BACKGROUND

Melioidosis is an infectious disease caused by Burkholderia pseudomallei. It is endemic in the Philippines and is underreported. Of the reported cases, the most common comorbidity is diabetes mellitus. The increasing cases of antibiotic resistance and the relatively high mortality rate highlights the need for increased awareness among clinicians regarding this disease. We aim to report a case of Burkholderia pseudomallei resistant to trimethoprim/sulfamethoxazole (TMP-SMX), used in its eradication following initial intravenous therapy.

A 51-year-old male Filipino with poor health-seeking behavior came with generalized body weakness, weight loss, dysarthria, fever, cough, difficulty breathing, bloatedness, dysuria, joint pains, and bilateral lower extremity hyperpigmented macules for four months. He has diabetes mellitus and hypertension and is a mechanic by trade. Initial workups revealed hemoglobin A1c (HbA1c) of 14.7%, and urinalysis with bacteriuria. Imaging revealed bilateral pneumonia on chest xray, hepatosplenomegaly on whole abdomen ultrasound, and old cerebral infarcts on cranial computed tomography scan (CT scan). Empiric antibiotics for the impression of sepsis from community-acquired pneumonia and urinary tract infection were ertapenem and azithromycin. Upon isolation of Burkholderia pseudomallei from blood cultures, the team shifted to TMP-SMX and ceftazidime for initial therapy of melioidosis. Sensitivity showed resistance to TMP-SMX; hence the team revised the antimicrobials to four weeks of levofloxacin and ceftazidime. After eleven hospital days, the team sent the patient home, clinically improved. The team continued levofloxacin for eradication therapy for three months and the patient responded well.

Fever with multi-system involvement in a Filipino patient with diabetes mellitus with significant environmental risk factors, poor glycemic control, splenomegaly, and treatment failure with appropriate empiric antibiotic therapy should raise suspicion for melioidosis. It is paramount that antimicrobial resistance be detected and documented upon isolation of Burkholderia pseudomallei, given the high relapse rates and the need for a prolonged duration of treatment.

OBJECTIVE

To assess the diagnostic accuracy of point-of-care screening using Medios™ Artificial Intelligence (AI) in the diagnosis of diabetic retinopathy (DR).

This is a multi-center, cross-sectional, instrument validation study among adult Filipinos with Type 2 diabetes seen at Endocrine specialty clinics from May to November 2021. Retinal images were captured by a minimally trained nurse using the Remedio Fundus on Phone (FOP). Images were interpreted separately by the Medios™ AI and three retina specialists. The primary outcome measure is the accuracy of Medios™™ AI in diagnosing DR compared to retina specialists’ findings using sensitivity and specificity, predictive values, and likelihood ratios.

A total of 182 subjects with Type 2 diabetes were included in the study. The sensitivity and specificity of the Medios™ AI in diagnosing any DR were 73.68% (95%CI, 57.99-85.03) and 83.74% (95%CI, 79.35-87.35), respectively, compared with the retinal specialists’ findings using the same images. The positive and negative predictive values were 34.57% (95%CI, 25.12-45.41) and 96.47% (95%CI, 93.62-98.07). The positive and negative likelihood ratios were 4.53 (95%CI, 4.26 4.82) and 0.31 (95%CI, 0.26-0.38). The overall diagnostic accuracy of Medios™ AI in detecting DR was 82.69% (95%CI, 78.47-86.23).

The Medios™ AI system showed acceptable diagnostic accuracy when used as a point-of-care screening tool in detecting DR among patients with Type 2 diabetes seen at Endocrine specialty clinics. This technology can be a useful screening tool for endocrinologists as it is relatively inexpensive, safe, and easily performed. It can also shorten the lead time from screening to referral and intervention.

BACKGROUND

Diabetes Mellitus (DM) is a long-term metabolic disease distinguished by persistently elevated levels of glucose in the bloodstream. It affects 7.5% of adults in the Philippines, translating to 4,303,899 adults with diabetes in 2021. Type 2 DM (T2DM), which results from a combination of genetic predispositions and lifestyle choices, is the most prevalent form of diabetes in the Philippines. Foot ulcers are a common and highly comorbid complication of diabetes. By improving the knowledge and behavior regarding foot care using health education strategies, preventing diabetic foot ulcers is achievable.

This study aims to evaluate the effectiveness of health education strategies in improving the knowledge and behavior of participants diagnosed with T2DM regarding foot ulcer prevention in Binangonan, Rizal.

