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  1. Mai CW, Tan JSH, Koay GWL, Lim LYX
    Pharmacy (Basel), 2020 Sep 13;8(3).
    PMID: 32933158 DOI: 10.3390/pharmacy8030170
    Dietary supplementation is increasingly sought after by consumers looking to meet the demands of a modern lifestyle. Effective supplementation requires knowledge of the purpose and proper use of nutritional supplements. Unverified or inadequate guidance on supplementation can propagate misconceptions and increase undue fears of side effects. Community pharmacists are best placed to guide consumers on nutritional supplement use. In this review, a panel comprised of community pharmacists, pharmacy academia, and dietitians (n = 6) convened to provide an experience- and evidence-based guidance on rational drug use, patient education, and integrated and personalized nutrition care in both community and hospital pharmacy settings. A novel framework to guide community pharmacist-led consultations on supplementation is proposed. The four-step CARE (Categorize, Assess, Recommend, Empower) guide was developed to facilitate and optimize outcomes of pharmacist-led nutritional supplement consultation. Telehealth advancements in the form of digital health applications and personalized nutrigenomic DNA testing support Integrative Nutrition Care, and will further promote appropriate supplementation use to improve overall well-being in the community. Practical implementation of the CARE guide is necessary to ascertain its applicability for optimizing outcomes of pharmacist-led consultation and the recommendation of nutritional supplements.
  2. Tan DC, Quek A, Kassim NK, Ismail IS, Lee JJ
    Molecules, 2020 Nov 06;25(21).
    PMID: 33171900 DOI: 10.3390/molecules25215162
    Scopoletin has previously been reported as a biomarker for the standardization of Paederia foetida twigs. This study is the first report on the determination and quantification of scopoletin using quantitative nuclear magnetic resonance (qNMR) in the different extracts of Paederia foetida twigs. The validated qNMR method showed a good linearity (r2 = 0.9999), limit of detection (LOD) (0.009 mg/mL), and quantification (LOQ) (0.029 mg/mL), together with high stability (relative standard deviation (RSD) = 0.022%), high precision (RSD < 1%), and good recovery (94.08-108.45%). The quantification results of scopoletin concentration in chloroform extract using qNMR and microplate ultraviolet-visible (UV-vis) spectrophotometer was almost comparable. Therefore, the qNMR method is deemed accurate and reliable for quality control of Paederia foetida and other medicinal plants without extensive sample preparation.
  3. Wong XZ, Gan CC, Mohamed R, Yahya R, Ganapathy S, Tan SS, et al.
    BMC Nephrol, 2020 11 13;21(1):480.
    PMID: 33187498 DOI: 10.1186/s12882-020-02154-4
    BACKGROUND: Hepatitis C virus (HCV) infects more than 71 million people worldwide and chronic HCV infection increases the risk of liver cirrhosis and failure. Haemodialysis (HD) is one of the renal replacement therapies with risk of HCV transmission. Anti-HCV antibodies are the serological screening test for HCV infection that does not detect active phase of infection. Majority HCV infected HD patients in Malaysia do not have further HCV RNA performed due to high cost and thus HCV treatment is less frequently offered. HCV Core Antigen (HCV Ag) can potentially be used to diagnose active HCV infection in HD population in comparison to HCV RNA, at lower cost.

    METHODS: We conducted a cross-sectional study to assess the correlation between HCV Ag and HCV RNA and to identify the prevalence of active HCV infection among HCV seropositive HD patients from dialysis centres across West Malaysia from July 2019 to May 2020. Pre-dialysis blood was taken and tested for both HCV Ag and HCV RNA tests. HCV Ag was tested with Abbott ARCHITECT HCV Ag test.

