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A fatal twist in childhood: A post-mortem finding of intestinal volvulus with malrotation

Tan RZ, Darwin FL, Anuar Zainun K

Malays J Pathol, 2020 Dec;42(3):477-481.
PMID: 33361732

Gastrointestinal pathology leading to the death in paediatric age group is uncommon. The diseases that encountered were mostly intestinal obstruction, peritonitis and gastrointestinal bleeding. Due to the severe symptoms, most of the patients presented to hospital in time and were treated appropriately. However, with the presence of contributing factors, certain gastrointestinal pathology can progress rapidly leading to the death. We report a rare case of intestinal volvulus in a 3 years old girl where the deceased presented with one day short history of vomiting before her demise. The contributing factors were bronchopneumonia sepsis and underlying intestinal malrotation identified via post-mortem examination.
Fulltext Fusarium sp. infection in a patient with acute lymphoblastic leukaemia

Tan R, Ng KP, Gan GG, Na SL

Med J Malaysia, 2013 Dec;68(6):479-80.
PMID: 24632920 MyJurnal

In the past two decades, Fusarium species have been increasingly recognized as serious pathogens in immunocompromised patients. The outcome of fusariosis in the context of severe persistent neutropaenia has been almost universally fatal. The treatment of fusariosis in immunocompromised patients remains a challenge and the prognosis of systemic fusariosis in this population remains poor. This report presents a case of fatal fusariosis in a 37- year-old patient who was diagnosed with precursor-B cell Acute Lymphoblastic Leukaemia (ALL).
Mycobacterium brisbanense species nova isolated from a patient with chronic cavitary lung infection

Poh ME, Liam CK, Ng KP, Tan R

Chest, 2014 Apr;145(4):858-860.
PMID: 24687707 DOI: 10.1378/chest.13-1952

We describe the first case, to our knowledge, of Mycobacterium brisbanense species nova with the type strain W6743T (=ATCC 49938T=DSM 44680T) isolated from the lungs of a man with a 6-month history of productive cough and intermittent fever presenting with acute hypoglycemia. A CT scan of the thorax revealed multiple small nodules and consolidation over both lungs with cavitation. Sputum culture repeatedly grew M brisbanense species nova, a novel species never before isolated in Malaysia. The case met the American Thoracic Society criteria for the diagnosis of nontuberculous mycobacterial infection. There was dramatic clinical and radiologic response to treatment with an empirical combination of rifampicin, ethambutol, and levofloxacin and subsequently clarithromycin and levofloxacin once sensitivity was known. This report is the first, to our knowledge, of the pathogen isolated in a patient with chronic cavitary lung infection since it was first identified from an antral sinus in Brisbane, Queensland, Australia, and the first time it is isolated from a human subject in Malaysia.
Reference intervals for CTX and P1NP in a multi-ethnic Malaysian cohort

Tan RZ, C Thambiah S, Loh TP, Vasikaran S, Yeap SS

Malays J Pathol, 2023 Dec;45(3):391-396.
PMID: 38155380

BACKGROUND: Well defined reference intervals are central to the utility of serum C-terminal telopeptide of type 1 collagen (CTX) and N-terminal propeptide of type I procollagen (P1NP), designated as reference markers in osteoporosis, and useful for monitoring therapeutic response in that condition. This study reports the reference intervals for plasma CTX and serum P1NP in a multi-ethnic Malaysian population.
METHODS: Ethnic Malay, Chinese or Indian subjects aged 45-90 years old were recruited from Selangor, Malaysia from June 2016 to August 2018. Subjects with known medical conditions (e.g., bone disorders, malnutrition, immobilisation, renal impairment, hormonal disorders) and medications (including regular calcium or vitamin D supplements) that may affect CTX and P1NP were excluded. Additionally, subjects with osteoporosis or fracture on imaging studies were excluded. The blood samples were collected between 8 a.m. and 9 a.m. in fasting state. The CTX and P1NP were measured on Roche e411 platform in batches.
RESULTS: The 2.5th-97.5th percentiles reference intervals (and bootstrapped 90%CI) for plasma CTX in men (n = 91) were 132 (94-175) - 775 (667-990) ng/L; in post-menopausal women (n = 132) 152 (134-177) - 1025 (834-1293) ng/L. The serum P1NP reference intervals in men were 23.7 (19.1-26.4) - 83.9 (74.0-105.0) µg/L, and in post-menopausal women, 25.9 (19.5-29.3) - 142.1 (104.7-229.7) µg/L.
CONCLUSION: The reference intervals for plasma CTX and serum PINP for older Malaysian men and post-menopausal women are somewhat different to other published studies from the region, emphasising the importance of establishing specific reference intervals for each population.
Effect of time delay on survival in patients with non-small cell lung cancer--a Malaysian study

Loh LC, Chan LY, Tan RY, Govindaraju S, Ratnavelu K, Kumar S, et al.

