Hemichorea, a hyperkinetic disorder characterized by involuntary, rapid, irregular movements on one side of the body, typically originates from cortical basal ganglia involvement, particularly the striatum. We present a 63-year-old Filipino female with poor glycemic control and known idiopathic myelofibrosis exhibiting chorea-ballism movements in the right distal and proximal extremities. Significant improvement in involuntary movements was observed upon optimal glycemic control and benzodiazepine therapy. This report underscores the noteworthy presentation of uncontrolled hyperglycemia in type 2 diabetes, while highlighting the potential contribution of myelofibrosis.

BACKGROUND AND OBJECTIVE

The Philippine Package of Essential Noncommunicable Disease Interventions (PhilPEN) was introduced by the Department of Health through AO 2012-0029. This is anchored to WHO PEN, a prioritized set of cost-effective interventions that can be carried out to provide an acceptable standard of care at the primary health care level, even in low-resource settings. The study aims to evaluate the availability and adequacy of primary health care facilities in providing the PhilPEN package of interventions using the WHO assessment tool.

A cross-sectional survey was conducted in 25 randomly selected primary health care facilities in Metro Manila. Data were collected through structured interviews with facility staff and direct observation using a standardized questionnaire aligned with PhilPEN and WHO PEN guidelines. The tool assessed PhilPEN inputs (infrastructure, human resources, basic tools and equipment, essential medicines, record-keeping, financing) and services (risk assessment and screening, early diagnosis and monitoring, treatment and follow-up, counseling, referral of patients).

All facilities met the basic standards for infrastructure, human resources, record keeping, and financing. However, only 40% had all essential medicines, and just 16% had complete tools, including urine ketone/protein test strips. Risk assessment and patient counseling were consistently implemented, but early diagnosis and follow-up services were inconsistent due to training and supply gaps.

Primary health care centers in Metro Manila demonstrate partial readiness for PhilPEN implementation. Gaps in tools, medicines, and protocol availability should be addressed to optimize NCD service delivery.

Introduction: Insulin therapy is essential in the management of type 2 diabetes mellitus (T2DM), but is often associated with treatment burden, hypoglycemia, and potential overtreatment. Insulin deintensification is increasingly recommended for appropriately selected patients; however, there is limited real-world evidence to guide patient selection and to identify modifiable factors that influence successful insulin deintensification. This study aimed to identify clinical predictors, including modifiable factors, associated with successful insulin deintensification in a primary care setting. Methodology: A multicentre retrospective observational study was conducted across seven government primary care clinics in the Petaling District. Adult patients with T2DM undergoing insulin deintensification were included. Successful insulin deintensification was defined as maintenance or improvement of hemoglobin A1c following insulin discontinuation, dose reduction, or reduction in injection frequency. Paired outcomes were analyzed using the Wilcoxon signed-rank test. Between-group comparisons were performed using the Mann–Whitney U test and Chi-square or Fisher’s exact test. Multivariable logistic regression was used to identify independent predictors of successful insulin deintensification. Results: A total of 261 patients were included. Glycemic control remained stable following insulin deintensification (p = 0.334). Significant reductions in body weight (−0.41 kg, p = 0.012) and total daily insulin dose (23.1% reduction, p <0.001) were observed. Univariate analysis did not demonstrate significant differences between groups. However, multivariable logistic regression identified SGLT-2 inhibitor use (aOR 3.23, 95% CI 1.28–8.18, p = 0.013) and regular SMBG (aOR 2.00, 95% CI 1.05–3.81, p = 0.035) as independent predictors of successful insulin deintensification. Conclusion Insulin deintensification can be successfully implemented without compromising glycemic control. Identified predictors, including modifiable factors such as SGLT-2 inhibitor use and SMBG, provide clinically actionable insights to guide patient selection and treatment optimization. These findings challenge the traditional reluctance toward insulin deintensification and support a more evidence-based and individualized approach in routine clinical practice.
Primary Health Care ; Insulins