    RESULTS: We recruited 112 seropositive HD patients from 17 centres with mean age of 54.04 ± 11.62 years, HD vintage of 14.1 ± 9.7 years, and male constitute 59.8% (67) of the study population. HCV Ag correlates well with HCV RNA (Spearman test coefficient 0.833, p  3000 IU/mL, HCV Ag had a higher sensitivity of 95.1% and greater correlation (Spearman test coefficient 0.897, p 

  4. Goh SSL, Lai PSM, Liew SM, Tan KM, Chung WW, Chua SS
    PLoS One, 2020;15(11):e0242051.
    PMID: 33175871 DOI: 10.1371/journal.pone.0242051
    To date, several medication adherence instruments have been developed and validated worldwide. However, most instruments have only assessed medication adherence from the patient's perspective. The aim was to develop and validate the PATIENT-Medication Adherence Instrument (P-MAI) and the HEALTHCARE PROFESSIONAL-Medication Adherence Instrument (H-MAI) to assess medication adherence from the patient's and healthcare professional (HCP)'s perspectives. The P-MAI-12 and H-MAI-12 were developed using the nominal group technique. The face and content validity was determined by an expert panel and piloted. The initial version of these instruments consisted of 12 items were validated from October-December 2018 at a primary care clinic in Malaysia. Included were patients aged ≥21 years, diagnosed with diabetes mellitus, taking at least one oral hypoglycaemic agent and who could understand English. The HCPs recruited were family medicine specialists or trainees. To assess validity, exploratory factor analysis (EFA) and concurrent validity were performed; internal consistency and test-retest were performed to assess its reliability. A total of 120/158 patients (response rate = 75.9%) and 30/33 HCPs (response rate = 90.9%) agreed to participate. EFA found three problematic items in both instruments, which was then removed. The final version of the P-MAI-9 and the HMAI-9 had 9 items each with two domains (adherence = 2 items and knowledge/belief = 7 items). For concurrent validity, the total score of the P-MAI-9 and the H-MAI-9 were not significantly different (p = 0.091), indicating that medication adherence assessed from both the patient's and HCP's perspectives were similar. Both instruments achieved acceptable internal consistency (Cronbach's α: P-MAI-9 = 0.722; H-MAI-9 = 0.895). For the P-MAI-9, 7/9 items showed no significant difference between test and retest whereas 8/9 items in the H-MAI-9 showed significant difference at test and retest (p>0.05). In conclusion, the P-MAI-9 and H-MAI-9 had low sensitivity and high specificity suggesting that both instruments can be used for identifying patients more likely to be non-adherent to their medications.
  5. Wong PL, Ramli NS, Tan CP, Azlan A, Abas F
    Phytochem Anal, 2021 Sep;32(5):685-697.
    PMID: 33295100 DOI: 10.1002/pca.3015
    INTRODUCTION: Ardisia elliptica Thunb. (Primulaceae) is a medicinal herb that is traditionally used for the treatment of fever, diarrhoea, measles and herpes. However, there is limited information regarding the correlation of its phytoconstituents with the bioactivity. Optimisation of solvent extraction is vital for maximising retention of bioactive molecules.

    OBJECTIVE: This study investigated the metabolite variations in A. elliptica leaves and the correlation with antioxidant activities.

    METHODOLOGY: Total phenolic content (TPC), 2,2-diphenyl-1-picrylhydrazyl (DPPH) and nitric oxide (NO) radicals scavenging assays were performed on A. elliptica leaves extracted with four different ethanol ratios (0%, 50%, 70% and absolute ethanol). The correlation of metabolites with antioxidant activities was evaluated using a nuclear magnetic resonance (NMR)-based metabolomics approach.

    RESULTS: The results showed that the 50% and 70% ethanolic extracts retained the highest TPC, and the 70% ethanolic extract was the most active, exhibiting half maximal inhibitory concentration (IC50 ) values of 10.18 ± 0.83 and 43.05 ± 1.69 μg/mL, respectively, in both radical scavenging assays. A total of 46 metabolites were tentatively identified, including flavonoids, benzoquinones, triterpenes and phenolic derivatives. The 50% and 70% ethanolic extracts showed similarities in metabolites content and were well discriminated from water and absolute ethanol extracts in a principal component analysis (PCA) model. Moreover, 31 metabolites were found to contribute significantly to the differentiation and antioxidant activity.

