BACKGROUND

Thyroid storm (TS) continues to be a diagnostic and therapeutic challenge. It is a life-threatening severe thyrotoxicosis characterized by organ decompensation. This study aims to determine if there are any changes in this present century about TS diagnosis and management. Furthermore, it aims to describe the clinical profile, precipitants, and outcomes of patients with TS seen at the University of Santo Tomas Hospital (USTH) and assess the association of patient characteristics with mortality.

This is a retrospective cohort analysis of patients with TS admitted at USTH from 2009 through 2018. Logistic regression analysis was used to determine the association of age, Burch Wartofsky-Point Scale (BWPS) score, clinical manifestations, and precipitating factor with mortality.

A total of 21 cases were identified. Majority of the patients were female (90.48%) with a mean age of 42.90 years old. The overall mean BWPS was 49.52 (16.35) while those who expired had higher mean score of 61.67 (5.77). TS as the first clinical presentation was seen in only one patient (4.7%) while majority were previously diagnosed with hyperthyroidism, (95.24%). Graves’ disease (90.48%) was the most common etiology of thyrotoxicosis. Cardiac manifestations were predominant and tachycardia was the most common clinical manifestation (80.95%) with thyrotoxic heart disease as a comorbidity (23.81%). The most common precipitant was infection (52.38%) followed by noncompliance with treatment. The mean hospital length of stay was four days with two patients needing intubation, and both expired afterward. There were three mortalities (14.29%) due to multiple organ dysfunction and fatal arrythmia.

TS remains a life-threatening condition. Aggressive treatment is justified once with suspicion of TS. Age, BWPS on admission, clinical manifestation and precipitants did not predict the likelihood of mortality. Since predictive features are still not thoroughly identified due to its infrequency, it remains for us to be vigilant and not delay crucial treatment to improve the morbidity and mortality associated with TS.

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.

OBJECTIVE

To evaluate the effect of mySugr^TM app on diabetes self-management, HbA1c level and its acceptability among app users with type 2 diabetes (T2DM).

A prospective, single-arm interventional study in 70 adult Filipino patients with T2DM and HbA1c ≥ 8.0%. Participants used the basic mySugr^TM mobile app for 12 weeks. The Modified Behavior Score Instrument and the Diabetes Self-Management Questionnaire (DSMQ) pre- and post-intervention measured its impact on diabetes self-management while the Mobile Application rating Scale (MARS) assessed the quality of the app.

There was a significant increased adherence to the diabetes self-care behaviors. DSMQ showed that only 12% of the participants had poor self-care behaviors at week 12 particularly in physical activity and diet. The baseline median HbA1c [9.55% (8.43-11.30)] and estimated HbA1c [8.9% (8.3-10.9)] declined significantly after week 12, [8.0% (8.0-8.43)] and [7.2% (6.5-8.1)] respectively with a very significant p value of (p < 0.00001). About 42% of patients achieved an HbA1c level of ≤7%. MARS confirmed the app’s good quality and acceptability.

Mobile application such as mySugr^TM mobile app can be a viable tool for improved self-care behavior and help in achieving good glycemic control among patients with poorly controlled T2DM even as early as 12 weeks. The app has good quality and acceptability.

We report a case of a 24-year-old Filipino male who complained of general weakness, polydipsia, weight loss, bitemporal headaches, loss of libido and behavioral changes. Endocrine work-up revealed neurogenic diabetes insipidus and panhypopituitarism. Brain MRI showed multiple intracranial tumors in the left frontal lobe, pineal and suprasellar region with moderate non-communicating hydrocephalus. Intracranial mass biopsy with ventriculo-peritoneal shunting was done. Histopathology of the mass and CSF revealed a germinoma. He underwent chemoradiotherapy while on maintenance hormone replacement.
Neoplasms, Germ Cell and Embryonal ; Germinoma ; Hypopituitarism ; Diabetes Insipidus

Adrenocortical carcinoma (ACC) is a rare and aggressive neoplasm with poor prognosis. We report a case of a 30-year-old female who presented with profound classic features of an adrenocorticotrophic hormone (ACTH)-independent Cushing’s syndrome (CS) and a large adrenal mass with massive venous tumor thrombosis of the entire inferior vena cava (IVC), left renal and adrenal veins confirmed by imaging. Adrenal biopsy histopathology and immunohistochemistry confirmed ACC. Systemic palliative chemotherapy was administered. This rare case presents a unique and atypical presentation of an extensive tumor thrombosis of IVC. With the advanced stage at diagnosis, aggressive nature and poor prognosis of the disease, there is still a need to determine viable therapeutic options for metastatic ACC associated with venous invasion.
Adrenocortical Carcinoma

Background: A well-informed patient with Type 2 diabetes may be more compliant with treatment. This study aims to evaluate the diabetes-related knowledge and socio demographic determinants of patients seen at University of Santo Tomas Hospital through a translated and validated Filipino-DKT questionnaire.

Methods: Standard translation procedure was used to produce the Filipino version of the DKT2. A convenience sample of 112 outpatients with Type 2 diabetes was identified for six months at the University of Santo Tomas Hospital, Philippines. All data were collected using the Filipino-DKT and a demographic questionnaire.

