenous thrombolysis (IVT) plus mechanical thrombectomy (MT) versus IVT alone. This study aimed to evaluate the safety and efficacy in DMVO patients treated with either MT-IVT or IVT alone. Methods: This multinational study analyzed data from 37 centers across North America, Asia, and Europe. Patients with AIS due to DMVO were included, with data collected from September 2017 to July 2023. The primary outcome was functional independence, with secondary outcomes including mortality and safety measures such as types of intracerebral hemorrhage. Results: The study involved 1,057 patients before matching, and 640 patients post-matching. Functional outcomes at 90 days showed no significant difference between groups in achieving good functional recovery (modified Rankin Scale 0–1 and 0–2), with adjusted odds ratios (OR) of 1.21 (95% confidence interval [CI] 0.81 to 1.79; P=0.35) and 1.00 (95% CI 0.66 to 1.51; P>0.99), respectively. Mortality rates at 90 days were similar between the two groups (OR 0.75, 95% CI 0.44 to 1.29; P=0.30). The incidence of symptomatic intracerebral hemorrhage was comparable, but any type of intracranial hemorrhage was significantly higher in the MT-IVT group (OR 0.43, 95% CI 0.29 to 0.63; P<0.001). Conclusion The results of this study indicate that while MT-IVT and IVT alone show similar functional and mortality outcomes in DMVO patients, MT-IVT presents a higher risk of hemorrhagic complications, thus MT-IVT may not routinely offer additional benefits over IVT alone for all DMVO stroke patients. Further prospective randomized trials are needed to identify patient subgroups most likely to benefit from MT-IVT treatment in DMVO.

Purpose: Despite the significant role of varicocele in the pathogenesis of male infertility, the impact of varicocele repair (VR) on conventional semen parameters remains controversial. Only a few systematic reviews and meta-analyses (SRMAs) have evaluated the impact of VR on sperm concentration, total motility, and progressive motility, mostly using a before-after analytic approach. No SRMA to date has evaluated the change in conventional semen parameters after VR compared to untreated controls. This study aimed to evaluate the effect of VR on conventional semen parameters in infertile patients with clinical varicocele compared to untreated controls. Materials and Methods: A literature search was performed using Scopus, PubMed, Embase, and Cochrane databases following the Population Intervention Comparison Outcome (PICOS) model (Population: infertile patients with clinical varicocele; Intervention: VR [any technique]; Comparison: infertile patients with clinical varicocele that were untreated; Outcome: sperm concentration, sperm total count, progressive sperm motility, total sperm motility, sperm morphology, and semen volume; Study type: randomized controlled trials and observational studies). Results: A total of 1,632 abstracts were initially assessed for eligibility. Sixteen studies were finally included with a total of 2,420 infertile men with clinical varicocele (1,424 patients treated with VR vs. 996 untreated controls). The analysis showed significantly improved post-operative semen parameters in patients compared to controls with regards to sperm concentration (standardized mean difference [SMD] 1.739; 95% CI 1.129 to 2.349; p<0.001; I2=97.6%), total sperm count (SMD 1.894; 95% CI 0.566 to 3.222; p<0.05; I2=97.8%), progressive sperm motility (SMD 3.301; 95% CI 2.164 to 4.437; p<0.01; I2=98.5%), total sperm motility (SMD 0.887; 95% CI 0.036 to 1.738; p=0.04; I2=97.3%) and normal sperm morphology (SMD 1.673; 95% CI 0.876 to 2.470; p<0.05; I2=98.5%). All the outcomes showed a high inter-study heterogeneity, but the sensitivity analysis showed that no study was sensitive enough to change these results. Publication bias was present only in the analysis of the sperm concentration and progressive motility. No significant difference was found for the semen volume (SMD 0.313; 95% CI -0.242 to 0.868; I2=89.7%). Conclusions This study provides a high level of evidence in favor of a positive effect of VR to improve conventional semen parameters in infertile men with clinical varicocele. To the best of our knowledge, this is the first SRMA to compare changes in conventional semen parameters after VR with changes in parameters of a control group over the same period. This is in contrast to other SRMAs which have compared semen parameters before and after VR, without reference to a control group. Our findings strengthen the available evidence and have a potential to upgrade professional societies’ practice recommendations favoring VR to improve conventional semen parameters in infertile men.

