Prevailing Food Intake, Physical Activity and Health Beliefs in a Rural Agricultural Community in the Philippines: Factors to Consider Prior to a Diabetes Prevention Program.

Objective: A diabetes prevention program is being proposed in the rural agricultural town of San Juan, Batangas, Philippines. This study aims to determine the prevailing level of food intake, physical activity, and health beliefs prior to any intervention. Methodology: Adults were recruited via random sampling with proportional allocation. Interviews were done to determine food intake and physical activity. Small group discussions were held to determine prevailing health beliefs. Results: The average energy intake (1,547 kcal/d) is only 72% of the recommended values for Filipinos. Only 12% of the respondents achieved the recommended energy intake. Carbohydrates comprise a large part (71%) of calorie intake. A majority (91%) already have moderate to high levels of physical activity. There are prevailing health beliefs that need to be considered when dietary modifications and physical activity interventions are to be done. Conclusion: Internationally recommended diabetes prevention interventions such as reducing calorie intake and increasing physical activity may not be directly applicable here. We recommend that the features of a diabetes prevention program for this locale must include the following: 1) introduction of affordable plant sources of proteins; 2) decreasing the proportion of rice as a source of carbohydrates in the diet; 3) maintaining the level of physical activity; and 4) being sensitive to the prevailing health beliefs.

Qualities of Role Models of Internal Medicine Residents in a Tertiary National University Hospital in the Philippines.

Background: Teachers in medicine do not only teach scientific facts about health and disease to their learners but they are also looked up to as role models. Little is known about the qualities of consultant-faculty members who are regarded as role models by Filipino internal medicine residents. Objective: This study aimed to determine the reasons why consultant-faculty members are considered role models by Filipino internal medicine residents. Methods: A cross-sectional survey was conducted among internal medicine residents at a tertiary national university hospital in the Philippines. Participants were asked to give the reasons for citing consultant-faculty members who they consider as role models. Results: There were 81 residents who participated (93% response rate) who gave a total of 332 qualities as reasons for citing them as role models. The most commonly cited quality category was those of personal qualities (35.84% of all responses). This was followed by academic, clinical, teaching, leadership and research qualities. Physical qualities were the least cited (0.30% of all responses). Across the four batches of residents, personal qualities were consistently cited the most number of times, while physical qualities were consistently cited the least. Conclusion: Filipino internal medicine residents identified personal qualities as the most frequent reason for considering their consultant-faculty as role models.

3-in-1: bilateral subcutaneous leg abscesses and liver abscess from Klebsiella pneumoniae.

Hypervirulent strains of Klebsiella pneumoniae are known to cause liver abscesses and other metastatic infections. Being Asian and having diabetes are known host risk factors. Here we present an unusual case of a Filipino ballet dancer-choreographer with diabetes presenting with bilateral leg pains initially thought to be cellulitis, but was eventually diagnosed as bilateral subcutaneous leg abscesses. He also had a liver abscess, thankfully asymptomatic, which was only discovered on imaging. The occurrence of three distant abscesses in one patient, hence '3-in-1,' makes this case worth reporting. Bilateral subcutaneous leg abscesses as the presenting manifestation of this infection have not been reported yet. We hypothesise that his occupation which makes use of frequent contractions of leg muscles led to increased blood flow and preferentially directed blood-borne bacteria to localise in both legs. We have also characterised the pathogen with regards to its hypermucoviscous phenotype, capsular type, virulence genes and phylogeny.

Resistant hypertension after shockwave lithotripsy: the rude awakening of an adrenal incidentaloma.

A 41-year-old woman presented to the hospital because of left flank pain. CT scan of the kidneys revealed left-sided calculi and an incidental right adrenal mass, no other symptoms noted. She then underwent shockwave lithotripsy (SWL). However, immediately postoperatively, she had elevated blood pressure and remained hypertensive despite having four different medications. How SWL could have increased blood pressure could not be identified. On endocrine consult 16 months after SWL, she was found to now exhibit signs and symptoms of Cushing's syndrome. Further workup revealed the adrenal incidentaloma to be cortisol-secreting. After undergoing right laparoscopic adrenalectomy, her blood pressure normalised, cortisol levels decreased and signs of Cushing's syndrome gradually improved. We hypothesise that the performance of the SWL could have triggered the adenoma to 'awaken' from being non-functioning to cortisol-producing since this was the only intervening event. Observations of other patients are needed to validate our hypothesis.

