Displaying publications 1 - 20 of 399 in total

  1. Hashim, E., Wan Hasyila, W.O., Ang, Y.H., Azlan Helmy, A.S., Husyairi, H.
    Medicine & Health, 2018;13(1):106-116.
    The aim of the study was to determine the psychometric properties of the Malay translated State-Trait Anxiety Inventory (STAI) for use in exploring the burden of anxiety amongst parents of a child visited hospital for medical treatment. The instrument was administered to 53 parents of children seen in the Emergency Department and 52 parents in the outpatient Physiotherapy Unit. Internal consistency reliability (α) for state anxiety and trait anxiety subscale was high with values of 0.94 and 0.84, respectively. Test-retest reliability demonstrated wide range of scores with only 25 items showed significant intra-class correlation
    coefficients, ICC (range 0.60 – 0.94, 95% CI, p<0.05) after 4-weeks retest. Performances of matrix following a factor analysis were consistent with 4-factors
    structure of original STAI. A few items did not perform as expected but did not impair the overall performance. This Malay translated version is a valid and reliable measure of anxiety for parents with children visiting hospital for medical treatment, with caution in the interpretation of some items.
    Keywords: anxiety, factor analysis, psychometrics, reliability
    Study site: Emergency department, outpatient physiotherapy unit, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
  2. Shafinaz, S., Chan, L.C., Adawiyah, J., Norazirah, M.N.
    Medicine & Health, 2018;13(1):71-76.
    Discontinuing antihistamines for patch testing (PT) in allergic contact dermatitis (ACD) is more conventional than evidence based. Data suggests that non-sedating antihistamines do not interfere with PT. Investigating the effects of sedating antihistamines are more relevant as these are recommended for eczema. We aimed to evaluate the effect of chlorpheniramine on PT, to determine the prevalence of nickel sensitization and common sensitizing allergens. An open labeled cohort study was conducted at two dermatology clinics. Patients indicated for PT underwent standard protocol where antihistamines were discontinued. Patients sensitised to nickel were subjected to a second nickel PT while taking chlorpheniramine. Results were evaluated using the North American Contact Dermatitis Research Group (NACDRG) score, a Mexameter measured erythema and pruritus was assessed using a visual analogue score. A total 82 patients were recruited, 28 (34.1%) were sensitised to nickel. The mean age was 40 ± 17.7 years with 22(26.8%) males and 60 (73.2%) females. Indications for PT included suspected ACD (57.3%), hand and feet eczema (34.1%) and severe eczema with suspected superimposed ACD (6.1%). The commonest sensitizing allergens were methyldibromoglutaronitrile (40.2%) nickel sulphate (34.1%), potassium dichromate (29.3%) and formaldehyde (24.4%). A second PT was performed on 23 patients. There was no difference in the NACDRG score with chlorpheniramine or without chlorpheniramine (p=0.968). Pruritus score was reduced by 1.39 ± 2.9, p=0.031 with chlorpheniramine. The degree of erythema was 611.46 ± 21.59 with chlorpheniramine versus 613.87 ± 27.5 without chlorpheniramine, p=0.671. Chlorpheniramine did not affect PT based on clinical and objective scorings. It has the additional benefit of reducing test-induced itch.
    Study site: Dermatology clinics, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur and Hospital Pulau Pinang, Malaysia
  3. Nurzazlin, B.Z.N., Shamsul, B.S., Yahya, N.H.M., Ruszymah, B.H.I., Abdul Rani, R., Chowdhury, S.R.
    Medicine & Health, 2018;13(1):77-87.
