Diagnosis and management of Dyslipidemia in family practice

Background@#Atherosclerotic cardiovascular disease (ASCVD) is a top cause of mortality in the Philippines. A known modifiable risk factor for ASCVD is dyslipidemia. Thus, proper diagnosis and management of dyslipidemia in family practice clinic could significantly decrease the burden of cardiovascular disease in the country@*Objectives@#This clinical pathway was developed to guide family and community physicians on the diagnosis and management of dyslipidemia.@*Methods@#To develop evidence -based recommendations, the authors searched for the latest guidelines of reputable international and local societies. They also searched PubMed using the terms “dyslipidemia”, “diagnosis”, “therapeutics”, “family” and “community medicine”. The more rigorous meta-analysis of clinical trials and observational studies were prioritized over lowquality trials in the formulation of the recommendations.@*Recommendations@#Thorough ASCVD risk assessment for all adults should be done during initial visit in family practice. The physician should review patient’s present medication; probe regarding lifestyle habits; conduct complete physical examination; use family assessment tools; and assess risk for ASCVD using calculators or risk factor counting method. For patients ≥ 45 years old and all adult patients regardless of age at increase ASCVD risk the following should be requested: lipid profile, urinary albumin- creatinine ratio/ urinary dipstick test, alanine transaminase (ALT), 12-lead electrocardiography (12-L ECG) and fasting blood sugar (FBS). During subsequent visits, re-assessment of ASCVD risk; checking compliance to non-pharmacologic intervention; and review of medication adherence and adverse effects should be performed. Repeat measurement of lipid profile should be done 6-8 weeks after initiation of statin therapy; 8-12 weeks after dose adjustment; and biannually for patients with controlled lipid levels. For individuals on statin therapy who have already achieved their low-density lipoprotein cholesterol (LDL-C) goal, compute for non- high density lipoprotein cholesterol (non-HDL C). Repeat ALT 6-8 weeks after initiation of statin therapy for those at high risk of statin-induced liver injury. Request creatine kinase (CK) if with development of muscle symptoms while on statin therapy. For primary prevention, start low-moderate intensity statins for following: individuals with diabetes mellitus (DM) Type 2 without ASCVD; individuals with mild-moderate chronic kidney disease (CKD); and individuals without ASCVD aged ≥ 45 years old with LDL -C ≥ 130 mg/dl AND with ≥ 2 risk factors. Start high intensity statins for individuals diagnosed with Familial Hypercholesterolemia. Give high intensity statins as secondary prevention for individuals with established ASCVD. For individuals with ASCVD on maximally tolerated statin therapy not meeting target LDL-C, ezetimibe could be added to their regimen. Low saturated fat diet rich in fruits and vegetable; regular exercise; and smoking cessation should be advised for all adult patients. The physician should also engage other family members to adopt healthy lifestyle. Formation of a community-based lifestyle intervention program to reduce cardiovascular risk should also be supported by the family physician.@*Implementation@#Adherence to pathway recommendations that are graded as either A-I, A-II or B-I is strongly advised. However, the authors also recommend using sound clinical judgment and patient involvement in the decision making before applying the recommendations.

