Displaying publications 81 - 100 of 137 in total

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  1. Fulltext Hot towel massage relieved a 7 years orofacial pain – a case report
    Ma MS
    Ann Dent, 2012;19(2):66-69.
    MyJurnal
    Diagnosis and management of orofacial pain of non-odontogenic origin has always been a challenge to dentists. Inaccurate diagnosis would result in delay of treatment and in cases of orofacial pain, affects patient’s quality of life. Temporomandibular pain dysfunction syndrome is the most common temporomandibular disorder that presents to dental clinics. Trigeminal neuralgia, also known as ticdouloureux is a relatively rare condition that causes electric shock-like pain when the trigger zone is stimulated by triggering factor. Case report: A case of temporomandibular pain dysfunction syndrome in a 52 years old Indian lady that was managed as trigeminal neuralgia for 7 years is presented. Conclusion: The aim of this case report is to make dentists aware of the signs and symptoms of different orofacial pain, so that early and accurate diagnosis can be made and appropriate treatment instituted.
    Matched MeSH terms: Diagnostic Errors
  2. Fulltext Hoarseness as the sole symptom of an impending thoracic aneurysm rupture?
    Jaafar R, Mohamad I
    Malays Fam Physician, 2014;9(1):25-7.
    PMID: 25606294 MyJurnal
    Unilateral vocal cord palsy secondary to thoracic aortic aneurysm is a rare occurrence. Direct compression of the enlarging thoracic aneurysm on the left recurrent laryngeal nerve causes neuronal injury of the nerve, which is manifested as hoarseness. We present a rare case of unilateral vocal cord palsy in a 60-year-old healthy gentleman caused by a large thoracic aortic aneurysm. This rare presentation, with a serious underlying pathology might be misdiagnosed or delayed. Therefore, it is important for us to have high index of suspicion in cases with a rare presentation such as this.
    Matched MeSH terms: Diagnostic Errors
  3. Fulltext Hamman’s syndrome: a rare benign syndrome
    Aida Abdul Rahim, Mohd Taufiq Yahaya1, Siti Nor Farhana Mohd Shafie, Laila Mastura Ahmad Apandi
    Malaysian Journal of Medicine and Health Sciences, 2020;16(1):357-359.
    MyJurnal
    Hamman’s syndrome by definition is spontaneous pneumomediastinum with the exclusion of thoracic trauma or iatrogenic cause. It is rare and is more common in adolescence male. Amongst the risk factors are underlying lung condition such as asthma and interstitial lung disease, drug inhalation and parturient woman. Patient usually pres- ents with sudden onset of shortness of breath and chest pain with subcutaneous emphysema on examination. The diagnosis is confirmed with chest radiograph. The prognosis of Hamman’s syndrome is excellent. Most cases are self-limiting and resolve spontaneously. However, Hamman’s syndrome is a poorly recognised disease due to its rarity. Therefore, the patient may be subjected to misdiagnosis and treatment. This is a case report of Hamman’s syn- drome misdiagnosed and treated as pneumothorax. The objective of this case report is to highlight the importance of differentiating this benign syndrome with life threatening differentials which may have similar clinical presentation. Thus, avoiding unnecessary costly investigation, treatment and invasive procedures.
    Matched MeSH terms: Diagnostic Errors
  4. Fulltext Foundation and methodologies in computer-aided diagnosis systems for breast cancer detection
    Jalalian A, Mashohor S, Mahmud R, Karasfi B, Saripan MIB, Ramli ARB
    EXCLI J, 2017;16:113-137.
    PMID: 28435432 DOI: 10.17179/excli2016-701
    Breast cancer is the most prevalent cancer that affects women all over the world. Early detection and treatment of breast cancer could decline the mortality rate. Some issues such as technical reasons, which related to imaging quality and human error, increase misdiagnosis of breast cancer by radiologists. Computer-aided detection systems (CADs) are developed to overcome these restrictions and have been studied in many imaging modalities for breast cancer detection in recent years. The CAD systems improve radiologists' performance in finding and discriminating between the normal and abnormal tissues. These procedures are performed only as a double reader but the absolute decisions are still made by the radiologist. In this study, the recent CAD systems for breast cancer detection on different modalities such as mammography, ultrasound, MRI, and biopsy histopathological images are introduced. The foundation of CAD systems generally consist of four stages: Pre-processing, Segmentation, Feature extraction, and Classification. The approaches which applied to design different stages of CAD system are summarised. Advantages and disadvantages of different segmentation, feature extraction and classification techniques are listed. In addition, the impact of imbalanced datasets in classification outcomes and appropriate methods to solve these issues are discussed. As well as, performance evaluation metrics for various stages of breast cancer detection CAD systems are reviewed.
