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Fulltext Peer-led group tele-supervision of clinical psychologists: optimizationof resources – a malaysian case study

Umi Izzatti Saedon, Nicholas Pang Tze Ping, Loo, Jiann Lin

Borneo Journal of Medical Sciences, 2019;14(1):67-71.
MyJurnal

Inaccessibility to clinical supervision is an issue faced by solo clinical psychologist practitioners. Combination use of web-based instant messaging and video call application were tried by 28 clinical psychologists in conducting a peer-led group tele-supervision to address ethical dilemmas, discuss case management, provide technical instruction, explore resistance and analyse countertransference, provide emotional support, and share knowledge and updated guidelines. Despite facing challenges including difficulty in face-to-face session scheduling, limited time for in-depth discussion, internet connection issues, and documentation dilemma, we believe it has potential to influence supervision practice for clinicians working in isolation in rural or remote locations.
Fulltext Stigma related to tuberculosis interventions to improve treatment adherence in developing countries: a systematic review

Mohamed Hashi Faraade, Mohammad Saffree Jeffree, Osman A. Fiidow, Richard Avoi, Kamaruddin Ahmed, Loo Jiann Lin

Malaysian Journal of Medicine and Health Sciences, 2019;15(106):25-25.
MyJurnal

Introduction: Despite considerable effort invested for tuberculosis (TB) control, the outcome has not been optimal due to several barriers. Stigma has been an important factor that hinders the completion of full course of TB treat-ment, i.e. it results in poor treatment adherence. This systematic review is aimed to review the interventions target-ing tuberculosis related stigma in order to improve treatment adherence among tuberculosis patients in developing countries. Methods: A systematic electronic database search (PubMed, Google Scholar, ProQuest, Science Direct, Ovid, Spring and Cochrane) covering articles published between 2008 and 2019 had been conducted using truncat-ed search words of “stigma related to tuberculosis”, “TB Stigma”, “Intervention”, “treatment adherence”, “treatment compliance”, and “developing countries”. Only English articles exploring stigma among TB patients and its anti-stig-ma intervention in developing countries were included. Results: A total of 846 articles were retrieved and 346 were excluded due to duplication while another 361 non-relevant articles at the stage of title screening were excluded. Subsequently, 119 articles were excluded for not fulfilling inclusion criteria and only 3 studies remained. Conclu-sion: From the three articles, TB treatment outcomes were improved with the use of stigma intervention, including health education and counselling, self-support, and psychological support interventions. Optimal implementation of stigma interventions may vary by setting, resources, and the local TB epidemiology. More controlled interventional research is needed in stigma reduction that leads to improve TB adherence in developing countries.
Fulltext Unfitness to plead among female offenders: when looseness matters

Loo, Jiann Lin, Eu, Choon Leng, Johari Khamis, Raba'iah Mohd Salleh, Suarn Singh Jasmit Singh

ASEAN Journal of Psychiatry, 2018;19(1):0-0.
MyJurnal

Objective: Pritchard Criteria are adopted in a Malaysian criminal-justice system while assessing fitness to plead. There is limited data on the reason of unfitness to plead for female offenders in Malaysia.

Methods: A case series of five patients hospitalized to Hospital Bahagia Ulu Kinta, Malaysia due to unfitness to plead was presented and discussed.

Result: The offences include three homicides, one assault, and one stealing. All of them were diagnosed to have schizophrenia with prominent looseness of association. Four of them subsequently treated as Treatment-Resistant Schizophrenia (TRS) with a minimal response toward clozapine.

Conclusion: Looseness of association may be a contributing factor for unfitness to plead among Malaysian female offenders, which can result in indeterminate hospitalization. This should be confirmed in a larger prospective study.
Fulltext Inculcating collaborative practice among healthcare professionals: initiative from Hospital Universiti Malaysia Sabah

Jeanny John, Joanne Justin, Dainah Francis, Helen Benedict Lasimbang, Wendy Diana Shoesmith, Loo Jiann Lin, et al.

