INTRODUCTION: Trastuzumab deruxtecan (T-DXd) has revolutionised treatment for metastatic breast cancer (MBC). While effective, its high cost and toxicities, such as fatigue and nausea, pose challenges. METHOD: Medical records from the Joint Breast Cancer Registry in Singapore were used to study MBC patients treated with T-DXd (February 2021-June 2024). This study was conducted to address whether reducing dose intensity and density may have an adverse effect on treatment outcomes. RESULTS: Eighty-seven MBC patients were treated with T-DXd, with a median age of 59 years. At the time of data cutoff, 32.1% of patients were still receiving T-DXd. Over half (54%) of the patients received treatment with an initial relative dose intensity (RDI) of <;85%. Overall median real-world progression-free survival (rwPFS) was 8.1 months. rwPFS was similar between RDI groups (<85%: 8.7 months, <85%: 8.1 months, P=0.62). However, human epidermal growth receptor 2 (HER2)-positive patients showed significantly better rwPFS outcomes compared to HER2-low patients (8.8 versus 2.5 months, P<0.001). Only 16% with central nervous system (CNS) involvement had CNS progressive disease on treatment. No significant progression-free survival (PFS) differences were found between patients with or without CNS disease, regardless of RDI groups. Five patients (5.7%) developed interstitial lung disease (ILD), with 3 (3.4%) having grade 3 events. Two required high-dose steroids and none were rechallenged after ILD. There were no fatalities. CONCLUSION Our study demonstrated that reduced dose intensity and density had no significant impact on rwPFS or treatment-related toxicities. Furthermore, only 5.7% of patients developed ILD. T-Dxd provided good control of CNS disease, with 82% of patients achieving CNS disease control.
Humans ; Female ; Breast Neoplasms/mortality* ; Middle Aged ; Trastuzumab/adverse effects* ; Aged ; Adult ; Singapore/epidemiology* ; Antineoplastic Agents, Immunological/adverse effects* ; Camptothecin/adverse effects* ; Immunoconjugates/adverse effects* ; Retrospective Studies ; Progression-Free Survival ; Receptor, ErbB-2/metabolism* ; Neoplasm Metastasis ; Dose-Response Relationship, Drug ; Treatment Outcome ; Registries

BACKGROUND AND OBJECTIVE

Oral ivermectin is recommended as an alternative to topical permethrin in Japanese, European, and CDC-STI guidelines for treating classic scabies. The combination of oral ivermectin and topical permethrin is also used in some settings. Partial economic evaluations conducted in India and Egypt have conflicting results, and no cost-effectiveness analysis in the Philippines has compared ivermectin-based regimens to permethrin for scabies treatment. We aimed to determine the cost-effectiveness of oral ivermectin, alone or in combination with permethrin, compared to permethrin, in the treatment of Filipino adult patients with classic scabies.

We used a decision tree model to estimate the cost-effectiveness of two regimens, oral ivermectin alone or in combination with permethrin, compared with permethrin to treat adults and children aged five years and older with classic scabies in the outpatient setting from the household perspective in the Philippines. We estimated total costs and disability-adjusted life years (DALYs) over a one-month follow-up. Input parameters were obtained from secondary data, such as effect estimates for probabilities of clinical outcomes from a network meta-analysis, DALYs from the Global Burden of Disease 2019, and prevailing market cost in the Philippines (DPRI 2022 with recommended markup by DOH, and leading drugstores) as of August 2022. We computed for incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) to determine which of the interventions are cost-effective. Univariate and probabilistic sensitivity analyses, and scenario analyses were conducted to assess the impact of parameter and structural uncertainty.

