Think Global, Act Local

Editorial

Abstract

In the Philippines, many people would think that items made in other countries have better quality and are more desirable.
More recently, with numerous goods coming from nearby countries also having built their reputation for similar or even better
quality – for example, those coming from Japan, Taiwan and more lately, China – goods from these countries are now also
popular. But it remains unusual that we would generally prefer local brands, i.e., those made in the Philippines.
When it comes to using scientific evidence as basis for local medical practice, it should be argued that high quality local
data is superior and should be used. After all, it is derived from our countrymen who may have a different disease biology and/
or natural history, sociocultural determinants, as well as clinical practices. It is unfortunate, however, that such local data are
not always available. Even if it exists, it is also not easily accessible.

In this, and other issues of Acta Medica Philippina, we see some of the efforts being made by our colleagues to look into
this local experience. They offer varied insights into how global diseases are manifested locally: are there differences that we
should be aware of?

As far back as 2006, the Philippine Council for Health Research and Development (PCHRD) has already facilitated
the creation of a National Unified Health Research Agenda (NUHRA) which is reviewed every five years to identify
research priorities in the Philippines.¹ In its latest iteration, the 2017-2022 NUHRA prioritizes among others, the holistic
approach to health and wellness that aims to produce evidence geared towards the application and recognition of traditional,
sociocultural, and alternative approaches to health.²  The study by Sanico and Medina in this issue highlights this objective.
It looked into the potential health benefits and risks of an indigenous fermented rice wine called tapuy. Utilizing a modern
biotechnology technique called metagenomic sequencing, the authors found significant presence of probiotic bacteria that
can be explored for health applications. However, they also detected the presence of harmful bacteria which may indicate the
need for possible standardization of the fermentation practices.

The Acquired Immunodeficiency Syndrome (AIDS) has long plagued the global landscape ever since it was first described
in 1981.³  Because cases have not been described previously, AIDS with its increasing numbers, was soon labeled as an
epidemic.^4,5 In the Philippines, the HIV/AIDS epidemic has been a fairly more recent one.^6-9 Sadly, our country is now
identified as one with the fastest growing HIV epidemic in the Western Pacific.¹⁰ Identifying perceptions of the general
community, especially the high risk populations, can go a long way in curtailing the rising numbers.¹¹ The article by James
and colleagues looked further into this by evaluating the knowledge, attitudes and practices on prevention and transmission of
HIV/AIDS among college students in Pampanga, Philippines. The participants were found to have a low knowledge of HIV/
AIDS, but had a good attitude toward HIV positive individuals. The authors recommended that education on HIV/AIDS
could help control the local epidemic.

The study by Rogelio and Santiago looked into screening for retinopathy in patients with gestational diabetes mellitus
(GDM). Their data did not support screening to be done in this population. A study had previously reported that GDM has a
prevalence of 14% in the Philippines making GDM a disease that is worth addressing.¹² On a related note, several international
guidelines define how GDM can be diagnosed.¹³ The Philippine Obstetrics and Gynecology Society advocates for a one-step
approach (a single OGTT using a 75-g anhydrous glucose load with fasting blood sugar ?92 mg/dL, and a 2-hour level of
<126 mg/dL). The one-step approach may be more convenient for patients as it also needs a single visit. A recent report from
Australia, which also follows a one-step screening process, showed at least a 25% overdiagnosis and its consequent need for
further testing and the patient anxiety that goes with it.¹⁴ An earlier US study also showed 50% more women diagnosed with
GDM using the one-step approach compared to a two-step one.¹⁵ To be fair, the US study, similar to another one done also
in Australia, showed no significant differences in the pregnancy outcomes between the two approaches.¹⁶ Although a local
study identified numerical differences in pregnancy outcomes (e.g., risk for primary caesarean section, large for gestational age
infants, etc.) comparing the two criteria, these were not found to be statistically significant.¹³ Perhaps there is a need to look
into this matter again using larger cohorts. As the Philippines gears up for Universal Healthcare, the outcomes of screening
for GDM can become even more important.