Malaysian Journal of Medicine and Health Sciences, 2020;16(105):8-0.
MyJurnal

Introduction: Collaborative working culture is an important milestone to be inculcated in a hospital setting. In the process of preparation for the upcoming teaching hospital of Universiti Malaysia Sabah (HUMS), the organisational value of innovative, collaborative, compassionate, empowering, and sustainable needs to be inculcated to the both management and clinical staffs. The objective of this study was to assess the efficacy of a collaborative practise workshop in staff. Methods: A two days experiential learning workshop was conducted to deliver and inculcate the organisational value of HUMS to 32 existing and newly recruited healthcare professionals, which include doctor, nurses, assistant medical officer, dental assistant, pharmacist, and radiographer. The topics consisted of principles of collaborative practice, skill of validation, feedback-giving method, approach for value identification and goal setting, reflective practice, public communication during crisis, shared decision making, and organisational problem solving. Different delivery methods include round table discussion, role play, and group work were used. Innovative real time practice of giving feedback to the management was performed directly to the hospital chief executive officer and chief clinical officer. Results: Immediate feedback from the participants found that the candidates found the course was enriching and it helped them to develop an alternative perspective on how to get work done. The staffs expressed their idea, concern, and expectation more openly with the method learned using what they had learnt. The limitation included the challenge of transition from previous working culture to new environment without further supervision. Conclusions: Further systematic evaluation using more detailed assessment tool is needed to understand the long term efficiency and translatability of the learning outcomes into clinical practice once the hospital is ready.
Fulltext Aphagia in frontal lobe syndrome following traumatic brain injury: Delightful lessons from olanzapine treatment

Ahmedy F, Loo JL, Mazlan M

Indian J Psychiatry, 2020 12 12;62(6):732-733.
PMID: 33896983 DOI: 10.4103/psychiatry.IndianJPsychiatry_334_19

A case of persistent aphagia in frontal lobe syndrome after traumatic brain injury (TBI) with successful use of olanzapine to improve the eating disorder is presented. A 20-year-old man suffered a severe TBI with right frontal intracerebral haemorrhage At four-month post-TBI, he had agitation, concurrent apathy with constant refusal for oral swallow despite gustatory sensory stimulation, hence the needs for nasogastric tube (NGT) feeding. He was diagnosed with frontal lobe syndrome and prescribed olanzapine 5mg daily that was optimised to 10mg due to worsened aggression. One month later, the aggression reduced with gradual improvement in oral intake. Percutaneous enterogastrostomy (PEG) tube insertion was cancelled and the NGT was sucessfully removed. Olanzapine prescription in this case improved aggression and aphagia simultaneously. Although olanzapine is proven beneficial and surgical intervention for long-term enteral feeding was avoided in this case, its usage requires judicious judgement.
Fulltext Prevalence and associated factors of depression, anxiety and stress among doctors in North Borneo

Syarifah Nurul Ain, Chua Sze Hung, Aida Nurbaini Arbain, Sarah Marilyn Amin, Teoh Eu Vin, Ferro Firdaus Ibrahim, et al.

Malaysian Journal of Medicine and Health Sciences, 2020;16(3):124-131.
MyJurnal

Introduction: Doctors are known to deal with high occupational stress, causing increased risk of depression, anxi- ety and stress.Nevertheless, the prevalence and associatedfactors of depression, anxiety and stress among registered doctorsworking in 24 public hospitals in Sabah, Malaysia are not known yet. Methods: This cross-sectional study was conducted using convenient sampling from September-October 2018. The data of 21-item Depression Anxiety Stress Scale (DASS-21) was collected via online link anonymously. Results: Among 314 doctors, majority of them were females (62.1%), mean age 29 (SD 2.72), non-Sabahan (82.8%), Malays (46.8%), not married (78.3%) and medical officers (93.6%). Prevalence of severe/extremely severe anxiety symptoms was 27.4%,depression (22.9%) and stress (18.5%). Doctors perceiving themselves to be depressed, anxious and/or stressed were more likely to develop the corresponding symptoms. Females and Chinese were twice more likely to report anxiety symptoms. Being married had protective effect against depressive symptoms, while working in same hospital for longer time had a significant but weak protective effect against anxiety and stress symptoms. Conclusions: Mental health issue among doctors is substantial and need to be addressed effectively for the benefit of their life, patients and country.
Fulltext A staff-initiated quality improvement project: from paper to web report

Daphne Clemente, Nurul Amiella Abdullah, ZurianahJusmin Jasmin, Muhammad Syafiq Abdullah, Helen Benedict Lasimbang, Wendy Diana Shoesmith, et al.

