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>

Physicians’ perceptions on the role of telemedicine in cancer care during and post-COVID-19 Pandemic

@#Objectives. This study aims to determine perceptions of physicians in our institution on the role of telemedicine in cancer care during the COVID-19 pandemic and to assess its perceived benefits and barriers. Methods. This is a cross-sectional study of physicians involved in cancer care in a tertiary referral hospital in the Philippines. We administered a 21-item online survey questionnaire between August to October 2020. Results. We received and analyzed 84 physician responses. Ninety-six percent of physicians currently use telemedicine, an increase from 59% pre-pandemic. Eighty-nine percent use telemedicine for follow-up virtual consults, while 75% use telemedicine for case discussions in multidisciplinary meetings. The mean number of monthly patient consults conducted through telemedicine increased to 29.5 (SD: 24.8) from a pre-pandemic mean of 7.7 (SD: 18.7). Eighty-four percent of respondents perceived its main benefit as an infection control measure. The other perceived benefits of telemedicine include convenience (78%), accessibility to cancer care (72%), cost-effectiveness (68%), and time efficiency (44%). A quarter of the respondents believed that telemedicine has the potential to improve cancer outcomes. Ninety-two percent of the respondents expressed that they will use telemedicine occasionally in their practice. Conclusion. Telemedicine was perceived by Filipino physicians in a tertiary hospital as an acceptable solution for the provision of cancer care during and after the COVID-19 pandemic. Tele-oncology should be further investigated to maximize patient and physician satisfaction and improve cancer outcomes. Data from this study can be used to improve oncology practice and service delivery to suitable patients during and after the COVID-19 pandemic.

Evaluation of tuberculosis infection control strategies at the Philippine General Hospital

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Nosocomial TB transmission adversely affects inpatients and healthcare workers (HCWs). HCWs have a higher risk of tuberculosis and MDR-TB compared to the general population. Nosocomial TB outbreaks have occurred among patients with HIV/AIDS. Hospitals need to examine TB infection control measures in order to address this growing concern.</p><p style="text-align: justify;"><strong>OBJECTIVE:</strong> This study aimed to evaluate the TB infection control strategies in the adult service wards of the Philippine General Hospital (PGH).</p><p style="text-align: justify;"><strong>METHODS:</strong> This descriptive study was conducted on adult inpatients with bacteriologically-confirmed PTB admitted in April-August 2016. A data collection tool based on Center for Disease Control (CDC) guidelines was utilized for chart review. Baseline characteristics, diagnosis, treatment, and isolation intervals were obtained and compared between areas. In-hospital TB infection control practices were reviewed using the CDC TB Risk Assessment Worksheet with data from the TB-DOTS, UP Health Service, PGH Hospital Infection Control Unit, and PGH Department of Laboratories.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Of the 95 patients with bacteriologically-confirmed PTB, data from 72 medical records were available and included in the analysis. Majority were Medicine patients (55.6%) with a diagnosis of pneumonia (52.8%). Only 61.1% were PTB suspects on admission. The mean diagnosis interval was 5.82 days±5.473, the mean treatment interval was 0.77 days±2.941, and the mean isolation interval was 8.23 days±6.372. Only 41.7% were successfully isolated. The most common reasons for isolation failure/delay were lack of vacancy (ER, Medicine wards) and lack of isolation room (Surgical wards). Treatment initiation rate was 66.7% while TB-DOTS inpatient referral rate was 55.6%. The hospital is classified as having potential ongoing transmission of PTB.</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> In this study, TB treatment was promptly started but there were delays in diagnosis and isolation. Gaps included 1) lack of recognition of a PTB case, 2) limited isolation rooms, and 3) inadequate utilization of TB-DOTS. TB infection control measures need to be strengthened in order to prevent nosocomial transmission of PTB.</p>