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Fulltext What, Where, and How to Collect Real-World Data and Generate Real-World Evidence to Support Drug Reimbursement Decision-Making in Asia: A reflection Into the Past and A Way Forward

Kc S, Lin LW, Bayani DBS, Zemlyanska Y, Adler A, Ahn J, et al.

Int J Health Policy Manag, 2023;12:6858.
PMID: 37579427 DOI: 10.34172/ijhpm.2023.6858

BACKGROUND: Globally, there is increasing interest in the use of real-world data (RWD) and real-world evidence (RWE) to inform health technology assessment (HTA) and reimbursement decision-making. Using current practices and case studies shared by eleven health systems in Asia, a non-binding guidance that seeks to align practices for generating and using RWD/RWE for decision-making in Asia was developed by the REAL World Data In ASia for HEalth Technology Assessment in Reimbursement (REALISE) Working Group, addressing a current gap and needs among HTA users and generators.
METHODS: The guidance document was developed over two face-to-face workshops, in addition to an online survey, a face-to-face interview and pragmatic search of literature. The specific focus was on what, where and how to collect RWD/ RWE.
RESULTS: All 11 REALISE member jurisdictions participated in the online survey and the first in-person workshop, 10 participated in the second in-person workshop, and 8 participated in the in-depth face-to-face interviews. The guidance document was iteratively reviewed by all working group members and the International Advisory Panel. There was substantial variation in: (a) sources and types of RWD being used in HTA, and (b) the relative importance and prioritization of RWE being used for policy-making. A list of national-level databases and other sources of RWD available in each country was compiled. A list of useful guidance on data collection, quality assurance and study design were also compiled.
CONCLUSION: The REALISE guidance document serves to align the collection of better quality RWD and generation of reliable RWE to ultimately inform HTA in Asia.
Observation of a cubical-like microstructure of strontium iron garnet and yttrium iron garnet prepared via sol-gel technique

Nasir N, Yahya N, Kashif M, Daud H, Akhtar MN, Zaid HM, et al.

J Nanosci Nanotechnol, 2011 Mar;11(3):2551-4.
PMID: 21449424

This is our initial response towards preparation of nano-inductors garnet for high operating frequencies strontium iron garnet (Sr3Fe5O12) denoted as SrIG and yttrium iron garnet (Y3Fe5O12) denoted as YIG. The garnet nano crystals were prepared by novel sol-gel technique. The phase and crystal structure of the prepared samples were identified by using X-ray diffraction analysis. SEM images were done to reveal the surface morphology of the samples. Raman spectra was taken for yttrium iron garnet (Y3Fe5O12). The magnetic properties of the samples namely initial permeability (micro), relative loss factor (RLF) and quality factor (Q-Factor) were done by using LCR meter. From the XRD profile, both of the Y3Fe5O12 and Sr3Fe5O12 samples showed single phase garnet and crystallization had completely occurred at 900 degrees C for the SrIG and 950 degrees C for the YIG samples. The YIG sample showed extremely low RLF value (0.0082) and high density 4.623 g/cm3. Interesting however is the high Q factor (20-60) shown by the Sr3Fe5O12 sample from 20-100 MHz. This high performance magnetic property is attributed to the homogenous and cubical-like microstructure. The YIG particles were used as magnetic feeder for EM transmitter. It was observed that YIG magnetic feeder with the EM transmitter gave 39% higher magnetic field than without YIG magnetic feeder.
Fulltext Caesarean delivery and its correlates in Northern Region of Bangladesh: application of logistic regression and cox proportional hazard model

Rahman M, Shariff AA, Shafie A, Saaid R, Tahir RM

J Health Popul Nutr, 2015;33:8.
PMID: 26825988 DOI: 10.1186/s41043-015-0020-2

Caesarean delivery (C-section) rates have been increasing dramatically in the past decades around the world. This increase has been attributed to multiple factors such as maternal, socio-demographic and institutional factors and is a burning issue of global aspect like in many developed and developing countries. Therefore, this study examines the relationship between mode of delivery and time to event with provider characteristics (i.e., covariates) respectively.
Fulltext Prevalence and Predictors of Clinically Undiagnosed Cognitive Impairment Among Older Residents of Nursing Homes in Association with HRQOL

