Knowledge, Attitude, and Practice Towards Safety ; Health Risks ; Food Manufacturing Introduction Food manufacturing in Malaysia exposes workers to numerous potential hazards and health risks throughout the work process. This study aimed to determine the level of knowledge, attitude, and practice (KAP) towards safety and health risks among food manufacturing workers and to examine the relationship between these domains. Methods A cross-sectional study was performed involving 80 workers from three food manufacturing factories in Negeri Sembilan. KAP was assessed through a validated questionnaire adapted from a previous study. Results All workers (100%) demonstrated a positive attitude, 98.7% show good practice, and 93.8% exhibit a good level of knowledge towards safety and health risks. The correlation study showed significant positive correlations between gender and attitude, and between education level and attitude, indicating that these sociodemographic factors influence safety attitudes. Work experience is significantly associated with knowledge, suggesting that work experience enhances knowledge. The study also reveals weak positive correlations among knowledge, attitude, and practice (KAP) regarding safety and health risk, but a significant correlation is observed between knowledge and practice. Conclusions These findings suggest that fostering practical knowledge is essential for ensuring safe work behaviors. Prioritizing hands-on safety training can help bridge the gap between theoretical attitude and daily operational safety, ultimately reducing occupational health risks among food manufacturing workers.

Introduction: Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy, with an incidence of 1–2 cases per million annually. Its occurrence during pregnancy is exceptionally uncommon, presenting significant diagnostic and management challenges due to overlapping physiological changes and concerns for both maternal and fetal outcomes. While most cases are hormonally functional, non-functioning ACC during pregnancy is particularly rare and may result in delayed diagnosis. Case: A 35-year-old Malay female was referred following ultrasonography for persistent back and left flank pain, which revealed a left adrenal incidentaloma and a concurrent 10-week intrauterine pregnancy. There were no clinical signs of hormone excess. Physical examination revealed a normotensive patient with a large, palpable left abdominal mass, without Cushingoid or virilizing features. Magnetic resonance imaging (MRI) demonstrated a 12.1 × 10.3 × 12.8 cm heterogeneous left adrenal mass with cystic and necrotic components, displacing adjacent structures. Hormonal evaluation was within normal limits: 24-hour urinary cortisol 320.2 nmol/24 hours (reference range [RR] 11.8–350), midnight salivary cortisol <3 and 4.2 nmol/L (RR <11.3), plasma metanephrine <0.2 nmol/L (RR <0.5), normetanephrine 0.6 nmol/L (RR <0.9), and 17-hydroxyprogesterone 223 ng/dL (RR <285), consistent with a non-functioning tumor. Following multidisciplinary consultation, the patient underwent open left adrenalectomy at 16 weeks’ gestation. Histopathological analysis confirmed ACC (Weiss score 8/9) without extra-adrenal extension. Surveillance MRI at 32 weeks demonstrated no recurrence or residual mass. At 40 weeks’ gestation, she delivered a healthy infant, and both mother and child remain well on follow-up. Conclusion Non-functioning ACC during pregnancy is rare and poses significant diagnostic challenges. Early imaging, comprehensive hormonal assessment, and timely surgical intervention during the second trimester are essential. Multidisciplinary management is crucial to optimizing maternal and fetal outcomes.
Female ; Pregnancy ; Heart Rate ; Neoplasms