    CONCLUSION: This study provides information on bioactive compounds in A. elliptica leaves, which is promising as a functional ingredient for food production or for the development of phytomedicinal products.

  6. Wong EYL, Loh GOK, Tan YTF, Peh KK
    Drug Dev Ind Pharm, 2021 Feb;47(2):197-206.
    PMID: 33300818 DOI: 10.1080/03639045.2020.1862177
    OBJECTIVE: The aim of the study was to develop a simple, highthroughput and sensitive LC-MS/MS method and apply to a bioequivalence study of montelukast, a light sensitive drug.

    METHOD: The effects of organic modifiers in mobile phase, protein precipitation agent to plasma sample ratio, and light on montelukast stability in unprocessed and processed human plasma, were evaluated. Validation was conducted in accordance with European Medicines Agency Guideline on bioanalytical method validation.

    RESULTS: No interference peak was observed when acetonitrile was used as an organic modifier. Acetonitrile to plasma ratio of 4:1 produced clean plasma sample. Approximately 3 % of cis isomer was detected in unprocessed plasma samples while 21 % of cis isomer was detected in processed plasma samples after exposing to fluorescent light for 24h. The standard calibration curve was linear over 3.00-1200.00 ng/mL. All method validation parameters were within the acceptance criteria.

    CONCLUSION: The validated method was successfully applied to a bioequivalence study of two montelukast formulations involving 24 healthy Malaysian volunteers. The light stability of a light sensitive drug in unprocessed and processed human plasma samples should be studied prior to pharmacokinetic/bioequivalence studies. Measures could then be taken to protect the analyte in human plasma from light degradation.

  7. Arulsamy A, Tan QY, Balasubramaniam V, O'Brien TJ, Shaikh MF
    ACS Chem Neurosci, 2020 Nov 04;11(21):3488-3498.
    PMID: 33064448 DOI: 10.1021/acschemneuro.0c00431
    Dysbiosis of gut microbiota may lead to a range of diseases including neurological disorders. Thus, it is hypothesized that regulation of the intestinal microbiota may prevent or treat epilepsy. The purpose of this systematic review is to evaluate the evidence investigating the relationship between gut microbiota and epilepsy and possible interventions. A systematic review of the literature was done on four databases (PubMed, Scopus, EMBASE, and Web of Science). Study selection was restricted to original research articles while following the PRISMA guidelines. Six studies were selected. These studies cohesively support the interaction between gut microbiota and epileptic seizures. Gut microbiota analysis identified increases in Firmicutes, Proteobacteria, Verrucomicrobia, and Fusobacteria with decreases in Bacteroidetes and Actinobacteria in epileptic patients. Ketogenic diet, probiotics, and fecal microbiota transplantation (FMT) improved the dysbiosis of the gut microbiota and seizure activity. However, the studies either had a small sample size, lack of subject variability, or short study or follow-up period, which may question their reliability. Nevertheless, these limited studies conclusively suggest that gut microbiota diversity and dysbiosis may be involved in the pathology of epilepsy. Future studies providing more reliable and in depth insight into the gut microbial community will spark promising alternative therapies to current epilepsy treatment.
  8. Sim CY, Wan Zaidi WA, Shah SA, Wan Yahya WNN, Tan HJ
    J Stroke Cerebrovasc Dis, 2021 Jan;30(1):105421.
    PMID: 33160125 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105421
    BACKGROUND: Around 15.0% of all strokes occurred in hospitalised patients and studies showed significant delay in the stroke recognition and lack of awareness on thrombolytic therapy for acute ischaemic stroke (AIS) which lead to higher mortality for in-hospital stroke. We aimed to develop and validate a new instrument known as acute stroke management questionnaire (ASMaQ) to evaluate the awareness of healthcare professionals in managing acute ischaemic stroke cases.