Chen LL, Ch'ng SH, Shafie AA, Hasali MA, Tagiisuran B

Value Health, 2014 Nov;17(7):A770.
PMID: 27202837 DOI: 10.1016/j.jval.2014.08.310
Vertical infestation of the dengue vectors Aedes aegypti and Aedes albopictus in apartments in Kuala Lumpur, Malaysia

Roslan MA, Shafie A, Ngui R, Lim YA, Sulaiman WY

J Am Mosq Control Assoc, 2013 Dec;29(4):328-36.
PMID: 24551965

Dengue is a serious public health problem in Malaysia. The aim of this study was to compare the vertical infestation of Aedes population in 2 apartments in Kuala Lumpur with different status of dengue incidence (i.e., high-dengue-incidence area and area with no reported dengue cases). The study was also conducted to assess the relationship between environmental factors such as rainfall, temperature, and humidity and Aedes population that may influence Aedes infestation. Surveillance with a mosquito larvae trapping device was conducted for 28 continuous weeks (January to July 2012) in Vista Angkasa (VA) and Inderaloka (IL) apartments located in Kuala Lumpur, Malaysia. The results indicated that both Aedes spp. could be found from ground to higher floor levels of the apartments, with Aedes aegypti being more predominant than Ae. albopictus. Data based on mixed and single breeding of Aedes spp. on different floors did not show any significant difference. Both rainfall (R3; i.e., the amount of rainfall collected during the previous 3 wk before the surveillance period began) and RH data showed significant relationship with the number of Aedes larvae collected in VA and IL. No significant difference was found between the numbers of Aedes larvae in both study areas as well as maximum and minimum temperatures. Results also indicated adaptations of Ae. aegypti to the ecosystem at each elevation of high-rise buildings, with Ae. albopictus staying inside of apartment units.
Mosquito Biology and Mosquito-Borne Disease Awareness Among Island Communities In Malaysia

Shafie A, Roslan MA, Ngui R, Lim YA, Sulaiman WY

J Am Mosq Control Assoc, 2016 Dec;32(4):273-281.
PMID: 28206867 DOI: 10.2987/16-6604.1

Mosquito-borne diseases have been increasing at an alarming rate over the past decades. In Malaysia, one finds several important mosquito-borne diseases such as Japanese encephalitis, dengue, malaria, and chikungunya. Mosquito surveillance and control programs are the most effective way of detecting and controlling mosquito-borne diseases, but these programs are less effective without an aware and well-informed general public. In 2014 we used a questionnaire to evaluate the extent of awareness of basic mosquito biology and mosquito-borne diseases in 6 villages, Kampung Masjid, Kampung Teluk Gedung, Kampung Teluk Dalam, Kampung Ujung Kelawai, Kampung Sungai Pinang Besar, and Kampung Sungai Pinang Kechil on Pangkor Island, Malaysia. A total of 1,012 individuals responded to the questionnaire, consisting of 790 Malay (78.1%), 164 Chinese (16.2%), and 58 Indian (5.7%). More than 60% (Malay = 73.7%, Chinese = 64.0%, Indian = 79.3%) of the respondents were familiar with basic mosquito biology and practiced personal protection against mosquito bites, and the association was statistically significant (P = 0.02). However, the majority of the respondents had limited knowledge on mosquito-borne diseases, and this varied significantly among the 3 ethnic groups (P = 0.0001). Our recommendations are to improve and intensify public health education outreach programs to the island residents and to encourage community participation in vector control programs.
Fulltext Assessing the cost effectiveness of an anticoagulation clinic in comparison with the usual medical clinic In Kuala Lumpur Hospital [Abstract]