    Matched MeSH terms: Diagnostic Errors
  5. Factors involved in the diagnosis of oral squamous cell carcinoma in Malaysia
    Khoo SP, Shanmuhasuntharam P, Mahadzir WM, Tay KK, Latif A, Nair S
    Asia Pac J Public Health, 1998;10(1):49-51.
    PMID: 10050209 DOI: 10.1177/101053959801000111
    The delay in the diagnosis of oral cancer has been variously reported as being contributed by the clinicians, patients or both. The purpose of this study was to evaluate the referral pattern of 65 patients eventually diagnosed as having oral squamous cell carcinoma. The results showed that 50% of the patients delayed seeking professional help for more than 3 months after being aware of the lesion. The majority of the patients consulted medical practitioners as the first source of help. The mean clinicians' and patients' delay were 10.3 weeks and 28.9 weeks respectively. Dental practitioners showed a tendency to refer more advanced lesions compared to the medical practitioners. The findings raise the concern that lack of patients' awareness, misdiagnosis by clinicians and late detection by dental practitioners prevail thus calling for urgent measures towards early detection of the disease.
    Matched MeSH terms: Diagnostic Errors/statistics & numerical data
  6. Fulltext Evaluation of three rapid diagnostic tests for the detection of human infections with Plasmodium knowlesi
    Foster D, Cox-Singh J, Mohamad DS, Krishna S, Chin PP, Singh B
    Malar J, 2014;13:60.
    PMID: 24548805 DOI: 10.1186/1475-2875-13-60
    Plasmodium knowlesi, a malaria parasite of Southeast Asian macaques, infects humans and can cause fatal malaria. It is difficult to diagnose by microscopy because of morphological similarity to Plasmodium malariae. Nested PCR assay is the most accurate method to distinguish P. knowlesi from other Plasmodium species but is not cost effective in resource-poor settings. Rapid diagnostic tests (RDTs) are recommended for settings where malaria is prevalent. In this study, the effectiveness of three RDTs in detecting P. knowlesi from fresh and frozen patient blood samples was evaluated.
    Matched MeSH terms: Diagnostic Errors
  7. Endometrial amoebiasis
    Othman NH, Ismail AN
    Eur J Obstet Gynecol Reprod Biol, 1993 Dec 15;52(2):135-7.
    PMID: 8157142
    A case of endometrial infection by Entamoeba histolytica is described in an elderly lady who presented with profuse vaginal discharge and was clinically misdiagnosed as endometrial carcinoma.
    Matched MeSH terms: Diagnostic Errors
  8. Fulltext Diagnostic tools in childhood malaria
    Amir A, Cheong FW, De Silva JR, Lau YL
    Parasit Vectors, 2018 01 23;11(1):53.
    PMID: 29361963 DOI: 10.1186/s13071-018-2617-y
    Every year, millions of people are burdened with malaria. An estimated 429,000 casualties were reported in 2015, with the majority made up of children under five years old. Early and accurate diagnosis of malaria is of paramount importance to ensure appropriate administration of treatment. This minimizes the risk of parasite resistance development, reduces drug wastage and unnecessary adverse reaction to antimalarial drugs. Malaria diagnostic tools have expanded beyond the conventional microscopic examination of Giemsa-stained blood films. Contemporary and innovative techniques have emerged, mainly the rapid diagnostic tests (RDT) and other molecular diagnostic methods such as PCR, qPCR and loop-mediated isothermal amplification (LAMP). Even microscopic diagnosis has gone through a paradigm shift with the development of new techniques such as the quantitative buffy coat (QBC) method and the Partec rapid malaria test. This review explores the different diagnostic tools available for childhood malaria, each with their characteristic strengths and limitations. These tools play an important role in making an accurate malaria diagnosis to ensure that the use of anti-malaria are rationalized and that presumptive diagnosis would only be a thing of the past.
    Matched MeSH terms: Diagnostic Errors/prevention & control
  9. Diagnostic accuracy of pneumonia in Hospital Tuanku Ja'afar Seremban, a tertiary hospital
    Poh KW, Cheok LH, Liow JH, Mat Soom MA, Azlina S, Nadiah MN, et al.
    Med J Malaysia, 2020 01;75(1):7-11.
    PMID: 32008012
    OBJECTIVES: The primary objective of this study was to describe the accuracy of pneumonia diagnosis, both community-acquired pneumonia (CAP) and hospitalacquired pneumonia (HAP). Secondary objectives were describing the choice of antibiotics used, pathogens isolated, and predictive parameters in diagnosing pneumonia.