Malaysian Journal of Medicine and Health Sciences, 2020;16(105):14-0.
MyJurnal

Introduction: Continuous quality improvement of system is essential to improve efficiency of working environ- ment. Limited financial allocation in low resource setting results in the vicious circle of having inadequate money to purchase a new system and print paper documents that are required for the operation of clinic. A staff-initiated system improvement with the name of “PRW UMS Staff Portal” was attempted to break-free from the vicious cycle. Methods: An online system covering different aspects of routine clinical work of healthcare workers was created in Dec 2019 and implemented in Feb 2020 using Google SiteTM by the nurses of a local university community clinic, which included: submission of daily reports of nurses and assistant medical officers, submission of reports of all programmes conducted by the clinic, surveillance of health status of working staffs, announcement and request of working roster, archiving of documents, and medication inventory. The system could only be accessed using official working email for general documents while accesses to sensitive documents were restricted to relevant staffs to pro- tect privacy and confidentiality of information. Qualitative interviews were performed with all nursing staff involved. Results: Qualitative feeling of improvement in coordination of workflow was reported by all 23 staffs working in the clinic in view of the easy access of system using smartphone and computer at workstation. It also reduced the need to move away from the working station in order to access, replenish, or submit the printed documents and reports. Significant amount of paper and printing were saved monthly. Conclusions: Despite positive feedback from the staffs, the system requires further improvement in terms of function and security. Further evaluation on cost-efficiency of the system can be done to promote the system to other universities.
Fulltext Beginner crisis communication for nurses: an introductory module of Hospital Universiti Malaysia Sabah

Megawanah Mohd Razalee, Prisia Jibin, Sabrina Paul, Muhammad Syafiq Abdullah, Helen Benedict Lasimbang, Wendy Diana Shoesmith, et al.

Malaysian Journal of Medicine and Health Sciences, 2020;16(105):65-0.
MyJurnal

Introduction: Crisis communication is an important skill for healthcare professionals, especially during disaster peri- od including the current 2019-nCoV pandemic. Nevertheless, the skill of crisis communication is not commonly an integral part of Malaysian nursing diploma and degree course. Methods: A half days session on how to communicate in the context of crisis was incorporated into an experiential learning workshop to 25 existing and newly recruited nurses together with 7 other healthcare professionals. The topics of nature of disaster, disease outbreak, preparation for disaster, principles and responsibility of crisis communication, preparing statement for press conference, and corporate communication were covered through brief lecture, round table discussion and tabletop simulations. Real time example of 2019-nCoV crisis communication was used to illustrate the skills required in the situation. Results: All participants confirmed that this was the first exposure to hands-on training on crisis communication and enlightening although majority of them were uncertain that they are capable to perform it during the crisis despite the ongoing 2019-nCoV issue in view of their the position that they are holding. Most nursing curriculums focus on clinical theory and clinical skill competency acquisition without addressing the need of learning how to commu- nicate beyond clinical setting in the situation of disaster and panic, which is mostly learned at job. The limitation included the practice in tabletop simulations might not be immediately translatable into real life practice. Conclu- sion: Regular reinforcement through more workshops and incorporation into disaster may potentially be a solution to improve the competency of healthcare professionals in crisis communication. Further assessment on the practice of the participants in performing crisis communication is needed to ensure the competency level has been achieved and to evaluate the efficiency of the workshop delivery method.
Fulltext The prevalence and associated factors of premature ejaculation (PE) and erectile dysfunction (ED) among patients on antidepressants in a teaching hospital (TH)

Lim, Jun Yi, Mohammad Izzat Najmi Kamaruddin, Jamuna Vijayakumaran, Nur Diyanah Talib, Nur Diana Ahmad Fitri, Hatta Sidi, et al.

