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: Insulin deintensification is an emerging strategy to reduce hypoglycemia and treatment burden in patients on multiple daily injection (MDI ≥3), with potential to improve adherence and glycemic control. However, evidence in poorly controlled type 2 diabetes mellitus (T2DM) remains limited. This study evaluated its effectiveness and identified factors associated with achieving adequate glycemic control following deintensification among patients with poorly controlled T2DM attending Malaysian primary care. Methodology: A retrospective cohort study was conducted among 107 T2DM patients with hemoglobin A1c (HbA1c) >9%, attending Enhanced Diabetic Clinic at Cheras Health Clinic between 2021 and 2025. All patients on basal-bolus insulin (BBI) underwent deintensification. Multivariate logistic regression was performed to identify factors associated with achieving adequate glycemic control (HbA1c <7.5%). Changes in HbA1c following deintensification were assessed using paired t-tests. Results: Overall, 50.5% of patients achieved adequate glycemic control. Hypoglycemia events (AOR 9.5, 95% confidence interval [CI] 1.6–58.3; p = 0.015), MDI (AOR 9.6, 95% CI 1.4–67.1; p = 0.023) and Diabetes Medication Therapy Adherence Clinic (DMTAC) visits (AOR 1.1, 95% CI 1.0– 1.2; p = 0.039) were significantly associated with achieving HbA1c <7.5%. Conversely, patients transitioned from BBI to premixed regimens were less likely to achieve HbA1c <7.5% (AOR 0.22, 95% CI 0.05–0.93, p = 0.039). All insulin deintensification strategies were associated with significant HbA1c improvements with transitioned from BBI to premixed human insulin (mean difference -2.54%, 95% CI 1.77–3.31, p <0.001, Cohen’s d = 1.09), BBI to premixed analogue insulin (mean difference -3.38%, 95% CI 2.26– 4.49, p <0.001, Cohen’s d = 1.62), BBI to basal insulin (mean difference -3.67%, 95% CI 1.79–5.54, p = 0.004, Cohen’s d = 2.05). Conclusion Insulin deintensification is an effective strategy for improving glycemic control in poorly controlled T2DM. These findings highlight the importance of deintensification with careful consideration of hypoglycemia, MDI-related treatment burden, and patient engagement through regular DMTAC visits, which are integral to achieving optimal outcomes and support a personalized approach to diabetes management in primary care.
Diabetes Mellitus, Type 2 ; Glycemic Control ; Retrospective Studies ; Primary Health Care ; Insulins

Introduction: Cushing’s disease (CD) in adolescents may present with subtle clinical features, resulting in a significant diagnostic challenge. We report a case of a young lady whose CD initially masqueraded as Type 2 diabetes (T2D), highlighting the difficulties in differentiating early hypercortisolism from T2D. Case: A 12-year-old female was incidentally diagnosed with diabetes during routine medical screening. Examination revealed an overweight female without the classical features of Cushing’s syndrome. Due to the presence of acanthosis nigricans, a diagnosis of T2D was initially made. Her diabetes remained well-controlled with a single oral glucose-lowering drug. The diagnostic challenge became apparent over time. She experienced delayed menarche at the age of 17, and a diagnosis of Cushing’s syndrome was suspected when she subsequently developed hypertension and reduced bone mineral density. Biochemical evaluation was consistent with adrenocorticotropic hormone (ACTH)- dependent hypercortisolism, evidenced by the failure of serum cortisol suppression on low dose and overnight dexamethasone suppression tests. Her 24-hour urinary cortisol was elevated twofold, and plasma ACTH was elevated (17.8 pmol/L). MRI demonstrated a right-sided pituitary microadenoma (0.3 × 0.5 × 0.3 cm), and inferior petrosal sinus sampling confirmed the diagnosis of CD. She underwent endoscopic transsphenoidal surgery 7 years later, which was complicated by panhypopituitarism and cranial diabetes insipidus. Postoperatively, CD was cured, with the resolution of her metabolic comorbidities. Conclusion Despite the increasing prevalence of T2D in adolescents, clinicians must recognize the diagnostic challenge of CD in this age group. Atypical manifestations in a presumed T2D patient should prompt consideration of Cushing’s syndrome.
Adolescent ; Humans ; Diabetes Mellitus, Type 2

