Management of patent foramen ovale in embolic stroke of undetermined source patients: Malaysian experts' consensus.

INTRODUCTION: About 20 to 40% of ischaemic stroke causes are cryptogenic. Embolic stroke of undetermined source (ESUS) is a subtype of cryptogenic stroke which is diagnosed based on specific criteria. Even though patent foramen ovale (PFO) is linked with the risk of stroke, it is found in about 25% of the general population, so it might be an innocent bystander. The best way to treat ESUS patients with PFO is still up for discussion. MATERIALS AND METHODS: Therefore, based on current evidence and expert opinion, Malaysian expert panels from various disciplines have gathered to discuss the management of ESUS patients with PFO. This consensus sought to educate Malaysian healthcare professionals to diagnose and manage PFO in ESUS patients based on local resources and facilities. RESULTS: Based on consensus, the Malaysian expert recommended PFO closure for embolic stroke patients who were younger than 60, had high RoPE scores and did not require long-term anticoagulation. However, the decision should be made after other mechanisms of stroke have been ruled out via thorough investigation and multidisciplinary evaluation. The PFO screening should be made using readily available imaging modalities, ideally contrasttransthoracic echocardiogram (c-TTE) or contrasttranscranial Doppler (c-TCD). The contrast-transesophageal echocardiogram (c-TEE) should be used for the confirmation of PFO diagnosis. The experts advised closing PFO as early as possible because there is limited evidence for late closure. For the post-closure follow-up management, dual antiplatelet therapy (DAPT) for one to three months, followed by single antiplatelet therapy (APT) for six months, is advised. Nonetheless, with joint care from a cardiologist and a neurologist, the multidisciplinary team will decide on the continuation of therapy.

Outcomes in breast cancer-does ethnicity matter?

Ethnic or racial differences in breast cancer (BC) survival outcomes have been reported, but current data are largely restricted to comparisons between African Americans and non-Hispanic whites. Most analyses have traditionally been based on self-reported race which may not always be accurate, or are oversimplified in their classification. With increasing globalization, quantification of the genetic ancestry from genomic data may offer a solution to infer the complex makeup from admixture of races. Focusing on the larger and the latest studies, we will discuss recent findings on the differing host and tumor biology that may be driving these disparities, in addition to the extrinsic environmental or lifestyle factors. Socioeconomic disparities with lower cancer literacy may lead to late presentation, poorer adherence to treatment, and other lifestyle factors such as unhealthy diet, obesity, and inadequate physical activity. These hardships may also result in greater allostatic load, which is in turn associated with aggressive BC features in disadvantaged populations. Epigenetic reprogramming may mediate the effects of the environment or lifestyle factors on gene expression, with ensuing differences in BC characteristics and outcome. There is increasing evidence that germline genetics can influence somatic gene alterations or expression, as well as modulate the tumor or immune microenvironment. Although the precise mechanisms remain elusive, this may account for the varying distribution of different BC subtypes across ethnicities. These gaps in our knowledge highlight the need to interrogate the multiomics landscape of BC in diverse populations, ideally in large-scale collaborative settings with standardized methodology for the comparisons to be statistically robust. Together with improving BC awareness and access to good quality health care, a holistic approach with insights of the biological underpinnings is much needed to eradicate ethnic disparities in BC outcomes.

Palliative Prognostic Index as a predictor of mortality among geriatric patients with advanced chronic medical conditions.

INTRODUCTION: This study is to validate Palliative Prognostic Index (PPI) as a tool for six months prognostication in geriatric patients with advanced chronic medical conditions and to identify other independent prognostic markers of survival. METHODS: This was a prospective and observational study of 108 geriatric patients conducted at Pusat Jantung Hospital Umum Sarawak (PJHUS) Kota Samarahan and Sarawak General Hospital (SGH). The PPI scores were calculated and determined at the time of admission. Mortality is considered as the primary outcome. Sensitivity and specificity analysis were conducted to test the accuracy of PPI. The ideal cut-off value for PPI and other associated markers were determined based on the highest value of Youden Index. Cox regression analysis and survival analysis were applied to test the association between potential markers within six months. RESULTS: PPI score has a significant association with survival within six months based on univariate and multivariate analyses (p<0.05). Total PPI had a hazard ratio of 1.56 (95% Confidence Interval (95%CI): 1.33,1.57). The study shows PPI reported area under the curve-ROC of 0.945 with p<0.001. PPI score with cut-off value of six reports the highest accuracy in predicting death within six months with sensitivity and specificity of 88.6% and 90.6%, respectively. Total PPI score of >6 with serum albumin level ≤25, the sensitivity and specificity tested were 100.0%. CONCLUSION: PPI has the potential to be a useful and significant predictor of mortality within six months in the geriatric population with an advanced chronic medical condition. This study also re-emphasised the strong prognostic role of other markers such as Palliative Performance Scale, Barthel Index, and serum albumin level. This study has identified that hypoalbuminemia cut-off value of 25g/dL analysed against PPI score of >5 revealed extremely high accuracy of prognostication for mortality.

