Neurotoxic snakebite envenomation treated with Philippine cobra antivenom in the eastern Visayas: a descriptive study between 2016 and 2020.

Introduction: There is a significant shortage of observational studies on neurotoxic snakebite envenomation in the Philippines. This lack of data, especially concerning treatment using Purified Cobra Antivenom (PCAV), has prompted the initiation of this foundational study. Methods: The target population included snakebite patients admitted to the Eastern Visayas Medical Center and treated with PCAV between 2016 and 2020. A retrospective chart review was conducted for data collection. The investigation analyzed the hospital stay and patient features of individuals who were administered either lower or higher doses of PCAV. Results: Eighty-two patients were identified during the study. Of these, 27 (33%) were under 20 years of age and 50 (61%) were male. Most patients, totalling 75 (92%) were hailed from rural areas. Of the 82 patients, 59 (72%) received one or two ampoules of PCAV during the course. However, patients who received more than two ampoules had a longer median hospital stay than those who received less than three ampoules [96 h (interquartile range, IQR 66-122) vs. 125 h (IQR 96-218), P = 0.038]. The study reported five in-hospital mortalities (6.1%). Conclusions: The individuals who needed a high dosage of PCAV tended to have more extended hospital stays, yet over 70% of the patient population required a lower dosage. To gain a clearer understanding of the burden of neurotoxic snakebites and determine the optimal PCAV dosage based on disease severity in the area, a more comprehensive, prospective study is recommended.

Efficacy and safety of intravenous immunoglobulin retreatment amongst Guillain-Barré syndrome patients who poorly responded to initial IVIG cycle: a systematic review.

INTRODUCTION: Small cross-sectional studies and case reports observed improvement after administration of second IVIG dose (SID) amongst Guillain-Barré Syndrome (GBS) patients not responsive to initial IVIG cycle. Nevertheless, recent clinical trial and larger observational studies did not find any positive effects of SID. Instead, an increased risk of thromboembolism and mortality was noted. The conclusions of these studies however were not robust as confounding and selection bias were present. METHODOLOGY: Two neurologists conducted the search process (KBA and MBP) using the following terms in Medline: [(" Guillain-Barré Syndrome"[MeSH Terms] or GBS or Acute Motor Axonal Neuropathy or Acute Motor Axonal Neuropathy or Acute Inflammatory Demyelinating Polyneuropathy) AND (Poorly Responsive or Poor Prognosis or Progressive)] AND [("Intravenous Immunoglobulin"[MeSH Terms] or IVIG or IGIV) AND (second dose or retreatment or SID)]. RESULTS: Only 7 articles were included in this review. In terms of primary outcomes, although the cross-sectional study found improvement in GBS DS score at 4 weeks (Median GBS DS: 3 vs 5, p = 0.033) and the 2 case series observed improvement after SID, no significant differences between the control and intervention groups were found in the cohort [Early SIV OR: 0.7 (95% CI 0.16-3.04), Late SIV OR: 0.66 (CI: 0.18-2.5)] and clinical trial studies (Adjusted OR: 1.4 (95% CI:0.6-3.3, p = 0.45). Moreover, 4 patients who died in the clinical trial were from the intervention group. CONCLUSION: Based on studies with research designs of higher quality, SID is not effective in the management of GBS patients who poorly responded to initial IVIG. Nevertheless, an adequately powered, randomized, double-blinded, placebo-controlled clinical trial, using GBS-DS of 3 and above after first IVIG dose should be done to effectively establish the efficacy and safety of SID as intervention for this cohort of patients.

Ranking Alpha Lipoic Acid and Gamma Linolenic Acid in Terms of Efficacy and Safety in the Management of Adults With Diabetic Peripheral Neuropathy: A Systematic Review and Network Meta-analysis.

