Diabetes mellitus is associated with inadequate bone health and quality and heightened susceptibility to fractures, even in patients with normal or elevated bone mineral density. Elevated advanced glycation end-products (AGEs) and a suppressed incretin pathway are among the mechanisms through which diabetes affects the bone. Accordingly, the present review aimed to investigate the effects of antidiabetic medications on bone quality, primarily through AGEs and the incretin pathway. Google Scholar, Cochrane Library, and PubMed were used to examine related studies until February 2024. Antidiabetic medications influence AGEs and the incretin pathway directly or indirectly. Certain antidiabetic drugs including metformin, glucagon-like peptide-1 receptor agonists (GLP-1RA), dipeptidyl-peptidase-4 (DDP-4) inhibitors, α-glucosidase inhibitors (AGIs), sodium-glucose co-transporter-2 inhibitors, and thiazolidinediones (TZDs), directly affect AGEs through multiple mechanisms. These mechanisms include decreasing the formation of AGEs and the expression of AGEs receptor (RAGE) in tissue and increasing serum soluble RAGE levels, resulting in the reduced action of AGEs. Similarly, metformin, GLP-1RA, DDP-4 inhibitors, AGIs, and TZDs may enhance incretin hormones directly by increasing their production or suppressing their metabolism. Additionally, these medications could influence AGEs and the incretin pathway indirectly by enhancing glycemic control. In contrast, sulfonylureas have not demonstrated any obvious effects on AGEs or the incretin pathway. Considering their favorable effects on AGEs and the incretin pathway, a suitable selection of antidiabetic drugs may facilitate more protective effects on the bone in diabetic patients.

Background: and Purpose Repetitive transcranial magnetic stimulation (rTMS) of the cerebellar hemisphere represents a new option in treating essential tremor (ET) patients. We aimed to determine the efficacy of cerebellar rTMS in treating ET using different protocols regarding the number of sessions, exposure duration, and follow-up duration. Methods: A randomized sham-controlled trial was conducted, in which 45 recruit patients were randomly allocated to 2 groups. The first (active group) comprised 23 patients who were exposed to 12 sessions of active rTMS with 900 pulses of 1-Hz rTMS at 90% of the resting motor threshold daily on each side of the cerebellar hemispheres over 4 weeks. The second group (sham group) comprised 22 patients who were exposed to 12 sessions of sham rTMS. Both groups were reassessed at baseline and after 1 day, 1 month, 2 months, and 3 months using the Fahn-Tolosa-Marin tremor-rating scale (FTM). Results: Demographic characteristics did no differ between the two groups. There were significant reductions both in FTM subscores A and B and in the FTM total score in the active-rTMS group during the period of assessment and after 3 months (p=0.031 and 0.011, respectively).However, subscore C did not change significantly from baseline when assessed at 2 and 3 months (p=0.073 and 0.236, respectively). Furthermore, the global assessment score was significantly higher in the active-rTMS group (p>0.001). Conclusions Low-frequency rTMS over the cerebellar cortex for 1 month showed relative safety and long-lasting efficacy in patients with ET. Further large-sample clinical trials are needed that include different sites of stimulation and longer follow-ups.

Malignant melanoma is a neoplasm of melanin-producing cells predominantly of cutaneous origin, which uncommonly develops within gut mucosa. We present the case of a 58-year-old woman with complaints of abdominal pain, loss of appetite and weight.Esophagogastroduodenoscopy revealed a gastric mass and systemic imaging demonstrated widespread nodal and bilateral adrenal gland involvement. Histopathology of the gastric mass confirmed primary malignant mucosal melanoma of the stomach. The patient received three cycles of Nivolumab but did not respond, and thus, was then offered best supportive care. Although infrequent, mucosal melanoma can arise from the gastrointestinal tract, and in contrast to the cutaneous form, advanced disease usually has a dismal prognosis and responds poorly to immune checkpoint inhibitors. Primary gastric melanoma is an aggressive disease that is diagnosed by exclusion after the differential diagnosis of metastasis from a cutaneous or unknown primary site has been conducted. If available, patients with treatment-naïve mucosal melanoma should be considered for enrollment in clinical trials.

