 to the 54th episode of the Stop COVID Deaths webinar series brought to you by the University of the Philippines. So we are glad that you can join us today as we continue on with our fifth season of our COVID-19 learning journey together. So gaya po na nabanggit po natin sa mga nakaraang mga linggo, ngayon po ay ang kaunaonahin po nating virtual grand rounds and because of the increasing number of cases po, no, will continue to increase po ang ating mga number of cases in the NCR plus areas but also down south in the Philippines po, we wanted to bring to the audience point to our avid viewers another episode that deals and tackles with the clinical management of COVID-19. Well, many hospitals or clinics may just be experiencing their first cases, but as compared to COVID cases in 2020, the cases that we see this time around are in clusters of households. So today, we will be featuring a case of an entire household getting COVID-19. I'm Dr. Raymond Francis Sarmiento, director of the National Telehealth Center, National Institutes of Health, At the University of the Philippines, Manila, it's always a pleasure that we get to get together during our Friday lunch dates and always a pleasure also to be able to share, posting duties with my partner in crime and my mentor, the special advisor of the president for Global Health Initiatives and also our adjunct research faculty at the National Telehealth Center, Dr. Susie Pineda Mercado. Dr. Susie. Hi, good afternoon Raymond. Magandang hapon kusay nyo lahat sa'n man kayo na roon, binabati po namin kayo. We'd like to thank everyone for joining us today and for joining us every Friday. As Raymond said, babalikan po natin ang ating virtual grand rounds, kasi when we started the year, Raymond, we got very focused on vaccination, parang adaming naging issue na nag-vaccine, nag-surge, andaming mga iba-ibang nangyari, pero ayon manong balik po tayo doon sa, pano po natin, mabuting mapapangalagaan ng ating mga pacienting may COVID? At sa araw po na ito, pag-usapan po natin yung mga medyo bata pa na nagkakarun ng moderate and severe COVID. So we're going to talk about COVID families, households and I would just like to welcome everybody who's watching from the Philippine Academy of Family Physicians. Nong minsan po, meron tayong mga specialty societies na naimbitahan na, so mama po sa ating discussion dito and we'd like to welcome all the family med practitioners who are with us today, dahil ang nangyari nga sa COVID ngayon ang mga pamilya po ang na-affectoan. So welcome everyone and we hope you will learn a lot from today's session. Over to you, Raymond. Thank you, Dr. Susie. So for those who are joining us in the Zoom webinar po, please and join and encourage ang inyong mga kapatid, kamagana, kapitbaha'y mga kaibigan to join us not just in the Zoom webinar but also in the YouTube channel of TV UP as well as the live streaming pages and links po of the University of the Philippines, the TV UP and the Stop COVID Deaths page at www.facebook.com. For those naman po na sa kauna-una ang pagkakataon ay makaka-experience or makaka-attend po ng virtual grand rounds, ganito po ang ating structure. So there will be a case presentation followed by from a theoretical perspective also, a clinical perspective from our main discussion followed by reactions po to the case. Oftentimes we try to endeavor po to get the side of the patient po and hopefully we will be able to get that perspective specifically from the patient's side po for today's virtual grand rounds. Afterwards, we will be entertaining questions from our Q&A and as mentioned po, we are using mga makabagong tools outside of the Zoom webinar that will be introduced by Dr. Susie. Okay, thanks Raymond. So ano mga maraming pa-kuluto si Raymond eh. So mayan tayong Mentimeter and some of you have already been asking about the Mentimeter. So you have to go to your browser and go to www.menti.com and then use the code 31823619. So if we're doing this so that those who are not on the Zoom but are watching us, binabati ka lahat naman ahikinig sa ating yung livestream sa Facebook and YouTube. Pwede po kayong sumama doon sa ating opinion poll. We usually have one or two questions and this gives everyone an opportunity to join. So www.menti.com and code 31823619. Okay, over to you Raymond. Thank you Dr. Susie. Ulitin lang po, buksan nyo po muna in yung browser before going into www.menti.com and entering the code. But before we go into our webinar proper, I'd like to take this opportunity to thank the hardworking team behind the stop covid death webinar series. Kung wala po kayo, each and every one of you, we will not be here every week. It really is a labor of love in terms of being able to figure out the topics for the week and the weeks ahead. I'm trying to come up with a very, very exciting webinar structures and also a very informative resource. So maraming-maraming salamat po sa lahat. At para naman po sa lahat ng mga nagkatanong, patongkul po sa certificate. May we have the graphic po. Okay. There we go. Okay, so for those who are- oh, si Dr. Susie naman po pa lang may certificate for this week for webinar 54. Pwede bang cash na lang cash? Or yung ano po, no, yung t-shirt o kaya yung- Certificates will be sent out to those who have attended at least 50% of the duration of the webinar along with a copy of the presentations of our speakers. So for those who feel that they should have received a certificate but did not, please let us know and stop COVID deaths at up.edu.ph. Gayo po na nasabi po namin, request po for changing the names will not mostly be entertained po just because kailam po talaga you have to be very, very careful in terms of what to input in the registration link, how it appears in the registration link will be how it will be inputed po and will be reflected in your webinar certificate. So bro, so bro, I'm strict to ka naman Raymond para ka naman- Because if you do that for 1000, we won't be able to distribute the certificates. But obviously there are those that we accommodate po, Dr. Suzy. Pero po, for the previous 53 webinars, we have already distributed them so kaki sabi po sa amin. And obviously if you tell us, please tell us kung anong webinar po kasi we cannot do anostradamus in terms of which webinar certificate po if you are talking about. Over to you Dr. Suzy. Parang meron nata tayo parang hong katok ngayon dahil bilogin ba na. Anyway, so okay, so we have a very interesting case today. We are going to talk about a young adult who developed moderate and severe COVID and actually he is going to join us Raymond, he's going to join our discussion today. And so ang tabayan na nyo po. To introduce our webinar, we have none other than the Deputy Director for Hospital Operations. Kailala nyo po siya, si Dr. Stella Marie Legaspi Jose. Stella, welcome to the webinar. Hello, good afternoon everyone. Kamusta na? Kamusta na pagkatapos ng sunog? Okay naman. Okay naman, we're on the recovery phase. Later on, I'll say our thank yous to all those who helped in our fire problem. So maraming tupulong? Maraming tupulong? Maraming, maraming. So first, pwede ko na ba sabihin? Oko, ko, ko Stella go ahead. So I would like to thank first of all the Bureau of Fire Prevention and Fire Volunteers and they were really so helpful and they were really on the job here on the site itself. And we also like to thank the hospitals who helped us, Santaana Hospital, Tondo Medical Center and San Lasaro Hospital. So some of our patients were transferred there. And we'd like to thank all those who donated in our PGH Fire Fund. And I'd like to specifically mention the Father Barbero Foundation. And they helped us by the autoplave and also many of the donors so they gave us food and cash. And so we were able to buy surgical instruments. And we are really grateful to all of you. For other hospitals, they said that the TV UP webinar was like a wake up call because they were also checking their fire extinguishers and fire prevention methods. And lastly, we think that because some of the surgeons lost their instrument, their personal instruments in the fire. So it will be a good thing if doctors will have fire insurance on their instruments. Okay, so before anything else, I'd like to just say a brief summary of this webinar that we have a young healthy male who eventually contacted COVID-19 infection. And had complications of pulmonary embolism. But the other part there is because they stay in one house and other family members are also infected. So it's a very interesting case and I hope we all learn from it. Thank you. Over to you, Susie. I thank you very much. Dr. Stella Joseo is the Deputy Director for Hospital Operations at the Philippine General Hospital. So Raymond, I think we are going in and Stella, please join us later for the panel discussion. You'll be able to join us. Okay, great. So Raymond, let's go to our mentee meter. Okay. Thank you so much. Thank you to the PGH Deputy Director for Hospital Operations, Dr. Stella Marie Jose. And maraming salamat din po sa lahat ko ng tumulong sa Philippine General Hospital, lala po dun sa kapanahunan ng pagkakasunog. Okay, so for those who would want to join us, we also would encourage everyone watching outside of the Zoom but also those who are in the Zoom to go to www.mentee.com. And enter po lep yung code na 3182-3619, that's 3182-3619. TVUP may we have on the screen our two questions po which essentially would serve as our pre-test question and also our post-test question po para mamaya. Okay, TVUP. Okay, well TVUP is pulling that up po, no? We have those who are joining us, Dr. Suzy all the way from Zamrohas, Zambuanga del Norte from General Santos City. Also representatives from the Philippine Academy of Family Physicians. Maraming salamat po sa pag-attend at pag-view ng ating webinar number 48. We have one from UNESCO. If I'm reading this correctly, all the way north of here, Kabanatuan in Inueva, Isija, those also watching from, wow, Alfonso Lista in Ifugaw. I was caught off guard because of that. From our educators din po, Dr. Suzy, the Philippine High School for the Arts in Los Baños Laguna. We also have those who are joining us from Dumagheti. So maraming salamat po also staff, maybe lawyers po, from the UP Law Center, the Institute of Government and Law Reform. Maraming-maraming salamat po, from Calavera, Nueva Isija. Okay, so let me just, okay, there are those who are still asking for our code, ilalagi ko lang po, para po for the benefit of our audience. Raymond, I also want to greet all of our Metro Manila Hospitals who are always watching us. Rizal Medical Center, Marikina, among Rodriguez, Tondo Medical Center, Philippine Orthopedic Center, Philippine Lang Center. So lahat po yung mga Metro Manila Hospitals na suki na natin, lagi silang na sa webinar natin. Ang binabating ko kayo. Palamat na nags-masama kayo sa ating webinar. Thank you din po. And then for those who are joining us from downshot, ay lang ko po nakakarod po ng mga panibagong community quarantine measures. One of my professors in my master's class also is undergoing, so it's something, experiencing that. So ayun po ang, silangan din po natin mga matutuka. At mamraming salamat po, obviously for those who are joining us. If TVU pick and flash on the screen, I don't know if they are technical difficulties, but obviously those who are invented.com, you will be able to see that the very first question is asking young adult COVID positive patient on day 28 with severe difficulty of breathing. Ano po ba ang pwedeng i-considera? Raymond, tanam mo na. Hindi na hikita. Hindi siya na hikita. There we go. Let me repeat the first question po. It's question one of two. Thank you po sa pag flash. The question reads, young adult COVID positive patient on day 28 with severe difficulty of breathing. Ano po ba ang kailangan i-considera? I mean it's all about the diagnosis po. Number one, pulmonari embulisin. Option two, hospital