Visual Status of Private Vehicle Drivers in Klang Valley, Malaysia Introduction Vision play an important role during driving and many driving related injuries have been connected with visual problems. However, there is little information in profiling visual status among private vehicle drivers in rural area of Malaysia. The aim of this study is to determine visual function and binocular function status among private vehicle drivers in Klang Valley, Malaysia Methods A descriptive cross-sectional study was conducted in the major towns within the Klang Valley of Malaysia. Participants were taken through a comprehensive eye examination after the administration of a structured questionnaire Results Fifty private vehicle drivers (52% males and 48% females) participated in this study with mean age of 26±7 year. The mean of visual acuity and contrast sensitivity is 0.03±0.1 logMAR and 0.2±0.1 at 2.5% respectively. This study also found 2% of subject with colour deficiency and 4% of subjects had constricted visual field. The mean value for amplitude of accommodation, facility of accommodation, and stereopsis is 10.16±2.11 D, 8±1 cycle per minute (cpm), and 46 second of arc respectively. Based on chi square test, there is a significant association (p=0.018) between reduced binocular vision function and history of road traffic accident (RTA). Conclusions Fifty private vehicle drivers (52% males and 48% females) participated in this study with mean age of 26±7 year. The mean of visual acuity and contrast sensitivity is 0.03±0.1 logMAR and 0.2±0.1 at 2.5% respectively. This study also found 2% of subject with colour deficiency and 4% of subjects had constricted visual field. The mean value for amplitude of accommodation, facility of accommodation, and stereopsis is 10.16±2.11 D, 8±1 cycle per minute (cpm), and 46 second of arc respectively. Based on chi square test, there is a significant association (p=0.018) between reduced binocular vision function and history of road traffic accident (RTA).

Parenting Factors and Child Obesity: A Study Among Preschoolers in Selangor, Malaysia Introduction Child obesity is a pressing global concern. In Malaysia, the rates of child obesity have risen significantly over recent decades, with 5.6% of children under the age of five being categorized as overweight or obese. Children's behavior is influenced by their home environment, which includes both physical and social aspects such as parental behavioral models, parenting styles, practices, beliefs, and societal norms. However, there is a scarcity of data on the prevalence of child obesity and its relationship with parental factors. This research set out to explore the link between parenting styles, parental physical activity, dietary habits, body image perception, screen time, and child obesity. Methods A survey using a quantitative approach was conducted among preschoolers in Selangor to test the proposed relationships between these factors. Data were gathered from 354 preschool students in Selangor. This study used a multi-stage sampling technique. In the multi-stage sampling technique, the researcher used a series of sampling frames by developing population strata and then selected using purposive sampling method. Results The analysis was carried out using SPSS version 26 and Smart PLS version 4.0. The direct effect analysis revealed that parenting styles (p = 0.000), along with parental dietary habits and body image perception (p=0.001), were significantly associated with child obesity. In contrast, parental physical activity (p = 0.167) and screen time (p = 0.739) did not show a significant relationship with childhood obesity. Conclusions The study's outcomes can assist healthcare practitioners in understanding and providing substantial evidence of the significant relationship between parenting styles, dietary practices, body image perception, and child obesity.

