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Fulltext APASL clinical practice guideline on hepatitis B reactivation related to the use of immunosuppressive therapy

Lau G, Yu ML, Wong G, Thompson A, Ghazinian H, Hou JL, et al.

Hepatol Int, 2021 Oct;15(5):1031-1048.
PMID: 34427860 DOI: 10.1007/s12072-021-10239-x

BACKGROUND & AIM: Hepatitis B reactivation related to the use of immunosuppressive therapy remains a major cause of liver-related morbidity and mortality in hepatitis B endemic Asia-Pacific region. This clinical practice guidelines aim to assist clinicians in all disciplines involved in the use of immunosuppressive therapy to effectively prevent and manage hepatitis B reactivation.
METHODS: All publications related to hepatitis B reactivation with the use of immunosuppressive therapy since 1975 were reviewed. Advice from key opinion leaders in member countries/administrative regions of Asian-Pacific Association for the study of the liver was collected and synchronized. Immunosuppressive therapy was risk-stratified according to its reported rate of hepatitis B reactivation.
RECOMMENDATIONS: We recommend the necessity to screen all patients for hepatitis B prior to the initiation of immunosuppressive therapy and to administer pre-emptive nucleos(t)ide analogues to those patients with a substantial risk of hepatitis and acute-on-chronic liver failure due to hepatitis B reactivation.
Correction to: APASL clinical practice guideline on hepatitis B reactivation related to the use of immunosuppressive therapy

Lau G, Yu ML, Wong G, Thompson A, Ghazinian H, Hou JL, et al.

Hepatol Int, 2022 Jan 25.
PMID: 35076895 DOI: 10.1007/s12072-022-10301-2
Fulltext May Measurement Month 2019: an analysis of blood pressure screening results from Malaysia

Chia YC, Devaraj NK, Chook JB, Chew MT, Ooi PB, Mohamed M, et al.

Eur Heart J Suppl, 2021 May;23(Suppl B):B98-B100.
PMID: 34054370 DOI: 10.1093/eurheartj/suab058

Despite hypertension remaining the leading cause of death worldwide, awareness of hypertension and its control rate is still suboptimal in Malaysia. This study aims to determine the proportion of both diagnosed and undiagnosed hypertension, awareness and its control rate during the yearly May Measurement Month (MMM) campaign that has been coordinated by the International Society of Hypertension. Participants aged ≥18 years were recruited at various screening sites namely universities, health facilities, shopping malls, and other sites. Participant's socio-demographic, environmental, and lifestyle data were captured using a questionnaire. Three blood pressure (BP) readings as well as anthropometric measurements were obtained from all participants. The mean of the second and third BP readings was used in analyses. Hypertension was defined as a systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or taking antihypertensive medication. A total of 3062 participants were recruited. The proportion with hypertension in our study was 18.7% (n = 572). The proportion who were aware of their BP status was 63.2%. More than half (57.2%) of the hypertensives were on antihypertensive medication and 70.3% of those treated were controlled. In conclusion, in this BP screening campaign, one in five were hypertensive with almost two thirds aware of their hypertensive status. BP control among those who are taking medications was high at 70% but under 60% of hypertensives were on treatment. Hypertension screening programmes are important to promote awareness and control of hypertension as well as to reduce the devastating complications associated with this disorder.
Fulltext Identification and characterization of a novel Epstein-Barr Virus-encoded circular RNA from LMP-2 Gene

Tan KE, Ng WL, Marinov GK, Yu KH, Tan LP, Liau ES, et al.