This study uses a quantitative quasi-experimental design. A 2-day workshop will be held by the researchers, including a screening, pretest, orientation on the health education material (HEM), and demonstration of the HEM content, followed by 2-weeks of self-intervention and posttest. The study will include males and females from Binangonan, Rizal, aged 20-79, who are medically diagnosed with T2DM by a physician. The effectiveness of the strategies will be evaluated using paired t-tests based on the mean of the pre-test and post-test scores obtained from the Diabetic Foot Knowledge Subscale (DFKS) and Foot Self-Care Behavior Scale (FSCBS) questionnaire.

The researchers expect an increase in the post-test scores of the participants in the DFKS and FSCBS questionnaires. This would mean increased behavior and knowledge of foot care practices to prevent diabetic foot ulcers after 2 weeks of self-intervention guided by the HEM and strategies.

INTRODUCTION

Patients with diabetes are at higher risk of developing severe COVID-19 infection with a two-fold increased risk of mortality. This study described the risk factors affecting clinical outcomes of confirmed COVID-19 patients with diabetes mellitus at the University of Santo Tomas Hospital, Manila, Philippines.

This retrospective study included 204 patients with COVID-19 (34 with known type 2 diabetes and 2 with new-onset diabetes) from March to October 2020. Clinical characteristics and laboratory parameters were collected and analyzed in subjects with diabetes. A univariate logistic regression was used to calculate the odds ratios and 95% confidence interval (CI) for the patient’s risk factors associated with mortality or poor prognosis.

Moderate COVID-19 infection occurred in 52.8% of type 2 diabetes mellitus (T2DM) patients and critical COVID-19 infection in 27.8%. All patients with critical COVID-19 infection presented with acute respiratory distress syndrome, half had concomitant septic shock and respiratory failure was observed in 27.8%. The average length of hospital stay was approximately 17.5 days. T2DM patients with established atherosclerotic cardiovascular disease (ASCVD) are 5.1 times (95% CI 1.2 to 21.4) more likely to develop severe or critical COVID-19 infection, and more likely to stay in the hospital for more than 14 days. HbA1c >8.5% is a potential risk (OR = 3.7, 0.6 to 21.6) for severe to critical disease. T2DM patients with concomitant coronary artery disease are 7.6 times (95% CI 1.3 to 43.4) more likely to stay longer (more than 14 days) as compared to those without existing coronary artery disease. Prior statin use was a significant risk factor for ICU admission (p-value 0.0341). Other potential risk factors affecting clinical outcomes are obesity (OR 3, 0.4 to 22.7), prior use of thiazolidinedione (OR 7.8, 0.5 to 126.7) or sodium-glucose transporter 2 (SGLT2) inhibitors (OR 7.5, 0.4 to 145) and prior use of anti-thrombotic (OR 4.6, 0.4 to 56.8). The recovery rate of T2DM patients hospitalized for COVID-19 infection was 86.1%.

Patients with T2DM are more vulnerable to COVID-19 infection. The presence of established ASCVD increases the likelihood of severe COVID-19 disease as well as longer length of hospital stay for more than 14 days. Early recognition and prompt treatment led to a favorable recovery rate.

INTRODUCTION

Administration of antenatal corticosteroids (ACS) between 24 and 36 weeks of gestation is recommended to pregnant women at risk of preterm delivery to decrease the risk of respiratory distress syndrome, intra-ventricular hemorrhage and neonatal death. However, it may worsen glycemic profile primarily in those with gestational diabetes mellitus (GDM).

To determine the effects of ACS on maternal glycemia in Filipino women with GDM and to analyze the factors associated with insulin use or increased insulin requirement.

A retrospective study of the medical records of Filipino women with GDM who were admitted and received ACS treatment (betamethasone) between 24- and 36-weeks age of gestation (AOG) for fetal lung maturity from 2017-2019. Clinical characteristics (age, parity, completed ACS dose, AOG at ACS administration and mode of delivery) and glycemic control were retrieved and compared before and after ACS treatment. Data collection began the day or on the day before steroids were given and continued until discharge or delivery.

Included were 42 pregnant women with GDM. Of these, 28 women with GDM were treated by diet alone (Group A) while 14 women with GDM were started on insulin in addition to diet (Group B). After betamethasone therapy was initiated, only three (Group A1; n=3/28) patients had good glycemic control with diet alone and the rest were given insulin treatment (Group A2; n=25/28). In this subpopulation of Group A2, insulin requirement within 24 hours after ACS was at 0.3 units per kg of body weight. There was a steady increase with maximum requirement observed on day 4 and decreased thereafter to 0.33 units per kg of body weight on day 5. For GDM women in Group B, only three maintained their insulin dose (Group B1; n=3/14) while 11 (Group B2; n=11/14) women with GDM previously on insulin, required further increase in insulin from day 1-2 reaching 140% increase in insulin dose on day 2. Thereafter, there was a gradual decrease of insulin dose almost returning to initial dose on day 5.