Introduction: Insulin deintensification is an emerging strategy to reduce hypoglycemia and treatment burden in patients on multiple daily injection (MDI ≥3), with potential to improve adherence and glycemic control. However, evidence in poorly controlled type 2 diabetes mellitus (T2DM) remains limited. This study evaluated its effectiveness and identified factors associated with achieving adequate glycemic control following deintensification among patients with poorly controlled T2DM attending Malaysian primary care. Methodology: A retrospective cohort study was conducted among 107 T2DM patients with hemoglobin A1c (HbA1c) >9%, attending Enhanced Diabetic Clinic at Cheras Health Clinic between 2021 and 2025. All patients on basal-bolus insulin (BBI) underwent deintensification. Multivariate logistic regression was performed to identify factors associated with achieving adequate glycemic control (HbA1c <7.5%). Changes in HbA1c following deintensification were assessed using paired t-tests. Results: Overall, 50.5% of patients achieved adequate glycemic control. Hypoglycemia events (AOR 9.5, 95% confidence interval [CI] 1.6–58.3; p = 0.015), MDI (AOR 9.6, 95% CI 1.4–67.1; p = 0.023) and Diabetes Medication Therapy Adherence Clinic (DMTAC) visits (AOR 1.1, 95% CI 1.0– 1.2; p = 0.039) were significantly associated with achieving HbA1c <7.5%. Conversely, patients transitioned from BBI to premixed regimens were less likely to achieve HbA1c <7.5% (AOR 0.22, 95% CI 0.05–0.93, p = 0.039). All insulin deintensification strategies were associated with significant HbA1c improvements with transitioned from BBI to premixed human insulin (mean difference -2.54%, 95% CI 1.77–3.31, p <0.001, Cohen’s d = 1.09), BBI to premixed analogue insulin (mean difference -3.38%, 95% CI 2.26– 4.49, p <0.001, Cohen’s d = 1.62), BBI to basal insulin (mean difference -3.67%, 95% CI 1.79–5.54, p = 0.004, Cohen’s d = 2.05). Conclusion Insulin deintensification is an effective strategy for improving glycemic control in poorly controlled T2DM. These findings highlight the importance of deintensification with careful consideration of hypoglycemia, MDI-related treatment burden, and patient engagement through regular DMTAC visits, which are integral to achieving optimal outcomes and support a personalized approach to diabetes management in primary care.
Diabetes Mellitus, Type 2 ; Glycemic Control ; Retrospective Studies ; Primary Health Care ; Insulins

Ischemic heart disease (IHD) remains the most common cause of death while cerebrovascular disease (CVD) is the third most common in the Philippines. IHD and CVD represent complications resulting from prevalent non-communicable diseases (NCDs) and risk factors which present important opportunities for primary and secondary prevention.

This study aimed to pilot a sustainable multisectoral approach for community-based screening and management of cardiovascular (CV) risk factors and determine the effects of a multisectoral collaboration approach on the rate of screening, prevalence and control rates for selected risk factors.

This is a quality improvement project that determines the baseline prevalence and control rates of CV risk factors followed by intense screening efforts with support from private partnerships. The project's core components are: (a) capacity building (b) information dissemination; (c) service provision; and (d) health monitoring. Rates of screening, prevalence and control were monitored over a two-year period.

A total of 94,125 patients were screened through the ONE Cavite Project over two years (January 2021 to December 2022). A total of 61,271 were newly identified as having hypertension (65.1%), 24,069 diagnosed with diabetes mellitus type 2 (25.6%), 29,257 diagnosed to have dyslipidemia (31.1%) and 13,204 smokers (14.0%) were identified.

Intensification of screening was successful in improving identification of individuals with NCDs. The impact of continued educational support for both providers and patients in this study reaffirmed its role as a central component of NCD diagnosis, management and prevention.

Ischemic heart disease (IHD) remains the most common cause of death while cerebrovascular disease (CVD) is the third most common in the Philippines. IHD and CVD represent complications resulting from prevalent non-communicable diseases (NCDs) and risk factors which present important opportunities for primary and secondary prevention.

This study aimed to pilot a sustainable multisectoral approach for community-based screening and management of cardiovascular (CV) risk factors and determine the effects of a multisectoral collaboration approach on the rate of screening, prevalence and control rates for selected risk factors.

This is a quality improvement project that determines the baseline prevalence and control rates of CV risk factors followed by intense screening efforts with support from private partnerships. The project's core components are: (a) capacity building (b) information dissemination; (c) service provision; and (d) health monitoring. Rates of screening, prevalence and control were monitored over a two-year period.

A total of 94,125 patients were screened through the ONE Cavite Project over two years (January 2021 to December 2022). A total of 61,271 were newly identified as having hypertension (65.1%), 24,069 diagnosed with diabetes mellitus type 2 (25.6%), 29,257 diagnosed to have dyslipidemia (31.1%) and 13,204 smokers (14.0%) were identified.

Intensification of screening was successful in improving identification of individuals with NCDs. The impact of continued educational support for both providers and patients in this study reaffirmed its role as a central component of NCD diagnosis, management and prevention.