acquired pneumonia. Option three, long COVID syndrome or option four, lahat ng nabanggit or all of the above. So please key in. We are seeing a little over 200 of our participants, but sa sana po ay mas marami po po mag key in because that only represents one fifth po of all of our Zoom participants at the very least. We are now numbering a little over 1,150 participants. So please join us po. Next question po if we could go to question number two. Okay. Question number two reads, young adult COVID positive patient on day 28 pa rin with severe difficulty of breathing. Ano naman po ang mga diagnostic tools na kailangan po gamitin. Option A, x-ray. Option two, city scan. Option three, sputum culture. And option four, all of the above. Abang hinihintay po natin na pumasok ang kanilang mga kasagutan. Let me take this opportunity to greet our attendees all the way from Louis Hora Memorial Regional Hospital in Bawko, Mountain Province. From the Bulacan Medical Center in Malolos, Bulacan. From Vehicle Regional Training and Teaching Hospital in Darada, Alpai. From Alijad Regional Care Hospitals in Lapu-Lapu City in Cebu. Jen Santos Foundation College Incorporated General Santos City in South Potobato. Internationally, there are those who are also joining us from the National University Health System in Singapore from the Jai Institute of Nursing and Research in India. Iingat po kayo dyan. Taipei City in Taiwan, Sarikei, Malaysia, Surakarta, Indonesia, Bangkok, Thailand, Kochiming, Vietnam, Maca Saudi Arabia, Dubai, UAE, Salmiya Kuwait, and our regular viewer from the Niagara Falls on Taryok, Canada. We will show po mamaya towards the end of our webinar the results of our pre-test. Patuloy nyo lang po ang sagotan ang ating pre-test po doon sa dalawang questions sa menti.com at ipapost din po namin ulit ang code para limpo sa mga gusto po ang sumali at sumunod sa pag gagasagod po ng mga tanong. Over to you, Dr. Susie. Okay, thank you very much Raymond. Right now, right, so usually for our workbook grand rounds we have a dramatization and I just wanted to say that this dramatization is not exactly the case but similar to the case because we wanted to share with the audience what would happen in a family where somebody developed COVID unexpectedly. So we're going to turn over to TV UP for our dramatization. Go ahead. Dexter is a healthy 36-year-old. He cannot remember the last time he got sick. He works for a local company. He is fit and athletic. And plays football when he has time. He has no underlying comorbidities, no diabetes or hypertension. For the past year he has been working from home and has avoided crowded areas. One month before admission of Dexter to PGH, Raya, his 35-year-old partner, a working mother, was not feeling well. Inay, kayo nang mo na ang mag-asikaso kayo baby, parang matamlaya ko eh. Hindi mo na ako papasok. Her husband, Dexter, was concerned. Are you sure you're okay? Raya immediately replied, this is nothing sweetheart. Nahamugan lang ako. Nagpantigent test ako sa opisina, negative naman. Don't worry. Raya has very mild symptoms and continues to interact with the family. Two weeks later, Dexter developed a sore throat. Fever loses his sense of smell and taste. Mukhang may COVID ako. He tells his family. He is brought to a local hospital where Dexter tests positive using RT-PCR. He is admitted and treated for COVID-19. The family is now worried. They are living in a small space with the parents of Raya, and her sister and their 10-month-old baby. Raya says, ipatesin natin si Ate at si Baby. They both test positive. Dexter doesn't seem to be improving in the hospital. He has great difficulty in breathing and his fever does not go away. Nagihirapan ako ng mingadok. Parang hindi ako gumagaling, parang maslumalala. The doctor at the local hospital requests for a transfer to the Philippine General Hospital where Dexter is admitted. Raya and her parents are in tears, wondering how things could have happened so quickly. She cannot get the baby to stop crying and her sister is coughing. Thank you very much, TV UP, for that dramatization. Thank you all for waiting for our main presentation. We know that over the past month, there have been entire families that have gotten COVID. This is just one example. We are going to focus today on the young male who got moderate and severe COVID when he was previously healthy, no comorbidities, pero naging malubahapu inside. To introduce our case, we would like to welcome a fellow in training from the Division of Infectious Diseases at the Philippine General Hospital, Dr. Grace Astudillo. Grace, welcome to the webinar. Sana si Grace. Hi, good morning. Hello Grace, kamusta ka na? Afternoon, sorry. I feel okay. Okay, good. Grace, did you personally handle the case? Yes ma'am, I was the fellow in charge of the patient. For the fellow in charge, okay. And Sige, go ahead and make your presentation. A pleasant day to everyone. Hi, I am Dr. Grace Astudillo, a fellow in training under the Division of Infectious Diseases in UPTGH. And today, we are discussing about our patient who recently got admitted in our institution and his complicated COVID case. So, at the end of my presentation, my goal is to be able to dissect his case, briefly tackle on the approach to this persistent Disney COVID patient and determine the common causes of Disney in COVID patients. So, we have MC, a 36-year-old male from Metro Manila. And compared to his admission at TGH, he was known to be healthy with no comorbidities. He was admitted because of incestant coughing last April 21 in our institution. So, his symptoms started actually on March 25 as dry cough and colds and anosmia or the lack of the sense of smell. He took supportive medications for all his symptoms, but this did not provide any relief. Eventually, he developed shortness of breath and progressive difficulty of breathing and he was sent to the emergency room of another institution last March 31 due to severe dyspnea. He was admitted as a COVID suspect pending his swab results. It was also hoped oxygen via face mask to achieve adequate oxygenation. At the same time, despite not having the swab results yet, he was started on remdesivir and dexamethasone because they were hiding thinking of a COVID-19 infection. He was given broad spectrum antibiotics for a possible bacterial pneumonia as well. On April 11, his COVID swab turned out to be positive. During this time, he was also diagnosed to have diabetes mellitus. His blood sugars were monitored and he was given insulin as needed for elevated sugars. On his fifth day of admission, his cough and difficulty of breathing progressed and a repeat chest X-ray was done revealing increasing and infiltrates. He was then assessed to have a hospital acquired pneumonia and due to this, they shifted the antibiotic to a broader spectrum one. On April 10, or on his 11th hospital day, he developed fibril episodes. They repeated his chest X-ray which again showed increasing and infiltrates. Due to this, they decided to add two more antibiotics on top of the first one. There were also episodes of desaturation while he was still on face mask. However, since the patient or the institution did not have any instruments for intubation and did not have the capacity to take care of intubated patients, they maintained oxygen support to 10 to 30 per minute face mask. Even after using three different classes of antibiotics, he was still fibril on the 18th of April and his sputum production become greenish and difficult in expectorating. He was still disnake on maximum oxygen support while on face mask. Eventually, because his symptoms were not improving and seems to be worsening, the family decided to transfer him to PGH. So he was given different medications in the previous hospital. As you can see on three different antibiotics, he was also given medications for COVID such as remdesivir, indexometasone, and enoxaparine. For his diabetes, he was put on insulin and it was also given medications to help him expectorate. But despite everything, his symptoms continued to progress and he did not feel well. So he is a newly diagnosed diabetic patient during his admission in the previous hospital. But prior to this, he denied any other comorbid conditions and he did not also have any prior hospitalization, no surgeries, and no allergies to any medication or any food. For his personal and social history, he denies any biases aside from occasional drinking. He works as a branch manager in a memorial plants company. However, due to the recent COVID surge, he was put on work-from-home set up, para to be in sick. He is also known to be athletic and physically active. He goes to the gym weekly and plays soccer every Saturday. He also took type 1 the classes before. So for his home arrangements, he stays at home with his partner and his partner's family. His partner developed viral episodes two weeks before he got symptomatic. However, when she tested for the antigen test, it was negative. Her sister also had symptoms of COVID and tested positive on March 20, approximately five days prior to his symptoms. It was also a baby in the household who had respiratory symptoms and tested positive for COVID, but they were not admitted. Almost everyone from the household had symptoms including her mother, but only our patient had severe COVID symptoms needing hospitalization. His family history is significant for heart disease and malignancy on both sides. When he was admitted in PGH, he was hypertensive, tachycardic, tachypnic, and he speaks in phrases with low-grade fevers and the saturation on room air. His lung findings were pertinent. He had adventitious lung sounds on both sides and the rest of the physical examination findings were unremarkable. So to summarize our patient case, we have a young adult male who is physically active and newly diagnosed diabetic during his previous admission or previous institution. He developed COVID from a probable household transmission even if his household members also had symptoms of COVID. He presented with a three-week history of cough and difficulty of breathing. At about admission to the previous institution, he was already given remdesivir, dexamethasone, and broad-spectrum antibiotics for a possible concomitant bacterial infection. He was hooked to oxygen by a face mask all throughout his previous admission and he was also feeble for most days of the admission, especially towards the end. But despite all the interventions and medications, he remained to have significant dyspnea and with physical examination findings on the lungs on osculation. So what could be happening with him? So dyspnea in COVID-19 patients was a lot of causes. So the most common cause of persistent or worsening dyspnea in admitted COVID patients are the following. So the patient can have hospital acquired pneumonia, pulmonary embolism, and a possible lung COVID syndrome. Hospital acquired pneumonia is a type of pneumonia that you can get when you stay admitted for at least 48 hours. It is important to recognize this disease entity because it is the leading cause of infection-related deaths in the hospital. Most patients with severe disease, elderly or those who are more than 70 years old and above. Okay, I think Raymond did we lose doctor us to deal? I think so. I was trying to figure out if it was me. I thought it was me. I thought my internet was gone. Okay, if you look at one ngayon, if you look at one Raymond. For everyone's information, almost each member of the production team has been having internet connection probably so we automatically assume it was us. But I think Dr. Grace is back. Dr. Grace? Okay. Okay. Grace, ulitin mo yung slide na yun. Yung hospital acquired pneumonia. Oh, yun ka na wala eh. I'm sorry. Masala si Grace. Grace is here. Go ahead. Go ahead. Okay, next slide please. Okay, so. As I have said, the hospital acquired pneumonia is expected if you stay in the hospital