September 2008 News

BMS Champions in Socio-cultural Night

(September 2008)

As this year’s Laguna Medical Society themes the Socio-cultural Night with “Hollywood Silverscreen” Movies held last September 19, 2008 at the Performing Arts Theater of the University of Perpetual Help Laguna, numerous “celebrity” MDs filled the evening with glamour and vibe.

With former PMA President Dr Jose Sabili as one of the guests and judges, presidents and members of the various medical societies in the Laguna Province attended the affair as well, once more exhibiting the versatile physicians’ talents amidst busy schedules.

The Biñan Medical Society garnered First Place for presenting their own rendition of “Mamma Mia”, dancing and singing to ABBA songs such as “Dancing Queen”, “Honey, Honey”, “S.O.S”, and “The Winner Takes it All”.

With its main cast fully-costumed in glittery gold and multi-colored satin,

Dr. Marcus Brillantes and Dr. MariRose Ramos were both awarded Stars of the Night while our very own Chair Dr. Amelita Brillantes and BMS President

Dr. Jocelyn Rosales portrayed the role of Meryl Streep’s bestfriends. Residents, UPH Graduates, Consultants including former BMS President

Dr. Jun Lasala danced delightfully to the colorful choreography of Arnel.

Running 2^nd Place is Sta. Cruz Medical Society’s “All That Jazz”, followed by Calamba Medical Society’s “Grease”. Makiling Medical Society partied up to “Saturday Night Fever”, San Pedro Society sexily presented “Cabaret”, while Sta. Rosa Laguna offered a pop and upbeat “Highschool Musical”.

Solvay Pharma Inc. was sponsor in the event while venue was made available thru the assistance of Dr. Anna Sofia Victoria T. Salazar-Fajardo.

The Champion, “Mamma Mia”, will present its musical play once again on September 26, 2008 at Manila Pavilion for the Fellowship Night of the Medicine Week. Voules vous! Keep up the good work, vibrant Biñan Medical Society!

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Asian Hospital Holds 2^nd Post-Graduate Course:

Dr. Brillantes as Guest Speaker

(September 2008)

As the Southern Tagalog region beams with a great array of medical centers and health experts, the Asian Hospital and Medical Center together with our institution take part in this lead. In its 2^nd Post-graduate Course held last September 17-18, 2008 at The Palms Country Club in Alabang with the theme “Hot Topics in Outpatient Medicine”, topics such as PTB, vaccination for all ages, outpatient asthma management, cancer screening and prevention, and many more were highlighted and reviewed.

Our Chair Dr. Amelita Catalan- Brillantes was invited as guest speaker on “Lipid Management updates: Targeting beyond just LDL” where she emphasized on the importance of raising patients; HDL levels aside from lowering triglycerides and LDL cholesterol through the help of the long-studied drug nicotinic acid (Niacin).

The Coronary Disease Project (CDP) spearheaded by Merck Sharp and Dohme (MSD) highlights the re-entry of Niacin as a prime cholesterol-lowering agent which may be combined with statins.

When asked on how Niacin can be used for chronic kidney disease (CKD) patients, Dr. Brillantes noted that although there are no really randomized control trials, based on expert experience, “it would not be wise to remove these medications once the patent has been started on it prior to the CKD.” She, however, raised the already evident need to take particular care in using multiple agents in patients with CKD to prevent further complications.

Combination of Niacin whether with statins or fibrates has been another area of debate. Dr. Brillantes recalled that although there are no hard and fast rules as to whether fibrates should be prioritized over statin-niacin combination, she prefers using two agents with two different mechanisms of action to effect potentiation, thus, niacin with statins. Also citing the CDP study of MSD, she mentions mortality rates were tremendously decreased by 11% by using even niacin alone and that even though past studies have shown fear on the use of Niacin due to its major side effect - flushing, MSD is currently coming out with several researches into developing extended-release reformulations to possibly improve its delivery.

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Thoughts on my way to work: “Make Them Happy And You Make Them Good”
By Dr Amelita C. Brillantes

January 2009

The summer after graduation from Grade VII, our year book ASSUMPTA 1976 became one of my favorite reading materials. In it were our pictures in gala uniform, our formal names (Amelita Geisha Catalan y Levardo), birthdays, addresses, ambitions, and a quote from each of us.

“Make them happy and you make them good” was a quote from a classmate who was a quite, simple, ordinary girl - much like me. What kind of a quote is that, I thought. How unsophisticated. Unlike one that says “I cried and cried because I had no shoes, until I saw a man who had no feet” or the other one “God, grant me the courage to change the things that I can change, the serenity to accept the things that I cannot change, and the wisdom to know the difference.” Wow. To a 13 yr old, those words were profound.

Over the years, I have come to appreciate the depth and veracity of such a simple quote. “Make them happy and you make them good.” When one is “happy”, it is because one is at peace with himself- and one is able to be more loving and understanding, able to overlook another’s fault, and focus on what is good and positive. One would be more willing and able to forgive.

When one is un”happy”- one tends to be hypercritical over minute mistakes, easily provoked, unreasonable, explosive. One will tend to gloss over negatives, unwilling or unable to forgive. The days when one is at odds with one’s neighbors, those are the days when one is most at odds with himself. One simply cannot give what one does not have.