    METHODS: This was a prospective cross-sectional study to determine the accuracy of the diagnosis of CAP and HAP admitted to Hospital Tuanku Ja'afar. All patients aged ≥12 years admitted to the general medical ward with the diagnosis of CAP or HAP were included in the study. Chest radiograph interpretation was done by certified radiologists. An accurate diagnosis of pneumonia was defined by clinical signs and symptoms of pneumonia supported by radiographical evidence.

    RESULTS: A total of 159 patients were enrolled into the study from January 2018 to February 2018. Of these only 59(37.1%) cases were accurately diagnosed as pneumonia. Amongst those with pneumonia diagnosis made by the emergency department, medical officers and specialists of medical department; 65.4%, 60% and 47.3% respectively were not pneumonia. Amoxicillin with clavulanate and azithromycin were amongst the most common first choice of antibiotic used (46.5%). In this study, pathogens were isolated either by blood culture or sputum culture in only 20 (12.6%) patients. There was no significant predictive parameter identified in this study, which included white cell counts, Creactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), and Pao2/FiO2 ratio.

    CONCLUSION: About two-thirds of patients diagnosed with pneumonia did not have a compatible radiological finding. Better tools and systems are needed to aid in the diagnosis of pneumonia.

    Matched MeSH terms: Diagnostic Errors/prevention & control*
  10. Fulltext Detection of anti-cell membrane DNA antibodies by indirect immunoflouresencence technique in systemic lupus erythematosus
    Faten Nurul Amira Awing Kechik, Maha Abdullah, Masriana Hassan, Masita Arip, Hasni Mahayidin
    Malaysian Journal of Medicine and Health Sciences, 2019;15(108):28-28.
    MyJurnal
    Introduction: Systemic lupus erythematosus (SLE) has a broad spectrum of clinical presentations. The diagnosis of SLE remains a challenge and largely depends on the presence of several serum autoantibodies including anti-nuclear antibody (ANA), anti-double-stranded DNA antibody (anti-dsDNA) and anti-Smith antibody (anti-Sm). ANA, a highly sensitive but not specific marker is used for SLE screening Anti-dsDNA and anti-Sm are SLE-specific biomarkers but has lower sensitivity of 80% and 30% for SLE, respectively. However, it is noted that there are SLE patients who are persistently negative for SLE-specific autoantibodies. Anti-dsDNA and anti-Sm were reported to be negative in up to 51.2% and 62.4% of SLE, respectively. This limitation can lead to misdiagnosis and halter proper treatment to SLE patients. Previous studies have suggested that cell membrane DNA (cmDNA) can act as a specific target for the autoantibodies in SLE patients. Autoantibodies towards cmDNA (anti-cmDNA) were reported to have promis-ing value as a reliable biomarker for SLE. In this study, we would like to determine the usefulness of anti-cmDNA in diagnosing SLE as compared to the standard SLE-specific autoantibodies. Methods: Serum samples from 83 SLE patients, 86 other connective tissue diseases and 61 healthy subjects were included in this study. The other connec-tive tissue diseases include samples from 10 Sjogren’s syndrome, 56 rheumatoid arthritis, 12 scleroderma and eight mixed connected tissues disease (MCTD) patients. All samples were analysed by indirect immunofluorescence (IIF) technique using Raji cells as substrate to detect the presence of anti-cmDNA. Anti-cmDNA was reported as positive if there was presence of a fluorescent ring, either continuous or punctate. Sera from SLE patients were also tested for anti-dsDNA and anti-Sm antibodies by using enzyme-immunoassays. Results: Anti-cmDNA positivity was highest in SLE (55.4%) than in other connective tissue diseases (9.3%) and healthy subjects (0%). Anti-cmDNA was 100% spe-cific at differentiating SLE from healthy subjects and 90.7% specific at differentiating SLE from other connective tissue diseases. There was no difference in the sensitivity (55.4%) of anti-cmDNA at differentiating SLE from both groups. Anti-cmDNA were present in 46 SLE samples negative for standard SLE-specific autoantibodies. It was detected in 11 (42.3%) of anti-dsDNA, 23 (63.9%) of anti-Sm and 8 (12.9%) of both anti-Sm and anti-dsDNA negative samples. Conclusion: The high specificity of anti-cmDNA detection using IIF method makes it an excellent diagnostic tool for SLE. Anti-cmDNA is potentially a very useful biomarker for SLE with negative anti-dsDNA or/and anti-Sm antibodies.
    Matched MeSH terms: Diagnostic Errors
  11. Dengue associated haemophagocytic lymphohystiocytosis: An often-missed complication of a common infection
    Takkinsatian P, Sowithayasakul P, Prommalikit O
    Med J Malaysia, 2020 09;75(5):588-590.
    PMID: 32918433