ASEAN Journal of Psychiatry, 2017;18(2):0-0.
MyJurnal

Objective: Sexual problems are common among patients who are on antidepressants treatment. The objective of this study is to determine the prevalence of PE and ED, and their potential risk factors that may impair their sexual function in a TH
Methods: A cross-sectional study using simple random sampling was conducted among adult male patients who are on antidepressant treatment in the TH psychiatric outpatient clinic. Respondents’ sociodemographic data were obtained. Participants were interviewed using a structured self-report questionnaire with 15-item International Index of Erectile Function (IIEF-15)where the scores lesser than 25 were indicative for having an ED. A validated Malay Premature Ejaculation Diagnostic Tool (MAPET) was used to assess PE and those with a score ≥ 23 were considered to have PE.
Results: Hundred respondents were participated, and the prevalence of PE and ED was 66% and 85%, respectively. Using multivariate binary logistic regression, the potential risk factors of PE were race, i.e. being non-Malay (p=0.044), lesser in the frequency of sexual activity (p=0.03) and also an ED (p=0.03), respectively. The only risk factor for ED was PE (p=0.026). No significant association was noted for the other factors, including type of the antidepressant, dose and duration of antidepressant used (p>0.05). There was a strong correlation of MAPET and IIEF-15 (r=-0.345, p < 0.01) signifying patient with more severe PE had more severe ED.
Conclusions: Due to very high rate of ED and PE in this group of respondents, it is pivotal to screen for sexual problem among patients who are taking an antidepressant in a psychiatric setup.
Study site: Psychiatric clinic, Pusat Perubatan University Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia.
Fulltext Atraumatic trismus induced by duloxetine: an uncommon presentation of acute dystonia

Ohn MH, Loo JL, Ohn KM

BMJ Case Rep, 2021 Feb 04;14(2).
PMID: 33542006 DOI: 10.1136/bcr-2020-237065

Atraumatic trismus can be one of the presentations of medication-induced acute dystonia, particularly by antipsychotics and less commonly antidepressants. A case of an unusual emergency presentation of atraumatic trismus on initiation of duloxetine is reported. The patient was a 40-year-old woman experiencing sudden difficulty in mouth opening and speaking due to a stiffened jaw after taking 5 days of duloxetine prescribed for her fibromyalgia-related chest pain. Assessment of vital signs is prudent to ensure there is no laryngeal involvement. Other physical examinations and her recent investigations were unremarkable. She was treated for acute dystonia and intravenous procyclidine was given together with oral diazepam. Her symptoms improved immediately and her duloxetine was suggested to be stopped. To our knowledge, this is the first case of isolated trismus induced by duloxetine. Clinicians should be aware of this risk, especially considering the limitation of important physiological functions (such as swallowing, eating, etc) associated with this condition.
Fulltext Bridging exhibitionism and internet pornography: is there a link?

Lee SC, Sidi H, Zakaria H, Loo JL, Yahaya R

Malaysian Journal of Medicine and Health Sciences, 2018;14(3):51-53.
MyJurnal

Exhibitionism is a distressing condition which may have a link with the increasing availability and usage of online sexual activities (OSA). We highlight a 42-year-old man who presented with a constant craving for OSA to achieve his sexual satisfaction which included exposing his genitalia to virtual partners, unsuspected strangers, and colleagues in public areas. His sexual behaviours were further reinforced by an online video chatting with genitalia exposure, which ended commonly with an exchange of masturbatory acts. He denied any problem with his erection and able to achieve orgasm via common sexual acts. There was no past psychiatric history nor family history of mental disorder. He volunteered to seek psychiatric help and subsequently given a psycho education on his illness and how to cope with the distress associated with his sexual acts. He was scheduled for an intensive psychotherapy to instil insight and hope to deal with his sexual difficulties.
Improving undergraduate obstetrics and gynaecology education through the use of WhatsApp™

Soe MZ, Pang NTP, Loo JL

Eur J Obstet Gynecol Reprod Biol, 2020 Apr;247:269.
PMID: 32145995 DOI: 10.1016/j.ejogrb.2020.02.036
Use of WhatsApp in assisting psychiatry learning

Loo JL, Koh EB, Pang NT, Nor Hadi NM

Med Educ, 2016 Nov;50(11):1165.
PMID: 27762032 DOI: 10.1111/medu.13195
Dialectical behavior therapy in the Asia-Pacific Rim region

Loo JL, Keng SL, Ramírez-Espinosa IG, Nor Hadi NM, Ramírez-Gutiérrez JA, Shoesmith W

Asia Pac Psychiatry, 2021 Mar;13(1):e12437.
PMID: 33188568 DOI: 10.1111/appy.12437