Asia Pac J Public Health, 2006;18(1):69-71.
PMID: 16629441

The prognosis of lung cancer remains poor with overall five year survival figures varying between five and 10% worldwide, However, it has been shown that surgery in patients with early stage disease in non-small cell lung cancer can achieve five year survival rates up to 80%, suggesting that early or delay diagnosis can influence prognosis. Nevertheless, studies addressing this have been inconclusive and mostly derived from Western countries.
Fulltext Delayed Post-operative Spinal Epidural Haematoma after Posterior Spinal Surgery: Report of Two Cases

Chung WH, Tan RL, Chiu CK, Kwan MK, Chan C

Malays Orthop J, 2020 Nov;14(3):170-173.
PMID: 33403080 DOI: 10.5704/MOJ.2011.027

Delayed post-operative spinal epidural haematoma (DPSEH) is diagnosed when the onset of symptoms is more than three days from the index surgery. DPSEH is a rare but serious complication of spinal surgery. Missed diagnosis will result in irreversible neurological deficit which may lead to permanent disabilities. We report two cases of DPSEH who presented with worsening neurological deficit four days after the index surgery. Magnetic resonance imaging (MRI) showed the presence of an epidural haematoma compressing the spinal cord. Surgical evacuation of haematoma were performed for both patients. Both patients experienced neurological improvement. Surgeons should have high index of suspicion to identify delayed onset of spinal epidural haematoma (SEH) and timely intervention should be taken to avoid irreversible neurological damage.
Fulltext Ranking negative emissions technologies under uncertainty

Ng WY, Low CX, Putra ZA, Aviso KB, Promentilla MAB, Tan RR

Heliyon, 2020 Dec;6(12):e05730.
PMID: 33364497 DOI: 10.1016/j.heliyon.2020.e05730

Existing mitigation strategies to reduce greenhouse gas (GHG) emissions are inadequate to reach the target emission reductions set in the Paris Agreement. Hence, the deployment of negative emission technologies (NETs) is imperative. Given that there are multiple available NETs that need to be evaluated based on multiple criteria, there is a need for a systematic method for ranking and prioritizing them. Furthermore, the uncertainty in estimating the techno-economic performance levels of NETs is a major challenge. In this work, an integrated model of fuzzy analytical hierarchy process (AHP) and interval-extended Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) is proposed to address the multiple criteria, together with data uncertainties. The potential of NETs is assessed through the application of this hybrid decision model. Sensitivity analysis is also conducted to evaluate the robustness of the ranking generated. The result shows Bioenergy with Carbon Capture and Storage (BECCS) as the most optimal alternative for achieving negative emission goals since it performed robustly in the different criteria considered. Meanwhile, energy requirement emerged as the most preferred or critical criterion in the deployment of NETs based on the decision-maker. This paper renders a new research perspective for evaluating the viability of NETs and extends the domains of the fuzzy AHP and interval-extended TOPSIS hybrid model.
Could bacteriophages isolated from the sewage be the solution to methicillin-resistant Staphylococcus aureus?

Tan CS, Aqiludeen NA, Tan R, Gowbei A, Mijen AB, Santhana Raj L, et al.