    Hemophagocytic lymphohistiocytosis (HLH) is a severe and life-threatening condition causing multisystem involvement such as cytopenia, hepatosplenomegaly, and death. Dengue infection is one of the leading causes of HLH. We reviewed three cases of children at HRH Princess Maha Chakri Sirindhorn Medical Center, Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand, with dengue fever who subsequently developed HLH, based on the HLH-2004 diagnostic criteria. Following treatment with dexamethasone and intravenous immunoglobulin, there was a dramatic response including defervescence and improvement of cytopenia, hyperfibrinogenemia, and hyperferritinemia. Key features for diagnosis of dengue fever complicated by HLH include a history of prolonged fever exceeding seven days, splenomegaly, and worsening cytopenia. Early recognition and treatment are crucial for a successful outcome.
    Matched MeSH terms: Diagnostic Errors
  12. Delay and misdiagnosis in adult myasthenia gravis: A case report
    Kwa, Siew Kim, Zainab Abdul Majeed, Tan, Kah Nian
    International e-Journal of Science, Medicine & Education, 2016;10(3):37-39.
    MyJurnal
    Myasthenia gravis (MG) is a rare autoimmune disorder
    characterised by fluctuating and variable combination
    of muscle weakness and fatigue. Most cases are due to
    T-cell mediated autoantibodies against post-synaptic
    acetylcholine receptors (AChR-Ab), thus preventing
    acetylcholine from binding and signalling skeletal
    muscle to contract.1
    The annual incidence is 7-23 new cases per million.1
    It can occur at any age but with two peaks; an earlyonset
    (20-40 years) female-predominant and a late-onset
    (60-80 years) male-predominant peak. MG is classified
    into ocular and generalised (80%). More than half the
    patients initially present with ptosis and diplopia but half
    will progress to generalised disease with involvement of
    bulbar, limb and respiratory weakness. Those presenting
    as generalised MG can also develop eye signs later.1
    It is important to recognise MG early because it is
    highly treatable. Untreated disease leads to permanent
    weakness.2 Treatment reduces mortality from lifethreatening
    myasthenic crisis.1,3 Misdiagnosis leads to
    potentially harmful interventions and inappropriate
    management.4,5 Diagnosis in late-onset MG is easily
    missed2,3,4,5 because of overlapping symptoms with
    other diseases common in the elderly. We report a case
    of delay and misdiagnosis in an elderly patient with
    co-morbidities. (Copied from article).
    Matched MeSH terms: Diagnostic Errors
  13. Fulltext Delay In Diagnosis Of Oral Cancer In Malaysia: A Study Of Five Centres
    Khoo, Suan Phaik, Shanmuhasuntharam, P., Mahadzir, W.M., Tay, K.K., Latif, A., Nair, S.
    Ann Dent, 1996;3(1):-.
    MyJurnal
    The diagnosis of oral cancer have been variously reported as being due to delay by clinicians, patients or both. The purpose of this study was to evaluate the referral pattern of 65 patients eventually diagnosed as having oral squamous cell carcinoma. The results showed that 50% of the patients delayed seeking professional help for more than 3 months after being aware of the lesion. The majority of the patients consulted medical practitioners as the first source of help. The mean clinicians' and patients' delay were 10.3 weeks and 28.9 weeks respectively. Dental practitioners showed a tendency to refer on more advanced lesions compared to the medical practitioners. The findings raise the concern that lack of patients' awareness, misdiagnosis by clinicians and late detection by dental practitioners prevail thus calling for urgent measures towards early detection of the disease.
    Matched MeSH terms: Diagnostic Errors
  14. Fulltext Deaths due to Plasmodium knowlesi malaria in Sabah, Malaysia: association with reporting as Plasmodium malariae and delayed parenteral artesunate
    Rajahram GS, Barber BE, William T, Menon J, Anstey NM, Yeo TW
    Malar J, 2012;11:284.
    PMID: 22905799 DOI: 10.1186/1475-2875-11-284
    The simian parasite Plasmodium knowlesi is recognized as a common cause of severe and fatal human malaria in Sabah, Malaysia, but is morphologically indistinguishable from and still commonly reported as Plasmodium malariae, despite the paucity of this species in Sabah. Since December 2008 Sabah Department of Health has recommended intravenous artesunate and referral to a general hospital for all severe malaria cases of any species. This paper reviews all malaria deaths in Sabah subsequent to the introduction of these measures. Reporting of malaria deaths in Malaysia is mandatory.
    Matched MeSH terms: Diagnostic Errors*
  15. Cystic lesion of the parotid gland with squamous metaplasia mistaken for squamous cell carcinoma. A case report
    Jayaram G, Pathmanathan R, Khanijow V
    Acta Cytol., 1998 Nov-Dec;42(6):1468-72.
    PMID: 9850664
    BACKGROUND: The diverse range of diseases that affect the salivary glands may lead to problems and pitfalls in cyto-diagnosis. While false negative diagnosis of cystic salivary gland tumors is well known, false positive cytodiagnosis in nonneoplastic salivary cysts is less well documented.