Chemoselective decarboxylation of ceiba oil to diesel-range alkanes over a red mud based catalyst under H2-free conditions.

Concerns over global greenhouse gas emissions such as CO x and NO x as well as the depletion of petroleum fossil resources have motivated humankind to seek an alternative energy source known as green diesel. In this study, green diesel was produced via a deoxygenation (DO) reaction of ceiba oil under a H2-free atmosphere over Ni modified red mud-based catalysts, which have been synthesized via a precipitation - deep-deposition assisted autoclave method. The obtained catalyst was further characterized by XRF, XRD, BET, FTIR, TPD-NH3, FESEM, and TGA. Based on the catalytic activity test, all Ni/RMO x catalysts facilitated greater DO activity by yielding 83-86% hydrocarbon yield and 70-85% saturated diesel n-(C15 + C17) selectivity. Ni/RMO3 was the best catalyst for deoxygenizing the ceiba oil owing to the existence of a high acidic strength (12717.3 µmol g-1) and synergistic interaction between Fe-O and Ni-O species, thereby producing the highest hydrocarbon yield (86%) and n-(C15 + C17) selectivity (85%). According to the reusability study, the Ni/RMO3 could be reused for up to six consecutive runs with hydrocarbon yields ranging from 53% to 83% and n-(C15 + C17) selectivity ranging from 62% to 83%.

A retrospective cross-sectional study on the risk factors and survival outcome of End Stage Kidney Disease patients receiving regular maintenance haemodialysis with COVID-19 infection in Hospital Enche' Besar Hajjah Khalsom, Kluang.

INTRODUCTION: COVID-19 pandemic has affected healthcare services around the globe as hospitals were turned into designated hospitals to accommodate high risk groups of patients with COVID-19 infection including end stage kidney disease (ESKD) patients. In Malaysia, there was insufficient data on COVID-19 infection among ESKD patients. This study aims to determine factors and survival outcomes associated with COVID-19 infection among ESKD patients in a designated COVID-19 hospital in Malaysia. METHODS AND MATERIALS: A retrospective cross-sectional study involving 80 haemodialysis (HD) patients recruited from March 2020 till March 2021. Patients' information and results was retrieved and evaluated. Risk factors affecting the COVID-19 mortality were analysed using a one-way analysis of variance (ANOVA) and binary logistic regression. RESULTS: The mean age of the patients was 54 years who were predominantly Malays (87.5%) and living in rural areas. Majority of them had comorbidities such as diabetes mellitus (71%) and hypertension (90%). The most common presentations were fever (46%) and cough (54%) with chest radiographs showing bilateral lower zone ground glass opacities (45%). A quarter of the study population were admitted to the intensive care unit, necessitating mechanical ventilation. This study found that 51% of the patients were given steroids and 45% required oxygen supplementation. The COVID-19 infection mortality among the study population was 12.5%. Simple logistic regression analysis showed that albumin, Odd Ratio, OR=0.85 (95% Confidence Interval, 95%CI: 0.73, 0.98)) and absolute lymphocyte count OR=0.08 (95%CI: 0.11, 0.56) have inverse association with COVID-19 mortality. C-reactive protein OR=1.02 (95%CI: 1.01, 1.04), lactate dehydrogenase OR=1.01 (95%CI: 1.00, 1.01), mechanical ventilation OR=17.21 (95%CI: 3.03, 97.67) and high dose steroids OR=15.71 (95%CI: 1.80, 137.42) were directly associated with COVID-19 mortality. CONCLUSION: The high mortality rate among ESKD patients receiving HD was alarming. This warrants additional infection control measures to prevent the spread of COVID- 19 infection among this vulnerable group of patients. Expediting vaccination efforts in this group of patients should be advocated to reduce the incidence of complications from COVID-19 infection.

A rare presentation of ectopic thyroid gland at right axilla.