Med J Malaysia, 2020 03;75(2):110-116.
PMID: 32281590

INTRODUCTIONS: The emergence of multidrug-resistant bacteria such as Methicillin-Resistant Staphylococcus aureus (MRSA) complicates the treatment of the simplest infection. Although glycopeptides such as vancomycin still proves to be effective in treating MRSA infections, the emergence of vancomycin-resistant strains limits the long term use of this antibiotic. Bacteriophages are ubiquitous bacterial viruses which is capable of infecting and killing bacteria including its antibiotic-resistant strains. Bactericidal bacteriophages use mechanisms that is distinct from antibiotics and is not affected by the antibioticresistant phenotypes.
OBJECTIVES: The study was undertaken to evaluate the possibility to isolate bacteriolytic bacteriophages against S.aureus from raw sewage water and examine their efficacy as antimicrobial agents in vitro.
METHODS: Bacteriophages were isolated from the raw sewage using the agar overlay method. Isolated bacteriophages were plaque purified to obtain homogenous bacteriophage isolates. The host range of the bacteriophages was determined using the spot test assay against the 25 MRSA and 36 MSSA isolates obtained from the Sarawak General Hospital. Staphylococcus saprophyticus, Staphylococcus sciuri and Staphylococcus xylosus were included as non-SA controls. The identity of the bacteriophages was identified via Transmission Electron Microscopy and genomic size analysis. Their stability at different pH and temperature were elucidated.
RESULTS: A total of 10 lytic bacteriophages infecting S.aureus were isolated and two of them namely ΦNUSA-1 and ΦNUSA-10 from the family of Myoviridae and Siphoviridae respectively exhibited exceptionally broad host range against >80% of MRSA and MSSA tested. Both bacteriophages were specific to S.aureus and stable at both physiologic pH and temperature.
CONCLUSION: This study demonstrated the abundance of S.aureus specific bacteriophages in raw sewage. Their high virulence against both MSSA and MRSA is an excellent antimicrobial characteristic which can be exploited for bacteriophage therapy against MRSA.
Fulltext Induction approach via P-Graph to rank clean technologies

Low CX, Ng WY, Putra ZA, Aviso KB, Promentilla MAB, Tan RR

Heliyon, 2020 Jan;6(1):e03083.
PMID: 31909259 DOI: 10.1016/j.heliyon.2019.e03083

Identification of appropriate clean technologies for industrial implementation requires systematic evaluation based on a set of criteria that normally reflect economic, technical, environmental and other aspects. Such multiple attribute decision-making (MADM) problems involve rating a finite set of alternatives with respect to multiple potentially conflicting criteria. Conventional MADM approaches often involve explicit trade-offs in between criteria based on the expert's or decision maker's priorities. In practice, many experts arrive at decisions based on their tacit knowledge. This paper presents a new induction approach, wherein the implicit preference rules that estimate the expert's thinking pathways can be induced. P-graph framework is applied to the induction approach as it adds the advantage of being able to determine both optimal and near-optimal solutions that best approximate the decision structure of an expert. The method elicits the knowledge of experts from their ranking of a small set of sample alternatives. Then, the information is processed to induce implicit rules which are subsequently used to rank new alternatives. Hence, the expert's preferences are approximated by the new rankings. The proposed induction approach is demonstrated in the case study on the ranking of Negative Emission Technologies (NETs) viability for industry implementation.
A web-based educational intervention module to improve knowledge and attitudes towards thalassaemia prevention in Malaysian young adults

Ngim CF, Ibrahim H, Abdullah N, Lai NM, Tan RKM, Ng CS, et al.

Med J Malaysia, 2019 Jun;74(3):219-225.
PMID: 31256177

BACKGROUND: Thalassaemia is a public health burden in Malaysia and its prevention faces many challenges. In this study, we aimed to assess the effectiveness of a web-based educational module in improving knowledge and attitudes about thalassaemia prevention amongst Malaysian young adults.
METHODS: We designed an interactive web-based educational module in the Malay language wherein videos were combined with text and pictorial visual cues. Malaysians aged 18-40 years old who underwent the module had their knowledge and attitudes assessed at baseline, post-intervention and at 6-month follow-up using a selfadministered validated questionnaire.
RESULTS: Sixty-five participants: 47 Malays (72.3%), 15 Chinese (23.1%), three Indians (4.6%) underwent the module. Questionnaires were completed at baseline (n=65), postintervention (n=65) and at 6-month follow-up (n=60). Out of a total knowledge score of 21, significant changes were recorded across three time-points- median scores were 12 at pre-intervention, 19 at post-intervention and 16 at 6-month follow-up (p<0.001). Post-hoc testing comparing preintervention and 6-month follow-up scores showed significant retention of knowledge (p<0.001). Compared to baseline, attitudes at 6-month follow-up showed an increased acceptance for "marriage avoidance between carriers" (pre-intervention 20%, 6-month follow-up 48.3%, p<0.001) and "prenatal diagnosis" (pre-intervention 73.8%, 6-month follow-up 86.2%, p=0.008). Acceptance for selective termination however, remained low without significant change (pre-intervention 6.2%, 6-month follow-up 16.7%, p=0.109).
CONCLUSION: A web-based educational module appears effective in improving knowledge and attitudes towards thalassaemia prevention and its incorporation in thalassaemia prevention programs is potentially useful in Malaysia and countries with a high internet penetration rate.
Fulltext A five-year survey of dematiaceous fungi in a tropical hospital reveals potential opportunistic species

Yew SM, Chan CL, Lee KW, Na SL, Tan R, Hoh CC, et al.

