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  1. Lakshmanan S, Yung YL
    PMID: 33596165 DOI: 10.1080/19440049.2020.1842516
    Chloride reduction in crude palm oil (CPO) of greater than 80% was achieved with water washing conducted at 90°C. Inorganic chloride content in CPO was largely removed through washing, with no significant reduction in the organic chloride. Phosphorous content of CPO reduced by 20%, while trace elements such as calcium, magnesium and iron were also reduced in the washing operation. The 3-MCPDE formed in the refined, bleached and deodorised palm oil displayed (RBDPO) a linear relationship with the chloride level in washed CPO, which could be represented by the equation y = 0.91x, where y is 3-MCPDE and x represents the chloride in RBDPO refined from washed CPO. In plant scale trials using 5% water at 90°C, mild acidification of the wash water at 0.05% reduced chloride by average 76% in washed CPO. Utilising selected bleaching earths, controlled wash water temperature and wash water volume produced low chloride levels in RBDPO. Chloride content less than 1.4 mg kg-1 in plant RBDPO production was achieved, through physical refining of washed CPO containing less than 2 mg kg-1 chloride and would correspond to 3-MCPDE levels of 1.25 mg kg-1 in RBDPO. The 3-MCPDE reduced further to 1.1 mg kg-1 as the chloride level of washed CPO decreased below 1.8 mg kg-1. Chloride has been shown to facilitate the 3-MCPDE formation and its removal in lab scale washing study has yielded lower 3-MCPDE levels formed in RBDPO. In actual plant operations using washed CPO, 3-MCPDE levels below 1.25 mg kg-1 were achieved consistently in RBDPO.
  2. Lakshmanan S, Murugesan T
    Water Sci Technol, 2017 Jul;76(1-2):87-94.
    PMID: 28708613 DOI: 10.2166/wst.2017.182
    Chlorates are present in the brine stream purged from chlor-alkali plants. Tests were conducted using activated carbon from coconut shell, coal or palm kernel shell to adsorb chlorate. The results show varying levels of adsorption with reduction ranging between 1.3 g/L and 1.8 g/L. This was higher than the chlorate generation rate of that plant, recorded at 1.22 g/L, indicating that chlorate can be adequately removed by adsorption using activated carbon. Coconut based activated carbon exhibited the best adsorption of chlorate of the three types of activated carbon tested. Introducing an adsorption step prior to purging of the brine will be able to reduce chlorate content in the brine stream. The best location for introducing the adsorption step was identified to be after dechlorination of the brine and before resaturation. Introduction of such an adsorption step will enable complete recovery of the brine and prevent brine purging, which in turn will result in less release of chlorides and chlorates to the environment.
  3. Arunachalam K, Lakshmanan S, Maan A, Kumar N, Dominic P
    J Clin Med Res, 2018 May;10(5):384-390.
    PMID: 29581800 DOI: 10.14740/jocmr3338w
    Background: Drug induced long QT syndrome is quite common in daily clinical practice but its impact is unknown.

    Methods: PubMed and EMBASE databases (until May 2, 2017) were searched to identify studies reporting drug induced long QT syndrome and followed the PRISMA guidelines. The main outcomes measured in these studies were QTc prolongation, ventricular arrhythmias, torsade de pointes (TdP) and death.

    Results: Out of 176 non-duplicate reports, 36 studies satisfied inclusion criteria and provided data on patients exposed to drugs that can potentially cause long QT. Totally, 14,756 patients were exposed and 930 patients (6.3%) were found to have QTc prolongation. The number of males was 6,400 and females were 5,723 patients. The mean age of the patients was 43.8 ± 9.36 years. Ventricular arrhythmias were found in 379 patients (2.6%), 26 patients were found to have premature atrial contractions (PACs) and premature ventricular contractions (PVCs). TdP was found in 49 patients (0.33 %), sudden cardiac death (SCD) was found in five patients and 586 patients were found to have all-cause mortality.

