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