PLoS One, 2014;9(8):e104352.
PMID: 25098697 DOI: 10.1371/journal.pone.0104352

Dematiaceous fungi (black fungi) are a heterogeneous group of fungi present in diverse environments worldwide. Many species in this group are known to cause allergic reactions and potentially fatal diseases in humans and animals, especially in tropical and subtropical climates. This study represents the first survey of dematiaceous fungi in Malaysia and provides observations on their diversity as well as in vitro response to antifungal drugs. Seventy-five strains isolated from various clinical specimens were identified by morphology as well as an internal transcribed spacer (ITS)-based phylogenetic analysis. The combined molecular and conventional approach enabled the identification of three classes of the Ascomycota phylum and 16 genera, the most common being Cladosporium, Cochliobolus and Neoscytalidium. Several of the species identified have not been associated before with human infections. Among 8 antifungal agents tested, the azoles posaconazole (96%), voriconazole (90.7%), ketoconazole (86.7%) and itraconazole (85.3%) showed in vitro activity (MIC ≤ 1 µg/mL) to the largest number of strains, followed by anidulafungin (89.3%), caspofungin (74.7%) and amphotericin B (70.7%). Fluconazole appeared to be the least effective with only 10.7% of isolates showing in vitro susceptibility. Overall, almost half (45.3%) of the isolates showed reduced susceptibility (MIC >1 µg/mL) to at least one antifungal agent, and three strains (one Pyrenochaeta unguis-hominis and two Nigrospora oryzae) showed potential multidrug resistance.
Antineoplastic agents. Part 409: Isolation and structure of montanastatin from a terrestrial actinomycete

Pettit GR, Tan R, Melody N, Kielty JM, Pettit RK, Herald DL, et al.

Bioorg Med Chem, 1999 May;7(5):895-9.
PMID: 10400343

A Montana soil actinomycete, Streptomyces anulatus, produced (1 x 10(-2)% yield) a new cancer cell growth inhibitory cyclooctadepsipeptide named montanastatin (1) accompanied by the potent anticancer antibiotic valinomycin (2) in very high (5.1%) yields. Valinomycin but not montanastatin inhibited growth of a number of pathogenic bacteria and fungi. Interpretation of high-field (500 MHz) NMR and high-resolution FAB mass spectral data allowed assignment of the structure cyclo-(D-Val-L-Lac-L-Val-D-Hiv) to montanastatin. Valinomycin (2) was also isolated from actinomycetes cultured from a tree branch and animal feces collected in Malaysia. Streptomyces exfoliatus, isolated from the tree branch, was found to contain valinomycin in 1.6% yield, while the fecal isolate, S. anulatus, gave valinomycin in 0.9% yield.
Fulltext The Chemical Chaperone, PBA, Reduces ER Stress and Autophagy and Increases Collagen IV α5 Expression in Cultured Fibroblasts From Men With X-Linked Alport Syndrome and Missense Mutations

Wang D, Mohammad M, Wang Y, Tan R, Murray LS, Ricardo S, et al.

Kidney Int Rep, 2017 Jul;2(4):739-748.
PMID: 29142990 DOI: 10.1016/j.ekir.2017.03.004