Introduction: Diabetic peripheral neuropathy (DPN) is a common complication of type 2 diabetes mellitus (T2DM), with nerve conduction studies recognized as the diagnostic gold standard. Serum neuron-specific enolase (NSE) has been linked with DPN. This study aims to determine the prevalence of DPN among T2DM patients, evaluate clinical characteristics, and explore the relationship between NSE and DPN. Methodology: A cross-sectional study was conducted at Universiti Teknologi MARA Specialist Centre Sungai Buloh and Hospital Al-Sultan Abdullah, involving patients aged 18–60 years, diagnosed with T2DM for more than 5 years (n = 132). All participants underwent anthropometric measurement, completed the Michigan Neuropathy Screening Instrument evaluation, and biochemical parameters, including lipid profile, hemoglobin A1c, and serum creatine and NSE. The diagnosis of DPN was made based on positive NCS findings. Logistic regression was used to identify factors associated with DPN. Results: The study population had a mean age of 60.16 ± 10.28 years and a mean duration of diabetes of 14.82 ± 6.66 years. The prevalence of DPN was 51.5% (n = 68). Serum NSE levels were significantly higher (p = 0.003) and independently associated with the presence of DPN (adjusted odds ratio [OR] 1.033, 95% confidence interval [CI] 1.009–1.058, p = 0.006). Participants with DPN were also more likely to be on insulin therapy (p = 0.040). In addition, retinopathy (adjusted OR 3.567, 95% CI 1.528–8.329, p = 0.013) and elevated Urine Albumin-to-Creatinine Ratio levels indicating albuminuria (adjusted OR 1.031, 95% CI 1.002– 1.061, p = 0.037) were significantly associated with DPN. Conclusion More than half of the study population had DPN, which was significantly associated with both retinopathy and nephropathy, as well as with elevated serum NSE. This emphasizes the importance of early screening and highlights the role of NSE as a surrogate marker for neuropathy in diabetes.
Humans ; Diabetes Mellitus, Type 2 ; Diabetic Neuropathies ; Prevalence ; Phosphopyruvate Hydratase

The Rotated Bipedicled Tram Flap: Maximising Breast Projection but Minimising Donor Morbidity - A Case Report Autologous breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap remains a cornerstone of breast reconstructive surgery. However, with the classical TRAM flap, it is challenging to close a large post mastectomy defect in nulliparous and/or slim women. The resultant reconstructed breast also lacks projection. This case reported a novel modified TRAM flap technique performed in a nullipara. She had previously undergone a hysterectomy and oophorectomy for endometrial carcinoma via a pfannenstiel incision. She presented with a large left breast invasive micropapillary carcinoma (ER/PR negative HER2 3+) with only marginal response to neoadjuvant chemotherapy. She underwent a left mastectomy with axillary dissection and immediate breast reconstruction. The rotated bipedicled TRAM Flap was used to close the large defect, maximising breast projection while minimising donor site morbidity.

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: Steroid-responsive encephalopathy associated with thyroiditis (STREAT) is a rare clinical entity. Clinical presentations of STREAT can range from a strokelike presentation to psychiatric symptoms. STREAT is diagnosed based on four major criteria which include altered cognitive function, new or worsening psychiatric symptoms, elevated antithyroid antibodies, and exclusion of infectious, toxic, metabolic, or neoplastic causes. Corticosteroids are the cornerstone of treatment, with reported excellent response in neurocognitive symptoms resolution. Case: This was a case of a 48-year-old male with Graves’s disease who underwent radioiodine therapy 4 months earlier and was started on levothyroxine 100 mcg 2 weeks prior to presentation. He presented with 4 days of behavioral symptoms, irritable mood with auditory and visual hallucinations. There was no history of fever, headache, limb weakness, or seizure. On general appearance, the patient was agitated, talking incoherently, and disorientated with normal vitals. There was no delayed relaxation of the reflex. The examination of the cranial nerve, motor, sensory, and cerebellar system was normal. A lumbar puncture showed normal opening pressure with a high protein CSF content of 1,596 mg/L. The thyroid-stimulating hormone (TSH) was elevated at 72.7 uIU/mL and T4 at 9.56 pmol/L. Serum antithyroid peroxidase was elevated at 877.42 IU/mL, and antiTSH receptor antibody at 21.30 IU/L. CSF oligonal band, serum aquaporin-4, and viral screening were negative; noncontrasted computed tomography brain revealed normal findings. Based on the clinical history and examination, a diagnosis of STREAT was made at the emergency department. The patient was initiated on hydrocortisone 100 mg three times a day. Within 24–48 hours of steroid therapy, marked improvement and subsequent resolution of the mental status and behavioral symptoms were seen. Conclusion Hashimoto’s thyroiditis can rarely lead to STREAT, a condition with diverse neurological manifestations, where early recognition and prompt corticosteroid therapy are essential for favorable outcomes.
Brain Diseases ; Thyroiditis ; Steroids