OBJECTIVES: Current medications for diabetic neuropathy (DN) recommended by the American Diabetes Association and American Academy of Neurology do not address the pathologic process of denervation among patients with DN, because ancillary treatments, such as reactive oxygen scavengers, may be needed. The purpose of this work was to summarize the available evidence about the efficacy and safety of alpha lipoic acid (ALA) and gamma linolenic acid (GLA) in the management of DN. METHODS: Using the search terms [(alpha lipoic acid or ALA or thioctic acid or thioctacid) or (gamma linolenic acid or GLA)] AND [(diabetes or diabetes mellitus) AND (polyneuropathy or neuropathy or sensorimotor polyneuropathy or radiculopathy)], 11 studies were included in this review and combined meta-analysis. RESULTS: Eight of the 11 articles (73%) reported significant benefit of ALA vs placebo. In the meta-analysis, the Total Symptom Score (TSS) for ALA 600 mg/day (ALA600) was 1.05 points lower (standard mean difference [SMD] -1.05, 95% confidence interval [CI] -2.07 to -0.04, p=0.04, I2=98.18%) compared with control at the end of the study. In the network meta-analysis, ALA600 (SMD -1.68, 95% CI -2.8 to -0.6) and GLA (SMD -2.39, 95% CI -4.3 to -0.5) had significantly lower TSSs compared with placebo. Moreover, GLA had the highest probability of being the best (52.7%) for improving DN symptoms. In all studies, most adverse events include gastrointestinal disturbances. In terms of tolerability, no differences were detected between ALA and control groups. CONCLUSION: ALA and GLA appear to be safe and efficacious biofactors for improvement of DN symptoms.

Diagnostic accuracy of 68Ga-PSMA PET hybrid imaging in evaluating treatment response to 177Lu-PSMA radioactive ligand therapy in patients with advanced metastatic prostate cancer: A systematic review and meta-analysis

INTRODUCTION@#68Ga-PSMA PET is an effective imaging modality in the evaluation of prostate cancer. However, there is limited data on its use in the evaluation of therapeutic response, particularly in radioligand therapy.@*OBJECTIVE@#Our aim is to investigate the diagnostic accuracy of 68Ga-PSMA PET hybrid imaging in evaluating response to 177Lu-PSMA therapy in patients with mCRPC compared with the standard use of serum PSA.@*METHODOLOGY@#A systematic review was done according to the Cochrane diagnostic accuracy reviews guidelines and the PRISMA checklist of literature from January 2015 to August 2020. Literature search, study selection, and data extraction were conducted by 2 reviewers. Statistical analysis of data was done using Meta-DiSc v1.4@*RESULTS@#A total of 5 studies were included following screening. A total of 128 patients were included in the review. Using PSA response as the reference standard, the pooled sensitivity and specificity of 68Ga-PSMA PET hybrid imaging to evaluate treatment response to 177Lu-PSMA therapy was 85% (Cl: 74 to 92%) and 74% (Cl: 62 to 84%), respectively. The computed diagnostic accuracy was 79.7%.@*CONCLUSION@#68Ga-PSMA PET hybrid imaging is an effective diagnostic procedure in evaluating treatment response to 177Lu-PSMA therapy ligand therapy with good sensitivity, specificity, and diagnostic accuracy.

Bullous presentation of Acrodermatitis Enteropathica in three female siblings: A case series

@#Acrodermatitis enteropathica is a rare autosomal recessive disease that results from a defect in zinc metabolism. It is clinically characterized by a phenotypic triad of periorificial and acral dermatitis, diarrhea, and alopecia. Oral zinc therapy gives a rapid excellent clinical response and reduces mortality. We report three female pediatric siblings who presented with periorificial and acral dermatitis, diffuse alopecia, nail dystrophy, irritable mood, and stunted growth. A diagnosis of acrodermatitis enteropathicawas confirmed with markedly decreased levels of serum zinc. The patients were successfully treated with oral zinc sulfate at a dose of 5mg/kg/day for the first two weeks then maintained on a dose at 2mg/kg/day.

Exploring job satisfaction and performance of staff nurses in Baguio City, Philippines: A descriptive cross-sectional study