Ivermectin-based regimens are suggested to be likely cost-saving compared to permethrin in the Philippine outpatient setting. Base case analysis showed that oral ivermectin had higher cost-savings (change in cost, -1,039.31; change in DALYS, 0.00027), while combination oral ivermectin/permethrin had higher DALYs averted (change in cost, PhP -1,019.78; change in DALYs, 0.00045), compared to permethrin. Combination oral ivermectin/permethrin (56%) was the most cost-effective, followed by oral ivermectin (44%) compared to permethrin (0%) through probabilistic sensitivity analysis. Estimates for ivermectin were sensitive to risk of cure for ivermectin vs permethrin using 1-way deterministic sensitivity analysis. Oral ivermectin was favored over combination oral ivermectin/permethrin at all thresholds based on the cost-effectiveness acceptability curve.

Both ivermectin-based regimens seem to be cost-saving compared to permethrin in the treatment of classic scabies in the Philippine outpatient setting. Clinicians may consider oral ivermectin, alone or in combination with permethrin as an alternative first-line or second-line treatment depending on patient preference, adverse event risk profile, availability, and economic capacity. This needs to be confirmed using primary data from Filipino patients to enhance the robustness of the findings and support evidence-based local decision-making in different settings. Less uncertainty in modelled parameters can give greater confidence in the results, which can be adopted for budget impact analysis and allow more rational resource allocation. Value of information analysis can be done to determine whether the expense of future RCTs or surveys in Filipinos to collect primary data is worth it. The cost of reducing uncertainty, if deemed worth the cost of further studies, may facilitate population-level decision-making and budget planning. Findings may further inform practice guideline development, coverage decisions, and national control program planning by providing the most cost-effective scabies intervention.

OBJECTIVE

Given that rabies remains endemic in the Philippines despite government interventions and the pandemicrelated restrictions have hampered its surveillance, this study aimed to estimate the effect of human population, anti-rabies vaccination efforts, and COVID-19 situation on the spread of rabies cases in the districts of Davao City, Philippines.

A retrospective study of the canine records at Davao City Veterinarians’ Office was done from January 2018 to June 2021. Monthly rabies cases were ascertained, and the effect of the human population, COVID-19 season, and vaccination ratio on rabies cases was estimated using panel regression models adjusting for confounding factors.

The reporting of rabies cases was lower during COVID-19 than during the non-COVID-19 season, with an IRR of 0.52 [95% confidence interval (CI): 0.33–0.82]. Furthermore, rabies cases increased by 2.23% (95% CI: 0.60–3.89) per 1% increase in vaccination ratio. Additionally, high-population districts recorded more rabies cases than low-population districts.

Consistency in monitoring rabies cases during the pandemic is suggested as a roadmap for future program initiatives. Vaccination efforts should be reinforced to increase rabies awareness and ensure early response to emerging diseases. Moreover, highpopulated districts should be prioritized in implementing rabies control interventions to gain optimal development.

BACKGROUND AND OBJECTIVE

Rabies continues to be a challenge in Davao City despite the efforts of the city’s local government to vaccinate primarily the non-stray dog population. Meanwhile, studies have shown that time-dependent vaccination strategy is considered a prime factor for a cost-effective rabies control strategy. Hence, this study aims to provide information that will determine the optimal vaccination strategy targeted to the stray dog population that minimizes the rabies-infected dog population and vaccination costs using optimal control theory (OCT).

OCT is used to identify the optimal level of key rabies control, i.e., vaccination. Here, OCT was applied to a modified Susceptible-Exposed-Infectious-Vaccinated (SEIV) compartmental model. The study's key parameters were derived from published articles on rabies in Davao City and similar regions, along with the city's rabies reports.

The findings revealed that while rabies remains endemic in the city, it is possible to reduce the number of cases through consistent implementation of vaccination programs to the exposed and susceptible dog populations. Nevertheless, the feasibility of these findings relies to the effective targeting of vaccine coverage for the dog population. From the simulations performed, the exposed dog population (i.e., pre-rabid dogs) was able to reach zero observation when the transmission rate (?) is 0.001 for all values of anti-rabies vaccine coverages for exposed (?) and susceptible (b) dog populations and ? = 0.01 only when ? = 0.7 and b = 0.7, ? = 0.7 and b = 0.5, and ? = 0.5 and b = 0.7. Consequently, the number of infectious dogs will thereby decrease. Moreover, a nonlinear correspondence was also observed in all scenarios between the vaccination rate and the number of rabies-exposed dogs such that the reduction in the incidence of rabies cases becomes apparent only when the vaccination rate is at least 0.9995.