Gawad Kalinga reports a decrease in crime rates and increased productivity among recipients of their housing projects. It may be not only because their dignities has been restored with decent homes, but also because they are “made happy” to be recipients of such a package of love and care.

Of course human happiness is not a permanent static state. Nor is it something you wish for then sit waiting till kingdom come for it to alight on you. I am coming to realize that happiness is actually a choice. There will always be negatives and irritants in life. On the way to work, there is the driver who recklessly cuts into your lane who manages to wreck your mood and your day- if you so allow it. And yet there are the other hundreds of motorists who stick to their lanes and who follow the rules allowing orderly movement of traffic. They never ever manage to enter our consciousness, entirely eclipsed by the one reckless driver. In the clinic there is the arrogant patient with their hundred-and-one questions, fresh from browsing the internet about their diseases, challenging our decisions every step of the way. They always manage to disrupt our peace, if we let them. Along side them are the many more patients who put their trust and their lives into our hands who come bearing gifts from bags, shoes and perfumes to baskets of balut and itlog na pula in thanksgiving for us saving their lives. At home there is the yaya who never seems to get what we want, along side the other yayas who are efficient, loyal, and able to anticipate our needs even before we need them. It is only a matter of choosing who to look at and who to relegate to our peripheral vision; which memories to store and which to delete; which messages to save, which to erase.

I read somewhere recently: Happiness needs to be practiced, like the violin. How true!

Thoughts on my way to work: on Children

By Amelita C. Brillantes, MD

(Previously Published in the PHA Newsletter)

In the afternoons when I go down from my Silang clinic, the street is already teeming with vendors with merchandise of all sorts: fresh vegetables, hairpins and ornaments, cell phone accessories, slippers, shiny wall-sized posters unmistakably made in China. Last Monday, as I walked to the car, I was tempted by the array of ripe red tomatoes which made me think of making salsa so I stopped to buy. The tomatoes were sold to me by a young girl about 10 years old, with straight black hair held back by a pink headband, still chubby cheek, keen intelligent eyes and an honest disarming smile. During the customary haggling, I learned that she just got off from school. Her name Marlen, the sixth of nine (!) siblings. Her parents who are also vegetable vendor were in another puwesto somewhere in the vicinity.

In the car on the way home, I can’t stop brooding over the fact that this very young girl is out there selling tomatoes for a living, learning the way of the world at such a tender age, and she didn’t seem to mind. Still practically a baby and a girl at that, there she was – already a merchant out in the crowded street, dealing with strangers, handling money loaded with “germs” , when she should be home playing with Barbie dolls.

That set me off to thinking about our own children. At 10, our children would still be safely cocooned in their soft safe, “sterile” world: driven to and from school with yaya in tow, not allowed to go out of the gate by themselves, not allowed to talk with strangers, and they’d only have the faintest idea about money since they are given everything they need. Our children would generally be shielded from the bad news of the world. They’d only hear of harsh bites bit-by-bit from TV Patrol, and are gently eased into the adult world with firm, supportive hands.

Would the child vendor be better equipped in becoming a full-fledged adult? Or is she greatly disadvantaged by the early loss of her childhood? What about the internists’ child? Will material adequacy always give them an edge in life? Or will their Polly pockets and their PSPs do them a disservice by lulling them into complacency and dependency? Jose Rizal who was sent to a boarding school and traveled over Europe became a national hero, just like Andres Bonifacio who sold abaca fans as a child.

As parents, we will do all we humanly can to lead our offspring to the right path. Then we can only hope and pray that whatever strategy we use will work. In the end, we will be comforted by the thought that our children are their own persons. We can try to mold, train, suggest, recommend, but ultimately they will make their own choices, just as we ourselves do.

ACLS

Advanced Cardiac Life Support Seminar held

Rene Librojo,MD,FPCP,FPCC

The UPH – Dr. Jose G. Tamayo Medical Center’s Department of Internal Medicine, in cooperation with the Philippine Heart Association, Southern Tagalog Chapter (PHA STC) and Philippine Heart Association Council for CPR held a succesful 2 day Advanced Cardiac Life Support seminar (ACLS) on January 27-28, 2007 at the Medicine Auditorium, University of Perpetual Help College of Medicine-Biñan Laguna. Council Head Raul Ramboyong, MD with PHA-STC President Nanette Rey,MD and Scientific committee head Amelita Brillantes,MD headed the organizing committee. Lectures and facilitators were Drs. Raul Ramboyong, Jenny Beltran, John Paul So, Amelita Brillantes, Marian Almazan, Albert Bautista, and Mr. Reynaldo Grande.

There were 50 participants mostly doctors, nurses and health care professionals from nearby hospitals in the area who were given lectures and hands-on workshop on the new recommendations and techniques of ACLS. The Department of Medicine plans to do this annually to help health care professionals and students of UPH and health care workers of other hospitals be trained & updated on the proper and new recommendations of ACLS.