Introduction: Insulin therapy is essential in the management of type 2 diabetes mellitus (T2DM), but is often associated with treatment burden, hypoglycemia, and potential overtreatment. Insulin deintensification is increasingly recommended for appropriately selected patients; however, there is limited real-world evidence to guide patient selection and to identify modifiable factors that influence successful insulin deintensification. This study aimed to identify clinical predictors, including modifiable factors, associated with successful insulin deintensification in a primary care setting. Methodology: A multicentre retrospective observational study was conducted across seven government primary care clinics in the Petaling District. Adult patients with T2DM undergoing insulin deintensification were included. Successful insulin deintensification was defined as maintenance or improvement of hemoglobin A1c following insulin discontinuation, dose reduction, or reduction in injection frequency. Paired outcomes were analyzed using the Wilcoxon signed-rank test. Between-group comparisons were performed using the Mann–Whitney U test and Chi-square or Fisher’s exact test. Multivariable logistic regression was used to identify independent predictors of successful insulin deintensification. Results: A total of 261 patients were included. Glycemic control remained stable following insulin deintensification (p = 0.334). Significant reductions in body weight (−0.41 kg, p = 0.012) and total daily insulin dose (23.1% reduction, p <0.001) were observed. Univariate analysis did not demonstrate significant differences between groups. However, multivariable logistic regression identified SGLT-2 inhibitor use (aOR 3.23, 95% CI 1.28–8.18, p = 0.013) and regular SMBG (aOR 2.00, 95% CI 1.05–3.81, p = 0.035) as independent predictors of successful insulin deintensification. Conclusion Insulin deintensification can be successfully implemented without compromising glycemic control. Identified predictors, including modifiable factors such as SGLT-2 inhibitor use and SMBG, provide clinically actionable insights to guide patient selection and treatment optimization. These findings challenge the traditional reluctance toward insulin deintensification and support a more evidence-based and individualized approach in routine clinical practice.
Primary Health Care ; Insulins

Introduction: Adrenal insufficiency (AI) is a life-threatening condition that frequently presents with non-specific symptoms, complicating early diagnosis. Morning serum cortisol serves as an effective initial screening tool for assessing the hypothalamic-pituitary-adrenal (HPA) axis, potentially reducing the necessity for dynamic investigations such as the Short Synacthen Test (SST). This study aims to assess the clinical indications for morning cortisol testing and evaluate institutional compliance with guideline-based cortisol cut-offs, the initiation of hydrocortisone therapy, and the provision of “sick day” education. Methodology: A retrospective cross-sectional study was conducted among inpatients at a tertiary hospital in Central Pahang who underwent morning cortisol evaluation between March and August 2025. Data regarding demographics, indications, biochemical results, and clinical management were analyzed using SPSS version 26.0. Results: Among the 111 patients included (mean age: 54.96 ± 15.88 years), the primary indications for testing were hyponatremia (54.1%), hypotension (27.9%), and a history of traditional medication use (26.1%). Based on Endocrine Society guidelines: <150 nmol/L (AI likely): 16.2%, 150–300 nmol/L (Borderline): 26.1%, and >300 nmol/L (AI unlikely): 57.7%. Notably, only 10 of the 18 patients with cortisol levels <150 nmol/L were formally diagnosed and initiated on appropriate therapy. In the borderline group, only two patients underwent an SST. Although 12 patients overall were treated for AI, only eight received documented “sick day” education. Low cortisol levels were significantly associated with hyponatremia, hypotension, and traditional medication use, and demonstrated a negative correlation with serum sodium and albumin levels. Conclusion Morning serum cortisol is a valuable screening tool for AI, particularly in patients presenting with hyponatremia or hypotension. However, significant gaps persist in follow-up management, confirmatory testing, and patient education. Implementing standardized protocols and enhancing clinician education are essential to optimize care.
Hydrocortisone ; Adrenal Insufficiency ; Tertiary Care Centers