In high rabies transmissibility scenarios, a time-dependent vaccination strategy demonstrated a reduction in the number of rabies-infected dogs. However, this approach involves a trade-off, limiting the period during which monthly vaccinations can be relaxed. Consequently, a robust and timely vaccination program for dogs is crucial to manage high rabies transmission rates. Lastly, the model simulation underscores the importance of initiating monthly vaccinations.

BACKGROUND

Intraoperative transfusion for gynecologic surgery, when appropriately used, can improve patient outcomes. However, when utilized incorrectly, blood transfusion can worsen patient outcomes and increase patient cost. This study aimed to evaluate the blood transfusion practices of tertiary hospitals in the Philippines.

The study utilized a cross-sectional design wherein prospective data were gathered through multiple sources across seven tertiary-level hospitals. Women admitted to undergo gynecologic surgery were recruited based on a set of criteria. A chart review was conducted, and blood utilization indices were calculated. Outcomes were compared between public versus private facilities and transfused versus nontransfused patients.

Among 514 patients, 79.7% underwent cross-matching and 75.1% received transfusions. Adverse events were rare, with no transfusion-related deaths. The overall crossmatch-to-transfusion ratio (C/T ratio) was 2.8, exceeding the 2.5 optimal benchmark; all public hospitals recorded a C/T ratio >2.5, whereas private centers had more efficient usage. Six hospitals met acceptable benchmarks for transfusion probability and transfusion index. Open abdominal procedures, particularly hysterectomy, accounted for the most blood used. Transfused patients had longer operative times, greater blood loss, lower preoperative hemoglobin, and more frequently involved resident physicians in training. Public hospitals recorded higher cross-match and transfusion rates, greater resident physician participation, and broader use of general anesthesia.

Results of the study highlight the importance of monitoring blood transfusion parameters to optimize blood utilization. The observed differences between public and private institutions in the country highlight the urgent need for standardized and evidence-based practice to ensure efficient transfusion protocols nationwide.

BACKGROUND

Sepsis is a life-threatening organ dysfunction in response to an infection, and immediate administration of the first antibiotic dose, along with other resuscitative efforts, improves patient outcomes. This paved the way for the development of evidence-based sepsis pathways in different health institutions.

This study aims to assess the process of initial antibiotic therapy, from the time the loading dose of antibiotic was ordered to the time it was administered, for adult patients with sepsis admitted at the Emergency Department (ED) of the University of the Philippines – Philippine General Hospital (UP-PGH).

In phase 1 of the study, a review of medical records was done to identify all adult patients diagnosed with sepsis in the ED from February 1 to August 31, 2022. A variant of time-motion analysis was used wherein three points in the sepsis pathway were identified: the t ime of diagnosis of sepsis/first chart order of antibiotics (point A), the time the chart order was noted by the nurse-in-charge (point B), and the documented time of f irst dose administration (point C). The mean and median duration (in hours) were then computed between these points. As an additional aim, we briefly presented the outcome of the population used. In phase 2, individual interviews and focused group discussions were done, involving key medical personnel in the sepsis pathway: physicians, nurses, pharmacists, and utility personnel. The data transcribed from these interviews was analyzed through a thematic examination.