ETO's Corner

Dr. Rhodora D. Valenzona

Executive Training Officer

Presently the department has the most number of residents in UPH-DJGTMC (Binan). The Department of Internal Medicine has filled 8 of the 9 slots allotted for its residents. This comes at a time when most other hospitals with a residency training program are facing a “crisis” in terms of applicants for residency training.

Like a phoenix rising from the ashes, it is not only the “numbers” that we are proud of, our present crop of residents are among the “cream of the crop” in terms of academic standing during their years as medical students.

The rising phoenix, which is our department, has made its presence felt by reaping awards in the Interdepartmental Residents Research Paper presentation for the last two years. We have in fat started testing the waters outside our institution by joining interhospital competitions – warming up for that big win.(!)

HARRISONS’ CLUB

Our goal after achieving full accreditation – residents’ passing the PCP Board exam! Done every Wednesday (hopefully!). a consultant moderates each fora with the residents giving a synopsis of assigned chapters of Harrisons’. Post-tests are given after each sessions.

IM ICU LINE and IM WARD LINE

Better communication to achieve better interaction between residents and consultants with the ultimate goal of better patient care and monitoring. It is with this in mind that the department now has two cellphone lines for the residents. One for use in the ICU and one in the wards. The IM ICU line is 0917-8592286 and the IM Ward Line is 0917-8592285. Consultants are encouraged to use these lines for faster communication with the residents. The IM ICU line is always with the ICU Officer-on-duty while the IM Ward line is always with the ward resident-on-duty. For concerns with the ER IM resident-on-duty, consultants are requested to use the landline number of UPHMC.

Grey Matters

By: Dr. Rosalina Espiritu-Picar

THE BRAIN WAVE MACHINE

The Medical Center recently launched our very own Electroencephalography Unit at Suite 411. The EEG is an important diagnostic tool as it gives us a glimpse into the functioning of the brain.

The EEG records the cortical nerve cell excitatory and inhibitory postsynaptic potentials as they are transmitted through the cortex and picked up by surface electrodes. It is a totally painless and non-invasive procedure making it ideal for infants up to the geriatric population

The main indication for the EEG is the evaluation of paroxysmal disorders such as epilepsies, syncope and headache. Recently, it has also been discovered to be helpful in diagnosing a myriad of diseases ranging from differentiating organic from psychiatric disorders, transient ischemic attacks from seizures as well as the documentation of brain death.

The addition of the EEG unit to our diagnostic capabilities will guarantee a more comprehensive assessment and treatment of our patients.

Neuro-NewsBits

Dr. Rey Murillo lectures on Headache

by Marie Grace Almarinez, MD

It was a day for ‘head check’ during Dr Rey Murillo’s special lecture on “Headache: Various Types and Management”, rendered last February 27, 2007 at the Medicine Lounge. The Department of Internal Medicine’s Consultants, Residents, Interns and Clerks, attended the lecture where a

review of the clinical presentations of various types of headache and their respective management were presented.

Dr. Murillo, one of only few Internist-Neurologists in the whole of Laguna and a Professor in Neurology at the College of Medicine, noted that headache, one of the most common complaints presented by patients consulting at a Neurologist’s or any Internist’s office for that matter, deserves thorough examination from funduscopy to simple muscle tension evaluation. The lecture included a list of medications available, given according to severity of migraine headaches, tension headache, or even plain muscle spasms. He reiterated that radiologic diagnostic tests such as Head CT Scan or MRI with contrast are available options for patients needing further assessment to rule out probable malignancies, arterio-venous malformations and the like.

Bronchial THree

By: Felicitos A. Obillo, MD

ASTHMA- New classification, Simplified Guidelines

The Global Initiative for Asthma (GINA) recently revised its classification. GINA 2004 previously classified asthma by severity (traditionally by the degree of symptoms, airflow limitation, and lung function variability) – as intermittent, mild persistent, moderate persistent or severe persistent. GINA 2006 now classifies asthma by level of control: controlled, partly controlled, and uncontrolled. This classification recognizes that asthma severity involves both the severity of the underlying disease and its responsiveness to treatment. A stepwise approach is used to classify severity; guide treatment, and assess, achieve and maintain control. The number and frequency of medication increase as the need for asthma therapy increases, and decrease when asthma is under control. The Asthma Control Test (ACT) is a validated measure that is used for assessment of clinical control and can be easily applied to our patients in the clinic.

The GINA was created to increase awareness of asthma among health professional, public health authorities, and the general public, to improve prevention and management through a concerted worldwide effort.

A Pocket Guide for physicians and nurses of GINA 2006 is available upon request.

Pulmo Lab Potpourris

Effective last Feb 15, the laboratory started using new ABG forms. Aside from improving its aesthetic look, the new format contains additional information (A-a DO2, a-A, P/F ratio) which may effectively guide a clinician in the assessment of mechanically-ventilated and other critically-ill patients in the ICU. The new form was approved by the Hospital Administrator. Official interpretation is done by the pulmonary consultants on a rotation basis.

