Treatment decisions based on clinical trials

@#The randomized Controlled Trial is the standard design to prove the effectiveness of drugs or other forms of interventions. In this type of clinical research, individuals are randomly assigned (randomization) to either of the two or more groups, one with the intervention the other without the intervention being tested or another intervention. When done properly, it can provide the best evidence of effectiveness

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.

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.

Clinical and Histopathological Profile Of BRAF V600E Mutation In Conventional Papillary Thyroid Carcinoma in A Filipino Population

BRAF V600E is a possible biomarker for risk stratification and prognostication in papillary thyroid carcinoma. Studies on its association with aggressive clinicopathological features among East Asian populations are limited. This study examines the clinical and histopathological features of this mutation in Filipinos with conventional papillary thyroid carcinoma. Methods: Formalin-fixed, paraffin embedded thyroid tissue blocks of papillary carcinoma for the study period January 2010 to December 2012 were retrieved. Slides were reviewed and described according to tumour size, variant type, sclerosis, multifocality, subcapsular location, extra-thyroidal extension, nodal metastasis, and nodal extracapsular spread. Medical records were reviewed for patient demographics and characteristics. Mutation status was determined using realtime polymerase chain reaction and sequencing. Results: Sixty-five patients were included in this study. BRAF V600E mutation prevalence was 38.46%. The mutation positive group was predominantly female, young (mean age 36 years), with tumour size less than 4 cm, and late-stage disease. Extra-thyroidal extension (60%), significant sclerosis (96%), and subcapsular tumour location (72%) were the most frequent findings. Eighty-three percent of patients with nodal metastasis had extracapsular spread. Conclusions: Compared to some Asian populations, this study of Filipino patients shows a lower prevalence of BRAF V600E mutation. The clinical and histopathological features of mutation positive patients raise important issues regarding extent of surgical excision and appropriate management of neck metastasis for this group.

Primary pulmonary diffuse large B-cell non-Hodgkin's lymphoma in a child.

A 3-year-old girl presented with a history of intermittent fever of six months duration associated with respiratory symptoms consisting of recurrent cough, fever, wheeze and a suspected history of contact with tuberculosis (TB). Chest radiograph revealed pulmonary infiltrates mimicking miliary TB. She was started on anti-tuberculous treatment, but in view of clinical deterioration, a further work-up including a lung biopsy revealed non-Hodgkin’s lymphoma (NHL). This case documents the extremely rare occurrence of pulmonary involvement and miliary infiltrates on the chest radiograph in NHL.

Comparative study on supplementation of potato flour biscuits on the nutritional and cognitive profile of the selected children

Nutrition of the early childhood is of paramount importance because the foundation for life time strength and intellectual vitality is laid during this period. The present study aims to evaluate the effect of weaning biscuits supplementation of the nutritional parameters and cognitive performance of the selected children. Three Balwadies situated in Salem District, Tamilnadu, India were selected. A total number of 40 school children in Grade II malnutrition, 15 from Balwadi I, 14 from Balwadi II and 11 from Balwadi III comprised the study sample. All the 40 were selected for the experimental study. Home diet without any supplementation was followed by Group I [n=10, control group], potato flour biscuit was supplemented to Group II [n=10], Maize biscuits were given to Group III [n=10] and Green gram biscuits were given to Group IV [n=10] for the period of 3 months. Parameters like anthropometric measurements, hemoglobin content and clinical picture were analyzed before and after supplementation, cognitive performance of the supplemented children was assessed at the end of the study period. There was significant difference in height, weight, blood hemoglobin and clinical picture after three months on their home diet in group I. In groups II, III and IV significant increase in all the above parameters was noticed. More increase was found in group II children supplemented with potato flour biscuits for a period of 3 months. About cognitive performance better results were obtained in Group II followed by group IV [supplemented with green gram biscuits] and group III [supplemented with maize biscuits]. Least was obtained by control group children who were in their home diet. All these observations evidence that if such weaning biscuits made with potato flour, maize and green gram can form a daily ingredient in their diets, it will bring out better all round development of the children

Evaluation of chronic abdominal pain--a test of "patience".

A 4 year old girl with chronic abdominal pain of 6 months duration was provisionally diagnosed as eosinophilic gastroenteritis based on endoscopic biopsy This case is reported for its rarity.