for at least 48 hours and it's important to recognize this entity because it is the leading cause of infection-related deaths in the hospital. Most patients with hospital acquired pneumonia have severe underlying disease. Those are more than for 70 years of age. Those who have cornetrition and poor sense for you and there are presence of other severe comorbid conditions. Most of the time, the most common causes are gram-negative bacteria. Most of the time, they are klebschala pneumonia and E. coli. It can cause highly severe disease. Next slide. So, we usually suspect hospital acquired pneumonia if there are significant respiratory symptoms such as cough, sputum production and this niya along with fibril episodes. The treatment for this infection consists of IV antibiotics initially, but when the patient is stable enough, and if the gut works, we can shift the IV antibiotics to the oral ones. So, another entity that can cause persistent or worsening dyspnea in COVID patients is pulmonary embolism. The cause for this phenomenon in COVID is not yet fully understood. However, the theory is that there are dramatic changes in crotombotic factors and damage to the blood vessels brought about by the inflammatory response and the certain coagulation of dermalities. So, in the laboratories, we've activated the dimer test. The fibrillation levels are also elevated. We also have prolonged CT and PTP and abnormal platelet counts. The diagnosis is confirmed only through CT scan of the chest with pulmonary anggiography to visualize the arteries. So, this shall be discussed further by one of our distinguished reactors. So, another possibility in patients with difficulty of breathing and COVID and cough is the long COVID syndrome. This is also known as the post-acute COVID, post-COVID syndrome or PASC, or post-acute sequela of SARS-CoV-2. We can think of this diagnosis if the patient symptoms continued for more than 12 weeks and are not explained by any other alternative diagnosis. So, the most common persistent symptoms are fatigue in up to 87% of cases. You can also have dyspnea, chest pain and cough. Other less common symptoms are insomnia, anxiety, cognitive dysfunctions, myalgia and occasionally diarrhea. The duration of symptoms depends on how severe the COVID infection was. So, in patients with critical COVID, we expect the symptoms to be more prominent and possibly stay longer than a symptomatic COVID case. The treatment is entirely supportive and is geared towards a symptom experienced by the patient. One can take pain relievers for the pain of headaches at it's present. So, out of the three possibilities, what could have been the cause of our patient's significant symptoms? So, let us look at our patient's hospital course. So, during his first day in PGH, when I saw him, he was really disneyed and had incestant coughing. I remember him not finishing his sentences because of persistent cough. He was also fibral at that time. So, we had leukocytosis or elevated WBC so, with predominance of utrophil. And this can signify an ongoing bacterial infection. So, he also had normal renal function but his liver enzymes are elevated to more than five times. He was hypoxemic as shown in his arterial blood gas and still with elevated inflammatory markers or the LDH, ferritin, was also borderline high. And the HPA1C levels confirmed the diagnosis that he is really diabetic. So, during this time, we just continued the antibiotics from the previous hospital and requested for further lab tests. So, for his chest x-ray, it showed airspace opacities in both lungs which was signed out as pneumonia or progressing pneumonia. Then on the next day, because of his increased breathlessness, we referred to our pulmonary friends who shifted the oxygen support to high flow nasal cannula. We also requested for a CT scan of the chest with pulmonary angiogram during this time because we really wanted to rule out pulmonary embolism. On the third hospital day, his symptoms were becoming persistent and the sputum cultures showed a common cause of nosocomial cause that acquired pneumonia which is acinetobacter baumanihae. On the next day, the sensitivity of his sputum cultures came out and the bacteria is unfortunately a multi-drug resistant organism which was only sensitive to certain antibiotics. Because of this, we started him on another broad spectrum agent and continued his previous antibiotics. So, on the next slide, you can see that the x-ray is a kind of worsening pneumonia. On the fifth hospital day, he had bouts of severe right-sided chest pain. So, makit talagin dibib niya on his right side. So, we did ECG which did not show any changes or any signs that he might be having a heart attack. And then his chest x-ray was also repeated which still showed bilateral infiltrates and did not show any regression of the pneumonia. So, we just attributed chest pain from possible pulmonary embolism and possible pneumonia and gave pain medications which relieved his symptoms. So, this is his chest x-ray. Kung mapapansin niyo po on the left side is the more recent one. The right x-ray is the previous one. So, the chest x-ray may have any white infiltrates or densities because it should show air. But his chest x-ray is really white. But the latest one showed regression. Okay, I think we lost grace again. Raymond, are you there? I think so. It might be a converged thing. Apparently, it's with the internet provider. Are you back? We lost her. Okay. Okay. She is trying to get in. Okay, Dr. Grace, give the floor to you before we move on. Go ahead, ma'am. The basics of admission he was still with productive cough but this time he did not have any feveral episodes. He is tolerating lower oxygen support. Then on the next hospital day, eventually, we are able to shift high-flow nasal cannula to just a nasal cannula so a lower oxygen support. We maintained his antibiotics as well. Then on the succeeding days, fast forward to his last day of hospitalization in PGH. We gave his last dose of IV antibiotics and were able to discharge the patient improved from the baseline difficulty of breathing and cough and stable. As for our patient, the three diseases that we are thinking of for his persistent symptoms, the hospital acquired pneumonia and pulmonary embolism and the long COVID syndrome, we can probably not think of the long COVID syndrome anymore because the symptoms did not happen more than 12 weeks and his symptoms are actually explained by other entities such as hospital acquired pneumonia and pulmonary embolism which was clearly demonstrated or seen in the laboratories of our patient. So the cause of our patient's persistent business is actually hospital acquired pneumonia and pulmonary embolism. So that would be the end of my presentation. Okay. Thank you so much, Dr. Astudilio. Well, for those who are joining us again and this would probably very first time seeing the virtual grand rounds for 2021. That was just a very, very quick overview of what happened to the patient especially at the treatment side and obviously we will go into more detail as we go into our next presenter. So thank you so much. Thank you Dr. Grace and please stay on for our panel discussion. Thank you. We will move on to our main discussant who well, he used to be the one who was in Dr. Grace's shoes I think a year ago around a year ago but for today he will be our discussant. You all know him. He's a consultant with the Division of Pulmonary Medicine at the UP Philippine General Hospital none other than Dr. Ralph LV Villalobos. Dr. Villalobos, welcome to the webinar again. Afternoon po, doc. So good afternoon everyone. Right now I'm the discussant. Go ahead with your presentation Dr. Ralph. It will be very short lang because I want to focus on some things lang. Ang title kasi na ating talk is COVID lahat talaga tayo na affectuhan at walang na despair na tao with COVID and this is one of the reasons why young people have severe complications with COVID. So it's thromboembolism actually. So if we thought that COVID just causes pneumonia because it causes a lot of other manifestations and some of them can be very severe and fatal. So this is one of the reasons why. So we all know this epidemiology of COVID as this is from the CDC in the global data. We all know the epidemiology to be like this. So the younger patients if you look at hospitalization and death here the younger patients ang kanilang rate of hospitalization and death and as you go along 30 to 39, 40, 50, 60 and above the death and hospitalization really, really increases in magnitude by thousands actually kapag 85 years old ka. But what we do not know and this is another graph that looks at the rate of death from 100,000 people there is actually logarithmic logarithmic increase as the age goes older. This is what we thought we know but what we do not know actually is that this is even from local data that even young people 20, 25, 30 to 35 our patient is around this age some of them can experience some of them actually can die from COVID. That's what I want to emphasize about Hindi-porket, healthy ka active lifestyle fit, nagdijim and all that you are not you are spared from COVID you are immune kung baga iniisip mo na okay lang yan ba, tapan mo na ko I won't stick to the health standards and all that sa ayokong lalabas, ako magmamola ko mamimili ako mag-grocery, mag-malenke, mag-vacation something like that yun ang ating misconception kahit na mababa ang mortality rate ng mga ganyang edad the fact is that you can still die you can still have severe disease from COVID kahit batak and healthy this is from our IDS infectious diseases friends and this is our local data actually in PGH this is March 31, 2021 a lot of our patients are on the elderly age group and a lot of 25 to 39 years old but what I can say is that hindi zero ang death rate nila hindi zero hindi lahat ng mabata ang patient ay nakakaservay ng COVID so what I want to drive here is that really really no one is safe from COVID and as the presentation kanina went ahead kahit buong pamilya ng COVID hindi lahat tayo and this is one data na sino sa mga batang paciente who among the young adult patients are at risk from COVID-19 so if you have one two or three comorbids the risk goes on but again I will emphasize this one the no comorbid part the people who are seemingly healthy they are not immune and they are not spared from being mechanically ventilated hindi siya flat na flat hindi siya zero it might be lower than those with comorbidities but the fact is hindi talaga siya zero and you can still have severe COVID if you are healthy and we know this presentation we know this slide by pre-existing medical conditions so these are the most common comorbids associated with death so cardiovascular disease diabetes chronic respiratory disease hypertension cancer and again here even those without pre-existing conditions can die from COVID so this is from the CDC and these are conditions that are associated with severe COVID so these on the left part are only associated with severe COVID so we have disease cancer, celibate vascular diseases chronic kidney disease COPD diabetes ato yung maalam natin ka cardiovascular disease obesity, pregnancy I highlighted smoking because I think this is one of the factors in younger individuals who develop severe COVID chronic and previous smoking actually is associated with severe COVID on the right side are associated with severe COVID this one on the left strongly associated kong baga sigurado-sigurado ito na sa left side for that area the key takeaway point there is that COVID-19 does not discriminate among age groups and this is with a resounding tone that no one and no one is really safe against COVID do not be complacent in this seemingly young individuals COVID-19 is not safe so COVID-19 is not safe in this seemingly young individuals because of this fact COVID-19 and thromboembolism so this is one of the reasons