Results: The Filipino-DKT demonstrated an acceptable Cronbach's alpha of 0.70 and an acceptable average inter-item correlation of 0.40 (p<0.001). The test-retest reliability was excellent, with a Pearson coefficient r of 1.00 (p<0.001). Our study demonstrated that of the 112 patients with diabetes who answered the general knowledge test, the majority had average knowledge of 78.64%, while 16.07% had poor knowledge. A total of 55 participants on insulin answered the second part of Filipino-DKT that measures insulin knowledge. Surprisingly, 56% of the subjects on insulin had poor knowledge, and only 7% had good knowledge. Results showed that the majority (56%) had poor knowledge. Participants who reported poor control of their diabetes (HbA1c >7%) also reported lower levels of knowledge about diabetes and insulin use. There was no association between duration of diabetes, family history of diabetes, and type of diabetes with knowledge of diabetes.

Conclusion: The Filipino diabetic knowledge of diabetes is poor and not related to age, sex, and duration of diabetes. Filipino-DKT is an acceptable, reliable, and valid measure of diabetes knowledge used in our clinical practice and research.

Background & Objective: Chronic pain impacts the quality of life of patients, with neuropathic pain causing profound negative sequelae. Assessment of pain whether nociceptive or neuropathic is important to provide appropriate treatment. The objective of this study is to translate and validate the pain-DETECT Questionnaire (PDQ) to two widely spoken regional languages in Filipino. Methods: The PDQ, a self-administered questionnaire, was translated from English into the Filipino version, painDETECT Tagalog (PDQ-Tag) and painDETECT Cebuano (PDQ-Ceb). One hundred Filipino patients suffering from pain for at least three months were recruited in the out-patient clinics of a hospital and completed the questionnaire. The investigators, blinded to the subjects PDQ-Tag and PDQ-Ceb scores, examined the subjects using the standard clinical and neurological examination. The PDQ-Tag and PDQ-Ceb, scores were validated. Both questionnaires were administered to the same patient twice, two days apart by the same investigator. Results: Seventy subjects completed the (PDQ-Tag) and thirty subjects the (PDQ-Ceb). The sensitivity and specificity of PDQ-Tag were both 80% for an upper limit cut-off value of ≥ 17. The sensitivity and specificity of PDQ-Ceb were 62.5% and 80% respectively, for an upper limit cut-off value ≥ 18.0. Both questionnaires were reliable [Cronbach’s alpha coefficient: 0.78 (PDQ-Tag) and 0.70 (PDQ-Ceb), good test-retest stability with intra-class correlation coefficient: 0.93 for PDQ-Tag and 0.99 for PDQ-Ceb]. Cohen’s kappa were 0.64 and 0.61 for PDQ-Ceb and PDQ-Tag respectively, with P value<0.001 indicating a significant agreement on the assessment of neuropathic pain. Conclusion: PDQ-Tag and PDQ-Ceb are reliable and valid self-administered screening tools to detect neuropathic pain among Filipinos.

Introduction: The potential efficacy of a board game in health education has been demonstrated. This study aims to develop a simple and useful diabetes education board game for adult Filipinos with T2DM that can supplement diabetes education. Methods: This study used a mixed methods design involving a multistep process to develop and evaluate the board game. The initial phase involved the generation of comprehensible illustrations. Diabetes experts including three endocrinologists, one diabetes education nurse, and one dietician and 20 patients evaluated each illustration incorporated into the game board patterned after snakes and ladders. Twenty adult patients were then recruited to play the board game. Each patient subsequently completed a survey regarding perception of the game’s acceptability in terms of usability, replay appeal, and ability to reinforce knowledge. Results: The illustrations’ comprehensibility or mean correct response of participants to the illustrations was 75%. At least 50% of patients correctly identified each of the illustrations. Eighteen (56.25%) out of the 32 illustrations had a mean correct response of 75% or higher. The illustrations were perceived to depict their intended meaning (translucency). All illustrations had a median translucency score of five and above in a scale of one to seven. The game had a high median rating for acceptability of five on a scale of one to five. All the participants agreed that they liked playing the game and would recommend the game to other patients with diabetes. Conclusion The developed adult diabetes board game – “Winning at Diabetes”, is a simple, useful and acceptable supplement to standard diabetes education.
Adult

Introduction: Approximately 40% of women with gestational diabetes mellitus (GDM) will require insulin when diet failed to reduce glycemic levels. Insulin analogs have been noted to result in an improved glycemic control and an acceptable safety profile in diabetes mellitus. Our general objective was to evaluate the efficacy, safety, and pregnancy outcomes of insulin analog versus human insulin in women with GDM. Methods: Retrospective cohort analysis of women with singleton pregnancy and GDM from January 2013 to March 2016 at the University of Santo Tomas Hospital was performed. Women were grouped into Group A (diet-controlled), Group B (supplementary insulin analog), Group C (supplementary human insulin), and Group D (combination of supplementary insulin analog and human insulin). Maternal characteristics, glycemic data, and outcomes and neonatal outcomes were compared among the treatment groups. Parametric data were expressed as mean, standard deviation, frequency, and percentage. Chi-square and one-way analysis of variance were utilized to analyze data. Results: Of 144 women with GDM, 59 received insulin analog and 19 received human insulin. Good glycemic control and low rate of hypoglycemia in Group B were comparable to other groups. Maternal outcomes (hypertensive disorders of pregnancy and primary cesarean section) in Group B were not increased and similar to other groups. Neonatal outcomes (birth weight, large for gestational age, neonatal hypoglycemia, neonatal jaundice, and acute respiratory distress syndrome) in Group B were also not increased and comparable to other groups. Rates of prematurity were higher in Groups A and B. Conclusion Our study demonstrated that insulin analog was comparable to human insulin in terms of non-increased rates of adverse pregnancy outcomes with the exception of prematurity, and can be safely used as a viable treatment option without increased risk of hypoglycemia while achieving optimal glycemic control throughout pregnancy in Filipino women with GDM.
Diabetes, Gestational ; Pregnancy Outcome