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

Introduction: Accurate diagnosis of thyrotoxicosis, a condition resulting from excessive thyroid hormone activity, is essential for appropriate management. However, access to diagnostic tools such as thyrotropin receptor antibody (TRAb) assays and thyroid ultrasonography remains limited in resource-constrained settings, highlighting the need for cost-effective alternatives. Recent studies suggest that the free triiodothyronine to free thyroxine (FT3/FT4) ratio may serve as a potential biomarker for differentiating the causes of thyrotoxicosis. Methodology: This cross-sectional study evaluated the FT3/FT4 ratio in newly diagnosed thyrotoxicosis patients aged ≥18 years recruited from Hospital Tengku Ampuan Rahimah, Hospital Banting, Klinik Kesihatan Pelabuhan Klang, and Klinik Kesihatan Pandamaran between February and December 2025. All participants underwent thyroid function testing (FT3, FT4, and TSH) and autoantibody assessment (TRAb and anti-thyroid peroxidase [anti-TPO]). Diagnostic performance of the FT3/FT4 ratio for Graves’ disease was assessed using receiver operating characteristic (ROC) curve analysis. Results: Fifty-eight patients were included, of whom 58.6% were diagnosed with Graves’ disease. Patients with Graves’ disease had significantly higher FT3 levels (median 16.8 pmol/L; IQR 10.9–25.7) compared to those with non-Graves’ thyrotoxicosis (median 8.3 pmol/L; IQR 5.3–13.5; p <0.001), with similar trends observed for FT4 levels (p <0.001). However, the FT3/ FT4 ratio did not differ significantly between groups (p >0.05), with an overall ROC AUC of 0.572, indicating poor discriminatory ability. Subgroup analysis based on FT4 levels improved performance; at FT4 <30 pmol/L, the FT3/FT4 ratio demonstrated 75.0% sensitivity, 91.7% specificity, and 87.5% diagnostic accuracy at a cutoff of 0.3445 (AUC = 0.813; 95% CI: 0.570–1.000; p = 0.069). No significant association was observed between the FT3/FT4 ratio and TRAb or anti-TPO. Conclusion The FT3/FT4 ratio has limited overall diagnostic utility but may provide adjunctive value in selected biochemical contexts, particularly in settings with limited access to immunological testing.
Diagnosis, Differential ; Thyroxine ; Triiodothyronine ; Thyrotoxicosis ; Cross-Sectional Studies

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) improve glycemic control, promote weight loss, reduce insulin requirements, and confer cardiometabolic benefits in type 2 diabetes mellitus (T2DM). This audit evaluated glycemic and metabolic outcomes of GLP-1 RAs in T2DM patients at a single-centre diabetes clinic. Methodology: This audit included T2DM patients who initiated GLP1 RAs between January 2022 and March 2025 at Hospital Sultan Abdul Halim. Primary outcomes were changes in hemoglobin A1c (HbA1c), body weight, and body mass index (BMI) at 3 and 12 months. Secondary outcomes included percentage weight loss, changes in systolic blood pressure (SBP), insulin total daily dose (TDD), low-density lipoprotein (LDL) cholesterol, gastrointestinal adverse effects, and treatment discontinuation. Results: Sixteen patients were included; median age was 58.5 years (interquartile range [IQR] 47.5–65), and 56.3% were female. Median diabetes duration was 15 years (IQR 11.5–20.3). Median HbA1c decreased from 9.7% (IQR 8.6–10.4) at baseline to 8.8% (IQR 7.7–9.1) at 3 months and 7.8% (IQR 7.0–8.5) at 12 months. Body weight decreased from 88.1 kg (IQR 79.5–122.1) at baseline to 85.0 kg (IQR 75.9–113.7) at 3 months and 82.0 kg (IQR 74.8–117.3) at 12 months. BMI decreased from 37.8 kg/m&sup2; (IQR 31.7–47.1) to 37.3 kg/m&sup2; (IQR 30.7–45.5) at 3 months and 36.0 kg/m&sup2; (IQR 30.1–45.6) at 12 months. At 12 months, weight loss was 5.8% (IQR 3.0–8.0), with 56.5% achieving >5% weight reduction. In all, 93.8% achieved >1% HbA1c reduction. Mean SBP decreased by 10 ± 20 mmHg, LDL cholesterol 0.29 mmol/L (IQR -0.77 to 0.07), and insulin TDD 8 units/day (IQR -13 to 10). No gastrointestinal adverse effects reported. Three patients (18.8%) discontinued treatment due to excessive weight loss, treatment plateau, and limited drug availability. Conclusion From our single-centre experience, the observed improvements in glycemic and metabolic outcomes support the benefits of GLP-1 RAs in managing T2DM.
Diabetes Mellitus, Type 2 ; Glucagon-Like Peptide-1 Receptor Agonists ; Clinical Audit

