Addressing Health Concerns Interrupted by the COVID-19 Pandemic
Authors: Aguilar Juliet Sio 
Published: April 2022

As the Novel Coronavirus Disease (COVID-19) levels down to a more manageable state in the Philippines, after having logged 3,678,968 confirmed cases and 59,324 deaths from January 3, 2022, to April 2, 2022,1 the medical community exerts greater efforts toward addressing the health concerns hindered by the demands of the global scourge. With the 7-day moving average of 378 new cases as of March 20, 2022, a weekly positivity rate of 2.0% out of the 125,107 samples tested as reported on March 27, 2022, and the COVID-19 hospital bed utilization rate of 16%,2 the Philippine Health System has steadily redirected its focus on addressing the equally important non-COVID diseases.
Mental health issues have particularly surged during the COVID-19 pandemic and the resultant harmful psychological consequence especially among the frontline healthcare workers have been dubbed as the “silent pandemic.”3 The excessive work demands along with the greater personal risk of exposure and possibly exposing family members were real mental stressors to healthcare workers during the height of the pandemic. This publication issue describes the observations made among the resident physicians from the Departments of Internal Medicine (IM) and Pediatrics of one of the largest tertiary government hospitals in the country. The first paper among the IM medical residents revealed that a good 40 percent of the physicians were at-risk for physician burnout with four percent assessed as having physician burnout, defined as a work-related syndrome causing “emotional exhaustion, depersonalization and a sense of reduced personal accomplishment.”4 The other paper is an interventional research on the effectiveness of a physician resilience and wellness program (”I-CARE” program) in reducing burnout among IM and pediatric resident physicians in the same institution. It is conjectured that resilience reduces the risk for burnout, but its protective effect is predicated on the degree of exposure that the individual has to various stresses including patient deaths. Hospital administrators and other stakeholders in the healthcare delivery system must collaborate to develop effective programs to combat physician burnout.
Appropriate nutrition in any individual is essential for optimal metabolic functions. This is particularly crucial among hospitalized patients for the promotion of good health outcomes. Control of infection, healing of wounds, and early recovery from all types of illnesses are important endpoints in the nutritional management of patients. Early versus late initiation of nutrition for postoperative patients and rapid versus slow feeding advancement in preterm infants are issues that are commonly encountered by clinicians. In a meta-analysis comparing the clinical outcomes of rapid versus slow feeding advancement among preterm infants reported in this publication, rapid enteral feeding has been associated with an earlier establishment of full feeds and weight gain in preterm low birth weight infants with a corresponding reduction in hospital stay and hospitalization costs and no significant differences in the incidence of feeding intolerance.
Nutritional care among critically ill patients has been a subject of focus in critical care medicine. These patients require adequate nutrition to meet the energy requirements during and after the critical phase of their illness. A subset of these patients can progress to a state of persistent low-grade inflammation and protein catabolism referred to as persistent inflammatory catabolism syndrome (PICS).5 The provision of optimal nutrition may spell the difference in the quality of life of these patients after the critical care experience. Utilizing a mixed-method approach in assessing the quality of care in the intensive care units (ICUs) of a tertiary government, one paper in this publication underscores the need to address the observed suboptimal healthcare practices, institute routine systems review, and establish nutrition teams in all hospitals providing critical care.
Optimizing outpatient care in a world where increasing healthcare costs are progressively casting economic burdens on patients offers a pragmatic strategy for resolving the numerous demands on the healthcare system. One paper in this publication revealed that minimally invasive spine surgery that is transitioned from an inpatient to an ambulatory setting even in a developing country like ours can be safely and effectively performed with good pain control and minimal complications. Similarly, the astute management of chronic illnesses and the attendant complications, which can be a source of distress for patients and their families, can be successfully delivered in the outpatient setting to minimize the negative impact on disease control. The recognition of the specific sources of diabetes distress, for instance, is advantageous. Such distresses as tackled in this issue can be attributed to factors such as socioeconomic, psychoemotional, medication-related, healthcare service delivery, and even caregiver-related. Maximizing outpatient management of patients is expected to benefit not only the patients themselves but their families and caregivers as well.
The timely diagnosis of any disease has always been underscored in medicine as such impacts greatly on the disease outcomes and the subsequent medical care. The time interval from the first symptom to surgery among women with ovarian malignancies, the determinants of surgical care and outcomes of patients with appendicitis, and the timely intervention of Fournier gangrene (necrotizing fasciitis of the perineal area) were evaluated in a tertiary public hospital and reported in this publication. The median delay of approximately seven months from the first symptom to surgery in ovarian malignancies has been primarily due to system concerns and secondarily patient issues. Interestingly, the length of time intervals did not significantly affect the final staging of the disease and the extent of surgery. Among those with appendicitis, certain determinants such as age, the assessment of a complicated disease state, and the economic status of the patients influenced the utilization and outcome of surgical care. Extremes of age were likely to be associated with delayed consultation, complicated appendicitis, and longer hospitalization. Among those with Fournier gangrene, the female gender was associated with a higher mortality and the need for bowel diversion. It is interesting to note that the timing of surgery and the infusion of antibiotics did not significantly affect patient survival.
Effective management and control of infectious diseases invariably relate to good clinical outcomes. The identification of microbial agents causing the infection is particularly relevant, especially in centers where facilities supporting the etiologic diagnosis are existent. Molecular diagnostics are increasingly popular as these rapid diagnostic procedures are viewed as highly efficient in providing information on the etiologic agents compared with the time-consuming conventional methods. The early detection of the pathogenic organism (e.g., through the gastrointestinal PCR panel) and the institution of judicious antimicrobial therapy may reduce the unnecessary use of antibiotics and shorten hospital stays.6 Caution has been raised however when dealing with the respiratory viral panel (RVP). Issues such as the highly sensitive multiplex PCR-based panels in detecting viruses long after these are clinically relevant, especially among children and the immunocompromised hosts, can leave the clinicians further in a medical quandary. Some caveats are worthy of note: (1) Not all positive results relate to an active infection. (2) A positive result from the RVPs does not rule out other concomitant infections such as those caused by bacterial pathogens. (3) Suboptimal sampling procedures may lead to false-negative results.7 Because of the observation that parallel broad multiplex testing during the COVID-19 pandemic yielded significantly low rates of SARS-CoV-2 coinfection, a transition to more streamlined diagnostic algorithms targeting only those respiratory pathogens of public health importance may be more valuable and may relieve undue stress on the already burdened clinical laboratories.8
The management of infections in surgical patients can be a challenging one as this may crucially contribute to the overall rates of surgical success. Two papers in this publication propose the implementation of surveillance programs, with one citing the use of standardized protocols to improve the quality of surgical care and reduce postoperative complications.
Finally, the ultimate thrust of patient care is to accord health-related quality of life to all individuals whenever possible. Such may be predicated on the quality of care delivered by the health care team. The timely recognition of the evolving disease states and the conscientious efforts at instituting the processes vital for the recovery or improvement of the disease conditions can be significant correlates linked to flourishing, positive mental health and palpable hedonic well-being.