na ko-complicit na COVID-19 if we thought nanimon na lang we are wrong there are a lot of other organs that suffer because of COVID-19 what do you think is the incidence gaano karamin 20%, 5% if we thought that the number is low actually that actual incidence is 14.1% so that's quite high so around 2 in 10 patients with COVID actually will develop DVD or pulmonary thromboembolism so we have really to be careful and watch out for that so this is the pathogenesis of thrombosis in COVID so as we know the virus enters through the lungs the lung cells and it produces inflammation and complement activation and then this one activates the micro thrombi malili it na mga blood clots and then if that happens activate sila, nag-aggregate namidikit-dikit sila until such time na visible na sila and the bad part there is that it can travel it can block the blood supply to the organs which are vital and the kidney so when do we suspect thrombosis in COVID so in pulmonary when do we suspect like our patient big luck siyang nga chest pain and shortness of breath so if we think that there's a sudden event usually embolism yun or cardiac or thrombine and at pumatang somewhere so shudden on kung meron kayong leg swelling leg cramping or leg pain it could also suggest a thrombosis and if you have leg pain thrombosis that the fact that you can also have pulmonary thrombosis is very, very high it can also happen in the brain which sudden onset weakness so learning of speech headache and learn of vision so what do we do if you are suspecting pulmonary embolism of course we have this the dimer test so your elevated level suggest inflammation and thrombosis but it's very nanspecific we have a lot of patients with very, very high d-dimer levels who do not have thrombosis but what we're sure of is that if your d-dimer is very, very low or with normal limits the suspicion of pulmonary embolism or thrombosis is actually lessened kung baga if it's high it doesn't tell you kung that you do not have pulmonary embolism okay, troponin ay will tell us that the higher the levels of troponin ay baka ito delicado itong pulmonary embolism ito high risk siya for the imaging studies we do the leg venous duplex scan in our institution since we are a tertiary institution pulmonologists and even residents in internal medicine do this bedside and because it's an easy procedure that we do bedside I think in my previous presentation I presented it but we were the ones who really did that to the echo can be done to check for cardiac involvement if the embolism is very, very high and of course the best test you can do if you agree to make sure that there's pulmonary embolism is the CT scan with pulmonary angiography it's the gold standard in CT scans white the vessels appear white because of blood flow there if there is something there like this may itim sa gitna so ito ang pulmonary embolism okay so what's the management of the summary of management of pulmonary embolism so this is basically the same like how we manage pulmonary embolism in non-COVID patients so the basic is anticoagulation to check for hemodynamic instability we check for hemodynamic instability if it's high risk we need to hospitalize and to admit the patient to the ICU okay if not naman we check for severity we perform troponin test as I told you earlier if it's high then intermediate to high risk we admit that patient if it's low but if it has serious comorbidity it can be hospitalized okay for those without comorbids or very subtle pulmonary embolism some of our institutions manage them in an outpatient setting but actually in the Philippines we usually admit these patients with pulmonary embolism for anticoagulation this is from our local guidelines so this is thanks to our society in the it's a collaboration of societies that do evidence summary for the local guidelines ang bagaating talagawa natin ito of course the evidence can be from anywhere in the world so the anticoagulation should be used in COVID-19 as prophylaxis I told you earlier two in ten patients or one in five patients with COVID will develop pulmonary embolism okay and this is not a small number and catastrophic effect of pulmonary embolism so what we do is give prophylaxis doses of anticoagulation to prevent pulmonary embolism so this is the dose that we use and this is also from our local guidelines in QGH here you can just take a screenshot of that okay and it's basically inoxaparin or low molecular weight haparin and it's based on the weight okay and for our patient I actually just to have for your information I just saw the patient I think last Tuesday I'm not sure and I think he's here to join so what determines the length of anticoagulation our patient still has a clot in the lung so what we did was we extended the anticoagulation which means that you need to be hospitalized for the entire duration of the pulmonary embolism there are oral equivalents and usually we do that three months nga huwala ng ibang risk factor like healthy naman okay and what's important there is that treating pulmonary embolism does not end in the hospital it's always important to ensure that this patient will be recovering from pulmonary embolism so important here is pulmonary rehabilitation with gradual return to normal pre-COVID functioning our patient nakakakiat na yan nakakalakat nakakalakat nakakalakat nakakalakat when we admitted him hindi talaga kong ting sa litalang niya ano siya because some of these patients bleed as a side effect because we have to anticoagulate pinapalab na o natin yung blood nila para ma-lesson yung chance na ang embolize na okay so that's the basically the end of my talk so the key takeaways here is that COVID-19 affects all age groups so the emphasis there is all age groups with varying frequencies hindi naman equal yung yung individuals with no comorbidities and can have severe disease and no one is spared so that's one of the reasons why these yung individuals have severe disease test is that the is one of the complications of COVID and it's brought about the information and the silver lining there is that it is not always fatal so pulmonary embolism in COVID and then it can really be managed successfully and the important thing there is that you should have a multidisciplinary approach so I hope you learn something thank you very much for listening to my talk okay thank you very much that was Dr. Rao Villalobos who is a consultant at the department of pulmonary medicine at the department of medicine right now we are going to and later you will be able to meet the patient so we will have a little bit of interaction para makitan nyo din kamusta na yung patientin at me we are going to have okay so because a family was involved here we are going to have a very special guest Dr. Anna Gia Limpoco who is trustee yes thank you pa for inviting me in this webinar so I think meron kang mga kasama sa family med na nakikimig ngayon yes I would like to welcome all the family physicians who are tuned in right now as well as my colleagues at the department of family and community medicine here in PCHPOP great kasi we thought okay so there is the management then there is also the discussion and a lot of issues around what do we do with families who have exposure so please go ahead with your presentation here okay thank you very much ma'am so as for my reaction for this very important and very relevant case is that I would like to share from the perspective of what we family physicians would always do use the lens of a patient-centered family-focused community-oriented care I think my next slide will highlight that so the patient-centered family-focused community-oriented approach to care is what trained family physicians would usually do in the management of diseases that we see in family and community practice so not necessarily just with COVID but with a lot of diseases and we see because we value the importance of putting the family and being allies to care for a member that is sick so for this particular instance we were able to provide a very good patient-centered care for a COVID-19 patient so let me go back okay thank you so for this patient a quality patient-centered care was provided that there is a family that this patient belongs to and we have to also identify their concerns we have to also listen what are the effects of a family member being diagnosed of COVID-19 as well as being able to network or tap what are the available resources in the community that the family can actually access to really I understand that Filipino families are closely meet so most of the time in our household extended po tayo so we have our in-laws or probably our cousins with us our grandparents staying with us and alam naman natin that when a family member gets sick lahat po ng family member is affected and so communication is vital meaning communication with the patient is not just identifying their medical concerns but we want to also listen and understand their context or their perception regarding the disease so a family focus home care plan is very very important and so the academy next slide po and so the academy started to come up with consensus statements that the members of the management of our patients and families dealing with COVID so we have released a family focus home care plan during COVID-19 statements in March 2020 and then on the following month we also shared a community-oriented healthcare plan that was in April 2020 and come August we've shared a clinical pathway for the diagnosis and management of patients and also there's also a need for us to be able to highlight the importance of family and as well as the community-oriented care and lately we have also launched the family and community engagement through telehealth services the facets as well as the tele home care in primary care so in my next few slides I will be sharing a family focus home care plan there are very important statements that really puts emphasis on the need why a family caregiver or a family liaison or an identified family spokesperson is very important so one of the statement really highlights to identify a family caregiver who will remind the family to follow and implement the family focus home care plan that this family caregiver has been voted upon or has been chosen by the family kasi nakikimig sila sa kanya so this is also important for us doctors because this is it is through this person that we can actually get the feeling, the thoughts the concerns of all other family members regarding their patient who is sick and then it is also important that we have to identify those who are at risk and all those family members with existing home orbit conditions and we have to always put emphasis on the advice on the precautionary measures so it's always included in the advice and in the management the practicing of personal hygiene that includes regular appropriate hand washing, daily baths cough etiquette minimizing hand contact etc and even advising the patient is staying at home a patient with mild COVID or asymptomatic that family member should be isolated meaning nakahiwalay po talaga yung room even the what are the recommendations ano po dapat yung meron sa noob ng kwarto niya so these things we are able to share with the members so actually not just family physicians but this is open to anyone na pwede po nilang mad-download ito so this is the family focus home care plan the next one are some of the statements that are included in the community oriented care plan why is this also important so we have to understand that majority of our COVID patients with mild or asymptomatic cases are not being admitted or are not in the facility or in the quarantine facility so most of them are advised to stay at home and so it is important that the other family members what to do in case a family member is there in the household so what to do when a member or household is exposed or diagnosed with COVID-19 so we have to