Diagnosis and management of acute Tonsillopharyngitis in family practice

Background@#Acute tonsillopharyngitis is a common reason for consult in the primary care setting. Although most cases are viral in etiology, more than half of patients with acute tonsillopharyngitis still receive antibiotic therapy for group A beta-hemolytic streptococcal infection. Streptococcal throat infection may lead uncommonly to suppurative complications like peritonsillar abscess and non-suppurative complications like acute rheumatic fever. It is with this consideration that streptococcal throat infection must be distinguished from viral infections. Clinical practice guidelines have focused their efforts on how it can be accurately diagnosed to prevent complications while reducing unnecessary antibiotic prescribing.@*Objective@#This clinical pathway was developed to serve as guidance for family and community medicine practitioners in making clinical decisions regarding the diagnosis and management of acute tonsillophrayngitis.@*Methods@#After defining the scope of the pathway, the PAFP Clinical Pathways Group first identified the key issues in managing patient with acute tonsillopharyngitis. These key issues were then translated to review question. The group then reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication. Databases were first searched for existing clinical practice guidelines from reputable medical organizations. Further search for evidence was also conducted using the terms “tonsillopharyngitis” or “tonsillitis”, “diagnosis” and “treatment”. Evidence was then summarized and its quality assessed using the modified GRADE approach. From the evidence-based summaries, the CPDG then developed general guideline and pathway recommendations which are stated as time-bound tasks of patient-care processes in the management of acute tonsillopharyngitis in family and community practice. The recommendations were then presented to a panel of family and community practitioners in both urban and rural settings, for a consensus agreement on the applicability of the recommendations to family and community practice. Lastly, the final clinical pathway was written and developed to include the recommendations, the clinical pathway tables, and an algorithm. The clinical pathway can be used as a checklist or standards of care. The algorithm can be used to explain the process of care to the patient.@*Recommendations@#This clinical pathway contains updates on recommendations in the 2010 clinical practice guidelines on acute tonsillopharyngitis. Recommendations on the utilization of clinical scoring and rapid antigen tests as basis for deciding on need for antibiotic therapy comprise the major changes from the previously published guidelines. Penicillin remains as the first-line antibiotic therapy for streptococcal throat infection.@*Implementation@#Implementation of the clinical pathway will be at the practice and the organizational levels. The pathway may be used as a checklist to guide family medicine specialists or general practitioners in individual clinic and community medicine practice. It may also be used as reference for exams by the training programs and the specialty board. In the commitment to achieve the goal of improving the effectiveness, efficiency and quality of patient care in family and community practice, the clinical pathway may also be implemented through quality improvement activities in the form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.

Clinical pathway for the management of uninvestigated Dyspepsia among adults in family and community practice: Updated 2021

Background@#Uninvestigated dyspepsia is a common complaint in family practice in the Philippines. Patients usually seek consult due to severity of symptoms which affect their quality of life. The goals of management are short- and long-term symptom control, with reversal of possible underlying mechanisms, achievable through a combination of pharmacologic and non-pharmacologic interventions.@*Objective@#The main objective of this pathway is to guide family physicians and primary care physicians in the assessment, diagnosis and management of adult patients with uninvestigated dyspepsia through a shared decision-making process.@*Method@#This clinical pathway is an update of the PAFP’s Clinical Pathways for the Management of Dyspepsia in Adults (2016). The current panel utilized the ADAPTE method and prioritized reviewing relevant clinical practice guidelines from 2017 to present. Grading of recommendation was achieved through a mixture of strength of available evidence and a consensus from a panel of experts.@*Summary of Recommendations@#The main changes in the recommendations in this update are as follows: symptom-based classification of dyspepsia, screening for anxiety and depression, family and SCREEM assessment; initiation of therapeutic trial for most patients to whom H. pylori testing is not available; extension of initial PPI treatment to 4-8 weeks, consideration of antacids/alginates for immediate symptom relief, consideration of tricyclic antidepressants for non-responders to initial treatment; symptom-based non-pharmacologic advice, consideration of counseling and other psychosocial interventions; empowerment for self-treatment and as-needed therapy for those who have completed the initial treatment regimen@*Dissemination and Implementation@#This guideline shall be disseminated and implemented at the clinic and organizational level. It will be published in the “The Filipino Family Physician” journal, social media platforms and will be disseminated through PAFP local chapters, training institutions and during the national convention. Non-FCM primary care physicians will also be reached through relevant agencies. It shall be included in the references required during training activities and national exams of accredited training institutions, in coordination with the PAFP committee on Residency Training. It shall be incorporated in checklists for compliance in audits and QA cycles, with support from the PAFP committee on Quality Assurance and that on Standards for Family Practice. Feedback on utility and applicability will be actively sought from the intended users and other stakeholders.

Preparation and resumption of clinic services after enhanced community quarantine: A consensus statement by the standards of medical practice and ethics committee