Insulin initiation was observed among GDM diet-controlled mothers (Group A) who were given ACS therapy at ≥31 weeks age of gestation. Age, parity, family history of diabetes and mode of delivery did not have significant effects on insulin use nor increased insulin requirement. Fasting capillary glucose (FCG) and one-hour post-prandial capillary glucose (PPCG) were elevated within 24 hours after administration of corticosteroid (betamethasone) in 60%-70% of our population. The FCG values remained elevated on day 2-3 in about 70% of patients. While the first hour PPCG was elevated in 85% of patients on day 2 and remained elevated in 70% of women on day 3-4, it reached 53% on day 5. Insulin requirement among Group B2 reached to 140% increase in insulin dose on day 2 followed by a gradual decrease of insulin dose almost returning to initial dose on day 5.

ACS administration caused maternal hyperglycemia in Filipino women with GDM during the first 24 hours and lasting up to five days. Both fasting glucose and post-prandial glucose were elevated, hence intensified monitoring of maternal glucose levels and temporary addition or increase of insulin doses may be necessary. The timing (≥31 weeks AOG) of administration of ACS on GDM women was associated with subsequent insulin initiation but only on patients initially controlled on diet alone.

BACKGROUND

Non-Alcoholic Fatty Liver Disease (NAFLD) is common in Type 2 Diabetes Mellitus (T2DM). The FIB-4 index is one of the most-studied non-invasive biomarkers that combines age and laboratory parameters (platelet count, alanine-and aspartate- aminotransferase) to evaluate underlying hepatic fibrosis. This study aims to determine the diagnostic value of Fibrosis-4 (FIB-4) index scoring in screening for non-alcoholic fatty liver disease in patients with type 2 diabetes mellitus, which is a high-risk population in development of advance fibrosis.

A single center, analytical cross-sectional study was conducted among adult T2DM patients with and without NAFLD seen at the Out-Patient Department (OPD) and those with NAFLD enrolled under the Liver Disease Databank of the Liver Disease and Transplant Center in collaboration with Research and Biotechnology Division at St. Luke’s Medical Center, Quezon City. Medical history was obtained by reviewing charts of eligible patients using data collection form. Liver ultrasound was used as the reference standard in the diagnosis of NAFLD. The FIB-4 index was calculated with this formula: age (years) x AST (U/L)/(platelets (10^9/L) x ALT (U/L)^1/2.

A total of 305 adult patients with type 2 diabetes mellitus were included in the study. The prevalence of non-alcoholic fatty liver disease based on ultrasound among diabetic patients is 76.07%. The median age (p = 0.0204), AST (p < 0.00001), ALT (p < 0.00001) were significantly higher in patients with NAFLD than those without. Platelet count (p = 0.0002) was significantly lower in patients with NAFLD than those without. The proportion of patients with low platelet count, high AST and high ALT were significantly higher in patients with NALFD than those without. In this study, the FIB-4 index cutoff score for screening of NAFLD is ≥0.76, which has an accuracy of 66.23%, sensitivity of 75%, specificity of 38.3%, PPV of 79.46% and NPV of 32.56% in detecting fatty liver.

A FIB-4 index value of ≥0.76 has an acceptable sensitivity for screening NAFLD even in the absence of fibrosis among patients with T2DM. However, due to its low specificity, additional tests to establish NAFLD diagnosis may be required.

BACKGROUND

There is an increasing population of elderly patients with diabetes. Malnutrition has been associated to higher morbidity and mortality among these patients. Currently, there are limited data on malnutrition and its risk factors among elderly patients with diabetes in the Philippines.

This study determined the prevalence, clinical profile and risk factors associated with malnutrition and identify the association of malnutrition with glycemic status and insulin resistance among elderly patients with diabetes.

This is a cross-sectional study involving 117 elderly patients with diabetes seen at a tertiary hospital in Manila, Philippines. Demographic, anthropometric, and clinical data were collected. Mini-Nutritional Assessment-Short form (MNA-SF), Simple FRAIL questionnaire and Mini-cog assessment were administered. Patients were categorized into normal, at risk for malnutrition, and malnourished using the MNA-SF. Comparative and logistic regression analyses were performed to identify the clinical profile and possible risk factors.

The prevalence of malnutrition was 1.71% with 29.06% at risk for malnutrition. There was no significant difference in demographic, anthropometric and biochemical parameters between the different nutrition statuses. High BMI, central obesity, and increased insulin resistance were observed across all nutrition status. Frail patients had almost five times increased likelihood (OR=4.94, p=0.043) of developing malnutrition. Good glycemic control had two-fold decreased likelihood (OR=0.44, p=0.050) of malnutrition. Insulin resistance was not associated with malnutrition.