Bilateral adrenal histoplasmosis presenting as adrenal insufficiency in an immunocompetent host in the Philippines.

Disseminated histoplasmosis, with the adrenal glands as being the only site of demonstrable disease in an immunocompetent adult, is a rare infection leading to adrenal insufficiency. This disease carries high mortality when unrecognised. We describe the first reported case of adrenal histoplasmosis in the Philippines in a 72-year-old immunocompetent, Filipino man who presented with a 3-month history of intermittent flank pain, weight loss and generalised weakness. His imaging demonstrated bilateral adrenal masses on ultrasonography and contrast-enhanced CT scan. The initial impression was adrenal cancer, however, fine-needle aspiration cytology revealed the presence of yeast cells and blood culture grew Histoplasma capsulatum The diagnosis of the case represents a diagnostic challenge in immunocompetent individuals because they manifest with non-specific symptoms. A heightened suspicion is therefore needed to prevent significant morbidity and mortality.

Development of a Patient Decision Aid for the Treatment of Osteoporosis Among Filipino Postmenopausal Women.

BACKGROUND: Guidelines for osteoporosis have provided recommendations on when to offer pharmacologic management for postmenopausal women, but do not specify which "best" medication to start. The choice of therapy depends on the efficacy, safety/tolerability of the drug and the patient's profile and preferences. Patient decision aids (PtDA) are tools designed to facilitate shared decision-making (SDM) between the patient and health care provider for conditions where there are several available options, and the "best" choice is unclear. We aimed to develop a culturally acceptable patient decision aid on the treatment of osteoporosis among Filipino postmenopausal women at risk of osteoporotic fractures. METHODOLOGY: A qualitative approach and an iterative process was employed in this study following the guidance of the International Patient Decision Aid Standards (IPDAS). Phase 1 (Needs Assessment) involved interviews with 8 physicians who are involved in the care of women with osteoporosis and focus group discussions with 19 postmenopausal women with osteoporosis who have received treatment. Phase 2 (PtDA Development) involved a systematic review of evidence and development of an initial prototype through several iterations with an expert panel. The final prototype was pilot tested in actual clinical encounters (Phase 3). RESULTS: The final PtDA consists of 6 laminated flashcards, which illustrate the different considerations that are important to patients when selecting an anti-osteoporosis treatment (efficacy, method, frequency of administration, side effects and cost), and a fracture worksheet to illustrate individualized effects of the treatments on the patient's fracture risk. These are accompanied by a clinician guide on how to use the PtDA during consultations, which includes information on non-pharmacologic management of osteoporosis. The PtDA was acceptable to physicians and patients. CONCLUSION: With the integration of decisional needs assessment, clinical expertise, user preference and iterative revision testing, we were able to develop a culturally adapted PtDA on the treatment of osteoporosis among Filipino postmenopausal woman at risk of osteoporotic fractures for use during clinical encounters.

Management of Hydrocephalus in Paget's Disease of Bone: Systematic Review and Illustrative Case.

OBJECTIVE: Paget's disease of the bone (PDB) is a focal bone disorder characterized by excessive resorption and deposition of pathologic bone. It can involve the skull and cause neurologic dysfunction. Hydrocephalus occurring as a complication has also been reported. However, owing to its rarity, the optimal treatment has not yet been determined. METHODS: We report the case of a 60-year-old woman with a diagnosis of PDB who had presented with symptomatic hydrocephalus and was successfully treated with ventriculoperitoneal shunt insertion. We also performed a systematic review of the Scopus and PubMed databases for case reports and series documenting patients with PDB complicated by hydrocephalus and discussed the clinical features and therapeutic strategies used. RESULTS: We found 28 cases of PDB complicated by hydrocephalus in reported studies, including the present case. The median age was 67 years (range, 48-85 years; interquartile range, 7 years), with a female sex predilection. The most common neurologic manifestations were cognitive impairment, gait unsteadiness, urinary incontinence, hearing loss, and headache. Surgery had been performed in 73% of the 28 cases. The most common operation was insertion of a ventriculoperitoneal shunt (63.2%). Cerebrospinal fluid diversion resulted in significant or complete neurologic recovery in 78.9% of the 28 patients. Posterior fossa decompression was performed in 15.8% of operative cases but did not significantly alter the clinical course. CONCLUSION: Patients with hydrocephalus occurring as a complication of PDB will most commonly present with cognitive impairment, gait unsteadiness, and urinary incontinence. Surgery plays an important role in the treatment, with CSF diversion procedures resulting in significant neurologic recovery in most cases.