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) induce clinically meaningful weight reduction in patients with type 2 diabetes mellitus (T2DM), but real-world data in Southeast Asian populations are limited. This study evaluated the effectiveness of GLP-1 RAs in achieving clinically significant weight loss in Malaysian patients with obesity and T2DM. Methodology: A retrospective cohort study was conducted among adults with T2DM and obesity attending the Endocrinology Clinic at Hospital Sultan Abdul Aziz Shah between January 2023 and December 2024. Patients receiving GLP-1 RAs (semaglutide or liraglutide) were compared with those on standard care. Anthropometric outcomes were assessed over 6–12 months, with weight loss thresholds of ≥3, ≥5, and ≥10%. Between-group comparisons used Fisher’s exact test, and odds ratios (OR) were calculated. Results: Eighty-five patients were included (GLP-1, n = 47; control, n = 38). The GLP-1 group achieved significantly higher rates of any weight loss (70.0% vs 41.2%; OR = 3.33, p = 0.019) and ≥3% weight loss (42.5% vs 14.7%; OR = 4.29, p = 0.011). Number needed to treat was 3–4 patients. Proportions achieving ≥5 and ≥10% weight loss were higher in the GLP-1 group but did not reach statistical significance. Conclusion GLP-1 RA therapy significantly improves the likelihood of clinically meaningful weight loss in Malaysian patients with obesity and T2DM. These findings support the integration of GLP-1 RAs into routine obesity management strategies in Southeast Asia.
Humans ; Diabetes Mellitus, Type 2 ; Glucagon-Like Peptide-1 Receptor Agonists ; Weight Loss

Introduction: While Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are effective for weight reduction in type 2 diabetes mellitus (T2DM), interindividual variability exists. Lifestyle factors, particularly baseline physical activity, may modify weight loss outcomes. This study examined whether baseline activity influences GLP-1 RA efficacy in Malaysian patients. Methodology: A retrospective cohort of adults with obesity and T2DM receiving GLP-1 RAs (semaglutide or liraglutide) from January 2023 to December 2024 was analyzed. Baseline physical activity was classified as active or inactive. Primary outcomes were achievement of ≥3 and ≥5% weight loss over 6–12 months. Associations were assessed using Fisher’s exact test and logistic regression. Results: Among GLP-1-treated patients, those reporting baseline physical activity were more likely to achieve ≥3% weight loss and demonstrated trends toward higher, ≥5%, weight loss. Logistic regression suggested baseline activity increased the odds of clinically meaningful weight reduction, though statistical significance was limited by sample size. Conclusion Baseline physical activity may enhance GLP-1 receptor agonist-mediated weight loss in obese patients with T2DM. Integrating lifestyle interventions with pharmacotherapy may optimize treatment outcomes. Larger prospective studies are warranted to confirm these findings.
Humans ; Glucagon-Like Peptide-1 Receptor Agonists ; Exercise ; Weight Loss ; Obesity ; Diabetes Mellitus, Type 2