Thanimalai S, Shafie AA, Ahmad HM, Sinnadurai J

Value Health, 2014 Nov;17(7):A487.
PMID: 27201439 DOI: 10.1016/j.jval.2014.08.1428

Objectives: Systematic anticoagulation management clinic is now recommended to manage warfarinized atrial fibrillation (AF) patient. In Malaysia, the service is recently introduced as pharmacist managed Warfarin Medication Therapy Adherence Clinic (WMTAC). The objective of the present study was to assess the cost effectiveness of anticoagulation clinic in comparison with usual medical in Kuala Lumpur Hospital.
Methods: A Markov model built using the provider perspective and 20 year time horizon was used to assess the cost effectiveness. The base case analysis assumed a cohort of patients with AF 57 years of age with comorbid illnesses. Data sources include a 6 month retrospective cohort analysis of the effectiveness of the clinics, the cost of drugs, cost of personnel and space of the clinics, cost of monitoring and cost of adverse events were obtained from the local source and publications. The transition probabilities of these clinics outcomes were obtained from a literature search. Future costs were discounted by 3% to convert to present values. All costs were in Ringgit Malaysia (RM) based on year 2012.
Results: The results of a 20-year period model showed that UMC was dominated by the WMTAC in the same time period. The mean cost of the WMTAC was RM 5864 whereas the UMC cost was RM 6550. The sensitivity analysis showed that clinic treatment costs and effectiveness influenced the cost-effectiveness. If the cost of WMTAC was increased by 50% of the current cost, the WMTAC would not be a dominant intervention. WMTAC was also cost effective for a willingness to pay of RM32000.
Conclusions: The anticoagulation management service appears to cost less and provide greater effectiveness than usual care. In conclusion, the Markov model suggests that from the provider perspective the anticoagulation clinic is a more cost effective option than the usual medical clinic in Kuala Lumpur Hospital.
Study site: Medication Therapy Adherence Clinic, Hospital Kuala Lumpur, Malaysia
Fulltext Input attributes optimization using the feasibility of genetic nature inspired algorithm: Application of river flow forecasting

Afan HA, Allawi MF, El-Shafie A, Yaseen ZM, Ahmed AN, Malek MA, et al.

Sci Rep, 2020 03 13;10(1):4684.
PMID: 32170078 DOI: 10.1038/s41598-020-61355-x

In nature, streamflow pattern is characterized with high non-linearity and non-stationarity. Developing an accurate forecasting model for a streamflow is highly essential for several applications in the field of water resources engineering. One of the main contributors for the modeling reliability is the optimization of the input variables to achieve an accurate forecasting model. The main step of modeling is the selection of the proper input combinations. Hence, developing an algorithm that can determine the optimal input combinations is crucial. This study introduces the Genetic algorithm (GA) for better input combination selection. Radial basis function neural network (RBFNN) is used for monthly streamflow time series forecasting due to its simplicity and effectiveness of integration with the selection algorithm. In this paper, the RBFNN was integrated with the Genetic algorithm (GA) for streamflow forecasting. The RBFNN-GA was applied to forecast streamflow at the High Aswan Dam on the Nile River. The results showed that the proposed model provided high accuracy. The GA algorithm can successfully determine effective input parameters in streamflow time series forecasting.
Fulltext The measurement of utilities in asthma patients: a preliminary study. [Abstract]

Yong YV, Shafie AA

Value Health, 2014 Nov;17(7):A568.
PMID: 27201892 DOI: 10.1016/j.jval.2014.08.1892