    METHODS: This study consisted of 3 steps; the formulation of ASMaQ draft, content validation and construct validity. A total of 110 questions were drafted with 5-point Likert scale answers. From the list, 31 were selected and subsequently tested on 158 participants. The results were analysed and validated using exploratory factor analysis on SPSS. Components were extracted and questions with low factor loading were removed. The internal consistency was then measured with Cronbach's alpha.

    RESULTS: Following analysis, 3 components were extracted and named as general stroke knowledge, hyperacute stroke care and advanced stroke management. Two items were deleted leaving 29 out of 31 questions for the final validated ASMaQ. Internal consistency showed high reliability with Cronbach's alpha of 0.82. Our respondents scored a total cumulative mean of 113.62 marks or 66.6%. A sub analysis by occupation showed that medical assistants scored the lowest in the group with a score of 57% whilst specialists including neurologists scored the highest at 79.4%.

    CONCLUSION: The ASMaQ is a newly developed and validated questionnaire consisting of 29 questions testing the respondents' acute stroke management knowledge.

  9. Nik Salleh NNH, Othman FA, Kamarudin NA, Tan SC
    Molecules, 2020 Dec 02;25(23).
    PMID: 33276419 DOI: 10.3390/molecules25235677
    In Southeast Asia, traditional medicine has a longestablished history and plays an important role in the health care system. Various traditional medicinal plants have been used to treat diseases since ancient times and much of this traditional knowledge remains preserved today. Oroxylum indicum (beko plant) is one of the medicinal herb plants that is widely distributed throughout Asia. It is a versatile plant and almost every part of the plant is reported to possess a wide range of pharmacological activities. Many of the important bioactivities of this medicinal plant is related to the most abundant bioactive constituent found in this plant-the baicalein. Nonetheless, there is still no systematic review to report and vindicate the biological activities and therapeutic potential of baicalein extracted from O. indicum to treat human diseases. In this review, we aimed to systematically present in vivo and in vitro studies searched from PubMed, ScienceDirect, Scopus and Google Scholar database up to 31 March 2020 based on keywords "Oroxylum indicum" and "baicalein". After an initial screening of titles and abstracts, followed by a full-text analysis and validation, 20 articles that fulfilled all the inclusion and exclusion criteria were included in this systematic review. The searched data comprehensively reported the biological activities and therapeutic potential of baicalein originating from the O. indicum plant for anti-cancer, antibacterial, anti-hyperglycemia, neurogenesis, cardioprotective, anti-adipogenesis, anti-inflammatory and wound healing effects. Nonetheless, we noticed that there was a scarcity of evidence on the efficacy of this natural active compound in human clinical studies. In conclusion, this systematic review article provides new insight into O. indicum and its active constituent baicalein as a prospective complementary therapy from the perspective of modern and scientific aspect. We indicate the potential of this natural product to be developed into more conscientious and judicious evidencebased medicine in the future. However, we also recommend more clinical research to confirm the efficacy and safety of baicalein as therapeutic medicine for patients.
  10. Chong BTW, Wahab S, Muthukrishnan A, Tan KL, Ch'ng ML, Yoong MT
    Psychol Res Behav Manag, 2020;13:949-962.
    PMID: 33204188 DOI: 10.2147/PRBM.S266976
    Purpose: The shorter life expectancy and increased risk of suicide in patients with schizophrenia have been well documented. However, study outcomes on suicidality in this special population have been few to date. This study investigated the prevalence and factors associated with suicidal ideation in a population of institutionalized patients with schizophrenia.

    Methods: Two hundred fifty-six patients with schizophrenia between the age of 18 and 65 years were randomly recruited. This cross-sectional study utilised the Calgary Depression Scale for Schizophrenia (CDSS), the Positive and Negative Syndrome Scale (PANSS) and the Psychotic Symptom Rating Scale (PSYRATS-AH). Univariate analysis was performed using an independent t-test or chi-square test, followed by binary logistic regression to determine the factors associated with increased suicidal risks.

