An anticipated difficult airway requires careful planning and teamwork among the anesthesiologists and the surgical team. This paper reports the airway management of a 7-year-old female scheduled for LASER excision of a huge, obstructing laryngeal neoplasm. Initial attempts to secure the airway with the patient minimally sedated using a C-MAC Video Laryngoscope (C-MAC) and a traditional intubating stylet failed. Successful tracheal intubation was achieved when C-MAC was combined with a pediatric Bonfils Intubating Fiberscope (BIF) with the patient under general anesthesia.

Airway Management ; Laryngeal Neoplasms ; Laryngoscopy ; Intubation, Intratracheal

Introduction: Insulin delivered by multiple daily injection (MDI), for a time, has been considered to be the most physiologic among the different insulin regimen. Among patients on MDI, there is still a significant proportion who remains uncontrolled. Continuous subcutaneous insulin infusion (CSII) or insulin pump has been shown to benefit some patients who are still uncontrolled despite intensive insulin therapy with MDI. Currently, there is little information on the use of insulin pump in the Philippines. The researchers aim to determine the change in HbA1c and the proportion of patients with HbA1c of <8% after shifting from MDI to CSII. To correlate the change in HbA1c with age and baseline HbA1c. To compare the change in HbA1c between gender, type of diabetes and type of bolus regimen. Methods: This is a retrospective cohort analytical study of 33 adult patients with type 1 or type 2 diabetes mellitus (DM), switched from MDI to insulin pump. Chart review was done to obtain data on age, gender, type of bolus, baseline HbA1c and HbA1c six to twelve months after switching insulin pump initiation. The change in HbA1c was correlated with baseline HbA1c and age. Mean change in HbA1c was also compared between gender, type of bolus and type of diabetes. Results: Mean HbA1c prior to switching to insulin pump was 10±1.7. The HbA1c reduction was 1.86±1.6 (p<0.001, CI 1.38-2.34), resulting to a mean final A1c of 8.1±1.2 after CSII initiation. Seventeen out of 33 patients (52%) achieved an average HBA1c of <8%. A positive correlation was observed between HBA1c reduction and baseline HbA1c (r =0.738, p<0.001) but not with age (r = -0.002, p=0.99). There was no significant difference in the HbA1c reduction between male and female (p=0.353), Type 1 DM and Type 2 DM (p=0.133), and those that used fixed bolus vs bolus calculator (p=0.559). The reduction in A1c remains significant when analyzed as individual subgroups: 2.1±2.3 (p=0.001) in males; 1.6±1.0 (p<0.001) in females; 1.5±1.6 (p=0.001) in type 1; 2.3±1.6 (p<0.001) in type 2; 2.1±1.5 (p<0.001) in bolus calculator, and 1.7±1.8 (p<0.001) in fixed bolus group. Conclusion There is significant reduction in HbA1c among this cohort of Filipino diabetic patients after switching from MDI to CSII. While majority of patients had >1% reduction, achieving an ideal goal of <7% remains to be a challenge. Greater HbA1c reduction are seen in patients with higher baseline HbA1c. There is no significant difference in the reduction in HbA1c with respect to gender, type of diabetes and type of bolus used.
Diabetes Mellitus

Objective: Assess safety and effectiveness of liraglutide among Filipino participants with type 2 diabetes (T2D) in routine clinical practice. Methodology: A 26-week, prospective, multicenter, open-label, observational study was conducted in adults with T2D prescribed liraglutide (1.2 mg or 1.8 mg) in routine clinical practice in the Philippines. Primary endpoint: incidence rate and type of serious adverse drug reactions (SADRs). Secondary endpoints included other aspects of safety, and effectiveness. Results: Participants (n=1056) had a mean (standard deviation) age of 53.2 (12.0) years, and glycated hemoglobin (HbA1c) level of 8.8% (2.0). Of 19 ADRs reported in 17 participants, none were SADRs (primary endpoint). No serious adverse events were reported. From baseline to week 26: the proportion of participants with major hypoglycemic episodes (requiring assistance) decreased from 2.0% to 0.2%; and with minor episodes (plasma glucose <3.1 mmol/L [<56 mg/dL]) decreased from 6.1% to 1.5%; serum creatinine remained unchanged. Among secondary effectiveness endpoints, improvements were seen from baseline to week 26 in HbA1c level, fasting and postprandial blood glucose levels, body weight, blood pressure, and fasting lipid profile. Conclusion During routine clinical use of liraglutide for T2D in the Philippines, no new safety concerns were identified and blood glucose was lowered effectively.
Glucagon-Like Peptides ; Liraglutide ; Diabetes Mellitus, Type 2 ; Safety ; Observational Study