Introduction: Parathyroidectomy is the definitive treatment for primary hyperparathyroidism (PHPT) due to parathyroid adenoma. However, surgery may be contraindicated in patients with significant comorbidities. Ultrasound-guided percutaneous ethanol ablation (PEA) is a minimally invasive alternative that induces biochemical remission through targeted destruction of hyperfunctioning tissue. We report a case of PHPT successfully managed with PEA in a patient unfit for surgery due to cardiac dysfunction. Case: In 2023, a 53-year-old female with stage IB breast carcinoma was found to have persistent hypercalcemia (2.68– 3.59 mmol/L) during chemotherapy and post-mastectomy follow-up. Evaluation excluded bone metastases. Biochemical assessment demonstrated elevated intact parathyroid hormone (iPTH) levels 38.6 pmol/L (Reference: 1.6–6.0 pmol/L), hypophosphatemia (0.42–0.80 mmol/L), and elevated alkaline phosphatase (ALP) 215–309 U/L (30–120 U/L)—consistent with PHPT. Tc-99 m sestamibi scintigraphy localized a 1.1 × 1.5 × 1.2 cm hyperfunctioning parathyroid adenoma. Initial management prioritized oncological therapy, including trastuzumab for 1 year. Hypercalcemia was intermittently controlled with intravenous hydration and zoledronic acid when calcium exceeded 3 mmol/L. Her disease was complicated with severe osteoporosis (DEXA T-score −3.3) with vertebral fractures, renal impairment requiring cessation of alendronate, and medullary nephrocalcinosis on computed tomography surveillance. Following completion of cancer therapy, she was evaluated for parathyroidectomy. Preoperative assessment revealed NYHA class II heart failure, with reduced ejection fraction (36%) and severe tricuspid regurgitation attributed to trastuzumab-related cardiomyopathy. Despite optimal medical therapy, she was deemed high-risk for surgery. Cinacalcet failed to achieve sustained calcium control with levels exceeding 3 mmol/L. She was therefore referred for PEA. Post-procedure, iPTH decreased 80% by Day 5 (54.9–10.6 pmol/L), with sustained normocalcemia (2.25 mmol/L) at 10 days without further need for cinacalcet. Conclusion This case illustrates that PEA can serve as definitive therapy for PHPT in patients unsuitable for surgery. It provides rapid and sustained biochemical control, while avoiding operative risk, supporting its role in individualized management.
Hyperparathyroidism, Primary ; Ethanol

Introduction: Primary hyperparathyroidism (PHPT) is a common disorder that typically leads to increased bone turnover and reduced bone mineral density (BMD). Osteopetrosis, in contrast, is a rare, inherited disorder of defective osteoclast function, resulting in diffusely sclerotic but structurally fragile bones. The coexistence of both conditions is rare and can significantly alter the expected skeletal phenotype of PHPT. Case: We report a 77-year-old female with a previous history of resected ovarian carcinoma in remission, chronic iron deficiency anemia, and hypothyroidism. During a hospital admission for a lacunar infarct, an incidental finding of sclerotic skull lesions on computed tomography (CT) brain prompted further investigation. She had no history of fractures, hearing impairment, or family history of parathyroid or bone disorders. Biochemistry revealed parathyroid-dependent hypercalcemia with normal renal function. Bone turnover markers showed a normal resorption marker (BCTx) but an elevated formation marker (P1NP), with a mildly raised alkaline phosphatase. A sestamibi scan localized a probable left upper parathyroid adenoma, despite a negative neck ultrasound. Skeletal survey unexpectedly revealed widespread osteosclerosis of the skull, spine, and long bones, with a markedly elevated BMD on densitometry. Review of prior imaging confirmed that these sclerotic changes predated her current presentation, having been present on CTs from over a decade ago. Recurrent malignancy was excluded with repeat imaging and tumor markers. A diagnosis of PHPT secondary to parathyroid adenoma, coexisting with underlying, previously unrecognized osteopetrosis, was made. The patient declined both recommended parathyroidectomy and genetic studies. Conclusion This case demonstrates a rare coexistence of two pathologies with opposing effects on bone metabolism. The underlying osteopetrosis, characterized by defective osteoclasts, likely rendered the patient’s osteoclasts resistant to the catabolic effects of elevated PTH. This resulted in an atypically normal bone resorption marker and an unexpectedly high BMD, despite the diagnosis of PHPT.
Bone Density' ; Hyperparathyroidism ; Primary Osteopetrosis