Development of a Patient Decision Aid on the Choice of Diabetes Medication for Filipino Patients with Type 2 Diabetes Mellitus.

OBJECTIVE: To develop a locally adapted patient decision aid (PtDA) on treatment intensification among Filipino patients with Type 2 Diabetes Mellitus and to test the feasibility of using PtDAs in a low middle-income country. METHODOLOGY: A qualitative approach and an iterative process of development of a PtDA were employed for this study. We describe the process of developing a Filipino version of the Diabetes Medication Decision Aid. This PtDA was designed to help the patient choose the appropriate treatment intensification based on his own values and preferences, in consultation with his physician. The process involved decisional needs assessment through focus group discussions and key informant interviews, systematic literature review, iterative process of the development of a PtDA with clinical encounters (pilot testing), and preliminary field testing. RESULTS: Decisional needs assessment revealed that Filipino patients are open to participate in shared decision-making if given the opportunity, including those with low socioeconomic status who likely have low health literacy. Physicians prefer to have visual aid tools to help them support their patient's decision-making. A PtDA prototype of a set of flash cards in Filipino was created and revised in an iterative method. We developed a more visually appealing tool after inputs from the expert panel and patient advisory group. Its use during clinical encounters provided additional insights from patients and clinicians on how to improve the PtDA. Preliminary field testing showed that its use is feasible in the target patient population. CONCLUSION: Filipino patients, clinicians, and diabetes nurse educators have contributed to the creation of the first Filipino PtDA for diabetes treatment intensification.

Glucosuria without diabetes: key to the diagnosis of fragility fractures due to Fanconi syndrome.

A 64-year-old woman had fragility fractures which caused her to have gross deformities and confined her to bed. These were initially ascribed to vitamin D deficiency. However, despite correction of the deficiency, she did not improve. A review of previous records already showed glucosuria in the absence of diabetes, but this finding was overlooked. Eight years into the disease, it was realised that the glucosuria despite normal blood sugar could also mean that the patient was losing other substances needed for proper bone formation. Further investigations showed hypophosphataemia, renal phosphate wasting, hypokalaemia, mild metabolic acidosis, alkaline urine pH, hypouricaemia and aminoaciduria, all compatible with a proximal renal tubular defect (Fanconi syndrome). The fragility fractures were due to poor bone mineralisation because of hypophosphataemia induced by the inability of the kidneys to conserve phosphorus.

Successful treatment of tumour-induced osteomalacia after resection of an oral peripheral ossifying fibroma.

Tumour-induced osteomalacia is a paraneoplastic syndrome wherein bone is affected by a hormone from a tumour that causes renal phosphate wasting and hypophosphataemia. Here, we present the case of a 31-year-old man who has been suffering from generalised bone pains and a spine deformity that led to loss of height. Pertinent findings are low serum phosphorus, low vitamin D and decreased bone mineral density. These findings led to a diagnosis of osteomalacia. However, the finding of an oral mass raised some questions as to what role it plays in the patient's disease. It was suspected that the oral mass (fibroma) was producing a hormone that led to renal phosphate wasting, hypophosphataemia and then osteomalacia. This hypothesis was proven after surgical removal of the mass led to normalisation of the metabolic derangements and eventually led to a resolution of the bone pains.

Pituitary Abscess Mimicking a Pituitary Adenoma Presenting with Secondary Amenorrhea and Blurring of Vision: A Case Report.

