The efficacy and safety of Emblica officinalis aqueous fruit extract among adult patients with dyslipidemia: A systematic review and meta-analysis

Background@#Flavonoids from Emblica officinalis effectively reduced serum and tissue lipid levels through their inhibitory effect on the hepatic β-hydroxy-β-methylglutaryl coenzyme A reductase activity. This study aimed to determine the efficacy and safety of E. officinalis extract in adults with dyslipidemia.@*Methods@#We searched the following electronic databases: MEDLINE (PubMed), MEDLINE (Ovid), Google Scholar, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science, and ClinicalTrials.gov from inception until January 31, 2022. Two reviewers independently screened the abstracts, reviewed full-text papers, and critically appraised the quality of included studies. Meta-analysis was performed using the random-effects model. Our primary outcomes were total cholesterol, LDL-C, serum triglycerides, and HDL-C levels, while secondary outcomes included adverse events.@*Results@#A total of four randomized trials (N = 227) were included in the final analysis. There were statistically significant decreases in total cholesterol levels (SMD = -21.23 mg/dL, 95% CI: -34.22, -8.25; P = 0.001) and LDL-C levels (SMD = -25.12 mg/dL, 95% CI: -40.24, -10.00; P = 0.001) and significant increase in HDL-C levels (SMD = 4.74 mg/dL, 95% CI: 0.40, 9.07; P = 0.03) after 12 weeks of intervention favoring the use of the Emblica extract over placebo. However, there were no statistically significant difference in the serum triglycerides levels following 12 weeks of treatment (SMD = -22.28 mg/dL, 95% CI: -53.33, 8.76; P = 0.16). There was high heterogeneity noted across all outcomes: total cholesterol (P = 0.01, I2 = 72%), LDL-C (P = 0.0004, I2 = 83%), HDL-C (P < 0.00001, I2 = 91%) and serum triglycerides (P < 0.00001, I2 = 93 %). The intervention was well tolerated and adverse events reported in the three of four studies were all mild: dyspepsia (7 events – treatment), mild diarrhea (3 events – placebo), fever (1 event – placebo), headache (1 event – placebo).@*Conclusion@#Compared to placebo, Emblica officinalis fruit extract resulted in lower total cholesterol and LDL-C levels and increased HDL-C levels but with no effect on serum triglyceride levels based on low certainty of evidence. Trials with a larger sample size that directly compare E. officinalis extract to statins, preferably local data, are needed to support its use in patients with dyslipidemia further.

The prevalence of metabolic syndrome among adult Filipinos with hypothyroidism: A retrospective cohort study

Background and Objective@#Dyslipidemia in hypothyroidism results from the effects of thyroid hormones on lipid metabolism. These, in combination with hypothyroidism-induced hemodynamic changes, are risk factors for cardiometabolic diseases. We determined the prevalence of metabolic syndrome (MS) among adult Filipinos with hypothyroidism and compared clinical and laboratory characteristics of those with versus without MS. @*Methods@#This is a retrospective study of 105 patients with biochemically confirmed hypothyroidism. A review of records obtained anthropometric measurements, blood pressure, fasting blood glucose, lipid profile, and thyroid hormones. Clinical and laboratory characteristics were then compared between MS and those without. Significant differences were determined by two-way ANOVA, while heterogeneity of categorical variables was determined by chi-square or Fisher exact test. All data analyses were performed using Stata version 17.0 with a significance level of p<0.05.@*Results@#The prevalence of MS is 36.19% (95%CI: 27.04%,46.15%). Body mass index (BMI) peaks at obese class I among those with MS. There is a significantly higher proportion of patients diagnosed to have diabetes (28.95% vs. 7.46%; p=0.003) and hypertension (52.63% vs. 14.93%; p<0.001) in the MS group. No significant differences were noted between groups regarding age, sex, etiology of hypothyroidism, blood pressure, fasting glucose, lipid profile, and thyroid hormone levels.@*Conclusion@#Our study showed that the prevalence of MS in adult Filipinos with hypothyroidism is increased at 36.19%. Only BMI, presence of diabetes, and hypertension were shown to be significantly higher. Emphasis must be placed on early screening among hypothyroid patients at high risk of developing MS. A prospective study using waist circumference and clinical and metabolic parameters is needed to validate these findings.

