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Factors related to prehospital delay and decision delay among acute stroke patients in a district hospital, Malaysia

Lim SH, Tan TL, Ngo PW, Lee LY, Ting SY, Tan HJ

Med J Malaysia, 2023 Mar;78(2):241-249.
PMID: 36988537

INTRODUCTION: Time is the greatest challenge in stroke management. This study aimed to examine factors contributing to prehospital delay and decision delay among stroke patients.
MATERIALS AND METHODS: A cross-sectional study involving acute stroke patients admitted to Seri Manjung Hospital was conducted between August 2019 and October 2020 via faceto- face interview. Prehospital delay was defined as more than 120 minutes taken from recognition of stroke symptoms till arrival in hospital, while decision delay was defined as more than 60 minutes taken from recognition of stroke symptoms till decision was made to seek treatment.
RESULTS: The median prehospital delay of 102 enrolled patients was 364 minutes (IQR 151.5, 1134.3) while the median for decision delay was 120 minutes (IQR 30.0, 675.0). No history of stroke (adj. OR 4.15; 95% CI 1.21, 14.25; p=0.024) and unaware of thrombolysis service (adj. OR 17.12; 95% CI 1.28, 229.17; p=0.032) were associated with higher odds of prehospital delay, while Indian ethnicity (adj. OR 0.09; 95% CI 0.02, 0.52; p=0.007) was associated with lower odds of prehospital delay as compared to Malay ethnicity. On the other hand, higher National Institutes of Health Stroke Scale (NIHSS) score (adj. OR 0.86; 95% CI 0.78, 0.95; p=0.002) was associated with lower odds of decision delay.
CONCLUSION: Public awareness is crucial to shorten prehosital delay and decision delay for better patients' outcomes in stroke. Various public health campaigns are needed to improve the awareness for stroke.
Clinical characteristics and computed tomographical features of pulmonary thromboembolic disease associated with COVID-19 infection: A tertiary hospital analysis

Tan TL, Illa NE, Ting SY, Hwong PL, Azmel A, Shunmugarajoo A, et al.

Med J Malaysia, 2023 Mar;78(2):155-162.
PMID: 36988524

INTRODUCTION: The co-existence of coronavirus disease 2019 (COVID-19) and pulmonary thromboembolic (PTE) disease poses a great clinical challenge. To date, few researches have addressed this important clinical issue among the South-East Asian populations. The objectives of this study were as follow: (1) to describe the clinical characteristics and computed tomographical (CT) features of patients with PTE disease associated with COVID-19 infection and (2) to compare these parameters with those COVID-19 patients without PTE disease.
MATERIALS AND METHODS: This cross-sectional study with retrospective record review was conducted in Hospital Tengku Ampuan Rahimah, Selangor, Malaysia. We included all hospitalised patients with confirmed COVID-19 infection who had undergone CT pulmonary angiogram (CTPA) examinations for suspected PTE disease between April 2021 and May 2021. Clinical data and laboratory data were extracted by trained data collectors, whilst CT images retrieved were analysed by a senior radiologist. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 20.
RESULTS: We studied 184 COVID-19 patients who were suspected to have PTE disease. CTPA examinations revealed a total of 150 patients (81.5%) suffered from concomitant PTE disease. Among the PTE cohort, the commonest comorbidities were diabetes mellitus (n=78, 52.0%), hypertension (n=66, 44.0%) and dyslipidaemia (n=25, 16.7%). They were generally more ill than the non-PTE cohort as they reported a significantly higher COVID-19 disease category during CTPA examination with p=0.042. Expectedly, their length of both intensive care unit stays (median number of days 8 vs. 3; p=0.021) and hospital stays (median number of days 14.5 vs. 12; p=0.006) were significantly longer. Intriguingly, almost all the subjects had received either therapeutic anticoagulation or thromboprophylactic therapy prior to CTPA examination (n=173, 94.0%). Besides, laboratory data analysis identified a significantly higher peak C-reactive protein (median 124.1 vs. 82.1; p=0.027) and ferritin levels (median 1469 vs. 1229; p=0.024) among them. Evaluation of CT features showed that COVID-19 pneumonia pattern (p<0.001) and pulmonary angiopathy (p<0.001) were significantly more profound among the PTE cohort. To note, the most proximal pulmonary thrombosis was located in the segmental (n=3, 2.0%) and subsegmental pulmonary arteries (n=147, 98.0%). Also, the thrombosis predominantly occurred in bilateral lungs with multilobar involvement (n=95, 63.3%).
CONCLUSION: Overall, PTE disease remains prevalent among COVID-19 patients despite timely administration of thromboprophylactic therapy. The presence of hyperinflammatory activities, unique thrombotic locations as well as concurrent pulmonary parenchyma and vasculature aberrations in our PTE cohort implicate immunothrombosis as the principal mechanism of this novel phenomenon. We strongly recommend future researchers to elucidate this important clinical disease among our post- COVID vaccination populations.
Molecular cloning, phylogenetic analysis and functional characterisation of an Elovl7-like elongase from a marine crustacean, the orange mud crab (Scylla olivacea)