    CASE: An 85-year-old female presented with a painless left parotid gland swelling of three months' duration. Fine needle aspiration cytology yielded fluid, smears of which showed keratinizing squamous cells with nuclear atypia leading to a cytologic diagnosis of cystic squamous cell carcinoma. A total radical parotidectomy followed. Histopathologic study showed cystic dilatation of many of the salivary ducts, which were lined with metaplastic squamous epithelium that showed atypia. There was no evidence of squamous cell carcinoma.

    CONCLUSION: Squamous metaplasia is known to occur in benign salivary gland lesions, such as pleomorphic adenoma and Warthin's tumors, as well as in salivary duct cysts and necrotizing sialometaplasia. However, atypical squamous metaplasia of salivary duct cysts mimicking squamous cell carcinoma on cytology is unusual.
    Matched MeSH terms: Diagnostic Errors
  16. Fulltext Cutaneous mycobacterial spindle cell pseudotumour
    Tan GC, Yap YP, Shiran MS, Sabariah AR, Pathmanathan R
    BMJ Case Rep, 2009;2009.
    PMID: 21686408 DOI: 10.1136/bcr.11.2008.1221
    Mycobacterial spindle cell pseudotumour (MSCP) has been reported in various sites, including skin, lymph nodes, bone marrow, lung and spleen. Cutaneous lesions are extremely rare and the differential diagnoses include various spindle cell lesions. Literature review shows that this lesion has preponderance for upper limb involvement and occurs largely in immunosuppressed individuals. We report a case of MSCP of the skin due to atypical mycobacterium and discuss the risk of misdiagnosis as a sarcoma.
    Matched MeSH terms: Diagnostic Errors
  17. Cutaneous larva migrans in a beach volleyball player
    Krzywanski J, Kuchar E, Mierzynski R
    IDCases, 2021;24:e01084.
    PMID: 33889485 DOI: 10.1016/j.idcr.2021.e01084
    Athletes playing beach volleyball come into contact with sand and may contract skin parasites. We present a case of cutaneous larva migrans in a 20-year-old Polish female beach volleyball player. The athlete participated in The World Tour in Asia (China, Malaysia, Cambodia) a month before. In the beginning, her skin lesions were misdiagnosed as allergic reactions and treated with antihistamines. The disease in the form of a pruritic, migratory serpiginous skin eruption on legs was diagnosed during routine medical examination at the National Centre for Sports Medicine in Warsaw. She was treated successfully with albendazole and cetirizine. The skin lesions resolved entirely within two weeks.
    Matched MeSH terms: Diagnostic Errors
  18. Context based error modeling for lossless compression of EEG signals using neural networks
    Sriraam N, Eswaran C
    J Med Syst, 2006 Dec;30(6):439-48.
    PMID: 17233156
    Two-stage lossless data compression methods involving predictors and encoders are well known. This paper discusses the application of context based error modeling techniques for neural network predictors used for the compression of EEG signals. Error modeling improves the performance of a compression algorithm by removing the statistical redundancy that exists among the error signals after the prediction stage. In this paper experiments are carried out by using human EEG signals recorded under various physiological conditions to evaluate the effect of context based error modeling in the EEG compression. It is found that the compression efficiency of the neural network based predictive techniques is significantly improved by using the error modeling schemes. It is shown that the bits per sample required for EEG compression with error modeling and entropy coding lie in the range of 2.92 to 6.62 which indicates a saving of 0.3 to 0.7 bits compared to the compression scheme without error modeling.
