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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 Development and validation of a cancer awareness questionnaire for Malaysian undergraduate students of Chinese ethnicity

Loo JL, Ang YK, Yim HS

Asian Pac J Cancer Prev, 2013;14(1):565-70.
PMID: 23534795 DOI: 10.7314/apjcp.2013.14.1.565

OBJECTIVES: To describe the development and validation of a cancer awareness questionnaire (CAQ) based on a literature review of previous studies, focusing on cancer awareness and prevention.

MATERIALS AND METHODS: A total of 388 Chinese undergraduate students in a private university in Kuala Lumpur, Malaysia, were recruited to evaluate the developed self-administered questionnaire. The CAQ consisted of four sections: awareness of cancer warning signs and screening tests; knowledge of cancer risk factors; barriers in seeking medical advice; and attitudes towards cancer and cancer prevention. The questionnaire was evaluated for construct validity using principal component analysis and internal consistency using Cronbach's alpha (α) coefficient. Test-retest reliability was assessed with a 10-14 days interval and measured using Pearson product-moment correlation.

RESULTS: The initial 77-item CAQ was reduced to 63 items, with satisfactory construct validity, and a high total internal consistency (Cronbach's α=0.77). A total of 143 students completed the questionnaire for the test-retest reliability obtaining a correlation of 0.72 (p<0.001) overall.

CONCLUSIONS: The CAQ could provide a reliable and valid measure that can be used to assess cancer awareness among local Chinese undergraduate students. However, further studies among students from different backgrounds (e.g. ethnicity) are required in order to facilitate the use of the cancer awareness questionnaire among all university students.
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.
Fatty acid preference of mycelium-bound lipase from a locally isolated strain of Geotrichum candidum

Loo JL, Lai OM, Long K, Ghazali HM

World J Microbiol Biotechnol, 2007 Dec;23(12):1771-8.
PMID: 27517833 DOI: 10.1007/s11274-007-9427-2

Mycelium-bound lipase (MBL) was prepared using a strain of Geotrichum candidum isolated from local soil. At the time of maximum lipase activity (54 h), the mycelia to which the lipase was bound were harvested by filtration and centrifugation. Dry MBL was prepared by lyophilizing the mycelia obtained. The yield of MBL was 3.66 g/l with a protein content of 44.11 mg/g. The lipase activity and specific lipase activity were 22.59 and 510 U/g protein, respectively. The moisture content of the MBL was 3.85%. The activity of free (extracellular) lipase in the culture supernatant (after removal of mycelia) was less than 0.2 U/ml. The MBL showed selectivity for oleic acid over palmitic acid during hydrolysis of palm olein, indicating that the lipase from G. candidum displayed high substrate selectivity for unsaturated fatty acid containing a cis-9 double bond, even in crude form. This unique specificity of MBL could be a direct, simple and inexpensive way in the fats and oil industry for the selective hydrolysis or transesterification of cis-9 fatty acid residues in natural triacylglycerols.
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
Functional neurological disorder during the perinatal period: A case report

Samuel Kanniah E, Subhas N, Silim UA, Loo JL, Tharumalingam T

Med J Malaysia, 2021 Nov;76(6):930-932.
PMID: 34806689

Functional neurological disorder (FND) is a rare neuropsychiatric illness that commonly presents to the medical setting as opposed to the psychiatric setting. FND is characterised by signs and symptoms affecting the voluntary motor or sensory function that cannot be explained by a specific neurological or general medical condition. FND in pregnancy and postpartum is rare. We report here a case of FND in a 32-year-old woman who presented with multiple medical problems during her perinatal period. She exhibited 'la belle indifference', history of vague unexplained medical symptomatology while all relevant investigations were normal. There were longstanding psychosocial and interpersonal difficulties with significant distress including multiple personal, marital, and family issues which stemmed from her childhood. This left her feeling inadequate as a mother to her infant. The diagnosis of FND was finalised by the multidisciplinary team consisting of a neurologist, physicians, and psychiatrists, based on longitudinal assessment. Psychological intervention for the patient included psychoeducation, supportive psychotherapy, stress management, and parental intervention. The key point in our management of the patient was the delivery of the diagnosis to help her understand the illness and treatment plan. For this patient, functional and psychological recovery is achievable with a good therapeutic alliance, early diagnosis of the illness, and the acceptance of her diagnosis.
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
Fulltext Mycelium-bound lipase from a locally isolated strain of Geotrichum candidum