And last march 1, a new RT staff was appointed in the laboratory. He was selected from five applicants who underwent a rigid screening process – one written examination and three interviews. The vacancy in the department was created by yet another resignation, that of our Chief RT who qualified for work abroad. While I cannot blame the RTs to seek greener pastures elsewhere as they also seek to provide for a better future for themselves and their families, I have been witness to this evolving pattern over the past few years. As we continue to lose some of our bright and promising staff RTs we continue to search for new talents and seek to employ.

them in our hope that they will continue to maintain if not to upgrade the standard of quality care and service they provide to our patients.

The Pulmonary Laboratory is currently staffed by a director, three Assistant Directors, a Technical Director, a Chief RT, and seven staff RTs. Occasionally, volunteer RTs – graduates who seek experience and further training - work in the laboratory for six months. A certificate is issued after a satisfactory stay. Assistant Directors are Drs. Geraldine Almarinez-So, Ariel Boongaling, and Carol Mendoza. Dra. Ge handles CME and training of the Department. Dr. Ariel - Asthma Education Program under the National Asthma Movement (NAM) and Dra. Carol is in-charge of the PPMD TB-DOTS program.

It is through the combined effort of the staff that the programs of the department are carried out. Keep up the good work!

PCCP Convention

The Philippine College of Chest Physicians held its 26^th Annual Chest Convention last March 6-9, 2007 at the Sofitel Phil. Plaza, CCP Complex Pasay City. The theme of the convention was “Synergy Integration in Chest Medicine.” Invited foreign speaker were ATUL MEHTA, MD, MBBS who gave updates on flexible bronchoscopy; and Professor PETER GIBSON, on asthma. Outstanding local speakers also served as faculty in the other sessions. The event found a new venue, a refreshing change, after spending many years at the Shangri-La EDSA Hotel.

What’s in a title?

Yes of course, the “BRONCHIAL THREE” refers to us three adult pulmonary consultants in the Department of Medicine---Ge, Ariel, and myself. With due respect to our fourth member, Dra. Carol Mendoza (Pedia) from whom we asked permission - this column could have been entitled: “Stage 1V” (with some misgivings). They will also share their thoughts and insights in future issues.

RHEUMATalk

By: Armando C. Lontoc, MD

The Rebirth of Rheumatology Section of the UPHMC Department of Medicine

It was barely a month after my PRA subspecialty board examination in May 2006 that I decided to submit my application as a visiting consultant in the department. It was really my plan to be accredited, UPHMC being the closest hospital from where I stay (Carmona, Cavite). I was met by Dra. Rhodora “Doray” De Lara-Valenzona, who is the present training officer and the acting chairman during that time in the absence of Dra. Elizabeth Carreon who chairs the department. “Approved! No need for an interview” was the first statement I heard from her. The department is in need of a rheumatologist and my coming in was such a perfect timing. Shortly thereafter, I was asked to meet Dr. Umil who encouraged me to be an active staff of the department instead of just a visiting consultant. I was immediately invited in the department’s weekly conference to be introduced to the consultants, residents and medical students. Eventually, I was asked to lecture for them and later teach the subject for the medical students in the college and the rest is history.

Based on my previous conversations with the other consultants, I learned that Dr. Perry Tan, (the immediate past president of PRA) used to be connected with the department but not for a long time. Then Dra. Vinny Mina, who is now based mainly at Binan Doctors’ Hospital, was also asked to see rheumatology referrals/patients/cases until my arrival.

Rheumatology is one subspecialty where there are only less than a hundred consultants nationwide. And so, there are still places in the country where no rheumatologist attends properly to patients with arthritic conditions and other connective tissue diseases. Many of us think this way, “arthritis lang yan, NSAIDs or steroids lang ang gamot dyan!” There are a lot of misconceptions. Generalizations are common, and therefore, mismanagements are likewise committed. With over a hundred kinds of arthritis, identification of specific type is important. And rheumatology is not all about arthritis per se but it is also concerned with other systemic diseases, which more often than not, we are called at the very end when everything cannot be explained and seems not to be compatible with a much more common disease. Rheumatology is one such dynamic field with several researches in the offing. Expect more updates in the coming articles

Renal Output

By: Dr. Rene V. Baltazar

THE AILING KIDNEY

Some very common chronic disorders, which we usually encounter in clinical practice may predispose to chronic renal failure. These chronic illnesses include diabetes mellitus, hypertension, glomerulonephritis and gout to name a few. A majority of these chronic renal failure patients progressed relentlessly to end stage renal failure (ESRD). A small percentage appears to lose their renal function at constant fracture rate hence a stable renal function for a sustained period of time. However, they seem to have a breakpoint in the disease course suggesting an acceleration of the rate of progression of their renal insufficiency. This breakpoint could either be spontaneous or secondary to such events as infection, dehydration, uncontrolled blood pressure, intrarenal precipitation of uric acid or calcium and drugs that can worsen intraglomerular hypertension and alter prostaglandin synthesis. Hence these secondary factors have to be corrected or modified in order to prevent these renal failure patients from going to end stage renal failure.