Sci Rep, 2021 Jul 13;11(1):14392.
PMID: 34257379 DOI: 10.1038/s41598-021-93781-w

Epstein-Barr virus (EBV) has been recently found to generate novel circular RNAs (circRNAs) through backsplicing. However, comprehensive catalogs of EBV circRNAs in other cell lines and their functional characterization are still lacking. In this study, we have identified a list of putative EBV circRNAs in GM12878, an EBV-transformed lymphoblastoid cell line, with a significant majority encoded from the EBV latent genes. A novel EBV circRNA derived from the exon 5 of LMP-2 gene which exhibited highest prevalence, was further validated using RNase R assay and Sanger sequencing. This circRNA, which we term circLMP-2_e5, can be universally detected in a panel of EBV-positive cell lines modelling different latency programs. It ranges from lower expression in nasopharyngeal carcinoma (NPC) cells to higher expression in B cells, and is localized to both the cytoplasm and the nucleus. We provide evidence that circLMP-2_e5 is expressed concomitantly with its cognate linear LMP-2 RNA upon EBV lytic reactivation, and may be produced as a result of exon skipping, with its circularization possibly occurring without the involvement of cis elements in the short flanking introns. Furthermore, we show that circLMP-2_e5 is not involved in regulating cell proliferation, host innate immune response, its linear parental transcripts, or EBV lytic reactivation. Taken together, our study expands the current repertoire of putative EBV circRNAs, broadens our understanding of the biology of EBV circRNAs, and lays the foundation for further investigation of their function in the EBV life cycle and disease development.
Fulltext Automatic COVID-19 Detection Using Exemplar Hybrid Deep Features with X-ray Images

Barua PD, Muhammad Gowdh NF, Rahmat K, Ramli N, Ng WL, Chan WY, et al.

Int J Environ Res Public Health, 2021 07 29;18(15).
PMID: 34360343 DOI: 10.3390/ijerph18158052

COVID-19 and pneumonia detection using medical images is a topic of immense interest in medical and healthcare research. Various advanced medical imaging and machine learning techniques have been presented to detect these respiratory disorders accurately. In this work, we have proposed a novel COVID-19 detection system using an exemplar and hybrid fused deep feature generator with X-ray images. The proposed Exemplar COVID-19FclNet9 comprises three basic steps: exemplar deep feature generation, iterative feature selection and classification. The novelty of this work is the feature extraction using three pre-trained convolutional neural networks (CNNs) in the presented feature extraction phase. The common aspects of these pre-trained CNNs are that they have three fully connected layers, and these networks are AlexNet, VGG16 and VGG19. The fully connected layer of these networks is used to generate deep features using an exemplar structure, and a nine-feature generation method is obtained. The loss values of these feature extractors are computed, and the best three extractors are selected. The features of the top three fully connected features are merged. An iterative selector is used to select the most informative features. The chosen features are classified using a support vector machine (SVM) classifier. The proposed COVID-19FclNet9 applied nine deep feature extraction methods by using three deep networks together. The most appropriate deep feature generation model selection and iterative feature selection have been employed to utilise their advantages together. By using these techniques, the image classification ability of the used three deep networks has been improved. The presented model is developed using four X-ray image corpora (DB1, DB2, DB3 and DB4) with two, three and four classes. The proposed Exemplar COVID-19FclNet9 achieved a classification accuracy of 97.60%, 89.96%, 98.84% and 99.64% using the SVM classifier with 10-fold cross-validation for four datasets, respectively. Our developed Exemplar COVID-19FclNet9 model has achieved high classification accuracy for all four databases and may be deployed for clinical application.
Customised weight-based volume contrast media protocol in CT of chest, abdomen and pelvis examination

Yap LPP, Wong JHD, Muhammad Gowdh NF, Ng WL, Chung E, Eturajulu RC, et al.

J Med Imaging Radiat Sci, 2021 06;52(2):257-264.
PMID: 33531272 DOI: 10.1016/j.jmir.2021.01.003

INTRODUCTION: Fixed volume (FV) contrast media administration during CT examination is the standard practice in most healthcare institutions. We aim to validate a customised weight-based volume (WBV) method and compare it to the conventional FV methods, introduced in a regional setting.
METHODS: 220 patients underwent CT of the chest, abdomen and pelvis (CAP) using a standard FV protocol, and subsequently, a customised 1.0 mL/kg WBV protocol within one year. Both image sets were assessed for contrast enhancement using CT attenuation at selected regions-of-interest (ROIs). The visual image quality was evaluated by three radiologists using a 4-point Likert scale. Quantitative CT attenuation was correlated with the visual quality assessment to determine the HU's enhancement indicative of the image quality grades. Contrast media usage was calculated to estimate cost-savings from both protocols.
RESULTS: Mean patient age was 61 ± 14 years, and weight was 56.1 ± 8.7 kg. FV protocol produced higher contrast enhancement than WBV, p
Shear wave elastography for characterization of breast lesions: Shearlet transform and local binary pattern histogram techniques

Acharya UR, Ng WL, Rahmat K, Sudarshan VK, Koh JEW, Tan JH, et al.

