Introduction: Primary aldosteronism (PA), most commonly caused by aldosterone-producing adenomas (APAs), represents the leading form of surgically curable secondary hypertension. While genomic studies have elucidated the mutational landscape of APAs, the spatial organisation and functional role of immune populations across APAs, aldosterone-producing micronodules (APMs), and adjacent adrenal cortex remain poorly defined at single-cell resolution. Methodology: Single-cell RNA sequencing (scRNA-seq) was integrated with spatial transcriptomics in APAs and paired adjacent adrenal cortex, complemented by immunohistochemical (IHC) validation. Immune populations were spatially mapped using canonical markers (CD14, CD68, CD163, HLA-DR, CD8A, and CD4) across defined adrenocortical regions. Results: The adrenal microenvironment in PA demonstrates structured immune organisation rather than passive infiltration. CD14+ monocyte-lineage cells localize intraparenchymally within APAs (n = 10), intercalating between CYP11B2+ aldosterone-producing cells and forming a pattern distinct from perivascular immune niches. scRNA-seq further identified a transcriptionally distinct CD14+ population within the zona reticularis (zR) that co-expresses steroidogenic markers (CYB5A, SULT2A1, TSPAN12) while lacking canonical monocyte transcripts. IHC supported this observation, demonstrating CD14 expression within adrenocortical zR parenchymal cells (n = 5). In parallel, CD4 and HLA-DRA exhibited diffuse cytoplasmic staining within zR parenchymal cells in the absence of classical macrophage marker coexpression (CD68), suggesting non-canonical or context-dependent expression within steroidogenic compartments. CD68+ and CD163+ macrophages were sparsely distributed across APA, APM and adjacent cortex, consistent with lowdensity tissue-resident populations, while CD8A+ cytotoxic lymphocytes were enriched in APAs and APMs with diffuse parenchymal cytoplasmic staining of CD8A additionally observed within the zR. Conclusion These findings reveal a previously unrecognized spatially organised immune-steroidogenic interface within the adrenal cortex. The presence of immune-associated transcriptional and protein signatures within zR cells suggests potential functional plasticity of steroidogenic cells, possibly extending to antigen presentation-related pathways, warranting further mechanistic investigation
Hyperaldosteronism ; Humans

Introduction: Early identification of patients at risk for severe multisystem inflammatory syndrome in children (MIS-C) is essential for favourable clinical outcomes. This study aims to identify the clinical characteristics, factors and outcomes associated with severe MIS-C. Materials and methods: In this retrospective cohort study involving 14 major hospitals in Malaysia, children <15 years who met the United States Centres for Disease Control and Prevention case definition for MIS-C were included. Severe MIS-C was defined as children who required inotropic support, ventilatory support (invasive or non-invasive ventilation), or left ventricular ejection fraction of <55%. The factors investigated for severe MIS-C were demographic characteristics, the presence of comorbidities, clinical characteristics, and laboratory measures. Multivariable logistic regression was used to compute the adjusted odds ratio (aORs) of factors associated with severe MIS-C. Results: Among the 155 patients, 91 (58.7%) presented with severe MIS-C. Severe MIS-C was more likely in patients aged ≥5 years old (aOR 2.13, 95% confidence interval [CI] 1.08-4.21), with dehydration (aOR 3.80, 95% CI 1.53-9.45), lethargy (aOR 2.02, 95% CI 0.97-4.18), tachycardia (aOR 8.33, 95% CI 3.27-21.22), albumin <30g/L (aOR 3.36, 95% CI 1.58-7.13), creatine kinase >200U/L (aOR 3.68, 95% CI 1.57-8.64), D-dimer >3.0µg/mL (aOR 2.11, 95% CI 1.08-4.13), ferritin >500ng/mL (aOR 3.77, 95% CI 1.88-7.55), prothrombin time >12.7 seconds (aOR 3.22, 95% CI 1.61-6.43), and urea >6mmol/L (aOR 5.09, 95% CI 2.04-12.71). Conclusion: Identification of these associated factors of severity in MIS-C could aid in early recognition and prompt escalation of care, leading to better outcomes.

