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.

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.

Where is the culprit? A case of acromegaly that defied the management algorithm.

A 30-year-old Filipino man presented with a 11-year history of coarse facial features and progressive enlargement of hands and feet. Initial work-up revealed elevated insulin-like growth factor-1 and non-suppressible growth hormone level after 75 g glucose challenge test. Initial cranial MRI performed in the year 2010 showed absence of pituitary adenoma. The patient was lost to follow-up. He again consulted in the year 2011 and a repeat cranial MRI and a dedicated pituitary MRI were performed and both did not reveal any pituitary mass. Further investigation included chest and abdominal CT scan, both of which did not show any neoplasm. At present, there has been no practice guideline on the management of acromegalic patients on whom the identifiable source cannot be found. The patient was given the option to undergo surgical exploration of the pituitary gland or medical treatment with somatostatin analogues. He decided to undergo surgery but has not given consent for the procedure.

A case of noonan syndrome associated with nephrotic syndrome, pituitary mass and pes varus

We report a case of a Filipino male diagnosed with Noonan syndrome on the basis of facial dysmorphism, chest deformity, short stature, mental and skeletal retardation, pulmonic stenosis and hypogonadism. In addition, he has three clinical features which are not known to be associated with the syndrome and are perhaps being reported for the first time:structurally normal kidneys with nephrotic syndrome, pituitary macroadenoma and pes varus.

Effect of malunggay (Moringa oleifera) capsules on lipid and glucose levels

OBJECTIVES: To determine the effect of malunggay leaf capsules on LDL (primary efficacy outcome measure); weight, BMI, FBS, serum glucose 2 hours after a 75 g oral glucose load, cholesterol, HDL and triglycerides (secondary efficacy outcome measures); creatinine, ALT and CBC (secondary safety outcome measures); and to determine if these are associated with adverse events. STUDY DESIGN: randomized controlled trial PARTICIPANTS: Seventy nine Filipinos, 18-55 years old with LDL>2.6 mmol/L (100 mg/dL) but of low cardiovascular risk were randomized into malunggay and placebo groups. INTERVENTION: Malunggay capsules for 30 days versus placebo RESULTS: 33 and 35 participants in the malunggay and placebo groups, respectively, completed the treatment. There was a reduction of 13.76 mg/dL in the LDL of the malunggay group, compared to a 19.28 mg/dL reduction in the placebo group (p=0.564). CONCLUSION: Malunggay leaf capsules given for 30 days among adults with serum LDL >2.6 mmol/L (100 mg/dL) but with low cardiovascular risk decreased LDL levels to the same degree as placebo. There were no significant differences in the change in the secondary efficacy and safety outcome measures, and in the occurence of adverse events.

46 XY gonadal dysgenesis in adulthood 'pitfalls of late diagnosis'.

Disorders of sex development (DSD) include congenital conditions where developments of chromosomal, gonadal or anatomical sex are atypical. Ostrer in 2000, reported a prevalence of 1:20 000 for 46 XY DSD and complete gonadal dysgenesis. A 21-year-old patient consulted for sexual ambiguity at the out-patient department of the Philippine general hospital. At birth, the perceived female external genitalia and clitoromegaly, led the parents to register and eventually rear the patient as a female. At puberty, he developed masculine features and growth of phallus. Patient was more interested in male activities and began to identify himself as male in the community. The discrepancy between his birth certificate and his male gender jeopardised his ambition to become a policeman; this led him to seek medical consult. On physical examination, he was phenotypically male. The external genitalia showed the phallus length of 3.5 cm and perineoscrotal hypospadias. Chromosomal sex was normal 46 XY with neither numerical nor structural aberrations in all cell lines, serum testosterone was low and gonadotrophins were elevated. Whole abdominal CT scan showed bilaterally undescended testes and a 4.5 cm blind vaginal pouch seen on genitogram. Bilateral orchidectomy with first stage repair of hypospadias was performed. On histopathology, the right testis was fibrotic and the left testis showed minimal testicular tissue with absent spermatids. The clinical, endocrine, cytogenetic and histopathologic data are consistent with gonadal dysgenesis syndrome.

Hurthle cell carcinoma of the thyroid.

A 63-year-old man consulted for a non-toxic thyroid nodule of 2 years' duration. Fine needle aspiration revealed cell findings consistent with papillary thyroid carcinoma. He eventually underwent total thyroidectomy. Microscopic examination revealed histologic features of Hurthle cell carcinoma of the thyroid. He received radioactive iodine therapy and suppressive levothyroxine treatment. Post-therapy whole body iodine-131 scan revealed thyroid tissue remnants limited to the anterior neck. Four months after radioactive iodine therapy, thyroglobulin level is low and the patient remains to have no evidence of disease.

Primary hyperparathyroidism with classic and severe skeletal involvement.

A 63-year-old woman has had multiple repeated fractures. A diagnosis of primary hyperparathyroidism (PHPT) was made after she was found to be hypercalcaemic with an elevated level of intact parathyroid hormone (iPTH). Radiographs revealed classic and severe bone findings in PHPT, features which were common in the past but are thought to be rare at this modern age. She also had nephrolithiasis and osteoporosis. An enlarged parathyroid gland was seen on ultrasound and CT scan, and hyperfunction was demonstrated by scintigraphy. Parathyroidectomy was performed. Histopathologic analysis revealed a parathyroid adenoma. She developed the hungry-bone syndrome 7 days postoperatively, which resolved with with administration of calcium and calcitriol.

Insular thyroid carcinoma in a Filipino woman.

A 30-year-old Filipino woman presented with goitre of 4 years' duration. The right thyroid lobe was enlarged with no palpable lymph nodes. She had no thyrotoxic signs and symptoms. Free thyroxine and thyrotropin were normal. Ultrasound revealed a cystic nodule on the right lobe. Fine needle aspiration biopsy was consistent with colloid nodule. She underwent right lobectomy with extended isthmusectomy. Microscopic examination of the 6.5 cm mass showed well-defined, round, nests of tumour cells surrounded by a rim of collagen. Mitotic figures and necrosis were absent. There was capsular invasion. Immunohistochemical staining was positive for thyroglobulin and negative for calcitonin. These findings gave the diagnosis of insular thyroid carcinoma. She underwent complete thyroidectomy with central node dissection. Five weeks after, she received 3700 MBq of radioactive iodine 131. Post-treatment, whole body scan revealed functioning thyroid tissue limited to the thyroid bed. The patient is on regular follow-up 2 years after diagnosis with no evidence of disease.

A giant myelolipoma discovered as an adrenal incidentaloma: radiological, endocrine and pathological evaluation.

A 51-year-old Filipino woman presenting with hypertension was unexpectedly found to have a large right adrenal mass by ultrasound. As she did not have symptoms of adrenal disease, this was labelled an adrenal incidentaloma. Ultrasound and CT imaging demonstrated a large adrenal mass on the right measuring 15 cm at its greatest diameter, with both benign and malignant features. Tests for endocrine hyperfunction (excess of cortisol, catecholamines and aldosterone) concluded that the mass was hormonally non-functioning. The patient eventually underwent open adrenalectomy. Histopathological examination revealed myelolipoma.