The thyroid gland and its hormones play important roles in organ development and in the homeostatic control of physiological mechanisms in human beings. As a result of embryogenic descent of thyroid gland, it commonly resides along the midline - from tongue to mediastinum (90%). Ectopic thyroid gland is a rare occurrence, with extra-lingual ectopic thyroid gland being even rarer. Thus, there is a concern for malignant metastasis. Madam H, a 56-year-old healthy woman presented to the Hospital Sultanah Nora Ismail, Johor, Malaysia in April 2020 with an increasing size of right axilla mass and history of weight loss. She was having right axilla mass for the previous 7 years but only noticed the increase in size about 1 year ago. She has no other constitutional symptoms. A tru-cut biopsy performed demonstrated a benign ectopic thyroid tissue. Thyroid function test showed primary hypothyroidism. Serum Chromogranin A and other thyroid antibodies were within the normal value. Further radiological imaging showed the normal thyroid gland at neck, with no signs of distant malignancy. There was no other axillary, mediastinal or hilar lymph node enlargement. She was started on regular T. L Thyroxine 100mcg daily and given regular follow-up in endocrine clinic. Benign ectopic thyroid gland is an unusual finding. As such, follow up is needed with possibility of carcinomatous transformation such as papillary carcinoma should be considered.

Hypothalamic-pituitary fungal infection causing panhypopituitarism.

Madam LPS, a 69 years old lady complained of left eye blurring of vision since January 2017. It was associated with left orbital swelling with chemosis, eye redness, epiphora, several episodes of self-limiting epistaxis and bilateral ophthalmoplegia. Other neurological examinations and cerebellar systems were intact. Magnetic Resonance Imaging (MRI) Brain and Orbit were performed, depicting a sellar mass with suprasellar extension with blood investigations results showed panhypopituitarism. She underwent bilateral orbital decompression. Trans-nasal endoscopic biopsy showed suppurative granulomatous lesion, which cultured Candida Albicans and Candida Galbrata. She was started on antifungal and hormonal replacement therapy for panhypopituitarism. Unfortunately, she did not respond well to treatment as repeated MRI Brain on December 2018 showed increase in size of sellar mass causing obstructive hydrocephalus and increasing size of left orbital lesion. She was counselled for another debulking surgery with a ventriculoperitoneal (VP) shunt. HPE taken were reported as chronic inflammatory process in favour to fungal infection. Pituitary infections may mimic pituitary mass. Some may exhibit symptoms of panhypopituitarism as well. Thus, physical examination, MRI brain imaging as well as HPE of biopsy are important aids to achieve diagnosis. Optimal treatment of fungal pituitary abscess includes transsphenoidal surgery combined with antifungal therapy.

Oxidative stress cytotoxicity induced by platinum-doped magnesia nanoparticles in cancer cells.

The aim of this study was to prepare, characterize, and determine the in vitro anticancer effects of platinum-doped magnesia (Pt/MgO) nanoparticles. The chemical compositions, functional groups, and size of nanoparticles were determined using X-ray diffraction, Fourier transform infrared spectroscopy, energy dispersive X-ray spectroscopy, transmission electron microscopy, and scanning electron microscopy. Pt/MgO nanoparticles were cuboid and in the nanosize range of 30-50 nm. The cytotoxicity of Pt/MgO nanoparticles was determined via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay on the human lung and colonic cancer cells (A549 and HT29 respectively) and normal human lung and colonic fibroblasts cells (MRC-5 and CCD-18Co repectively). The Pt/MgO nanoparticles were relatively innocuous to normal cells. Pt/MgO nanoparticles downregulated Bcl-2 and upregulated Bax and p53 tumor suppressor proteins in the cancer cells. Pt/MgO nanoparticles also induced production of reactive oxygen species, decreased cellular glutathione level, and increased lipid peroxidation. Thus, the anticancer effects of Pt/MgO nanoparticles were attributed to the induction of oxidative stress and apoptosis. The study showed the potential of Pt/MgO nanoparticles as an anti-cancer compound.

Oxford knee score 1 year after TKR for osteoarthritis with reference to a normative population: What can patients expect?

