Knowledge and attitude towards HIV/AIDS among transsexuals in Kuantan, Pahang

Introduction: Lack of knowledge and negative attitude towards HIV/AIDS may be the risk factors for HIV infection among transsexuals. Research on knowledge and attitude towards HIV infection in transsexual communities is very limited at both local and international levels. This study aimed to assess the knowledge and attitude towards HIV infection among the male-to-female transsexual community in Kuantan, Pahang. Methods: A cross-sectional study was carried out from July to August 2014 among 33 male-to-female transsexuals in Kuantan, Pahang. Convenience sampling was used. Participants who gave consent answered a self-administered questionnaire. Data obtained was analyzed with descriptive statistics, χ2-test, and independent sample t test. Results: The majority of the subjects in this study were 29 years and below (48.5%), Muslims (93.9%), and had completed up to secondary education (60.6%). Most of them were sex workers (60.6%), and had relatively low income (no income to RM 3000, mean of RM1528). A total of 87.9% of the subjects demonstrated good knowledge and also positive attitude towards HIV/AIDS. Level of education was significantly associated with scores in knowledge (p=0.01). Conclusions: Despite the positive outcome from this study, misconceptions towards HIV/AIDS still exist among transsexuals. Education and interventions from multiple directions on HIV/AIDS are essential to deliver the correct information to this population, so as to emphasize prevention, early detection, and holistic medical care. Transsexuals also require attention from religious bodies and non-governmental organizations to help them in employment, financial, spiritual, and psycho-social issues

Cerebral salt wasting following traumatic brain injury

Hyponatraemia is the most commonly encountered electrolyte disturbance in neurological high dependency and intensive care units. Cerebral salt wasting (CSW) is the most elusive and challenging of the causes of hyponatraemia, and it is vital to distinguish it from the more familiar syndrome of inappropriate antidiuretic hormone (SIADH). Managing CSW requires correction of the intravascular volume depletion and hyponatraemia, as well as mitigation of on-going substantial sodium losses. Herein we describe a challenging case of CSW requiring large doses of hypertonic saline and the subsequent substantial benefit with the addition of fludrocortisone

Multi-disciplinary approach for managing plasmacytoma: a case report

Solitary plasmacytoma (SP) is a tumor with evidence of clonal plasma cells and no other features of multiple myeloma (MM). We report a case of SP which showed multiple recurrences of SP and then evolution into overt MM. A 56-year-old man presented with the 5-month-history of right nasal obstruction and intermittent epistaxis. He had SP (extraosseous) of right nasopharynx (3.5 × 2 × 2.5 cm), with no paraproteinaemia. He received radiotherapy (56 Gy), achieving complete remission. Ten years later, he had recurrence of SP (osseous) in left tibia, presenting with pathological fracture. He received radiotherapy (50 Gy), achieving partial response. Three years later, he had recurrence of SP (osseous) in right tibia, presenting with right leg pain. He received radiotherapy (45 Gy). While receiving treatment, he had progressive swelling in the area around right eye, double vision and headache. Imaging scans showed multiple plasmacytomas. There were presence of monoclonal paraprotein, hypercalcemia and lytic bone lesions. He was diagnosed as MM (at the age of 70 years) and treated with Bortezomib-based therapy. Currently, after one cycle of treatment, clinical improvement is achieved. The importance of multi-disciplinary team approach for managing patients with plasmacytoma is highlighted in order to achieve the holistic approach of management

Prostaglandin F2-Alpha Eye Drops (Bimatoprost) in Graves' Orbitopathy:A Randomized Controlled Double-Masked Crossover Trial (BIMA Trial)