BACKGROUND: Borderline personality disorder (BPD) contributes to suicide-related morbidity and mortality and requires more intensive psychotherapeutic resources due to its high mental health service usage. Accessibility to an evidence-based treatment program is a cornerstone to support patients with BPD and part of broader suicide prevention efforts as well as improving their quality of life.
AIMS: In this article, the authors aim to discuss and review available dialectical behavior therapy (DBT) and DBT-informed services of selected countries in the Asia-Pacific Rim, namely Singapore, Malaysia, and Mexico.
MATERIALS & METHODS: We contacted providers of different services and gathered information on the process of setting up the service and adapting the treatment, in addition to reviewing the available literature published in the countries.
RESULTS: To date, there have been a pair of DBT-informed services in Singapore, four in Malaysia, and several in Mexico with a few of them offering standard DBT. Different efforts have been put in place to increase the accessibility to training and also the number of DBT practitioners.
DISCUSSION: Important considerations during the process of setting up new services include the use of domestic examples and local language that are contextually appropriate for the local community. Selected challenges faced in common include shortage of workforce, affordability of training programs, and the need for language adaptation with or without translation.
CONCLUSION: Further long-term evaluation of locally adapted DBT-informed mental health services will help to elucidate the effectiveness and efficacy of the program which will potentially serve as a guide for other resource-scarce regions.
Flying solo in Myanmar: case study on challenges and important lessons learned by an early career psychiatrist in a district setting

Yadanar SM, Htoo NC, Zaw T, Pang NTP, Chua SH, Loo JL

BJPsych Int, 2021 May;18(2):37-39.
PMID: 34287407 DOI: 10.1192/bji.2020.36

The transition from trainee early career psychiatrist (ECP) to independent practitioner can be challenging. Upon completion of training in well-equipped academic settings, an ECP from Myanmar is required to serve in a divisional hospital for at least 3 years. Significant challenges are faced by ECPs practising solo in divisional hospitals, including inexperience in administrative aspects, lack of future-proof training, scarcity of resources and facilities, struggles in the provision of holistic biopsychosocial treatment, work-life imbalance, and limited career advancement and access to continuous training. The solutions tried thus far include the incorporation of information and communication technology in training, gathering support and distant supervision from both local and international settings, and task shifting. Bigger challenges are often rewarded by faster growth, and difficult times stimulate creative solutions. The sacrifice of these solo ECPs has significantly improved the mental health service of Myanmar district regions.
Learning Psychodynamic Psychotherapy in Southeast Asia

Loo JL, Ang JK, Subhas N, Ho BK, Zakaria H, Alfonso CA

Psychodyn Psychiatry, 2017;45(1):45-57.
PMID: 28248565 DOI: 10.1521/pdps.2017.45.1.45

The subjective nature of psychodynamic psychotherapy (PP) makes training and supervision more abstract compared to other forms of psychotherapy. The issues encountered in the learning and supervision process of PP of Malaysian psychiatry trainees are discussed in this article. Issues of preparation before starting PP, case selection, assessment of patients, dynamic formulations, supervision, anxieties in the therapy, countertransference, termination of therapy, the treatment alliance, transfer of care, the therapeutic setting, and bioethical considerations are explored. Everyone's experience of learning PP is unique and there is no algorithmic approach to its practice. With creative thinking, effort, and "good enough" supervision, a trainee can improve PP skills, even in underserved areas of the world.
Fulltext A pilot project to introduce the multiple mini interview (MMI) at a Borneo medical school: The universiti Malaysia Sabah experience- a cross-sectional study

Pang N, Kadir F, Kamu A, Mun HC, Loo JL, Ahmedy F, et al.