    Culture expanded chondrocytes isolated from non-load bearing region of osteoarthritic (OA) joint has been used to construct tissue engineered cartilage for treatment purposes. The aim of the study was to compare the histological properties of the cartilage tissue and morphological properties of the chondrocytes isolated from less and severely affected OA knee. Human articular cartilage was obtained as redundant tissue from consented patients with late-stage OA undergoing total knee replacement surgery at Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Articular cartilage was graded according to Dougados and Osteoarthritis Research Society International (OARSI) classification. Articular cartilage was classified into less affected (LA; Grade 0-1) and severely affected (SA; Grade 2-3). Cartilage tissue from less and severely affected region was stained with Safranin O staining. Isolated chondrocytes from each group were cultured until passage 4 (P4). Their growth patterns, cell areas, and circularity were compared. LA-cartilage tissue shows uniform spread of safranin O staining indicating intact extracellular matrix (ECM) component. However, SA-cartilage shows significant reduction and unstable staining due to its degraded ECM. LA-chondrocytes showed an aggregated growth compared to SA-chondrocyte that remains monolayer. Moreover, LA-chondrocytes have significantly higher cell area with wider spreading at passage 0 and 4 compared to SA-chondrocytes. It was also found that chondrocyte circularity increased with passage, and circularity of LAchondrocytes was significantly higher than that of the SA-chondrocytes at passage 3. This study demonstrated the considerable difference in the cellular properties for less and severely affected chondrocytes and implication of these differences in cell-based therapy needed to be explored.
  4. Nur Aqilah, S., Wong, H.S., Syed Zulkifli, S.Z., Mushawiahti, M.
    Medicine & Health, 2018;13(1):88-96.
    Anti-vascular endothelial growth factor (VEGF) reduces choroidal thickness by choroidal hypoperfusion in diabetic macula oedema (DME) patients. Indirect effect of anti-VEGF towards outer retinal layers (ORL) which supplied by choroidal circulation has not been well described. We evaluate the ORL thickness between retinal pigment epithelium (RPE) with inner-segment-outer-segment photoreceptor junction (IS/OS) and RPE with external limiting membrane (ELM) in pre- and postintravitreal Ranibizumab (IVR) treated eyes with central foveal diabetic macula edema. A total of 60 eyes (40 patients) were analysed. ORL thickness measured with optical coherence tomography at pre- and post-injection day 1, week 4 and week 6. Mean thickness of RPE-IS/OS was statistically significant over time (p=0.023) but not for RPE-ELM (p=0.216). Thickness ratio between RPE-IS/OS and RPE-ELM and central subfoveal thickness (CST) both showed statistically significant result over time with p=0.038 and p=0.000, respectively. We observed an initial reduction of ORL thickness at day 1 followed by increased in thickness at week 4 with subsequent reduction at week 6 was observed. ORL is an aspect that can be explore and emphasized further in patients considered for IVR injections. The long-term effects of IVR to the ORL however could not be concluded due to short follow up period.
  5. Khairani O, Mohamed NA, Ismail Z, Shalinawati R, Chamhuri NH, Rahim NS
    Medicine & Health, 2018;13(1):97-105.
    Choosing a course to pursue is an important decision for students to make. A suitable career should correspond to the students’ personalitiy for future work satisfaction and success. The objectives of this study were to determine the students’ reasons for choosing medicine, their personality traits and aptitude (suitability). This was a cross-sectional study involving all third-year medical students at Universiti Sains Islam Malaysia. A self-administered questionnaire was used, which included questions on demographic data, Sidek Career Interest Inventory and reasons for choosing medicine. The inventory was used to measure the students’ personality traits and career suitability. A total of 80 students participated in the study. Majority of them were females (n=56, 70.0%). The findings showed that 45.7% (n=44) of the repondents chose medicine because of ‘passion and interest’, while 24.7% (n=20) and 19.8% (n=16) because of ‘parental influence’ and ‘to help the society’, respectively. For medicine, two personality traits are essential which are investigative and social personality traits. Approximately, 47.5% (n=38) of the respondents had high scores in investigative personality trait. However, only 13.8% (n=11) of them had high scores in social personality trait. Only 12.5% (n=10) of the students had high scores when combining both of the traits. Majority of the students chose medicine for altruistic reasons. However, only a few of them had suitable aptitude for this course namely investigative and social skill. Therefore, the students and the teachers need to be aware of these issues and cultivate the required skills in the students for better career outcome.
  6. Sakthiswary R
    Medicine & Health, 2018;13(1):12-19.