Introduction: The coexistence of thyroid storm and Guillain–Barré syndrome (GBS) is rare, with few reported cases. A shared autoimmune mechanism has been suggested, although the exact pathophysiology remains unclear. In severe thyrotoxicosis, new neurological symptoms may be overlooked or attributed to metabolic causes, delaying diagnosis and posing a diagnostic and therapeutic challenge. We report a case of a 43-year-old female with Graves’ disease complicated by thyroid storm and Acute Motor Axonal Neuropathy (AMAN), a variant of GBS, highlighting the importance of early recognition and multidisciplinary management. Case: A 43-year-old female with no prior medical illness presented with fever, generalized weakness, fine tremors, and 10 kg weight loss over 5 months. On arrival, she was lethargic, febrile (40.2°C), and tachycardic (148 bpm), consistent with thyroid storm by Burch–Wartofsky criteria. She denied preceding diarrheal illness or upper respiratory tract symptoms. The thyroid function test showed markedly elevated free thyroxine 4 (>64.35 pmol/L) and suppressed thyroid-stimulating hormone (TSH) (<0.008 mIU/L). Subsequent testing revealed elevated TSH receptor antibodies (>40 IU/L), confirming Graves’ disease. Her course was complicated by anaphylactic shock with transient cardiac arrest, followed by acute kidney injury and respiratory failure requiring intensive care unit admission and mechanical ventilation. Following extubation, symmetrical limb weakness with generalized areflexia and bilateral foot drop was observed. Nerve conduction studies demonstrated a symmetrical axonal motor-predominant polyneuropathy consistent with AMAN. She received five sessions of plasma exchange and showed marked neurological improvement, while thyroid and renal function normalized at discharge. Conclusion This case highlights a rare and potentially life-threatening association of thyroid storm and AMAN. Severe thyrotoxicosis can precipitate atypical autoimmune complications, underscoring the need for vigilance. Clinicians should consider neurological evaluation in patients with severe thyrotoxicosis presenting with newonset motor weakness.
Thyrotoxicosis

BACKGROUND: Acute decompensated heart failure (ADHF) is one of the leading causes of mortality, highlighting the importance of early identification of high-risk patients. The fibrosis-5 (FIB-5) index, traditionally used to evaluate hepatic fibrosis, may hold prognostic value in ADHF patients by reflecting systemic congestion, inflammation, and organ dysfunction. The hypothesis of this study is that the FIB-5 index is an independent predictor of 1-month mortality in patients with ADHF. METHODS: This retrospective study included 155 patients diagnosed with ADHF between 2020 and 2024. Patients were divided into two groups based on their left ventricular ejection fraction (LVEF ≤ 40% or LVEF > 50%). Survival was monitored for one month, and clinical, biochemical, and echocardiographic parameters were compared between survivors and death. Logistic regression and receiver operating characteristic curve analyses were performed to assess the prognostic value of the FIB-5 index. RESULTS: During the 1-month follow-up, 66 patients (42.6%) died. The mean FIB-5 index was significantly lower in non-survivors (-10.46 ± 6.93) compared to survivors (-8.10 ± 6.67) (P = 0.03). Multivariate regression analysis identified the FIB-5 index as an independent predictor of 1-month mortality (OR = 1.089, 95% CI: 1.022-1.160, P = 0.009). The receiver operating characteristic curve analysis demonstrated an area under the curve of 0.609 (95% CI: 0.51-0.699) with sensitivity of 59.6% and specificity of 63.4%. Kaplan-Meier survival analysis revealed significantly higher mortality rates among patients with lower FIB-5 values (log-rank: 7.887, P = 0.005). CONCLUSIONS The FIB-5 index is an independent predictor of 1-month mortality in ADHF patients. Its low cost, non-invasive nature, and ability to reflect systemic inflammation and congestion make it a promising tool for risk stratification. Prospective studies are needed to validate its utility in clinical practice and evaluate its role in guiding therapeutic decisions.