tell that patient and the family that that person should be encouraged to stay home preferably in a room or area adequate for isolation always wear mask for the fact that that patient and the identified family caregiver is advised to do monitoring for the member for the patient and we actually do that we give specific advice on how to monitor when to take the temperature if they have pulse oximeter at home if they have BP apparatus at home they have to elicit down and report to the doctor via telemedicine so members are also advised to watch out and monitor for the appearance of symptoms because this is also important kailangan pa ulit-ulit natin itong sasabihin sa mga family members once any of the family member would present with the symptoms fever, cough, cold and if the person is low risk but with difficulty of breathing or worsening symptoms then kailangan nilang man-notify they have to notify their doctor kung meron po silang doctor na tatawagan to tele-consultation or their community health worker who then informs a referral hospital and facilitates transport arrangement so this important community-oriented strategies or a community health care plan will also tell us some plans of adjustments as well so kailangan po kasi kailangan matigal yung mga usual community services that we offer in the area meaning the delivery of other health care services child health, immunization et cetera should continue kahit po we have the COVID-19 of course kailangan may precautionary measures nintong kalaga and I do appreciate po that even the doctors at the start of the pandemic tried to see ano ba saan ba mag-reach out ano ba yung mga numbers that we need to tell our patients who to contact to meron po ba silang be heard sa parang guy so things like that as doctors kailangan alam natin because these patients will really contact us and ask for sound advice so these are just some of the statements in the community now there are another thing that we've shared with the member which we released last August is the clinical pathway for the diagnosis and management of patients with COVID-19 in family practice because a lot of our members are asking ano ba yung po eding guide nila because they've been getting or seeing patients with mild asymptomatic COVID so kailangan may guide lang po so the slide is not very clear but we've released this may pathway na po yan as you can see nakappatient intervention, family intervention parin, community intervention and there's even an algorithm it tells us na kailangan pag anito na yung symptoms or paano yung referral so it's really a big help even for doctors or general practitioners naklulis paano po ba ina navigate or how will I help my patients survive or access the services lalo na during this pandemic and so another service that was also shared by the academy are the following so we have the facets the facets is the telemedicine for COVID and non-COVID consults so this thing we've partnered with right now po merong po ang four chapters na nakapartner po sa kanilang LGU so this is Kesson City Pasig City Pangasinan and Bulacan Chapters with agreement sa kanilang mga respective LGUs that we can we can accept referrals we can do telemedicine for COVID initially for COVID concerns but eventually po again helping our patients and families po and then the Philippine Society of the Philippine Society for Hospice and Palliative Medicine in partnership with the academy has shared recommendations on telehome care for confirmed COVID-19 patients with mild or no symptoms so may mga recommendations po following clinical decisions etiquette confidentiality informed consent clinical evaluation and management family focus care and as well as community involvement and collaboration and so having said that telemedicine has been a very good tool in reaching out to all our patients na hindi talaga kaya na mga punta or most of them are afraid to really go out and having said that I would like to share that the UP Health Service has been offering this already the telemedicine services po to our employees from the disclosure process to talking to their family members assisting them and listening ano po ang concerns nila other than COVID-19 so I think the lesson or the key take a ways for my reaction is that I cannot put more emphasis on the importance of really being able to understand and guide as well as help the families of our COVID-19 patients so malaking malaking tulong po nila and I think kailangan din po nating ma assist ang effects ng COVID-19 sa kanala physically, mentally, psychosocially and even emotionally so that's for my reaction that was Dr. Gia Timpoko who is Board of Trustees of the Philippine Academy of Chest Physicians. Okay, we're going to go into our panel discussion right now and I would like to call on our speakers so Grace can we have you Ralph Gia Doctor Stella is going to join us as well but before we go into the panel discussion this pandemic is really hitting as close to home and one of our associate producers Agnes Mejia had a very serious case in her family and she wants to share her story so before we go into the panel we would like to play this message from Agnes Mejia. Agnes, please go ahead. Kako si Agnes Mejia Tagal Los Manes Ang tatay ko po ay 17 na years old siya po ay matagal ng na more than 20 years na po Nito po ang April 20 martes po sumamala ang kanyang pakiramdam sabi niya masakit lang nyan usually kung masama pakiramdam niya ang papayingat na tuturog lang ko siya na lang ko siya nagsuka siya na ko po ang blood sugar niya at ang taas natin po pala mericulos na madaling araw lapansin ko na na hirapan na siya humi niya na parang na disorient na siya kaya sabi ko sa kanyang taya likad na sa hospital pagdating namin sa hospital sa emergency room halos na ngingitim na pala ang ang dalirin niya nababa na talaga ang oxygen niya hirap na hirap na siya humi niya sobrang taas na rin ang blood sugar hindi na bumawa ba ang blood sugar niya kaya ang sabi ng doktor kailangan na siyang intubate naka intubate na siya siya nabi ng doktor na wala ng available na ICU kailangan siyang ilipat ng ibang hospital so na kanap naman yung mga nurse ng hospital na pwedeng paglipatan kaya ang wala ng hospital wala ng ICU na na pwedeng pagdalahan sa kanya hanggang naung April 22 webes na madaling araw after 24 hours kami sa emergency room inataki na po siya nirebipe siya pero wala na po talaga after nung namatay na si Tatay nilagay na siya sa morgue pero nagahantay paring kami ng resort ng kanyang soft test kasi hindi namin siya malalabas sa hospital hindi siya ko ko nilang punerariya kung wala resort yung kanyang test pero nung lumabasang resort pasitive siya kaya choice kami na kailangan siya ikremain doon na din lumabas ang takap ko sa pamilya na baka meron na din kami kasi kasama namin si Tatay sa bahay kami sa region 4 DOH sa Lasvanyos Municipal Health Center sa baranggay namin kaya na quarantine kami ng 2 weeks nipapasalamat naman kami dahil araw-araw naman kami minomonitor ng Municipal Health Center napadala din ang tulong ang DSW, mga kaibigan namin, ang simbahan namin ang padala ng tulong ang padala sila ng supplies because dilatad during the quarantine po at ang sabi ng Municipal Health Center kung meron kaming symptoms na mararam daman between 5-7 days kailangan magpaswap din ka pinin pero mabuti naman po hindi naman kami nakaramdam ng symptoms I still have pain in my heart hindi natin alam po siyong tataman ng COVID bataman ang atanda kaya magingat pa rin tayong lahat magmas ang face shield magbukos ng kamay at magpabakuna ang paka pinakaimportante sa lahat sa panhong ito ay magdasal tumulong apong tayong mahianan sabihin sa mga mga nating sa buhay sa ating mga magulang sa ating mga anak na mahal na mahal natin sila ok, thank you very much that was Agnes Mejia who is one of our associate producers at TVUP thank you Agnes for sharing your story and our deepest condolences on your loss you can see in the chat box our audience is also extending their sympathies to you and to your family ok, so we are going now into our panel panel discussion and to start off our panel we are going to call in our patient so Marco is here and Marco can you open your video nang jama si Marco yes ma'am here hi Marco ok, kamusakana how are you doing Marco kamusakana ngayon po it may japos pa rin po dahil dahil meron pa rin po tayo kumbuhang kaka dahil nga po sabi ni Doc Villalobos it's caused by the yung sacavity po na nangyari dun sa langsuko in the fibrosis and hopefully po ang reling na maging better na mawala po yung coughing ko and that's it for now ok, thank you Marco I mean I'll ask you one question but then after this I'm going to give you an opportunity to ask your doctors some questions your doctors are here and we have consultants who can also answer answer some of your questions so but for me I would like to ask on a personal level Marco na hirapan kang uming ano yung mga tumatak mo sa isip mo nung panahon na yan first po nung of course I'm trusting with the hospital that I've been to I hope they do they do something for me for me to get better pero there was a really a low point in in my experience na I pray na Lord if this is it phoning nyo na ko kasi sa sobrang hirap nung situasyon dinadanas ko at that time na I think para I was subject to be intubated but thankfully I was not at that time talaga na talaga ang nadasal ko na lang sa sobrang hirap nung nung dinadanas ko nung which I didn't think that would happen to me to say at that time din po before I got infected talagang I have a I have a bottle of alcohol with me every time and I'm really wearing mask and the face mask and everything so medyo nagulat lang din ako kasi na infect ako ng COVID with all the necessary precautions that I did pero still in na nandun na tayo sa point nyo in na pundok talagang ang nadasal ko nila sa sarili ko na Lord if this is it din phoning nyo na ko sa sobrang hirap talaga so yun lang Mark, I'm not going to ask you to talk too much kasi alam mo pangang magsalita pero nandito mga doktor mayanong kabang mga do you have some questions for them mayanong kabang mga tanong para sa kanila go ahead and you heard the presentations go ahead ang nga sabi nga po dun kanina ang isang ang mga isang side effect ng COVID po especially or the severe cases is yung mga bara po sa ogat and nultrasound po yung ako po before yung legs if meron po bang bara hindi po ayun lang po yung result na I think na hindi mo ba so hindi namin nakita so yun lang naman po yung tanong ko kasi right now after po mga manhid mga ako mo after ab mga four days ago para hindi na po na wala yung namin sa balat alam nyo po yung pahiramdam before mga manhid yung isang part ng Katon is yung parang may may koreante na dumandalo yung sa balat but I can feel my leg but yung nga lang pagkinahawa akong po yung balat parang gusto niyang mga manhid so hindi po siya na wala after po mga manhid ko yun lang po yung tanong po is that the side effect or do I have to consult face to face or do an examination for it to be determined kung ano po yung nangyari we'll ask Ralph and then we'll also ask Grace but Ralph would you like to comment on this yung namanhid yung sa leg niya nyo go ahead Ralph it can happen po talaga if you have a dbt so pwede talagang yung ang bullism kasi sa lungs yung usually ha hindi siya nang gagaling sa lungs kung baga nang gagaling talaga siya sa paa and it happens that it goes to the lungs yung ano natin and it goes to the lungs so that you could be experiencing that and the good thing about it naman is nakaantay ko agulit ka na I mean you are on medication for that so you don't have to worry but you still have to watch out for signs na hirapan ka huminga or more than today more than today kung niya ila mas na hirapan ko or yung usual mo na randaman yung big la kang na gano yung usual presentation simple monary ang bullism is big la ka nalang hiningal out of the blue yun yung parong tell-tale sign na nagpunta na talaga siya