Loo JL, Khoramnia A, Lai OM, Long K, Ghazali HM

Molecules, 2014 Jun 23;19(6):8556-70.
PMID: 24959682 DOI: 10.3390/molecules19068556

Mycelium-bound lipase (MBL), from a locally isolated Geotrichum candidum strain, was produced and characterized as a natural immobilized lipase. A time course study of its lipolytic activity in 1 L liquid broth revealed the maximum MBL activity at 4 h for mycelium cells harvested after 54 h. The yield and specific activity of MBL were 3.87 g/L dry weight and 508.33 U/g protein, respectively, while less than 0.2 U/mL lipase activity was detected in the culture supernatant. Prolonged incubation caused release of the bound lipase into the growth medium. The growth pattern of G. candidum, and production and properties of MBL were not affected by the scale. The stability of mycelia harboring lipase (MBL), harvested and lyophilized after 54 h, studied at 4 °C depicted a loss of 4.3% and 30% in MBL activity after 1 and 8 months, while the activity of free lipase was totally lost after 14 days of storage. The MBL from G. candidum displayed high substrate selectivity for unsaturated fatty acids containing a cis-9 double bond, even in crude form. This unique specificity of MBL could be a direct, simple and inexpensive way in the fats and oil industry for the selective hydrolysis or transesterification of cis-9 fatty acid residues in natural triacylglycerols.
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.
Rationale and methodology for a population-based study of eye diseases in Malay people: The Singapore Malay eye study (SiMES)

Foong AW, Saw SM, Loo JL, Shen S, Loon SC, Rosman M, et al.

Ophthalmic Epidemiol, 2007 Jan-Feb;14(1):25-35.
PMID: 17365815

Although there are approximately 200 million people of Malay ethnicity living in Asia, the burden and risk factors of blinding eye diseases in this ethnic group are unknown. This study summarizes the rationale and study design of a population-based study of eye diseases among adult Malays in Singapore.
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.
Fulltext The Role of Oxidative Stress in Suicidal Behaviour Among Bipolar Patients: A Cross-Sectional Study in a Malaysian Sample

Loo JL, Mohamad Kamal NA, Goon JA, Ahmad Damanhuri H, Tan JAC, Abdul Murad NA, et al.

Front Psychiatry, 2021;12:698911.
PMID: 34916966 DOI: 10.3389/fpsyt.2021.698911

Background: Oxidative stress markers are found to be linked with depression and suicide attempts in bipolar disorder (BD), although the role of DNA damage as a marker of suicidal ideation and attempt has yet to be determined. We aim to investigate the association between DNA damage and suicidal behaviour, i.e., suicidal ideation and suicide attempt, among suicidal ideators in BD patients while accounting for clinical and psychosocial risk factors. Methods: A cross-sectional study was conducted in the Universiti Kebangsaan Malaysia Medical Centre on 62 consecutive BD patients diagnosed using the M.I.N.I. Neuropsychiatric Interview and 26 healthy control participants. Socio-demographic and clinical assessments were performed using the Columbia Suicide Severity Rating Scale (C-SSRS) for lifetime suicidal ideation and attempt, Quick Inventory of Depressive Symptomatology (QIDS) for depression severity, Clinical Global Impression for Bipolar Disorder (CGI-BD) for illness severity [both mania (CGI-Mania) and major depressive episode (CGI-MDE)], Social Readjustment Rating Scale (SRRS) for change in life events, and Barratt Impulsiveness Scale (BIS) for behavioural impulsivity. The degree of DNA damage in peripheral blood samples was determined using a standard protocol of comet assay. Results: Multivariable logistic regression revealed higher scores of CGI-MDE as the sole significant factor for lifetime suicidal ideation (OR = 1.937, 95% CI = 1.799-2.076). Although initial bivariate analysis showed a significant association between DNA damage, malondialdehyde (MDA), catalase (CAT), and suicidal behaviour, the findings were not seen in multivariable logistic regression. Bivariate subgroup analysis showed that moderate and severe DNA damage (p = 0.032 and p = 0.047, respectively) was significantly associated with lifetime suicide attempts among lifetime suicidal ideators. The study is the first to look at the connexion between DNA damage and suicidal risk in bipolar patients. It is limited by the small sample size and lack of information on illicit substance use. Conclusions: More severe DNA damage was significantly associated with lifetime suicide attempts among lifetime suicidal ideators in BD. However, the severity of depression was found to be independently associated with lifetime suicidal ideation per se rather than DNA damage in BD. Larger prospective studies are required to ascertain the potential of DNA damage as a biomarker for the transition from suicidal ideation to a suicide attempt.

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