Mah MQ, Kuah MK, Ting SY, Merosha P, Janaranjani M, Goh PT, et al.

Comp Biochem Physiol B Biochem Mol Biol, 2019 Mar 01;232:60-71.
PMID: 30831207 DOI: 10.1016/j.cbpb.2019.01.011

The capacity of crustaceans to biosynthesise long-chain polyunsaturated fatty acids has yet to be fully defined, due to the lack of evidence on the functional activities of enzymes involved in desaturation or elongation of fatty acid substrates. We report here the cloning and in vitro functional analysis of an elongase from the orange mud crab, Scylla olivacea. Sequence and phylogenetic analysis placed the elovl close to the vertebrate Elovl1 and Elovl7 clade, which is distinct from the other remaining five Elovl families. The elongase was also clustered together with several elongases from crustaceans and insects. This elongase showed activities towards 16:1n-7, and at lower rate, linoleic acid (18:2n-6) and linolenic acid (18:3n-3). To our knowledge this is the first description of a functional enzyme involved in biosynthesis of long-chained polyunsaturated fatty acids in a crustacean species. Expression of the S. olivacea elovl7-like mRNA was prominent in stomach, intestine and gill tissues, due to the need to regulate the permeability of epithelial tissue through modification of fatty acid compositions. The implication of our findings, in terms of ability of Crustacea phylum to biosynthesise polyunsaturated fatty acids is discussed.
The Role of Isocitrate Lyase (ICL1) in the Metabolic Adaptation of Candida albicans Biofilms

Ishola OA, Ting SY, Tabana YM, Ahmed MA, Yunus MA, Mohamed R, et al.

Jundishapur J Microbiol, 2016 Sep;9(9):e38031.
PMID: 27800147

A major characteristic of Candida biofilm cells that differentiates them from free-floating cells is their high tolerance to antifungal drugs. This high resistance is attributed to particular biofilm properties, including the accumulation of extrapolymeric substances, morphogenetic switching, and metabolic flexibility.
Metabolic adaptation via regulated enzyme degradation in the pathogenic yeast Candida albicans

Ting SY, Ishola OA, Ahmed MA, Tabana YM, Dahham S, Agha MT, et al.

J Mycol Med, 2017 Mar;27(1):98-108.
PMID: 28041812 DOI: 10.1016/j.mycmed.2016.12.002

The virulence of Candida albicans is dependent upon fitness attributes as well as virulence factors. These attributes include robust stress responses and metabolic flexibility. The assimilation of carbon sources is important for growth and essential for the establishment of infections by C. albicans. Previous studies showed that the C. albicans ICL1 genes, which encode the glyoxylate cycle enzymes isocitratelyase are required for growth on non-fermentable carbon sources such as lactate and oleic acid and were repressed by 2% glucose. In contrast to S. cerevsiae, the enzyme CaIcl1 was not destabilised by glucose, resulting with its metabolite remaining at high levels. Further glucose addition has caused CaIcl1 to lose its signal and mechanisms that trigger destabilization in response to glucose. Another purpose of this study was to test the stability of the Icl1 enzyme in response to the dietary sugars, fructose, and galactose. In the present study, the ICL1 mRNAs expression was quantified using Quantitative Real Time PCR, whereby the stability of protein was measured and quantified using Western blot and phosphoimager, and the replacing and cloning of ICL1 ORF by gene recombination and ubiquitin binding was conducted via co-immuno-precipitation. Following an analogous experimental approach, the analysis was repeated using S. cerevisiaeas a control. Both galactose and fructose were found to trigger the degradation of the ICL1 transcript in C. albicans. The Icl1 enzyme was stable following galactose addition but was degraded in response to fructose. C. albicans Icl1 (CaIcl1) was also subjected to fructose-accelerated degradation when expressed in S. cerevisiae, indicating that, although it lacks a ubiquitination site, CaIcl1 is sensitive to fructose-accelerated protein degradation. The addition of an ubiquitination site to CaIcl1 resulted in this enzyme becoming sensitive to galactose-accelerated degradation and increases its rate of degradation in the presence of fructose. It can be concluded that ubiquitin-independent pathways of fructose-accelerated enzyme degradation exist in C. albicans.
Functional characterisation of fatty acyl desaturase, Fads2, and elongase, Elovl5, in the Boddart's goggle-eyed goby Boleophthalmus boddarti (Gobiidae) suggests an incapacity for long-chain polyunsaturated fatty acid biosynthesis