Objectives: To assess the feasibility of a computer-based Standard Gamble (SG) visual prop whilst measuring utilities of different asthma health states at the same time.
Methods: Twenty adult asthma patients literate in either Malay or English language were conveniently sampled from a public hospital in Penang, Malaysia. They were interviewed by two trained interviewers using a bilingual script. Each patient was requested to value the given health states using Visual Analogue Scale (VAS) prior to SG exercise. There were three chronic health states (C1-C3) for 10 years, three temporary states (T1-T3) for 3 months, and two anchor states (healthy and dead). During the SG exercise, the visual prop was fully operated by the interviewers. The probability of being in a worse state was changed in a ‘ping-pong’ fashion until the indifference point was reached.
Results: All patients understood the SG exercise and rated SG easier than VAS. Around 85% (n=17) completed SG within 30 minutes. There was 90% (n=18) who ranked T3 as the worst temporary health state during VAS. Two patients provided logical inconsistency data in SG. The preferences by SG were higher than VAS. Preferences were also higher in temporary states measured by chained SG than other states by conventional SG. The mean utilities for C1=0.56 (SD 0.38), C2=0.47 (SD 0.33), C3=0.53 (SD 0.38), T1=0.65 (SD 0.31), T2=0.53 (SD 0.35), and T3=0.38 (SD 0.38).
Conclusions: The SG methods including the props are feasible for utilities measurement in asthma, based on the agreements achieved with other studies on the pattern of utilities measured in this preliminary study.
Economic evaluation of respiratory medication therapy adherence clinic (RMTAC) on asthma patients in Malaysia. [Abstract]

Yong YV, Shafie AA

Value Health, 2015 Nov;18(7):A501.
PMID: 26532812 DOI: 10.1016/j.jval.2015.09.1419

Objectives: To evaluate the long-term cost-effectiveness of RMTAC (an adjunct
pharmaceutical asthma management) vs. usual physician care clinic by using decision analytic modelling method. Methods: A dynamic adherence asthma Markov
cohort model was developed. The economic evaluation was based on a lifetime
horizon and cycle length of one month, from the healthcare provider‘s (Ministry
of Health) perspective, with the outcomes assessed in cost per QALY gained and
cost per hospitalization averted. Probabilities of asthma control-adherence states
from RMTAC database, costs from national sources, utilities using standard gamble method on Malaysia’s asthma patients, and other inputs from secondary data
sources were used to inform the probabilistic model, according to gender and age
subgroups. A scenario analysis was conducted to test the structural assumption on
follow-up visits after the final treatment visit. Results: In female subgroup, RMTAC
management dominates the usual care by having 0.91 (95% CI 0.24 – 1.69) QALY
gained and 0.58 (95% CI -2.30 – 6.23) hospitalization averted, at a lower cost. For male
subgroup, the ICERs were RM10 (95% CI -RM14431 – RM8323) per QALY gained and
RM18 (95% CI -RM35790 – RM30266) per hospitalization averted. At the willingnessto-pay threshold of RM29000 per an additional QALY gained, the RMTAC intervention
is likely to be cost-effective 99% and 57% of the time (for QALY and hospitalization
outcome, respectively). The analysis was robust to assumptions of follow-up visits
frequency and patients’ gender. Conclusions: Implementing RMTAC in Malaysia
has high probability of being more cost-effective than the usual care management
for both male and female subgroups across all age groups. Further investigation is
necessary to ensure that implementing this decision does not exceed the overall
national healthcare expenditure

Study site : Universiti Sains Malaysia, Penang, Malaysia
Cost-Effectiveness of Clinical Pharmacy Education on Infection Management among Patients with Chronic Kidney Disease in an Indonesian Hospital

Nasution A, Syed Sulaiman SA, Shafie AA

Value Health Reg Issues, 2013 May;2(1):43-47.
PMID: 29702851 DOI: 10.1016/j.vhri.2013.02.009