Ann Med Surg (Lond), 2021 Nov;71:103019.
PMID: 34840767 DOI: 10.1016/j.amsu.2021.103019

Introduction: The Multiple Mini Interview (MMI) demonstrates efficacy and superiority over traditional medical interviews in assessing non-cognitive domains during the recruitment of medical undergraduates. At Universiti Malaysia Sabah (UMS), a five-station MMI was piloted in 2019, featuring a mix of three examiner-driven stations (assessing professionalism, ethics, and motivation to study medicine), and two roleplayer-driven stations (assessing empathy and science communication specifically, and communication skills in general).
Methods: 260 candidates were grouped into two separate geographical groups - urban and suburban/rural. Descriptive analysis, skewness and kurtosis were performed for normality assessment, whereas Cronbach's alpha, McDonald's omega, and Greatest lower bound assessed internal consistency. For validity measures, correlations were calculated between scores for separate stations, overall scores, urban and suburban/rural status. Also, exploratory factor analysis was performed on the five stations as validity measures. Difficulty and discrimination indices were calculated as quality measures. Qualitative analysis was performed on "red flag" comments detailing grossly unsuitable candidates.
Results: Roleplayer-driven stations yielded more red flags than examiner-driven stations. The three examiner-driven stations were significantly and moderately correlated (rho between 0.602 and 0.609, p 0.530), whereas the stations were distributed equally in difficulty index.
Conclusion: The UMS MMI has identified specific skillsets that may be in short supply in our incoming medical students. Also, it illustrates the yawning gap between academic knowledge and 'translational' scientific knowledge and communication skills.
Fulltext The Behaviour Changes in Response to COVID-19 Pandemic within Malaysia

Koh Boon Yau E, Pang Tze Ping N, Shoesmith WD, James S, Nor Hadi NM, Loo JL

Malays J Med Sci, 2020 Mar;27(2):45-50.
PMID: 32788840 MyJurnal DOI: 10.21315/mjms2020.27.2.5

The novel coronavirus infection, COVID-19, is a pandemic that currently affects the whole world. During this period, Malaysians displayed a variety of behaviour changes as a response to COVID-19, including panic buying, mass travelling during movement restriction and even absconding from treatment facilities. This article attempts to explore some of these behaviour changes from a behaviourist perspective in order to get a better understanding of the rationale behind the changes.
Fulltext Medical record abstraction in a hospital with paper-based records: experience of early career psychiatrists in northern Borneo

Ahmad Shahabuddin F, Wah KY, Buji RI, Zulkafli NS, Lee SW, Soon HL, et al.

BJPsych Int, 2020 May;17(2):43-44.
PMID: 32558818 DOI: 10.1192/bji.2019.29

We used medical record abstraction to conduct research in a psychiatric hospital with paper-based medical records. The challenges we encountered included: the difficulty in retrieving files; the extensive effort and time needed to extract clinical information; the lack of a standardised documentation system of medical records; and the need for advanced computer literacy. To promote future research using electronic medical records, potential solutions include creating a registry of all patients receiving treatment, as well as equipping busy clinicians with computer skills.
Is Ketamine the Future Clozapine for Depression? A Case Series and Literature Review on Maintenance Ketamine in Treatment-resistant Depression With Suicidal Behavior

Chan LF, Eu CL, Soh SY, Maniam T, Shahidii Kadir Z, Chong BTW, et al.

J Psychiatr Pract, 2018 07;24(4):279-291.
PMID: 30427812 DOI: 10.1097/PRA.0000000000000316

Ketamine has shown effectiveness as a rapid-acting antidepressant with antisuicidal effects in terms of reduction of suicidal ideation in the short term. However, the evidence for long-term maintenance ketamine therapy for treatment-resistant depression (TRD) and suicidal behavior is limited. This case series (N=13) highlights the role of adjunctive serial maintenance ketamine infusions in restoring functionality in treatment-resistant unipolar and bipolar (mixed) depression with significant suicide risk and multiple comorbidities, including alcohol dependence. Two cases of TRD achieved functional remission with long-term maintenance ketamine treatment. The first case illustrates the potential synergistic interaction between ketamine and lamotrigine to achieve a sustained antidepressant response in the patient for 7 months. The second case may possibly be the longest reported case of maintenance ketamine therapy, with treatment continuing for 5 years to date. Ketamine treatment showed acute effectiveness in another 7 cases, especially in terms of reduction of suicidal ideation, albeit without significant long-term antidepressant effect. Factors that may contribute to lack of effectiveness of serial ketamine include inadequate mood stabilization in TRD in bipolar spectrum diagnoses, concomitant benzodiazepine use, complex comorbidities, and adverse effects such as significant hypertension and severe dissociation. Future systematic controlled studies are warranted to establish the efficacy and safety profile of long-term ketamine as maintenance therapy for TRD with suicidal behavior.

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