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.

Objective: This study aims to determine the clinical profile and course on follow-up of newborns delivered to a SARS-CoV-2 positive mother from two private tertiary hospitals. Methodology: This is a retrospective, cross-sectional study. A chart review of all neonates delivered to SARS-CoV-2 positive mothers was conducted. Subsequent interview was done to determine their clinical course and neurologic status at 3-, 6-, 9-, 12-, and 15-month-old. Data collected was presented as frequencies, percentages, or proportions. Results: Out of the 67 newborns born to SARS-CoV-2 positive mothers, three neonates tested positive for SARS-CoV-2. All three were delivered to mothers with mild symptoms, were full term, with good APGAR score and appropriate for gestational age. One was eventually intubated and managed as COVID-19 confirmed critical. Among the SARS-CoV-2 negative newborns, majority had an unremarkable neonatal outcome. Thirty-six neonates were available for follow-up: 1 expired due to aspiration pneumonia at 2 months of age, 4 were readmitted for pneumonia, UTI, acute gastroenteritis, and cow’s milk allergy. Twenty-one had infection at one point prior to this study follow-up but were all mild not requiring admission. Two had abnormal head size, while 2 had developmental delay, these 4 infants with neurological findings on follow-up were all RT-PCR negative at birth. Conclusion Maternal COVID-19 infection does not necessarily result to a neonatal infection. For those neonate swith mild symptoms, SARS-CoV-2 causality could not be established. On follow-up, there were a few who developed significant problems that have long-term implications in the overall growth and development of the child.
SARS-CoV-2

BACKGROUND

Coronary artery disease is the leading cause of death in the Philippines and can present as acute coronary syndrome. Hospitalization for ACS has epidemiologic and economic burden. In fact, last 2017, there were 1.52% or 152 admissions for every 10,000 hospitalized patients for medical conditions in PhilHealth-accredited hospitals locally. However, coronary angioplasty was performed in only less than 1% of these cases mainly because of its cost and the out-of-pocket expense that the treatment entail, when primary percutaneous intervention has been proven to be effective in reducing mortality in STEMI and early invasive intervention performed during index hospitalization for NSTEMI is likewise recommended. Moreover, there is a big disparity between the current case rates for ACS for medical therapy alone and for invasive intervention compared to the actual ACS hospitalization cost.

1) To propose revisions to the current PhilHealth case rates for acute coronary syndrome (ACS); and 2) To determine the budget impact of the proposed ACS case rates.

The Philippine Heart Association with the assistance of a technical working group undertook the study. A panel of experts composed of general and invasive cardiologists from Luzon, Visayas, and Mindanao was formed. The ACS hospitalization costs based on the recent study by Mendoza were presented and discussed during the focus group discussions with the panelists. Issues pertinent to their localities that may affect the costs were discussed. The proposed revised costs on the particular ACS conditions and therapeutic regimens were then voted and agreed upon. A budget impact analysis of the proposed case rates was then performed.

The proposed case rates for ACS ranged from Php 80,000 (for low risk unstable angina given medical treatment) to Php 530,000 (for ST-elevation myocardial infarction initially given a thrombolytic agent then underwent PCI which necessitated the use of three stents). The budget impact analysis showed that the proposed ACS rates would require an additional PHP 1.5 billion to 2.3 billion during the first year of a 3- versus 5-year implementation period, respectively. The period of implementation will be affected by budgetary constraints as well as the availability of cardiac catheterization facilities in the country.

The proposed revised PhilHealth hospitalization coverage for ACS is more reflective or realistic of the ACS hospitalization costs in contrast with the current PhilHealth case rates. The corresponding budget impact analysis of these proposed case rates showed that PHP 7.6 billion is needed for full implementation. However, given the budget constraints, the percentage of the total costs for the first and subsequent years of implementation may be modified.

BACKGROUND

Hospitalization for acute coronary syndrome (ACS) has epidemiologic and economic burden. The coverage for hospitalization in the local setting is much less than the actual costs. Many patients do not consent to or avail of the optimal and timely management because of financial challenges.

The paper aimed to propose revised PhilHealth case rates/packages for ACS, namely: 1) unstable angina (UA), 2) non-ST-elevation myocardial infarction (NSTEMI), and 3) STelevation myocardial infarction (STEMI).

