Evidence-Based Teaching (EBT) in medical education: Addressing the challenges of bridging didactic knowledge to clinical application

@#Although evidence-based teaching has been adopted in various learning disciplines, its adoption in medical education remains challenging. To graduate a full-fledged well-rounded physician equipped to face the real-world challenges of diagnosis and treating diseases is the ultimate goal of every medical institution. Medical students’ clinical competence is anchored on the approach of facilitators’ acquired teaching expertise and how they apply learned techniques to connect basic knowledge to clinical skill enhancement. Are these approaches within the realm of evidence-based teaching? The subsequent discussion will elaborate on proven effective strategies [Problem-Based Learning (PBL), Outcome-Based Education (OBE)] and how a strategic teaching and learning tool [Target-Oriented Clinical Skill Enhancement (TOCSE)] has proven to address the issue.

Educating and promoting health - A community-based prevention and control program for soil-transmitted helminth infections in a community in Rodriguez, Rizal

@#The impact of soil-transmitted helminthiases on the overall health of an individual may lead to significant morbidity related to the number of worms harbored by the person. Light intensity infections usually present no significant effect on the individual except in times of more massive infections, in which complications may lead to impaired growth and physical development. With this, international and local health programs aim to increase the proportion of community households aware of proper helminthiases prevention and control strategies. Access to potable water, and drainage and disposal or reuse of household water, to safe and sanitary facilities, safe human excreta disposal, and proper management of solid waste appropriate information on prevention and treatment of soil-transmitted helminthiases (STH), and dissemination of key messages to promote safe water storage, hand washing, bathing practices, safe food handling, latrine use and wearing of shoes and regular deworming practices are recommended points of intervention to reduce the prevalence of helminthiases in children and other high-risk population groups. Guided with the principles of health promotion and education and the health program framework of the Department of Health (DOH) and World Health Organization (WHO), community health may be achieved equitably by leveraging accurate information, community mobilization, and sustainable health partnerships.

Target-Oriented Clinical Skill Enhancement (TOCSE) builds up confidence of fourth-year medical students during first-time patient encounter: An effective bridging tool after online didactic undergraduate classes during the COVID-19 pandemic

@#<jats:p>Background and Objective: Teaching clinical skills to undergraduate medical students has brought significant challenges during the COVID-19 pandemic. Patient discussion utilized hypothetical cases from history taking to diagnosis and management. Further, everything was delivered online. Target-Oriented Clinical Skill Enhancement (TOCSE) is a teaching and learning tool that integrates the basic medical sciences, such as anatomy, physiology, pathology, microbiology, and pharmacology, at the clinical level. TOCSE has been proven to improve the clinical performance of fourth-year medical students. However, clinical confidence remains an issue, especially for medical students on pure online mode of learning during the pandemic. Therefore, this study was undertaken to determine if TOCSE also facilitates the development of confidence in the clinical performance of 4th-year medical students during the first-time patient encounter after online undergraduate classes. Methods: Eight-item Clinical Performance Confidence Scale survey was performed at three (3) time points of fourth-year medical student’s rotation in the Department of Medicine: (1) prior to the deployment to the outpatient department (Pre-OPD), (2) after the first-time patient encounter without TOCSE workshop (Post-OPD no TOCSE), and (3) after the patient encounter with TOCSE workshop (Post-OPD with TOCSE). Mean and standard deviations were used to summarize the confidence level of the 4th-year medical students, based on the 10-point differential scale being 0 as not confident at all and 10 as very confident. Wilcoxon Signed Rank assessed improvements of confidence level from Pre-OPD to Post-OPD. Effect sizes were also calculated to compare the improvement in the items. All statistical tests were performed in SPSS version 26.0. P-values less than 0.05 indicate a significant increase in the confidence level of 4th-year medical students. Results: There is a significant increase in the clinical confidence of 4th-year medical students from Pre-OPD to Post-OPD no TOCSE (mean ± SD: 6.32 ± 1.02 to 7.06 ± 0.95, p<0.001). Comparing the eight items between Pre-OPD and Post-OPD with no TOCSE, performing a complete physical examination has the most remarkable improvement. Further, there is a significant increase in the clinical confidence of 4th-year medical students from Post-OPD no TOCSE to Post-OPD with TOCSE (mean ± SD: 7.06 ± 0.95 to 7.51 ± 0.89, p<0.001). The performance of a complete history-taking has the most considerable improvement (7.29 + 1.03 to 7.89 + 1.01, p<0.001). Correspondingly, the most significant increase in the clinical confidence of 4th-year medical students was seen among the Post-OPD with TOCSE compared to their Pre- OPD confidence scores (mean ± SD: 6.32 ± 1.02 to 7.51 ± 0.89, p<0.001). Among the eight items between Pre-OPD and Post-OPD with TOCSE confidence scores, the item on performing a complete physical examination has the most remarkable improvement (5.67 ± 1.37 to 7.20 ± 1.22, p<0.001), closely followed by performing a complete history-taking (6.53 ± 1.19 to 7.89 ± 1.01, p<0.001). The most significant improvements in clinical confidence were seen in all the items in the Post-OPD with TOCSE than in the Post-OPD with no TOCSE versus Pre-OPD confidence scores. In addition, with TOCSE, the number of medical students who scored 7.50 and above was amplified more than 3 times (17.4% to 58.7%, p<0.001, Pre-OPD vs. Post-OPD with TOCSE, respectively). Conclusion: Target-Oriented Clinical Skill Enhancement (TOCSE) effectively builds up confidence during first-time patient encounters among fourth-year medical students taught online with hypothetical cases during their undergraduate classes. Key words: Target-Oriented Clinical Skill Enhancement, clinical confidence, clinical skill, fourth-year medical students, medical undergraduate challenge, online teaching in COVID-19 pandemic</jats:p>

