The diameter of the normal extrahepatic bile duct among patients diagnosed with cholecystolithiasis managed at the Philippine General Hospital

Background and Objective@#Understanding the normal anatomy and size of the extrahepatic biliary tree is vital for surgeons to make informed decisions regarding the necessity of additional procedures beyond cholecystectomy. The extrahepatic bile duct (EHBD) comprises the common hepatic duct (CHD) and the common bile duct (CBD), with the former formed by the convergence of the right and left hepatic ducts and the latter extending from the CHD to the duodenum. A normal diameter is indicative of the absence of any signs of obstruction in the EHBD, and the determination of the average range for these ducts are essential for identifying pathologies that may require further surgical intervention. Cholecystolithiasis is a common condition managed at the Philippine General Hospital (PGH). Trans-abdominal ultrasonography is frequently utilized to diagnose cholecystolithiasis, and it can also be used to determine the size of the common bile duct. Knowledge of the normal CBD diameter aids clinicians in distinguishing obstructed bile ducts from normal ones, prompting further diagnostic tests for improved patient management. However, there is limited data on the average diameter of the CBD among Filipino patients with this condition. The study aimed to determine the mean diameter of the common bile duct and common hepatic duct among patients diagnosed with cholecystolithiasis with no signs of obstruction in the EHBD managed at the Philippine General Hospital.@*Methods@#This prospective cross-sectional study included 80 patients who underwent cholecystectomy with intraoperative cholangiography. The CBD and CHD diameters were measured using intraoperative ultrasonography, and the data were analyzed using descriptive statistics and independent t-test.@*Results@#The mean diameter of the CBD was 5.17 mm, with a range of 2.7-10 mm (1.41) mm. The mean diameter of the CHD was 4.71 mm, with a range of 2.3- 10 mm (1.59) mm. There was no significant difference in the CBD and CHD diameters between male and female patients, and across different age groups.@*Conclusion@#In patients with cholecystolithiasis managed at the PGH, the mean diameter of the CBD and the CHD was 5.17 mm and 4.71 mm, respectively, with no significant difference between genders and age groups. The mean diameter of the CBD among Filipino patients with cholecystolithiasis is similar to those reported in other countries. These findings may have clinical implications for the management of patients with cholecystolithiasis, particularly in the planning of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy. Further studies with larger sample sizes and different populations are recommended to validate these results. These findings can aid clinicians in determining the need for pre-operative Magnetic Resonance Cholangiopancreatography (MRCP) or selective intraoperative cholangiography to detect extrahepatic bile duct obstruction.

Perspectives on the use of telegenetics services in the Philippines

@#The Philippines is a densely populated nation faced with multiple challenges in the healthcare field given its geographic, cultural, and socioeconomic barriers. Due to the geographic limitations of medical services in the country, many patients must travel a great distance to referral centers. This was further exacerbated by the Coronavirus disease 2019 (COVID-19) pandemic, which spread across the world and upended lives. This pandemic triggered a public health crisis that impacted healthcare systems, healthcare workers, and communities worldwide. It compounded current difficulties with the provision and accessibility of medical services, necessitating the employment of alternative methods of providing health coverage. As a result, advanced technological methods for patient diagnosis, monitoring, treatment, and counseling were rapidly implemented.1 Interest in these technological advances began prior to the COVID-19 pandemic, though primarily in developed countries. However, during this global outbreak, telehealth practices – which refer to online health care services provided by all health care professions – have seen a rapid increase in popularity.2,3 Telehealth was brought to the forefront in all countries in order to surmount lockdown constraints, allow continuous provision of health care for patients, and limit exposure to health systems and health providers.4 Traditional medical education and training were likewise disrupted during this time, resulting in the incorporation of telehealth into medical education. To reduce the risks associated with more personnel in the hospital, medical students were withdrawn from clinical environments during the COVID-19 outbreak. This created an environment of uncertainty and limited clinical exposure, with concerns surrounding progression through the medical course and training program.5 Continuing medical education, which has traditionally been based on clinical knowledge and skills, now requires online technical communication skills. Innovative services were rapidly developed with health professionals embracing this new technological competence, enabling general consultation for patients, remote patient monitoring, and self-directed patient care, thereby decreasing the burden on health facilities. Digital learning platforms also provided an effective way to address the learning gaps caused by the pandemic. The restriction of “in-person” delivery of healthcare services due to the global outbreak has prompted physicians, including clinical geneticists and genetic counselors, to investigate alternative methods of providing health care to patients. A telehealth innovation for online delivery of clinical genetic and genetic counseling services is the Philippine General Hospital’s Telegenetics Service. Despite being launched in 2013 to serve genetics patients across the country, this service has since been upgraded and capitalized resulting in patient appreciation for its COVID-19 exposure prevention, increased access, and time and cost efficiency. However, the telegenetics service has its limitations.6,7 Despite the expanding scope of telehealth/telegenetics and its immediate application, issues such as data/patient privacy, organizational readiness, digital maturity, regulatory impediments, access and acceptance of the technology, geographical and digital disparities, and its integration with traditional medical services have emerged.8 Lack of a detailed physical examination is also lost in a virtual visit, with focused questions leading to fragmented, impersonal interactions. Even when restrictions were lifted, telehealth usage nonetheless remained significantly higher than it had been prior to the pandemic. This may indicate a shift in public opinion in favor of this innovative medical practice.9 With the expansion of genetic services in the country, there is now a greater need for telegenetics due to the increased demand for clinical genetic and genetic counseling expertise. Therefore, evidence on the safety and efficacy of this technology in comparison to the traditional healthcare delivery approach is required. If the technology has the potential to improve health care, we must guarantee its availability in all resource-limited areas. Future efforts should thus focus on establishing solutions to address the aforementioned issues and concerns within our healthcare and education systems, thereby ultimately enhancing the standard of medical care.

