Introduction: Staphylococcus aureus is the leading biofilmforming microorganisms in orthopaedic implant infections. The biofilms formed are difficult to eradicate and resistance to antibiotics. This current study aims to determine the effectiveness of povidone-iodine; an antiseptic solution in eradicating S. aureus biofilm on stainless steel alloy. In addition to the usual Colony-Forming Unit (CFU) used for verification, Scanning Electron Microscope (SEM) is used to validate the formation and eradication of the biofilms. Materials and methods: This is an in vitro study where the biofilm is formed by inoculating clinically isolated S. aureus, incubated for 24 hours onto stainless steel alloy 316L implants. The implants are then irrigated using povidoneiodine solution with varying concentrations (5 and 10%) and durations (30, 60, and 180 seconds). The anti-biofilm effect was evaluated using plating and SEM methods to confirm its effectiveness. The process is repeated after 24 hours of postirrigation reincubation to detect any rebound growth. Results: No biofilm seen after irrigation with povidoneiodine at 5% and 10% concentrations at 30, 60 and 180 seconds, respectively, in both CFU count and SEM. This result is replicated after 24 hours of reincubation, in assessing for rebound growth. Conclusion: Our study supports that a minimum of 5% povidone-iodine with a minimum irrigation time of 30 seconds are effective at eliminating S. aureus biofilm on stainless steel alloy implants. Both CFU count and SEM yield similar value in validating the presence of biofilm. Additionally, SEM allows visualisation of the morphology of the biofilm.

INTRODUCTION: Glaucoma is a leading cause of permanent blindness, often going undetected in its early, asymptomatic stages, especially in older age groups. In Malaysia, glaucoma is a growing public health issue due to an increase in the ageing population. While screening is essential for early glaucoma detection, the most suitable strategy for Malaysia's healthcare system remains unclear. This study explored the perspectives of eye healthcare professionals on the most suitable glaucoma screening strategies for Malaysia. MATERIAL AND METHODS: This qualitative study used semi-structured interviews with 19 eye health professionals (ophthalmologists, optometrists, nurses, ophthalmic technicians, and assistant medical officers) practicing in the Klang Valley. The interviews were conducted face-to-face in their workplace or via a video conferencing platform. All interviews were recorded, transcribed, and analysed using thematic analysis. RESULTS: Six major themes were identified: types of glaucoma screening programmes, accessible screening locations, target screening population, instruments and use of digital technology, trained personnel, and referral criteria. Opportunistic case finding and population-based programmes were identified as the glaucoma screening programmes in which trained personnel conducted screening at accessible locations. Glaucoma screening for high-risk individuals was recommended, focusing on visual acuity testing, tonometry, anterior chamber angle assessment, funduscopy, perimetry, and retinal nerve fibre assessment. A lack of clear referral criteria due to low awareness and poor implementation of existing guidelines was observed. CONCLUSION: Further investigations are required to identify the best combination of components for glaucoma screening. This will enable policymakers to develop an effective glaucoma screening programme in Malaysia.

Introduction: Adrenal incidentalomas are increasingly detected with the widespread use of imaging, whereby the large or heterogeneous lesions often raise concern for adrenocortical carcinoma (ACC). However, certain rare benign and infectious conditions may closely mimic malignant features, posing a diagnostic challenge. Case: A 64-year-old female with diabetes mellitus, hypertension, and dyslipidemia was noted to have progressively rising alkaline phosphatase during routine follow-up. She had non-specific gastrointestinal symptoms. A computed tomography abdomen pelvis showed a large, lobulated mass at the left flank, likely of adrenal origin. An adrenal protocol computed tomography revealed a large, heterogeneously enhancing left suprarenal mass measuring 10.7 × 10.3 × 10.7 cm, with a plain-phase attenuation of +81 Hounsfield Unit and absolute (28%) and relative (18%) washout. The right adrenal gland was normal, with no evidence of distant metastasis. Hormonal evaluation showed normal 24-hour urinary metanephrines, excluding pheochromocytoma. The overnight dexamethasone suppression test demonstrated cortisol of 89 nmol/L, suggestive of mild autonomous cortisol secretion, without clinical features of overt hypercortisolism. DHEA was low (0.371 µmol/L), and adrenocorticotropic hormone was suppressed (1.26 pg/mL). Evaluation for primary aldosteronism was not done due to the absence of resistant hypertension or hypokalemia. The gonadotropin profile was consistent with postmenopausal status (follicle-stimulating hormone (89 IU/L) and luteinizing hormone (28.9 IU/L) with low estradiol. The patient underwent open left adrenalectomy. Histopathology revealed an adrenal cavernous hemangioma with extensive hemorrhage and infarction, alongside necrotizing granulomatous inflammation with numerous intracellular fungal organisms and narrow-based budding yeast forms, highly suggestive of histoplasmosis, with no evidence of malignancy. She was subsequently comanaged with infectious disease team and commenced on intravenous amphotericin B. Conclusion This is a rare coexistence of an adrenal hemangioma and histoplasmosis, presenting as a large adrenal mass mimicking ACC. The limitations of imaging in differentiating benign from malignant adrenal lesions are revealed and emphasize the role of histopathological confirmation. Increased awareness of such entities can support the diagnosis and management.
Neoplasms