Improving systems to promote research integrity

@#Research integrity is manifested thru the use of honest and verifiable research methods with adherence to accepted professional codes. Recently, trustworthiness in research has been challenged by various forms of research misconduct, such as analytical flexibility, data dredging, HARKing (hypothesis after research knowledge), plagiarism, and selective and distorted reporting. Drivers of research misconduct have been identified as institutional--publication incentives to pursue a career, researcher--metric of success is publication volume, and the journal-- more likely to accept papers with positive. The open-access mode propelling the proliferation of predatory journals is causing a dilemma to sound research reporting. Measures were established to curtail research integrity challenges, such as study registration, open data, common reporting standards, a team of rivals, and blind analysis. This report will elaborate and provide insight into what influenced research misconduct, how it can be mitigated, and how to maintain a credible research environment.

Safe, Nourishing, Accessible Community Kitchen (S.N.A.C.K.): A community kitchen manual for public health emergencies

@#<p style="text-align: justify;"><strong>Objective:</strong> The project aims to develop a community kitchen manual for public health emergencies.</p><p style="text-align: justify;"><strong>Participants:</strong> The officers and members of the Samahan ng Nagkakaisang Kababaihan ng BASECO served as community respondents for this project. These eight women were in charge of the community kitchen operations, particularly the feeding program during the COVID-19 pandemic.</p><p style="text-align: justify;"><strong>Implementation:</strong> The whole project comes in three phases. The design stage was executed in phase one of this project. The phase one also focused on the development of manual content based on available literatures and considered the interviews conducted with respondents.</p><p style="text-align: justify;"><strong>Discussion:</strong> The manual contains guidelines on food safety and meal preparations. Based on the interview, the proponents identified specific contents that must be included in the guidelines, as compared with the need to improve current operations of the group's community kitchen. Looking at the activities of the community, the proponents indicated the food flow guidelines to ensure a safe, nourishing and accessible community kitchen (S.N.A.C.K).</p><p style="text-align: justify;"><strong>Conclusion:</strong> The designed community kitchen manual may be of use to lay groups putting up community kitchens, since there is no existing manual in the Philippines. However, phases two and three must be conducted to validate its usefulness and accuracy in the field.</p>

Giving insulin is not a guessing game: Insulin replacement therapy in type 2 diabetes mellitus