Objectives: Total knee replacement (TKR) procedure is commonly carried out in patients with advanced osteoarthritis to reduce pain and increase mobility, with on average 84% rated satisfactory outcome, but some (some suggest 44%) continue to experience debilitating pain. The study aimed to investigate factors affecting pain and function outcomes (using Oxford Knee Score, OKS) one year after TKR, with normative comparison to a reference population. Design: We recruited TKR patients from one hospital (Nottinghamshire, UK); collected pre- and post-operative OKS; graded radiographs for severity of osteoarthritis (K-L grade) in a sub-group. We also collected OKS by postal survey from the local area, calculated age and sex specific normative scores and z-scores of post-operative OKS (Z-OKS). The associations between K-L grade, pre-operative OKS, age, sex, against change in OKS and Z-OKS were analysed. Results: There were 536 TKR cases, 91 in radiographic sub-group and 360 people in reference cohort. Post-operative Z-OKS was associated with K-L grade (ߠ​= â€‹0.368; p<0.001). Change in OKS was associated with K-L grade (ߠ​= â€‹0.247; p â€‹= â€‹0.003); pre-operative OKS (ߠ​= â€‹-0.449; p<0.001); age (ߠ​= â€‹0.276; p â€‹= â€‹0.001); and female sex protective (ߠ​= â€‹-0.213; p â€‹= â€‹0.008). On average TKR patients returned to 74% of their normative age and sex adjusted OKS, with younger women achieving worst outcomes. More severe radiographic osteoarthritis predicted greater improvement and better post-operative outcome when compared to normative population. Conclusion: This study identified factors and provided normative OKS data intended to guide clinicians in counselling patients regarding likely surgical outcomes. This could help manage patients' expectations, aid decision making and increase post-surgery satisfaction rate.

Catalytic ketonization of palmitic acid over a series of transition metal oxides supported on zirconia oxide-based catalysts.

Modification of a ZrO2 based catalyst with selected transition metals dopants has shown promising improvement in the catalytic activity of palmitic acid ketonization. Small amounts of metal oxide deposition on the surface of the ZrO2 catalyst enhances the yield of palmitone (16-hentriacontanone) as the major product with pentadecane as the largest side product. This investigation explores the effects of addition of carefully chosen metal oxides (Fe2O3, NiO, MnO2, CeO2, CuO, CoO, Cr2O3, La2O3 and ZnO) as dopants on bulk ZrO2. The catalysts are prepared via a deposition-precipitation method followed by calcination at 550 °C and characterized by XRD, BET-surface area, TPD-CO2, TPD-NH3, FESEM, TEM and XPS. The screening of synthesized catalysts was carried out with 5% catalyst loading onto 15 g of pristine palmitic acid and the reaction carried out at 340 °C for 3 h. Preliminary studies show catalytic activity improvement with addition of dopants in the order of La2O3/ZrO2 < CoO/ZrO2 < MnO2/ZrO2 with the highest palmitic acid conversion of 92% and palmitone yield of 27.7% achieved using 5% MnO2/ZrO2 catalyst. Besides, NiO/ZrO2 exhibits high selectivity exclusively for pentadecane compared to other catalysts with maximum yield of 24.9% and conversion of 64.9% is observed. Therefore, the changes in physicochemical properties of the dopant added ZrO2 catalysts and their influence in palmitic acid ketonization reaction is discussed in detail.

Focal Segmental Membranoproliferative Glomerulonephritis: A Histological Variant of Denys-Drash Syndrome.

Introduction: Denys-Drash Syndrome (DDS) consists of a triad of pseudohermaphroditism, Wilms'tumor and nephropathy. This condition may manifest as a complete triad or in an incomplete form; with either one or a combination of the above features. The characteristic glomerular abnormality in DDS is diffuse mesangial sclerosis (DMS).Case report: We report two cases of DDS with focal membranoproliferative glomerulonephritis (MPGN). Both of our cases were males with ambiguous genitalia. They had a similar heterozygous germline mutation in exon 9 of WT1, c.1180C>T, p.R394W; a known mutation hotspot for DDS. Case 1 had nephropathy at the age of 4 years and Case 2 at 2.5 years with different rates of progression to end-stage renal failure. Conclusion: Our findings, in combination with other reports, illustrate the clinicopathological heterogeneity of DDS. There are no universal recommendations for optimal management of patients with DDS due to the inability to accurately predict affected individuals' progress.

Production of green diesel from catalytic deoxygenation of chicken fat oil over a series binary metal oxide-supported MWCNTs.

Deoxygenation processes that exploit milder reaction conditions under H2-free atmospheres appear environmentally and economically effective for the production of green diesel. Herein, green diesel was produced by catalytic deoxygenation of chicken fat oil (CFO) over oxides of binary metal pairs (Ni-Mg, Ni-Mn, Ni-Cu, Ni-Ce) supported on multi-walled carbon nanotubes (MWCNTs). The presence of Mg and Mn with Ni afforded greater deoxygenation activity, with hydrocarbon yields of >75% and n-(C15 + C17) selectivity of >81%, indicating that decarboxylation/decarbonylation (deCOx) of CFO is favoured by the existence of high amount of lower strength strong acidic sites along with noticeable strongly basic sites. Based on a series of studies of different Mg and Mn dosages (5-20 wt%), the oxygen free-rich diesel-range hydrocarbons produced efficiently by Ni10-Mg15/MWCNT and Ni10-Mn5/MWCNT catalysts yielded >84% of hydrocarbons, with n-(C15 + C17) selectivity of >85%. The heating value of the green diesel obtained complied with the ultra-low sulphur diesel standard.