Environmental Determinants in Sustaining the Transmission of Lymphatic Filariasis: A Systematic Review IntroductionSince mass drug administration continues in many of the endemic countries, it is vital to synthesise evidence to adapt the challenges contributed by the environments. As such, the aim of this review was to explore relationship between lymphatic filariasis prevalence and potential environmental determinants .MethodsWe searched the electronic databases PubMed, Web of Science, Cochrane, and Scopus between Jan 1, 2013, and Dec 31, 2022, for studies fulfilling the following criteria: it was an original article investigating the environmental determinants associated with transmission of lymphatic filariasis; and the study was published in English. The quality assessment tools for observational studies from the National Heart, Lung, and Blood Institute was used to assess the study quality. This systematic review was registered with the PROSPERO database (CRD42023393018).ResultsWe identified 409 potentially eligible published articles, of which 11 met our inclusion criteria. The main environmental determinants associated with lymphatic filariasis transmission were Normalised Difference Vegetation Index (NDVI), land cover, distance to waterbody, rainfall/precipitation, elevation, slope, day land surface temperature, average annual temperature, house type and distance to stable light. ConclusionsThis review is one of the steps towards understanding the associations between environmental determinantsand transmission of lymphatic filariasis. These results can be used in future evidence-based strategies to strengthen surveillance and control strategies.

Socio-Ecological Framework on Risk of Prolonged Dengue Outbreak in Seremban District: A Qualitative Study IntroductionA prolonged duration of a dengue outbreak in a locality poses a detrimental risk to the susceptible population. There have been limited studies looking into the socio-ecological factors that can be modified to break the chain of transmission. Therefore, this study aimed to explore and identify the socio-ecological attributes experienced by the health authority in the Seremban district.MethodsA qualitative study was performed using an in-depth interview (IDI) technique based on semi-structured questionnaires. Results were thematically analysed when theoretical saturation was achieved.ResultsA total of 12 respondents participated in this study, representing various backgrounds and involved in dengue control activities. There were nine modifiable socio-ecological themes generated, namely (1) illegal dumpsite, (2) illegal gardens, (3) illegal man-made structures, (4) old unused items, (5) idle damaged vehicles, (6) construction site, (7) drainage system, (8) physical structure, and (9) lack of community engagement. A model framework was conceptualised from the analysis. The health authority identified that these issues require urgent attention and collaborative action by various stakeholders.ConclusionThe identified socio-ecological factors have been a challenge for the health authority. Nevertheless, identifying these attributes signifies the key to tackling the prolonged duration of the dengue outbreak. Ultimately, a multi-agency approach and community participation are vital to ensure a sustainable vector control program.

Gema Ekologi: Meneroka Interaksi Antara Persekitaran Hutan dan Vektor Malaria Pendahuluan Malaria kekal sebagai salah satu cabaran kesihatan awam yang penting di seluruh dunia, dengan kemajuan telah terbantut dalam kebelakangan ini. Memandangkan peningkatan kes malaria terutamanya di beberapa kawasan tropika, pemahaman yang lebih baik tentang hubungan ekologi yang mendasari penularan vektor malaria perlu diberikan fokus. Pendekatan pelbagai disiplin yang melibatkan ekologi, entomologi dan kesihatan awam adalah diperlukanuntuk memahami kaitan antara malaria dan habitat persekitaran. Ulasan ini bertujuan untuk mensintesis penyelidikan sedia ada tentang bagaimana ekosistem hutan mempengaruhi dinamik penularan malaria.MetodologiMenggunakan pangkalandata PubMed, Google Scholar dan Scopus, kajian literatur komprehensif telah dijalankan menggunakan kata kunci tertentu. Artikel yang berkaitan telah dinilai untuk aliran tematik. Secara keseluruhan, 42 artikel telah dipilih untuk naratif ini.Hasil Iklim mikro hutan mempengaruhi kecergasan, tingkah laku, corak aktiviti dan fisiologi organisma. Relung biologiberbeza yang disebabkanoleh suhu, kelembapan, pendedahan cahaya dan kerpasan boleh memberi kesan kepada populasi nyamuk. Ciri-ciri fiziko-biokimia badan air, termasuk suhu, pH, jumlah pepejal terlarut (TDS), kandungan nitrat, dan paras oksigen terlarut, mempunyai kesan yang ketara ke atas banyaknya larva nyamuk anopheline. Kelimpahan vektor mungkin dipengaruhi oleh kehadiran perumah dan pemangsa semulajadi. Interaksi rumit geografi, tumbuh-tumbuhan hutan, kepadatan vektor malaria, dan tingkah laku mempunyai pengaruh besar ke atas dinamik penularan malaria. Penebangan hutan mengubah landskap dan ekosistem serpihan, yang mempunyai kesan besar ke atas habitat larva vektor Plasmodium. Perubahan iklim menimbulkan ancaman besar kepada kelimpahan vektor malaria dan dinamik penghantaran.KesimpulanTerdapat banyak aspek kepada interaksi kompleks antara persekitaran hutan dan penyebaran malaria,memerlukan pengetahuan yang mendalam dan lebih banyak penyiasatan. Kerjasama antara ahli ekologi, entomologi dan pakar kesihatan awam adalah penting dalam menghasilkan model komprehensif yang meramalkan risiko malaria dengan tepat dalam persekitaran yang berubah-ubah