Pituitary abscess is a rare condition. It can present with hormonal deficiencies and may affect reproductive health. We present a case of a 43-year-old female presenting with bitemporal hemianopsia and amenorrhea. Imaging of the pituitary showed a sellar-suprasellar mass 2.6 x 2.4 x 1.8 cm with an enhancing nodular component. Pre-operative diagnosis was pituitary adenoma with panhypopituitarism and compression of the optic chiasm. The patient underwent transsphenoidal excision of the tumor. Intraoperative findings revealed purulent fluid consistent with pituitary abscess. There was immediate improvement of vision post operatively. She did not develop diabetes insipidus. Gram stain showed polymorphonuclear (PMN) cells 0-1 per oil immersion field (OIF) and Gram-positive cocci 0-1 per OFI, however there was no growth on culture. The abscess was also negative for acid-fast bacilli and was negative on polymerase chain reaction. Histopathologic evaluation showed benign cyst contents. The patient was treated with ceftriaxone 2 grams every 12 hours for 14 days and was eventually discharged with prednisone and levothyroxine. Pituitary abscess is an important differential diagnosis for sellar and suprasellar masses. There are no specific clinical and radiologic features that will enable a preoperative diagnosis of pituitary abscess.

Effectiveness of a community-based diabetes self-management education (DSME) program in a rural agricultural setting.

Introduction The purpose of this study is to assess the effectiveness of diabetes self-management education (DSME) in a rural agricultural town. METHODS: In this prospective, education-intervention trial, 85 adults with type 2 diabetes mellitus from villages randomly assigned to DSME and 70 from villages assigned to standard care participated. The DSME group underwent a curriculum delivered by peer educators; those in the standard group received usual advice. Outcome measures were anthropometric, biochemical, health behaviors, and medication use data taken at baseline then after three and six months. RESULTS: DSME group had a lower median A1C after three and six months. After six months, there was a 0.5% median A1C reduction in DSME group and a 0.25% increase in the standard group. There were more participants in DSME group with A1C ⩽7.0% after three and six months. By the third month, there were more participants in DSME group performing foot examination. CONCLUSION: DSME in this rural agricultural town improved glycemic control and promoted foot examination.

Multiple brown tumours from parathyroid carcinoma.

We report a case of a 29-year-old woman who suffered from severe bilateral inguinal pain and left mandibular mass. CT scan showed innumerable expansile osteolytic bone masses on the iliac wings, femur, ribs and vertebral bodies, diffuse skeletal osteopaenia, calyceal lithiasis on the right kidney and a left thyroid mass. Ionised calcium and intact parathyroid hormone (PTH) were elevated. Parathyroid sestamibi scan showed a hyperfunctioning left inferior parathyroid gland. Biopsy of the left mandibular mass was consistent with brown tumour. The patient underwent parathyroidectomy of the enlarged parathyroid gland. Final histopathology, however, revealed parathyroid carcinoma, 4.7 cm in widest dimension, with capsular and vascular space invasion. The patient underwent repeat surgery, specifically, left thyroid lobectomy, isthmectomy and central node dissection. Intact PTH decreased from 681.3 to 74 pg/mL (normal range: 10-65) 24 hours postoperatively. Follow-up at 6 months showed normal serum calcium levels, size reduction of bone lesions and improvement of quality of life.

A malignant cause of hypoglycaemia: a metastatic insulin-secreting pancreatic neuroendocrine carcinoma.

Most cases of insulinomas are benign. We report a case of a malignant form of insulinoma. A 46-year-old man presented with behavioural changes associated with hypoglycaemia. Diagnostic work up revealed high serum insulin, high C-peptide and low glucose levels, compatible with endogenous hyperinsulinaemic hypoglycaemia. CT imaging of the abdomen revealed a pancreatic head mass and multiple liver masses. Biopsy of the pancreatic mass revealed a grade three pancreatic neuroendocrine carcinoma. Histological analysis of a liver mass showed that it was identical to the pancreatic mass, confirming its metastatic nature. The patient underwent distal pancreatectomy with en bloc splenectomy. There was persistence of hypoglycaemic symptoms after removal of the pancreatic mass, suggesting that the liver metastases were also functioning. Symptoms were controlled by diazoxide and octreotide long-acting release. The patient is already 1 year postsurgery with no recurrence of severe hypoglycaemia, and he has good functional capacity and has returned to his office job.