naman so yeah it could be part of the thrombosis problem so but it could also be since you're diabetic so I think it could also be warranted na you work up current for the effect of diabetes on the leg lalo na in neuropathy we're calling that neuropathy we can have and the chronologist and orthopedic specialist to check on that okay Thank you Ralph I think we'll also you can ask your questions in the Q&A box or in the chat box and both Raymond and I are monitoring that Grace did you want to say something go ahead nakamut ka Grace I agree with Dr. Villalobos yung parang different sensations sa legs can also be from the known embolism or thrombolic disease so usually kung gana naman yung mga symptomatic relief and then he is on anticoagulation which is the treatment for that so you just have to monitor and continue or you can take in medications for yung upamangin if there is pain paring mga pain relievers yung upamang Thank you Gia, would you like to comment on itong nga sabi mo kailangan meron tayo we have to have one person in the family who is like the care caregiver so if we have a post hospitalization patient with COVID who had COVID what should that person be watching out for ano ba dapat yung mga binabantayan na maaring kasi mukhang ang nangyari dito kay Marco napawina siya di ba wina sa bahay and all and yet meron parin siya mga lumalabas na symptoms pag atapos so go ahead Dr. Guillain So this is where effective communication with your doctors would come in talaga so I think it is important that even prior to the discharge of the patient naknadeskas ito sa kanya ano yung mga possible ano yung mga anticipatory care na dapat doin sa kanya and it should also be communicated to the family as well para alam din nila probably sila yung mga kapansin di yung pasyemte so in that way it can be communicated to the doctor malalaman na nang doctor na may ganyong symptoms si Misi Lama Tatakot P. Costino na heads up sila that this can happen the importance of follow up and monitoring with their doctors is also very important and at the same time dito papasok yung talagang yung health seeking natin na even if you don't feel anything or you have no symptoms at all the importance of doing wellness check up yearly lalo na kung may mga risk factors may family history is very important not just for the patient but for other family members as well and even for us doctors kasi hindi rin naman tayo spared from this from this pandemic so I would like to really put emphasis na importante talagay yung prevention aspect and kailangan may communicate to natin ipo not just to the patient but to the family as well Doc Stella kung meron silang mga questions may silang tumawag sa Bayanihan Center di ba? Yes 155-200 that's Bayanihan operation center may sumasagot naman 24-7 ba yung Stella? Noong puna 24-7 napos later on na naging ano na lang siya daytime so wala na yung night shift I see, okay Raymond I have a question that you would like to bring in from the audience or from the chat and Marco if you have some more questions this is a good opportunity na magtanong saan nila kasi na dito lahat yung mga doctor mo Sige go ahead Raymond Yes we have Chen Okampo Chen can you may refresh you to open your audio and your video you are one of two audience members who have been selected to ask your question live to our panelists Hi Hi Chen it's kind of dark Yeah, no it's um I'm actually calling from Michigan Oh, go ahead So it's like midnight it's it's 1.30 in the morning here Hi Okay So this can you at least you can see my face sorry So I'm a nurse I work in a hospital and I had COVID last year so when this was all started out nobody knew what was going on most of my most of the unit that I work that I worked at had COVID like maybe 91st 95% of the staff had COVID I was furloughed from work for about six weeks I was at home I had moderate symptoms but not severe enough to be hospitalized and I refused to go to the hospital at that time and I had at that time I have two girls with me living with me so we live in a small condominium and we never social distance I stayed at home we shared common areas like the kitchen the bathroom and but we never really social social distance within the three of us and then you know I I recovered I I got well I had all the symptoms except shortness of breath and difficulty breathing and I also have asthma just asthma so you know think that I recovered and then after that you know I've been hearing about asymptomatic carriers and I said how can a person be considered a carrier if they don't have the symptoms just like you know just like the chicken pox when I was little I had chicken pox my mom my mom was touching me caring for me cleaning me and stuff but she never had chicken pox and I know about the incubation period so I was you know when I had the the onset of the symptoms I was not near my sisters when I lived in the Philippines and you know I I got well but after that I was cured and I never gave it to somebody else you know the chicken pox so going back going to the COVID how can anyone without the symptoms of flu or pneumonia or COVID be a carrier okay I think we will throw that question to our infectious disease specialist to Grace so Grace please go ahead Grace you're on mute okay I think we lost Grace we're going to give it to then to Ralph Ralph thank you okay Grace go ahead so we got Grace okay go okay try again Grace you're on mute unmute yourself Grace hello can you hear me? can you hear me? there we go hi so the only way for a person to be called a carrier is when you detect the virus through the RTPCR but as what what mom said a while ago nap time ako anang ka COVID na siya before she was previously infected so the chance of the chance of her having a positive test result for RTPCR is still there so but in studies naman po that was reviewed by a lot of accredited organizations such as World Health Organization I think we lost Grace okay we're going to turn over to Ralph Ralph ikaw mo na so again para makabalik si Grace go ahead Ralph Doctor Villalobos really actually is actually established so there is truth to the fact that COVID asymptomatic carriers exist they can transmit the infection to the others even if they have no symptoms but what is most important to remember here is that these symptoms na the COVID is most infectious I think I see it also in the Q&A COVID is most infectious one to two days before the actual onset of symptoms na so these patients who they mingle with everyone they play around they they eat they interact with everyone without their symptoms and they can actually transmit this to the others even without symptoms especially if they were exposed to other individuals who tested positive na so the fact the confusion na is that these individuals may actually have symptoms soon na so that's not a true asymptomatic infection so that was pre-symptomatic infection so that's contrast to the fact that so these pre-symptomatic individuals have higher chances of transmitting them to the others compared to the totally asymptomatic individuals who do not develop symptoms up to the 14 days but just to tell you that both pre-symptomatic and asymptomatic transmission can occur so they actually occur hindi ibig sabihin na wala kang wala kang symptoms you can transmit it so it's very important pa rin to kaya what we do is we advise patients to quarantine lalo na kung na expose sila I think it's in the guidelines talaga na you have to self quarantine if you have a high risk exposure to COVID because of the fact that both pre-symptomatic and asymptomatic infection transmission can occur Thank you Martin, thank you, Chen for staying up so late to join us with me. We appreciate your question and you're joining us Thank you so much from the main land. Okay. Grace, did you want to add to what Dr. Villalobo said? Sorry. I got lost a while ago. Medyo unstable yung internet ko dito sa saan ng clinic. Sorry ko. Yung regarding yung sa inexplain ko lang ano yung mam kasi most of our most of the patients when whenever they are recovered na from the COVID tapos at some point they need to be tested again sample for work purposes tapos big lang nagpapositive sila they come to our clinics para mag-ask ng clearance or they don't know what to do kasi they they are positive again but for us naman if the required isolation day days for your COVID infection is already done you're considered to be non-infectious na so we we usually clear them for for work na po or return to their activities na so even if there is still positive RTPCR test it might mean that the detected viral particles are ready yung mga those that are yung mga patay na na viruses or just the viral particles not really active virus or not actively replicating viruses so we ear them usually to return to work or to return to their everyday lives po hey thank you very much thank you very much Grace Marko kinakabahan ka ba na na nakahawa ka pa? sorry po na yung kabahan na nakahawa? actually mam ako po hindi naman na dahil prior to this meeting yung pinoprosess ako po yung papers ko for me to return to work nag swab test naman ako and sa hospital pa lang naman po sinapinasakir na hindi naman na po ko nakakahawa hinyalang po hinyalang and then nag antigen din po ko negative na mat tapos yung nagparapid test din na po for antibody testing niya po nag positive po ko sa IgG and sa negative naman ko sa IgM which na explain naman ko sa ame ng HR na kailangan lumabas namin is yung sa IgM na negative yun naman po yung lumabas pero for for me it was clarified to me po when I got out of the hospital na I'm no longer infectious to others but still nandun po yung pag-al na kailan ba ko baka mamaya kasi because of the cavity I was warned na baka to stay out of humid areas kasi nga po baka magkaroon ako ng foaming infection and yun lang po yung worry ko na baka dahil po dun sa COVID is mas maging prone po ako sa mga sakit yun nga po siguro with the help of the doctors that has worked with me siguro po it would be wise for me to ask for their advices okay so maybe we'll ask our doctors to give you some advice kasi it's a question that's in the Q&A na parang may isang question na po after diagnosis of COVID one man inubukapa nakakawa kaba so let's go maybe we'll throw that to Ralph to Gia and then to to Grace go ahead so if we follow the time course of the COVID talaga Marco na if you follow the time course you should be clearing your infection in two weeks time na that's the basis of the recommendation I think it's a universal recommendation even here in the Philippines that it's two weeks time na wawala talaga yung COVID and you have cleared that from your system but what you're feeling right now yung kaf mo we have an alternative explanation kasi for example ilalang kami alternative explanation for the symptoms that persist it's I think safe to say that you are not infectious anymore plus the fact na nagswab ka na negative and the fact na IGG na yung anti-bohalismo so kung bagad madaming madaming madaming evidence na you should not be worried about you being infectious already thank you Dr. Villalobos Dr. Gia go ahead siguro Mark ang kailangan ko lang ma-emphasize dito is the importance of you being able to communicate with your doctor pag ming mga ganyto kang concerns so siguro kagalang magbasa sa mga internet ganyan kasi lalo kang mas-stress ay we always tell that to our patients before they come to us they've searched already Google and stuff and then lalo silang na mas-stress ka kabasa ng mga ganyto so I think it's safe to palagang ask your doctor about it kung meron ka mga concerns and even your family regarding the symptoms kasi alam naman natin na talagang everyone mentally talagang in terms of COVID really don't know its course pa kahit may mga evidences na as of now it's safe to say na hindi ka na nakakakahawa so that's one good thing na pangkahawakan mo talaga and if you have any more questions about it just feel free to reach out