Malnutrition is prevalent among elderly patients with diabetes. Frailty and poor glycemic control increased the risk of malnutrition. Therefore, malnutrition screening should be routinely performed among these patients. Diabetes management among elderly patients should include maintaining good glycemic control and preventing frailty and its complications.

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is prevalent in patients with Type 2 Diabetes Mellitus (T2DM) and is associated with chronic kidney disease (CKD). The aim of this cross-sectional study was to determine the association of Fibrosis-4 (FIB-4) index with CKD among T2DM patients with concomitant NAFLD.

A single center, analytical cross-sectional study was conducted among 216 T2DM patients with concomitant NAFLD. Clinical data were obtained via retrospective review of medical charts. The outcome of interest was CKD which was based on self-report obtained from medical charts or estimated Glomerular Filtration Rate (eGFR)RESULTS

Higher FIB-4 index was found to be significantly associated with CKD. Patients with FIB-4 index of 1.45-3.25 (moderate risk) and >3.25 (high risk) have about 3 times higher odds of CKD. However, after controlling for the significant confounders, only those who belong to high-risk group was found to be associated with CKD.

This study has demonstrated that FIB4 index > 3.25, an index of liver fibrosis, is significantly associated with development of CKD in T2DM patients with concomitant NAFLD.

BACKGROUND

Diabetes is a chronic metabolic condition that represents a major public health issue worldwide, with Type 2 diabetes comprising 80-90% of all cases1. It is estimated that individuals with diabetes will increase from 451 million in 2021 to 693 million by 2045, with around 4.3 million individuals affected in the Philippines as of 20212,3,4. While insulin therapy is vital for managing diabetes, acceptance among patients is frequently obstructed by concerns about side effects, potential disruptions to their lifestyle, and stigma associated with injections.

The objective of the study was to determine the barriers to insulin therapy among adult patients with Type 2 Diabetes mellitus of the Department of Family and Community Medicine of Quezon City General Hospital.

This is a cross-sectional study carried out between July and September 2024 involving 117 participants with Type 2 diabetes. Information was gathered through self-administered questionnaires consisting of the Insulin Treatment Appraisal Scale (ITAS) and the SCREEM-RES questionnaire.

Majority of the participants (67.06%) were aged between 60 and 65, predominantly female (56%) and unemployed with a monthly family household income of less than 8,000 pesos. ITAS revealed negative perceptions towards insulin treatment, primarily due to fear and perceived loss of control. Family resources among the participants was revealed to be inadequate, as reflected in the SCREEM-RES questionnaire.

Age, education, employment status, household income, high negative attitude towards insulin and inadequate family resources are found to be barriers to initiating insulin. The study highlights the need for improved education to foster a supportive environment for insulin use and emphasizes the importance of involving patients in their treatment decisions for effective diabetes management and better long-term health outcomes.

BACKGROUND

Diabetes mellitus (DM) is a significant and growing global health concern. Worldwide, 537 million adults have diabetes and 206 million of them are from the Western Pacific Region1. Local prevalence continues to remain high at 7.5%, with 4,303,899 adult Filipinos suffering from diabetes in 2021. DM significantly contributes to the growing burden of chronic kidney disease (CKD) worldwide with about 50% of end-stage renal disease (ESRD) being due to diabetic nephropathy alone. Likewise, 60% of Filipinos on maintenance dialysis have ESRD due to DM and hypertension. The primary care setting is the initial point of contact between healthcare providers and patients with type 2 diabetes, hence, the development of clinical practice guidelines that will provide guidance in caring for patients with stable complications of diabetes. The guideline is the first of 3 that are being developed by the Philippine Academy of Family Physicians for the diagnosis and management of adult patients with type 2 diabetes and stable microvascular complications – nephropathy, retinopathy and neuropathy.

This guideline aims to provide evidence-based recommendations on the diagnosis and management of adults with type 2 diabetes mellitus (T2DM) and early stage CKD and is divided into 5 main sections – Clinical Assessment, Diagnostic Tests, Pharmacologic Treatment, Non-pharmacologic Treatment and Patient Outcomes.

The method of guideline development followed the ADAPTE process. The Technical Working Group identified 19 key questions after consultation with colleagues and patients. Recommendations were adopted from high-quality clinical practice guidelines whenever applicable for most of the key clinical questions. On the other hand, the De Novo method of evidence review was used to answer key clinical questions for which recommendations from reviewed guidelines were not available. A modified GRADEPro was used in assessing the quality of evidence – high, moderate, low or very low. Following external review by a nephrologist, the draft recommendations were sent to the members of the consensus panel. Voting on whether to include or not by the consensus panel was facilitated to determine the strength of each recommendation – strong, moderate or weak.

After reviewing 3 high-quality clinical practice guidelines and the current evidence, the technical working group was able to develop 40 recommendations for the 19 key clinical questions.