Introduction: Thyroid hormone resistance syndrome (THR) is a disorder characterized by reduced responsiveness of target tissues to thyroid hormones with non-suppressed thyroidstimulating hormone (TSH) despite elevated free thyroxine 4 (FT4). Diagnosing and managing THR in athyreotic patients, however, is challenging; indeed, TSH levels post thyroidectomy for Differentiated Thyroid Carcinoma in patients with THR have been reported to reach levels as high as 112.59 mIU/L despite high-dose thyroxine-suppressive therapy. This case highlights the complexities in diagnosing Resistance to Thyroid Hormone (RTH) post-thyroidectomy. Case: A 63-year-old female with end-stage renal failure (ESRF) on hemodialysis and prior parathyroidectomy for tertiary hyperparathyroidism underwent total thyroidectomy in 1997 for presumed benign goiter. Following surgery, she demonstrated persistently elevated TSH, ranging from 93.2 to 670.4 mIU/L (0.55–4.78 mIU/L), with normal to mildly elevated FT4 levels, ranging from 17 to 35 pmol/L (11.5–22.7 pmol/L), while on thyroxine replacement doses as low as 0.86 ug/kg. Discordant thyroid function tests (TFTs) were consistent across different assay platforms. Polyethylene glycol precipitation excluded macro-TSH interference. Intermittent levothyroxine increments suppressed TSH but led to thyrotoxic symptoms, including weight loss, heat intolerance, insomnia, and fragility fracture. Uncontrasted pituitary magnetic resonance imaging (risk of nephrogenic systemic fibrosis with gadolinium in ESRF) showed a small pituitary gland without adenoma, excluding TSH-oma. T3 suppression test was relatively contraindicated due to her advanced age and co-morbidities. There was no family history of thyroid disorder; the patient’s only child had a normal TFT, and her parents/siblings could not be tested. A working diagnosis of RTH&beta; was made. She declined genetic testing for RTH. She is currently on levothyroxine 50 mcg OD (1.07 ug/kg) with FT4 16.1 pmol/L and TSH 562 mIU/L with no symptoms/signs of hypo or hyperthyroidism. Conclusion This case highlights the diagnostic challenges in managing possible RTH&beta; post-total thyroidectomy. Treatment should be guided by clinical status and target of mid-to-normal FT4 rather than TSH to avoid iatrogenic thyrotoxicosis.
Thyroidectomy ; Thyroid Hormones

Introduction: Discordant thyroid function tests (TFTs), characterized by elevated free thyroxine 4 (FT4) with non-suppressed thyroid-stimulating hormone (TSH), pose a significant diagnostic challenge. Differentiating between Resistance to Thyroid Hormone (RTH) and TSH-secreting pituitary adenoma (TSH-oma) is essential, as management strategies differ substantially. Case: A female with a history of hyperthyroidism diagnosed in 2011 was treated with antithyroid drugs for 1 year before defaulting on follow-up. She was later found to have discordant TFTs at a private centre, where a brain computed tomography scan was reportedly normal. She was referred to our centre for optimization of thyroid function prior to planned thyroidectomy for a solitary large right thyroid nodule measuring 4.2 × 2.8 × 4.7 cm. Fine-needle aspiration cytology demonstrated a benign follicular lesion (Bethesda II). Despite restarting antithyroid medication, she remained clinically euthyroid with no overt thyrotoxic symptoms apart from intermittent palpitations without documented tachycardia. Antithyroid therapy was discontinued. Serial TFTs across multiple assay platforms consistently demonstrated elevated FT4 with inappropriately normal TSH levels. Thyroid autoantibodies, including TSH receptor and anti-thyroid peroxidase antibodies, were negative. Pituitary magnetic resonance imaging showed no evidence of adenoma, and serum &alpha;-subunit level was normal (0.3 ng/ mL), making TSH-oma unlikely. Dynamic testing was not performed as thyrotropin-releasing hormone stimulation was unavailable at our centre, while T3 suppression testing was deemed inappropriate due to symptomatic palpitations. Family screening was not possible as the patient was not in contact with her relatives. In the absence of pituitary pathology and given her largely euthyroid clinical status, RTH was considered the most likely diagnosis. Conclusion This case highlights the importance of considering RTH in patients with persistent discordant TFTs, particularly when clinical findings do not correlate with biochemical abnormalities. Early recognition and appropriate pituitary evaluation are essential to prevent misdiagnosis and avoid unnecessary antithyroid therapy or thyroidectomy.
Pituitary Neoplasms ; Thyroid Hormones ; Thyrotropin