A total of 508 adult patients were diagnosed with sepsis on record review, 442 of whom met the inclusion criteria. The median time it took for the nursein-charge to acknowledge the antibiotic order (points A to B) is 0.73 hours (IQR 0.27-1.7). Meanwhile, the median time between acknowledgment of the order to administration of antibiotics is 1.94 hours (IQR 0.83-6.63). More importantly, the median time from diagnosis-to-first dose (points A to C) is 3.53 hours (IQR 1.59–7.96), while the corresponding mean duration is 5.72 hours. In all cases, 44.6% and 12.4% of loading doses were given within three hours and within one hour after diagnosis, respectively. The all-cause mortality of all qualified cases was 64.7%. A total of 28 key medical personnel were recruited for phase 2. Issues regarding governance, information systems, finances, service delivery, and human resources were identified. In particular, the electronic chart system, a more stable supply of antibiotics, and the new pharmacy at the ER helped facilitate antibiotic delivery. Lack of personnel, gaps in information, and repetitive paperwork were cited as areas for improvement in the existing system.

In more than half of the study population, the target time from diagnosis to loading dose of at least 1 hour was not reached. The significant delays in sepsis treatment call for system-wide improvements to hasten the process of antibiotic delivery and reduce the poor outcomes associated with sepsis.

INTRODUCTION

Dementia has been a public health concern for several years. As the population continuously ages, the prevalence of dementia is projected to significantly rise, thus governments will face an increasing demand for support services. Unfortunately, dementia is not recognized as a major public health concern in the Philippines. As the extent of the dementia epidemic needs to be further delineated in the Philippines, and research on dementia is still limited, a larger study is needed to provide more information about the disease burden. This will raise awareness and inform policy makers about the necessity of social and health care reform in dementia care.

We aimed to collect uniform data from patients with cognitive impairment and determine the frequency of dementia and mild cognitive impairment in the study population. These data are crucial for providing information to policy makers in the country.

This is a multi-center, prospective, observational, non-interventional study and standing database of patients clinically diagnosed with Mild Cognitive Impairment (MCI) or dementia seen at the participating training institutions. Corresponding anonymized data on demographics, medical history, risk factors, level of functional impairment, diagnosis, baseline cognitive scores and management will be collected from each patient and entered into the database using a secure online data collection tool. Collective data will be extracted, summarized and analyzed every year with oversight provided by the Philippine Neurological Association (PNA).

Approval from the ethics committees or institutional review boards (EC/IRB) was obtained from the Single Joint Research Ethics Board and all participating institutions.

The PNA1DB-Dementia initiative will be crucial in providing information to policy makers, to further enhance the implementation of the Mental Health Act. The dissemination of results will be conducted through scientific or public conferences and scientific journal publication.

NCT05484960; ClinicalTrials.gov.

Background: Sepsis is a life-threatening organ dysfunction in response to an infection, and immediate administration of the first antibiotic dose, along with other resuscitative efforts, improves patient outcomes. This paved the way for the development of evidence-based sepsis pathways in different health institutions. Objectives: This study aims to assess the process of initial antibiotic therapy, from the time the loading dose of antibiotic was ordered to the time it was administered, for adult patients with sepsis admitted at the Emergency Department (ED) of the University of the Philippines – Philippine General Hospital (UP-PGH). Methods: In phase 1 of the study, a review of medical records was done to identify all adult patients diagnosed with sepsis in the ED from February 1 to August 31, 2022. A variant of time-motion analysis was used wherein three points in the sepsis pathway were identified: the t ime of diagnosis of sepsis/first chart order of antibiotics (point A), the time the chart order was noted by the nurse-in-charge (point B), and the documented time of f irst dose administration (point C). The mean and median duration (in hours) were then computed between these points. As an additional aim, we briefly presented the outcome of the population used. In phase 2, individual interviews and focused group discussions were done, involving key medical personnel in the sepsis pathway: physicians, nurses, pharmacists, and utility personnel. The data transcribed from these interviews was analyzed through a thematic examination. Results: A total of 508 adult patients were diagnosed with sepsis on record review, 442 of whom met the inclusion criteria. The median time it took for the nursein-charge to acknowledge the antibiotic order (points A to B) is 0.73 hours (IQR 0.27-1.7). Meanwhile, the median time between acknowledgment of the order to administration of antibiotics is 1.94 hours (IQR 0.83-6.63). More importantly, the median time from diagnosis-to-first dose (points A to C) is 3.53 hours (IQR 1.59–7.96), while the corresponding mean duration is 5.72 hours. In all cases, 44.6% and 12.4% of loading doses were given within three hours and within one hour after diagnosis, respectively. The all-cause mortality of all qualified cases was 64.7%. A total of 28 key medical personnel were recruited for phase 2. Issues regarding governance, information systems, finances, service delivery, and human resources were identified. In particular, the electronic chart system, a more stable supply of antibiotics, and the new pharmacy at the ER helped facilitate antibiotic delivery. Lack of personnel, gaps in information, and repetitive paperwork were cited as areas for improvement in the existing system. Conclusion In more than half of the study population, the target time from diagnosis to loading dose of at least 1 hour was not reached. The significant delays in sepsis treatment call for system-wide improvements to hasten the process of antibiotic delivery and reduce the poor outcomes associated with sepsis.
Human ; sepsis