Readiness of Health Care Staff@#Statement 1. Family physicians and their staff should prepare themselves mentally, physically and emotionally before resuming clinic services. Prior to starting every clinic day, physicians and their staff should take their temperature and note respiratory symptoms. Statement 2. All clinical staff should be properly trained on proper use of PPEs, clinic disinfection, infection control and other safety procedures. Statement 3. Family Physicians should design an office management and operations plan that includes triage, patient flow, treatment and other patient care protocols including strict implementation of infection prevention and control procedures, management of PPE supplies and potential staff shortages. Statement 4. The clinic staff must inform their patients of the changes that may result from the new management and operations plan that will be made in the facility@*Clinic Procedures, Disinfection and Infection Control@#Statement 5. After undergoing proper triage, non-COVID 19 patients entering the clinic should use a hand sanitizer, step on a foot bath or pad soaked in chlorine or any approved disinfectant solution at the entrance. All clinic staff, patients and accompanying persons should be wearing at least a mask inside the clinic. They should be instructed to avoid touching their face or mask and perform hand hygiene immediately before and after if cannot be avoided. Statement 6. Appropriate visual alerts or educational posters regarding infection control, proper handwashing, cough or sneezing etiquette should be visible inside the clinic. Statement 7. The clinic facility must have infection prevention and control measures that adhere to international and local standards. Statement 8. After appropriate triaging, a family physician when attending to a patient shall wear mask, single use gloves and eye protection while apron or gown is optional. It is up to the discretion of the family physician to use higher level of protection based on his risk assessment of the clinic environment and if resources are available.@*Clinical Services@#Statement 9. As much as possible, family physicians should continue all primary care services in the clinics. However, it is advisable to first limit the service to non-COVID-19 (suspect or diagnosed) patients. Patients needing COVID-19 assessment and management should be referred to appropriate facilities and follow the guidelines set forth by the Department of Health. Statement 10. A patient who consulted and whose symptoms were resolved may choose not come back for follow-up. Patients with chronic diseases may be followed-up at longer intervals if their illness is stable. Statement 11. Referrals for further assessment, diagnostic tests, or other procedures not available in the clinic must first be coordinated with the referral center/site

Síndrome de insuficiencia torácica debido a escoliosis congénita y fusiones costales tratado mediante toracoplastía de expansión, combinada con sistema de distracción sucesiva / Thoracic insufficiency syndrome due to congenital scoliosis and fused rib treated with expansion thoracoplasty in combination with growing rods

Introducción. Las escoliosis congénitas asociadas a fusiones costales pueden causar disminución de crecimiento en el tórax y un efecto adverso sobre el desarrollo y función pulmonar. Esta condición se conoce como Síndrome de Insuficiencia Torácica (SIT). Objetivo. Reportar nuestra experiencia en tratamiento de pacientes con síndrome de insuficiencia torácica debido a escoliosis congénita y fusiones costales, tratados con toracoplastia de expansión combinada con distracciones sucesivas (V.E.P.T.R. - Vertical Expandable Prosthetic Titanium Rib). Material y Método. Evaluación retrospectiva clínica y radiográfica de 9 pacientes. Resultados. Se evaluaron 9 pacientes. Seguimiento promedio 2.1 años. Edad promedio de primera intervención 2.5 años. Valor angular pre-operatorio promedio 71.3 grados y descompensación del tronco 3.4 cm. El promedio de corrección de la escoliosis durante el último control fue de 37.4%, para la descompensación del tronco de 51.7% y la relación de longitud, entre los hemi-tórax, mejoró 24.6%. Se registraron 2.7 complicaciones por paciente. Conclusión. La toracoplastía de expansión, combinada con distracciones sucesivas es una buena alternativa para tratar el síndrome insuficiencia torácica debido a escoliosis congénita y fusiones costales. Las complicaciones son frecuentes y condicionan el tratamiento. El VEPTR requiere modificaciones de diseño.

Correlation of optic-disc area and refractive error

Objective@#This study measured the optic-disc area using optical coherence tomography (OCT) and correlated it with the type of refractive error.@*Methods@#A cross-sectional study was conducted involving 73 healthy Filipinos aged 20 to 60 years. All underwent a full ophthalmologic examination including visual acuity, automated refraction, Goldmann applanation tonometry, and dilatedfundus examination. Fast optic-nerve-head imaging was performed with 6 radial linear scans centered on the optic-nerve head. Data were tabulated and the association between optic-disc measurements and refractive error was analyzed using analysis of variance and linear regression.@*Results@#A total of 142 eyes of 73 patients were included, of which 39 (27.5%) were classified as emmetropia or hyperopia, 47 (33%) as low myopia, 37 (26.2%) as moderate myopia, and 19 (13.4%) as high myopia. The mean refractive error was –9.2 ± 2.98D for those with high myopia, –4.7 ± 0.74D for moderate myopia, –1.7 ± 0.78D for low myopia, and 1.1 ± 2.55D for emmetropia and hyperopia. The mean optic-disc area for all groups was 2.70 ± 0.59 mm2 (range, 1.6 to 4.7 mm2 ); the mean optic-disc area was similar for high myopia (2.7 ± 0.57 mm2 ) and low myopia (2.7 ± 0.52 mm2 ). There was no significant difference in the optic-disc area of the different types of refractive errors (p = 0.30).@*Conclusion@#This study showed that the optic-disc area is statistically independent of the refractive error.