The article by Arcilla, et al., on validation of foreign instruments to assess disease and treatment outcomes represents
another area where local data is needed.¹⁷ Such validation seeks to investigate whether an instrument developed elsewhere will
likewise yield accurate – and comparable – data for which it was intended. The BREAST-Q is a patient-reported outcome
instrument designed to evaluate outcomes among women undergoing different types of breast surgery.¹⁸ The authors found
high internal consistency, test-retest reliability, and acceptability. But there was only low to moderate construct validity in
the Filipino cohort. Among other findings, the authors report respondents having difficulty in understanding some language
translations, and even negative reactions to some of the questions. The authors recommend further studies with a larger
number of respondents including those who have undergone nipple reconstruction. The initial results also note that it may be
better to interpret the “sexual well-being” subscale separately because of the influence that culture may play.

The study of Manalili, et al. looked into hemoperfusion as an intervention for COVID-19. The authors report a high
mortality and a long length of hospital stay. To put this into perspective, the period of study was from April to September 2020,
early in the pandemic period when little is relatively known about the disease. Since then, we know more about COVID-19,
with vaccination and anti-virals being available that could alter the disease severity. As of December 2021, local experts do
not recommend the use of hemoperfusion among patients diagnosed with COVID-19 mostly because of low certainty of
evidence.¹⁹ The option to use it in COVID-19 patients with clinical deterioration despite standard medical therapy including
tocilizumab is however still suggested. The study published here would have been more interesting if there was a comparison
of the outcomes with a similar group who did not undergo hemoperfusion. But it certainly illustrates how generating local
data and local experience goes a long way in examining relevant medical practice/s in our Philippine setting.

Case reports help to enhance clinical knowledge by describing the profile and management of patients who have an
uncommon or rare disease or may have presented atypically.^20-22 We have the opportunity in this issue to share four of these
rare cases. The report submitted by Terencio, et al. on the combination of COVID-19 and Guillain-Barre syndrome (GBS)
allows us better understanding of COVID-19 and its neurologic complications. As we continue to gain more important
information on COVID-19, describing the possibility of GBS as a possible consequence can help clinicians anticipate additional
treatments as in this case. The same is true for the report submitted by Ablaza and Salonga-Quimpo on abdominal dyskinesia
(with its more colorful description as “belly dancer dyskinesia”).

Then we have the case of SOLAMEN syndrome, reported by Maceda and colleagues. This case is more dramatic in that
it presents with disfigurement of the patient. Its management is more nuanced as it requires a multidisciplinary approach
to address all the affected body parts.^23,24 Unfortunately, it also has a strong genetic component as well as predilection to
malignancy which would require longer-term care. Another genetic disease, X-linked dystonia parkinsonism, is likewise
reported in this issue in the article by Jamora and others. It is a rare movement disorder that is highly prevalent in Panay Island
in the Philippines.^25-28 All cases described so far have been linked to Filipino ancestry, suggesting a single genetic founder and
genetic homogeneity. Although extremely rare globally, the prevalence of XDP in the Philippines is 0.31 per 100,000; and in
Panay Island, 5.74 per 100,000. Ninety-five percent of affected individuals are males; the average age is 44 years (20–70 years);
and the average age at onset is 39 years (12–64 years).²⁷ Cases in patients of Filipino descent have been described in other
countries.²⁹ The report published here is of particular interest as it is the first time the procedure called Unilateral Transcranial
Magnetic Resonance-guided Focused Ultrasound Pallidothalamic Tractotomy has been tried for this condition; a condition
which leads to significant progressive disability but no definite treatment.²⁷

All of these case reports may well be the first ones in the Philippines and we have it published here in Acta Medica
Philippina.

I am certain there will be many more insightful studies done locally that will be published – and had been published – in
this journal. These are testament to the recognition that even as we are able to think following the highest global standards,
we are also able to act (and do studies) locally in ways that are beneficial to our own Philippine community.

                                                                                                                        Joven Jeremius Q. Tanchuco, MD, MHA
                                                                                                                       Department of Biochemistry and Molecular Biology
                                                                                                                       College of Medicine, University of the Philippines Manila

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