Reinfection rates, change in antibody titers and adverse events after COVID-19 vaccination among patients previously infected with COVID-19 in Metro Manila, Philippines: a secondary analysis of a completed cohort study.

BACKGROUND: Variation in immune response to COVID-19 vaccines is observed among different ethnicities. We aimed to describe the reinfection rates, change in antibody titers, and adverse events among Filipinos. METHODS: This is a secondary analysis of a cohort study of 307 participants within one year of having COVID-19 infection. We measured COVID-19 antibody levels at pre-determined timepoints (Days 21, 90, 180, 270, and 360 from initial infection). We monitored for COVID-19 symptoms and obtained details on COVID-19 vaccination. An adjudication committee classified the participants as probable, possible, or unlikely COVID-19 reinfection. We determined the probable reinfection rate, adverse events, and the geometric mean titer (GMT) ratio of pre- and post-vaccination antibody levels according to type and brand of COVID-19 vaccine. RESULTS: At the end of the follow-up period, 287 (93.5%) out of 307 study participants were fully vaccinated, 1 was partially vaccinated (0.3%), and 19 were unvaccinated (6.2%). Among the fully vaccinated participants, those given mRNA vaccines had the lowest reinfection rate (19.2 cases/100 person-years, 95% CI 9.6, 38.4), followed by viral vector vaccines (29.8 cases/100 person-years, 95% CI 16.9, 52.4). We observed the highest reinfection rate among those given inactivated virus vaccines (32.7 cases/100 person-years, 95% CI 23.6, 45.3). The reinfection rate was 8.6 cases/100 person-years (95% CI 4.1, 17.9) for unvaccinated participants and 3.6 cases/100 person-years (95% CI 0.5, 25.3) for partially vaccinated participants. We observed the largest rise in antibody titers among those given mRNA vaccines (GMT ratio 288.5), and the smallest rise among those given inactivated virus vaccines (GMT ratio 16.7). We observed the highest percentage of adverse events following immunization with viral vector vaccines (63.8%), followed by mRNA vaccines (62.7%), and the lowest for inactivated virus vaccines (34.7%). No serious adverse events were reported. CONCLUSION: Vaccinees given the mRNA vaccines had the lowest reinfection rate and the highest rise in antibody titers. Vaccinees given inactivated virus vaccines had the highest reinfection rate, smallest rise in antibody titers, and lowest percentage of adverse events. The small sample size and imbalanced distribution of the type of vaccines received limits the external generalizability of our results. STUDY REGISTRATION: The cohort study was registered at the Philippine Health Research Registry on December 14, 2020 (PHRR201214-003199).

Durability and extent of protection of SARS-CoV-2 antibodies among patients with COVID-19 in Metro Manila, Philippines.

Introduction: Information on the magnitude and durability of humoral immunity against COVID-19 among specific populations can guide policies on vaccination, return from isolation and physical distancing measures. The study determined the durability of SARS-CoV-2 antibodies after an initial infection among Filipinos in Metro Manila, Philippines, and the extent of protection SARS-CoV-2 antibodies confer against reinfection. Methods: We conducted a cohort study to monitor the antibody levels of patients diagnosed with COVID-19. Receptor-binding domain (RBD)-specific antibodies were measured at Days 21, 90, 180, 270 and 360. Antibody levels were reported as geometric mean titers (GMT) with geometric standard deviation (GSD). Differences in GMT were tested using Friedman test and Kruskal Wallis test, with Bonferroni multiple comparisons procedure. Adjusted hazard ratios on the development of probable reinfection were estimated using Cox proportional models. Results: There were 307 study participants included in the study, with 13 dropouts. Study participants received SARS-CoV-2 vaccines at varying times, with 278 participants (90.5%) fully vaccinated by the end of study. The GMT of the study cohort increased over time, from 19.7 U/mL (GSD 11) at Day 21; to 284.5 U/mL (GSD 9.6) at Day 90; 1,061 U/mL (GSD 5.3) at Day 180; 2,003 U/mL (GSD 6.7) at Day 270; and 8,403 U/mL (GSD 3.1) at Day 360. The increase was statistically significant from Day 21 to Day 90 (p<0.0001), Day 90 to Day 180 (p=0.0005), and Day 270 to Day 360 (p<0.0001). Participants with more severe initial infection demonstrated significantly higher antibody levels compared to those with milder infection at Day 21. Sixty-four patients had probable COVID-19 reinfection (incidence of 20.8%, 95% CI 16.4, 25.8%). The GMT of these 64 patients was 411.8 U/mL (GSD 6.9) prior to the occurrence of the probable reinfection. Majority (87.5%) were fully vaccinated. Antibody titers significantly affected the risk of developing reinfection, with adjusted hazard ratio of 0.994, 95% CI 0.992-0.996, p<0.001. Conclusion: Antibody levels against SARS-CoV-2 increased over a one-year follow-up. Higher antibody levels were observed among those with more severe initial infection and those vaccinated. Higher antibody levels are associated with a lower risk of probable reinfection.