@#<strong>BACKGROUND</strong><p style="text-align: justify;" data-mce-style="text-align: justify;">Nursing, as a profession, is a facet where job satisfaction and performance matter. In the changing landscape of nursing practice in the Philippines and the aftermath of the COVID-19 pandemic, it is imperative to revisit and to perform an empirical investigation of the current state of nurses' job satisfaction and performance in the hospital setting. This study aimed to describe the job satisfaction and performance among staff nurses in private and government hospitals in Baguio City.</p><strong>DESIGN</strong><p style="text-align: justify;" data-mce-style="text-align: justify;">Using a quantitative descriptive cross-sectional survey design, a sample of 313 randomly selected staff nurses working in two private and two government hospitals in Baguio City were surveyed from March to April 2023, using a questionnaire. This study's protocol was approved by two ethics committees, namely the Saint Louis University Research Ethics Committee and the BGHMC REC. Nominal data was analyzed using the SPSS trial version employing frequencies, percentages, and the Chi-square test.</p><strong>FINDINGS</strong><p style="text-align: justify;" data-mce-style="text-align: justify;">There are more staff nurses in both private and government hospitals who reported satisfactory job satisfaction levels (276 nurses, 87.9%) and had good job performance (303 nurses, 96.5%) in all domains. However, results show that there are more nurses (209 nurses, 90.7% ) in government hospitals who are satisfied with their jobs than in private hospital nurses (67 nurses, 80.1%) in the domains Intra practice Partnership/Collegiality (p=0.010); Challenge/Autonomy (p=0.001); Professional, Social and Community Interaction (p=0.010); Professional Growth (p=0.036); Time (p=0.009); and Benefits (p=0.045). In terms of job performance, more government nurses at 97.3% (224 nurses) rated a higher self-appraisal of job performance. In comparison, only 94.8% (79 nurses) of private staff nurses appraised themselves as having good performance. No significant differences were found in the domains of job performance, namely leadership, teaching, planning, communications, and professional development, except in critical care. In "Critical care," which showed significance, the results suggest that more nurses in government hospitals perceive higher job performance, revealing a significant difference (p=0.011) in the "critical care" domain, indicating that a higher proportion of nurses in government hospitals demonstrate superior performance in this area.</p><strong>CONCLUSION</strong><p style="text-align: justify;" data-mce-style="text-align: justify;">Through this study, it was learned that nurses in both private and government hospitals generally experience high job satisfaction and performance, reflecting a fulfilled workforce and indicating commendable competency among the staff nurses. However, more nurses in government hospitals report high satisfaction and perceived performance in critical care compared to those in private hospitals. Thus, the findings of this study can contribute to and serve as a rationale for policy making regarding creating a positive work environment, proper management and leadership, creation of training and skill development for critical care, providing opportunities for professional growth, and conducting regular evaluation and feedback----- all geared towards a satisfied and productive workforce.</p>

Genetic diversity and population structure analysis of Philippine native pigs highlight five priority populations for conservation.

The Philippine native pig (PhNP) is a unique genetic resource composed of multiple domesticated Sus scrofa lineages and interspecific hybrids. No prior study has determined the population structure and genetic diversity of PhNPs on multiple islands and provinces, which is essential for establishing conservation priorities. In this study, we explore the population structure and genetic diversity of various PhNP populations in Luzon and the Visayas, Philippines, to identify conservation priorities. We analyzed seven PhNP populations (n = 20-27 samples each; Benguet [B], Kalinga [K], Nueva Vizcaya [N], Isabela [I], Quezon [Q], Marinduque [M], and Samar [S]) and four transboundary breeds present in the Philippines (n = 9-11 samples each; Duroc, Large White, Landrace, and Berkshire). The pigs were compared against a panel of 20 microsatellite markers recommended by the ISAG-FAO. We tested for population structure at the island, region, and province levels. Strong genetic differentiation between native and transboundary breeds was confirmed by Bayesian clustering (k = 2) and Nei's D A genetic distance (100% bootstrap support for the PhNP cluster). PhNP exhibited high heterozygosity (Ho: 0.737), a high allele count (Na: 7.771), and a low inbreeding coefficient (Fis: -0.040-0.125). Bayesian clustering supported genetic differentiation at the island (k = 2; North Luzon and South Luzon-Visayas cluster), region (k = 3), and population (k = 8) levels. The pairwise F'st between PhNP populations ranged from 0.084 (N and I) to 0.397 (Q and K), confirming that some PhNP populations exhibited sufficient genetic distance to be considered separate populations. This study shows that native pigs from B, K, I, Q, M, and S are unique genetic units for conservation. Furthermore, the small effective population sizes of B, I, Q, M, and S (Ne: 3.9, 19.1, 14.2, 44.7, and 22.5, respectively) necessitate immediate conservation actions, such as incentivizing PhNP farming.

Neuromuscular Ultrasound Findings of Myokymia in a Young Woman With Generalized Anti-LGI-1 and Anti-Caspr2 Antibodies Negative Isaac Syndrome.

