Penang Adventist Hospital

Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal tumor occurring in ~1 in 1,000,000 patients. It can arise in many parts of the body, and gynecologic PEComa accounts for a quarter of all PEComa cases. We discuss a case of a 43-year-old woman with a history of total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAHBSO) 14 years ago for uterine leiomyoblastoma, which did not require adjuvant treatment. She presented in late 2024 with vague abdominal discomfort and was subsequently found to have a left pelvic malignant PEComa.

Introduction: Pressure ulcers (PUs) remain a global health issue, contributing to increased morbidity and premature mortality. Nurses play a central role in prevention, underscoring the significant role in addressing this issue through the rapidly evolving healthcare environment. Clinical competence requires sound knowledge, attitude, and practice that contribute to excellent outcomes, focusing on individual patient needs and the changing conditions of the healthcare setting. Therefore, this study is aimed to evaluate nurses’ knowledge, attitudes, and practices on preventing PUs. Methods: This quantitative cross-sectional survey was conducted across three public hospitals in Malaysia. Using the two-stage cluster sampling strategy, registered nurses were recruited (n=210). Data were collected using a self-administered questionnaire with good reliability scores (α=0.76–0.82). Descriptive and inferential analyses were computed to address the objectives. Results: Findings revealed low knowledge score (M=67.07, SD=7.78), neutral attitudes (M=73.28, SD=10.37), and excellent practices for pressure ulcer prevention (M=86.78, SD=15.05). Nurses’ attitudes were positively correlated with their practices (p<0.05), though no significant associations were observed between demographic factors and knowledge, attitude, and practice (p>0.05). Conclusions: The findings provide valuable information about nurses' understanding of pressure ulcer prevention that may assist with future strategies and interventions to enhance the knowledge and attitudes among practicing nurses. The identified gaps may be filled with targeted interventions, and future studies looking at variables affecting nurses' attitudes and practices, and the effectiveness of educational interventions can be beneficial.

Biallelic inactivating variants in ZNF142 underlie a clinically variable neurodevelopmental disorder. ZNF142 is a zinc-finger transcription factor with potential roles on chromatin organization, implying a possible association of ZNF142 loss of function with perturbed genome-wide DNA methylation (DNAm) pattern. We performed EPIC array-based methylation profiling of peripheral blood-derived DNA samples from 27 individuals with biallelic ZNF142 inactivating variants, together with 6 heterozygous carriers and 40 controls. A DNAm signature discovery pipeline was applied by using 440 controls for discovery and validation analyses, and a machine-learning model was trained to classify 8 individuals carrying ZNF142 variants of uncertain clinical significance. Analyses directed to explore the genome-wide DNAm landscape in affected individuals revealed 88 differentially methylated probes constituting the minimal informative set specific to ZNF142 loss of function. This reproducible pattern of DNAm changes involved regulatory regions of a small number of genes. The DNAm signature derived from peripheral blood allowed us to diagnose individuals carrying biallelic inactivating ZNF142 variants when applied to fibroblasts. Our findings provide evidence that biallelic loss-of-function ZNF142 variants result in a specific and robust DNAm signature. The identified DNAm pattern suggests occurrence of a methylation disturbance involving a small number of loci that appears to be shared by different cell lineages.

Head and neck cancers (HNCs) are in general treated with conventional fractionation regimen of 1.8-2 Gy per fraction. Altered fractionation (ALFT) strategies such as hypofractionation radiotherapy (HYPO-RT), accelerated fractionation radiotherapy (AFRT), and hyperfractionation radiotherapy (HFRT) have not been practiced uniformly across centers in different parts of the world. Countries in Asia share common cancer demographics, and we designed this survey for Federation of Asian Radiation Oncology (FARO) member countries to understand the usage and challenges in the delivery of ALFT in HNCs. A 21-point electronic survey (Federation of Asian Radiation Oncology Research Network [FERN]-S-005) was designed by the FERN and was circulated through the FARO research secretariat to the FARO council member countries and the responses were collected between August and November 2023. Twelve of 14 member countries (85.7%) responded to the survey. Twenty-seven responses were received and 78% of the respondents belonged to government/teaching academic institute. 4/27 (14.8%) reported never using HYPO-RT for any of the clinical subsite of HNCs, while the majority (85.2%) used it for glottic cancers and 22% also used it for postoperative setting. Majority (77.7%) used a fractionation schedule with dose per fraction ranging between 2.2 and 2.5 Gy. 6/27 (22.2%) used AFRT for definitive setting and five of these also used concurrent chemoradiotherapy. 4/27 (14.8%) centers reported using HFRT. The most common reason (62.9%) for the limited usage of AFRT/HFRT was reported to be logistical, such as unavailability of machine slots, patient load, and so on. The result of the survey suggests that among the ALFT strategies for HNCs, HYPO-RT schedules have common interest and feasibility among the FARO member countries and also highlights the challenges in the delivery of AFRT/HFRT in the Asian region.