A review of the clinical outcomes in idursulfase-treated and untreated Filipino patients with mucopolysaccharidosis type II: data from the local lysosomal storage disease registry.

BACKGROUND: Mucopolysaccharidosis type II (MPS II; Hunter syndrome) is an X-linked multisystem disorder characterized by glycosaminoglycan (GAG) accumulation, caused by a deficiency of iduronate-2-sulfatase (I2S). Enzyme replacement therapy (ERT) with recombinant idursulfase (IDS), the standard of care, was started in the Philippines in 2017. This study reviewed the clinical outcomes in idursulfase-treated and untreated Filipino MPS II patients who were included in the local Lysosomal Storage Disease (LSD) registry of the Institute of Human Genetics-National Institutes of Health (IHG-NIH) from January 1999 to December 2019. METHODS: A retrospective audit of records of MPS II patients listed in the registry was done. Qualified patients were divided into two cohorts: idursulfase-treated group (patients on enzyme replacement therapy, ERT, for ≥ 6 months) and untreated group. Baseline characteristics, including demographic data, biochemical results, neurocognitive classification, respiratory involvement, mortality, and adverse events, were recorded. Height, weight, cardiac pathology, liver and spleen sizes, six-minute walking test (6MWT), joint mobility, were determined at baseline and at year 1 and 2 of follow up. RESULTS: Forty male patients were included in this review, with only 8 receiving ERT since 2017. The mean age at diagnosis was 6.99 years (SD 4.15; 0.75-20) and mean age at start of ERT was 14.03 years (SD 7.1; 4-21.5), more delayed than previous reports. Eighty percent have early progressive phenotype which was higher than reported average. The early growth pattern differed in our Filipino cohort, but was followed by the expected slowed growth in later years. Improvements in the following endpoints were observed in the treated cohort: height and weight, cardiac disease, liver and spleen sizes, and joint mobility. There were also positive effects on respiratory involvement and mortality rate. Adverse events were consistent with previous reports. CONCLUSIONS: ERT is generally well tolerated and effective in reducing GAG storage and improving clinical endpoints among our Filipino MPS II patients. In untreated patients, typical disease progression was observed.

High TB burden and low notification rates in the Philippines: The 2016 national TB prevalence survey.

SETTING: The 3rd national tuberculosis (TB) survey in the Philippines in 2007 reported a significant decline in the prevalence of TB. Since then, more significant investments for TB control have been made, yet TB burden estimates from routine surveillance data remain relatively stable. OBJECTIVE: To estimate the prevalence of bacteriologically confirmed pulmonary TB in the Philippines amongst individuals aged ≥15 years in 2016. DESIGN: In March-December 2016, we conducted a population-based survey with stratified, multi-stage cluster sampling of residents in 106 clusters aged ≥15 years. Survey participants were screened for TB by symptom-based interview and digital chest X-ray. Those with cough ≥2 weeks and/or haemoptysis and/or chest X-ray suggestive of TB were requested to submit 2 sputum specimens for Xpert MTB/RIF, direct sputum smear microscopy using LED fluorescent microscopy, and mycobacterial solid culture (Ogawa method). Bacteriologically confirmed pulmonary TB was defined as MTB culture positive and/or Xpert positive. RESULTS: There were 46,689 individuals interviewed, and 41,444 (88.8%) consented to a chest X-ray. There were 18,597 (39.8%) eligible for sputum examination and 16,242 (87.3%) submitted at least one specimen. Out of 16,058 sputum-eligible participants, 183 (1.1%) were smear-positive. There were 466 bacteriologically confirmed TB cases: 238 (51.1%) Xpert positive, 69 (14.8%) culture positive, and 159 (34.1%) positive by both Xpert and culture. The estimated TB prevalence per 100,000 population aged ≥15 years was 434 (95% CI: 350-518) for smear-positive TB, and 1,159 (95% CI: 1,016-1,301) for bacteriologically confirmed TB. CONCLUSION: This nationally representative survey found that the TB burden in the Philippines in 2016 was higher than estimated from routine TB surveillance data. There was no evidence of a decline in smear and culture positive TB from the 2007 survey despite significant investments in TB control. New strategies for case-finding and patient-centered care must be intensified and expanded.