A consensus panel was organized to provide inputs such as cost and other matters pertaining to the revision of the PhilHealth ACS case rates/packages. The results of the cost of hospitalization of the different ACS conditions derived from a study on hospitalization cost for ACS were presented to the panel. Several focused group discussions were held afterward for propositioning new case rates through votation and by nominal group technique, using the costs from the study as the bases of rate adjustment.

Final costs agreed upon by the consensus panel for medical management alone for UA, NSTEMI, and STEMI were adjusted or amended in increments of Php 20,000, (80,000, 100,000, and 120,000, respectively). Thrombolysis of a patient admitted for STEMI increased the cost to Php 140,000. An additional cost of Php 150,000 was added on top of the cost for medical management and coronary angiogram for NSTE- ACS for PCI with use of a single stent. For STEMI, the same category had an additional cost of Php 180,000. For each additional stent used for all clinical scenarios undergoing PCI, Php 65,000 was added, to cover up to a total of 3 stents.

Based on the consensus process with Philippine Heart Association ACS panelists, the cost proposed ranges from 80,000 pesos to 530,000 pesos depending on the clinical scenarios.

OBJECTIVE

This study aimed to determine the budget impact of the proposed revised PhilHealth case rate packages for acute coronary syndrome (ACS).

This budget impact analysis used the static approach or cost calculator modeling method. The prevalence of hospitalization for coronary artery disease in all PhilHealth-accredited hospitals in the country in 2017 and the data from the ACS registry project of the Philippine Heart Association were used in this study. The study multiplied the present PhilHealth coverage with the number of ACS hospitalization claims to come up with the total cost of ACS hospitalization in the next three years with the assumptions that the eligible population and the ACS PhilHealth case rates will remain constant for these years. The future ACS hospitalization costs were also determined if the proposed case rates were used rather than the current PhilHealth case rates. The cost of re-admissions was considered as savings in hospitalization cost (due to prevention of admissions if the appropriate interventions were given) and were deducted from the future total cost of ACS hospitalizations.

The annual total ACS hospitalization cost using the current case rates was Php 1,134,683,000. Using the proposed case rates, the total hospitalization costs over five years was Php 2,653,019,000 in the first year (proposed case rates implemented to only 20% of the ACS patients) and increased to Php 8,726,364,000 by year 5 (full implementation of the proposed case rates or to 100% of ACS patients). This resulted in a lower incremental cost in the first year of implementation compared with a less gradual implementation over 3 years. The total incremental costs would amount to PHP7.6 billion for full implementation.

The study provided the budget impact of the proposed revised ACS case rates. The incremental cost is relatively huge, however the benefits of providing coverage of guidelinedirected therapy including invasive strategies for ACS must be considered.

OBJECTIVE

Natriuretic peptides are increasingly used in clinical practice to diagnose myocardial dysfunction in heart failure (HF) with preserved ejection fraction (HFpEF). Recent studies indicate that plasma brain natriuretic peptide (BNP) may have a role in the diagnosis and management of HF. However, there is marked heterogeneity in BNP levels among subjects with HFpEF, which is only partially explained by differences in left ventricular (LV) dimensions or systolic function. This study aims to investigate if N-terminal proBNP (NT-proBNP) can be a useful tool to guide management in patients with HFpEF when echocardiography is not easily accessible.

N-terminal proBNP in patients admitted in Chong Hua Hospital from July 2019 to July 2020 was collected from the hospital laboratory. Data of patients with HF symptoms with preserved LV systolic function and other echocardiographic parameters were collected from the hospital records. The correlation between the different echocardiographic parameters and NT-proBNP was determined.

The NT-proBNP levels increased significantly in HFpEF as the values of left atrial volume index (P < 0.001), E/A ratio (P = 0.042), E/e′ (P < 0.001), and tricuspid regurgitation velocity (P < 0.001) increased. The mean NT-proBNP level was 5588 pg/mL. Highest levels were seen predominantly in diastolic dysfunction grade II.

Our findings indicate that NT-proBNP is positively correlated to echocardiographic parameters, namely, left atrial volume index, E/A ratio, E/e′, and tricuspid regurgitation velocity in patients with preserved LV systolic function.