@#<p style="text-align: justify;" data-mce-style="text-align: justify;">In 2021, 537 million adults were living with diabetes. Being a progressive disease, there would eventually be failure of oral hypoglycemic agents (OHA) to maintain good glycemic control and a majority will require insulin. However, optimal glycemic control has not been satisfactory in a significant proportion of patients who were on insulin therapy. Patient factors (eg, awareness, compliance, socioeconomic) have been identified but physician-related factors are as important. These include incorrect choice and inappropriate combination of insulin therapy which could be corrected by making the treatment physiologic. The purpose of this article is to improve management decisions in type 2 diabetes by reviewing its pathophysiology and identifying the optimum insulin regimen that could mimic such. Since eventual beta cell failure is central to its pathophysiology, it is but reasonable to replace insulin by mimicking its physiologic secretion. Hence, the term Insulin Replacement Therapy (IRT) should be utilized. This could be provided by the combination of premix insulin (ie, NPH + regular insulin) and rapid-acting insulin which has been reported to provide an initial 17.5% HbA1c reduction and even 18% reduction on 5-year follow-up providing sustainable control. A stepwise approach is an effective tool for insulin intensification. Hypoglycemia in insulin therapy could be prevented with an appropriate dietary regimen through automatic snacking.</p>

Geriatric medicine in the medical curriculum: A MUST in the globally aging world

@#Geriatrics is a branch of medicine concerned with diagnosing, treating, and preventing diseases in older people and problems specific to aging. The World Health Organization (WHO) has reported that the number of people aged 65 or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050. The burden of diseases in the aging population will dramatically impact healthcare expenses in low- and middle-income countries and even developed ones. A preventive approach is essential. The role of medical institutions and inclusion of geriatrics in the medical curriculum have become important. However, incorporating geriatrics into the medical curriculum is associated with various issues and challenges: compact preexisting curriculum, attitudes of teachers and students, and shortage of teaching geriatricians. An individualized institutional approach to curricular integration guided by the American Geriatrics Society’s minimum required competencies for the undergraduate will circumvent these challenges.

Promoting Academic Exchange in Public Health: A Transnational Education Model

International collaborative Master in Public Health programs provide students wider opportunities to engage in vital public health related work with specific populations and communities to improve health through awareness, education, policy, and research. A transnational education model to promote academic exchange in public health is hereby showcased with the collaboration of the University of Santo Tomas, Faculty of Medicine and Surgery and the University of Leeds, Nuffield Center for International Health and Development. The program was established through initial institutional visits of each respective staff, faculty capacity building through workshops and symposia, and final agreement on a laddered structure of curriculum. This article describes how this program was established.

Target-Oriented Clinical Skill Enhancement (TOCSE) is an effective tool to bridge didactic to clinical learning: A randomized, controlled trial

@#<p style="text-align: justify;"><strong>Purpose:</strong> To connect didactic learning to clinical application is a challenging task both for the teachers and students. Target-Oriented Clinical Skill Enhancement (TOCSE) is a teaching and learning tool that integrates basic medical sciences at the clinical level. The authors sought to determine if TOCSE is effective in bridging didactic knowledge to clinical skill and enhancing the clinical performance of fourth year medical students.</p><p style="text-align: justify;"><strong>Method:</strong> Between March 2021 and June 2021, in an online platform, the authors randomly allocated 141 fourth year medical students into the experimental (n=12 groups; n=63) and control groups (n=12 groups; n=78). Participants in the experimental group underwent the TOCSE module workshop while the control group utilized the standard method of teaching. The actively teaching faculty staff blinded of group allocation were invited to assess case presentations using a standardized rubric. A survey was done by the students (experimental and control) to evaluate how they perceived TOCSE to their performance and learning. Independent parametric t-test was performed to compare the clinical skill scores between the two groups.</p><p style="text-align: justify;"><strong>Results:</strong> The experimental group had a mean clinical skill score of 35.29 (SD=2.64, excellent) while the control group had a mean clinical skill score of 31.96 (SD=4.04, satisfactory). The between-group comparisons using independent t-test indicated that the mean difference of -3.33 clinical skills scores between the experimental and control groups was statistically significant (t=-2.39, p=0.026, 95% CI=-6.22 to -0.45). Moreover, the perceived usefulness score (scale 10 as highest) among the TOCSE presenters (experimental groups) was 8.43 (SD=0.84) and scores among the TOCSE audience (control groups) was comparable at 8.36 (SD=0.71), both of which were interpreted as very helpful.</p><p style="text-align: justify;"><strong>Conclusion:</strong> TOCSE is effective in bridging didactic knowledge to clinical skill and enhancing clinical performance of fourth year medical students.</p>