Introduction: X-linked Alport syndrome (OMIM 301050) is caused by COL4A5 missense variants in 40% of families. This study examined the effects of chemical chaperone treatment (sodium 4-phenylbutyrate) on fibroblast cell lines derived from men with missense mutations.
Methods: Dermal fibroblast cultures were established from 2 affected men and 3 normals. Proliferation rates were examined, the collagen IV α5 chain localized with immunostaining, and levels of the intra- and extracellular chains quantitated with an in-house enzyme-linked immunosorbent assay. COL4A5 mRNA was measured using quantitative reverse transcriptase polymerase chain reaction. Endoplasmic reticulum (ER) size was measured on electron micrographs and after HSP47 immunostaining. Markers of ER stress (ATF6, HSPA5, DDIT3), autophagy (ATG5, BECN1, ATG7), and apoptosis (CASP3, BAD, BCL2) were also quantitated by quantitative reverse transcriptase polymerase chain reaction. Measurements were repeated after 48 hours of incubation with 10 mM sodium 4-phenylbutyrate acid.
Results: Both COL4A5 missense variants were associated with reduced proliferation rates on day 6 (P = 0.01 and P = 0.03), ER enlargement, and increased mRNA for ER stress and autophagy (all P values < 0.05) when compared with normal. Sodium 4-phenylbutyrate treatment increased COL4A5 transcript levels (P < 0.01), and reduced ER size (P < 0.01 by EM and P < 0.001 by immunostaining), ER stress (p HSPA5 and DDIT3, all P values < 0.01) and autophagy (ATG7, P < 0.01). Extracellular collagen IV α5 chain was increased in the M1 line only (P = 0.06).
Discussion: Sodium 4-phenylbutyrate increases collagen IV α5 mRNA levels, reduces ER stress and autophagy, and possibly facilitates collagen IV α5 extracellular transport. Whether these actions delay end-stage renal failure in men with X-linked Alport syndrome and missense mutations will only be determined with clinical trials.
Fulltext Draft Genome Sequence of Herpotrichiellaceae sp. UM 238 Isolated from Human Skin Scraping

Ng KP, Yew SM, Chan CL, Tan R, Soo-Hoo TS, Na SL, et al.

Genome Announc, 2013 Jan;1(1).
PMID: 23409267 DOI: 10.1128/genomeA.00148-12

Herpotrichiellaceae spp. are known to be opportunistic human pathogens. Here, we report the ~28.46-Mb draft genome of Herpotrichiellaceae sp. UM 238, isolated from human skin scraping. The UM 238 genome was found to contain many classes of protective genes that are responsible for fungal adaptation under adverse environmental conditions.
Fulltext Estimating direct medical costs of type 2 diabetes mellitus in the Philippines: a protocol

Ng JYS, Clement IJ, Jimeno C, Sy RA, Mirasol R, De La Pena P, et al.

BMJ Open, 2020 07 28;10(7):e025696.
PMID: 32723733 DOI: 10.1136/bmjopen-2018-025696

INTRODUCTION: Diabetes and its complications are a major cause of morbidity and mortality in the Philippines. The prevalence of diabetes in the Philippines has increased from 3.4 million in 2010 to 3.7 million in 2017. The government has formulated strategies to control this increase, for example, through its non-communicable disease prevention and control plan. However, there is scarce research on the financial burden of diabetes. Filling this gap may further help policymakers to make informed decisions while developing and implementing resource planning for relevant interventions. The primary objective of the current study is to estimate the direct medical costs associated with type 2 diabetes mellitus (T2DM).
METHODS AND ANALYSIS: This is a 1-year retrospective cohort study of patients with T2DM in 2016. Data will be collected from: (1) hospital databases from public institutions to estimate the cost of diabetes treatment and (2) physician interviews to estimate the cost of management of diabetes in outpatient care. We will perform descriptive and comparative analyses on direct medical costs and healthcare resource utilisation, stratified by the presence of diabetes-associated complications.
ETHICS AND DISSEMINATION: Research ethics board approval has been obtained from the Department of Health Single Joint Research Ethics Board and Cardinal Santos Medical Center Research Ethics Review Committee. Findings from the study will be reported in peer-reviewed scientific journals and local researcher meetings.
Socioecological differences in factors associated with inconsistent condom use with female sex workers and casual partners: an observational study of heterosexual men attending an anonymous HIV testing clinic in Singapore

Takashima K, Yeoh GWJ, Chua HE, Ting PLM, Chong JY, Tan RKJ, et al.

Sex Health, 2019 11;16(6):593-595.
PMID: 31615617 DOI: 10.1071/SH18230

Sexual practices among heterosexual men may differ between female sex workers (FSWs) and casual partners. We surveyed 203 heterosexual men and investigated the attributes associated with inconsistent condom use among them. Lower educational attainment was positively associated with inconsistent condom use with FSWs (adjusted prevalence ratio (aPR) 2.63; P = 0.018) and casual partners (aPR 1.55; P = 0.022), whereas early age of sexual debut (aPR 3.00; P = 0.012) and alcohol use during sex (aPR 7.95; P < 0.001) were positively associated with inconsistent condom use with FSWs. Socioecological factors may explain such differences.
Fulltext A Consensus of Key Opinion Leaders on the Management of Pre-diabetes in the Asia-Pacific Region

Mirasol R, Thai AC, Salahuddin AA, Tan K, Deerochanawong C, Mohamed M, et al.