Introduction: Precocious puberty is increasingly recognized in children. Effect of gonadotropin-releasing hormone agonist (GnRHa) on height velocity (HV) and body mass index (BMI) during treatment of Central Precocious Puberty (CPP) is not welldocumented. Methodology: Records of all patients treated with GnRH for CPP who attended the paediatric endocrine clinic over a 5-year period (2021–2025) [N1.1] were reviewed retrospectively for HV and BMI changes for 3 consecutive years. Basal luteinizing hormone levels ≥0.3 IU/L or stimulated levels ≥5 IU/L are considered diagnostic of CPP. Results: Twenty patients were reviewed and median age at the start of study was 7.8 years (4.3–10.3). Majority were female (n = 18, 90%) with median Tanner Stage 3 and of Malay origin (n = 18, 90%[N2.1]). Median chronological age was 7.8 years (4.3–10.3) with bone age 10.3 years (5.8–13.4). Causes of CPP were idiopathic (n = 16, 80%), CNS lesion (n = 2, 10%) and poorly controlled congenital adrenal hyperplasia (n = 2, 10%). Nine (82%) of the 11 patients who had MRI brain done had normal findings. After 1 year of treatment, the median HV SDS was −0.83 (range −2.45 to 2.42), and BMI SDS was 0.45 (−1.94 to 2.15). After 2 years (n = 12), HV SDS declined to −1.3 (−3.44 to 0.69), with BMI SDS of 0.13 (−1.16 to 1.79). After 3 years (n = 9), HV SDS declined further to −1.51 (−3.52 to 3.13), and BMI SDS was 0.16 (−0.12 to 1.25). After 1 year of treatment, 20% (n = 4) of patients were overweight and 10% (n = 2) were obese. By 3 years, 22% (n = 2) remained overweight, and none were obese. Conclusion Premature growth plate senescence induced by prior estrogen exposure may lead to HV decline. Although obesity is a risk factor for the onset of CPP, whether GnRHa treatment directly increases BMI remains controversial as our cohort’s BMI change reveals otherwise.
Child ; Body Mass Index ; Puberty, Precocious ; Hormones

OBJECTIVE: To observe the effect of perioperative transcutaneous electrical acupoint stimulation (TEAS) on postoperative fatigue syndrome (POFS) in elderly patients undergoing laparoscopic radical gastrectomy. METHODS: A total of 80 elderly patients scheduled for laparoscopic radical gastrectomy were randomized into a TEAS group and a sham TEAS group, 40 cases in each one. In the TEAS group, TEAS intervention was applied at bilateral Hegu (LI4), Neiguan (PC6), Zusanli (ST36) and Sanyinjiao (SP6) from 30 min before anesthesia induction until surgery completion, and at 18:00 on 1st, 2nd and 3rd days after surgery, once a day, 30 min a time. In the sham TEAS group, the same acupoints were selected and connected to the electroacupuncture device at the same time, without electrical stimulation. One day before surgery and 1, 3, 7 days after surgery, the 10-item short form of identity consequence fatigue scale (ICFS-10) score was observed, and the POFS incidence rate of 1, 3, 7 days after surgery was assessed in the two groups. One day before surgery, surgery completion, and 1, 3 days after surgery, the serum levels of superoxide dismutase (SOD), β-endorphin (β-EP) were detected; 1 day before surgery and 1, 3, 7 days after surgery, the serum level of tumor necrosis factor-α (TNF-α) was detected in the two groups. The pain visual analog scale (VAS) score was observed at 24, 48 and 72 h after surgery; the intraoperative dosage of propofol and remifentanil, and the incidence rate of postoperative nausea and vomiting, itching, respiratory depression were recorded in the two groups. RESULTS: In the TEAS group, on 1, 3, 7 days after surgery, except for the scores of item 8-10, the item scores and the total scores of ICFS-10 were lower than those in the sham TEAS group (P<0.001); on 3 and 7 days after surgery, the POFS incidence rates were lower than those in the sham TEAS group (P<0.05). In the TEAS group, on 1 and 3 days after surgery, the serum levels of SOD were higher than those in the sham TEAS group (P<0.05, P<0.01); at surgery completion, and on 1, 3 days after surgery, the serum levels of β-EP were higher than those in the sham TEAS group (P<0.001, P<0.01); on 1, 3, 7 days after surgery, the serum levels of TNF-α were lower than those in the sham TEAS group (P<0.01, P<0.001). In the TEAS group, at 24, 48 and 72 h after surgery, the pain VAS scores were lower than those in the sham TEAS group (P<0.001, P<0.01, P<0.05); the intraoperative dosage of remifentanil was lower than that in the sham TEAS group (P<0.001); the incidence rate of postoperative nausea and vomiting was lower than that in the sham TEAS group (P<0.01). CONCLUSION Perioperative TEAS intervention can effectively reduce the incidence rate of POFS, improve fatigue symptom and mental state in elderly patients undergoing laparoscopic radical gastrectomy, its mechanism may related to enhancing endogenous β-EP release, inhibiting inflammatory response, and reducing central oxidative stress, thereby promoting postoperative recovery.
Humans ; Acupuncture Points ; Male ; Female ; Aged ; Transcutaneous Electric Nerve Stimulation ; Postoperative Complications/therapy* ; Middle Aged ; Fatigue/etiology* ; Gastrectomy/adverse effects* ; beta-Endorphin/blood* ; Tumor Necrosis Factor-alpha/blood*