Comput Biol Med, 2017 12 01;91:13-20.
PMID: 29031099 DOI: 10.1016/j.compbiomed.2017.10.001

Shear wave elastography (SWE) examination using ultrasound elastography (USE) is a popular imaging procedure for obtaining elasticity information of breast lesions. Elasticity parameters obtained through SWE can be used as biomarkers that can distinguish malignant breast lesions from benign ones. Furthermore, the elasticity parameters extracted from SWE can speed up the diagnosis and possibly reduce human errors. In this paper, Shearlet transform and local binary pattern histograms (LBPH) are proposed as an original algorithm to differentiate malignant and benign breast lesions. First, Shearlet transform is applied on the SWE images to acquire low frequency, horizontal and vertical cone coefficients. Next, LBPH features are extracted from the Shearlet transform coefficients and subjected to dimensionality reduction using locality sensitivity discriminating analysis (LSDA). The reduced LSDA components are ranked and then fed to several classifiers for the automated classification of breast lesions. A probabilistic neural network classifier trained only with seven top ranked features performed best, and achieved 98.08% accuracy, 98.63% sensitivity, and 97.59% specificity in distinguishing malignant from benign breast lesions. The high sensitivity and specificity of our system indicates that it can be employed as a primary screening tool for faster diagnosis of breast malignancies, thereby possibly reducing the mortality rate due to breast cancer.
Fulltext Utility and usability of an automated COVID-19 symptom monitoring system (CoSMoS) in primary care during COVID-19 pandemic: A qualitative feasibility study

Lim HM, Abdullah A, Ng CJ, Teo CH, Valliyappan IG, Abdul Hadi H, et al.

Int J Med Inform, 2021 Nov;155:104567.
PMID: 34536808 DOI: 10.1016/j.ijmedinf.2021.104567

BACKGROUND: COVID-19 telemonitoring applications have been developed and used in primary care to monitor patients quarantined at home. There is a lack of evidence on the utility and usability of telemonitoring applications from end-users' perspective.
OBJECTIVES: This study aimed to evaluate the feasibility of a COVID-19 symptom monitoring system (CoSMoS) by exploring its utility and usability with end-users.
METHODS: This was a qualitative study using in-depth interviews. Patients with suspected COVID-19 infection who used CoSMoS Telegram bot to monitor their COVID-19 symptoms and doctors who conducted the telemonitoring via CoSMoS dashboard were recruited. Universal sampling was used in this study. We stopped the recruitment when data saturation was reached. Patients and doctors shared their experiences using CoSMoS, its utility and usability for COVID-19 symptoms monitoring. Data were coded and analysed using thematic analysis.
RESULTS: A total of 11 patients and 4 doctors were recruited into this study. For utility, CoSMoS was useful in providing close monitoring and continuity of care, supporting patients' decision making, ensuring adherence to reporting, and reducing healthcare workers' burden during the pandemic. In terms of usability, patients expressed that CoSMoS was convenient and easy to use. The use of the existing social media application for symptom monitoring was acceptable for the patients. The content in the Telegram bot was easy to understand, although revision was needed to keep the content updated. Doctors preferred to integrate CoSMoS into the electronic medical record.
CONCLUSION: CoSMoS is feasible and useful to patients and doctors in providing remote monitoring and teleconsultation during the COVID-19 pandemic. The utility and usability evaluation enables the refinement of CoSMoS to be a patient-centred monitoring system.
Fulltext A comparison of 25 complete chloroplast genomes between sister mangrove species Kandelia obovata and Kandelia candel geographically separated by the South China Sea

Xu X, Shen Y, Zhang Y, Li Q, Wang W, Chen L, et al.