Adenotonsillectomy for Paediatric Sleep Disordered Breathing – Post Surgery Placement and Outcome Adenotonsillectomy (AT) is the treatment of choice for children with sleep disordered breathing (SDB) caused by adenotonsillar hypertrophy. However, there is an increased risk of post operative complications among those with identified risk factors. Therefore, they are electively admitted to critical care wards after surgery. Unfortunately, due to limited resources and availability of beds in critical care wards, the cancellation rate for AT can be significant at some hospitals. It is becoming more difficult to satisfy the heightened demand for close monitoring post AT due to the increasing number of obese children and surge of SDB cases. Delaying surgery may indirectly worsen the child’s co-morbidities. Thus, it is vital to have a flowchart for post AT placement, which can be practical to many centres facing similar logistics concerns. This retrospective chart review done over 6 months included all paediatric patients who had AT for SDB at our centre. The objectives of this review were to identify factors contributing to elective admission to the paediatric intensive care unit (PICU)/paediatric high dependency unit (PHDU) following AT among patients with paediatric SDB, recognize association between obesity and PICU/PHDU admission as well as find the association between severity of allergic rhinitis with outcome post AT. We aim to have a flow chart for preoperative planning of post-surgery nursing placement among patients with SDB who are managed with AT at this centre. Obese patients without significant co-morbidities can be nursed in the general ward, the real admission rate to PHDU/PICU is lesser compared to that was planned pre-operatively and children with moderate- severe AR tend to have residual snoring post AT. A flow chart for preoperative planning of post-surgery nursing placement among patients with SDB can help to reduce unnecessary booking and admission to critical care wards, decreasing the waiting time for AT and backlog of cases at public hospitals.

Reverse transcription-polymerase chain reaction (RT-PCR) cycle threshold (Ct) value in detecting the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is inversely proportionate to the virus load in the patient’s specimen. These values could be beneficial in the epidemic trajectory at the population level. The SARS-CoV-2 B.1.617.2 (Delta) variant which emerged in late 2020, caused an unprecedented exponential increase in SARS-CoV-2 infection cases worldwide. In Malaysia, the surge in coronavirus disease 2019 (COVID-19) cases and the inclining positivity rate contributed to the epidemic waves in late May 2021. Sudden surge in cases was suggested to be associated with increased transmission caused by the emergence of the B.1.617.2 variant. In the present study, Ct value distribution of the positive COVID-19 samples from 2020 and 2021 was tabulated against SARS-CoV-2 genomic variants determined from genomic sequencing. A significant decreasing pattern of median Ct values from overall 2020 and 2021 samples was evident (p<0.01). However, notable variability was observed in the Ct values between 2020 and 2021, which samples showing lower median Ct values in 2021. The percentages of SARS-CoV-2 genomic variants B.1.36 and B.1.524 were 31.6% and 68.4%, respectively, for samples obtained in October and December 2020. Whereas samples obtained in June and July 2021 were 100% of the B.1.617.2 variant. The population neutralizing antibody against SARS-CoV-2 during the initial peak of B.1.617.2 was low, however, increased during the B.1.617.2 wave. A decreasing trend in the Ct value distribution from samples tested in our laboratory correlated well with the increasing weekly COVID-19 cases reported by the Malaysia national data, which was subsequently attributed to the emergence of B.1.617.2 variant. This study proposes that analyzing Ct value distribution in screened SARS-CoV-2 samples could reveal population-level transmission dynamics and emerging variants. Coupled with genomic sequencing, it supports early control strategies against new SARS-CoV-2 strains.