to your doctors and be able to communicate with them okay Grace go ahead I just want to emphasize that COVID is a relatively very new disease actually I'm very fortunate in my fellowship training na nakakahabot ko ako sa pandemic season na experience ko kung panong magkaroon ang isang pandemic so ang ibig ko lang kung sabihin ay whatever it is that we know right now probably after a few months or a few years hindi natin alam kung ito pa rin ba yung magiging tama so constantly lahat ng doctors ay nag-check ko na mga studies ng scientific evidences para husa aming kaalaman din para meron kami makakakontribute din sa aming mga patients so kailangan lagi pa rin tayo lahat maging updated sa mga researches para yung maibahagi natin information sa mga patients natin ay maging appropriate tama so for Marco Mr. Marco I'm really glad you're okay kasi yung nakita ko sa kanya during his hospital stay he was really in a bad shape at that time so I'm really glad na wala ka ng oxygen yung mga symptoms mo ngayon basa sa mga pagaara especially with what your lungs have been through kung makikita mo lang yung city scan mo so yun lang so hopefully makabalik ka na sa trabaho kasi yung talaga yung goal natin for all hospitalized COVID patients yung magbalik sa normal life or as much as possible close to normal man lang hopefully eventually you'll be able to play sports again pagmaskaya na nang long sa chapa ng katawan Thank you very much Grace Raymond, I think we're going close to the top of the hour maybe we can look at our mentimeter and ask our doctors to answer the questions go ahead Raymond Okay, thank you doctor Susie so just like our previous virtual grand rounds we often flash this on the screen it serves as our pre-test and then thereafter our post-test the expectation is that our resource persons will also be the ones to answer the questions this one I will throw to doctor Astudillo young adult COVID positive patients on day 28 with severe difficulty of breathing what should be considered po is it pulmonary embolism hospital acquired pneumonia young COVID syndrome or all of the above well definitely not long COVID syndrome kasi more than 12 weeks po of symptoms persistent symptoms yan so probably either mas common po ang hospital acquired pneumonia and pulmonary embolism Okay, thank you doctor Grace and then for our second question this one I will throw to doctor Villalobos young adult COVID positive patient on day 28 again with severe difficulty of breathing the diagnostic tools that should be used are X-ray CT scans beauty and culture all of the above what's the correct answer sir? Very good ng audience natin almost all of them answered all of the above and they think you have to have all these tests to be considered Okay, very good Raymond we're gonna post the evaluation form now but go ahead Raymond Thank you so much so we have five questions here this is an assessment po of your assessment of the webinar based on the following questions the panelists demonstrated of the case study it's just a four point strongly agree, agree, strongly disagree the same question on well preparedness and organization number three the panelists spoke clearly and audibly the panelists is appropriate language with technical medical jargon adequately explained and last but not the least the panelists contributed to new perspectives and knowledge on managing various key COVID-19 health issues we are seeing a little less than 500 attendees a little... lumakasta po ng 500 but we hope that for those who are still in the webinar numbering a little over 1260 to please answer po assessment of the final discussion Okay, thank you very much Marco, is your family watching right now? Okay, so your mother is watching again I'm gonna ask the panelists to give their parting words for the family of Marco so we're gonna start with Dock Gia So for Marco's family po I do would understand ano yung pinagdaan na nang panel so it will be very difficult but you've survived and that's a good thing siguro from this day on talagang medyo magiking conscious na tayo in terms of our health-seeking so you're closer probably by this time because you've gone through this crisis but the good thing ka-survived kayo nang maayos and saan na ma-value pa rin talaga yung always putting premium to prevention and health promotion so I would do encourage na please do coordinate or communicate feel free to talk to your doctors to your provider kahit through telemedicine as long as makakaritch out tayo for any medical concerns medical, even psychosocial mental or social concerns that you may have for your family Thank you very much Dr. Gia let's go to Dr. Ralph Dilobos, go ahead Ralph Hi Marco, so kaka kita lang natin face to face na this week na so don't worry you will recover because you're a young individual and then what's important here is kilangan mo lang magpakatagang guys always agree with Dr. Gia you have to follow our recommendations and I think we talked about having your vaccine so I think it's a good idea for you, your family for everyone to have the vaccine already since you're already it doesn't mean that if you had COVID you are spared from another COVID and if you're clear of COVID already it's a common question na mga tao you ask me about when I can give you the vaccine you are already clear for vaccination since you have already recovered from COVID Thank you very much Dr. Ralph Dr. Grace, your message for the family My message really is for them to be vaccinated it's one of our strongest weapons for pandemic so if you can please do consider vaccination and not just one dose if you need a second dose finish the vaccination and also follow strict protocols to prevent acquiring or spread of the virus Thank you very much Grace Doc Stella All of the panelists were advice already it's just that I just want to emphasize parang silang plaka na tayo sa social distancing, hand washing, hand hygiene pero actually yun yung ane yun yung ginto dito it's the goal practice the advice na health protocols too simple and it will save your life and also your family ako, I go to PGH every day atinatanggal ko lang yung mask ngayon dahil sa webinar pero naka mask and shield ako until I get home it's not even if it's a COVID referral center lahat kami dito we go to work physically face to face, we are here you have to overcome the fear kasi of the virus if you practice all these precautions we're good we're on the right track and thank you for coming over and participating I can see your difficulty of breathing and talking we're grateful we thank you and we appreciate your presence here Thank you Doc Stella Marko, just a few words for the audience anong advice mo sa mga nanonon ako ang advice ko lang if there are participants here non-medical ko when I was in the hospital I saw an ad regarding I can't breathe ang nag-re-reclam mo sa face mask and face shield ako, don't wait for oxygen for you to say na ang hirap kumina kasi when you're there talagang ang hirap kumina tiyisin nyo na po ang face shield at saka yung face mask and follow the protocol that the medical expert are all telling us here na ito lang po talaga inya po sinasabi ko po is ako nga po nag-i-ingat talagang every now and then sanitize po ako but still I contracted the virus so please follow ko natin yung protocol na yun where always the face mask and the face shield and maintain the social distancing that's the only thing that would prevent or lessen the fact that you can be infected by COVID talaga ko thank you very much Marko and we are all going to be praying for your recovery your doctors are saying you're well on the way to recovery and I hope we wish you the best in the rest of your journey Raymond let's introduce our closing remark speaker go ahead okay so for our closing remarks we are okay so habang ini-introduce po natin ang closing remark speaker we are very happy that a lot of you majority of you answered our assessment poll so maraming-uraming salamat po and to just bring everything tie everything up together and bring everything to a close may we call on the Dean of the College of Medicine of the University of the Philippines Dean Charlotte Chong for the closing remarks po Dean Charlotte hello can you hear me yes we can hear you Dean go ahead ma'am well we are now on the 54th webinar to go back to our ground routes format so basically what we found out is a patient who was relatively young at 36 years old who actually came to PGH as a referral because the hospital where he was confined no longer handled his case and it's very typical of actually what's not the situation is in the country yesterday I lost my elementary classmates and basically was also in a very small hospital and for 14 days and then he had difficulty breathing so he went to the Bulacan Medical Center and had to undergo a chest CT but couldn't be done right away so he asked the family to transfer him to PGH which I did but after basically three days in the hospital despite the fact that we did so yan meron kaming meron kaming necrological service for him tonight he's 60 years old he just had his birthday last May 8th so it's really COVID still out there and so for even young patients like Marco nakita natin how one can still be affected despite all the precautions that he has followed and I suppose they are born and we still really do not know whether he might have had some comorbids that he was not aware of because he had diabetes when he got to the hospital one is to look at our health care system of course so the referral network is very important and of course sabingani dr. limpoco it's the family we have to be able to assign a safety officer within that family who will be constantly monitoring the patients and reminding them about health protocols and if one develops kaita mild symptoms I think that person has to already be isolated or quarantined from the rest of the family and they have to practice the two meters distancing and being able to not share common area and so forth at the same time and if positive then perhaps others will have to be quarantined as well at least for one week so that we know whether one will not develop the symptoms so I think for the young people it was also emphasized by dr. graces to do that there could be other associated problems that one might not be aware of like if you are a smoker a strong association with actually developing severe COVID there are of course aside from just the infection the development of hospital acquired pneumonia which will entail antibiotic treatment IB antibiotic treatment and of course with a non-improving shortest of breath one has to of course rule out pulmonary embolism kaya lang, gold standard ang pulmonary embolism CT scan with pulmonary andrography and our hospitals up there probably will not have that capacity and so one has to be aware kung hindi gumagaling ang patient maybe that patient will have to be referred to a higher care facility so that this can be also ruled out we have already heard about the post acute cepweli of COVID-19 where one might have cognitive problems like brain fog and the long haulers who will have difficulty of breathing for a long time and we are seeing that in Marco na meno siya difficult of breathing up to now despite the fact na hindi na siya positive for COVID so he has been advised to always follow up with the doctors and be monitored and we can see here that as emphasized by doctor din poko by the Philippine Academy of Family Physicians very important for each family to have a family doctor babalikho siguro tayo sa sinang una nung tayong populasyon ng Pilipinas ay hindi pa masyadong malaki dahat po ng pamilya may family doctor at ito po yung nilalapita nila every time they have problems sa ngayon although we do have telemed and we can also access specialty care, I think it's important to go back to that old tradition of having a family doctor in that family who can basically advise you about prevention and health