OBJECTIVES: This study evaluated the clinical and economic impacts of clinical pharmacy education (CPE) on infection management among patients with chronic kidney disease (CKD) stages 4 and 5 in Haji Adam Malik Hospital, Indonesia.
METHODS: A quasi-experimental economic evaluation comparing CPE impact on 6-month CKD mortality was conducted on the basis of payer perspective. The experimental group (n = 63) received care by health care providers who were given CPE on drug-related problems and dose adjustment. The control group (n = 80) was based on the historical cohort of patients who received care before the CPE. Measure of clinical outcome applied in this study was number of lives saved/100 patients treated. Cost-effectiveness ratios for CKD stages 4 and 5 patients without CPE and with CPE and incremental cost-effectiveness ratios (ICERs) for CKD stages 4 and 5 patients were analyzed.
RESULTS: Lives saved (%) in the treatment of CKD without CPE: CKD stage 4, 78.57; CKD stage 5, 57.58. Lives saved (%) in the treatment of CKD with CPE: CKD stage 4, 88.89; CKD stage 5, 65.45. Cost-effectiveness ratios for stage 4 with and without CPEs were Rp3,348,733.27 and Rp3,519,931.009, respectively. Cost-effectiveness ratios for stage 5 with and without CPEs were Rp7,137,874.93 and Rp7,871,822.27, respectively. ICERs were Rp2,045,341.22 for CKD stage 4 and Rp1,767,585.60 for CKD stage 5.
CONCLUSIONS: Treatment of CKD stages 4 and 5 with CPE was more effective and cost-effective compared with treatment of CKD stages 4 and 5 without CPE. The ICERs indicated that extra costs were required to increase life saved in both stages.
Fulltext A literature review of the cardiovascular risk-assessment tools: applicability among Asian population

Liau SY, Mohamed Izham MI, Hassali MA, Shafie AA

Heart Asia, 2010;2(1):15-8.
PMID: 27325935 DOI: 10.1136/ha.2009.001115

Cardiovascular diseases, the main causes of hospitalisations and death globally, have put an enormous economic burden on the healthcare system. Several risk factors are associated with the occurrence of cardiovascular events. At the heart of efficient prevention of cardiovascular disease is the concept of risk assessment. This paper aims to review the available cardiovascular risk-assessment tools and its applicability in predicting cardiovascular risk among Asian populations.
Wavelet neural networks applied to pulping of oil palm fronds

Zainuddin Z, Wan Daud WR, Pauline O, Shafie A

Bioresour Technol, 2011 Dec;102(23):10978-86.
PMID: 21996481 DOI: 10.1016/j.biortech.2011.09.080

In the organosolv pulping of the oil palm fronds, the influence of the operational variables of the pulping reactor (viz. cooking temperature and time, ethanol and NaOH concentration) on the properties of the resulting pulp (yield and kappa number) and paper sheets (tensile index and tear index) was investigated using a wavelet neural network model. The experimental results with error less than 0.0965 (in terms of MSE) were produced, and were then compared with those obtained from the response surface methodology. Performance assessment indicated that the neural network model possessed superior predictive ability than the polynomial model, since a very close agreement between the experimental and the predicted values was obtained.
Fulltext Assessing the role of urban green spaces for human well-being: a systematic review

Jabbar M, Yusoff MM, Shafie A

GeoJournal, 2021 Jul 20.
PMID: 34305268 DOI: 10.1007/s10708-021-10474-7

Human has been evolving in a natural environment over a long time; thus, he is habitual to adapt it. Green spaces are obligatory landscapes in an urban structure that provide a natural environment and accelerate other life events. In contrast, unplanned urbanization, and conversion from green to grey structures have damaged natural environmental resources. Studies through different angles have highlighted the importance of urban green spaces for human well-being but now need to identify their role according to the potential. The demands of urban green spaces may differ with the change of population size, types of grey structure, urban expansion, the altitude of the place, and geographical location. Therefore, this systematic review aims to analyse the significance of urban green spaces for human well-being. The study opted for a systematic process during the selection and organization of studies for this review. After analysing, 46 studies were finalized with the consensus of three review authors. Accordingly, literature was analysed under the central theme of "Urban Green Spaces for Human Well-being." Human Well-being was assessed under six sub-themes; physical, psychological, mental, social, subjective, and environmental well-being. The review concluded that urban green spaces are the primary pillar for a sustainable urban place and human well-being due to highly positive and positive correlations. Moreover, the study did not find any demarcation line between green spaces and grey structures according to any specific need. Therefore, the study suggested that the role of urban green spaces for human well-being should be analysed according to their potential and required optimal ratio under different communities' urban specific environments and social behaviour.
Fulltext Professional training and roles of community pharmacists in Malaysia: views from general medical practitioners