Introduction: Sepsis has been redefined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. The quick sepsis-related organ failure assessment (qSOFA) is a simple tool developed to prompt clinicians to consider patients at high risk for poor outcome. Studies have compared its utility with National Early Warning Score (NEWS) and the systemic inflammatory response syndrome (SIRS) criteria. These scoring systems may be utilized to prognosticate illness severity among patients with suspected infection and may be relevant in low- and middle-income settings where laboratory data are not readily available. Objective: To determine and compare the accuracy of qSOFA, NEWS, and SIRS criteria in predicting in-hospital mortality in patients suspected to have infection presenting at the emergency department (ED) Methods: This is a prospective cohort study. Patients ≥18 years old with suspected infection admitted to the ED between June 2018 to July 2018 were included in the study. SIRS, NEWS, and qSOFA scores were collected at presentation and patients were followed up until expired or discharged. Results: A final population of 213 were included in the study with a mean age of 47 years (SD 21.2) and 124 (58.2%) females. The most common site of infection was respiratory (33.8%). Twelve patients (5.6%) died in-hospital. Among patients with qSOFA≥2, mortality rate was at 38% vs 3.5% for qSOFA<2. Specificity for mortality was highest for qSOFA (96%). Sensitivity was highest for SIRS (75%). SIRS, qSOFA, and NEWS had no significant difference in predicting in-hospital mortality with an area under the receiver operating curve of 0.659, 0.711, 0.711 respectively. Conclusion SIRS, qSOFA, and NEWS have similar prognostic accuracy to predict mortality but have limited use when applied individually which brings into question the sole utility of qSOFA despite its high specificity. It is reasonable to further validate or develop new scoring systems with higher predictive accuracy appropriate across different populations.
Sepsis ; News

Background: The benefits of infant massage in hospital and community settings have been documented in literature: better weight gain of preterm and low birthweight infants, shortened hospital stay, slightly better scores on developmental tests, fewer postnatal complications, and effects on physical and mental health. Objectives: This study described the perceptions and experiences of infant massage among caregivers of infants 2-6 months old consulting in two public health centers in Quezon City before and after infant massage training. Methods: This qualitative study assessed perceptions and experiences at baseline and after infant massage training of mothers and caregivers taking care of infants 2-6 months old. Pre-training interviews were conducted, as well as immediately after, and seven days after training on infant massage delivered by the Philippine League of Government and Private Midwives, Inc. (PLGPMI). Training consisted of lectures and demonstrations, after which mothers/caregivers gave their babies the massage under the trainer's supervision. Post-training interviews were conducted immediately after the training and seven days after. Responses to the interviews were transcribed. The transcripts and interview notes were analyzed independently by two research team members. Qualitative Content Analysis (QCA) was done. Disagreements were settled by discussion. Results: The infant’s mother was identified as the best person to perform infant massage. Infant massage was a new concept to many participants before the training. In general, the perception was positive. It was believed to promote the baby's physical development and bonding with the mother/caregiver. These same benefits were reported after the training. Post-training, all 11 participants who returned for follow-up interviews reported having massaged their babies at home. They were also able to describe the process and timing of massage as taught to them. The participants’ responses centered on seven (7) identified themes, identified at baseline and after training: 1) general concepts of infant massage, 2) benefits of infant massage, 3) methodologies, materials, and considerations, 4) persons credible to perform infant massage, 5) application/performance of infant massage, 6) intentions and 7) infant massage as a public health measure. Conclusion There was a positive perception of infant massage among mothers and caregivers of infants 2-6 months old, whether or not they had prior knowledge. The sharing of information and the training given enhanced this. Participants showed good reception and retention of infant massage's basic concepts and process and improved their confidence in handling their babies and massaging them.
Mother-Child Relations ; Caregivers ; Health Education ; Community Health Centers

Humans ; Rectal Neoplasms/surgery* ; Anastomosis, Surgical ; Anal Canal/surgery* ; Treatment Outcome

Androgen insensitivity syndrome is an X-linked recessive condition resulting in a failure of normal masculinization of the external genitalia in a chromosomally male individual. We describe two phenotypically female siblings aged 27 and 18 years, who presented with primary amenorrhea. The older sibling first consulted because of her desire to be pregnant while her younger sibling consulted upon the physician’s advice. Clinical presentation, physical examination, hormonal and imaging studies and a male (46XY) karyotype confirmed the diagnosis of Complete Androgen Insensitivity Syndrome (AIS) in both individuals. Both of them underwent exploratory laparotomy with histopathology confirming presence of immature testicular tissue. Hormone replacement therapy was then started. Both were advised to undergo psychosocial counseling and both chose to be women. This case report is significant since there are only a few local case reports about siblings presenting with this condition.
Androgen-Insensitivity Syndrome ; Karyotyping