Prevalence and prognostic associations of cardiac abnormalities among hospitalized patients with COVID-19: a systematic review and meta-analysis.

Although most patients recover from COVID-19, it has been linked to cardiac, pulmonary, and neurologic complications. Despite not having formal criteria for its diagnosis, COVID-19 associated cardiomyopathy has been observed in several studies through biomarkers and imaging. This study aims to estimate the proportion of COVID-19 patients with cardiac abnormalities and to determine the association between the cardiac abnormalities in COVID-19 patients and disease severity and mortality. Observational studies published from December 1, 2019 to September 30, 2020 were obtained from electronic databases (PubMed, Embase, Cochrane Library, CNKI) and preprint servers (medRxiv, bioRxiv, ChinaXiv). Studies that have data on prevalence were included in the calculation of the pooled prevalence, while studies with comparison group were included in the calculation of the odds ratio. If multiple tests were done in the same study yielding different prevalence values, the largest one was used as the measure of prevalence of that particular study. Metafor using R software package version 4.0.2 was used for the meta-analysis. A total of 400 records were retrieved from database search, with 24 articles included in the final analysis. Pooled prevalence of cardiac abnormalities in 20 studies was calculated to be 0.31 [95% Confidence Intervals (CI) of (0.23; 0.41)], with statistically significant heterogeneity (percentage of variation or I-squared statistic I2 = 97%, p < 0.01). Pooled analysis of 19 studies showed an overall odds ratio (OR) of 6.87 [95%-CI (3.92; 12.05)] for cardiac abnormalities associated with disease severity and mortality, with statistically significant heterogeneity (I2 = 85%, between-study variance or tau-squared statistic τ2 = 1.1485, p < 0.01). Due to the high uncertainty in the pooled prevalence of cardiac abnormalities and the unquantifiable magnitude of risk (although an increased risk is certain) for severity or mortality among COVID-19 patients, much more long-term prognostic studies are needed to check for the long-term complications of COVID-19 and formalize definitive criteria of "COVID-19 associated cardiomyopathy".

Early experience with COVID-19 patients in a private tertiary hospital in the Philippines: Implications on surge capacity, healthcare systems response, and clinical care.

BACKGROUND: Our healthcare institution was one of the first to see SARS CoV-2 cases in the country. We describe the early COVID-19 experience of a private hospital in the Philippines and discuss the healthcare system response in the setting of surge capacity. METHODS: We reviewed the medical records of adult COVID-19 hospitalized patients admitted in March 2020. We reported their demographic and clinical characteristics using descriptive statistics. RESULTS: Of 40 patients admitted, 23 (57.5%) were male and 19 (47.5%) were aged <60 years. Most (n = 27, 67.5%) had moderate-risk, 9 (22.5%) had high-risk, and 4 (10%) had low-risk COVID-19. SARS-CoV-2 testing took 5.5 (range 1-10) days. Overall mortality rate was 6/40 (15.0%). Clinical cure was documented in all low-risk patients, 25 (92.6%) moderate-risk patients, and only 1 (11.1%) high-risk patient. In response to the surge, the hospital rapidly introduced one-way traffic systems, dedicated screening, triage and Emergency Department areas for COVID-19, a clinical pathway, engineering controls, patient cohorting, and strict infection prevention and control measures. CONCLUSION: Majority of patients recovered from COVID-19. Older age and high-risk pneumonia were associated with poor outcomes. Adaptations to hospital structure and staff were quickly made in response to surge capacity, although our response was hampered by prolonged time to COVID-19 confirmation. Our study underscores the urgent need for rapid adaptive response by the healthcare system to address the surge of cases.