    Conclusions: Around 6% of patients have risk of QT prolongation when exposed but only 0.3% developed TdP and 2.6% developed ventricular arrhythmias. Risk of developing arrhythmias is higher with concomitant use of multiple QT prolonging drugs.

  4. Yung YL, Lakshmanan S, Kumaresan S, Chu CM, Tham HJ
    Food Chem, 2023 Dec 15;429:136913.
    PMID: 37506659 DOI: 10.1016/j.foodchem.2023.136913
    The 3-Monochloropropane-1, 2-diol ester (3-MCPDE) and glycidyl ester (GE) are formed at high processing temperatures with the presence of respective precursors. Both are potentially harmful to humans, causing adverse health impacts including kidney damage, reproductive problems, and increased risk of cancer. The presence of 3-MCPDE and GE in palm oil is of particular concern because of its widespread use by the food industry. There are a variety of methods for reducing 3-MCPDE and GE. For example, water washing eliminates mostly inorganic chlorides that, in turn, reduce the formation of 3-MCPDE. 3-MCPDE has also been reduced by up to 99% using combinations of methods and replacing stripping steam with alcohol-based media. Activated carbon, clay, antioxidants, potassium-based salts, and other post-refining steps have positively lowered GE, ranging from 10 to 99%. Several approaches have been successful in reducing these process contaminants without affecting other quality metrics.
  5. Yung YL, Lakshmanan S, Chu CM, Kumaresan S, Tham HJ
    PMID: 37549246 DOI: 10.1080/19440049.2023.2235608
    The rising concern about the presence of 3-monochloropropane 1,2 diol ester (3-MCPDE) and glycidyl ester (GE) in food has prompted much research to be conducted. Some process modifications and the use of specific chemicals have been employed to mitigate both 3-MCPDE and GE. Alkalisation using NaOH, KOH, alkali metals or alkaline earth metals and post sparging with steam or ethanol and short path distillation have shown simultaneous mitigation of 51-91% in 3-MCPDE and of 13-99% in GE, both contaminants achieved below 1000 µg/kg. Some of the mitigation methods have resulted in undesirable deterioration in other parameters of the refined oil. When the processed oil is used in food processing, it results in changes to 3-MCPDE and GE. Repeated deep frying above 170 °C in the presence of NaCl and baking at 200 °C with flavouring (dried garlic and onion), resulted in increased 3-MCPDE. Repeated frying in the presence of antioxidants (TBHQ, rosemary and phenolics) decreased 3-MCPDE in processed food. The GE content in foods tends to decline with time, indicating instability of GE's epoxide ring.
  6. Yung YL, Lakshmanan S, Chu CM, Tham HJ, Kumaresan S
    PMID: 38011619 DOI: 10.1080/19440049.2023.2283873
    The presence of 3-monochloropropane-1,2 diol ester (3-MCPDE) and glycidyl ester (GE) in processed palm oils is of concern, as these oils are widely used for edible purposes. The mitigation method studied here optimizes the removal of chloride through water washing of crude palm oil (CPO), to limit the formation of 3-MCPDE. The contaminant removal obtained via washing CPO supports the quantitative findings. By utilizing 5% water in the washing step, water-soluble chlorides in CPO are removed by up to 76%, resulting in a 71% reduction of 3-MCPDE to within statutory limits. In this study, a linear correlation was developed between the chloride and the corresponding 3-MCPDE with a correlation coefficient (R2) of 0.99. Using the correlations, 1.0 mg/kg of 3-MCPDE in refined, bleached and deodorized palm oil (RBDPO) will be obtained from CPO with 1.2 mg/kg chloride with 7% wash water usage. The study also showed minor GE reduction between 7 and 11% was attained after water washing.
  7. Yussof SJM, Zakaria MI, Mohamed FL, Bujang MA, Lakshmanan S, Asaari AH
    Med J Malaysia, 2012 Aug;67(4):406-11.
    PMID: 23082451
    INTRODUCTION: The importance of early recognition and treatment of sepsis and its effects on short-term survival outcome have long been recognized. Having reliable indicators and markers that would help prognosticate the survival of these patients is invaluable and would subsequently assist in the course of effective dynamic triaging and goal directed management.