The prevalence and analysis of related factors of anxiety, depression, and quality of life of out-patients in the Cancer Institute of a COVID-19 referral tertiary hospital: One year into the pandemic

Objective@#This study aimed to determine the prevalence, analyze, and compare the risk factors of anxiety, depression, and quality of life of cancer patients in the out-patient cancer clinic of the Cancer Institute one year into the pandemic. These were compared to the prevalence of anxiety and depression before the pandemic.@*Methods@#A cross-sectional analytic study described the prevalence of anxiety, depression, and quality of life and analysis of its related factors among patients with cancer seen in the outpatient cancer clinic of the Cancer Institute of the Philippine General Hospital from November 1 to 20, 2021, using the Hospital Anxiety and Depression Scale – Pilipino and EORTC (European Organisation for Research and Treatment of Cancer) QLQ-C30 (Quality of Life questionnaire) tools.@*Results@#A total of 408 cancer patients were enrolled in the study. The prevalence of anxiety and depression was 58.33% and 24.51%, respectively. Before the pandemic, the prevalence of anxiety and depression was 9.45% and 4.72%, respectively. Two hundred seventy participants (66.18%) had a positive quality of life. The comparison between the prevalence of anxiety and depression between this study (one year into the pandemic) and the pre-pandemic study revealed a statistically significant difference in the majority of both, with more anxious and depressed cancer patients in this study. The participants agreed that the pandemic had affected their daily activities.@*Conclusion@#The study showed that the COVID-19 pandemic significantly increased anxiety and depression among cancer patients. The quality of life (QOL) of cancer patients in this study has not been distinctly affected by the pandemic, but for those who have, they still require the attention and support of not just the physicians but the community as a whole. Our findings highlight the need to integrate better psychosocial support and the important role of carers in the evolving pandemic response measures.

Association of BRAF V600E mutation with tumor recurrence in a small sample of Filipino patients with papillary thyroid cancer in a single center

Background and Objective@#Epidemiological studies have shown that Filipinos have a higher prevalence of welldifferentiated thyroid cancer and a higher rate of recurrence. The BRAF V600E mutation has been proposed as a potential prognostic marker in aggressive papillary thyroid cancers. In this study, we determined whether this mutation is a risk factor for tumor recurrence in papillary thyroid cancer among Filipinos.@*Methods@#We conducted an age and sex-matched case-control study of patients with papillary thyroid cancer; we had two groups – with and without tumor recurrence – of 14 patients each, with at least a 5-year follow-up. We extracted the DNA samples from the patients’ (paraffin-embedded) tumor biopsy tissue blocks from thyroidectomy specimens, then detected the BRAF V600E mutation using polymerase chain reaction. The McNemar’s test for difference of proportions in paired data was used to determine the association of BRAF V600E mutation with recurrence. @*Results@#The BRAF V600E mutation was found in 57.14% of all cases. We found a prevalence of 64.29% among those with recurrence and 50.00% among those without recurrence, with no significant difference between the two groups (p = 0.688).@*Conclusion@#Our study showed the BRAF V600E mutation was not associated with recurrence. We encountered several limitations: we had limited data regarding molecular methodologies in the Philippine setting, we had a small sample size, and therefore we could not study other parameters (e.g., tumor characteristics, lymph node metastasis, stage of disease). We hope that this paves the way for future studies and collaborations to establish the role of BRAF V600E in Filipinos with papillary thyroid tumor recurrence.

Exophytic and fungating papillary thyroid carcinoma: A rare and complex presentation of a well-differentiated malignancy

@#Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.

Sheehan’s Syndrome presenting as postpartum psychosis

@#Sheehan’s syndrome is characterized by hypopituitarism following ischemic necrosis of the pituitary gland caused by postpartum hemorrhage and impaired blood supply to the enlarged pituitary gland during pregnancy. The worldwide prevalence has since decreased due to improvements in obstetric care. Behavioral change is a rare presentation and is often misdiagnosed and managed as psychosis. We report a 42-year-old woman presenting with behavioral changes associated with postpartum failure of lactation and amenorrhea. Hormonal work-up revealed panhypopituitarism; serum cortisol, 98.93 (NV: 138–690 nmol/L); free T4, less than 5.15 (NV: 11.5–23.00 pmol/L); free T3, less than 2.30 (NV: 2.89–4.88 pmol/L); FSH, 3.63 (NV: 30–135 mIU/mL); LH, 3.88 (NV: 13–80 mIU/mL); serum estradiol, 3.89 (NV: 10.41–35.0 pg/mL); IGF-1, 13.13 (NV: 56–194 ng/mL); and serum prolactin, 1.8 (NV: 2.6–24.8 ng/mL). Cranial MRI with contrast revealed an atrophic pituitary gland consistent with Sheehan's syndrome. The symptoms improved substantially upon replacement with steroids and thyroid hormones and she was able to resume her routine activities. The psychiatric features of hypopituitarism can be attributed to a combination of hypothyroidism, hypoglycemia, and hypocortisolism and have been shown to reverse with adequate hormone replacement.