“Fake braces” is a term used to describe fixed orthodontic appliances that are fitted by unlicensed providers. This trend has raised public health concerns in certain countries with marketing typically undertaken on social media. We aimed to investigate the frequency and nature of Instagram posts by fake braces providers in Malaysia. Initial screening of Instagram accounts was performed using relevant hashtags (#fakebraces, #cheapbraces). Public Instagram accounts that fulfilled the inclusion criteria were assigned a code with posts evaluated over a one-month period. Data were coded and analysed using thematic analysis. Frequency distribution was calculated using Microsoft Excel. Thirty-eight Instagram accounts were analysed. 2831 images/videos were posted, receiving 7165 likes with videos being viewed 21, 918 times. The majority of posts were related to fake braces services (36.7%), followed by non-relevant posts (29.4%) and other services (14.5%). Services were provided mainly at home (44.7%) or offered both home and door-to-door services (23.7%). Although the posts on promotions were less frequent (5.4%), the displayed prices were low (RM150 to RM500), offering additional packages and discounts. Unlicensed providers have a variety of content to engage with social media audiences. Efforts should be made to increase public awareness, directing them towards reliable information about orthodontic services.
Orthodontics

Various methods have been developed for rapid and high throughput full genome sequencing of SARS-CoV-2. Here, we described a protocol for targeted multiplex full genome sequencing of SARS-CoV-2 genomic RNA directly extracted from human nasopharyngeal swabs using the Ion Personal Genome Machine (PGM). This protocol involves concomitant amplification of 237 gene fragments encompassing the SARS-CoV-2 genome to increase the abundance and yield of viral specific sequencing reads. Five complete and one near-complete genome sequences of SARS-CoV-2 were generated with a single Ion PGM sequencing run. The sequence coverage analysis revealed two amplicons (positions 13 751-13 965 and 23 941-24 106), which consistently gave low sequencing read coverage in all isolates except 4Apr20-64Hu. We analyzed the potential primer binding sites within these low covered regions and noted that the 4Apr20-64-Hu possess C at positions 13 730 and 23 929, whereas the other isolates possess T at these positions. The genome nucleotide variations observed suggest that the naturally occurring variations present in the actively circulating SARS-CoV-2 strains affected the performance of the target enrichment panel of the Ion AmpliSeq™ SARS CoV 2 Research Panel. The possible impact of other genome nucleotide variations warrants further investigation, and an improved version of the Ion AmpliSeq™ SARS CoV 2 Research Panel, hence, should be considered.

Diabetes mellitus has reached epidemic levels in Malaysia due to increase in its risk factors such as obesity, dietary and sedentary lifestyle. In patients with uncontrolled diabetes mellitus, diabetic foot ulcer (DFU)is a common complication. Managing diabetic foot infection is often multifactorial and intricate. The management DFU demands multi-speciality approach and often tedious. Hyperbaric oxygen therapy (HBOT) is a promising adjunctive treatment used to enhance the healing process plus reduces cost and recovery time. This is a case of a 52 years old lady, with underlying poorly diabetes mellitus, who presented with diabetic foot ulcer Wagner IV classification in sepsis. She underwent trans-metatarsal amputation followed by split skin grafting with additional adjunctive HBOT in a tertiary hospital.