Front Plant Sci, 2022;13:1075353.
PMID: 36684775 DOI: 10.3389/fpls.2022.1075353

In 2003, Kandelia obovata was identified as a new mangrove species differentiated from Kandelia candel. However, little is known about their chloroplast (cp) genome differences and their possible ecological significance. In this study, 25 whole cp genomes, with seven samples of K. candel from Malaysia, Thailand, and Bangladesh and 18 samples of K. obovata from China, were sequenced for comparison. The cp genomes of both species encoded 128 genes, namely 83 protein-coding genes, 37 tRNA genes, and eight rRNA genes, but the cp genome size of K. obovata was ~2 kb larger than that of K. candle due to the presence of more and longer repeat sequences. Of these, tandem repeats and simple sequence repeats exhibited great differences. Principal component analysis based on indels, and phylogenetic tree analyses constructed with homologous protein genes from the single-copy genes, as well as 38 homologous pair genes among 13 mangrove species, gave strong support to the separation of the two species within the Kandelia genus. Homologous genes ndhD and atpA showed intraspecific consistency and interspecific differences. Molecular dynamics simulations of their corresponding proteins, NAD(P)H dehydrogenase chain 4 (NDH-D) and ATP synthase subunit alpha (ATP-A), predicted them to be significantly different in the functions of photosynthetic electron transport and ATP generation in the two species. These results suggest that the energy requirement was a pivotal factor in their adaptation to differential environments geographically separated by the South China Sea. Our results also provide clues for future research on their physiological and molecular adaptation mechanisms to light and temperature.
Fulltext Factors associated with all-cause mortality in tuberculosis patients in a Malaysian tertiary hospital

Wong CK, Ng KS, Choo SQR, Lee CJ, Teo YP, Liew SM, et al.

J Infect Dev Ctries, 2023 Aug 31;17(8):1138-1145.
PMID: 37699097 DOI: 10.3855/jidc.16967

INTRODUCTION: The all-cause mortality for tuberculosis is 1 in every 10 patients in Malaysia. The currently available national surveillance database does not record patients' variables such as socio-economic factors, existing co-morbidities, and risk behavior for investigation. An electronic medical record system can capture this missing information and use it to determine all-cause mortality factors more accurately. Our study aims to determine the factors associated with all-cause mortality in a cohort of tuberculosis patients in a Malaysian tertiary hospital which is equipped with an electronic medical record system.
METHODOLOGY: Records of patients diagnosed with tuberculosis from 1st January 2018 to 30th September 2019 were retrieved. Sociodemographic and clinical data were extracted. Treatment outcomes and all-cause mortality were recorded at 1 year after diagnosis. Univariate, multivariate, and stepwise regression were used to determine the factors associated with all-cause mortality.
RESULTS: Four-hundred and seventy-one patients were reviewed. The mean age was 46.6 ± 19.7 years. The all-cause mortality rate at one year of diagnosis was 15.3%. Factors identified were age [aOR 1.026 (95% CI: 1.004-1.049)], chronic kidney disease [aOR 3.269 (1.508-7.088)], HIV positive status [aOR 4.743 (1.505-14.953)], active cancer [aOR 5.758 (1.605-20.652)], liver disease [aOR 6.220 (1.028-37.621)], and moderate to advanced chest X-ray findings [aOR 3.851 (1.033-14.354)].
CONCLUSIONS: On average, one in seven patients diagnosed with TB died within a year in a Malaysian tertiary hospital. Identification of this vulnerable group using the associated factors found in this study may help to reduce the risk of mortality through early intervention strategies.
Evaluation of an electronic clinical decision support system (DeSSBack) to improve low back pain management: a pilot cluster randomized controlled trial

Tun Firzara AM, Teo CH, Teh SY, Su JY, Mohd Zaini HS, Suhaimi A, et al.