Soo HJ, Sam KK, Chong J, Lau NS, Ting SY, Kuah MK, et al.

J Fish Biol, 2020 Jul;97(1):83-99.
PMID: 32222967 DOI: 10.1111/jfb.14328

The biosynthesis of long-chain polyunsaturated fatty acids (LC-PUFA), a process to convert C18 polyunsaturated fatty acids into eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) or arachidonic acid (ARA), requires the concerted activities of two enzymes, the fatty acyl desaturase (Fads) and elongase (Elovl). This study highlights the cloning, functional characterisation and tissue expression pattern of a Fads and an Elovl from the Boddart's goggle-eyed goby (Boleophthalmus boddarti), a mudskipper species widely distributed in the Indo-Pacific region. Phylogenetic analysis revealed that the cloned fads and elovl are clustered with other teleost orthologs, respectively. The investigation of the genome of several mudskipper species, namely Boleophthalmus pectinirostris, Periophthalmus schlosseri and Periophthalmus magnuspinnatus, revealed a single Fads2 and two elongases, Elovl5 and Elovl4 for each respective species. A heterologous yeast assay indicated that the B. boddarti Fads2 possessed low desaturation activity on C18 PUFA and no desaturation on C20 and C22 PUFA substrates. In comparison, the Elovl5 showed a wide range of substrate specificity, with a capacity to elongate C18, C20 and C22 PUFA substrates. An amino acid residue that affects the capacity to elongate C22:5n-3 was identified in the B. boddarti Elovl5. Both genes are highly expressed in brain tissue. Among all tissues, DHA is highly concentrated in neuron-rich tissues, whereas EPA is highly deposited in gills. Taken together, the results showed that due to the inability to perform desaturation steps, B. boddarti is unable to biosynthesise LC-PUFA, relying on dietary intake to acquire these nutrients.
Two Elongases, Elovl4 and Elovl6, Fulfill the Elongation Routes of the LC-PUFA Biosynthesis Pathway in the Orange Mud Crab (Scylla olivacea)

Ting SY, Janaranjani M, Merosha P, Sam KK, Wong SC, Goh PT, et al.

J Agric Food Chem, 2020 Apr 08;68(14):4116-4130.
PMID: 32186869 DOI: 10.1021/acs.jafc.9b06692

While the capacity for long-chain polyunsaturated fatty acid (LC-PUFA) biosynthesis has been elucidated in vertebrates and several invertebrate phyla, the comparative knowledge in crustaceans remains vague. A key obstacle in mapping the full spectrum of LC-PUFA biosynthesis in crustacean is the limited evidence of the functional activities of enzymes involved in desaturation or elongation of polyunsaturated fatty acid substrates. In this present study, we report on the cloning and functional characterization of two Elovl elongases from the orange mud crab, Scylla olivacea. Sequence and phylogenetic analysis suggest these two Elovl as putative Elovl4 and Elovl6, respectively. Using the recombinant expression system in Saccharomyces cerevisiae, we demonstrate the elongation capacity for C18-C22 PUFA substrates in the S. olivacea Elovl4. The S. olivacea Elovl6 elongated saturated fatty acids, monounsaturated fatty acids, and interestingly, C18-C20 PUFA. Taken together, both Elovl fulfill the elongation steps required for conversion of C18 PUFA to their respective LC-PUFA products. Elovl4 is expressed mainly in the hepatopancreas and gill tissues, while Elovl6 is predominant in digestive tissues. The mRNA expression of both enzymes was higher in mud crabs fed with vegetable oil-based diets. Tissue fatty acid composition also showed the existence of LC-PUFA biosynthesis intermediate products in tissues expressing these two elongases. In summary, we report here two novel Elovl with PUFA elongating activities in a marine brachyuran. This will contribute significantly to the understanding of the LC-PUFA biosynthesis pathway in crustaceans and advance the development of aquafeed for intensive farming of the mud crab.
Correction to: Comparative Analyses of Scylla olivacea Gut Microbiota Composition and Function Suggest the Capacity for Polyunsaturated Fatty Acid Biosynthesis

Lau NS, Ting SY, Sam KK, M J, Wong SC, Wu X, et al.