Abstract Background: Previous in vitro experiments have demonstrated that prostaglandin F2-alpha (PF2α) reduced proliferation and adipogenesis in a murine cell line and human orbital fibroblasts derived from subjects with inactive Graves' orbitopathy (GO). The objective of this study was to determine if the PGF2α analogue bimatoprost is effective at reducing proptosis in this population. Methods: A randomized controlled double-masked crossover trial was conducted in a single tertiary care academic medical center. Patients with long-standing, inactive GO but persistent proptosis (>20 mm in at least one eye) were recruited. Allowing for a 15% dropout rate, 31 patients (26 females) were randomized in order to identify a treatment effect of 2.0 mm (p = 0.05; power 0.88). Following informed consent, participants were randomized to receive bimatoprost or placebo for three months, after which they underwent a two-month washout before switching to the opposite treatment. The primary outcome was the change in exophthalmometry readings over the two three-month treatment periods. Results: The mean exophthalmometer at baseline was 23.6 mm (range 20.0–30.5 mm), and the mean age of the patients was 55 years (range 28–74 years). The median duration of GO was 7.6 years (interquartile range 3.6–12.3 years). The majority were still suffering from diplopia (61.3%) with bilateral involvement (61.3%). Using multi-level modeling adjusted for baseline, period, and carry-over, bimatoprost resulted in a −0.17 mm (reduction) exophthalmometry change ([confidence interval −0.67 to +0.32]; p = 0.490). There was a mean change in intraocular pressure of −2.7 mmHg ([confidence interval −4.0 to −1.4]; p = 0.0070). One patient showed periorbital fat atrophy on treatment, which resolved on stopping treatment. Independent analysis of proptosis by photographic images (all subjects) and subgroup analysis on monocular disease (n = 12) did not show any apparent benefit. Conclusions: In inactive GO, bimatoprost treatment over a three-month period does not result in an improvement in proptosis

Longitudinal characterization of autoantibodies to the thyrotropin receptor (TRAb) during alemtuzumab therapy; evidence that TRAb may precede thyroid dysfunction by many years.

BACKGROUND Thyroid autoimmunity, especially Graves’ disease or hypothyroidism with positive autoantibodies (TRAb) to the thyrotropin receptor (TSHR), occurs in 30-40% of patients with relapsing multiple sclerosis (MS) following treatment with alemtuzumab (ALTZ). ALTZ therapy therefore provides a unique opportunity to study the evolution of TRAb prior to clinical presentation. TRAb can stimulate (TSAb), block (TBAb) or not affect (“neutral”: TNAb) the TSHR function, causing hyperthyroidism, hypothyroidism or euthyroidism, respectively. METHODS We conducted a longitudinal retrospective analysis of TRAb bioactivity over a period of 9 years in 45 MS patients receiving ALTZ using available stored serum; 31 developed thyroid dysfunction (TD) and 14 remained euthyroid despite being followed for a minimum of 5 years (NO-TD). The presence of TRAb was evaluated at standardized time points: A) pre-ALTZ, B) latest time available post-ALTZ and before TD onset, C) post-ALTZ during/after TD onset. Serum TRAb were detected by published in-house assays (ihTRAb): flow cytometry (FC) detecting any TSHR-binding TRAb and luciferase bioassays (LB) detecting TSAb/TBAb bioactivity. Purified IgGs were used to verify TSAb/TBAb in selected hypothyroid cases. Standard clinical automated measurements of TRAb (autTRAb), anti-thyroid peroxidase autoantibodies (TPOAb), thyroid stimulating hormone, free-thyroxine and free-triiodothyronine were also collected. RESULTS Pre-ALTZ, combined ihTRAb (positive with FC and/or LB), but not autTRAb, were present in 5/16 (31.2%) TD versus 0/14 (0%) NO-TD (p=0.017). Detectable ihTRAb preceded TD development in 9/28 (32.1%) and by a median of 1.2 years (range 28 days – 7.3 years). Combination testing of ihTRAb and TPOAb at baseline predicted 20% of subsequent cases of hyperthyroidism and 83% of hypothyroidism. CONCLUSIONS We present evidence that TRAb measured with custom-made assays can be detected prior to any change in thyroid function in up to a third of cases of ALTZ-related TD. Furthermore, The presence of ihTRAb prior to ALTZ treatment was strongly predictive of subsequent TD. Our findings suggest that a period of affinity maturation of TRAb may precede clinical disease onset in some cases. Combined testing of TPOAb and ihTRAb may increase our ability to predict those who will develop thyroid dysfunction post ALTZ

Maturation in serum thyroid function parameters over childhood and puberty:results of a longitudinal study