Fam Pract, 2023 Dec 22;40(5-6):742-752.
PMID: 37237425 DOI: 10.1093/fampra/cmad044

BACKGROUND: Low back pain (LBP) is a common reason for primary care consultation; yet doctors often find managing it challenging. An electronic decision support system for LBP (DeSSBack) was developed based on an evidence-based risk stratification tool to improve the management of patients with LBP in a Malaysian primary care setting. This pilot study aimed to assess the feasibility, acceptability, and preliminary effectiveness of DeSSBack for the conduct of a future definitive trial.
METHODS: A pilot cluster randomized controlled trial (cRCT) with qualitative interviews was conducted. Each primary care doctor was considered a cluster and randomized to either the control (usual practice) or intervention (DeSSBack) group. Patient outcomes including Roland-Morris Disability Questionnaire (RMDQ), Hospital Anxiety and Depression Scale, and a 10-point pain rating scale were measured at baseline and 2-month postintervention. The doctors in the intervention group were interviewed to explore feasibility and acceptability of using DeSSBack.
RESULTS: Thirty-six patients with nonspecific LBP participated in this study (intervention n = 23; control n = 13). Fidelity was poor among patients but good among doctors. The RMDQ and anxiety score had medium effect sizes of 0.718 and 0.480, respectively. The effect sizes for pain score (0.070) and depression score were small (0.087). There was appreciable acceptability and satisfaction with use of DeSSBack, as it was helpful in facilitating thorough and standardized management, providing appropriate treatment plans based on risk stratification, improving consultation time, empowering patient-centred care, and easy to use.
CONCLUSIONS: A future cRCT to evaluate the effectiveness of DeSSBack is feasible to be conducted in a primary care setting with minor modifications. DeSSBack was found useful by doctors and can be improved to enhance efficiency.
TRIAL REGISTRATION: The protocol of the cluster randomized controlled trial was registered at ClinicalTrials.gov (NCT04959669).
Fulltext Implementing HLA-B*58:01 testing prior to allopurinol initiation in Malaysian primary care setting: A qualitative study from doctors' and patients' perspective

Ng WL, Hussein N, Ng CJ, Qureshi N, Lee YK, Kwan Z, et al.

PLoS One, 2024;19(1):e0296498.
PMID: 38206925 DOI: 10.1371/journal.pone.0296498

INTRODUCTION: Allopurinol, the first-line treatment for chronic gout, is a common causative drug for severe cutaneous adverse reactions (SCAR). HLA-B*58:01 allele was strongly associated with allopurinol-induced SCAR in Asian countries such as Taiwan, Japan, Thailand and Malaysia. HLA-B*58:01 screening before allopurinol initiation is conditionally recommended in the Southeast-Asian population, but the uptake of this screening is slow in primary care settings, including Malaysia. This study aimed to explore the views and experiences of primary care doctors and patients with gout on implementing HLA-B*58:01 testing in Malaysia as part of a more extensive study exploring the feasibility of implementing it routinely.
METHODS: This qualitative study used in-depth interviews and focus group discussions to obtain information from patients with gout under follow-up in primary care and doctors who cared for them. Patients and doctors shared their gout management experiences and views on implementing HLA-B*58:01 screening in primary care. Data were coded and analysed using thematic analysis.
RESULTS: 18 patients and 18 doctors from three different healthcare settings (university hospital, public health clinics, private general practitioner clinics) participated. The acceptability to HLA-B*58:01 screening was good among the doctors and patients. We discovered inadequate disclosure of severe side effects of allopurinol by doctors due to concerns about medication refusal by patients, which could potentially be improved by introducing HLA-B*58:01 testing. Barriers to implementation included out-of-pocket costs for patients, the cost-effectiveness of this implementation, lack of established alternative treatment pathway besides allopurinol, counselling burden and concern about genetic data security. Our participants preferred targeted screening for high-risk populations instead of universal screening.
CONCLUSION: Implementing HLA-B*58:01 testing in primary care is potentially feasible if a cost-effective, targeted screening policy on high-risk groups can be developed. A clear treatment pathway for patients who test positive should be made available.
Fulltext A cell-based screening system for anti-influenza A virus agents

Wong WY, Loh SW, Ng WL, Tan MC, Yeo KS, Looi CY, et al.

