Introduction: Accurate diagnosis of thyrotoxicosis, a condition resulting from excessive thyroid hormone activity, is essential for appropriate management. However, access to diagnostic tools such as thyrotropin receptor antibody (TRAb) assays and thyroid ultrasonography remains limited in resource-constrained settings, highlighting the need for cost-effective alternatives. Recent studies suggest that the free triiodothyronine to free thyroxine (FT3/FT4) ratio may serve as a potential biomarker for differentiating the causes of thyrotoxicosis. Methodology: This cross-sectional study evaluated the FT3/FT4 ratio in newly diagnosed thyrotoxicosis patients aged ≥18 years recruited from Hospital Tengku Ampuan Rahimah, Hospital Banting, Klinik Kesihatan Pelabuhan Klang, and Klinik Kesihatan Pandamaran between February and December 2025. All participants underwent thyroid function testing (FT3, FT4, and TSH) and autoantibody assessment (TRAb and anti-thyroid peroxidase [anti-TPO]). Diagnostic performance of the FT3/FT4 ratio for Graves’ disease was assessed using receiver operating characteristic (ROC) curve analysis. Results: Fifty-eight patients were included, of whom 58.6% were diagnosed with Graves’ disease. Patients with Graves’ disease had significantly higher FT3 levels (median 16.8 pmol/L; IQR 10.9–25.7) compared to those with non-Graves’ thyrotoxicosis (median 8.3 pmol/L; IQR 5.3–13.5; p <0.001), with similar trends observed for FT4 levels (p <0.001). However, the FT3/ FT4 ratio did not differ significantly between groups (p >0.05), with an overall ROC AUC of 0.572, indicating poor discriminatory ability. Subgroup analysis based on FT4 levels improved performance; at FT4 <30 pmol/L, the FT3/FT4 ratio demonstrated 75.0% sensitivity, 91.7% specificity, and 87.5% diagnostic accuracy at a cutoff of 0.3445 (AUC = 0.813; 95% CI: 0.570–1.000; p = 0.069). No significant association was observed between the FT3/FT4 ratio and TRAb or anti-TPO. Conclusion The FT3/FT4 ratio has limited overall diagnostic utility but may provide adjunctive value in selected biochemical contexts, particularly in settings with limited access to immunological testing.
Diagnosis, Differential ; Thyroxine ; Triiodothyronine ; Thyrotoxicosis ; Cross-Sectional Studies

Introduction: The 2021 IDF-DAR risk calculator had been previously evaluated in multiple studies and subsequently widely accepted and applied in clinical practice as a practical standardized tool for patient risk stratification. Recently updated, the 2026 IDF-DAR Risk calculator enables a more individualized, evidence-related evaluation of patientrelated and disease-related risk factors, incorporating modern diabetes technologies, including continuous glucose monitoring (CGM), automated insulin delivery (AID) systems, and advanced insulin formulations to enhance risk stratification. This tool allows medical professionals to tailor Ramadan practices based on overall factors toward promoting safe fasting. Methodology: This prospective multicentre observational study recruited adults with Type 1 and Type 2 diabetes attending public hospitals nationwide. People with diabetes (PwD) intending to perform Ramadan fasting were invited to participate and assessed using the 2026 IDF-DAR Risk Calculator in the 6-week pre-Ramadan period between 30th January and 19th March 2026. Results: A total of 458 PwD were evaluated and stratified into low (15.7%), moderate (41%), and high risk (43.3%) categories. Most participants had Type 2 diabetes (83.6%), with 60.3% having a disease duration exceeding 10 years and 43% exhibiting poor glycemic control (hemoglobin A1c >9%). Insulin therapy was used by 76.4% of participants, including two individuals with Type 1 diabetes using AID systems. Most participants reported no recent hypoglycemia (76.4%), 81.0% performed glucose monitoring, and 3.3% used CGM. Severe comorbidities were uncommon, with 1.1% having unstable macrovascular disease and 4.4% advanced chronic kidney disease (estimated glomerular filtration rate <30). Notably, 72.2% received structured Ramadan education. Conclusion Majority of PwD attending tertiary diabetes clinics were in the moderate- to high-risk category and intended to fast despite medical advice against fasting in some cases. Although most participants were on insulin therapy, hypoglycemia was low in the pre-Ramadan period. Integration of modern technologies, advanced insulin therapies, and structured education may support safer fasting practices.
Risk Assessment ; Diabetes Mellitus ; Hospitals ; Fasting