    STUDY OBJECTIVES: To determine the prognosticative value of Shock Index (SI), taken upon arrival to the emergency department and after 2 hours of resuscitation on the shortterm outcome of severe sepsis and septic shock patients.
    METHODOLOGY: This is a retrospective observational study involving 50 patients admitted to the University of Malaya Medical Centre between June 2009 and June 2010 who have been diagnosed with either severe sepsis or septic shock. Patients were identified retrospectively from the details recorded in the registration book of the resuscitation room. 50 patients were selected for this pilot study. The population comprised 19 males (38%) and 31 females (62%). The median (min, max) age was 54.5 (17.0, 84.0) years. The number of severe sepsis and septic shock cases were 31 (62%), and 19 (38%) respectively. There were 17 (34%) cases of pneumonias, 13 (26%) cases of urological sepsis, 8 (16%) cases of gastro intestinal tract related infections and 12 (24%) cases of other infections. There were a total of 23 (46%) survivors and 27 (54%) deaths. The value of the shock index is defined as systolic blood pressure divided by heart rate was calculated. Shock Index on presentation to ED (SI 1) and after 2 hours of resuscitation in the ED (SI 2). The median, minimum and maximum variables were tested using Mann-Whitney U and Chi square analysis. The significant parameters were re-evaluated for sensitivity, specificity and cut-off points. ROC curves and AUC values were generated among these variables to assess prognostic utility for outcome.
    RESULTS: Amongst all 7 variables tested, 2 were tested to be significant (p: < 0.05). From the sensitivity, specificity and ROC analysis, the best predictor for death was (SI 2) with a sensitivity of 80.8%, specificity of 79.2%, AUC value of 0.8894 [CI 95 0.8052, 0.9736] at a cut-off point of > or = 1.0.
    CONCLUSION: (SI 2) may potentially be utilized as a reliable predictor for death in patients presenting with septic shock and severe sepsis in an emergency department. This parameters should be further analyzed in a larger scale prospective study to determine its validity.
  8. Ramli AS, Lakshmanan S, Haniff J, Selvarajah S, Tong SF, Bujang MA, et al.
    BMC Fam Pract, 2014;15:151.
    PMID: 25218689 DOI: 10.1186/1471-2296-15-151
    Chronic disease management presents enormous challenges to the primary care workforce because of the rising epidemic of cardiovascular risk factors. The chronic care model was proven effective in improving chronic disease outcomes in developed countries, but there is little evidence of its effectiveness in developing countries. The aim of this study was to evaluate the effectiveness of the EMPOWER-PAR intervention (multifaceted chronic disease management strategies based on the chronic care model) in improving outcomes for type 2 diabetes mellitus and hypertension using readily available resources in the Malaysian public primary care setting. This paper presents the study protocol.
  9. Ramli AS, Selvarajah S, Daud MH, Haniff J, Abdul-Razak S, Tg-Abu-Bakar-Sidik TM, et al.
    BMC Fam Pract, 2016 11 14;17(1):157.
    PMID: 27842495
    BACKGROUND: The chronic care model was proven effective in improving clinical outcomes of diabetes in developed countries. However, evidence in developing countries is scarce. The objective of this study was to evaluate the effectiveness of EMPOWER-PAR intervention (based on the chronic care model) in improving clinical outcomes for type 2 diabetes mellitus using readily available resources in the Malaysian public primary care setting.

    METHODS: This was a pragmatic, cluster-randomised, parallel, matched pair, controlled trial using participatory action research approach, conducted in 10 public primary care clinics in Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Patients who fulfilled the criteria were recruited over a 2-week period by each clinic. The obligatory intervention components were designed based on four elements of the chronic care model i.e. healthcare organisation, delivery system design, self-management support and decision support. The primary outcome was the change in the proportion of patients achieving HbA1c 
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