promotion palaikho with universal health care may yali yan Doctor din poko also told us that there are now partnerships between chapters of the Philippine Academy of Family Physicians as well as the LGUs I think this is a good practice because that means that our professional societies, even family doctors are now partnering with LGUs because when universal health care goes out, it's going to be that every family, every Filipino family will have to have this home kung saan sila po punta for everything and that there has to be a referral of network and that's how you improve or strengthen the health system so I think that is also a good possible possible practice although we also know that perhaps professional societies will not have too many chapters tamaran ang importante doan there is an advocate in that professional organization who can handle these things we thank Dr. Ralph Villalobos for actually being able to again clarify a lot of questions in our minds showing us the data of the CBC and the data of PGH that if you're young it doesn't mean that you cannot die from COVID even young people can die from COVID which is much highlighted by Dr. Ralph Villalobos and we thank him for that and I really like the way that he tried to tell us that there is already a protocol for anti-coagulation in order to prevent trauma embolism following COVID-19 and his advice to Marco na kahit na naka COVID ka Marco you still need to get vaccination and so I think that's a very important factor meron na lang anti-bodies nini na sila nag-iingat ang yung mga kasamala sa bahay hindi na rin nag-iingat so what we need to emphasize here is that even if you already contracted COVID it doesn't mean that you cannot be infected and although you might not get sick because of the anti-bodies that you have it doesn't mean that you cannot transmit it because we still do not know also the transmission of COVID-19 infection and post-vaccination as well that's why the minimum public health standards we always have to be followed everywhere, anywhere you go sa bahay, ang importati no mixing of falsehoods we still do not want parties or families happening and even if you may kapit-bay ng hihingi let's say ng yellow this morning may nang hihingi ng yellow sa bahay na namin nakita ko hindi nag-mask na pasok ng help so I actually reprimanded them na hindi pwedeng walang mask because I have my 95-year-old mother with me so and people are wondering papano pa mga baka ka doon ang COVID-19 na 95-years-old na rando na sa room niya na hindi naman umalais that's still a question in so many people's mind pero nang yayari po nga kasi the caregivers go out to eat to the others nag-kakuntuan sila and so it can still be transmitted until we get the herd immunity from the vaccination that we are aiming for I think it's important for everyone to always be very careful and stick to the minimum public health standards we now have telemed we have PGH telegabai we have 1-5-5-200 na pwede nipuntawagan sa PGH and even the UP Health Service also does also tele-consultation so in UP alone madami po mga groups nito willing to help anyone who has questions about COVID you just contact us and I was very much touched by the sharing of one of our staff no, Miss Agnes Mejia at nakikiramay ako sa you Agnes dahil na matayang daddy mo ang tatay mo dahil sa COVID at tama ang sinabi mo na dapat talaga lahat ng tao ay mag-ikingat dito because COVID really is something na hindi pa rin natin talaga na susupo hangga ngayon and therefore talagang kailangan mag-ikingat nakikita rin natin dito yung may kuwanti talagang delay ninsang it takes 5-7 days before they get a swab test where lucky in PGH sometimes you can get the results of the swab testing within 4 hours or within 12 hours or within 24 hours pero as you know at kung healthcare system ay iba may mga laboratory na kaya nilang ibigay yung resulta na maaga pero may mga laboratory na mas matagal dila mailabas kaya ang importanto dito pa ninyo nakukuha yung test wag huwag kayo mag you have to isolate yourself na kahit na wala pa yung test results kasi huwanta yung yung punglumabas yung bago tayo mag-isolate at you want a confirmation for your COVID bago kayo mag-isolate medyo mahirap ko yan kasi baka na hawa na punay nyo yung iba because according to Dr. Virial Lobos and we knew this early on in COVID you are most infectious 1-2 days even before you develop the symptoms of COVID so pag kami nalamang possible exposure ibig sabihin noon pwede nag-transmityan ng virus kahit hindi mo pa alam na may symptoms ka na pala ng COVID and that's the reason why it's been very difficult at PGH the symptomatic carriers was established at around 20% people who did not have symptoms who had antibody testing were found to have the antibodies against COVID and they could not recall kung kailan sila na kanala symptoms and I'm one of them ang hindi ko alam kung kailan ako nag-COVID because when I had my antibodies tested namin na pala ako antibody against COVID but you cannot recall having any of those symptoms so I think this is the reason why we all have to still ascribe to the minimum public health standards and we have to emphasize wag na po kayo mag-hesitate na mag-kabakuna because vaccination is something that we all should do in order for us to get that herd immunity so that we can get out of this quagmire of COVID-19 being still spread around in our communities there was a comment about fungal infection after recovery from COVID yam po ay isang malaking problema sa India because sa India ako mga 27 million na po yun naging kaso of COVID-19 at may mga namamat ay po sa Black Fungus at sinasabi na po doon na dapat ay mag-declin na na second epidemic hindi lang COVID-19 epidemic pero we also have a crisis epidemic wag na po nating hantahin mayariant sa ating bayan kasi napakahirap ko gamating yam you for my causes or fungal infection of Black Fungus after COVID and we also have to be careful with our borders kasing na po yung Indian variant na yan pagpumapasok ko sa bansa natin inabantayang po natin mabuti kasi baka big lang fumalat na po and that's the reason why even if some people let's say could be vaccinated already they can still have COVID-19 especially if the variant of concern that actually affected them is not something that the vaccine have sensitivity against so yung po ang importante so I think this continuing webinar series of TBUP is something that we ought to still follow we'd like to thank of course the organizers at TBUP we'd like to thank Dr. Susi Pineda and Dr. Raymond Sarmiento for hosting this it's really something that is of value we can see here that we still have more than a thousand people watching our webinar it's still of value to our healthcare workers all over the country and even abroad for us to be able to share new findings or our experiences with COVID and I really like the way that our patients like Marco and Agnes are able to share their personal experiences because I think it makes it closer to home I don't think there's any family that's not been affected when I look at May 5 March 5 last year when I lost one of my really close friends which I didn't think was due to COVID because it's a heart attack but now looking at the deaths from COVID I could think I could now say na probabing na baka COVID yung kinamatay niya and then I lost my classmate just yesterday so let's all be careful and let's continue to learn more about this disease let's all go get vaccinated thank you for allowing me to give the close of your marks thank you very much that's Dean Charlotte Chong of the U.P. College of Medicine and our condolences to you also Charlotte for your losses and for all of those who are in our audience who have lost somebody they love I've seen a couple of postings na a kikiramay po kami alam namin kung napakahirap na itong dinan daanan natin so na kikiramay po kami Raymond you wanted to do a post test to get people to answer the questions again yes just for obviously because this is a learning series we want to be able to hammer on to our audience the learning spono and one way of doing that is to be able to participate in this post test it's essentially the same set of questions that we ask for the pre-test and we hope that there's well a whole lot more of our audience already knows the correct answer for the questions lang po I will just reiterate the questions and the options before we do our closing for question one yung adult COVID positive patient on day 28 with severe difficulty breathing ano kung mga diagnosis ang kailangan kung may consider and the answers are the options are listed here we are seeing a whole lot more gravitate towards the correct answer for the second question yung adult COVID positive patient on day 28 with severe difficulty breathing again but what are the diagnostic tools nagagamitin po para malaman kung ito po ay COVID-19 so maraming-maraming salamat po and also it's not everyday that we get to have one of our patients po in our virtual grandals to participate in the discussion so not everyday that we get to hear sharing of personal experiences from everyone who is on the panel so maraming-maraming salamat po and also just to reiterate Dean Charlotte's message so that everyone will seek and be willing to be vaccinated as soon as possible over to you Dr. Suzie okay thank you very much everyone we hope you learned from our session today and next week okay ito na yung ano natin Dr. Tedder Bosa was telling us that only 11% of senior citizens have been vaccinated so siguro next week pag-usapan natin paano natin po convince hensy nana ito ka si Tata yung si Lola na magbabakuna and we're going to have Dr. Shelley de la Vega she's just confirmed that she's going to join us we have to continue to protect our seniors but as the message has been throughout this webinar is that it's not only the seniors but everyone needs to be protected so again this is a call for you to encourage all your patients all your family members to be vaccinated Reymond over to you thank you so much Dr. Suzie so that concludes our webinar 54 for those who are asking to be able to watch this on the playback and the YouTube channel of TVUP we also you also will be able to do that in the Facebook pages of University of the Philippines TVUP and the stuff COVID deaths Facebook pages we also would like to again show our deepest gratitude to our panelists our research speakers especially Marco Cordova for being able for willing to share his experience as a COVID-19 survivor so again next week same time from 12 noon to 2 pm every Friday makita kita po tayo let obviously we were very happy to see our attendee all the way from Michigan so sana po makasali po tayo let next week it's a date together we can stop COVID deaths so keep safe, keep healthy and see you online me remains unseen I'll keep your hand in mind let's say a prayer one more time I know you long for home but I am here you're not alone let's stay with you until the coast is clear the other's pain before my fears the other's lives before my tears but right behind the mask I look into myself and ask do I have strength to carry on my God our Lord what's this going on and leave you here to keep me strong I'm here to hold the line I'll keep my word until my his name to realize it's fine to be afraid just hold on to the word he gave this time we'll come to pass cause this salvation makes a last you'll carry you to see the break of day the other's pain before my fears the other's lives before my tears but right behind the mask I look into myself and ask do I have strength to carry on my God our Lord what's this going on he's strong I'm here to hold the line I'll keep my word until my his name to realize the other's lives before my tears but right behind the mask I look into myself and ask do I have strength to carry on if you're here to keep me strong I'll keep my pain before my tears I'm pushing on the spite of tears these things through another day