Morphea is a rare, chronic inflammatory condition that affects the skin and subcutaneous tissues with an unclear etiology. Genetic predisposition, autoimmune dysregulation, and environmental factors play a role in its pathogenesis. It affects both adults and children and presents as erythematous patches or plaques that develop sclerotic centers with a violaceous border. Early diagnosis and treatment are crucial to minimize damage and physical sequelae.

We present here a 30-year old female who presented with a solitary, violet-hue in color, indurated plaque on her left forearm after wearing a metal smartwatch for 4 months. She experienced on and off episodes of overheating from the watch but continued wearing it. There was no associated pruritus, tenderness, or loss of sensation. Anti-dsDNA showed a borderline positive result. Vitamin D levels were below the lower limit revealing a severe Vitamin D deficiency. Dermoscopy revealed fibrotic beams, branching vessels and an erythematous to pink background. Histopathologic analysis showed superficial and deep perivascular and periadnexal infiltrates of lymphocytes and plasma cells with compact collagen bundles and notable loss of periadnexal fat. The patient was started on topical halobetasol then shifted to tacrolimus 0.01% and started on targeted NB-UVB. Excellent response was seen after 9 sessions of phototherapy. There was a decrease in induration, size and no further progression.

Morphea is a rare inflammatory condition without a clear etiology and early diagnosis and treatment are important. This case highlights the relationship between gadget trauma and the development of Morphea.

Kaposi Sarcoma (KS) is a vascular tumor commonly associated with HIV/AIDS. There is unusual presentation of KS in a non-HIV patient, initially diagnosed as small vessel vasculitis. Early recognition and accurate diagnosis are important for the patient’s best management.

A 68-year-old male presented with spontaneous bluish-black patches on his extremities, swelling, pain, and bullae on his toes. Initial workup, including negative ANA and ANCA markers, pointed to small vessel vasculitis, with autoimmune, hematologic, and occlusive diseases considered. Peripheral vascular occlusion was ruled out, and a biopsy showed granulomatous vasculitis. Despite corticosteroid treatment, the lesions worsened. Five months later, the patient developed violaceous papules, plaques, and nodules. A second biopsy confirmed Kaposi Sarcoma (KS) with positive CD34 and HHV-8 stains. Restaining the initial biopsy also revealed KS. Treatment with Doxorubicin was initiated, but the disease progressed, affecting the gastrointestinal system. The patient’s condition deteriorated, and he died from complications of KS.

This case underscores the importance of considering Kaposi Sarcoma in HIV-negative patients with vascular lesions. The initial diagnosis of vasculitis, confirmed by granulomatous changes, delayed the KS diagnosis. Restaining the first biopsy later confirmed the presence of KS from the onset. The extensive skin and gastrointestinal involvement made management with Doxorubicin difficult, leading to a poor outcome.