Therapeutic plasma exchange in thyroid storm refractory to conventional treatment

@#<p style="text-align: justify;">Thyroid storm is a life-threatening condition with mortality rates reaching up to 20 to 30%. First-line treatment includes inhibition of thyroid hormone synthesis, prevention of release of preformed hormones, blocking of peripheral FT4 to FT3 conversion, enhancing hormone clearance, and definitive radioactive iodine ablation. However, in the presence of life-threatening adverse effects (e.g., agranulocytosis) and contraindications (e.g., fulminant hepatic failure), therapeutic plasma exchange (TPE) can be used to rapidly remove circulating thyroid hormones, antibodies, and cytokines in plasma; this is recommended by the American Society of Apheresis (ASFA) and the American Thyroid Association (ATA) as second-line treatment for thyroid storm. Here, we report a 49-year-old female with Graves' disease admitted in our emergency room for a 6-week history of fever, weight loss, jaundice, exertional dyspnea, palpitations, and diarrhea. Her initial thyroid hormone levels were: FT4 64.35 (NV 9.01-19.05 pmol/L), FT3 23.91 (NV: 2.89-4.88 pmol/L), and TSH 0.00000 (NV: 0.35-4.94 mIU/L) and we managed her as a case of thyroid storm (Burch-Wartofsky score 70) by initiating high dose propylthiouracil. However, her sensorium deteriorated and serum bilirubin continued to rise from 307.2 on admission to 561.6 umol/L on the 5th hospital day (NV: 3 - 22 umol/L). TPE was performed after consultation with the Division of Hematology. Over the treatment course, her thyroid hormones normalized: FT4 13.18 pmol/L, FT3 2.30 pmol/L. However, despite TPE, her symptoms worsened and she became comatose, had hypotension despite vasopressors and developed new-onset atrial fibrillation. She expired on her 7th hospital day from multiorgan failure. TPE is effective in decreasing circulating thyroid hormone levels. However, it had no effect on clinically important outcomes as our patient still deteriorated and eventually succumbed. We still wrote and submitted this case report since if only successful cases were reported, the true effectiveness rate of TPE could not be determined.Thyroid storm is a life-threatening condition with mortality rates reaching up to 20 to 30%. First-line treatment includes inhibition of thyroid hormone synthesis, prevention of release of preformed hormones, blocking of peripheral FT4 to FT3 conversion, enhancing hormone clearance, and definitive radioactive iodine ablation. However, in the presence of life-threatening adverse effects (e.g., agranulocytosis) and contraindications (e.g., fulminant hepatic failure), therapeutic plasma exchange (TPE) can be used to rapidly remove circulating thyroid hormones, antibodies, and cytokines in plasma; this is recommended by the American Society of Apheresis (ASFA) and the American Thyroid Association (ATA) as second-line treatment for thyroid storm. Here, we report a 49-year-old female with Graves' disease admitted in our emergency room for a 6-week history of fever, weight loss, jaundice, exertional dyspnea, palpitations, and diarrhea. Her initial thyroid hormone levels were: FT4 64.35 (NV 9.01-19.05 pmol/L), FT3 23.91 (NV: 2.89-4.88 pmol/L), and TSH 0.00000 (NV: 0.35-4.94 mIU/L) and we managed her as a case of thyroid storm (Burch-Wartofsky score 70) by initiating high dose propylthiouracil. However, her sensorium deteriorated and serum bilirubin continued to rise from 307.2 on admission to 561.6 umol/L on the 5th hospital day (NV: 3 - 22 umol/L). TPE was performed after consultation with the Division of Hematology. Over the treatment course, her thyroid hormones normalized: FT4 13.18 pmol/L, FT3 2.30 pmol/L. However, despite TPE, her symptoms worsened and she became comatose, had hypotension despite vasopressors and developed new-onset atrial fibrillation. She expired on her 7th hospital day from multiorgan failure. TPE is effective in decreasing circulating thyroid hormone levels. However, it had no effect on clinically important outcomes as our patient still deteriorated and eventually succumbed. We still wrote and submitted this case report since if only successful cases were reported, the true effectiveness rate of TPE could not be determined.</p>

Behçet’s disease presenting with recurrent vulvar abscesses, oral ulcers, and skin pustules in the Philippines

@#Behçet's disease (BD) is a systemic vasculitis characterized by recurrent acute vascular inflammation. There is currently limited epidemiological data in Southeast Asia. We discuss a 26-year-old woman who came to our institution for recurrent vulvar abscesses for a year. Physical examination showed labial, tongue, and vulvar ulcers. Pathergy test was negative and biopsy done were unremarkable . We diagnosed her clinically as a case of Behçet’s disease. We started her on colchicine 0.6 mg once daily and educated her on skin, oral, and perineal hygiene. On follow-up after one month, she noted resolution of her lesions. However, symptoms recurred in the last three months after discontinuing treatment. We used telemedicine to communicate due to the COVID-19 pandemic and lockdown, advising her to continue her medication. Timely diagnosis is essential in order to provide symptomatic relief and enhance patient education.