Ahmad Hassali MA, Awaisu A, Shafie AA, Saeed MS

Malays Fam Physician, 2009;4(2-3):71-6.
PMID: 25606167 MyJurnal

AIM: This pilot study aimed to explore the perceptions of general medical practitioners (GPs) towards the professional training and roles of community pharmacists.
METHODS: A self-administered questionnaire was distributed to all private clinics (n=160) run by GPs in a northern state of Malaysia. The instrument contained questions to evaluate the practitioners' level of agreement using a 5-point Likert-type scale.
RESULTS: Of 160 GPs, 80 returned the questionnaire (response rate 50%). The respondents agreed that: GPs should consider the community pharmacists' recommendations whenever there is/are any problem(s) with the prescriptions given by them (46.3%); community pharmacists are the best healthcare professionals to educate patients about safe and appropriate use of medications (52.5%); the pharmacy profession had undergone a major metamorphosis from a product-oriented profession to a more patient-centred and outcome-oriented one (61.3%); if dispensing separation is implemented, they will work closely with the community pharmacists in monitoring patients' pharmacotherapeutic outcomes (77.5%).
CONCLUSION: The current findings suggest that GPs would support an extension of the role of the community pharmacists in number of activities of patient care activities such as medication counselling. Thus, suggesting potential collaborative care between GPs and community pharmacists towards patient care and the needs to develop and incorporate topics on inter-professional relationship in the current medical and pharmaceutical education curriculums.
KEYWORDS: Community pharmacists; general practitioners; perceptions; roles; training
Fulltext Spatial distribution of malaria in Peninsular Malaysia from 2000 to 2009

Alias H, Surin J, Mahmud R, Shafie A, Mohd Zin J, Mohamad Nor M, et al.

Parasit Vectors, 2014;7:186.
PMID: 24735583 DOI: 10.1186/1756-3305-7-186

Malaria is still an endemic disease of public health importance in Malaysia. Populations at risk of contracting malaria includes indigenous people, traditional villagers, mobile ethnic groups and land scheme settlers, immigrants from malaria endemic countries as well as jungle workers and loggers. The predominant species are Plasmodium falciparum and P. vivax. An increasing number of P. knowlesi infections have also been encountered. The principal vectors in Peninsular Malaysia are Anopheles maculatus and An. cracens. This study aims to determine the changes in spatial distribution of malaria in Peninsular Malaysia from year 2000-2009.
Vascular intersection detection in retina fundus images using a new hybrid approach

Aibinu AM, Iqbal MI, Shafie AA, Salami MJ, Nilsson M

Comput Biol Med, 2010 Jan;40(1):81-9.
PMID: 20022595 DOI: 10.1016/j.compbiomed.2009.11.004

The use of vascular intersection aberration as one of the signs when monitoring and diagnosing diabetic retinopathy from retina fundus images (FIs) has been widely reported in the literature. In this paper, a new hybrid approach called the combined cross-point number (CCN) method able to detect the vascular bifurcation and intersection points in FIs is proposed. The CCN method makes use of two vascular intersection detection techniques, namely the modified cross-point number (MCN) method and the simple cross-point number (SCN) method. Our proposed approach was tested on images obtained from two different and publicly available fundus image databases. The results show a very high precision, accuracy, sensitivity and low false rate in detecting both bifurcation and crossover points compared with both the MCN and the SCN methods.
Hippocampal MR Volumetric Studies in Paediatric Patients with Epilepsy and Normal Controls