Introduction: Disseminated histoplasmosis is a rare but important cause of adrenal insufficiency (AI), particularly in tuberculosis (TB)-endemic regions, where it may mimic granulomatous diseases. Adrenal involvement occurs in up to 80% of disseminated cases, although overt AI is less common. Reported cases described bilateral adrenal masses mimicking malignancy or TB, even in immunocompetent individuals. Addisonian crisis may be the initial manifestation, especially when the diagnosis is delayed. In TB-endemic settings, fungal infections are often overlooked, leading to delayed diagnosis and inappropriate therapy. Case: We reported a case of a 68-year-old male with underlying diabetes mellitus who presented with fever, cough, dysphagia, and weight loss for 1 month. He was empirically treated as smear-negative disseminated TB. On day 2 of therapy, he developed hypotension (80/50 mmHg), hypoglycemia (3.9 mmol/L), hyponatremia (Na 129 mmol/L), and hyperkalemia (K 5.1 mmol/L), suggestive of adrenal crisis, and was started on intravenous hydrocortisone. Serum cortisol prior to treatment was 61 nmol/L. Computed tomography (CT) imaging revealed bilateral lipid-poor adrenal lesions (right: 3.6 × 2.2 × 4.9 cm, Hounsfield Unit (HU) 36 and absolute washout 33%; left: 3.5 × 2.4 × 5.4 cm; HU 35 and absolute washout 17%), raising suspicion of infectious or malignant etiologies. Endoscopic ultrasound-guided biopsy demonstrated necrotizing granulomatous inflammation with budding fungal yeasts on Pituitary Apoplexy Score and GMS staining, consistent with Histoplasma capsulatum. TB and malignancy were excluded. He received amphotericin B for 14 days, followed by oral itraconazole for 1 year, and oral hydrocortisone replacement. At 1-year follow-up, adrenal lesions remained stable on CT images, and he continued to require hydrocortisone replacement. Conclusion This case highlights the importance of considering disseminated histoplasmosis as a differential diagnosis of bilateral adrenal masses with AI, especially with poor response to anti-TB therapy. Early tissue diagnosis is essential, as imaging findings are non-specific. Prompt recognition is critical to prevent life-threatening adrenal crisis and improve clinical outcomes.
Histoplasmosis ; Tuberculosis

Introduction: Histoplasmosis is a rare opportunistic, inhalation-acquired systemic mycosis caused by Histoplasma capsulatum, endemic to Southeast Asia, including Malaysia. Although classically seen in immunocompromised hosts, it is increasingly reported in immunocompetent individuals. Infection is associated with environmental exposures such as bat or bird droppings and soil disruption. Histoplasmosis is a progressive granulomatous disease that can closely mimic tuberculosis and malignancy, making diagnosis challenging. Case: An 87-year-old Malay male with a history of treated pulmonary tuberculosis presented with a 6-month history of intermittent fever, anorexia, weight loss, and hypotension. Initial computed tomography imaging demonstrated bilateral heterogeneous adrenal masses (right: 2.2 × 3.7 × 5.0 cm; left: 2.0 × 3.7 × 5.2 cm) with indeterminate washout characteristics. Biochemical adrenal evaluation, including a short Synacthen test, confirmed primary adrenal insufficiency. Extensive microbiological and malignancy workup, including bronchoscopy, cultures, and tumor markers, was non-diagnostic. In view of clinical deterioration and epidemiological risk, empirical antituberculous therapy was initiated; however, no clinical improvement was observed after 2 months. PET-FDG revealed intensely hypermetabolic bilateral adrenal masses (SUVmax right 16.7, left 13.2) with no other abnormal foci. Non-invasive fungal investigations were negative. Definitive diagnosis was established via computed tomography-guided adrenal biopsy, which demonstrated necrotizing granulomatous inflammation with intracellular yeasts, subsequently identified as H. capsulatum. The patient was treated with oral itraconazole and corticosteroid replacement, resulting in significant clinical improvement and planned interval radiological reassessment. Conclusion Disseminated histoplasmosis is a diagnostic challenge, particularly in frail elderly patients, where invasive procedures may be delayed. It can mimic tuberculosis and malignancy and may lack an identifiable exposure history. Non-invasive tests may be inconclusive, making tissue biopsy essential. Adrenal involvement may result in primary adrenal insufficiency, further complicating the clinical picture. Early consideration and timely confirmation are crucial for appropriate management.
Adrenal incidentaloma ; Lung Neoplasms