Progression to end stage renal failure necessitates dialysis and eventually renal transplantation. These have been a marked increase in the incidence of ESRD around the world, including the Philippines. These were 5,605 new patients in dialysis per year according to the Philippine Renal Disease Registry report for 2005. The prevalence of ESRD is this country is approximately 68 patients per million. These are now over 290 dialysis centers nationwide catering to hemodialysis and peritoneal dialysis. About 56% of ESRD patients received dialytic therapy compared with 52% in 2003. Diabetic nephropathy continues to be the leading cause of ESRD and the figure is still rising. This is followed by chronic glomerulonephritis and hypertensive nephrosclerosis. Majority of these ESRD patients are undergoing hemodialysis. There is noted decreasing trend towards peritoneal dialysis in the nationwide registry. Very noticeable is a rapid increase in the number of dialysis units outside the national capital region. Hence, more dialysis procedures were done in the provinces throughout the country. In our center at Perpetual Help Medical Center, we have here eight machines doing over 200 treatments per month.

With the rising cost of dialysis therapy and transplantation as well as economic and productivity loss, there is now increasing awareness among the general population and caregivers in what constitute a normal renal function. Several modalities to measure renal function include urinalysis, serum urea and creatinine, creatinine clearance, glomerular filtration rate (GFR) and imaging studies. Urinalysis is a major, non – invasive diagnostic tool available to the physician. Determination of severity however, could be achieved with correlation of serum urea, creatinine, GFR, creatinine clearance and imaging studies. Exact values of GFR are not always available and are not usually needed in clinical practice. Endogenous creatinine clearance determination maybe available in most centers but the main drawback is inadequate and improper urine collection. Imaging studies are quite expensive and results are sometimes affected by technical factors.

Serum urea and creatinine determinations are easy to perform and readily available. Serum creatinine is more specific and sensitive indicator of renal disease compared with urea but the use of simultaneous urea and creatinine determination provides more information. Creatinine is endogenous substances mainly produce in muscle cells. Concentration of serum creatinine depends on its excretion which mainly reflects the GFR. However, serum creatinine is not a good marker of GFR in renal failure since tubular secretion is enhanced when renal function is reduced. Most important is the fact that production of creatinine depends on muscle mass. Therefore patients with reduced muscle mass such as in women, infants, children, elderly and patients with malnutrition may have markedly reduced renal failure but with normal values of serum creatinine.

It is therefore very important to correlate everything in determining renal function. Laboratory procedures are useful in assessing the nature and severity of renal failure. Although not a single test is really diagnostic, more precise evaluation can be made based on integration of all laboratory data. Much more important is complete comprehension of some common systemic disorders which can predispose some individuals to renal insufficiency. It is by vigilance and complete understanding of the causes of nephropathies that we can prevent and lessen the impact of chronic renal failure.

Endocrinology Updates

By: Lynn F.W. Bilar MD

INCRETIN BASED THERAPY

There is always something new in the management of type 2 diabetes. It is a never ending quest for finding new treatment modalities as we learn more about the disease. The latest is the INCRETIN BASED THERAPY. This write up is not an extensive discussion of the topic, but will just be an overview. There are 2 types of incretin based therapies, the INCRETIN MIMETICS and DPP 1V INHIBITORS.

INCRETINS are peptide hormones secreted from the GIT following ingestion that augment glucose stimulated insulin secretion. Oral glucose provokes 3-4 fold higher insulin response than an equivalent dose given intravenously. This is so because oral glucose causes release of gastrointestinal hormones principally GLP-1 (Glucagon like peptide-1) and Glucose dependent insulinotropic polypeptide (GIP 1) that augment glucose induced insulin release. This “incretin effect” is reduced in patients with type 2 diabetes. GLP 1 secretion (but not GIP 1) is impaired in patients with type 2 diabetes and when GLP 1 is infused in these patients it stimulates insulin secretion and lowers glucose levels. These represent a novel class of therapeutic agents that: targets deficient insulin secretion, reduce post prandial glucose, reduce glucagons levels, preserve/ restore beta cell mass, delays gastric emptying time and promotes satiety.

Native GLP1 and GIP in vivo are short lived (about 2 mins) due to the rapid inactivation of the proteolytic enzyme Dipeptidyl peptidase 1V. DPP 1V is expressed and can be found on the surface of various cell types including lymphocytes and epithelial cells. It is also found on the surface of the capillary endothelial cells in the vasculature of the small intestine, directly adjacent to the sites of GLP-1 and GIP secretion. Thus inhibition of DPP1V activity prevents the rapid breakdown and stabilizes the post prandial levels of bioactive endogenous Incretins thereby prolonging physiologic actions.

EXENATIDE (Exendin-4) marketed as Byetta is a GLP-1 receptor agonist isolated from the saliva of the Gila monster that is more resistant to DPP1V action. It lasts about 10 hour (vs 2 mins with native GLP-1). When given to patients by subcutaneous injection BID, this lowers blood glucose and HBa1c levels and produce weight loss of about 6-10 lbs in most patients. It can be used alone or in combination with sulfonylurea, metformin or insulin. The main side effect is nausea. This will be available in the Philippines this 2007.

Two Oral DPP 1V inhibitors are currently available, Sitagliptin (JANUVIA) which was launched over a month ago and the soon to be out Vidaglipitin (GALVUS). Sitagliptin can be used alone or in combination with Metformin or TZD. It is fairly well tolerated and is weight neutral.