Clinical features of Senior–Loken syndrome with IQCB1/NPHP5 mutation in a Filipino man

The Senior–Loken syndrome was first described in 1961 as an oculo-renal disease consisting of familial juvenile nephronophthisis and Leber congenital amaurosis. It is a rare autosomal recessive disorder with a prevalence of 1:1,000,000 caused by mutations in nine genes (NPHP 1-8 and NPHP 10). Ocular manifestations (e.g., photophobia, nystagmus, and extreme hyperopia) occur within the first few years of life while renal manifestations (e.g., formation of multiple cysts impairing kidney function and end-stage renal disease) appear in late childhood to adolescence. Here, we report a case of a Filipino male presenting with rotatory nystagmus and progressive deterioration of vision since childhood. He had congenital amaurosis and juvenile nephronophthisis that progressed to end stage renal disease by age 19. All laboratory and imaging findings were consistent with chronic kidney disease. Molecular genetic testing of ciliopathy-related genes was performed revealing a homozygous mutation in exon 11 of the IQCB1/NPHP5 gene, c.1090C>T (p.Arg364*). This sequence change created a premature translational stop signal resulting in a truncated protein product, nephrocystin-5 and its consequent loss of function. His symptoms eventually improved with initiation dialysis. The prognosis of Senior–Loken syndrome remains dismal and a high index of suspicion, early diagnosis and timely intervention of renal complications are warranted.

Oral versus Intravenous Antibiotic treatment for Osteomyelitis in Adults: A Systematic Review and Meta-Analysis

@#BACKGROUND: The worldwide incidence of osteomyelitis is approximately 21.8 cases per 100,000 person-years. The cornerstone of treatment is prolonged (4-6 weeks) intravenous antibiotic administration. This entails additional cost, inconvenience, and added manpower from the healthcare system. Thus, studies have explored the possible use of oral antibiotics as alternatives to improve patient compliance and reduce costs. Our meta-analysis aimed to compare the efficacy of oral versus intravenous antibiotics in treating adult patients with osteomyelitis. MATERIALS AND METHODS: Electronic databases (PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials, Google Scholar, and Research Gate) from 1966 to April 2020 were searched using the terms “oral antibiotics”, “osteomyelitis”, “randomized controlled trial”. Only studies that directly compared oral versus intravenous antibiotics and confirmed osteomyelitis through biopsy and/or imaging were included. Primary outcome is remission (resolution of symptoms with no relapse and bacteriologic eradication); secondary outcomes, (a) relapse (persistence of the pathogen after treatment) and (b) adverse events. The validity of included studies was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We performed a random-effects model in Review Manager Version 5.3 with 95% confidence interval. The I 2 test was used to assess heterogeneity. RESULTS: Seven of 89 trials comprised of 1,282 patients were included in the final analysis. All studies included patients with osteomyelitis of the lower extremities. Oral antibiotics used were Ciprofloxacin, Ofloxacin, and Co-trimoxazole; intravenous antibiotics used were deemed appropriate by the infectious disease specialist. Patients were only given either oral or intravenous antibiotics. Results showed an 8% increase in remission rates [RR 1.08 (0.81 to 1.44, 95% CI, Z = 0.52, p=0.60)] with no heterogeneity (I2 = 0%) in the intravenous antibiotics group. However, this was not statistically significant. Furthermore, there was a 62% decrease in relapse rates in the intravenous antibiotics group [RR 1.62 (0.85 to 3.07, 95% CI, Z = 1.47, p = 0.14)] with no heterogeneity (I2 = 0%) but was not statistically significant. CONCLUSION: Oral are comparable to intravenous antibiotics in treating osteomyelitis in terms of remission and relapse rates. However, larger and double-blinded trials should be done to generate more robust data to validate these claims.