Key concepts in clinical epidemiology: detecting and dealing with heterogeneity in meta-analyses.

In a meta-analysis, a question always arises. Is it worthwhile to combine estimates from studies of different populations using various formulations of an intervention, evaluating outcomes measured differently? Sometimes even study designs differ. Differences are expected in a meta-analysis. These may be negligible, and a pooled estimate of effect can guide the clinical decision. However, when the differences are large, this estimate may mislead. Effect estimates from study to study differ because of real differences (between-study variability) and because of chance (within-study variability). To combine estimates when there is heterogeneity (between-study differences are large) may not be sensible. Two complementary methods may be used to detect heterogeneity: visual inspection of the forest plot and calculating numerical measures of heterogeneity (I2 and Q). Visual inspection can show effects that are different from the rest. A large I2 (proportion of overall variability attributed to between-study variation) or a small P-value associated with Q may suggest heterogeneity. Large P-values, however, do not mean the absence of heterogeneity. It is more informative to report the confidence interval of the I2. If there is no heterogeneity, a pooled estimate of the true effect may be generated using only within-study variation (fixed-effect model). If there is substantial heterogeneity, reasons should be sought. Subgroup analysis or meta-regression using study-level characteristics may be done. Although more involved and potentially challenging, individual-level data (Individual Participant Data, IPD) may also be used. In the case of unexplained heterogeneity, both within- and between-study variation should be used to generate a pooled estimate (random-effects model). This estimate does not estimate a single true effect but estimates the average of a range of effects of the intervention on populations represented by the studies. If precise enough (narrow confidence interval), this estimate, together with the prediction interval (a measure of uncertainty in the effect one might see in a particular context), can guide clinical and policy decisions.

Quality of life of patients with traumatic brachial plexus injuries.

BACKGROUND: Traumatic brachial plexus injuries are devastating injuries with lifelong disability and pain. The objective of this paper was to determine the functional disability of adult patients with traumatic brachial plexus injuries. PATIENTS AND METHODS: A cross-sectional study was done to determine the functional disability of patients using the FIL-DASH (Filipino Disability of the Arm, Shoulder and Hand) and the BPI (Brief Pain Inventory) Severity Pain Score (Tagalog version) questionnaires to determine the functional disability and quality of life of patients with traumatic brachial plexus injuries. A regression analysis was done to determine the factors associated with the FIL-DASH score with the level of significance set at p < 0.05. RESULTS: A total of 126 adult patients with traumatic brachial plexus injuries were evaluated with a mean age of 30.1(standard deviation [SD], 9.1; range, 17-69). There were 123 males and three females. The mean quality of life (FIL-DASH Score) of the 126 patients was 45.6 (95% CI: 42.5 - 48.7), (SD, 17.4), (range, 2.5 - 89.2), the mean BPI Severity Pain Score was 16.1 (95% CI: 14.6-17.8; SD, 8.9; range, 0-36) among 126 patients. On multivariate analysis using the hierarchical method of model building, higher range of elbow flexion, lower Brief Pain Inventory Severity Score, and longer months from injury were found to be associated with a better FIL-DASH score. CONCLUSION: The study showed that elbow flexion recovery, pain and duration of the injury were significantly associated with the FIL-DASH scores.

The Validity, Reliability and Internal Consistency of the Cross-Cultural Adaptation of the FIL-DASH (Filipino Version of the Disability of the Arm, Shoulder and Hand) Questionnaire in Patients with Traumatic Brachial Plexus Injuries.