PURPOSE: Effective trauma resuscitation requires efficient and coordinated care from a team of providers; however, providers are rarely instructed on how to be effective members of trauma teams. Team-based learning using Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) has been shown to improve team dynamics among practicing professionals, including physicians and nurses. The impact of TeamSTEPPS on students being trained in trauma management in an undergraduate health professional program is currently unknown. We sought to determine the impact of TeamSTEPPS on team dynamics among undergraduate students being trained in trauma resuscitation. METHODS: We enrolled teams of undergraduate health professional students from four programs: nursing, physician assistant, radiologic science, and respiratory care. After completing an online training on trauma resuscitation principles, the participants completed a trauma resuscitation scenario. The participants then received teamwork training using TeamSTEPPS and completed a second trauma resuscitation scenario identical to the first. All resuscitations were recorded and scored offline by two blinded research assistants using both the Team Emergency Assessment Measure (TEAM) and Trauma Team Performance Observation Tool (TPOT) scoring systems. Pre-test and post-test TEAM and TPOT scores were compared. RESULTS: We enrolled a total of 48 students in 12 teams. Team leadership, situational monitoring, and overall communication improved with TeamSTEPPS training (P= 0.04, P=0.02, and P=0.03, respectively), as assessed by the TPOT scoring system. TeamSTEPPS also improved the team's ability to prioritize tasks and work together to complete tasks in a rapid manner (P<0.01 and P=0.02, respectively) as measured by TEAM. CONCLUSIONS: Incorporating TeamSTEPPS into trauma team education leads to improved TEAM and TPOT scores among undergraduate health professionals.
Education* ; Education, Professional ; Emergencies ; Health Occupations* ; Humans ; Leadership ; Learning ; Nursing ; Patient Safety ; Physician Assistants ; Resuscitation

INTRODUCTION: Current guidelines recommend that in patients presenting with clinically palpable nodules or with an ultrasound finding of a thyroid nodule, one has to evaluate its risk for malignancy by proceeding with a fine needle aspiration biopsy (FNAB). The decision to do FNAB would depend on ultrasonographic features of the nodule, which include its size, hypoechogenicity, presence of microcalcifications, increased central vascularity, infiltrative margins, and taller than wide measures on transverse plane. Elastography, a measure of tissue stiffness, is now also being utilized as another feature that has a positive correlation with malignancy. This study hopes to determine which among the abovementioned ultrasonographic features would best correlate with a higher risk for thyroid malignancy among adult patients who had undergone ultrasound guided FNAB.
METHODOLOGY: A prospective study was done in a cohort of all Filipino patients 19 years old and above who underwent ultrasound guided FNAB of the thyroid nodule/s from July to December 2013 at the Radiology Section of The Medical City, Pasig City, Philippines. Specimen obtained from FNAB were then reviewed by a pathologist to determine its cytopathology and categorized based on the Bethesda System of Classification. The cytopathology reports were correlated with the features seen on the patient's thyroid ultrasound to determine which characteristic would be predictive of malignancy.
RESULTS: A total of 100 patients underwent ultrasoundguided FNAB, from which 157 nodules were biopsied. 27 nodules were excluded from the analysis due to non-diagnostic or unsatisfactory (Bethesda Category I) findings on cytopathology. Among the 100 patients, 86% of which were females with the mean age of 41 ± 11.31 in those found to have malignant cytopathologic diagnosis. Of the 130 nodules biopsied, 115 nodules were identified as benign (Bethesda Category II) while 15 were identified to be malignant or suspicious for malignancy (Bethesda Category III-VI). Each of the five sonographic features that were predictive of malignancy was compared between the two outcome groups (benignversus malignant). Among them, only the presence of microcalcifications on ultrasound showed to be significantly correlated with malignancy with an odds ratio of 11.3. Ultrasound evaluation with elastography was only performed on 24 nodules and hence results were inconclusive. A nodule possessing more than two of the ultrasound features that were predictive of malignancy was more likely to be malignant on cytopathology (p value of 0.00).
CONCLUSION: The presence of microcalcifications on thyroid nodules as seen on ultrasound is a significant predictor of malignancy and remains to be consistent locally as with foreign studies. Nodules that were proven to be malignant on cytopathology presented with more of the ultrasound features that are said to be predictive of malignancy.