ABSTRACT: Isaac syndrome is one of the rare peripheral nerve hyperexcitability (PNH) syndromes, which manifests with gross fasciculations, muscle undulation, twitching, and cramps, with or without autonomic and sensory symptoms. The diagnosis relies on characteristic electromyogram findings and the presence of anti-leucine-rich glial inactivated 1 and anti-contactin-associated protein 2 antibodies in the serum. Here, we report the case of a 21-year-old woman, who presented with extremities and tongue myokymia whose electromyogram findings were compatible with PNH, albeit seronegative for antibodies. Neuromuscular ultrasound was performed showing high-frequency rotatory, to-and-fro, high-amplitude movement of superficial and deep muscle fascicles, more prominent in the proximal than distal muscles. Neuromuscular ultrasound may be a useful adjunct in the diagnosis of PNH.

Factors of early breastfeeding initiation among Filipino women: A population-based cross-sectional study.

BACKGROUND: Early breastfeeding initiation (EBI) within the first hour after birth has the potential to reduce neonatal mortality. However, the prevalence of EBI still falls short of the 70 % target set by the WHO for 2030. Limited research has been conducted on this issue. Therefore, the study aimed to assess the prevalence and factors of EBI in the Philippines. METHODS: This study is a secondary analysis of the data from the Philippine National Demographic and Health Survey (PNDHS) in 2017. Women survey participants aged 15 to 49 (n = 3750) who had given birth within the two years prior to the survey were included in this study. A p-value < 0.05 was used to define statistical significance when identifying the factors associated with EBI using hierarchical logistic regression analysis. RESULTS: Women who were more likely to practice EBI were those from the Cordillera Administrative Region, who read newspaper/magazines, and delivered infants at 2 or later birth order. On the contrary, women from Central Luzon, CALABARZON (Cavite, Laguna, Batangas, Rizal, and Quezon provinces), Central Visayas, Eastern Visayas, and the Autonomous Region of Muslim Mindanao; who listen to the radio at least once a week; and give birth through cesarean section were less likely to practice EBI. CONCLUSION: Channeling breastfeeding messages through printed mass media and provision of specialized breastfeeding support to mothers with cesarean section delivery may help in reducing the barriers to early breastfeeding initiation. Targeted interventions and strategies that promote breastfeeding practices, particularly among primigravida women and in regions with lower rates of EBI contribute to increased rate of optimal breastfeeding.

Rectal dural metastasis masquerading as chronic subdural hematoma: illustrative case.

BACKGROUND: Intracranial dural metastasis causing subdural hematoma formation is a rare clinical entity associated with significant morbidity and mortality. A 61-year-old female patient known to have rectal signet ring cell carcinoma presented with cranial computed tomography scan findings of bilateral subdural hematoma. She underwent evacuation of the hematoma with dural biopsy, which showed tumor emboli consistent with colorectal origin. There was an early recurrence of the subdural collection, and an emergency subdural-peritoneal shunt insertion was done; however, there was no sustained clinical improvement. This work reports the first case of rectal dural metastasis presenting as chronic subdural hematoma and discusses the clinical course and current literature. OBSERVATIONS: The cases described in these studies are consistent with the clinical course of our patient; that is, evacuation of the subdural hematoma provided temporary clinical improvement and re-accumulation occurred within 3 days. LESSONS: The authors recommend maintaining a high index of suspicion in this select group of patients, including prompt discussion about treatment plans with the patient's family.

Methotrexate in generalized myasthenia gravis: a systematic review.

Current myasthenia gravis guidelines recommend the use of azathioprine as first-line steroid sparing agent. However, due to its high cost, compliance to azathioprine is low in developing countries. To determine the efficacy and safety of the cheaper methotrexate as an alternative immunosuppressant, Medline/Pubmed, Embase and Cochrane databases and references were searched for clinical trials and observational studies using the search terms: "Myasthenia OR Myasthenia Gravis OR anti AchR antibody positive Myasthenia Gravis OR anti-MuSK antibody Myasthenia Gravis OR MG" AND "Methotrexate". Of 78 possible articles, only 4 were selected using the following eligibility criteria: population: generalized MG patients; intervention: methotrexate; and outcome: effectiveness, steroid sparing efficacy and adverse effects. Two clinical trials and one observational study noted improvement in different MG outcomes in patients given methotrexate. While one randomized controlled clinical trial concluded that methotrexate has no steroid sparing benefit, a single blinded clinical trial established that methotrexate was a better steroid sparing agent than azathioprine starting at 10th month of use. Adverse effects were rare with non-specific pain and elevated transaminases as the most common complaints. Based on available evidence, MTX may be a safe and effective alternative to AZA as steroid sparing agent in developing countries.