Purpose: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility. Materials and Methods: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field. Results: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/ uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available. Conclusions This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Purpose: Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. Materials and Methods: An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. Results: A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4–6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. Conclusions This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.

Background: Physician burnout is a growing problem worldwide. Several interventions aimed at lowering burnout rates among physicians have been implemented. To date, there is no established structured program to combat burnout in the Philippine General Hospital. This study evaluated the effectiveness of the I-CARE program, a physician resilience and wellness program which adapted the different components of the international programs for the Philippine setting.

Objective: To evaluate the effectiveness of the I-CARE program in reducing medical residents' burnout level.

Methods: After key components of the I-CARE program were identified, the program was implemented in 2 phases. The first phase involved training of consultants to hone their facilitation skills. The second phase was a before-and-after study of the I-CARE program. The participants' burnout level was measured before and after the program using the Maslach Burnout Inventory.

Results: The I-CARE program was implemented in the Department of Pediatrics from March to August 2020. There was no significant change in the overall burnout levels of 59 pediatric residents after the I-CARE implementation (p=0.32). This may be due to several challenges encountered during the implementation, such as time constraints, the increased workload caused by the COVID-19 pandemic, and the lack of physical meetings due to the restrictions of the pandemic. However, the feedback of the administrators, facilitators and residents was generally positive. All the interviewed participants recommended the continuation of the I-CARE program in the Department of Pediatrics.

Conclusion: The I-CARE program shows potential in promoting mental health and emotional wellness among physicians in training.

Objective: To determine refractive changes in children post-cataract extraction and intraocular lens (IOL) implantation at a Philippine tertiary hospital. Methods: This is a retrospective cohort study involving patients aged 1 to 10 years in the Department of Ophthalmology of a Philippine tertiary hospital who underwent cataract extraction and IOL implantation between 2004 to 2013. Results: We included 55 eyes of 34 patients in the analysis. Thirty-eight eyes (69%) eyes underwent primary IOL implantation. The mean duration of follow-up was 3.5 ± 2.1 years. The median refractive changes were -2.00 (-2.50, -0.50) diopters (D) for the 1- to 3-year-old group, -1.25 (-1.50, -0.25) D for the 4- to 7-year-old group, and -1.00 (-1.63, -0.25) D for the 8- to 10-year-old group. Only the 1- to 3-year-old group had significant difference between the initial post-operative refraction and the latest follow-up refraction (p<0.001). For the primary implantation group, patients in the 1- to 3-year-old group had the highest median refractive change at -2.00 (-3.125, -1.00) D while patients in the 8- to 10-year-old group had the highest median refractive change at -2.12 (-2.56, -1.69) D in the secondary implantation group. Refractions of eyes with IOL-implanted and normal eyes showed a median difference of -1.00 (-0.25, -3.5) D. Conclusion The determination of the power of IOL implants in pediatric patients who underwent cataract extraction remains challenging despite availability of recommendations.
Lens Implantation, Intraocular ; Child ; Cataract

In the past, many case series have reported the effectiveness of autologous blood patch pleurodesis (ABPP) in recurrent secondary spontaneous pneumothorax (SSP), particularly in those who were unfit for surgery. We describe two cases of persistent air leak in pneumoconiosis and pulmonary fibrosis with bronchiectasis, whereby the techniques employed had improved the success rate of ABPP. The determining factors that lead to the success of ABPP were determined by the volume of autologous blood instilled, Trendelenburg position post instillation, and early chest physiotherapy with mobilisation by application of pneumostat.