Introduction: The identification of a significant adrenal mass in a patient without a biopsy-confirmed malignancy poses a diagnostic challenge: Is it a metastatic lesion or an underlying adrenal condition? Adrenal metastases are the second most common site of spread for lung adenocarcinoma; approximately 3–7% of adrenal masses represent benign adenomas. Diagnosis is even harder if there are signs of primary aldosteronism (PA). Case: We present a case of a 62-year-old Chinese female with a 10-year history of hypertension, managed on dual antihypertensive therapy, who presented for evaluation of suspected PA following the discovery of hypokalemia. Biochemical screening revealed an elevated aldosteronerenin ratio (ARR, 65). The overnight dexamethasone suppression test (20 nmol/L) and testosterone (0.79 nmol/L) were both within normal limits. Saline Suppression Test (SST) showed an indeterminate post-infusion aldosterone level (202.8 pmol/L). Cross-sectional imaging via computed tomography (CT) Adrenals identified a large, 6.4 × 5.4 × 6.2 cm heterogeneous left suprarenal mass with a low mean attenuation (8.6 Hounsfield Unit [HU]). Concurrently, an incidental left upper lobe pulmonary lesion was identified, and PET-CT was performed; the SUVmax of the lung was identical to that of the adrenal lesion. An ultrasoundguided biopsy of the pulmonary lesion confirmed estimated glomerular filtration rate-mutation-positive lung adenocarcinoma. The patient started on targeted therapy with dacomitinib. Follow-up CT imaging at 9 months demonstrated disease progression within the thorax, marked by the appearance of a new pulmonary nodule. Notably, however, the adrenal mass remained stable in size and morphology. Conclusion The absence of mixed androgen/glucocorticoid hypersecretion, combined with the radiographically static nature of the mass, suggests a lower probability of adrenocortical carcinoma. This case highlights that while size is a major risk factor for adrenocortical carcinoma, it must be interpreted in conjunction with hormonal activity, HU, and growth patterns. Identifying these “mimics” helps avoid over-staging lung cancer and ensures patients receive targeted therapy instead of unnecessary adrenalectomies.

Introduction: Adrenal tuberculosis (TB) is a rare but important cause of adrenal insufficiency in TB-endemic regions, usually secondary to pulmonary or extrapulmonary disease, with primary involvement being uncommon. It typically affects both glands via hematogenous or lymphatic spread and presents late with nonspecific features after significant adrenal destruction, making diagnosis challenging. Diagnosis is more straightforward in the presence of extraadrenal TB, where imaging may obviate the need for biopsy, but remains difficult in isolated adrenal involvement. Case: We report a 69-year-old Malay male with diabetes mellitus, hypertension, and hyperlipidemia who presented with a 2-week history of chronic cough and 4 months of constitutional symptoms, including weight loss and anorexia. Initial TB workup in September 2025 was negative. He was subsequently admitted twice in October 2025 for pneumonia, with persistent upper lobe consolidation on chest radiography despite antibiotics. Contrast-enhanced computed tomography thorax, abdomen, and pelvis revealed bilateral mildly enhancing hypodense adrenal lesions (right 3.7 × 3.0 cm, left 2.5 × 2.6 cm), suggestive of adenoma, hyperplasia, or lymphoma. Bronchoscopy detected Mycobacterium tuberculosis via GeneXpert BAL, with no malignant cells on cytology. Adrenal biopsy was non-diagnostic. Biochemical evaluation showed low morning cortisol with elevated adrenocorticotropic hormone and findings consistent with adrenal insufficiency. The patient was treated as smear-negative pulmonary TB with adrenal involvement and initiated on anti-TB therapy, currently in the maintenance phase. Hydrocortisone replacement 10 mg twice daily was also initiated. Conclusion This case highlights the diagnostic challenge of adrenal TB, particularly when tissue sampling is inconclusive. In TB-endemic settings, a presumptive diagnosis based on clinical, radiological, and microbiological evidence is often necessary. Early empiric anti-TB therapy is essential to prevent adrenal crisis and preserve endocrine function.
Tuberculosis