J ASEAN Fed Endocr Soc, 2017;32(1):6-12.
PMID: 33442078 DOI: 10.15605/jafes.032.01.02

The Asia-Pacific region carries a high disease burden, with over half of the global diabetic population residing in this region. Increasing evidence shows that without targeted intervention, the progression from impaired glucose tolerance (IGT) to type 2 diabetes occurs more frequently in Asians compared with Caucasians. Furthermore, IGT is independently associated with an increased risk of cardiovascular disease, and should be managed as early as possible. Because diabetes is now a major public health issue, strategies aimed at prevention and treatment are urgently required. Lifestyle modification, including weight loss, dietary changes and increased physical activity, play a major role in controlling the disease. Significant evidence also supports the effectiveness of a combination of lifestyle modification and pharmacologic therapy, such as metformin, in delaying the onset of diabetes. Although the importance of lifestyle interventions is well recognized throughout Asia, many countries do not have formal recommendations to guide the diagnosis and management of individuals at risk of progression to diabetes. At a recent regional meeting, experts from the Asian region convened to develop consensus recommendations to guide clinicians in the management of Asian patients with pre-diabetes. These consensus recommendations provide a clear and concise approach to the management of individuals with IGT based on the available evidence and current best clinical practice.
Fulltext Moving Towards Optimized Noncommunicable Disease Management in the ASEAN Region: Recommendations from a Review and Multidisciplinary Expert Panel

Castillo-Carandang NT, Buenaventura RD, Chia YC, Do Van D, Lee C, Duong NL, et al.

Risk Manag Healthc Policy, 2020;13:803-819.
PMID: 32765135 DOI: 10.2147/RMHP.S256165

Introduction: Noncommunicable diseases (NCDs) are the leading cause of morbidity and mortality in the Association of Southeast Asian Nations (ASEAN) member states. Progress has been slow despite the World Health Organization action plan for the prevention and control of NCDs in the region. This paper presents recommendations focused on practical strategies for optimizing NCD management in the ASEAN region.
Methods: A multidisciplinary group of experts from six ASEAN member states convened for two face-to-face meetings to discuss barriers and possible recommendations for optimizing NCD management, focused on cardiovascular diseases and mental disorders, in the region. Multiple approaches, ie, analysis of insights from the meetings and a review of existing literature on NCD programs in the ASEAN region were followed. The proposed recommendations were also based on selected successful interventions in ASEAN member states, thus providing actionable strategies.
Results: The gaps identified in NCD management for cardiovascular diseases and mental disorders in the ASEAN region were classified into gaps relating to policies and to clinical and public health practice. The proposed solutions addressing policy gaps include fostering multisectoral public-private partnerships, employing "whole-of-government" and "whole-of-society" approaches and promoting "health-in-all policies approach" to manage issues with financing, accessibility, efficiency and quality of health services. Whereas proposed solutions to bridge clinical and public health practice gaps entail strengthening primary care services, building the capacity of trained healthcare workers and employing collaborative care for holistic management of patients.
Conclusion: The scale of premature and preventable deaths from NCDs in the ASEAN region remains a serious public health concern and requires a "whole-of-system approach". The interventions proposed in this paper build on regional collaborations and knowledge sharing to help develop a concerted and targeted response to NCDs.
Clinical recommendations on penile reconstructive and prosthetic surgery: a consensus statement from the Asia-Pacific Society of Sexual Medicine

Chung E, Moon DG, Hui J, Chang HC, Hakim L, Nagao K, et al.