References:

GREENSPAN’S BASIC AND CLINICAL ENDOCRINOLOGY

JCEM VOL 92 NO. 40

GUT Feel

By: Rogelio C. Umil, MD

FATTY LIVER AND THE METABOLIC SYNDROME

Obesity is now recognized as a major challenge to health, quality of life and longevity in the developed world. The adverse impact of overweight and obesity on the risks for cardiovascular disease, cancer and musculoskeletal disorders is well documented, especially when coupled with components of the metabolic syndrome. More recently recognized is the risk of developing end stage liver disease and hepatocellular cancer as a consequence of nonalcoholic fatty liver disease (NAFLD), the primary hepatic complication of obesity and insulin resistance. NAFLD is the most common cause of liver dysfunction and affects 10% to 24% of the general population. Although NAFLD has not been included as a component of the metabolic syndrome as it has been defined, available data indicate that the onset of NAFLD is an early event in the development of insulin resistance and might thus predict the presence or future development of the metabolic syndrome.

NAFLD is the consequence of excess triglyceride accumulation in hepatocytes in the absence of significant alcohol consumption. An exciting area of progress is in recognizing that the renin-angiotensin system (RAS) is a major modulator of insulin resistance. In one study of rats, the lower adiponectin levels and impaired insulin sensitivity appeared to be mediated by the receptor AT1 because the AT1-specific angiotensin receptor blocker (ARB) olmesartan improved NAFLD, insulin sensitivity and adiponectin levels. Moreover, a provocative study of the ARB telmisartan in fructose fed rats demonstrated that treated rats not only accumulated less fat in the liver, but that this particular ARB also increased energy expenditure and prevented weight gain. Other studies have provided new insights into mechanisms of fat accumulation in NAFLD. Resistin is an adipocyte derived peptide, or adipokine, that induces insulin resistance in all of the major targets of insulin: liver, muscle and adipose tissue. A small study of NAFLD patients treated with pioglitazone demonstrated improved insulin sensitivity and reduced resistin levels. A more recent study showed that resistin levels in humans correlate with necroinflammatory changes of NASH rather than insulin sensitivity. Another study demonstrated that circulating resistin levels in humans were elevated in patients with cirrhosis and may be a major mediator of the insulin resistance known to occur in cirrhosis. Another area of rapidly expanding knowledge is in the role of endoplasmic reticulum stress (ERS) as a cause of insulin resistance and NAFLD. The smooth endoplasmic reticulum is where proteins are processed into their final form and if the flux of proteins through the endoplasmic reticulum overwhelms its processing capacity or if defective proteins impair endoplasmic reticulum processing, a stress response can initiate the process of cellular death through apoptosis. ERS has now been implicated not only in the development of insulin resistance and diabetes, but also of various forms of liver disease including NASH. Lifestyle modifications comprising healthy eating habits and regular exercise are the primary interventions recommended to patients with NAFLD. Weight loss can be facilitated by the enteric lipase inhibitor orlistat, and a randomized clinical trial of 52 NASH patients treated for 6 months found that orlistat improved serum ALT levels and steatosis more than lifestyle modification alone. When all else fails, as it too often does, dietary portion control can be enforced by surgical alteration of the stomach (Bariatric surgery). A number of studies published just in the past year suggest that NASH improves with weight loss and improved insulin sensitivity following bariatric surgery.

Advances in our understanding of the pathogenesis of NAFLD and NASH continue to be made and give us hope that new therapeutic options will soon be available. Such options are certainly needed because of the failure or inability of many to sustain lifestyle modifications and the enormous burden of this disease in our society.

References:

1. Zandbergen AAM, Lamberts SWJ, Janssen JAMJL, et al. Short-term administration of an angiotensin-receptor antagonist in patients with impaired fasting glucose improves insulin sensitivity and increases free IGF-I. Eur J Endocrinol 2006; 155:293-296.

2. Nawrocki AR, Rajala MW, Tomas E, et al. Mice lacking adiponectin show decreased hepatic insulin sensitivity and reduced responsiveness to peroxisome proliferator-activated receptor γ agonists. J Biol Chem 2006; 281:2654-2660.

3. Ran J, Hirano T, Adachi M. Angiotensin II type 1 receptor blocker ameliorates overproduction and accumulation of triglyceride in the liver of Zucker fatty rats. Am J Physiol Endocrinol Metab 2004; 287:E227-232.

4. Aygun C, Senturk O, Hulagu S, et al. Serum levels of hepatoprotective peptide adiponectin in nonalcoholic fatty liver disease. Eur J Gastroenterol Hepatol 2006; 18:175-180.

5. Bajaj M, Suraamornkul S, Hardies LJ, et al. Plasma resistin concentration, hepatic fat content, and hepatic and peripheral insulin resistance in pioglitazone-treated type II diabetic patients. Int J Obes Relat Metab Disord 2004; 28:783-789.

6. Pagano C, Soardo G, Pilon C, et al. Increased serum resistin in nonalcoholic fatty liver disease is related to liver disease severity and not to insulin resistance. J Clin Endocrinol Metab 2006; 91:1081-1086.