Phylogeny and Genetic Diversity of Philippine Native Pigs (Sus scrofa) as Revealed by Mitochondrial DNA Analysis.

Philippine native pigs (PhNP) are small black pigs domesticated in rural communities in the Philippines. They are valued locally for their various sociocultural roles. Recently, considerable literature has accumulated in the field of native pig production and marketing. However, there is limited research on the genetic diversity of PhNP. No previous study has investigated the evolutionary relatedness among native pigs from various islands and provinces in Luzon and the Visayas, Philippines. In addition, a much debated question is whether the PhNP were interbreeding with or even domesticated from endemic wild pigs. This study aims to clarify some of the uncertainties surrounding the identity and classification of PhNP based on mitochondrial DNA (mtDNA) signatures. Native pig samples (n = 157) were collected from 10 provinces in Luzon and the Visayas. Approximately 650 base pairs of the mtDNA D-loop region were sequenced and analyzed together with publicly available sequences. Pairwise-distance analysis showed genetic separation of North and South Luzon (SL) and the clustering of SL with Visayan pigs. Phylogenetic analysis showed that the PhNP clustered within 3 recognized Asian pig domestication centers: D2 (East Asia), D7 (Southeast Asia) and the Cordillera clade (sister to the Lanyu). We identified 19 haplotypes (1-38 samples each), forming 4 haplogroups, i.e., North Luzon, South Luzon and Visayas, Asian mix and the Cordillera cluster. No endemic wild pig mtDNA was detected in the native pig population, but evidence of interspecific hybridization was observed. This study showed that the Philippine native pigs have originated from at least 3 Sus scrofa lineage and that they were not domesticated from the endemic wild pigs of the Philippines.

Building diverse leadership in an academic medical center: The ACCLAIM program.

As healthcare systems become more complex, medical education needs to adapt in many ways. There is a growing need for more formal leadership learning for healthcare providers, including greater attention to health disparities. An important challenge in addressing health disparities is ensuring inclusive excellence in the leadership of healthcare systems and medical education. Women and those who are underrepresented in medicine (URMs) have historically had fewer opportunities for leadership development and are less likely to hold leadership roles and receive promotions. One successful initiative for improved learning of medical leadership-presented as a case example here-is the Academic Career Leadership Academy in Medicine (ACCLAIM) at the University of North Carolina at Chapel Hill School of Medicine. ACCLAIM is uniquely designed for faculty identified as having emerging leadership potential, with an emphasis on women and URMs. Using a leadership learning system approach, annual cohorts of participants (Scholars) interactively participate in a multi-faceted nine-month long learning experience, including group (e.g., guest-speaker weekly presentations and exercises) and individual learning components (e.g., an individual leadership project). Since its initiation in 2012 and through 2021, 111 Scholars have participated in ACCLAIM; included were 57% women and 27% URMs. Two important outcomes described are: short-term impact as illustrated by consistent improvements in quantitively measured leadership knowledge and capabilities; and long-term leadership growth, whereby half of the ACCLAIM graduates have received academic rank promotions and almost two-thirds have achieved new leadership opportunities, with even higher percentages observed for women and URMs; for example, 87% of URMs were either promoted or achieved new leadership positions. Also consistently noted, through qualitative assessments, are broader healthcare system knowledge and shared tactics for addressing common challenges among Scholars. This case example shows that the promotion of leadership equity may jointly enhance professional development while creating opportunities for systems change within academic medical centers. Such an approach can be a potential model for academic medical institutions and other healthcare schools seeking to promote leadership equity and inclusion.

A case series of samar cobra, Naja samarensis Peters, 1861 (Elapidae) envenomation.