    Rheumatoid arthritis (RA) is the most common chronic systemic autoimmune disease worldwide. Although incurable, there are available therapies to effectively control the disease activity and minimize the joint damage. Numerous cytokines, enzymes and other forms of proteins have been implicated in the disease process of RA. In general, pharmacological therapies in RA target cytokine pathways. Despite a wide variety of disease modifying antirheumatic drugs (DMARD), a significant proportion of patients remain refractory to the available therapies. Hence, the search for newer drugs with different modes of actions is an ongoing process. The present review aimed to explore novel therapeutic targets in RA based on data from the literature. Inhibitors of spleen tyrosine kinase, choline kinase, galectin 3 and hypoxia-inducible factor may have a promising role in the

  7. Siti, H.N., Syarifah-Noratiqah, S.B., Zulfarina, M.S., Isa, N.M., Kamisah, Y.
    Medicine & Health, 2018;13(1):20-28.
    Eradication of tuberculosis seems to be a long way off especially with the growing of drug resistance tuberculosis and HIV co-infection tuberculosis. The gaps in our knowledge and the limited sensitive and specific biomarkers especially for latent tuberculosis infection make it defensive. The fate of tuberculosis treatment ranged from cured to failure and there are many risk factors involved apart from the immune state and age. Therefore, this review focuses on the understanding of tuberculosis disease progression and the associated risk factors of the events in the disease progression. This article also highlights the diagnostic and predictive marker that may predict the disease progression. In addition, this review highlights the potential use of rifabutin in tuberculosis treatment regimen. It is hoped that this review could give an overview on future directions of research in tuberculosis.
  8. Syarifah-Noratiqah, S.B., Zulfarina, M.S., 'Atiqah, A., Qodriyah, H.M.S., Naina-Mohamed, I., Fairus, S.
    Medicine & Health, 2018;13(1):29-48.
    Hyperlipidemia is a condition of high lipid levels in the plasma and often linked with the deposition of lipid droplets in the aorta which initiate the progression of atherosclerosis. Atherosclerosis is a common cardiovascular disorder initiated by the formation of foams cells in the vascular wall which leads to turbulent blood flow, injury to the endothelial layer and subsequent vascular thrombosis. Since the early 1980’s, Golden-Syrian hamsters have been widely used as an animal model in the research of hyperlipidemia and atherosclerosis. The use of hamsters in the hyperlipidemic and atherosclerotic model is due to their lipoprotein profile that is closer to human setting, sensitive to high-fat high-cholesterol (HFHC) diet and a suitable rodent model. Atherosclerosis can be induced in hamsters through dietary challenge with HFHC diet. Over the decades, coconut oil (CNO) was commonly used as the source of fat in the diet design of high saturated fatty acids (SFA) composition. In this review, we summarized published literature with designs involving CNO plus cholesterol-induced hyperlipidemia, atherosclerosis or both. The factors that may influence the ability of CNO and cholesterol combination to induce hyperlipidemia such as the period of dietary intervention, hamster strains and the dietary amount were evaluated and summarized.
  9. Lina Izzati, A., Haszianaliza, H., Zar, C.T.
    Medicine & Health, 2018;13(1):49-70.
    Malaysia is blessed to have several natural products. Since past decades, studies have been carried out to discover the highly effective anti-atherosclerotic supplements. The phytoestrogens and soy proteins have gained much attention, over the years. Several literature highlighted the therapeutic effect of alternative medicines on atherosclerosis. However, the overall anti-atherosclerotic mechanism of isoflavones regardless of menopause or postmenopausal state was not discussed, to date. This review aimed to summarize the molecular mechanism of different types of alternative medicines for the treatment of atherosclerosis in general population. The herbs commonly used in the treatment of atherosclerosis are garlic (Allium sativum), pomegranate (Punica granatum), ginger (Zingiber officinale), cinnamon (Cinnamomum spp.) and green tea (Camellia sinenses). Nevertheless, the palm oil, coconut oil, olive oil and omega-3 also plays significant role in attenuating the risk of atherosclerosis by decreasing the LDL level, increasing the endothelial nitric oxide synthase (eNOS), scavenging the free radicals and also decreasing the inflammatory process. Daidzein improves atherosclerotic changes by activating the NF-ĸB pathway and regulating the expression of inflammatory cytokines. Genistein reduces the monocyte-endothelial cell and adhesion molecules secretion via cAMP/PKA pathway, it decreases the inflammatory response via initiation of nuclear factor erythroid 2-related factor (Nrf2)/ heme oxygenase-1 (HO-1) pathway. Conclusively, we recognized that alternative medicines demonstrate remarkable therapeutic efficacy for the treatment of atherosclerosis in patients of all ages.