7. Yagmur E, Trautwein C, Gressner AM, et al. Resistin serum levels are associated with insulin resistance, disease severity, clinical complications, and prognosis in patients with chronic liver diseases. Am J Gastroenterol 2006; 101:1244-1252.

8. Ji C, Kaplowitz N. ER stress: can the liver cope? J Hepatol 2006; 45:321-333.

9. Zelber-Sagi S, Kessler A, Brazowsky E, et al. A double-blind randomized placebo-controlled trial of orlistat for the treatment of nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2006; 4:639-644.

The Residents' Box

The University’s Medical Center and Medical University is fast becoming an International hub for aspiring doctors and even specialists. As it opens another branch in the US this year, UPHDJGT is expected to bring many opportunities for health professionals here and abroad as well.

The Department of Internal Medicine-UPHDJGT in Binan, Laguna has a total of eight residents at present. Drs. Artur Araujo and Lelanih Tangpos as 3^rd year residents, Drs. Josephine Garcia and Owen Sutarez as 2^nd year residents, and Drs. Marie Grace Almarinez, Arnold De Chavez, Jo Cris Gutierrez, and Naheeda Dimacisil as 1^st year residents.

Our featured resident for this issue is senior resident Dr. Artur Araujo, an East Timorese/Portuguese, 11^th child and only MD in their family, who believes that the Philippines can offer valuable training, whether it is in IM residency or Fellowship training. Having stayed in the country for almost 3 years now, the tall yet humble Dr. Araujo agreed to relate to us part of his personal profile, achievements and experiences in the following IMpulse interview.

ARTUR ARAUJO, M.D.

Medical School: University of Udayana Bali, Indonesia, 1987 – 1994

Positions Held:

2001 – 2003, General Practitioner Aimutin & Kuluhun Clinic, Dili, East Timor

: 2000 – 2001, Logistic & Administration Coordinator, Division of Health Services, East Timor

Medical Staff of IOM (International Organization for Migration), East Timor

: 2000, Technical Supervision and Support services, Interim Health Authority, East Timor

: 1998 – 1999, Head of Health Department, District of Bobonaro, Maliana, East Timor-Indonesia

: 1997 – 1999, Director and General Practitioner, Maliana Hospital East Timor-Indonesia

: Head of Community Health Center and General Practitioner

Why did you choose Philippines for training?

The quality of the training is good; the environment is quite similar – Sunday Church habit; the climate is the same as what we have in East Timor; and the country has a lot of tourist spots to offer.

In your years of stay as IM resident, what so far were your most memorable experiences?

When I was invited to present my case report on duodenal tuberculosis during the Philippine College of Physician’s Annual Poster Presentation which was held in Manila in 2005 and when I won 2^nd place in the UPHDJGT Annual Residents’ Paper Contest for my study on “Acquired UTI in ICU Patients at the UPHDJGT Medical Center”.

Another unforgettable experience was our participation in the 4^th Southern Luzon PCP Research Paper Contest held in Batangas last March 16, 2007 where several PCP members attended. There were a total of 4 participants: two from Mediatrix Hospital (1 research and 1 case report), a case report from De La Salle Medical Center, and yours truly from UPHDJGT.

What is your favorite pastime when away from work/ residency?

Simply visiting Laguna’s malls with friends and co-residents, and trying out restaurants which include fresh vegetables in their varied menu, such as dishes with Thailand garlic, asparagus, water cress soup, broccoli, and Taiwan pechay.

Do you have plans of staying in RP?

So far, I still do not have plans of staying in the Philippines after my residency training program. I have to go back as soon as possible because some of my friends will be leaving the country at the end of the year for their Masters Degree and Doctoral program. We are only around 40 (General Practitioners) with 1 General surgeon to serve about 1 million East Timorese countrywide. We have to cover another’s absence while some leave the country for training. Given the right time and opportunity, I will not think twice of staying longer for Fellowship training.

Views on the political crisis in East Timor?

The ongoing crisis in East Timor until now appears to have arisen from conflicting interests by some political leaders, as the island prepares itself towards proclaimed independence. The importance of the participation of the Catholic Church, the potential moderate East Timor leaders and Traditional leaders during this transition was also not given much importance, probable reason for the continued unrest. There are many other groups, ambitious and sad to say opportunistic people, who remain eager to gain the topmost post and gain monopoly in the government. We continue to hope towards improvement from within.

What is your advice to incoming IM residents, from RP or other country?

It is nice to train in the Philippines, and have another major in 1 or 2 more countries for purposes of learning through fulfilling experiences. This should be followed then by sharing what you have earned to support and assist this institution including your respective hometown institutions in going international. By doing so, the University of Perpetual Help will have a great number of alumni Internists spread all over the world in the next 15 to 20 years or maybe even sooner.

JONELTA Foundation upgrades OPD

Owen Sutarez, MD

Most residents from the Northern part of Laguna as well as in Cavite who are now bonafide members of the Drs. Jose and Josefiina “Nena” Laperal Tamayo (JONELTA) Charity Foundation can now enjoy a more comfortable consultation clinic after having transferred to the air-conditioned rooms of the Elementary building beside the medical center.