Successful pregnancy in a patient with central hypothyroidism following tran-sphenoidal surgery for an adrenocorticotropic hormone-secreting pituitary adenoma

A case of a 26 year-old primigravid with central hypothyroidism resulting from transphenoidal excision surgery (TSE) for an adrenocortic-producing pituitary macroadenoma is presented. Free thyroxine level was low 8 months post TSE and patient was started on levothyroxine therapy. Fortunately, she became pregnant 18 months after levothyroxine medication was started. Repeat cranial Magnetic Resonance Imaging (MRI) did not show any evidence of tumor recurrence. She was also diagnosed with diabetes mellitus type 2 and hypertension and was maintained on premixed insulin and methyldopa. Patient's prenatal course was uneventful with essentially normal antenatal surveillance tests and normal thyroid function tests. Patient was admitted on her 38 1/7 weeks age of gestation for labor induction because of a non-reactive stress test. She delivered a live baby girl, weighing 2600 grams, 37 weeks by pediatric aging with an APGAR score of 9 becoming 9, via assisted vaginal delivery under epidural anesthesia. Postpartum courses were both unremarkable.

The Epstein Barr virus and gastric carcinoma.

The Epstein Barr Virus (EBV) is one of the viruses implicated in the pathogenesis of malignant tumors. Its association with Burkitt's Lymphoma, nasopharyngeal carcinoma and certain cases of Hodgkin's lymphoma is well known. More recently this virus has been found to be associated with gastric carcinoma. Studies on this association, in our country are lacking. We have studied 37 cases of carcinoma using immunohistochemistry for LMP1 protein. Most workers have found an expression of latency type I antigens in gastric adenocarcinomas, with only a few cases being LMP1 positive. In the 37 cases studied by us, 24.14% of cases were positive for LMP1. LMP1 is known to have oncogenic properties. In addition, it has been demonstrated earlier that the EBV particles in gastric carcinoma are monoclonal. These two factors support a pathogenetic role for EBV in gastric carcinoma.

Effective training in reproductive health: course design and delivery

This document constitutes a resource for trainers who lead training-of-trainers courses in the reproductive health issues. It provides instructions and materials trainers need to help learners strengthen their training; communication and facilitation knowledge and skills. It also enable them to plan and implement more effective training courses.The manual is organized into two parts that focus on (1) core training principles and skills and (2) clinical training approaches and coaching skills

Immune status of children suffering from minimal change nephrotic syndrome.

Twenty five children suffering from minimal change nephrotic syndrome were studied for immunological alterations at different stages of this disease i.e., onset, relapse and remission. Changes were found mainly at onset and during relapse in the form of altered helper and suppressor cell ratio, depressed delayed cutaneous hypersensitivity reaction, decreased S-IgG bearing lymphocytes with low serum IgG concentration, and increased S-IgM bearing lymphocytes with high serum IgM concentration. Majority of these parameters returned to normal values during remission. Serum IgE was found high at all stages of this. These alterations suggest defects in cell mediated immunity resulting in secretion of some substance which modifies the glomerular anionic charges.

Behaviour change in HIV infected subjects following health education.

A total of 85 HIV seropositive subjects among consecutive new registrants in the STD Department were given health education measures directed to avoiding high risk behaviours and also the events with a high potential for transmission of infection. The emphasis was on the use of condoms, discontinuing promiscuity, abstaining from homosexual acts and avoidance of pregnancy and advice against marriage for those contemplating it. The Health Education Programme was delivered individually to each subject over two or three sessions, each lasting for 30 to 45 min. At the time of follow up (one to 24 months) 42 per cent of subjects had become non-promiscuous. There was a good compliance on advice against marriage and pregnancy. Seven infants born during the follow up period were seronegative. The use of condom was not found to be acceptable. The prostitutes comprised the most resistant group to education. Among the factors that influenced the behaviour change favourably was the absence of earlier STD or a short duration of the current STD. Literacy, marital status, awareness of AIDS did not influence the outcome of education. The study demonstrated the feasibility of health education at individual level in the clinical setting of an STD Department. A longer follow-up may indicate the sustainability of behaviour change in the subjects.

Low serum immunoglobulin G--a predictor of frequent relapses in idiopathic nephrotic syndrome.

Serum immunoglobulins were measured in 25 children at the onset of nephrotic syndrome, in 20 during remission and in 19 during relapse. On follow up, 10 of them were frequent relapsers (FR). As compared to children who were infrequent relapsers (IFR), frequent relapsers had significantly lower levels of IgG at onset (p less than 0.001) which persisted during remission. IgG in FR at onset and at remission were 27.2 and 42.5% of normal mean as compared to 70.0 and 74.4% of normal mean observed at onset and remission, respectively in IFR. Very low levels of IgG may help predict onset of a tendency towards frequent relapses in children with minimal change nephrotic syndrome.