  10. Mahdy, Z.A., Srijit, D.
    Medicine & Health, 2018;13(1):1-2.
    Examination in any medical career has never been easy. Even after passing an examination in one’s medical career, one may still harbor nightmares and wake up with fright in the middle of the night. Rigorous examinations in the medical field require a lot of courage and resilience. Unfortunately, many succumb to mental illness.(Copied from article)
  11. Jemaima, C.H., Muhammad Syamil, M.S.
    Medicine & Health, 2018;13(1):3-11.
    Glaucoma is a group of diseases which result in a progressive loss of retinal ganglion cells, producing characteristic optic nerve head appearance with corresponding visual loss. The aetiology remains unclear until today. Previous authors had tried to associate its pathology in relation to intracranial pressure level. We review the literature on interrelation of intraocular pressure (IOP) and intracranial pressure (ICP) which gives rise to the study of translaminar pressure gradient (TLPG) in postulating its causal factor towards glaucoma. Several studies had demonstrated that ICP was reduced in patients with glaucoma, and in sequence with normal or raised IOP, leads to increased level of TLPG. The increased TLPG which acts across the lamina cribrosa may cause a posteriorly bowed lamina cribrosa, therefore leading to glaucomatous changes. This review also explores the current available methods in
    measuring ICP accurately. Further studies are needed to elucidate possible disease mechanism in keeping with IOP-ICP relationship, thus confirming the findings of
    previous authors.
    Keywords: Glaucoma, intracranial, intraocular, pressure, pathophysiology, translaminar
  12. Hashim, E., Samshiyah, A.S., Nik Azuan, N.I.
    Medicine & Health, 2018;13(1):215-219.
    Concomitant recent myocardial infarction (MI) in patients presenting with acute ischaemic stroke (AIS) is considered a relative contraindication for thrombolysis. Mechanical thrombectomy is recognised as an alternative recanalisation therapy to avoid risk of haemorrrhagic complications. We report a 77-year-old patient who previously had recent admission for late presentation ST elevation myocardial infarction (STEMI) and currently presented with right-sided hemiplegia, dysphasia and reduced level of consciousness at 30 minutes from the onset. An urgent cerebral angiography showed total occlusion of the left middle cerebral artery (MCA). Successful mechanical thrombectomy was performed instead of administration of intravenous (IV) thrombolysis with excellent neurological recovery. This case report highlights the importance of patient transfer to a more comprehensive stroke center in the management strategies of the AIS.
  13. Aminuddin, A., Luqman Hakim, A.Z., Chan, S.Y., Nur Elyatulnadia, S., Hul Aamizatkma, H., Nur Shahira Afifa, R., et al.
    Medicine & Health, 2018;13(1):117-129.
    Pulse wave velocity (PWV), augmentation index (AI) and finger photoplethysmography fitness index (PPGF) are non-invasive markers of vascular function and may predict future cardiovascular disease (CVD) risk. In women, the changes from both oestrogen and progesterone levels during menstrual cycle may give significant impact on vascular function. Thus, this study was designed to investigate the variation of vascular function during follicular and luteal phase in healthy young women. Twenty-two healthy young women with regular menstrual cycle were recruited. Blood pressure (BP), body mass index (BMI), PWV, AI, PPGF, estradiol (Es) and progesterone (Prog) level were measured during follicular (F) and mid-luteal (L) phase. Data was analyzed via SPSS version 20 and P value < 0.05 was considered to be significant. The mean age of the subjects was 22.73 ± 0.60 years. There was significant variations of estradiol and progesterone levels during menstrual cycle whereby the level of estradiol (EsF = 107.6 ± 52.56 pmol/L vs. EsL = 555.16 ± 152.79 pmol/L, P
  14. Munirah, M., Khalidah, M.B., Dian Nasriana, N., Hanita, O., Nor Azlin, M.I.
    Medicine & Health, 2018;13(1):143-152.