Introduction: Severe hypertriglyceridemia during pregnancy is a rare yet potentially life-threatening disorder. It is frequently linked to acute pancreatitis and poses considerable risks for both maternal and fetal morbidity. Case: We report a 35-year-old G4P3 female at 33 + 6 weeks gestation with underlying type 2 diabetes mellitus who presented with acute abdominal pain, nausea, vomiting, and poor oral intake, initially mistaken for preterm labor and sepsis. Further evaluation revealed profound hypertriglyceridemia (triglycerides 79.1 mmol/L) with markedly elevated total cholesterol (>32 mmol/L) and raised serum amylase, consistent with hypertriglyceridemia-induced acute pancreatitis. She was managed in a multidisciplinary setting with intravenous insulin infusion, dextrose supplementation, aggressive fluid resuscitation, and empiric antibiotics. Due to clinical deterioration and ongoing risk of maternal complications, she underwent emergency lower segment caesarean section and exploratory laparotomy at 34 weeks of gestation. Intraoperative findings included inflammatory intra-abdominal fluid and a bulky pancreas, supporting the diagnosis. Rapid biochemical improvement was observed following treatment, with triglyceride levels decreasing by approximately 70% within 24 hours (79.1– 24.0 mmol/L) and achieving >90% reduction over 10 days. Postpartum management included initiation of omega-3 fatty acids, fibrate, and statin therapy, resulting in sustained lipid control. Ophthalmologic examination demonstrated lipemia retinalis, further confirming severe dyslipidemia. Conclusion This case highlights the importance of early recognition of severe hypertriglyceridemia in pregnancy, particularly in patients with metabolic risk factors such as diabetes. Prompt initiation of insulin therapy can achieve rapid triglyceride reduction and may obviate the need for plasmapheresis in selected cases. Delivery should be considered in the setting of maternal instability. Long-term lipid management postpartum is essential for preventing recurrence and reducing future metabolic risk. A multidisciplinary approach remains critical in optimizing both maternal and fetal outcomes in this rare but serious condition.
Female ; Pregnancy ; Acute Disease ; Pancreatitis

This report describes an approach to recover SARS-CoV-2 RNA from rapid antigen test kit (RTK-antigen) cassettes for whole-genome sequencing (WGS). RNA samples were recovered from 33 RTK-antigen cassettes for WGS, with 18 samples achieving more than 80% genome coverage. This work provides a proof-of-concept that positive RTK-antigen cassettes can be safely transported, stored and subjected to WGS, enabling swift identification of circulating variants.

Hypoglycemic disorders are rare in persons without diabetes, and clinical evaluation to identify its etiology can be challenging. We present a case of insulin autoimmune syndrome induced by carbimazole in a middle-aged Chinese man with underlying Graves’ disease, which was managed conservatively with a combination of dietary modification and alpha-glucosidase inhibitor.
Hypoglycemia ; Hyperinsulinism ; Insulin Antibodies