Sci Rep, 2015;5:8672.
PMID: 25728279 DOI: 10.1038/srep08672

Emerging of drug resistant influenza A virus (IAV) has been a big challenge for anti-IAV therapy. In this study, we describe a relatively easy and safe cell-based screening system for anti-IAV replication inhibitors using a non-replicative strain of IAV. A nickel (II) complex of polyhydroxybenzaldehyde N4-thiosemicarbazone (NiPT5) was recently found to exhibit anti-inflammatory activity in vivo and in vitro. NiPT5 impedes the signaling cascades that lead to the activation of NF-κB in response to different stimuli, such as LPS and TNFα. Using our cell-based screening system, we report that pretreating cells with NiPT5 protects cells from influenza A virus (IAV) and vesicular stomatitis virus (VSV) infection. Furthermore, NiPT5 inhibits replication of IAV by inhibiting transcription and translation of vRNAs of IAV. Additionally, NiPT5 reduces IAV-induced type I interferon response and cytokines production. Moreover, NiPT5 prevents activation of NF-κB, and IRF3 in response to IAV infection. These results demonstrate that NiPT5 is a potent antiviral agent that inhibits the early phase of IAV replication.
Fulltext Shearwave Elastography Increases Diagnostic Accuracy in Characterization of Breast Lesions

Ng WL, Rahmat K, Fadzli F, Rozalli FI, Mohd-Shah MN, Chandran PA, et al.

Medicine (Baltimore), 2016 Mar;95(12):e3146.
PMID: 27015196 DOI: 10.1097/MD.0000000000003146

The purpose of this study was to investigate the diagnostic efficacy of shearwave elastography (SWE) in differentiating between benign and malignant breast lesions.One hundred and fifty-nine lesions were assessed using B-mode ultrasound (US) and SWE parameters were recorded (Emax, Emean, Emin, Eratio, SD). SWE measurements were then correlated with histopathological diagnosis.The final sample contained 85 benign and 74 malignant lesions. The maximum stiffness (Emax) with a cutoff point of ≥ 56.0 kPa (based on ROC curves) provided sensitivity of 100.0%, specificity of 97.6%, positive predictive value (PPV) of 97.4%, and negative predictive value (NPV) of 100% in detecting malignant lesions. A cutoff of ≥80 kPa managed to downgrade 95.5% of the Breast Imaging-Reporting and Data System (BI-RADS) 4a lesions to BI-RADS 3, negating the need for biopsy. Using a combination of BI-RADS and SWE, the authors managed to improve the PPV from 2.3% to 50% in BI-RADS 4a lesions.SWE of the breast provides highly specific and sensitive quantitative values that are beneficial in the characterization of breast lesions. Our results showed that Emax is the most accurate value for differentiating benign from malignant lesions.
Molecular genetic variation and structure of Southeast Asian crocodile (Tomistoma schlegelii): Comparative potentials of SSRs versus ISSRs

Shafiei-Astani B, Ong AH, Valdiani A, Tan SG, Yien CY, Ahmady F, et al.

Gene, 2015 Oct 15;571(1):107-16.
PMID: 26112832 DOI: 10.1016/j.gene.2015.06.053

Tomistoma schlegelii, also referred to as the "false gharial", is one of the most exclusive and least known of the world's fresh water crocodilians, limited to Southeast Asia. Indeed, lack of economic value for its skin has led to neglect the biodiversity of the species. The current study aimed to investigate the mentioned case using 40 simple sequence repeat (SSR) primer pairs and 45 inter-simple sequence repeat (ISSR) primers. DNA analysis of 17 T. schlegelii samples using the SSR and ISSR markers resulted in producing a total of 49 and 108 polymorphic bands, respectively. Furthermore, the SSR- and ISSR-based cluster analyses both generated two main clusters. However, the SSR based results were found to be more in line with the geographical distributions of the crocodile samples collected across the country as compared with the ISSR-based results. The observed heterozygosity (HO) and expected heterozygosity (HE) of the polymorphic SSRs ranged between 0.588-1 and 0.470-0.891, respectively. The present results suggest that the Malaysian T. schlegelii populations had originated from a core population of crocodiles. In cooperation with the SSR markers, the ISSRs showed high potential for studying the genetic variation of T. schlegelii, and these markers are suitable to be employed in conservation genetic programs of this endangered species. Both SSR- and ISSR-based STRUCTURE analyses suggested that all the individuals of T. schlegelii are genetically similar with each other.
Morphometric sex determination of Milky and Painted Storks in captivity

Ong HK, Chinna K, Khoo SK, Ng WL, Wong BY, Chow KL, et al.