Takayasu Arteritis Presenting as Bilateral Ocular Ischemic Syndrome

A 26-year-old female came in with progressive blurring of vision. She had developed memory loss and complained of headache, significant weight loss, and exertional left calf pain after prolonged walking. Pertinent physical findings included light perception on visual acuity examination, and the brachial and radial pulses of both arms were not appreciable. Thoracic and abdominal aortic imaging by computed tomography with contrast revealed narrowing along the thoracic aorta and its branches. Carotid Doppler showed bilaterally thickened walls in the common carotid arteries, with near total occlusion of the left carotid artery. These findings were consistent with bilateral ocular ischemic syndrome in Takayasu arteritis. She was given methylprednisolone 500 mg intravenously daily for 3 days with noted improvement in vision. She was discharged and showed improvement on prednisone 35 mg/day and aspirin 80 mg/day. On follow-up two weeks post-discharge, she reported being able to see silhouettes of persons and objects.

Balanced Crystalloids versus Normal Saline as Intravenous Fluid Therapy among Critically Ill patients: A meta-analysis of randomized controlled trials

Introduction@#Recent studies on critically ill adults has shown that use of normal saline with its supraphysiologic chloride content has been associated with an increased incidence of hyperchloremic metabolic acidosis, acute kidney injury (AKI), renal replacement therapy (RRT), hypotension and death. The objective of this meta-analysis was to assess the clinical outcomes associated with the use of balanced crystalloids versus normal saline solution.@*Methods@#We searched PubMed/MEDLINE, Embase and Cochrane Library (CENTRAL) databases in accordance with PRISMA guidelines. Our inclusion criteria were the following: randomized controlled trials, adult critically ill patients, comparisons between patients receiving either balanced crystalloids (lactated ringer’s solution, plasma-lyte) or normal saline, and at least one endpoint that measure intensive care unit mortality, risk of AKI (defined as stage 2 or greater in the RIFLE criteria) and risk of RRT. Risk ratios (RRs) and confidence intervals (C.I) were calculated via Review Manager Version 5.3 using the fixed-effect modelling.@*Results@#A total of four randomized controlled trials, which were all assessed to be good quality and low risk of bias, with 19,105 patients were included. Use of balanced crystalloids showed a trend towards lower incidence of AKI (RR 0.94, 95% C.I [0.87-1.02], P=0.69), RRT use (RR 0.91, 95% C.I. [0.771.07], P=0.29) and ICU mortality (RR 0.91, 95% C.I. [0.82-1.01], P=0.95). There is no significant heterogeneity identified.@*Conclusion@#Use of balanced crystalloids as intravenous fluid therapy among critically ill patients demonstrated a trend toward lower incidence of AKI, RRT and ICU mortality, compared to normal saline solution.

Racecadotril (Acetorphan) for diarrhea in adults infected with HIV/AIDS: A meta-analysis and systematic review

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Diarrhea is a common and disabling symptom seen in patients with Human Immunodeficiency Virus (HIV) infection and the Acquired Immune Deficiency Syndrome (AIDS). The diarrhea is chronic and results in malabsorption contributing to cachexia. Symptomatic treatment can improve the quality of life and nutritional status of these patients.</p><p style="text-align: justify;">The endogenous group of opiates known as enkephalins function as anti-secretory agents without affecting intestinal transit. Racecadotril (acetorphan) is an orally active enkephalinase inhibitor. Available studies have focused on the use of racecadotril in healthy adults and children with acute infectious diarrhea.</p><p style="text-align: justify;"><strong>OBJECTIVES:</strong>To assess the efficacy of racecadotril (acetorphan) in reducing the duration and frequency of bowel movement in adult HIV patients with chronic diarrhea.</p><p style="text-align: justify;"><strong>METHODS: </strong> Electronic databases were searched for randomized controlled trials which used racecadotril for chronic diarrhea in HIV patients. Three independent reviewers assessed the quality of the two studies based on the Cochrane Infectious Disease Group prior to inclusion in study. Data extracted were analyzed using Revman Version 5. Test for heterogeneity was performed using the chi square test.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Results showed the standardized mean difference for the two trials comparing racecadotril to placebo and octreotide in reducing bowel movements from baseline was -1.00 (95% CI -1.16 to -0.84, Z=12.08, p<0.00001), showing a beneficial effect. Response rate for the two trials comparing racecadotril to placebo or octreotide in reducing bowel movements from baseline was -0.13 (95% CI -0.26 to 0.01, Z=1.84, p<0.07), showing a trend towards benefit in terms of response rates. Heterogeneity was statistically insignificant (p=1, I2=0%).</p><p style="text-align: justify;"><strong>CONCLUSIONS:</strong> There is evidence pointing to a benefit in using racecadotril in HIV and AIDS-associated, non-infectious diarrhea by decreasing the frequency of loose stools. An individualized approach is still recommended in its use for HIV patients with chronic diarrhea.</p>