    Results: The socio-demographic factors associated with suicidal ideation included level of education (p=0.039); secondary-level education (OR=5.76, 95% CI:1.49, 22.34, p=0.011) and tertiary-level education (OR=9.30, 95% CI: 1.80, 48.12, p=0.008) posed a greater risk. A history of attempted suicide (OR=2.09, 95% CI: 1.01, 4.36, p=0.049) and the presence of co-morbid physical illnesses (OR=2.07, 95% CI: 1.02, 4.21, p=0.044) were also found to be associated with a suicidal ideation. Other significant factors associated with suicidal thoughts were concurrent depression (OR=9.68, 95% CI: 3.74, 25.05, p<0.001) and a higher PSYRATS score in emotional characteristics of auditory hallucinations (OR=1.13, 95% CI: 1.06, 1.21, p<0.001).

    Conclusion: Suicide in schizophrenia appears to be more closely associated with certain socio-demographic factors and affective symptoms. Appropriate screening and treatment addressing these challenges must be emphasized if suicidal thoughts and actions are to be reduced.

  11. Li Y, Ren J, Li N, Liu J, Tan SC, Low TY, et al.
    Exp Gerontol, 2020 11;141:111110.
    PMID: 33045358 DOI: 10.1016/j.exger.2020.111110
    BACKGROUND: Dehydroepiandrosterone (DHEA) has been aggressively sold as a dietary supplement to boost testosterone levels although the impact of DHEA supplementation on testosterone levels has not been fully established. Therefore, we performed a systematic review and meta-analysis of RCTs to investigate the effect of oral DHEA supplementation on testosterone levels.

    METHODS: A systematic literature search was performed in Scopus, Embase, Web of Science, and PubMed databases up to February 2020 for RCTs that investigated the effect of DHEA supplementation on testosterone levels. The estimated effect of the data was calculated using the weighted mean difference (WMD). Subgroup analysis was performed to identify the source of heterogeneity among studies.

    RESULTS: Overall results from 42 publications (comprising 55 arms) demonstrated that testosterone level was significantly increased after DHEA administration (WMD: 28.02 ng/dl, 95% CI: 21.44-34.60, p = 0.00). Subgroup analyses revealed that DHEA increased testosterone level in all subgroups, but the magnitude of increment was higher in females compared to men (WMD: 30.98 ng/dl vs. 21.36 ng/dl); DHEA dosage of ˃50 mg/d compared to ≤50 mg/d (WMD: 57.96 ng/dl vs. 19.43 ng/dl); intervention duration of ≤12 weeks compared to ˃12 weeks (WMD: 44.64 ng/dl vs. 19 ng/dl); healthy participants compared to postmenopausal women, pregnant women, non-healthy participants and androgen-deficient patients (WMD: 52.17 ng/dl vs. 25.04 ng/dl, 16.44 ng/dl and 16.47 ng/dl); and participants below 60 years old compared to above 60 years old (WMD: 31.42 ng/dl vs. 23.93 ng/dl).

    CONCLUSION: DHEA supplementation is effective for increasing testosterone levels, although the magnitude varies among different subgroups. More study needed on pregnant women and miscarriage.