Background: The objective of this paper was to determine the validity, reliability and internal consistency of the translated FILIPINO DASH (FIL-DASH) questionnaire in patients with traumatic brachial plexus injuries. Methods: Thirty-five adult patients with traumatic brachial plexus injury were enrolled in the validation stage. The same questionnaire was given to the patient between 7 to 14 days for the test-retest reliability. The validated Filipino version of the SF-36 was used as the gold standard to determine the construct validity of the translated DASH. We also compared the DASH score with the SF-36 total and subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Acuity Scale (VAS) for Pain. Results: The internal consistency was adequate, with Cronbach's Alpha for the 30 items of 0.93 and an average inter-item covariance of 0.399. The test-retest reliability was 0.87 (p < 0.001). There was no significant difference in establising the validity of the translated DASH against SF-36 total and Subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Analogue Scale (VAS). Conclusions: The translated DASH (FIL-DASH) questionnaire was internally consistent and showed no difference in testing for test-retest reliability and validity against functional outcome measures and pain scales validated for adult Filipinos.

Mixed-methods research revealed the need for dementia services and Human Resource Master Plan in an aging Philippines.

OBJECTIVE: To determine the status of dementia care services and workforce in selected public and private hospitals and geriatric care facilities in the Philippines. STUDY DESIGN AND SETTING: Framework analysis of 54 key informant interviews, 4 focus group discussions, and survey of 167 workers in 26 purposively selected facilities. RESULTS: Three dementia care models emerged: (1) separate unit, seen in 2 facilities, (2) partial dementia services, 9 facilities, and (3) integrated with the general services, 15 facilities. Only 1 of 26 facilities had specific outpatient services; only 1 provided care exclusively to dementia patients. Community day care services were rare. Physicians, nurses, and nursing assistants were available in all institutions. Nutrition and physical therapy services were generally available. There was a scarcity of physician specialists (e.g., geriatrics) and occupational therapists. Half of the workers surveyed rated the quality of their service at 80 or higher, 27% defined dementia correctly. Attitude toward dementia was very positive, in the form of willingness to care for and willingness to learn more. CONCLUSION: Mixed-methods research helped identify service and health workforce needs and elucidate understanding of health workers' attitude and perceptions toward a disease of which there is low knowledge and awareness.

Clinical, biochemical and molecular characteristics of Filipino patients with mucopolysaccharidosis type II - Hunter syndrome.

BACKGROUND: Mucopolysaccharidosis type II, an X-linked recessive disorder is the most common lysosomal storage disease detected among Filipinos. This is a case series involving 23 male Filipino patients confirmed to have Hunter syndrome. The clinical and biochemical characteristics were obtained and mutation testing of the IDS gene was done on the probands and their female relatives. RESULTS: The mean age of the patients was 11.28 (SD 4.10) years with an average symptom onset at 1.2 (SD 1.4) years. The mean age at biochemical diagnosis was 8 (SD 3.2) years. The early clinical characteristics were developmental delay, joint stiffness, coarse facies, recurrent respiratory tract infections, abdominal distention and hernia. Majority of the patients had joint contractures, severe intellectual disability, error of refraction, hearing loss and valvular regurgitation on subspecialists' evaluation. The mean GAG concentration was 506.5 mg (SD 191.3)/grams creatinine while the mean plasma iduronate-2-sulfatase activity was 0.86 (SD 0.79) nmol/mg plasma/4 h. Fourteen (14) mutations were found: 6 missense (42.9%), 4 nonsense (28.6%), 2 frameshift (14.3%), 1 exon skipping at the cDNA level (7.1%), and 1 gross insertion (7.1%). Six (6) novel mutations were observed (43%): p.C422F, p.P86Rfs*44, p.Q121*, p.L209Wfs*4, p.T409R, and c.1461_1462insN[710]. CONCLUSION: The age at diagnosis in this series was much delayed and majority of the patients presented with severe neurologic impairment. The results of the biochemical tests did not contribute to the phenotypic classification of patients. The effects of the mutations were consistent with the severe phenotype seen in the majority of the patients.

Challenges in the management of patients with maple syrup urine disease diagnosed by newborn screening in a developing country.