Microb Ecol, 2023 Jul;86(1):589.
PMID: 35713683 DOI: 10.1007/s00248-022-02059-9
Comparative Analyses of Scylla olivacea Gut Microbiota Composition and Function Suggest the Capacity for Polyunsaturated Fatty Acid Biosynthesis

Lau NS, Ting SY, Sam KK, M J, Wong SC, Wu X, et al.

Microb Ecol, 2023 Jul;86(1):575-588.
PMID: 35618944 DOI: 10.1007/s00248-022-02046-0

Although numerous studies in aquatic organisms have linked lipid metabolism with intestinal bacterial structure, the possibility of the gut microbiota participating in the biosynthesis of beneficial long-chain polyunsaturated fatty acid (LC-PUFA) remains vague. We profiled the gut microbiota of the mud crab Scylla olivacea fed with either a LC-PUFA rich (FO) or a LC-PUFA-poor but C18-PUFA substrate-rich (LOCO) diet. Additionally, a diet with a similar profile as LOCO but with the inclusion of an antibiotic, oxolinic acid (LOCOAB), was also used to further demarcate the possibility of LC-PUFA biosynthesis in gut microbiota. Compared to diet FO treatment, crabs fed diet LOCO contained a higher proportion of Proteobacteria, notably two known taxonomy groups with PUFA biosynthesis capacity, Vibrio and Shewanella. Annotation of metagenomic datasets also revealed enrichment in the KEGG pathway of unsaturated fatty acid biosynthesis and polyketide synthase-like system sequences with this diet. Intriguingly, diet LOCOAB impeded the presence of Vibrio and Shewanella and with it, the function of unsaturated fatty acid biosynthesis. However, there was an increase in the function of short-chain fatty acid production, accompanied by a shift towards the abundance of phyla Bacteroidota and Spirochaetota. Collectively, these results exemplified bacterial communities and their corresponding PUFA biosynthesis pathways in the microbiota of an aquatic crustacean species.
Pulmonary thromboembolic disease associated with COVID-19 infection: a comparison between geriatric and non-geriatric populations

Tan TL, Illa NE, Ting SY, Hwong PL, Makhtar NK, Sim YH, et al.

Med J Malaysia, 2023 May;78(3):379-388.
PMID: 37271849

INTRODUCTION: The magnitude of Coronavirus Disease 2019 (COVID-19) infection among the elderly population is expected to rise. Our study compares the clinical and computed tomographical (CT) features of pulmonary thromboembolic (PTE) disease associated with COVID-19 infection in geriatric and non-geriatric cases, and explores the 60-day mortality rate in these two groups.
MATERIALS AND METHODS: We conducted this retrospective cross-sectional study in Hospital Tengku Ampuan Rahimah, Selangor, Malaysia. Patients admitted in April 2021 and May 2021 with concomitant COVID-19 infection and PTE disease were included. Demographic, clinical and laboratory data were retrieved, whilst CTPA images were analysed by a senior radiologist.
RESULTS: A total of 150 patients were recruited, comprising 45 geriatric patients and 105 non-geriatric patients. The prevalence rate of hypertension, diabetes mellitus and dyslipidaemia were higher among the geriatric cohort. Evidently, the percentage of patients with fever and diarrhoea were significantly higher among the non-geriatric cohort. The geriatric cohort also recorded a significantly lower absolute lymphocyte count at presentation and albumin level during admission. Despite earlier presentation, the geriatric cohort suffered from more severe diseases. Analysis of the CT features demonstrated that the most proximal pulmonary thrombosis specifically limited to the segmental and subsegmental pulmonary arteries in both cohorts. The elderly suffered from a significantly higher inhospital mortality rate and their cumulative probability of survival was significantly lower.
CONCLUSION: Typical COVID-19 symptoms may be absent among the elderly, prompting a lower threshold of suspicion during the COVID-19 pandemic. Additionally, the elderly demonstrated a higher probability of adverse outcomes despite earlier presentation and treatment.

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