The effect of the COVID-19 pandemic on procedures performed by fellows of the Vitreo-Retina Training Program at the Philippine General Hospital

BACKGROUND@#The COVID-19 pandemic has affected ophthalmology training. The Vitreo-Retina Training Program extended the training periods of its trainees in anticipation of a drop in surgical cases during the pandemic to make up for the expected drop.@*OBJECTIVE@#This study aimed to determine the effect of the COVID-19 pandemic on the Vitreo-Retinal Fellowship Program at the Philippine General Hospital (PGH), specifically the number of procedures performed by the Vitreo-Retina Fellows before and during the pandemic and their compliance with the Vitreo-Retina Society of the Philippines (VRSP) standards.@*METHODOLOGY@#This is a document review of vitreo-retinal procedures done at the Department of Ophthalmology and Visual Sciences of the PGH from January 1, 2017, to December 31, 2021.@*RESULT@#During the COVID-19 pandemic in 2020, there was a drop in the number of procedures performed by both the first year and second year vitreo-retina fellows. Despite the drop in numbers, the first year vitreo- retina fellows were still in compliance with the VRSP-recommended number of procedures. The second year vitreo-retina fellows, on the other hand, were not able to comply with the recommended numbers by the VRSP. The extension year allowed the second year fellows to do more procedures and comply with the recommended numbers of pars plana vitrectomy only.@*CONCLUSION@#There was a drop in the vitreo-retinal procedures during the COVID-19 pandemic. The second- year fellows were the most affected with the decrease in the number of surgical cases.

Kangaroo mother care implementation at the Philippine General Hospital: A quality assurance initiative

Background@#The Philippine General Hospital (PGH) implemented the Kangaroo Mother Care (KMC) Program in 2014, recognizing its benefits in helping low birth weight (LBW) infants survive. @*Objective@#To determine the acceptability and compliance of the stakeholders to the KMC program after one year from implementation. @*Method@#Data were obtained from the NICU Annual statistics, KMC data forms, logbooks, and questionnaires to the stakeholders-doctors rotating at the NICU, NICU nurses, and mothers enrolled in the KMC program. @*Results@#One year into the KMC program implementation, the KMC enrollment increased from 57% in 2014 to 75% in 2015. All mothers enrolled in the program said that they received their KMC knowledge from the health providers and firmly believed that KMC benefited them and their infants. The mothers also became more confident in taking care of their babies after each KMC encounter. Although only 50% said they would continue KMC at home, 85% proceeded. Furthermore, both doctors and nurses believed that KMC was beneficial to both mothers and infants, decreased hospital cost and nursing workload. KMC provision was 0.5-6 hours/day. Also, less than half of the data forms were accomplished. The KMC program was acceptable to all stakeholders who believed in the benefits of KMC to preterm infants. The mothers were very receptive and continued KMC even after discharge. However, there was sub-optimal engagement provided by the health providers with the mothers. There was also low adherence to recommended duration of KMC per day provided by the mothers. KMC data records were frequently not accomplished. PGH has instituted strategies to improve the KMC implementation by providing dedicated KMC rooms and supplying meals to mothers to increase KMC duration and frequency. A computer-based program for data entry was developed for the health providers, and a dedicated encoder was assigned. @*Conclusion@#KMC acceptability was high among stakeholders. Compliance increased after one year, with enrolment going up to 75%. However, adherence to the recommended KMC duration per day and accomplishment of data forms were still sub-optimal.

Birth defects at the outpatient Department of the Philippine General Hospital from 2000-2010