Maple syrup urine disease (MSUD) is a rare inborn error of metabolism resulting from a deficiency in the branched-chain alpha-ketoacid dehydrogenase complex. MSUD has been reported to be the most common inborn error of metabolism in the Philippines. We described all patients with maple syrup urine disease patients diagnosed through newborn screening during its first 2 years of implementation and the challenges encountered during their medical management. There were 24 patients diagnosed with maple syrup urine disease for the 2-year period. All patients needed hospital admission. The most common complication during hospital admission was infection, needing intravenous antibiotics which were given to 21 of the patients. Out of the 24 diagnosed, 16 patients are alive, while eight have died. Several neurologic and non-neurologic complications have been observed during the follow-up of the patients. The common challenges of MSUD management in a low-resource setting identified in this study were late diagnosis, lack of access to metabolic specialists and medical supplies, nosocomial septicemia, and protein deficiency. Aside from early properly timed collection, improvement in other logistical concerns will also help in earlier diagnosis. Mechanisms of transfer of critically ill patients must be improved. Hospitals in difficult-to-reach areas must be equipped to handle critical metabolic cases when transfers are not possible. Newborn screening has been proven to improve outcome in patients with MSUD but the success of the program in preventing disability is also dependent on improvements in other aspects of healthcare.

Plasma amino acid and urine organic acid profiles of Filipino patients with maple syrup urine disease (MSUD) and correlation with their neurologic features.

BACKGROUND: Maple syrup urine disease (MSUD) is the most common inborn error of metabolism in the country. The cause of the neuropathology is still not well established although accumulation of branched chain amino acids (BCAA) and alteration in large neutral amino acids (LNAA) as well as energy deprivation are suggested. It is therefore the aim of this study to determine the plasma amino acid and urine organic acid profiles of patients with MSUD and correlate the findings with their neurologic features. METHODOLOGY: Twenty six Filipino patients with MSUD were studied in terms of their plasma amino acid and urine organic acid profiles. Their results were compared with 26 age and sex matched controls. The neurologic features were correlated with the results of the plasma amino acids and urine organic acids. RESULTS: Majority of the patients with MSUD had developmental delay/intellectual disability (88%), speech delay (69%), and seizures (65%). Their amino acid profiles revealed low glutamine and alanine with high levels of leucine, isoleucine, phenylalanine, threonine and alloisoleucine compared to controls (p < 0.05). The urine organic acids showed significantly elevated excretion of the branched chain ketoacids and succinate (p < 0.05). However there were no biochemical markers that correlated significantly with the neurologic features. CONCLUSION: The findings suggest that there could still be altered LNAA metabolism among patients with MSUD when the BCAAs are elevated. Although the biochemical findings were not significantly correlated with the neurologic features, the study showed that prevention and avoidance of neurologic disturbances may still rely primarily on early diagnosis and prompt institution of treatment, along with strict compliance with the dietary regimen and maintenance of good metabolic control over time.

Assessing the residual risk for transfusion-transmitted infections in the Philippine blood supply.

Due to a USAID-funded study on blood banks, a national policy was instituted in 1994 that set standards for Philippine blood services, promoted voluntary donation, and led to a ban on commercial blood banks. In this follow-up study, we assess the safety of the supply by determining the residual risk for transfusion-transmitted infections (syphilis, hepatitis B and C, HIV). We also identified unsafe facility practices and generated policy recommendations. A 1992 study found that transfusion-ready blood was not safe using the LQAS method (P > 0.05). We found that the 2012 residual risk became 0 to 0.9 percent attributable to the national policy. We noted poor to fair adherence to this policy. We identified unsafe practices such as use of rapid tests and lack of random blood retesting. Training and use of regional networks may improve safety. Despite improvement in safety, facilities complain of funding and logistical issues regarding compliance with the policy.

Factors associated with severe mucosal injury of esophagogastroduodenoscopy after caustic substance ingestion in pediatrics

OBJECTIVE: To determine the prevalence of and factors associated with severe mucosal injury on esophagogastroduodenoscopy (EGD) after caustic ingestion. METHODS: Consecutive patients ?19 years old with history of caustic ingestion were included. Factors considered were age, sex, caustic agent (acid or alkali) and presence of signs/symptoms (oral lesions, drooling, vomiting, abdominal pain, dysphagia).  RESULTS: 320 patients were investigated: 155 (48%) accidental and 165 (52%) intentional case. In accidental intake, majority (84%) were ?6 years old [mean(SD) age: 3.7 (4.3) yrs, 59% males]. 10% had severe mucosal injury. The odds of severe injury increased in the presence of ?2 signs/symptoms: OR=7.0 for 2 and OR=62.2 for >2. In intentional cases, the mean (SD) age was 16 (1.6) years, 74% females. Severe mucosal injury was seen in 5% and associated with acidic agent (OR=54.8). CONCLUSIONS: Severe mucosal injury on EGD occured in 10% and 5% among accidental and intentional cases, respectively. In accidental cases, probability of severe injury increased in the presence of ?2 signs/symptoms. In intentional cases, acid intake was the only factor associated with severe injury. In the local setting, presence of these factors among patients with caustic ingestion will help identify high-risk patients who need EGD-guided management.