Background: Diastasis rectus abdominis (DRA) involves the separation of the midline abdominal muscles and linea alba and affects more than half of postpartum women. This study aimed to assess the effect of a split tummy exercise program (STEP) on DRA closure in postpartum mothers. Methods: A randomized controlled trial was conducted from 2008 to 2020 at the Obstetrics and Gynaecology Clinic of the Universiti Kebangsaan Malaysia Medical Centre. Primigravida mothers diagnosed with DRA were selected and randomly assigned to the intervention (n=21) or control (n=20) group. The intervention group underwent a home-based STEP consisting of three phases of nine abdominal exercises. DRA size was assessed at baseline and at 8 weeks postpartum using two-dimensional ultrasound. Results: The mean age of the participants was 28 years (standard deviation, 3.6), with the majority of Malay ethnicity (87.8%) and working mothers (78%). After 8 weeks, the intervention group showed a significant reduction in DRA size of up to 27% (mean difference, 6.17 mm; 95% confidence interval, 3.7–8.7; P<0.001). No significant intergroup DRA changes were observed after 8 weeks of follow-up. Conclusion Early postpartum screening for DRA should be advocated to allow early STEP intervention to ensure favorable outcomes. STEP intervention is an effective postnatal training program for managing DRA.

Rare but serious thrombotic incidents in relation to thrombocytopenia, termed vaccine-induced immune thrombotic thrombocytopenia (VITT), have been observed since the vaccine rollout, particularly among replication-defective adenoviral vector-based severe acute respiratory syndrome coronavirus 2 vaccine recipients. Herein, we comprehensively reviewed and summarized reported studies of VITT following the coronavirus disease 2019 (COVID-19) vaccination to determine its prevalence, clinical characteristics, as well as its management. A literature search up to October 1, 2021 using PubMed and SCOPUS identified a combined total of 720 articles. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline, after screening the titles and abstracts based on the eligibility criteria, the remaining 47 full-text articles were assessed for eligibility and 29 studies were included. Findings revealed that VITT cases are strongly related to viral vector-based vaccines, which are the AstraZeneca COVID-19 vaccine (95%) and the Janssen COVID-19 vaccine (4%), with much rarer reports involving messenger RNA-based vaccines such as the Moderna COVID-19 vaccine (0.2%) and the Pfizer COVID-19 vaccine (0.2%). The most severe manifestation of VITT is cerebral venous sinus thrombosis with 317 cases (70.4%) and the earliest primary symptom in the majority of cases is headache. Intravenous immunoglobulin and non-heparin anticoagulant are the main therapeutic options for managing immune responses and thrombosis, respectively. As there is emerging knowledge on and refinement of the published guidelines regarding VITT, this review may assist the medical communities in early VITT recognition, understanding the clinical presentations, diagnostic criteria as well as its management, offering a window of opportunity to VITT patients. Further larger sample size trials could further elucidate the link and safety profile.

Background: Pre-exposure prophylaxis (PrEP) is an evidence-based strategy recommended for at-risk populations for prevention of HIV transmission. However, the level of PrEP awareness and acceptance among Malaysian undergraduate students is currently unknown. Objectives: To assess the sexual activities, sexual behaviors, risk perception, awareness, and acceptance of PrEP of medical compared to non-medical students in a private medical university. Method: Demographic data, sexuality, sexual activity and behaviors, source of HIV knowledge, self- perceived risk of HIV, awareness and acceptance of PrEP were collected using an online anonymous survey among medical and non-medical students at a private medical university. Descriptive, comparative and regression analyses were performed where applicable. A p-value < 0.05 was considered statistically significant. Results: A total of 369 (187 medical, 182 non-medical) students responded. The median age was 22 with female:male ratio of 2:1. Eighty-one (22%) were sexually active of which 54% used condoms inconsistently, 58% had condomless sex in the preceding six months and 35% had casual or transactional sex. Despite this, 33 perceived themselves to be at low risk of HIV. Most learned about HIV from their coursework. PrEP awareness was 40% versus 20% while PrEP acceptance was 69% versus 67%, between medical and non-medical students, respectively. Conclusion Awareness of PrEP among medical students was low and even lower among non-medical students. PrEP acceptance was fair after viewing an introductory video on PrEP. PrEP must be included in the course curriculum. Studies to identify reasons for PrEP-hesitancy should be conducted to help guide policies and initiatives toward promoting PrEP as an additional tool in HIV prevention.
Malaysia ; HIV ; Awareness

Myocardial infarction (MI) in the young adults are more common among the Asians compared to the Caucasians. It is of great interest to investigate the genetic risks that increase the susceptibility of MI in young patients with no family history. We conducted a genetic analysis on a young adult diagnosed with acute MI. The coronary angiogram showed acute complete occlusion of the left anterior descending artery with 40% left ventricular ejection fraction (LVEF). Patient’s DNA was subjected to genotyping using Infinium Asian Screening Array. The genotypes were annotated and associated with risks of cardiovascular diseases catalogued in GWAS database. Ninety-four genetic variants were detected. Patient has more than half of the genetic variants being homozygous risk genotypes for coronary artery and coronary heart diseases. Identifying the potential genetic modifiers associated with MI in young patients is of great interest to help the clinician make informed decisions to implement preventive and personalised medicine for this patient.