Human ; Male ; Female ; Middle Aged ; Adult ; Thyroid Nodule ; Biopsy, Fine-needle ; Elasticity Imaging Techniques ; Thyroid Neoplasms ; Ultrasonography ; High-energy Shock Waves ; Calcinosis

A 42-year-old Filipino female was admitted due to weight loss and recurrent abdominal pain over the past ten years. In 2010, she was diagnosed to have disseminated PTB associated with a liver mass. After 1 year of anti-TB treatment, lung condition was treated but her liver mass has enlarged. She also developed diarrhea, diabetes, and skin lesions with biopsy results showing Necrolytic Migratory Erythema (NME). CT scan showed liver and pancreatic tumors that were biopsied revealing a neuroendocrine tumor. Blood glucagon level was elevated. She was treated as a case of glucagon-secreting tumor with liver metastases with Everolimus and Octreotide. After 3 months of treatment, she gained weight, the skin lesions improved, and the liver mass decreased in size. Many of the initial symptoms of glucagonoma are nonspecific and subtle. As a result, glucagonoma is often diagnosed relatively late in the course of the disease. NME, the characteristic skin lesion of the glucagonoma syndrome, is often the clue that leads to the correct diagnosis.
Glucagonoma ; Necrolytic Migratory Erythema

BACKGROUND: Endocrine malignancy in the Filipino population has not been well documented particularly on the incidence, prevalence, demographic profile and survival rate. It is the aim of this study to determine the prevalence rate and demographic profile of all endocrine malignancies diagnosed at a tertiary hospital.
MATERIALS AND METHODS: This is a retrospective study from March 2003 to March 2008. Data were obtained from the Tumour Registry of St. Luke's Medical Center Cancer Institute (SLMC-CI) and from the Annual Report of the Diabetes, Thyroid and Endocrinology Center (DTEC) Section of SLMC-Quezon City. Only individuals with retrievable histopathology at this institution were included in the study.
STATISTICAL ANALYSIS: Data were calculated using percentages and proportions.
RESULTS: There were a total of 855 cases of endocrine malignancies documented in five years of which, 833 were cases of thyroid malignancies (97.4%). Fourteen cases of adrenal cancer (1.60%), seven cases of neuroendocrine carcinoma (0.79%), and one case of parathyroid carcinoma (0.14%). There was no note of pituitary cancer. There were a total of 833 newly diagnosed thyroid cancer: 652 papillary carcinoma (78.2%), 157 follicular carcinoma (18.8%), 11 anaplastic carcinoma (1.32%); nine medullary thyroid cancer (1.08%); two thyroid lymphoma (0.28%), one poorly differentiated carcinoma (0.14%) and one metastatic to the thyroid (0.14%). Among the 14 adrenal cancers, seven cases were due to adrenal cortical carcinoma, one case was due to adrenal neuroblastoma and six cases were due to adrenal metastases. Among the neuroendocrine carcinomas, four were pancreatic neuroendocrine carcinoma which included two malignant insulinoma and three patients were extra pancreatic neuroendocrine carcinoma.

Human ; Male ; Female ; Aged ; Middle Aged ; Parathyroid Neoplasms ; Pituitary Neoplasms ; Thyroid Neoplasms ; Adenocarcinoma, Follicular ; Adrenal Gland Neoplasms ; Carcinoma, Neuroendocrine ; Diabetes Mellitus

Objectives: To determine the skin and subcutaneous thickness of adult diabetic Filipinos using ultrasonography. Methodology: We studied 293 Filipino diabetic adults who had ultrasonographic measurements of their skin thickness (ST) and subcutaneous thickness (SCT) at common insulin injection sites. Results: The mean ST ranges from 1.76 mm to 2.75mm. The mean SCT ranges from 6.91 mm to 19.1 mm. The anterior thigh area has the thinnest mean ST and SCT. On the other hand, the buttocks have the thickest mean ST and area of abdomen has the thickest mean SCT. On multiple regression analysis, the predictors for skin thickness are injection site, age, BMI, gender and insulin use, however the overall influence of all these factors on skin thickness is variable at best. Conclusion Skin thickness among Filipinos varies marginally depending on injection site being thickest at the buttocks and thinnest at the thighs. On the other hand, there is greater variability in SCT depending on the injection site, being thickest at the abdominal area and thinnest at the anterior thigh.
Diabetes Mellitus ; Injections, Subcutaneous

The traditional binary classification of gender is repeatedly challenged throughout history with the presence of transgenders. Under the umbrella of transgenderism is transsexualism which pertains to individuals who identify with or desire to become the opposite sex. Transsexualism or Gender Dysphoria is classified as a medical condition under ICD 10 and DSM-5. The proposed treatment is sex reassignment that includes all treatments carried out to adapt to the desired sex. Sex reassignment involves a multidisciplinary approach wherein the psychiatrist or mental health practitioner, endocrinologist and surgeon play active roles. Certain legal and ethical issues exist in the treatment of transsexualism. This article provides a review of psychological, medical and surgical issues in the evaluation and treatment of Transgender individuals, with an Asian perspective, and in the context of an actual case.
Gender Dysphoria ; Transsexualism ; Transgender Persons

Human ; Female ; Middle Aged ; Graves Disease ; Graves Ophthalmopathy ; Skin Diseases ; Methimazole ; Thyrotoxicosis