Win Mar Salmah J, Noorfizura A, Mohd Shafie A, Helmy A, Salmi AR, Naing L

Neuroradiol J, 2011 Aug 31;24(4):503-10.
PMID: 24059706

The aim of this study was to determine and compare the hippocampal volume in children with epilepsy and in children in a control group and to compare the mean of right and left hippocampal volume in control subjects. This study was carried out at University Sains Malaysia (USM) from January 2008 to June 2009. This is a cross sectional study of 40 children with epilepsy and 40 children in a control volunteer group. Serial MRI of brain and temporal lobe were performed using a Signa Horizon LX 1.0 Tesla system. Oblique coronal sections perpendicular to the axis of temporal lobe were done with 4 mm slice thickness and 1 mm gap. T1, T2, FLAIR and SPGR series were done. The whole hippocampal volume was measured. Volumetry was done manually by using Osirix workstation (v 3.5.1-64 bit). All slices were measured three times and the average volume was taken. Data were analyzed by paired t test and independent t test for univariate data. The mean hippocampal volume in the control group was 2.81 cm(3) (SD=0.38) and 2.65 cm(3) (SD=0.41) for right and left hippocampus respectively. The mean hippocampal volume in epilepsy patients was 2.47 cm(3) (SD=0.52) and 2.39 cm(3) (SD=0.44) for right and left respectively. The hippocampal volume in epileptic children was significantly smaller than normal control children in average volume (p=0.001) and both right (p=0.002) and left (p=0.007) individually. In the control group, the right hippocampus volume was much greater than the left (p<0.001). The data of this study provide a useful reference for the study of hippocampal volume in the Malay paediatric population. It is useful in doubtful cases to determine which side is affected and also serves as part of the study to establish the whole age-related hippocampal growth.
Fulltext Solitary Skull Metastasis as Initial Manifestation of Hepatocellular Carcinoma - A Case Report

Ellyda, M.N., Mohd Shafie, A.

International Medical Journal Malaysia, 2009;8(2):47-52.
MyJurnal

Metastatic spread of tumors to the skull is quite unusual and often represents diagnostic and therapeutic issues. Skull involvement can be observed in various neoplasms of epithelial origin and are most often due to lung, breast, thyroid, kidney and prostate cancers. However, skull metastases from hepatocellular carcinoma (HCC) have been rarely reported. The prognosis for patients with hepatocellular carcinoma is so poor that treatment of such distant metastatic lesion cannot be achieved before death occurs due to the primary malignancy. Therefore, the clinical manifestations of cranial metastasis prior to that of primary hepatocellular carcinoma have rarely been reported. This case illustrates a rare case of skull metastasis as an initial manifestation of hepatocellular carcinoma. Although a solitary skull metastasis prior to the diagnosis of HCC demonstrates rare metastatic behavior for HCC, especially in Asia, skull metastases from HCC should be included in the differential diagnosis of skull tumors, even if the patient is asymptomatic of liver cirrhosis.
Fulltext Bilateral congenital renal arteriovenous malformation: A rare entity with uncommon presentation.

Radhiana, H., Mohd Shafie, A., Mohd Ariff, M.A.

International Medical Journal Malaysia, 2009;8(1):53-55.
MyJurnal

Renal arteriovenous malformation (AVM) is a rare congenital anomaly of the urinary system. We present a patient with bilateral renal AVMs who presented with back pain and microscopic hematuria. This case highlights the importance of careful diagnostic work-up in the evaluation of upper tract hematuria. Renal AVM was found to be the cause of mild back pain and persistent microscopic hematuria in a 45-year-old lady. This case highlights the importance of complete diagnostic work-up in the evaluation of microscopic hematuria in arriving at the correct diagnosis of an uncommon clinical entity.

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