The prevalence of multidrug-resistant and extensively drug-resistant pathogens has led to increased reliance on broad-spectrum antimicrobials, such as tigecycline. This medicine is commonly used to treat complicated skin and intraabdominal infections as well as community-acquired pneumonia. However, the increasing use of tigecycline has been linked to serious complications, including acute pancreatitis. We present a case of tigecycline-induced acute pancreatitis in a 78-year-old man with complex medical conditions, including type 2 diabetes mellitus, chronic renal insufficiency, and triple vessel disease. The patient was initially treated with tigecycline for bilateral dry gangrene of his toes. Six days after initiation of the tigecycline treatment, the patient developed symptoms of acute pancreatitis with electrocardiogram changes. Magnetic resonance imaging confirmed the diagnosis of acute pancreatitis. Tigecycline was stopped promptly, and supportive treatment was initiated. The patient recovered from the acute pancreatitis and was discharged home. He later passed away at home due to his underlying cardiac disease. This case highlights the potential complications of tigecycline therapy, particularly in patients with significant comorbidities. Elderly patients with complex medical issues, such as diabetes mellitus type 2, chronic renal insufficiency, and cardiovascular disease, are at higher risk for adverse drug reactions. Recognizing these risk factors is important for management.Addressing the use of magnetic resonance imaging for diagnosing acute pancreatitis in this specific patient due to their already compromised kidneys highlights the need for a tailored approach. Most commonly, angiographic transformers or computed tomography scan are used for high-risk patients.The symptoms of acute pancreatitis and the presence of cardiac diseases cause problems in managing patients. Changes on the electrocardiogram may suggest cardiac overload; as a result, constant follow-up is necessary for patients suffering from underlying cardiac conditions.

We described mortality and loss to follow-up (LTFU) in children and adolescents who were under care for more than 5 years following initiation of antiretroviral therapy (ART). Patients were followed from 5 years after ART until the earlier of their 25th birthday, last visit, death, or LTFU. We used Cox regression to assess predictors of mortality and competing risk regression to assess factors associated with LTFU. In total, 4488 children and adolescents initiating ART between 1997 and 2016 were included in the analysis, with a median follow-up time of 5.2 years. Of these, 107 (2.2%) died and 271 (6.0%) were LTFU. Mortality rate was 4.35 and LTFU rate 11.01 per 1000 person-years. Increased mortality was associated with AIDS diagnosis (adjusted hazard ratio [aHR] 1.71; 95% confidence interval [CI] 1.24-2.37), current CD4 count <350 cells/mm3 compared with ≥500 (highest aHR 13.85; 95% CI 6.91-27.76 for CD4 <200), viral load ≥10 000 copies/mL compared with <400 (aHR 3.28; 95% CI 1.90-5.63), and exposure to more than one ART regimen (aHR 1.51; 95% CI 1.14-2.00). Factors associated with LTFU were male sex (adjusted subdistribution hazard ratio [asHR] 1.29; 95% CI 1.04-1.59), current viral load >1000 copies/mL compared with <400 (highest asHR 2.36; 95% CI 1.19-4.70 for viral load 1000-9999), and ART start after year 2005 compared with ≤2005 (highest asHR 5.96; 95% CI 1.98-17.91 for 2010-2016). For children and adolescents surviving 5 years on ART, both current CD4 and viral load remained strong indicators that help to keep track of their treatment outcomes. More effort should be made to monitor patients who switch treatments.

Purpose: Intravitreal injections (IVT) of anti-vascular endothelial growth factor are standard treatment procedures in ophthalmology for many retinal diseases. We conducted a full-cycle clinical audit to evaluate patient compliance with IVT in Penang Hospital during the COVID-19 pandemic. Study design: Full cycle audit. Methods: A 3-month audit was carried out on patients scheduled to receive IVT in the operation theatre between August and October 2019 (COVID-19 pre-pandemic period). Patient compliance rates were calculated. We set a target of 95% patient compliance rate. Interventional steps taken to improve compliance were carried out from April 2020 to September 2021 (during the Movement Control Order period). A 3-month re-audit was conducted between October and December 2021. Results: A total of 481 patients were scheduled for IVT, and 50 patients (10.4%) did not present to the appointment. The compliance rate was 89.6%. The reasons for defaulting treatment included multiple hospital visits, transportation issues, cost of transportation, loss of daily wages, and fear of COVID-19 infection. Post-intervention, a total of 895 patients were scheduled for IVT in 3 months. Among these patients, 844 patients completed their IVT appointment, while 51 patients missed the scheduled IVT. The patients’ compliance rate also rose from 89.6% to 94.3%. There was also an increase of 87.1% in the total number of scheduled IVT as compared to the pre-intervention phase. Conclusion: These interventions not only increased the number of patients receiving treatment but also improved patients’ compliance with IVT despite the COVID-19 pandemic. Patients benefited from reduced hospital visits, the cost of follow-up, and the risk of hospital infection.

Humayera Kabir Hana, Sania Siddiqui, Siti Maisharah Sheikh Ghadzi, Irfhan Ali Hyder Ali, Siew Chin Ong, Nur Hafzan Md Hanafiah, Sabariah Noor Harun. R Clin Pharm 2024;2:18-26. https://doi.org/10.59931/rcp.24.0003