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: Gestational diabetes mellitus (GDM) is a common pregnancy complication associated with adverse maternal and neonatal outcomes, including hypertensive disorders, caesarean delivery, macrosomia, and increased lifetime risk of type 2 diabetes. Despite its clinical importance, considerable international variation exists in GDM screening and diagnostic criteria. Multiple frameworks are currently used, including those from the World Health Organization (WHO), International Association of Diabetes and Pregnancy Study Groups, Carpenter and Coustan, and the National Diabetes Data Group. Differences in glucose thresholds, testing protocols (one-step versus two-step), and universal versus risk-based screening contribute to heterogeneity in reported prevalence and healthcare burden. In multi-ethnic, middle-income settings such as Malaysia, identifying an evidence-informed and contextappropriate diagnostic approach is critical. Methodology: This scoping review follows the Joanna Briggs Institute methodology and will be reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). PubMed, Scopus, and ScienceDirect will be searched for English-language studies, reviews, guidelines, and consensus statements reporting GDM diagnostic criteria. Two reviewers will independently screen and select studies. Results: Data will be charted on country, study type, diagnostic criteria, gestational age at screening, and reported challenges. Findings will be synthesized descriptively and presented in tables and figures. No formal risk-of-bias assessment will be conducted. Conclusion This review will provide a comprehensive overview of global diagnostic practices, highlight variations and gaps, and support evidence-based selection of a suitable GDM screening and diagnostic strategy for Malaysia.
Diabetes, Gestational ; Malaysia ; Policy ; Review Literature as Topic

Introduction: Polycystic ovarian syndrome (PCOS) is a complex endocrine disorder that significantly affects adolescent girls, particularly those with overweight or obesity. However, data examining the determinants and metabolic profiles of PCOS among adolescents with overweight and obesity remain limited, especially in Malaysia. This protocol describes a case-control study investigating the cardiometabolic, dietary, and psychosocial determinants of PCOS among adolescents with overweight and obesity. Methodology: This study is designed as a case-control study involving adolescent girls aged 13–16 years with a body mass index z-score >+1 standard deviation. Cases are defined as adolescent girls with a confirmed diagnosis of PCOS based on the recommendations of the 2017 International Consortium of Paediatric Endocrinology (ICPE), while controls are those who do not meet the diagnostic criteria for PCOS. A total sample size of 440 participants is required. Participants will be recruited from 22 secondary schools selected from a list of schools in Kuala Lumpur. Data on sociodemographic characteristics, psychosocial health, physical activity, and dietary intake will be collected using structured questionnaires. Blood samples will be obtained and analyzed for diagnostic testing (free testosterone), exclusion tests (thyroid-stimulating hormone, folliclestimulating hormone, luteinizing hormone, estradiol, prolactin, and dehydroepiandrosterone sulfate), and biochemical parameters (liver function tests, lipid profile, hemoglobin A1c, fasting glucose, fasting insulin, and inflammatory markers). Results: The study is expected to generate comprehensive data on the cardiometabolic, dietary, and psychosocial determinants of PCOS among adolescents with overweight and obesity. The findings will inform early screening strategies and targeted interventions aimed at reducing long-term reproductive and cardiometabolic complications. Conclusion This protocol outlines a structured approach to investigating PCOS in adolescence and addresses current gaps in early identification and risk stratification among highrisk populations.
Adolescent ; Humans ; Case-Control Studies ; Overweight ; Polycystic Ovary Syndrome ; Obesity