Introduction@#Birth defects or congenital anomalies are a major global concern. An estimated 7.9 million children are born worldwide each year. Birth defects are among the top ten leading causes of infant deaths in the Philippines for more than six decades. The objectives of this study were to: 1) determine the frequency of birth defects among patients seen at the Outpatient Department (OPD) of the Philippine General Hospital (PGH) from 2000 to 2010; 2) describe the birth defects by organ systems and presentation (isolated, part of a recognizable syndrome, chromosomal syndrome or multimalformed case); 3) present the distribution of patients by geographic origin; 4) describe the birth defects according to age group and organ system; and 5) compare the data from this study to the previously published report among admitted patients at PGH in the same time period. @*Methods@#Medical records of new patients seen at the PGH OPD from 2000 to 2010 were reviewed. Medical records that included written diagnosis of any of the following International Classification of Diseases (ICD) -10 codes (Q 00 – Q 99, P 35.0, P 83.5, K40, H49.0, H50.0, H50.1, H53.0, H54.42, H54.7, and H55.01) were considered birth defect cases. @*Results@#Out of the 804,410 new patients at the PGH OPD from 2000 to 2010, 12,827 patients (1.59%) had a diagnosis of at least one major structural birth defect. The most common birth defects were cardiovascular, digestive, genital organ and nervous system anomalies. The top 5 anomalies in this report were: congenital malformations of cardiac septa, other congenital malformations not elsewhere classified, cleft palate with cleft lip, congenital hydrocoele, and congenital hydrocephalus. The highest percentage of birth defects were from the < 1 age group (40.3%), followed by the 1 to 4 age group (29%) and the 5 to 9 age group (14.6%). NCR, Region IV-A and Region III had the highest percentages of patients with birth defects, 51.4%, 26.03% and 10.97%, respectively. @*Conclusion@#This study revealed a prevalence of birth defects among PGH OPD patients of 1.59%. The most common birth defects were possibly surgically correctable reflecting the nature of PGH as a referral center. Majority of patients affected were in the under-5 population. The study reflects the importance of a birth defects surveillance to develop policies on strategies that will reduce the burden of morbidity and mortality secondary to preventable birth defects like congenital rubella syndrome that can be aborted by a successful immunization program. The birth defects surveillance will generate data that will support strengthening the regional hospitals with a better complement of specialists and capability for both medical and surgical management of the patients.

Test characteristics of core needle biopsy of palpable breast masses: A review of Philippine General Hospital out-patient cases from 1999 to 2001

Core needle biopsy (CNB) has been used increasingly as a diagnostic tool in evaluating mammary lesions. To determine the test characteristics of CNB, histopathologic review of palpable breast masses in 81 female patients (mean age: 48 years, range 17-71 years) obtained by non-imaging-guided CNB at the Philippine General Hospital Out-Patient Department from January 1999 to March 2001 was compared with the reviewed results of the subsequent excision (excision biopsy, simple mastectomy and modified radical mastectomy) as the reference standard. Of the 81 cases, 62 (77 percent) were histologically confirmed as malignant and 19 (23 percent) were benign. Of the 81 CNBs, 22 (27 percent) were unsatisfactory biopsies. Evaluation of CNB test characteristics was based on the rest of the 59 "satisfactory" CNBs. Test characteristics were: Sensitivity=82.2 percent, Specificity=92.2 percent, Accuracy=84.7 percent, Positive Predictive Value=97.4 percent, Negative Predictive Value=61.9 percent. The test characteristics were lower compared to previously reported values which were however largely based on image-guided CNBs. Specimen adequacy, operator differences in skills and expertise, and histopathologic interpretation error may account for the difference. (Author)

The distribution of hypertension in the Philippine General Hospital

The distribution of hypertension in patients admitted to five clinical departments of the Philippine General Hospital for two years (1966-1967) was analyzed. Out of a total of 32,731 admissions, 3,121 or 9.50 were hypertensive. The Department of Obstetrics & Gynecology contributed the highest number or 1,971 (63.10) and the Department of Medicine ranked second with 725 hypertensives (23.20). It should be noted that the former had the largest admissions or 21,592 in contrast to the latter which had only 3,729. Minor contributions or less than 10 came from the Departments of Surgery, Eye and Ear, Nose, ThroatHowever, based on the of admissions per department, the highest number of hypertensives came from the Department of Medicine or 725 (19.40). The Eye department ranked second with 14.80 of its admission followed by the Department of Obstetrics and Gynecology or 9.10The breakdown of the various types of hypertension revealed that toxemia of pregnancy (predominantly pre-eclampsia) was the most frequent or 1,773 out of a total of 2,711 (65.40). The next one was probable primary hypertension or 784 (28.91). The rest of the secondary types totalled 3.23 of which chronic renal diseases (glomerulonephritis and pyelonephritis) were the most common. The rarer types (less than 1) were as follows: aortic insufficiency, reno-vascular hypertension, increased intra-cranial pressure, atherosclerosis, endocrine hypertension, acute glomerulonephritis, Cushings syndrome and polycystic kidneys. (Summary)

Open heart operations using disposable plastic oxygenators, 5% dextrose in distilled water prime, normothermia, and a sigmamotor pump (T-M2)

Open heart operations were successfully performed on six consecutive patients at the Philippine General Hospital. Total cardiopulmonary bypass was accomplished using disposable plastic oxygenators, five percent dextrose in distilled water prime, normothermia and a single sigmamotor pump (T-M2). The technic of perusion, clinical material, physiologic data gathered and the financial costs of these operations were discussed. All the patients survived their operations. No complication could be attributable to the method of cardiopulmonary bypass employed. The technic of cardiopulmonary bypass described appears practical, safe, and relatively inexpensive. This method of bypass has been adopted for use by the Department of Surgery for all types of open heart operations. (Author)