    Pregnancy induced hypertension (PIH) is commonly encountered in hypertensive disease in pregnancy (HDP) and important cause of feto-maternal morbidity and mortality. Abnormal changes of placenta development in PIH leads to abnormal elevation of second trimester maternal hCG level. Thus, it may have a role in prediction of PIH. The objective of this study was to evaluate the ability of serum hCG levels during early second trimester to predict PIH and obstetric outcome at later gestation. We conducted a cohort study which comprised 34 pregnant women varying from 14–20 weeks of gestation with serum hCG level taken at points of recruitment. Serum hCG was measured by a chemiluminescent immunoassay. Three (8.8%) pregnant women developed late onset PIH while the remainder were normotensive. The diagnostic performance of second trimester hCG in predicting PIH as assessed by receiver operator characteristic curve was poor (AUC = 0.398). Multiple of median (MoM) were used to improve the hCG performance and MoM of >2 MoM were considered as elevated hCG level. All pregnancies with PIH had 0.655). There was no significant association of hCG level and pregnancy outcome. In conclusion, estimation of second trimester hCG is a poor predictive marker for PIH. These findings are limited by the less number of hypertensive cases
  15. Hng, S.H., Siti Nabihah, S., Siti Nabilah, S.
    Medicine & Health, 2018;13(1):153-164.
    Tuberculosis (TB) has become a worldwide public concern with 10.4 million new cases reported in 2015 and 1.4 million deaths. More importantly, an increase in trend in TB incidence among healthcare workers has become a major concern. Therefore, the present study was conducted to explore the knowledge and practice towards TB and the factors associated with it among nurses in a teaching hospital. The present study used cross-sectional design and stratified sampling method. A total of 275 nurses in a teaching hospital participated in this study. The knowledge and practice on management of TB was measured using a structured questionnaire. Majority of the respondents had good knowledge and practice on management of TB represented by 70.2% and 63.3%, respectively. However, knowledge gap (1.8%) and practice gap (0.4%) were identified in method of sputum collection. Work place setting was the only demographic factor found significantly associated with level of knowledge and practice (p=0.028). Level of knowledge and practice on management of TB identified among nurses was not associated with many socio-demographic factors. Nurses as frontline healthcare workers are at high risk of being exposed due to frequent contact with various patients especially those who are undiagnosed and TB suspect patients. Hence, implementation of TB Infection Control (TBIC) measures is important to minimize the risk of infection and cross-infection within hospital.
  16. Mohd Khairi, A.L., Nik Azlan, N.M., Faizal Amri, H.
    Medicine & Health, 2018;13(1):198-207.
    This study determined factors that influence usage of automated external defibrillation (AED) on out-of-hospital cardiac arrest among paramedics in Emergency Department of Universiti Kebangsaan Malaysia Medical Centre (UKMMC). It was a cross sectional prospective study conducted between December 2013 and January 2014. Paramedics from Emergency Department were enrolled and assessed using the self-filled questionnaire consisting of multiple sections including knowledge assessment, training and practice. In total, 53 paramedics participated in this study. Only 62% participants used AEDs previously. Not more than 83% participants admitted that they would use it if required. A positive correlation was observed between age and work experience with knowledge on AED usage (p=0.001 and p=0.005, respectively). Government’s institute graduates possess better knowledge and higher confidence level than private institutions graduates (p
  17. Muhammad Najmi, K., Logeswary, K., Rona Asnida, N., Wan Haslina Wah, Umi Kalthum, M.N., Aida Zairani, M.Z.
    Medicine & Health, 2018;13(1):208-214.
    We report the case series of phacoemulsification-related Descemet membrane detachment (DMD) encountered at a tertiary hospital in Kuala Lumpur. Case 1 was an iatrogenic DMD which was detected intraoperatively and managed early with good outcome. Case 2 and case 3 described unusual presentation of DMD which was initially undiagnosed. This report highlights the use of anterior segment optical coherence tomography (ASOCT) in detecting and confirming the correct diagnosis for DMD. With the aid of an experienced corneal specialist, the higher threshold for suspicious occurrence of DMD was confirmed using ASOCT. Treatment was tailored accordingly, with successful clearance of corneal oedema and visual recovery. This case series highlighted the importance of proper operative documentation and high threshold for suspicion for DMD in focal corneal oedema following an otherwise uneventful cataract surgery. It is concluded that ASOCT is an excellent tool to confirm diagnosis of DMD and success of treatment.
  18. Nur Ain, J., Ainaa Diyana, S., Nur Hazirah, R., Nur Fathiah, A.S., Fairus, A., Teoh, S.l., et al.
    Medicine & Health, 2018;13(1):165-174.