Assessment of physical activity level among patients with type 2 diabetes mellitus at the UP-Philippine General Hospital diabetes clinic / Journal of the ASEAN Federation of Endocrine Societies

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> Physical activity is an important factor in reducing morbidity from type 2 diabetes mellitus and maintaining quality of life. There is no available data on physical activity among Filipino patients with type 2 diabetes mellitus.<br /><strong>OBJECTIVES:</strong> The objectives are to assess the physical activity level of patients with type 2 diabetes mellitus at the UP-PGH Diabetes Clinic using Global Physical Activity Questionnaire and to determine the relationship between physical activity, health profiles and socio-demographic characteristics.<br /><strong>METHODOLOGY:</strong> A cross-sectional study was conducted to assess the physical activity levels of 151 patients with type 2 diabetes mellitus (46 men and 105 women) using GPAQ. Anthropometric measurements, socio-demographic profiles and HbA1c were also taken.<br /><strong>RESULTS:</strong> Majority of subjects had moderate to high physical activity (68.9%) and most of the patients had poor glycemic control based on HbA1c of ?7% (68.2%). Subjects aged 60 years and above (68.1%; p=0.022) and with poor glycemic control (89.4%; p=<0.001) had low physical activity level. There is no significant statistical correlation between physical activity, anthropometric profile and other socio-demographic characteristics.<br /><strong>CONCLUSION:</strong> Majority of the patients with type 2 diabetes mellitus at the UP-PGH Diabetes Clinic had moderate to high physical activity level. Subjects with poor glycemic control and older age group were associated with low physical activity.<strong><br /></strong></p>

Low indices of overweight and obesity are associated with cardiometabolic diseases among adult Filipinos in a rural community / Journal of the ASEAN Federation of Endocrine Societies

@#<p style="text-align: justify;"><strong>OBJECTIVES:</strong> To determine cut-off levels of body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) for overweight/obesity associated with cardiometabolic diseases (CMDs) among adult Filipinos in a rural community.<br /><strong>METHODOLOGY:</strong> This community-based cross-sectional observational study utilized data from our Phase II of Diabetes Self-Management Education Program in San Juan, Batangas, Philippines. It included 332 Filipino adults with no known illnesses and residing for at least 6 months in the rural communities. Optimal cut-offs were determined by the intersection of sensitivity and specificity curves of having at least 1 or 2 CMDs.<br /><strong>RESULTS:</strong> The study population included 332 participants (72.3% females). Mean BMI, WC and WHR were 23.5 kg/m2, 79.5 cm and 0.87 respectively. Twenty eight percent, 11.1%, 78.3% and 85.8% of the participants have hypertension, diabetes, dyslipidemia, and at least 1 CMD respectively. The optimal cut-off for overweight/obesity and central obesity in males and females are BMI of 24 and 23 kg/m2, WC of 84 and 77 cm, and WHR 0.91 and 0.85 respectively.<br /><strong>CONCLUSION:</strong> Similar to other Asian countries, cut-off levels for overweight, obesity, and central obesity associated with CMDs are lower than the currently recommended cut-offs among Filipino adults in rural communities, particularly for WC in both sexes.</p>

Development and validation of a thyroid cancer-specific health-related quality of life questionnaire for adult Filipinos with differentiated thyroid cancer / Journal of the ASEAN Federation of Endocrine Societies

@#<p style="text-align: justify;"><strong>OBJECTIVES:</strong> The study aims to develop and validate a health-related quality of life (HRQoL) questionnaire for adult Filipinos with differentiated thyroid cancer (DTC) that can be used in combination with the European Organization for Research and Treatment of Cancer QLQ-C30 Questionnaire.<br /><strong>METHODOLOGY:</strong> The study had 4 phases. Phase I involved generation of HRQoL issues from literature review, focus group discussions with 6 DTC patients and 5 health care professionals (HCP). Subsequent assessment for relevance and importance of the HRQoL issues by 20 patients and HCP panel was done. Phase II was formulation of the HRQoL issues into questionnaire and subsequent translation into Filipino. Phase III was pilot testing of the questionnaire in 15 patients. Phase IV was validation of the pre-final questionnaire in 231 patients.<br /><strong>RESULTS:</strong> In Phase I, 28 HRQoL issues were generated. In Phase II, a 28-item Filipino questionnaire was created. In Phase III, 22 items that were not upsetting or confusing to patients and with good range of responses were retained. After Phase IV, a 22-item questionnaire with 5 conceptual scales (perceived fears, psychological distress/anxiety, functionality, voice complaints, neck complaints) was created.<br /><strong>CONCLUSIONS:</strong> The developed and validated 22-item questionnaire can be used to assess HRQoL issues in adult Filipinos with DTC.</p>