Context: Serum thyroid hormone levels differ between children and adults, but have not been studied longitudinally through childhood. Objective: To assess changes in thyroid-stimulating hormone (TSH) and thyroid hormone levels over childhood and their interrelationships. Design: Cohort study. Setting: The Avon Longitudinal Study of Parents and Children, a population-based birth cohort. Participants: A total of 4442 children who had thyroid function measured at age 7, and 1263 children who had thyroid function measured at age 15. Eight hundred eighty-four children had measurements at both ages. Main Outcome Measures: Reference ranges for TSH, free tri-iodothyronine (FT3), free thyroxine (FT4), their longitudinal stability, and interrelationships. Results: Children at age 7 years had a higher FT3 [6.17 pmol/L, standard deviation (SD) 0.62] than children at age 15 (5.83 pmol/L, SD 0.74); P , 0.0001 with 23.2% of children at age 7 having FT3 above the adult reference range. Higher FT3 levels at age 7 in boys (P = 0.0001) and girls (P = 0.04) were associated with attainment of a more advanced pubertal stage at age 13. TSH was positively associated with FT3 at age 7 and age 15 even after adjusting for confounders. In contrast, TSH was negatively associated with FT

CATS II long-term anthropometric and metabolic effects of maternal sub-optimal thyroid function in offspring and mothers

Context and Objectives The Controlled Antenatal Thyroid Screening Study I (CATS-I) was a randomized controlled trial investigating the effects of levothyroxine therapy for suboptimal gestational thyroid function (SGTF), comparing outcomes in children of treated (SGTF-T) with untreated (SGTF-U) women during pregnancy. This follow-up study, CATS-II, reports the long-term effects on anthropometric, bone, and cardiometabolic outcomes in mothers and offspring and includes a group with normal gestational thyroid function (NGTF). Design & Participants 332 mothers (197 NGTF, 56 SGTF-U, 79 SGTF-T) aged 41.2±5.3 years (mean±SD) and 326 paired children assessed 9.3±1.0 years after birth for (i) body mass index (BMI); (ii) lean, fat, and bone mass by dual-energy X-ray absorptiometry; (iii) blood pressure, augmentation index, and aortic pulse-wave-velocity; and (iv) thyroid function, lipids, insulin, and adiponectin. The difference between group means was compared using linear regression. Results Offspring’s measurements were similar between groups. Although maternal BMI was similar between groups at CATS-I, after 9 years (at CATS-II) SGTF-U mothers showed higher BMI (median [interquartile ratio] 28.3 [24.6-32.6] kg/m2) compared with NGTF (25.8 [22.9-30.0] kg/m2; P = 0.029), driven by fat mass increase. At CATS-II SGTF-U mothers also had higher thyroid-stimulating hormone (TSH) values (2.45 [1.43-3.50] mU/L) than NGTF (1.54 [1.12-2.07] mU/L; P = 0.015), since 64% had never received levothyroxine. At CATS-II, SGTF-T mothers had BMI (25.8 [23.1-29.8] kg/m2, P = 0.672) and TSH (1.68 [0.89-2.96] mU/L; P = 0.474) values similar to NGTF mothers. Conclusions Levothyroxine supplementation of women with SGTF did not affect long-term offspring anthropometric, bone, and cardiometabolic measurements. However, absence of treatment was associated with sustained long-term increase in BMI and fat mass in women with SGTF

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Psycho-social and spiritual backgrounds, experiences, and needs as a transsexual: a qualitative study within Persatuan Insaf Pahang

Transsexuals face discriminations and rejections from the Malaysian society. The number of studies done on understanding the phenomenology, experiences, and problems faced by transsexuals is still few in Malaysia. This research aims to document their psycho-social and spiritual backgrounds and the relevant experiences, and to explore their perceptions and needs as male-to-female transsexuals in the context of Persatuan Insaf Pahang, Malaysia. Materials and Methods: A qualitative research was carried out in July and August 2015 among eight male-to-female transsexual adults in Kuantan, Pahang. Snowball sampling was used. Participants who gave consent were interviewed in two focus groups. Data obtained was transcribed and used as the primary data source. Results: Subjects in this study reported confusions over their gender identity since childhood. They struggled against conflicts regarding their transsexuality in adolescence, and eventually many quit their studies. As adults, they were discriminated against in employment and religious settings. They provided positive feedbacks on religious authorities who could understand problems unique to transsexuals and empathise with the transsexual community. Conclusion: The psycho-sexual phenomenology is the same in transsexuals all over the world. Misunderstanding and discrimination from the society remain heavy towards this community. Transsexuals should learn to adapt to meeting expectations from the society as well, so they could be accepted in public. They will need religious guidance and spiritual support for better quality of life. Dedicated efforts are still needed in training professionals in the educational, medical, and religious fields to attend to the specific needs of transsexuals in this country