Zoo Biol, 2012 Mar-Apr;31(2):219-28.
PMID: 21480370 DOI: 10.1002/zoo.20387

Logistic regression was applied to develop a morphometric sexing method of two closely related stork species that were previously sexed through amplification of the CHD gene. Tarsus length (TL) and bill length (BL) measurements were recorded from captive populations of adult Milky Stork (Mycteria cinerea) (n = 60) and Painted Stork (Mycteria leucocephala) (n = 58) at Zoo Negara Malaysia. Despite having monomorphic plumages, both stork species exhibited normal sexual size dimorphism in which males were significantly larger than females in the tested variables. Based on logistic regression analysis, BL correctly classified the sex of sampled individuals from Painted and Milky stork with an overall predicted accuracy of 94.8 and 90.0%, respectively. However, TL measurements generated a lower predicted accuracy level of 86.2% and a same accuracy level of 90% on the sex classification of individuals from Painted and Milky stork, respectively. By comparing the measurements of both species, only the average BL measurements of the Milky storks were significantly lower than that of Painted storks (t-test, P80.001). The logistic regression equation in this study may serve as a simple and more practical option for sexing Milky and Painted storks for their breeding and conservation programmes.
Fulltext Molecular sexing and preliminary assessment of population sex ratio of the endangered Malayan tapir (Tapirus indicus) in Peninsular Malaysia

Lim QL, Tan YL, Ng WL, Yong CSY, Ismail A, Rovie-Ryan JJ, et al.

Sci Rep, 2020 03 04;10(1):3973.
PMID: 32132572 DOI: 10.1038/s41598-020-60552-y

A molecular sexing method by polymerase chain reaction (PCR) amplification of a portion of the sex-determining region Y (SRY) and the zinc finger (ZF) gene, as well as six equine Y-chromosome-specific microsatellite markers, were tested in the Malayan tapir (Tapirus indicus). While the microsatellite markers did not yield any male-specific amplicons for sex-typing, the SRY/ZF marker system produced reliable molecular sexing results by accurately sex-typing 31 reference Malayan tapirs, using whole blood, dried blood spot (DBS), or tissue samples as materials for DNA extraction. The marker system was also tested on 16 faecal samples, and the results were in general consistent with the pre-determined sexes of the animals, despite some amplification failures. A preliminary estimation of wild Malayan tapir population sex ratio was estimated from the Wildlife Genomic Resource Bank (WGRB) database of the Malaysian Department of Wildlife and National Parks (PERHILITAN), zoos, and the Sungai Dusun Wildlife Conservation Centre (WCC), as well as from the results of molecular sexing 12 samples of unknown sex. The overall sex ratio favoured females, but the deviation from parity was statistically not significant when tested using the binomial test (p > 0.05), which may be due to reduced statistical power caused by small sample sizes.
Fulltext Desmoid Type Fibromatosis of the Breast Masquerading as Breast Carcinoma: Value of Dynamic Magnetic Resonance Imaging and Its Correlation

Ng WL, Teoh SY, See MH, Rahmat K, Jayalakshmi P, Ramli MT, et al.

Eur J Breast Health, 2021 Apr;17(2):197-199.
PMID: 33870121 DOI: 10.4274/ejbh.galenos.2020.5482

Desmoid type fibromatosis of the breast is a rare stromal tumor that accounts for <0.2% of all breast tumors. Bilateral and multicentric lesions are extremely rare, with only less than ten cases reported in the literature. Although benign, it is locally aggressive with frequent recurrence in up to almost one-third of the cases. We experienced our first case of bilateral multicentric breast fibromatosis in a 19-year-old woman, with a paternal aunt diagnosed with breast cancer at age 30, who presented to our institution with the chief complaint of retracted nipples for 1 year. The patient denied any history of trauma to her chest. Sonography showed suspicious bilateral hypoechoic masses. Magnetic resonance imaging (MRI) was performed for further evaluation because of the extensive involvement of both the breasts. This report aimed to illustrate the main clinical, radiological, and histopathological characteristics of this rare disease to increase awareness of this entity and discuss the role of MRI.
Fulltext An Automated Patient Self-Monitoring System to Reduce Health Care System Burden During the COVID-19 Pandemic in Malaysia: Development and Implementation Study

Lim HM, Teo CH, Ng CJ, Chiew TK, Ng WL, Abdullah A, et al.