The Samar cobra, Naja samarensis Peters, 1861 is one of the World Health Organization's category I venomous snakes in the Philippines. Although N. samarensis is known to inhabit Eastern Visayas, unlike N. philippinensis in Luzon, no clinical case reports have yet been published in the international literature. No immuno-diagnostic assays have been developed for venomous snakes in the Philippines, even for research purposes. Therefore, identification of the causative snake in hospitals is challenging. In vivo pre-clinical tests using mice showed that locally-produced antivenom raised against N. philippinensis venom ["Purified Cobra Antivenom (PCAV)"] cross-neutralised N. samarensis venom. Here, we present five snakebite envenomation cases where causative snakes were confirmed in photos as N. samarensis by an expert local herpetologist. Patients' symptoms and signs varied, from mild to extensive local cytotoxic to systemic neurotoxic envenomation. In one case, venom had been spat into the eye. Out of five patients, two underwent surgical debridement of necrotic tissue at the bite site. One paediatric patient was intubated because of cardiopulmonary arrest. Except for the spitting cobra case, four cases were successfully treated with PCAV and supportive management. These are the first clinical case reports of confirmed N. samarensis envenomation.

Roles and functions of rural health midwives in Cordillera Administrative Region: A qualitative pilot study

Background@#Midwives have been frontline health professionals at the grassroots level, especially in rural communities. Their role was expanded from maternal and child healthcare providers to primary healthcare services providers. Despite their expanded functions, there have been limited studies investigating the professional practice of midwifery in the Philippines in a rural setting.@*Objective@#This study aimed to investigate the professional practice of midwives in selected rural areas in the Cordillera Administrative Region, Philippines.@*Methods@#This research is a qualitative pilot study using a semi-structured interview guide to collect the data. Key informant interviews were conducted through mobile phone calls convenient for the participants from September to October 2021. Data were analyzed through qualitative content analysis.@*Results@#A total of seven rural health midwives participated in this study. From the data analysis, six themes emerged related to the professional functions of rural Filipino midwives: 1) antenatal and postnatal care, 2) basic emergency obstetrical and newborn care, 3) health education and counseling, 4) treating common children and adult infections, 5) health promotion, and 6) beyond midwifery role.@*Conclusion@#Rural midwives play a role in providing several primary healthcare services mandated by the government and the profession. They also offer health services beyond their scope as midwives because of geographical difficulties and logistic issues. The findings inform the policymaker to review and amend the expanded roles of practicing midwives so that they will be empowered in providing quality and legal healthcare services. The study results will also be important in preparing midwives for rural midwifery practice.

Telemedicine use and perspectives of municipal health officers in the Cordillera Administrative Region during the COVID-19 pandemic

Background@#Telemedicine has proven essential during COVID-19. However, concerns remain about the rural municipalities in the country such as those from the Cordillera Administrative Region (CAR), wherein perceived barriers by Municipal Health Officers (MHOs) include poor internet connectivity and inadequacy of the current telemedicine service.@*Objective@#This study aimed to assess the extent of Telemedicine use and perspectives in terms of perception, attitudes and perceived barriers among MHOs in CAR during COVID-19.@*Methods@#This is an analytical cross-sectional study that used a validated online questionnaire to 62 MHOs and DTTBs in CAR. Logistic regression analysis was employed to determine the effect of sociodemographic factors and physician perceptions and attitudes on the extent of Telemedicine use.@*Results@#Most MHOs use Telemedicine frequently in their practice for 0-1 year during COVID-19. There is no significant effect of sociodemographic factors to the extent of Telemedicine use except for IT expertise which had a negative influence on the extent of use [prevalence (p=0.011), frequency (p=0.013), length of use (p=0.044)]. Generally, MHOs agree that telemedicine is beneficial for them in performing consults with a positive effect on frequency (p=0.004) and length of use (p=0.009). There is positive attitude towards telemedicine, however, with no significant effect on extent of use (p=0.352, p=1.00, p=0.484). Compromised decision-making and network issues are the most prevalent perceived barriers that limit MHOs to practice Telemedicine. @*Conclusion and Recommendation@#This study showed that during COVID-19, there is good utilization of Telemedicine among MHOs in CAR. MHOs perceive Telemedicine as beneficial in their work and positive attitude remains. However, presence of barriers makes them apprehensive to fully incorporate it in their practice. Study results can contribute to policy-making on telemedicine as it is a key player in e- health to improve access to healthcare services in the attainment of the goal of Universal Healthcare.