Antigen sandwich ELISA predicts RT-PCR detection of dengue virus genome in infected culture fluids of Aedes albopictus C6/36 cells.

Antigen detection by sandwich ELISA was evaluated to predict RT-PCR detection of dengue viral genome in infected culture fluid of Aedes albopictus clone C6/36 cells. Serum specimens collected from dengue patients within 5 days from onset of fever in 2 hospitals in Metro Manila, Philippines, were inoculated into C6/36 cells, and incubated at 28 degrees C. A total of 282 infected culture fluid specimens were harvested and examined by sandwich ELISA and RT-PCR to detect dengue viral antigen and genome, respectively. In the sandwich ELISA, the P/N ratio was calculated by dividing optical density (OD) of a given test specimen by the OD of the standard negative specimen. Samples with a P/N ratio > or = 4.001 were positive for viral genome detection by RT-PCR. The sensitivity and specificity of antigen sandwich ELISA with RT-PCR as the standard, were 90.4% and 100%, respectively. Although antigen sandwich ELISA is less sensitive than RT-PCR, its usefulness lies in its capability to screen a large number of samples at a minimum cost, especially during an outbreak. Samples that meet a set cutoff value can undergo confirmation by RT-PCR for further epidemiological studies.

Anomalias vertebrales y anomalias asociadas / Vertebral anomalies and associated anomalies

Las anomalías vertebrales son trastornos embriopáticos.Muchas de ellas concurren con anomalías de otros órganos,en forma aislada,casual o formando parte de asociaciones y síndromes.El objetivo de este trabajo ha sido evaluar la incidencia de anomalías asociadas en los pacientes con anomalías vertebrales.Se evaluaron 1029 pacientes con anomalías de columna,sus registros fueron efectuados desde 1972 hasta el 2000.fueron excluidos del presente los pacientes con mielomeningocele y enanismo tipificados.Con el objetivo de obtener datos que probablemente fueran más completos se efectuaron tres mediciones:a)el grupo total(1029)b)el grupo de pacientes intervenidos quirúrgicamente por su deformidad espinal(390)c)el grupo de pacientes seguidos más allá de los 15 años(124).Como conclusión observamos distintos valores de incidencia de malformaciones asociadas a las deformidades espinales comparados con resultados de otros autores,nuestra prevalecencia es menor.A pesar de los distintos estudios sometidos a grupos de pacientes y a distinto tiempo de evolución los datos de los tres grupos parecen ser coincidentes

El raquis en la acondroplasia / The acrondroplastic spine

El propósito del trabajo fue determinar cuáles de las deformidades vertebrales de la acondroplasia requieren tratamiento quirúrgico, dado la poca tolerancia del conducto raquídeo a las deformaciones. Se evaluaron a 76 pacientes acondroplásicos atendidos en el hospital pediátrico entre los años 1987 y 1997, de los cuales 10 (13 por ciento) requirieron cirugía. La edad promedio de los operados fue de 11 años (rango, 4-19 años); 7 (70 por ciento) fueron varones y 3 (30 por ciento) mujeres. El seguimiento posoperatorio promedio fue de 3 años 9 meses (3+9) (rango, 0+6+9+6). Dos pacientes se presentaron con trastornos neurológicos. La cifosis dorsolumbar fue la desviación más frecuentemente tratada (6 casos, 60 por ciento). Por estenosis, en 3 pacientes se efectuó descompresión de la fosa posterior (escamotomía del occipital), por presentar estrechez del agujero magno y patología neurológica bulbar. En 2 pacientes se efectuó descompresión del conducto dorsolumbar. En uno, sólo se liberó y en el otro se completó con artrodesis anterior y posterior instrumentada con tornillos pediculares. Por cifosis, en 3 pacientes se realizó artrodesis anterior con arbotante de peroné y posterior simple, y en 2 se practicó artrodesis anterior con peroné y posterior instrumentada con tornillos pediculares. Es importante evaluar la patología de la columna en los acondroplásicos. En los pacientes pediátricos son más frecuentes las cifosis y la estrechez del agujero occipital, a diferencia de la población adulta, donde la patología predominante es la estenosis lumbar. Es fundamental en los niños acondroplásicos buscar patología del agujero magno. Las cifosis de más de 40 grados entre los 5 y 6 años debe ser tratada en forma preventiva con artrodesis anterior y posterior, dado que su progresión genera signos de compromiso neurológico en la adolescencia