Sex Med, 2023 Apr;11(2):qfad003.
PMID: 37056790 DOI: 10.1093/sexmed/qfad003

INTRODUCTION: Penile reconstructive and prosthetic surgery remains a highly specialized field where potential complications can be devastating, and unrealistic patient expectations can often be difficult to manage. Furthermore, surgical practice can vary depending on locoregional expertise and sociocultural factors.
METHODS: The Asia Pacific Society of Sexual Medicine (APSSM) panel of experts reviewed contemporary evidence regarding penile reconstructive and prosthetic surgery with an emphasis on key issues relevant to the Asia-Pacific (AP) region and developed a consensus statement and set of clinical practice recommendations on behalf of the APSSM. The Medline and EMBASE databases were searched using the following terms: "penile prosthesis implant," "Peyronie's disease," "penile lengthening," "penile augmentation," "penile enlargement," "buried penis," "penile disorders," "penile trauma," "transgender," and "penile reconstruction" between January 2001 and June 2022. A modified Delphi method was undertaken, and the panel evaluated, agreed, and provided consensus statements on clinically relevant penile reconstructive and prosthetic surgery, namely (1) penile prosthesis implantation, (2) Peyronie's disease, (3) penile trauma, (4) gender-affirming (phalloplasty) surgery, and (5) penile esthetic (length and/or girth enlargement) surgery.
MAIN OUTCOME MEASURES: Outcomes were specific statements and clinical recommendations according to the Oxford Centre for Evidence-Based Medicine, and if clinical evidence is lacking, a consensus agreement is adopted. The panel provided statements on clinical aspects of surgical management in penile reconstructive and prosthetic surgery.
RESULTS: There is a variation in surgical algorithms in patients based on sociocultural characteristics and the availability of local resources. Performing preoperative counseling and obtaining adequate informed consent are paramount and should be conducted to discuss various treatment options, including the pros and cons of each surgical intervention. Patients should be provided with information regarding potential complications related to surgery, and strict adherence to safe surgical principles, preoperative optimization of medical comorbidities and stringent postoperative care are important to improve patient satisfaction rates. For complex patients, surgical intervention should ideally be referred and performed by expert high-volume surgeons to maximize clinical outcomes.
CLINICAL IMPLICATIONS: Due to the uneven distribution of surgical access and expertise across the AP region, development of relevant comprehensive surgical protocols and regular training programs is desirable.
STRENGTHS AND LIMITATIONS: This consensus statement covers comprehensive penile reconstructive and prosthetic surgery topics and is endorsed by the APSSM. The variations in surgical algorithms and lack of sufficient high-level evidence in these areas could be stated as a limitation.
CONCLUSION: This APSSM consensus statement provides clinical recommendations on the surgical management of various penile reconstructive and prosthetic surgeries. The APSSM advocates for surgeons in AP to individualize surgical options based on patient condition(s) and needs, surgeon expertise, and local resources.
Management of status epilepticus in Malaysia: A national survey of current practice and treatment gap

Lim KS, Khoo CS, Fong SL, Tan HJ, Fong CY, Mohamed AR, et al.

J Clin Neurosci, 2023 Aug;114:25-31.
PMID: 37279626 DOI: 10.1016/j.jocn.2023.05.006

INTRODUCTION: Early and effective treatment is fundamental in status epilepticus (SE) management. At the initiative of the Epilepsy Council of Malaysia, this study aimed to determine the treatment gap in SE across different healthcare settings in Malaysia.
METHODS: A web-based survey was sent to clinicians involved in the management of SE, across all states and at all levels of healthcare services.
RESULTS: A total of 158 responses were received from 104 health facilities, including 23 tertiary government hospitals (95.8% of all government tertiary hospitals in Malaysia), 4 (80.0%) universities, 14 (6.7%) private, 15 (11.5%) district hospitals and 21 clinics. Intravenous (IV) diazepam was available in 14 (93.3%) district and 33 (80.5%) tertiary hospitals for prehospital management. Non-IV benzodiazepine (rectal diazepam and intramuscular midazolam) was not widely available in prehospital services (75.8% and 51.5%). Intramuscular midazolam was underutilised (60.0% in district and 65.9% in tertiary hospitals). IV sodium valproate and levetiracetam were only available in 66.7% and 53.3% of the district hospitals, respectively. Electroencephalogram (EEG) services were available in only 26.7% of the district hospitals. Non-pharmacological therapies such as ketogenic diet, electroconvulsive therapy, and therapeutic hypothermia were not available in most district and tertiary hospitals for refractory and super-refractory SE.
CONCLUSIONS: We identified several gaps in the current practice of SE management, including limited availability and underutilization of non-IV midazolam in prehospital services, underutilization of non-IV midazolam and other second-line ASMs, and lack of EEG monitoring in district hospitals and limited treatment options for refractory and super-refractory SE in tertiary hospitals.

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