Introduction: Paragangliomas are rare neuroendocrine tumors arising from extra-adrenal chromaffin cells, with an estimated incidence of 2–8 cases per million per year. These tumors originate from neural crest–derived cells of the sympathetic and parasympathetic paraganglia and may secrete catecholamines, resulting in malignant hypertension or symptoms such as headache, palpitations, and diaphoresis. They can occur anywhere along the paravertebral and para-aortic regions from the skull base to the pelvic floor. Case: We report a case of a 14-year-old male with no known premorbid conditions who presented with presyncope and a 1-month history of headache. On examination, he had severe hypertension (242/167 mmHg), tachycardia (127 bpm), and grade IV hypertensive retinopathy. Investigations showed preserved renal function with markedly elevated 24-hour urinary metanephrines (normetanephrine 90.75 µmol/L). Computed tomography revealed a lobulated, heterogeneously enhancing mass measuring 5.0 × 6.1 × 5.4 cm along the left margin of the abdominal aorta at the infrarenal level, suggestive of an extra-adrenal lesion. Gallium-68 PET scan demonstrated a somatostatin receptor–avid left peritoneal mass. The patient underwent exploratory laparotomy and tumor excision, complicated intraoperatively by blood pressure lability requiring nitroprusside and inotropic support. Postoperatively, he improved significantly and was able to wean off all antihypertensive medications. Histopathology confirmed left retroperitoneal paraganglioma. Conclusion Primary peritoneal paraganglioma is a rare but important cause of secondary hypertension, especially in young patients presenting with hypertensive emergency. High index of suspicion is essential for early diagnosis. Management requires a multidisciplinary approach with careful preoperative optimization to minimize perioperative complications. Surgical resection remains the definitive treatment and, as demonstrated in this case, can result in marked clinical improvement with resolution of hypertension.
Paraganglioma

Introduction: Brown tumors, also known as osteitis fibrosa cystica, are focal bone lesions resulting from increased osteoclastic activity and fibroblastic proliferation. They represent a rare complication of uncontrolled hyperparathyroidism (HPT) and may affect any part of the skeleton, including craniofacial bones. Case: We report a case of a 31-year-old Malay female diagnosed with primary HPT secondary to multiglandular disease, who initially presented with symptomatic hypercalcemia. Biochemical evaluation revealed elevated corrected calcium (2.84 mmol/L; reference range 2.2–2.6 mmol/L), low phosphate (0.63 mmol/L; reference range 0.8–1.6 mmol/L), and markedly elevated serum intact parathyroid hormone (iPTH) (286 pg/mL; reference range 14.9–56.9 pg/mL). Ultrasound parathyroid showed a large right extrathyroidal lesion, most likely suggestive of parathyroid adenoma, where sestamibi scan suggested multiglandular parathyroid adenomas with possible mediastinal involvement. She underwent exploratory parathyroidectomy on 19 June 2024, with excision of bilateral inferior parathyroid adenomas confirmed on histopathology. Despite surgery, she had persistent hypercalcemia (2.8–3.1 mmol/L) and rising iPTH levels (307 pg/mL on 24 June 2024, increasing to 413 pg/mL by 2 September 2024), consistent with persistent disease. Repeat imaging demonstrated hyperfunctioning parathyroid tissue in the anterior mediastinum. Subsequently, the patient developed progressive enlargement of the left upper gingiva associated with significant pain during mastication. Clinical and radiological evaluation revealed aggressive lesions with cortical expansion. Excisional biopsy of the gingival lesion confirmed the diagnosis of brown tumors involving the jaws. She later underwent a second parathyroidectomy with intraoperative parathyroid hormone monitoring at another centre. Postoperatively, normalization of serum calcium and iPTH levels was achieved, which led to marked clinical improvement and regression of the craniofacial brown tumor. Conclusion This case highlights that skeletal manifestations of HPT, including brown tumors, may regress following adequate biochemical control without additional local therapy. Early recognition and definitive surgical management of persistent or ectopic hyperfunctioning parathyroid tissue are essential to prevent progression and promote spontaneous bone healing processes.