Early diagnosis and specialist care in the management of congenital hypothyroidism

Background. Newborn screening for congenital hypothyroidism (CH) in the Philippines was introduced in 1996. It is universally accepted that early detection through newborn screening and timely treatment can improve the physical and neuro-cognitive development of patients. As of December 2010, the prevalence of CH is 1 in 3,324 among 2,389,959 newborns screened. Objective. We sought to evaluate the role of timing of diagnosis, compliance with treatment, and specialist care on growth and development (mental and physical) of patients with congenital hypothyroidism detected through newborn screening. Methods. Of the 326 patients identified through newborn screening between July 1996-December 2008 at the Newborn Screening Center-National Institutes of Health, 86 patients participated in the study. With the parents' or guardians' consent, general physical examination and neuro-cognitive evaluation were done; FT4 and TSH were determined. Prevalence of poor control of disease (high TSH with normal or low FT4 or normal TSH with low FT4), stunting, and cognitive delay were each estimated at 95% confidence level and the associations of early diagnosis, initial and continuing specialist care with these conditions were determined by multiple logistic regression analyses. Results. The prevalences (95% confidence interval) were: poor control of disease 63% (52-73%), stunting 24% (15-34%) and neuro-developmental delay 17% (8-25%). Delay in one aspect of neuro-development was seen in 54% (43-66%). Early diagnosis was protective against poor control of disease (adjusted Odds Ratio, ORa=0.24 [CI: 0.08-0.77]). Trends towards protection were seen for initial and continuing specialist care. For delay in at least one cognetive aspect, early diagnosis was found to be protective (ORa=0.19 [CI 0.05-0.76]); results for specialist care were inconclusive. For stunting, low parent education was found to be a risk factor. (ORa of 5.45 [CI: 1.3-22.7]). Conclusion. Fifty-four percent of the study patients had delay in one aspect of neuro-development. While other factors play a role in the outcome of CH, early diagnosis and treatment were shown to be protective of patients from poor control of disease and cognitive delays. Observed trends of positive benefits of specialist care at onset and continuing medical management, and the association of low parent education with poor growth should be considered in drafting specific guidelines for the long term follow-up care and monitoring of CH patients detected through newborn screening. The low percentage of participation and incomplete retrieval of information are major limitations of this retrospective study. This stresses the need for better monitoring tools that will ensure proper tracking, medical care and evaluation of CH patients.

Level of understanding and areas of application of cochrane reviews among practicing physicians affiliated with the Philippine General Hospital

Objective. The main objective of this study is to determine the level of understanding, accessibility and areas of application of Cochrane reviews (CR) among medical practitioners affiliated with a tertiary care medical center in Metro Manila, Philippines. Study Design. Survey using a self-administered questionnaire was conducted. Target Population and Setting. Consultant doctors of the Philippine General Hospital (PGH) were invited to participate. The PGH is the national university hospital of the Philippines and is a tertiary referral center and teaching hospital of the University of the Philippines Manila. Sampling Scheme. 101 doctors were chosen by stratified random sampling with the clinical department as the stratification variable. Strata samples were targeted according to strata size (proportional to size). Measurement Instrument. Eight domains that are important in the understanding of the CR were included in a 25-item multiple-choice questionnaire. In addition, facilitating factors and barriers to the application of CR or systematic reviews (SR) were asked. Data Analysis. Using a 25-point Multiple Choice Questionnaire, the knowledge of the respondents was measured and the mean score was estimated at a 95% confidence level. The percentage of CR awareness was also estimated at 95% confidence level. Facilitating factors and barriers in the use of SR were described. In addition, the following post-hoc analyses were done: descriptions of the total score according to gender, age, year graduated and year of last training. Results. Of 101 consultants invited, 59 participated (58% response rate) within the 6-month data collection period. The mean age was 47.2 years with a standard deviation (SD) of 7.8 years. Forty-five respondents (76%) had their last formal medical-related training from 1991 onwards. The mean score was 14.7 points (SD 6.7) using the 25-item multiple choice questions on concepts and principles of systematic reviews. Of these 59 respondents, 49 (83.0%: 95% CI: 75.2 - 90.9) indicated that they were aware of the existence of CR. Of those who were aware of CR, 42 (85.7%, 95% CI: 75.9 -95.6) have actually used them. The following factors help the respondents use CR: efficient Internet access, working knowledge of research methodology, working knowledge of how to critically appraise the medical literature, and familiarity with the terms used in the review. On the other hand, the following were considered barriers: inefficient access, poor knowledge of general research methodology, poor understanding of the principles of Evidence-based medicine (EBM) and difficulty in understanding the reviews. Conclusion. Practicing physicians in a tertiary university hospital in the Philippines were only able to get about 60% of the principles and concepts of understanding SR. Eighty three percent of them are aware of CR. Access to internet, familiarity with terms and working knowledge of CR and evidence-based medicine are the facilitating factors for application of the results of SR and CR. Although most claimed to use the SR results in literature reviews, only about 60% are able to use them in teaching, clinical practice or health policy development.