    Matched MeSH terms: Diagnostic Errors/prevention & control*
  19. Fulltext Congenital Absence of the Posterior Arch of the Atlas – A Strange but Benign Anomaly
    Tan, E.C., Soon, H.C., Kevin, M., Se To, B.C.
    Malays Orthop J, 2007;1(2):30-32.
    MyJurnal
    Congenital partial aplasia of the atlas with a posterior arch remnant is rare. It may be found as an incidental radiological finding or patients can present with neurological signs and symptoms after head or neck trauma. A 36-year-old female presented with a 3-day history of right sided neck pain radiating down the right arm. Radiographs of the cervical spine showed a radiolucent area in the region of the posterior arch of the atlas. Computed tomography subsequently revealed partial absence of the posterior arch of the atlas with a defect at the anterior ring. Her clinical condition subsequently improved with rest, analgesia and physiotherapy. This case report illustrates a situation where congenital defect of the posterior arch of the atlas was revealed in a patient with neck pain. Awareness of the existence of this condition will help clinicians avoid misdiagnosis and excessive investigations.
    Matched MeSH terms: Diagnostic Errors
  20. Comparative analysis of chromogenic vs clot.based one stage APTT assay for determination of factor VIII level
    Baig MA, Swamy KB
    Indian J Pathol Microbiol, 2021 1 13;64(1):123-127.
    PMID: 33433421 DOI: 10.4103/IJPM.IJPM_900_19
    Background: In the laboratory, factor VIII can be measured by three different methodologies, such as one-stage clotting assay, two-stage clotting assay, and chromogenic assay. These assays differ in ease of use, variety of reagents available, sensitivity to mild hemophilia A, and interference from lupus anticoagulants (LACs). Certain factor VIII gene mutations can cause discrepancy in results between one-stage activated partial thromboplastin time (APTT) and chromogenic assays.

    Materials and Methods: The coagulometer for factor VIII assay is Sysmex CS-5100. All data were expressed as mean ± standard deviation (SD).

    Results: A total of 135 cases were studied. Of these, 100 cases were of mild hemophilia A diagnosed by molecular genetics and, 15 cases were positive for LAC, which were confirmed by dilute Russell Viper venom test. Clot-based one-stage APTT assay showed 65% sensitivity and 80% specificity in diagnosing mild hemophilia A cases and out of 15 LAC cases, it showed false positivity in five cases. Chromogenic assay showed 85% sensitivity and 90% specificity in diagnosing mild hemophilia cases and was 100% specific in excluding LAC cases.

    Conclusions: One-stage APTT assay is the most commonly used test for determining factor VIII levels but chromogenic assay are considered as the gold standard and recommended as the reference method by European Pharmacopoeia and ISTH subcommittee. Mild hemophilia A patients with missense mutations show discrepancy between the one-stage clot-based APTT assay and chromogenic assays for determination of factor VIII level and this can lead to misdiagnosis or misclassification of mild hemophilia A. Therefore, it is recommended that both the assays should be used in the evaluation of mild hemophilia cases.

    Matched MeSH terms: Diagnostic Errors
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