  12. Ng BH, Tan YS, Pavitratha P, A Hing C, Zainul NH, Lim CH
    Med J Malaysia, 2020 11;75(6):759-761.
    PMID: 33219196
    A 40-year-old man presented to the Hospital Sultanah Bahiyah, Alor Setar, Kedah, with constitutional and respiratory symptoms. Physical examination and echocardiogram demonstrated massive pericardial effusion. Patient required multiple attempts of pericardiocentesis due to recurrent pericardial effusion. Initial workup including pericardial fluids examination and computed tomography imaging did not reveal any apparent cause. Magnetic resonance imaging showed a suspicious mass infiltrating into the right atrium. Autoimmune screening was negative. Patient was subsequently treated as having tuberculous pericarditis. However, his disease progressed rapidly and he eventually passed away due to right atrial rupture. Postmortem revealed a ruptured right atrial tumour leading to massive haemothorax. Histopathological examination confirmed the diagnosis of primary pericardial angiosarcoma.
  13. Cheo SW, Mohd Zamin H, Low QJ, Tan YA, Chia YK
    Med J Malaysia, 2020 11;75(6):745-747.
    PMID: 33219190
    Stroke is a debilitating disease as it carries significant morbidity especially when it affects the younger population. There are various etiologies of young stroke, namely arterial dissection, cardioembolism, thrombophilia, inherited genetic disorder and vasculitis. Young patient with stroke should undergo complete evaluation to identify the underlying etiology in order to prevent recurrence of stroke. Here, we would like to illustrate a case of Takayasu arteritis presenting as young stroke in a 17-years-old lady with no known medical illness.
  14. Khoo PLZ, Poon JS, Tan GJS, Yahya A, Chan KMJ
    Med J Malaysia, 2020 11;75(6):722-730.
    PMID: 33219184
    INTRODUCTION: Heart valve disease comprises a cluster of conditions affecting the aortic, mitral, pulmonary and tricuspid valves. This paper reviews all the research on heart valve disease in Malaysia published between the years 2000- 2016.

    METHODS: The methodology was based on the search process described in the paper, "Bibliography of clinical research in Malaysia: methods and brief results". The search databases included PubMed, Scopus and several Malaysian journals such as MyJurnal and UKM Journal Repository, by using the following keywords: (heart valve disease OR infective endocarditis OR rheumatic heart disease) and (Malaysia).

    RESULTS: In all 94 papers were identified of which 39 papers were selected and reviewed on the basis of their relevance. The local studies contributed to the knowledge and understanding of the epidemiology, aetiology, pathophysiology, clinical presentations, investigations, treatment, and outcomes of heart valve disease in the country.

    DISCUSSION: The clinical relevance of the studies performed in the country is discussed along with recommendations for future research.

  15. Chan EWL, Chin MY, Low YH, Tan HY, Ooi YS, Chong CW
    Microb Drug Resist, 2021 Aug;27(8):1018-1028.
    PMID: 33325795 DOI: 10.1089/mdr.2020.0311
    Aims: The fluid of Nepenthes gracilis harbors diverse bacterial taxa that could serve as a gene pool for the discovery of the new genre of antimicrobial agents against multidrug-resistant Klebsiella pneumoniae. The aim of this study was to explore the presence of antibacterial genes in the fluids of N. gracilis growing in the wild. Methods: Using functional metagenomic approach, fosmid clones were isolated and screened for antibacterial activity against three strains of K. pneumoniae. A clone that exhibited the most potent antibacterial activity was sent for sequencing to identify the genes responsible for the observed activity. The secondary metabolites secreted by the selected clone was sequentially extracted using hexane, chloroform, and ethyl acetate. The chemical profiles of a clone (C6) hexane extract were determined by gas chromatography/mass spectrometry (GC-MS). Results: Fosmid clone C6 from the fluid of pitcher plant that exhibited antibacterial activity against three strains of K. pneumoniae was isolated using functional metagenome approach. A majority of the open reading frames detected from C6 were affiliated with the largely understudied Acidocella genus. Among them, the gene that encodes for coproporphyrinogen III oxidase in the heme biosynthesis pathway could be involved in the observed antibacterial activity. Based on the GC-MS analysis, the identities of the putative bioactive compounds were 2,5-di-tert-butylphenol and 1-ethyl-2-methyl cyclododecane. Conclusions: The gene that encodes for coproporphyrinogen III oxidase in the heme biosynthesis pathway as well as the secondary metabolites, namely 2,5-di-tert-butylphenol and 1-ethyl-2-methyl cyclododecane could be the potential antibacterial molecules responsible for the antibacterial activity of C6.
  16. Tan SM, Ong SA, Ho LN, Wong YS, Thung WE, Teoh TP
    J Environ Health Sci Eng, 2020 Dec;18(2):793-807.
    PMID: 33312603 DOI: 10.1007/s40201-020-00504-w
    This study demonstrated the effectiveness of single chamber up-flow membrane-less microbial fuel cell (UFML-MFC) in wastewater treatment concurrently with bioelectricity generation. The objectives of this study were to examine the effect of influent substrate concentration (0.405 g/L, 0.810 g/L, 1.215 g/L, 1.620 g/L), anode distributions (11 cm, 17 cm, 23 cm ) and surface morphologies for biofilm formation on the performance of wastewater treatment and power generation. The optimum performance was obtained with substrate concentration of 0.810 g/L. The COD removal efficiency, output voltage, internal resistance, power density and current density obtained were 84.64%, 610 mV, 200 Ω, 162.59 mW/m2 and 468.74 mA/m2, respectively. The Coulombic Efficiency (CE), Normalized Energy Recovery (NERS and NERv) were 1.03%, 789.38 kWh/kg COD and 22.56 kWh/m3, respectively. The results also indicate that the output voltage and power generation obtained in a continuous up-flow MFC were higher with A3 (23 cm), which is of larger electrodes spacing followed by A2 (17 cm) and A1 (11 cm) caused by the enrichment of anaerobic microbial population at A1.
  17. Zain SM, Tan HL, Mohamed Z, Chan WK, Mahadeva S, Basu RC, et al.
    JGH Open, 2020 Dec;4(6):1155-1161.
    PMID: 33319051 DOI: 10.1002/jgh3.12414
    Background and Aim: Advanced fibrosis is the most important predictor of liver-related mortality in non-alcoholic fatty liver disease (NAFLD). The aim of this study was to compare the diagnostic performance of noninvasive scoring systems in identifying advanced fibrosis in a Malaysian NAFLD cohort and propose a simplified strategy for the management of NAFLD in a primary care setting.