Rail maintenance routines are necessary to enable the all rail operations to achieve its aim in maintaining a safe and efficient operation. The maintenance tasks expose the workers to vibration and noise, as they handle specialized machineries and heavy self-propelled vehicles. Exposure of noise above the permissible exposure limit and over the daily allowable duration may cause noise-induce hearing loss (NIHL). Investigation on the type of task that has high noise level exposure on the maintenance workers was conducted to justify the needs to further detailed of this study. This paper will describe the task analysis on maintenance workers and to identify possible tasks with exposure to high level of noise. It scopes down to grinding crew of the maintenance department of light rail transit. Methods used were real-time sound measurement using a sound level meter, observation and interviews. Then, data were analysed to understand the situation of exposure of noise during rail maintenance. An ergonomic risk assessment was also conducted by adoption of the latest guideline on Ergonomic Risk Assessment (ERA) at Workplace Guidelines recommended by Department of Occupational Safety and Health (DOSH), Malaysia. A hierarchical task analysis (HTA) was generated on the task of the maintenance worker, focusing on rail grinding crew. The newly generated HTA had allowed better understanding about the nature of work and the task conducted by a rail grinder during the work shifts. Tasks involving high noise level was identified. Data recorded shows that the noise level for the blowing activity was relatively high and exceeded the permissible exposure limit of 90dBA. The exposure level was currently controlled by practicing the usage of hearing protection equipment (HPE) and by controlling exposure time in accordance to recommendations of the Factory and Machinery Act (FMA). Thus, it had confirmed that maintenance workers were exposed to high noise levels when performing their daily task. Further studies are needed to investigate the relationship between the duration of exposure and noise-induce hearing loss (NIHL) with consideration of the lifestyles of the maintenance workers.

Leptospirosis is a zoonotic disease caused by bacteria of the genus Leptospira and most often acquired through contact with environments contaminated with leptospires shed in the urine of infected mammals. In urban environment, rodents are well-known as the main carriers of this bacteria, however there were no intensive study on the population structure of these animals, and how it associated with this disease. Hence, we use a case study from an outbreak in a residential area in Selangor, Malaysia, to investigate how community structure of small mammals, associated with the prevalence of Leptospira. One hundred cage traps were placed randomly in and around these houses in five phases with two months interval for a year. Community structures (species, sex, and age) were assigned for each individual, prior to screening for pathogenic Leptospira, using a partial lipL32 gene from the kidney samples. 185 small mammals from four species were captured, Rattus norvegicus (74.5%, N=138), R. rattus (20%, N=37), Tupaia glis (5%, N=9), and Suncus murinus (0.5%, N=1). From this number, 29 individuals were found PCR positive for pathogenic Leptospira (R. norvegicus, N=20; R. rattus, N=6; T. glis, N=2; S. murinus, N=1). The study shows that Leptospira occurrence in the small mammals were significantly correlated to age category and sampling phases, with Spearman Correlation (rs) p=0.02 and p=0.04 respectively. Adult individuals were significantly more prevalent with Leptospira infection, whereby March and June were found to associate with higher Leptospira prevalent among the small mammals, potentially coincide with low rainfall and relative humidity level. This information is important in designing a specific control method for rodents in Leptospira outbreak areas. In addition, intensive sampling and regular cleaning effort were found to significantly reduce the small mammal Leptospira reservoir, thus should be implemented in intervention strategies in the urban environment.

Dengue has been a public health concern for many years in Malaysia. Having knowledge on the current circulating dengue serotypes and population of vector mosquitoes is key in controlling outbreaks and future outbreak predictions. The current study reports the first study on detecting dengue virus serotypes in the Aedes mosquito population in Sibu and Miri divisions of Sarawak. Mosquito samples were collected at selected localities from September 2016 to December 2017. Localities were selected mainly focussing on urban residential areas. The mosquitoes collected comprises of the field-caught adults and immatures collected from artificial and natural water containers. Collected mosquitoes were identified to species level and screened for the presence of dengue virus using conventional reverse transcription polymerase chain reaction (RT-PCR). Dengue virus serotype 2 (DENV-2) was identified in 3 pools of field-caught female Aedes albopictus adults collected from Jalan Tong Sang, Sibu, Sibu Lake Garden, and Taman Ceria, Permyjaya, Miri, respectively. DENV-2 was also detected in one pool of adult male Ae. albopictus emerged from immatures collected from Taman Ceria, Permyjaya, Miri. The findings in this study revealed that Ae. albopictus was the main species colonizing the study areas, and the current circulating dengue virus serotype was DENV-2. This study also reports the first natural evidence of transovarial transmission of dengue in the natural population of Ae. albopictus within the study area and provides information as reference for further vector-pathogen studies.