KNOWLEDGE, ACCEPTANCE AND CONCERNS REGARDING COVID-19 VACCINATION AMONG PREGNANT WOMEN ON THE EAST COAST OF PENINSULAR MALAYSIA: ACROSS-SECTIONAL STUDY Introduction: This prospective cross-sectional study, conducted from 1 April 2022 to 31 October 2022, aimed to assess the knowledge, acceptance and concerns regarding COVID-19 vaccination among pregnant women visiting the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia. Methods: The study included all pregnant women aged ≥18 years. Sociodemographic data, information related to COVID-19 and vaccination and information on the knowledge, acceptance and concerns regarding COVID-19 vaccination were collected using a validated questionnaire. Results: Out of 420 eligible pregnant women, 412 participated in the study, yielding a response rate of 98.1%. Of the respondents, 97.1% had received a COVID-19 vaccine, while 2.9% had not. Approximately 85.2% demonstrated a good understanding of COVID-19 vaccination. Among those vaccinated, 76.8% based their decision on recommendations from healthcare providers or the Ministry of Health. Among those unvaccinated, 91.7% believed that COVID-19 vaccines could harm their pregnancy and baby. Although 51% of the respondents expressed concerns about vaccine safety, 202 still chose to be vaccinated, indicating a willingness to prioritise their health despite apprehensions. Conclusion: The study found no significant link between acceptance and good knowledge of COVID-19 vaccination. However, income and prior COVID-19 booster vaccination were strongly associated with acceptance. Despite safety concerns, 97.1% of the respondents had received a COVID-19 vaccine. This emphasises the importance of providing comprehensive information and addressing concerns to support informed decision-making among pregnant women. Healthcare providers play a vital role in guiding them through this crucial decision-making process.

CRITICAL APPRAISAL OF CLINICAL PRACTICE GUIDELINES FOR OTITIS MEDIA IN ASIAN AND WESTERN COUNTRIES WITH CONSIDERATION OF UPDATES: A NARRATIVE REVIEW Introduction: Acute otitis media is a common disease in children under the age of 5 years due to their primitive ear anatomy. One of its consequences is otitis media with effusion (OME), which is a condition wherein serous secretion accumulates in the middle ear due to Eustachian tube dysfunction. OME results in conductive hearing loss, impacting children’s learning and development. This review aimed to identify discrepancies in clinical practice guidelines (CPGs) for managing OME in children across Asian and Western countries, focusing on updates to these guidelines. Methods: A comparative review involving critical appraisal using the Appraisal of Guidelines for Research and Evaluation II tool was conducted. CPGs for managing ear effusion in children in Western and Asian countries published in the PubMed, Cochrane Library, Scopus and Science Direct databases were reviewed. Four CPGs from Western countries (Scotland, England, the United States of America and France) and three CPGs from Asian countries (Japan, Korea and Malaysia) were selected. Results: There was a mild discrepancy regarding conducting surgery after 3 months, particularly myringotomy and adenoidectomy with or without grommets, between the Scottish CPG and other CPGs. Conclusion: Asian CPGs for the management of OME share many similarities with Western CPGs. However, Asian CPGs tend to be stronger in most domains and levels of evidence. Japanese and American CPGs are up to date as of 2022 and 2016, respectively, while other CPGs are outdated for about 10 years.

Introduction: The purpose of this study is to determine the validity, reliability, and responsiveness of the Malay Shoulder Pain and Disability Index (M-SPADI) in Malay speakers suffering from shoulder pain. Materials and methods: The M-SPADI, the Numerical Rating Scale (NRS), and measurements of shoulder active range of motion (AROM) were completed by 140 patients with shoulder pain (68 with rotator cuff pathology and 72 with other shoulder pathology). Thirty-four patients were retested for test-retest reliability with M-SPADI after an average of 9.2 days. M-SPADI was performed on twenty-one individuals three months after completing treatment for rotator cuff disorders to assess response. Results: The results of exploratory factor analysis revealed a bidimensional structure for M-SPADI. M-SPADI disability score was significantly greater in patients with rotator cuff pathologies (median = 31.87, IQR 82.50) than in patients with other shoulder pathologies (median = 20.00, IQR 23.84). In multi-group factor analysis, measurement invariance revealed no significant difference between the two groups (p>0.05). There was a significant positive correlation between M-SPADI and NRS (Pain = 0.86, Disability = 0.75, Total = 0.82, p=0.005), and a significant negative correlation between M-SPADI and shoulder AROM (Pain = -0.34 to -0.67, Disability =-0.44 to -0.73, Total =- 0.43 to -0.72, p=0.005). M-SPADI had a high degree of internal consistency (Cronbach's 0.92 for pain and 0.95 for disability). Test-retest reliability was moderate to excellent (ICC Pain = 0.84, ICC Disability = 0.78, ICC Total = 0.81, p=0.001), and the smallest detectable change ranges (Pain = 8.74, Disability = 3.21, Total = 3.83) were less than the minimal detectable change ranges (Pain = 21.57, Disability = 6.82, Total = 8.79). The area under the receiver operating characteristic curve (AUC) for M-SPADI was greater than 0.90 (Pain = 0.99, Disability = 0.94, Total = 0.96). Conclusion: The M-SPADI has established construct validity, internal consistency, test-retest reliability, and responsiveness. The M-SPADI is a reliable and valid instrument for evaluating shoulder pain among Malayspeaking individuals. In addition, the M-SPADI disability subscale may be useful for monitoring functional score changes in patients with rotator cuff pathology.