    Methods: We enrolled and reviewed 122 biopsy-proven NAFLD patients. Advanced fibrosis was defined as fibrosis stages 3-4. Noninvasive assessments included aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, AST-to-platelet ratio index (APRI), AST/ALT ratio, diabetes (BARD) score, fibrosis-4 (FIB-4) score, and NAFLD fibrosis score.

    Results: FIB-4 score had the highest area under the receiver operating characteristic curve (AUROC) and negative predictive value (NPV) of 0.86 and 94.3%, respectively, for the diagnosis of advanced fibrosis. FIB-4 score 

  18. Chai WS, Tan WG, Halimatul Munawaroh HS, Gupta VK, Ho SH, Show PL
    Environ Pollut, 2021 Jan 15;269:116236.
    PMID: 33333449 DOI: 10.1016/j.envpol.2020.116236
    Microalgae have become imperative for biological wastewater treatment. Its capability in biological purification of wastewaters from different origins while utilizing wastewater as the substrate for growth has manifest great potentials as a sustainable and economical wastewater treatment method. The wastewater grown microalgae have also been remarked in research to be a significant source of value-added bioproducts and biomaterial. This paper highlights the multifaceted roles of microalgae in wastewater treatment from the extent of microalgal bioremediation function to environmental amelioration with the involvement of microalgal biomass productivity and carbon dioxide fixation. Besides, the uptake mechanism of microalgae in wastewater treatment was discussed in detail with illustrations for a comprehensive understanding of the removal process of undesirable substances. The performance of different microalgae species in the uptake of various substances was studied and summarized in this review. The correlation of microalgal treatment efficacy with various algal strain types and the bioreactors harnessed for cultivation systems was also discussed. Studies on the alternatives to conventional wastewater treatment processes and the integration of microalgae with accordant wastewater treatment methods are presented. Current research on the biological and technical approaches for the modification of algae-based wastewater system and the maximization of biomass production is also reviewed and discussed. The last portion of the review is dedicated to the assertion of challenges and future perspectives on the development of microalgae-based wastewater treatment technology. This review serves as a useful and informative reference for readers regarding the multifaceted roles of microalgae in the application of wastewater biotreatment with detailed discussion on the uptake mechanism.
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