Since its initial inception in 1987 at Las Piñas by Col. Antonio L. Tamayo, eldest son of the founders, and established in Biñan on September 10, 1997, the Foundation has now over 53,000-member patient in Laguna alone. Among the benefits of the membership include free consultations at the multi-specialty Out-Patient Department, discounted laboratory work-ups and medications, free ECG and capillary blood glucose monitoring on specified days, and free dental services to name a few.

Among the qualifications for membership include that an applicant should be a resident in Laguna or Cavite and has stayed for a period of equal to more than 6 months, should have not more than worth P25, 000 pesos of total monthly family income, and has no private health card insurance. Not to mention the required need to attend orientation meetings prior to the approval of application.

Members needing hospital admission are classified from A to E, depending on their financial status and other criteria set by the Health Medical and Administrative services headed by Dr. Winnie P. Siao, Family Medicine physician and present Dean of the College of Medicine; and Mrs. Sally Dagami, respectively. Dr. Cynthia Lubaton, Endocrinologist and Professor in the College of Medicine, has been very active for the past years in her weekly Diabetes day during Thursday despite her hectic schedule in other medical institutions.

According to our Internal Medicine department census for the 5 years, Hypertension and Diabetes Mellitus rank highest in the cases seen daily at the OPD Clinics, followed by Pulmonary cases. The JONELTA OPD renders services to an average number of 90-100 patients per day.

Aside from the OPD clinics, Internal Medicine residents find great opportunity in providing charitable services to underprivileged patients while at the same time, learning further through management of different cases among patients admitted in the medical center with the supervision and guidance of their respective consultants.

Together with the upgraded UPH-DJGT diagnostic services and OPD Clinics, it is hoped that the Department of Internal Medicine will find more inspiration to continue its active participation and setting of programs for JONELTA patients together with the Departments of Pediatrics, OB-Gynecology, Family Medicine, Surgery and Anesthesiology headed by Drs. Ma. Mirasol Tuaño, Marietta Rempola, Jay Ancheta, Rex Barza, and Emar Custodio, respectively.

Charge Nurse Mary Bautista and Cashier Tess Tayoto, RN with Midwife Emer de Sagun loyally institute the rules to ensure a daily smooth-sailing OPD service. Ms. Christine Casillano, on the other hand, currently serves as the OIC and Chair of Jonelta’s Social Services, attending to patients most urgent concerns on payments and hospital bills.

The JONELTA OPD Clinic is open daily from Mondays thru Fridays, 8:00am to 5:00pm . IMpulse

IM NEWS (February-May 2007)

Department of Medicine Commemorates 28^th Anniversary

Arnold G. de Chavez, MD

The Department of Internal Medicine has come a long way from its humble beginnings almost 30 years ago. Born as a consequence of the establishment of the College of Medicine, the department was created in 1979 under the chairmanship of Dr. Raymundo Katigbak and staffed by selfless and able physicians, most of whom either have retired or moved on to greener pastures years later. Only three of the pioneer staff members remained at the helm of the department: Drs. Carmelita Fernandez, Cynthia Lubaton, and Benigno Ong. The years that followed showed the inclusion to the department an array of competent practitioners who threw in their lot of expertise in building and strengthening the department: past chairmen including Dr. Lilia Maranan, Dr. Ricardo Salonga, Dra. Baby Tamayo, Dr. Tim De Mesa, and Dra. Beth Carreon; faculty, including Dr. Nick De Jesus, Dr. Toribio Jovellanos, Dr. Ramon Javier, Dr.Bernardo Conde, Dra. Pat Mallabo, and Dra. Socorro Martinez, to name a few. The department would not be complete without the ETO’s overseeing the residency training program: the likes of Dr. Robert Guzman, Dr. De Mesa, Dr. Carl De Leon, and Dra. Rhodora Valenzona.

Making a first in its 28-year history, the Department of Internal Medicine is organizing a gathering of its more illustrious personalities who in one way or another contributed to how it came about and what it is today: pioneers, former chairmen, executive training officers, consultants, faculty, graduates, and residents. The 1^st Annual Perpetualite Internists’ Night will be held on May 4^th, 2007 at the Vivere Hotel and Suites in West Gate, Filinvest, Alabang.

In what is aimed to be an exciting and memorable night, the department set in motion its preparation for this momentous occasion with the delegation of various committees that will carry out specific functions. A key committee was tasked to produce and document interviews with former department chairmen, a job that necessitated a pairing of consultant with residents. Others were tasked to trace former faculty and graduates of the training program to document their present status. Still others were designated to man the physical aspects of the event itself: the venue, invitations, the programme, and the like.

Dr. Elizabeth Carreon, the outgoing Chairman, painstakingly prepared a presentation of past and present affiliated Internists, pioneer consultants, and memorable activities successfully instituted during her term. As Dr. Amelita Brillantes receives the upcoming responsibilities as new Chair, a new long list of programs, expected to further shape a dynamic and increasingly productive department is at hand.

Together with the celebration of the department’s foundation comes the launching of the IMpulse Newsletter, scheduled to be published bi-annually, showcasing the varied insights of our residents and present consultants. Recent updates on management protocols, residents’ viewpoint with regards the training program, and profiles of the members of the Department are some of the issues that will be brought out.