Introduction: Primary hyperparathyroidism (PHPT) is frequently asymptomatic or detected incidentally; however, delayed diagnosis may lead to severe skeletal complications. Early recognition is essential, as timely identification and management of parathyroid disease can prevent significant morbidity, although diagnosis may be challenging when clinical and imaging findings are inconclusive. Case: A 46-year-old female with severe bilateral hearing impairment presented to the orthopedic clinic with 3 years’ history of bilateral knee pain and was found to have a right intertrochanteric femur fracture following minimal trauma. She was referred for evaluation of suspected secondary osteoporosis. She has had intermittent constipation and long-standing oligomenorrhea since menarche. There was no history of childhood fractures or use of medications affecting bone metabolism. Examination revealed bilateral knee bowing. Initial evaluation considered metabolic bone disease, including Paget’s disease; however, skeletal survey showed no features suggestive of Paget’s disease or multiple myeloma. Biochemical investigations demonstrated persistent hypercalcemia (2.65–3.1 mmol/L) with inappropriately elevated intact parathyroid hormone (peak 7.62 pmol/L), consistent with PHPT. Serum phosphate was low-normal. Concomitant vitamin D deficiency (25-OH vitamin D 34.46 nmol/L) improved following replacement. Bone mineral density confirmed severe osteoporosis (lumbar spine T-score −5, z-score -4.1); (forearm −6.7, z-score -6.1) reflecting prolonged untreated disease. Neck ultrasound demonstrated a mixed solid-cystic lesion posterior to the right thyroid lobe, suggestive of a parathyroid adenoma. The TC-99 m Sestamibi scan showed no definite focal uptake. However, subsequent SPECT-CT revealed focal tracer uptake at the posterior right thyroid gland, consistent with a hyperfunctioning parathyroid gland. Parathyroidectomy was done. Postoperatively, the calcium level normalized. Conclusion Severe osteoporosis and fragility fracture occur, reflecting prolonged exposure to excess parathyroid hormone and significant skeletal morbidity. Early biochemical evaluation in unexplained severe osteoporosis is essential, as timely diagnosis and definitive management of parathyroid disease are critical to halt ongoing bone loss and prevent irreversible complications.
Hyperparathyroidism, Primary ; Osteoporosis

Introduction: Hypercalcemic crisis, a decompensated state characterized by multiorgan dysfunction and a corrected serum calcium (CCa) level typically >3.5 mmol/L, is a rare but lifethreatening endocrine emergency that requires prompt recognition and aggressive multimodal management. We report a fatal case of hypercalcemic crisis secondary to primary hyperparathyroidism, which was refractory to multiple lines of medical therapy. Case: A 55-year-old female with diabetes mellitus, hypertension, and chronic kidney disease (creatinine 159 umol/L; estimated glomerular filtration rate 33 mL/min) presented with 3 days of confusion, profound fatigue, and constipation, preceded by a 1-month history of polyuria and polydipsia. Her Glasgow Coma Scale (GCS) was E4V3M5. Physical examination was unremarkable, with no palpable neck swelling. Significant laboratory findings included severe hypercalcemia with markedly elevated serum intact parathyroid hormone (iPTH) (CCa 4.49 mmol/L; phosphate 1.01 mmol/L; iPTH 60.1 pmol/L [N 1.6–6.0]; creatinine 149 umol/L). Saline diuresis was initiated together with subcutaneous calcitonin, resulting in an initial biochemical response, with CCa decreasing to a nadir of 3.61 mmol/L. However, the CCa subsequently rebounded to 5.00 mmol/L. Hemodialysis was performed, followed by administration of subcutaneous denosumab 60 mg. Nonetheless, the CCa decreased only modestly to 4.28 mmol/L. She became increasingly drowsy, and her clinical course was further complicated by aspiration pneumonia and lung collapse, leading to respiratory failure requiring intubation and inotropic support. Despite intensive care, additional sessions of hemodialysis and continuous renal replacement therapy, her CCa remained persistently above 4.0 mmol/L, peaking at 5.35 mmol/L. Due to her critical condition, imaging for lesion localization could not be performed. She eventually succumbed to her illness on day 10 of admission, before definitive surgery could be undertaken. Conclusion This case highlights the potentially fatal course of hypercalcemic crisis secondary to primary hyperparathyroidism. The reported mortality rate is high, at around 60%. Early recognition and intensive management, including emergency parathyroidectomy in resistant cases, have been shown to be crucial in improving outcomes.
Hyperparathyroidism, Primary