Primary hyperparathyroidism (PHPT) is rare in pregnancy. This condition is challenging to diagnose and manage due to the limited diagnostic and therapeutic options that are safe during pregnancy. If not diagnosed and managed in a timely manner, serious maternal and foetal complications may occur. We report two cases, one with surgical intervention and one without, to show the importance of timely surgical intervention and discuss the challenges in the management of PHPT in pregnancy.
Hyperparathyroidism, Primary ; Pregnancy

Background: s/Aims: The implementation of enhanced recovery after surgery (ERAS) protocols has demonstrated significant advantages for patients by mitigating surgical stress and expediting recovery across a spectrum of surgical procedures worldwide. This investigation seeks to assess the effectiveness of the ERAS protocol specifically in the context of major liver resections within our geographical region. Methods: Our department conducted retrospective analysis of prospectively collected data, gathered from consenting individuals who underwent liver resections from January 2018 to December 2023. The assessment encompassed baseline characteristics, preoperative indications, surgical outcomes, and postoperative complications among patients undergoing liver surgery. Results: Among the included 184 patients (73 standard care, 111 ERAS program), the baseline characteristics were similar. Median postoperative hospital stay differed significantly: 5 days (range: 3–13 days) in ERAS, and 11 days (range: 6–22 days) in standard care (p < 0.001). Prophylactic abdominal drainage was less in ERAS (54.9%) than in standard care (86.3%, p < 0.001). Notably, in ERAS, 88.2% initiated enteral feeding orally on postoperative day 1, significantly higher than in standard care (47.9%, p < 0.001). Early postoperative mobilization was more common in ERAS (84.6%) than in standard care (36.9%, p < 0.001). Overall complication rates were 21.9% in standard care, and 8.1% in ERAS (p = 0.004). Conclusions Our investigation highlights the merits of ERAS protocol; adherence to its diverse components results in significant reduction in hospital length of stay, and reduced occurrence of postoperative complications, improving short-term recovery post liver resection

The increasing number of homeless children is concerning. This study aimed to assess the dietary intake, diet quality, and nutritional status of homeless children in Klang Valley, as well as the relationship between diet quality and nutritional status. Methods: Approximately 120 homeless children aged 7 to 12 years from four locations in Klang Valley were enrolled. Their dietary intake and nutritional status were assessed using a two-day 24-hour dietary recall and body mass index-for-age, respectively. The Healthy Eating Index (HEI) was used to examine diet quality. Results: Prevalence of normal weight respondents was 58.3% (mean±SD: -0.79±1.80), with 25.0% classified as moderately and severely thin. Mean energy intake was significantly lower than recommended nutrient intakes (RNI) (p<0.050), while protein intake was higher (p<0.050). Calcium and zinc intakes were also significantly lower (p<0.001). Boys aged 7-9 years had significantly higher iron intake (median=11.6, IQR=8.7 mg, p=0.003), whereas girls aged 10-12 years had significantly lower intakes of iron (mean±SD=11.4±5.1, 11.1±4.7) and vitamin A (median=416.6, IQR=450.4 µgRE, p<0.001 for both). Mean HEI score was 51.30±6.78, indicating a need for diet quality improvement. No significant association between diet quality and nutritional status was observed (p=0.380). Conclusion: This study provided insights into dietary intake, diet quality, and nutritional status of homeless children. Further research is vital to shape evidence-based nutrition interventions.

The coronavirus disease (COVID-19) pandemic has led to an alarming increase in domestic violence against women owing to lockdown measures and limited access to support services. This article provides insights into the global prevalence of domestic violence, barriers to seeking help, its impact on women and children, and the best practices implemented worldwide. Domestic violence encompasses various forms of abuse; many young women experience partner violence. Barriers to seeking help include fear, financial constraints, lack of awareness of available services, and distrust among stakeholders. The consequences of domestic violence affect the mental health of both mothers and children. Countries have increased shelter funding and developed innovative protocols to reach survivors and address this issue. However, the healthcare sector’s involvement in addressing domestic violence has been limited. This review advocates collaboration among healthcare institutions and government bodies. Key recommendations include utilizing telehealth services, implementing comprehensive training programs, establishing effective referral systems, enhancing health education, developing a domestic violence registry, improving the responses of law enforcement and justice systems through healthcare integration, promoting data sharing, and conducting further research. Healthcare systems should recognize domestic violence as a public health concern and detect, prevent, and intervene in cases to support survivors.