Introduction: Psoriasis vulgaris has a significant association with obstructive sleep apnoea (OSA). The study intended to explore the relation between the severity of psoriasis vulgaris and OSA risk, and to identify the factors that are attributed to increased risk of OSA. Methods: A cross sectional, observational study was carried out from October 2020 until April 2021 at the dermatology clinic of Hospital Tengku Ampuan Rahimah, Malaysia. All study participants were evaluated for OSA risk using the STOP-Bang and Epworth Sleepiness Scale questionnaires. Results: Our study recruited 237 participants and the results revealed a higher percentage of moderate to severe psoriasis participants with intermediate to high risk of OSA than participants with mild psoriasis (35.3% versus 17.7%, respectively). There was also a 2.3 times higher incidence of daytime sleepiness among participants with moderate to severe psoriasis as opposed to participants with mild psoriasis (44.1% versus 19.2%, respectively). We have also detected a significantly higher probability for OSA in psoriasis patients with diabetes mellitus versus those without (odds ratio: 2.09). We also noticed that for every unit rise in body mass index (BMI), there seemed to be a 1.06 times higher risk of OSA. Furthermore, patients with moderate to severe psoriasis were found to possess 3.32 times increased odds to have OSA. Conclusion: Our results suggest that psoriasis severity and the existence of comorbidities i.e. diabetes mellitus and high BMI are linked with an enhanced risk of OSA in adults with psoriasis.

Introduction: Studies show that adolescents are more reward sensitive compared to other age groups. The nucleus accumbens (NAcc) has been identified as a key brain area involved in reward through its connectivity to other reward-related brain areas. Our study aimed to characterise the white matter structural connectivity of nucleus accumbens with brain areas that are most often associated with reward in female adolescents. Methods: Fifteen healthy female Malay adolescents were recruited and underwent diffusion-weighted brain scanning. Two behaviour scales were also given to verify typical reward responsiveness. Then, probabilistic tractography and NAcc segmentation were performed on the data using FMRIB Software Library (FSL). Probabilistic tractography was performed to determine the relative connection probability of nucleus accumbens (NAcc) to areas shown to be associated with reward, namely amygdala, anterior cingulate cortex (ACC), medial orbitofrontal cortex (mOFC), hippocampus, ventrolateral prefrontal cortex (vlPFC) and dorsolateral prefrontal cortex (dlPFC). Connectivity-based segmentation of NAcc was performed to determine the spatial distribution of its connectivity with the target brain areas according to the highest connection probability. Results: The highest relative connection probability was found between NAcc to mOFC, while the NAcc parcellation showed the widest distribution of connection to mOFC compared to the other five targets on both sides of the brain. Conclusion: Our findings demonstrated the strongest structural connectivity and widest distribution between NAcc and mOFC compared with other brain areas related to reward. This study’s findings could be used as baseline to compare with people with atypical reward circuit problems.