OBJECTIVE: To observe the regulatory effects of moxibustion at "Guanyuan" (CV4) on the synthesis of extragonadal estradiol (E₂) and the expression of estrogen receptor (ER) in ovariectomized rats, aiming to explore the mechanism of moxibustion treatment for perimenopausal syndrome. METHODS: Forty-eight SD female rats of SPF grade were randomly divided into a sham-operation group, a model group and a moxibustion group, with 16 rats in each group. The model group and the moxibustion group underwent bilateral ovariectomy by the back incision method. Ten days after surgery, moxibustion was applied at "Guanyuan" (CV4) in the moxibustion group, 30 min each time, once a day for 10 days. After intervention, in the 3 groups, the body mass and uterus weight were measured; the serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH) and E₂, as well as the skin and hypothalamus levels of E₂ were detected by ELISA; the mRNA expression of aromatase (P450arom) in the skin and hypothalamus was detected by real-time PCR; the expression of ERα and ERβ in the hypothalamus, skin, and uterus was observed by immunofluorescence staining, and the density of positive cells was calculated using the Aipathwell digital pathology image analysis software. RESULTS: Compared with the sham-operation group, the body mass was increased (P<0.01) and the uterus weight was decreased (P<0.001) in the model group. Compared with the model group, the body mass was decreased in the moxibustion group (P<0.01). Compared with the sham-operation group, in the model group, the serum, hypothalamus and skin levels of E₂ were decreased (P<0.01, P<0.05), while the serum levels of FSH and LH were increased (P<0.01); the expression of ERα and ERβ in the skin, hypothalamus and uterus was decreased (P<0.05, P<0.001). Compared with the model group, in the moxibustion group, the serum levels of E₂ and LH, as well as the hypothalamus and skin levels of E₂ were increased (P<0.05, P<0.01); the mRNA expression of P450arom, as well as the expression of ERα and ERβ in the skin and hypothalamus were increased (P<0.05). CONCLUSION Moxibustion at "Guanyuan" (CV4) reduces the body mass of ovariectomized rats by enhancing the synthesis of extragonadal E₂ and increasing the expression of ER in the skin and hypothalamus, yet it does not alleviate uterine atrophy.
Animals ; Female ; Moxibustion ; Rats ; Ovariectomy ; Acupuncture Points ; Rats, Sprague-Dawley ; Humans ; Receptors, Estrogen/genetics* ; Estrogens/metabolism* ; Estradiol/metabolism* ; Hypothalamus/metabolism* ; Follicle Stimulating Hormone/blood* ; Aromatase/genetics* ; Luteinizing Hormone/blood* ; Skin/metabolism*