    Piper betle (PB) leaves have been traditionally used in many Asian countries for the healing of wounds and other ailments. The aim of this study was to examine the wound healing effect of PB on skin injury-inflicted Sprague-Dawley rats. Eighteen male Sprague-Dawley rats were inflicted with wounds and then divided into three groups consisting of a control (normal wound healing without dressing), saline (wound healing aided by gauze soaked in saline) and PB (gauze impregnated with PB paste) dressings. Wounds were created on the back of rats with 6-mm sterilized punch biopsy needle. Wounds were examined on days 3, 5, 7, 9, 11 and 13 for dryness, exudation, and scar formation. Rats were sacrificed on day 14 and the granulation tissue formed on the wound was then excised for histological examination using Hematoxylin and Eosin staining. The formation of granulation tissue in rats treated with PB showed higher progress to wound closure with shorter days (on day 3) compared to the control and saline group (on day 5). PB dressing minimized the formation of scar tissue significantly (p
  19. Elvy Suhana, M.R., Fairus, A., Norazlina, M., Mohamad Fairuz, Y., Ima Nirwana, S.
    Medicine & Health, 2018;13(1):175-197.
    Long term glucocorticoids administration induces oxidative stress which leads to alteration of bone structure and strength. Palm oil is rich in tocotrienol, an antioxidant. It can be used for the prevention of oxidative stress related diseases. The main objective of this study was to determine the mechanism of palm tocotrienol in maintaining the bone structure and strength in glucocorticoidinduced osteoporosis. Thirty two adult male Sprague-Dawley rats, aged 3 months, weighing 300-320 g rats were used in this study. Sixteen rats undergone adrenalectomy and were administered with 120µg/kg/day intramuscular injection of dexamethasone. Eight rats were supplemented with oral palm tocotrienol 60 mg/kg/day (Adrx+Dex+PTT) and the other eight rats were given oral vehicle palm olein 0.1 ml/kg/day (Adrx+Dex). Eight rats underwent sham procedure and were given vehicle palm olein 0.05 ml/kg/day by intramuscularly and oral 0.1 ml/kg/day (Sham). The rats were euthanized after two months of treatments. Eight rats were euthanized after acclimatic action without receiving any treatment (Baseline). The right femurs were used for bone biomechanical strength and histomorphometry analysis while the left for gene expression and oxidative stress enzymes activities. The results indicated that long-term glucocorticoid treatment significantly increased bone resorption marker, CTX (6060.7 ± 410 pg/ml) and decreased bone structure and strength. Osteoblast and osteoclast related genes expressions indicated an increase in bone turnover. Supplementation of palm tocotrienol had maintained serum resorption (2619.4 + 209 pg/ml) marker level and preserved bone structure and strength. Gene expression analysis showed decrease in bone resorption. The findings suggested that palm tocotrienol has potential benefits against glucocorticoid-induced osteoporosis by regulating osteoblast and osteoclast related gene expressions.
  20. Seb, Omayma, Fauzana, K., Aisyah, M.R., Noraidah, M., Noor Hamidah, H.
    Medicine & Health, 2018;13(1):220-226.
    Langerhans cell histiocytosis (LCH) is a clonal histiocytic disorder. The variable clinical manifestations from isolated bone lesion to multisystem disease can cause difficulties and delay in diagnosis. We report a 2 years and 8 months-old girl who presented with a 2 weeks history of persistent fever and weight loss associated with progressive abdominal distension. Physical examination revealed pallor, bilateral proptosis, seaborrheic dermatitis over the scalp and hepatosplenomegaly. Skull X-ray demonstrated multiple lytic lesions at the base and the skull vault. Bone marrow morphology showed numerous abnormal Langerhans cells (LCs) and foamy macrophages. The trephine immunohistochemistry (IHC) stains for CD1a, S-100 and CD68 were inconclusive. The diagnosis of multisystem Langerhans cell histiocytosis (MS-LCH) in this patient was based on the clinical presentation, radiological and morphological analysis. She subsequently received chemotherapy and currently she is on maintenance therapy with a good clinical response. LCH is a rare disease and although the IHC was inconclusive, the correlation of clinical, radiological and morphological data are essential for the diagnosis.
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