JMIR Med Inform, 2021 Feb 26;9(2):e23427.
PMID: 33600345 DOI: 10.2196/23427

BACKGROUND: During the COVID-19 pandemic, there was an urgent need to develop an automated COVID-19 symptom monitoring system to reduce the burden on the health care system and to provide better self-monitoring at home.
OBJECTIVE: This paper aimed to describe the development process of the COVID-19 Symptom Monitoring System (CoSMoS), which consists of a self-monitoring, algorithm-based Telegram bot and a teleconsultation system. We describe all the essential steps from the clinical perspective and our technical approach in designing, developing, and integrating the system into clinical practice during the COVID-19 pandemic as well as lessons learned from this development process.
METHODS: CoSMoS was developed in three phases: (1) requirement formation to identify clinical problems and to draft the clinical algorithm, (2) development testing iteration using the agile software development method, and (3) integration into clinical practice to design an effective clinical workflow using repeated simulations and role-playing.
RESULTS: We completed the development of CoSMoS in 19 days. In Phase 1 (ie, requirement formation), we identified three main functions: a daily automated reminder system for patients to self-check their symptoms, a safe patient risk assessment to guide patients in clinical decision making, and an active telemonitoring system with real-time phone consultations. The system architecture of CoSMoS involved five components: Telegram instant messaging, a clinician dashboard, system administration (ie, back end), a database, and development and operations infrastructure. The integration of CoSMoS into clinical practice involved the consideration of COVID-19 infectivity and patient safety.
CONCLUSIONS: This study demonstrated that developing a COVID-19 symptom monitoring system within a short time during a pandemic is feasible using the agile development method. Time factors and communication between the technical and clinical teams were the main challenges in the development process. The development process and lessons learned from this study can guide the future development of digital monitoring systems during the next pandemic, especially in developing countries.
Fulltext Immunodeficiency and Thymoma: A Case Report on Good Syndrome, a Diagnosis Frequently Missed and Forgotten

Tang ASO, Loh WH, Wong QY, Yeo ST, Ng WL, Teoh PI, et al.

Am J Case Rep, 2021 Mar 13;22:e928659.
PMID: 33712551 DOI: 10.12659/AJCR.928659

BACKGROUND Good syndrome (thymoma with immunodeficiency) is a frequently missed and forgotten entity. It is a rare cause of combined B and T cell immunodeficiency in adults. To date, fewer than 200 patients with Good syndrome have been reported in the literature. CASE REPORT We report a case of type AB Masaoka-Koga stage I thymoma which predated the evidence of immune dysregulation by 5 years, manifesting as bilateral cytomegalovirus retinitis, multiple bouts of pneumonia, and bronchiectasis in a HIV-seronegative 55-year-old man. Intravitreal ganciclovir was administered in addition to intravenous systemic ganciclovir, which resulted in severe neutropenic sepsis. A thorough immunodeficiency workup confirmed the presence of hypogammaglobulinemia with complete absence of B cells and reduced CD4/CD8 ratio. The patient responded well to monthly intravenous immunoglobulin replacement therapy, with no further episodes of infection since then. The immunoglobulin level doubled after 1 year of treatment. However, as the patient refused further intravitreal and CMV-targeted treatment, his vision did not recover. CONCLUSIONS Clinicians should be aware that thymoma can precede the onset of immunodeficiency. Clinical suspicion should be heightened in at-risk patients who present with multiple bouts of infection, particularly in thymoma cases with adult-onset immune dysfunction. It is of paramount importance to follow up those patients with annual clinical reviews and immunodeficiency screening.

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