Introduction: Severe hypercortisolism is associated with profound impairment of both innate and adaptive immune responses, predisposing affected individuals to opportunistic infections. Excess glucocorticoids alter leukocyte trafficking, suppress pro-inflammatory cytokine production, and impair cellular immunity, increasing susceptibility to bacterial, viral, and fungal pathogens. In some cases, severe infections may precede the diagnosis of Cushing syndrome and represent the initial clinical manifestation. Early recognition is important as untreated hypercortisolism can lead to substantial morbidity and mortality. Case: A young adolescent male presented with progressive facial fullness and facial hyperpigmentation for 4 months, followed by 1 month of intermittent fever, cough, lower limb weakness, and hallucinations. On examination, he was tachypneic with cushingoid features including moon facies, pigmented acne over the face and chest, and nail bed hyperpigmentation. He was hypertensive and had severe hypokalemia with lymphopenia. Radiological imaging demonstrated multiple cavitary lung lesions and intracranial tuberculomas. Bronchoalveolar lavage identified multiple opportunistic pathogens, including Pneumocystis jirovecii, Aspergillus fumigatus, and Haemophilus influenzae, while cerebrospinal fluid testing was positive for cytomegalovirus. Given the unusual combination of infections, an underlying immunocompromised state was suspected. Endocrine evaluation revealed markedly elevated serum cortisol, with loss of diurnal rhythm and elevated adrenocorticotropic hormone (ACTH). Twenty-four-hour urinary cortisol was significantly increased, confirming severe ACTHdependent Cushing syndrome. Magnetic resonance imaging of the pituitary gland and computed tomography imaging of the thorax, abdomen, and pelvis did not identify the source of ACTH secretion. Conclusion This case highlights that overwhelming opportunistic infections may be the first manifestation of severe Cushing syndrome in children. Excess cortisol disrupts host defenses by impairing neutrophil chemotaxis and macrophage phagocytosis, suppressing T-cell-mediated immunity, and reducing cytokine signaling necessary for pathogen clearance. These mechanisms contribute to susceptibility to simultaneous bacterial, fungal, and viral infections. Clinicians should therefore consider underlying hypercortisolism in patients presenting with multiple or unusual opportunistic infections to enable earlier diagnosis and appropriate multidisciplinary management.
Cushing Syndrome ; Opportunistic Infections

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

Introduction: Diabetic nephropathy is a major complication of type 1 diabetes mellitus (T1DM) and a leading cause of endstage renal disease. This study aims to correlate long-term glycemic control and disease duration with renal decline, measured via estimated glomerular filtration rate (eGFR) and urinalysis proteinuria. Methodology: A retrospective cohort study was conducted among 15 patients with T1DM at Hospital Bentong. Independent variables were 3-year mean glycated hemoglobin A1c (HbA1c) and duration of diabetes. Dependent variables included the change in eGFR derived from baseline and latest serum creatinine (calculated using the CKD-EPI 2021 equation), and the shift in urine protein severity, mapped to an ordinal scale, over a 3-year follow-up. Multivariate linear regression and Spearman’s rank correlation were utilized for analysis. Results: The cohort consisted of 5 male patients and 10 female patients with a mean initial presentation HbA1c of 11.4%, a mean 3-year HbA1c of 9.15%, and a median disease duration of 11 years. Baseline eGFR was preserved (mean 117.15 mL/ min/1.73 m²). Regression analysis revealed that for every 1% increase in mean HbA1c, eGFR declined significantly by 9.6 mL/min/1.73 m² (p = 0.002). Furthermore, each additional year of disease duration independently reduced eGFR by 1.1 units (p = 0.008). Spearman validation confirmed the strong negative correlation between HbA1c and eGFR (Rho = -0.664, p = 0.006). Conversely, the correlation between 3-year mean HbA1c and worsening proteinuria was not statistically significant (Rho = -0.067, p = 0.827), and patient gender did not significantly impact progression (p = 0.129). Conclusion Poor long-term glycemic control and longer duration of diabetes mellitus are strong independent predictors of decline in functional glomerular filtration in T1DM. While worsening proteinuria may not be detected during a short 3-year window using a standard urinalysis (UFEME), a more sensitive test such as Urine Albumin-to-Creatinine Ratio may better detect early structural kidney damage.
Diabetes Mellitus, Type 1 ; Proteinuria

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