Formative research to develop and test messages to educate mothers on zinc supplementation in childhood diarrhea

BACKGROUND: Zinc is now recommended as part of childhood diarrhea case management but there are concerns regarding treatment duration and perceptions of its use when given with ORT. OBJECTIVES: This study developed and tested messages on zinc supplementation for childhood diarrhea. METHODS: Messages were based on 1) a review of literature and product advertisements, 2) drugstore seller interviews, and 3) focus group discussions (FGDs) among 10 mothers with children six to 59 months old. Subsequent FGDs with 15 mothers consulting at a government hospital helped determine message clarity, comprehension and appeal. A behavioral trial, involving nine mothers whose children had diarrhea, tested recall of and adherence to the messages. RESULTS: The trial tested three messages - zinc: 1) strengthens resistance; 2) is a vitamin for the gut; 3) increases the appetite of a child with diarrhea. Seven of nine mothers were able to follow instructions on zinc administration, and demonstrated recall and understanding of these messages. Mothers understood that zinc helps the child with diarrhea, improves appetite, reduces symptoms and hastens recovery, but had concerns regarding the side effects (vomiting), co-morbidities (fever, cough) and consequences of overdose. Standardized counseling cards addressed these concerns. Respondents preferred a simple logo labeled with zinc administration instructions on the packaging. Zinc supplementation did not affect ORT use. CONCLUSION AND RECOMMENDATIONS: Messages sufficiently addressed mothers concerns on zinc use during childhood diarrhea, with those on zinc improving and as a vitamin for the gu having the best recall. Results can contribute to introduction and promotion in the public sector.

Funding agencies in low- and middle-income countries: support for knowledge translation.

OBJECTIVE: The aim was to describe how selected health research funding agencies active in low- and middle-income countries promote the translation of their funded research into policy and practice. METHODS: We conducted inductive analysis of semi-structured interviews with key informants from a purposive sample of 23 national and international funding agencies that fund health research in Brazil, Colombia, India, the Philippines, South Africa and Thailand. We also surveyed web sites. FINDINGS: We found a commitment to knowledge translation in the mandate of 18 of 23 agencies. However, there was a lack of common terminology. Most of the activities were traditional efforts to disseminate to a broad audience, for example using web sites and publications. In addition, more than half (13 of 23) of the agencies encouraged linkage/exchange between researchers and potential users, and 6 of 23 agencies described "pull" activities to generate interest in research from decision-makers. One-third (9 of 23) of funding agencies described a mandate to enhance health equity through improving knowledge translation. Only 3 of 23 agencies were able to describe evaluation of knowledge translation activities. Furthermore, we found national funding agencies made greater knowledge translation efforts when compared to international agencies. CONCLUSION: Funding agencies are engaged in a wide range of creative knowledge translation activities. They might consider their role as knowledge brokers, with an ability to promote research syntheses and a focus on health equity. There is an urgent need to evaluate the knowledge translation activities of funding agencies.