Promoting academic exchange in public health: A transnational education model

@#<p style="text-align: justify;">International collaborative Master in Public Health programs provide students wider opportunities to engage in vital public health related work with specific populations and communities to improve health through awareness, education, policy, and research. A transnational education model to promote academic exchange in public health is hereby showcased with the collaboration of the University of Santo Tomas, Faculty of Medicine and Surgery and the University of Leeds, Nuffield Center for International Health and Development. The program was established through initial institutional visits of each respective staff, faculty capacity building through workshops and symposia, and final agreement on a laddered structure of curriculum. This article describes how this program was established.</p>

Medical education through distance learning: How does it work?

@#The application of distance learning in medical education has been a continuous challenge to approximate face-to-face clinical skill teaching. Nonetheless, online education has proven to be effective in addressing student satisfaction, engagement, motivation and excellent academic performance. How eLearning evolved in a medical setting through the years and the evolution of state-of-the-art teaching resources will be discussed accordingly.

Systemic hormonal unloading in unilateral adrenalectomy in a patient with bilateral adrenal hyperplasia: A case report

Background @#Unilateral adrenalectomy has not been recommended in the guidelines as a treatment for primary hyperaldosteronism secondary to bilateral adrenal hyperplasia (BAH). Interestingly, recent studies have shown that increased circulation of aldosterone increased oxidative stress, cardiovascular (CV) complications such as atrial fi brillation, myocardial infarction and heart failure; and that unilateral adrenalectomy led to improved CV function. Therefore, recognizing the role of unilateral adrenalectomy in BAH, specifi cally for improved quality of life is important.@*Clinical case@# A 47‐year-old hypertensive (highest blood pressure [BP] 150/90 mmHg) woman had a severe headache, muscle weakness, polyuria, and polydipsia. Her serum potassium (K) was low at 3.1 mmol/L (3.5–5 mmol/L). Initial tests showed elevated plasma aldosterone, suppressed plasma renin activity and elevated aldosterone-renin ratio (6.61 ng/ dL, <0.1 ng/mL and 66, respectively). Plasma aldosterone after saline suppression test (12.70 ng/dL) confi rmed the diagnosis of primary aldosteronism (PA). MRI showed a well-defi ned, oval-shaped solid nodule in the medial limb of the left adrenal gland (1.8 x 1.2 cm). Bilateral adrenal vein sampling with adrenocorticotropic hormone (ACTH) stimulation test was compatible with BAH (cortisol-corrected aldosterone ratio pre-ACTH stimulation 1.29 and postACTH 1.66), with dominant aldosterone secreting left adrenal gland (7200 vs 3760 ng/dL). She was started on spironolactone 200 mg/day and amlodipine 10 mg/day and eventually shifted to eplerenone. Despite the optimal dose of eplerenone and amlodipine, she still experienced severe headaches, palpitations and breakthrough elevations of BP that led to her recurrent admissions. Eplerenone was shifted back to spironolactone (150-200 mg/day) with amlodipine dose (10 mg/day) normalizing her blood pressure and potassium level, yet with persistent headache and muscle weakness. Repeat imaging using CT scan with contrast showed consistent results. Postoperatively, with all medications discontinued the patient was asymptomatic, normotensive (110/70 mmHg) and normokalemic (4.0 mmol/L). One month later, her BP started to increase again at 140/80 mmHg and her K decreased to 3.4 mmol/L. Normalization of said parameters (BP:120/70 mmHg K: 4.1 mmol/L), with stabilization following lower doses of amlodipine (5mg/day) and spironolactone (25 mg/day). Also, all the symptomatology of the patient resolved completely.@*Conclusion@#This present case exemplifi es a unilateral adrenalectomy approach in BAH, which led to improvement in BP and K levels, despite low medication doses. Furthermore, symptom relief and improved quality of life, as desired outcomes, were achieved.

Value of systemic hormonal unloading in pheochromocytoma

@#Systemic unloading of adrenaline improves blood pressure (BP), but the effect on quality of life is not emphasized. This report aims to examine the outcome of systemic hormonal unloading through unilateral adrenalectomy in three pheochromocytoma cases.