Juliet Sio Aguilar, MD, MSc Professor of Pediatrics, UP College of Medicine (ret.) Former Deputy Director for Health Operations, Philippine General Hospital

REFERENCES

Philippine Department of Health Updates on Novel Coronavirus Disease (COVID-19) [Internet]. 2022 [cited 2022 April]. https://doh.gov.ph/2019-nCoV?gclid=Cj0KCQjw6J-SBhCrARIsAH0y-MZhMipnezIEpbNP5_QCO9eR-R0OPNCYo1dwB_z6SpdN-VGEXnyNLeWsYaAgMLEALw_wcB
Philippine Department of Health COVID-19 Tracker [Internet]. 2022 [cited 2022 April]. https://doh.gov.ph/covid19tracker
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West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Int Med. 2018; 283:516-29.
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Beal SG, Tremblay EE, Toffel S, Velez L, Rand KH. A gastro-intestinal PCR panel improves clinical management and lowers health care costs. J Clin Microbio. 2018; 56 (1):e01457-17.
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Marshall NC, Kariyawasam RM, Zelyas M, Kanji JM, Diggle MA. Broad respiratory testing to identify SARS-CoV-2 SARS-CoV-2 viral co-circulation and inform diagnostic stewardship in the COVID-19 pandemic. Virol J. 2021; 18:93. https://doi.org/10.1186/s12985-021-01545-9