Efficient deoxygenation of waste cooking oil over Co3O4-La2O3-doped activated carbon for the production of diesel-like fuel.

Untreated waste cooking oil (WCO) with significant levels of water and fatty acids (FFAs) was deoxygenated over Co3O4-La2O3/ACnano catalysts under an inert flow of N2 in a micro-batch closed system for the production of green diesel. The primary reaction mechanism was found to be the decarbonylation/decarboxylation (deCOx) pathway in the Co3O4-La2O3/ACnano-catalyzed reaction. The effect of cobalt doping, catalyst loading, different deoxygenation (DO) systems, temperature and time were investigated. The results indicated that among the various cobalt doping levels (between 5 and 25 wt%), the maximum catalytic activity was exhibited with the Co : La ratio of 20 : 20 wt/wt% DO under N2 flow, which yielded 58% hydrocarbons with majority diesel-range (n-(C15 + C17)) selectivity (∼63%), using 3 wt% catalyst loading at a temperature of 350 °C within 180 min. Interestingly, 1 wt% of catalyst in the micro-batch closed system yielded 96% hydrocarbons with 93% n-(C15 + C17) selectivity within 60 min at 330 °C, 38.4 wt% FFA and 5% water content. An examination of the WCO under a series of FFA (0-20%) and water contents (0.5-20 wt%) indicated an enhanced yield of green diesel, and increased involvement of the deCOx mechanism. A high water content was found to increase the decomposition of triglycerides into FFAs and promote the DO reaction. The present work demonstrates that WCO with significant levels of water and FFAs generated by the food industry can provide an economical and naturally replenished raw material for the production of diesel.

Sulfonated SnO2 nanocatalysts via a self-propagating combustion method for esterification of palm fatty acid distillate.

Biodiesel derived from palm fatty acid distillate (PFAD) was produced via catalytic esterification using sulfonated tin oxide (HSO3 -/SnO2) as the superacid solid catalyst. In this work, the SnO2 catalyst was synthesised by the self-propagating combustion (SPC) method, and activated using chlorosulfonic acid. The SPC method was able to produce nano-sized particles with homogenous size and shape that were anchored with many HSO3 - ions, resulting in more exceptional acid properties that effectively esterified the PFAD feedstock into FAMEs (fatty acid methyl esters). Several studies based on metal oxide-based catalysts were also included for comparison. Under the optimised conditions of 9 : 1 (methanol-to-PFAD molar ratio), 4 wt% (catalyst loading), 100 °C (reaction temperature) and 3 h (reaction time), the FFA conversion and FAME yield were 98.9% and 93.8%, respectively. Besides, the sulfonated SnO2-spc catalyst can be reused in up to five consecutive cycles with an acceptable esterification performance and minimal sulfur leaching. It is worth mentioning that the SPC method is a greener and simpler technique to obtain the nanocatalysts. Overall, the production of FAME from low value, cheaper, abundant, and non-edible PFAD feedstock, assisted by a non-transition metal oxide of sulfonated SnO2 catalyst, could reduce the cost of biodiesel production.

Development of bimetallic nickel-based catalysts supported on activated carbon for green fuel production.

In this work, the catalytic deoxygenation of waste cooking oil (WCO) over acid-base bifunctional catalysts (NiLa, NiCe, NiFe, NiMn, NiZn, and NiW) supported on activated carbon (AC) was investigated. A high hydrocarbon yield above 60% with lower oxygenated species was found in the liquid product, with the product being selective toward n-(C15 + C17)-diesel fractions. The predominance of n-(C15 + C17) hydrocarbons with the concurrent production of CO and CO2, indicated that the deoxygenation pathway proceeded via decarbonylation and decarboxylation mechanisms. High deoxygenation activity with better n-(C15 + C17) selectivity over NiLa/AC exposed the great synergistic interaction between La and Ni, and the compatibility of the acid-base sites increased the removal of oxygenated species. The effect of La on the deoxygenation reaction performance was investigated and it was found that a high percentage of La species would be beneficial for the removal of C-O bonded species. The optimum deoxygenation activity of 88% hydrocarbon yield with 75% n-(C15 + C17) selectivity was obtained over 20% of La, which strongly evinced that La leads to a greater enhancement of the deoxygenation activity. The NiLa/AC reusability study showed consistent deoxygenation reactions with 80% hydrocarbon yield and 60% n-(C15 + C17) hydrocarbon selectivity within 6 runs.