A prospective, randomized, open label, single-centre study for assessment of safety and effectiveness of recombinant human insulin 30/70 + insulin glulisine compared to recombinant human insulin NPH + regular in the management of type 2 diabetes mellitus patients in the Philippines

Background@#The high prevalence of type 2 diabetes mellitus (T2DM) in the Philippines has burdened the health care system. Therefore, we compared the standard of care Insulin 30/70 + Insulin Glulisine (Arm B) to a traditional insulin regimen NPH Insulin + Regular Insulin (Arm A) to test the concept that both insulin regimens provide comparable effectiveness and safety in real-world practice.@*Methods @#This is a ‘proof-of-concept,’ prospective, randomized, open label pragmatic study of 40 consecutive Filipino T2DM patients from October 2015 to June 2016. The primary endpoint was a reduction in HbA1c at 12 weeks. The secondary endpoints were changes in Fasting Plasma Glucose (FPG), Post Prandial Glucose (PPG), Capillary Blood Sugar (CBS), weight and insulin dose at 12 weeks. ANCOVA and Fisher’s exact tests were used.@*Results @#Patients in treatment arm A showed comparable glycemic control to arm B as measured by reductions in HbA1c (2.89% vs. 2.67%; P = 0.657), FPG (65.94 vs. 46.71 mg/dl; P = 0.57), PPG (76.49 vs. 86.96 mg/dl; P = 0.271) and CBS (115.15 vs. 145.95 mg/dl; P = 0.420). Both treatment arms reported similar weight gain (1.92 vs. 1.22 kg), experienced similar incidence of hypoglycemia (7 vs. 6 patients) and adverse events (AE) (8 vs. 8 patients).@*Conclusion @#The traditional combination of NPH Insulin + Regular Insulin offers comparable glycemic control and tolerance as the standard of care without any new safety signals in the Filipino T2DM population. With a lower price, it can be one of the strategies to reduce the fi nancial burden of antidiabetic treatment.

Correlation of Glycosylated Hemoglobin And Oral Glucose Tolerance Test Results In Hyperinsulinemic Pre-Impaired Glucose Tolerance State Versus Normoinsulinemic-Normal OGTT

Background @#Prediabetes is an intermediate stage prior to development of diabetes mellitus. Preimpaired glucose tolerance state represents an early stage in the pathogenesis of diabetes wherein the normal glucose is attained by compensated hyperinsulinemia. Glycosylated hemoglobin is used in diagnosis and monitoring of diabetes but has not been explored in pre-IGT state. The objective of this study is to compare the 2-hour blood glucose, 2-hour insulin level, and HbA1c between normoinsulinemic-normal OGTT and pre-IGT groups.@*Methods@#Conducted at University of Santo Tomas Hospital, this was a retrospective analytical study of high-risk individuals for evaluation of type 2 diabetes from 2000-2011 and underwent 75-gm OGTT with 2-hour blood sugar and insulin determinations. The 2-hour glucose, insulin level and HbA1c in normoinsulinemic-normal OGTT were compared with the preIGT group using t-test. Correlation between the 2-hour blood glucose and insulin level with the HbA1c was done using Pearson correlation analysis. Statistical signifi cance was considered for p-value of <0.05@*Results@#Second-hour blood glucose and insulin levels were signifi cantly higher in the pre-IGT group as compared to the normoinsulinemic-normal OGTT group (128.60±18 and 89.29±68.82 vs. 90.68±26 and 17.40±8.15). The HbA1c of the pre-IGT group was signifi cantly higher than the normoinsulinemic-normal OGTT group (6.09±0.55 vs. 5.15±0.25, p-value <0.001). There was weak positive correlation between the HbA1c and 2-hour blood glucose levels between the two groups but not with the insulin levels.@*Conclusion@#The pre-IGT groups have signifi cantly higher 2nd hour blood sugar, insulin and HbA1c levels. This suggests that indeed the metabolic abnormality must be addressed as early as the pre-IGT stage.

Alternate Day Statin and Fibrate Given Alone or in Combination for Postprandial Dyslipidemia in Patients with Type 2 Diabetes Mellitus: A Preliminary Report

Introduction@#Postprandial lipemia represent an important risk factor for lifetime development of cardiovascular disease in patients with type 2 diabetes mellitus. Daily administration alone or combined statin and fi brate therapy has been shown to be an effective therapeutic approach but brings about serious logistics problem in our local setting. To address this concern, we report this observation where alternate day statin and fi brate treatment given alone or in combination in type 2 diabetes mellitus and similar effectiveness in lowering postprandial dyslipidemia has been obtained.@*Methodology@#This is a retrospective case study in an endocrine clinic involving 53 patients seen from April 2014 to October 2015. The patients were on statin and fi brate combination (atorvastatin 20- 40mg and gemfi brozil 300-600 mg or fenofi brate 145-160mg), statin alone (atorvastatin 20-40mg) and fi brate alone (gemfi brozil 300-600mg/fenofi - brate 145-160mg) given on alternate days. Percent reductions of cholesterol, triglycerides, LDL for combined statin and fi brate; cholesterol and LDL for atorvastatin alone; and triglyceride for fi brate alone were determined.@*Results@#In this preliminary report, 26 patients have available data. Follow-up period range was 4 to 48 weeks (mean 22.76+ 11.8 weeks). Alternate statin and fi brate (gemfi brozil) treatment yielded percent reductions from baseline as follows: cholesterol 7%, triglycerides 15%, and LDL 37% (P values= 0.02, 0.10 and 0.019, respectively). On the other hand, alternate statin and fi brate (fenofi brate) yielded percent reduction from baseline as follows: cholesterol 41% and LDL 20.4% (P=0.15 and 0.13, respectively). The population is small, the decrease did not yield signifi cant difference from baseline, however there is a tendency for triglyceride to decrease (P=0.09) with the combined statin and fenofi brate. With statin alone the percent reduction from baselinewere as follows: cholesterol 39% and LDL 62% (P= 0.29 and 0.11, respectively). No percent reduction of triglyceride is seen with fi brate given on alternate day with P= 0.19 The monthly cost reduction with combined alternate statin and fi brate treatment is at 34-48% while alternate day administration of the statin reduced cost by 60%.@*Conclusion@#This study showed lowering of postprandial total cholesterol, triglyceride and LDL with alternate statin and fi brate treatment, and total cholesterol and LDL with alternate day statin. The cost of treatment was also signifi cantly lowered with the alternate regimen. However, a follow through study with adequate sample size is recommended to support these observations.

Successful reduction in thyroid and nodule volumes in large solitary and multinodular goiters with serial 131 iodine therapy

Introduction@#131Iodine therapy is effective in nodular nontoxic goiter with enhanced effects using recombinant thyroid stimulating hormone (rTSH). The eventual fibrosis of the thyroid tissue and blood vessels ligates the vascular supply of the nodule. The study aims to show the successful reduction of thyroid and nodule volumes in large solitary and multinodular goiters using serial low dose 131iodine therapy (10mCi) at three to six months interval.@*Methods@#A retrospective analytical study was done from January 2010 to December 2012 and included twenty three patients with enlarged solitary and multinodular (nodule/s ≥2cm) non-toxic goiter (females: age range 35-65yrs) given serial 131iodine therapy (eight to10mCi) at three to six-month interval. Before each course, serum thyroid stimulating hormone (TSH) was done to document hypothyroidism while thyroid gland and nodule sizes were monitored by ultrasonographic measurements serially with each 131iodine therapy. Relief of compressive symptoms was monitored on follow-up at clinic.@*Results@#Thyroid size reduced by 38-40% from baseline after first radioactive iodine (RAI) and by 33-39% after the second RAI. Thyroid nodules reduced by 63-69% and 11-25% serially. Significant reduction was noted after the first RAI. One subject underwent third RAI with 80-85% overall reduction in nodule size. All patients developed post-RAI hypothyroidism and overall had greater than 50% increase in levothyroxine replacement dose after the last RAI. Significant relief of compressive symptoms was noted by 91% post-therapy. Four thyroid nodules disappeared which resulted in reduced total number of thyroid nodules from 29 to 25 nodules post serial RAI.@*Conclusion@#Serial 131iodine therapy proved to have thyroid and nodule size reduction by more than 70% in this study. Among patients who do not consent or have contraindications to surgery, serial 131iodine therapy may be considered a safe and effective non-surgical alternative.