Introduction: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an uncommon inflammatory demyelinating disorder of the central nervous system, with a reported prevalence of 1.3–2.5 per 100,000. Hypothalamic–pituitary involvement is rare and can mimic structural lesions, presenting with varying degrees of hypopituitarism and central diabetes insipidus. Case: A 30-year-old male presented with a 2-year history of poor concentration, blurring of vision and lethargy. Initial investigations revealed severe hypernatremia (serum sodium 165 mmol/L) and a 1.4 × 2.1 × 1.3 cm suprasellar cistern mass on CT scan, with differential diagnoses including meningioma and germinoma. Brain magnetic resonance imaging showed abnormal signals in the optic pathways and hypothalamus, raising suspicion of a demyelinating process. Endocrine evaluation confirmed panhypopituitarism: elevated prolactin (1125.2 mIU/L), hypogonadotropic hypogonadism (follicle-stimulating hormone 0.7 IU/L, LH 0.3 IU/L, testosterone <0.35 nmol/L), central hypothyroidism (TSH 3.8 mIU/L, free T4 5.88 pmol/L) and low cortisol (33.1 nmol/L). Persistent hypernatremia (up to 171 mmol/L) with high serum osmolality (370 mOsm/kg) and low urine osmolality (237 mOsm/kg) confirmed central diabetes insipidus, as urine osmolality rose to 755 mOsm/kg following intravenous desmopressin. He was commenced on sublingual desmopressin 60 micrograms twice daily, hydrocortisone (10 mg morning, 5 mg afternoon), levothyroxine 75 micrograms daily and monthly intramuscular testosterone 150 mg. Subsequent readmissions for generalized weakness and fever led to cerebrospinal fluid analysis and serum testing, which were positive for MOG antibodies and negative for aquaporin-4 antibodies, confirmed MOGAD. During a third admission with recurrent generalized weakness, he responded favorably to intravenous methylprednisolone (1 g daily for 5 days), followed by a tapering oral prednisolone regimen. Conclusion MOGAD can involve the hypothalamic–pituitary axis and mimic a suprasellar mass. In patients with panhypopituitarism, central diabetes insipidus and compatible imaging, inflammatory demyelination should be suspected. MOG antibody positivity and response to corticosteroids support diagnosis and guide management.
Diabetes Insipidus ; Hypopituitarism

Introduction: The increasing prevalence of diabetes represents a significant global health challenge. Modifiable risk factors, including physical inactivity, unhealthy dietary habits, and obesity contribute substantially to this rising burden. In conjunction with the 2025 World Diabetes Day (WDD) campaign focusing on “diabetes and the workplace,” we assessed diabetes risk among healthcare workers in our hospital using the Modified Asian Finnish Diabetes Risk Score (ModAsian FINDRISC). Methodology: Healthcare workers from various departments were invited to participate in the hospital WDD celebration. A total of 286 attendees underwent anthropometric measurements and completed the ModAsian FINDSRIC questionnaire. Descriptive statistics were used to summarize the prevalence of risk factors and overall diabetes risk. Results: The participants included doctors, nurses, allied healthcare professionals, as well as hospital support and administrative staff. The majority of participants (74.8%) were aged below 45 years. 39.2% were overweight while 30.8% were obese. One-third (37.4%) had increased waist circumference (WC) (≥90 cm for men, ≥80 cm for women). Additionally, 20% of respondents reported being on antihypertensive medication, and 23.8% had previously recorded high blood glucose. A family history of diabetes mellitus (DM) was reported by 62.6% of respondents. Additionally, about onethird were sedentary with less than 30 minutes of daily exercise or physical activity, another one-third did not consume fruits or vegetables on a daily basis. The median ModAsian FINDRISC score was 8, with approximately 30% of them classified as having moderate to very high risk of developing DM (moderate: 17.5%; high: 10.8%; very high: 2.8%). Conclusion These results revealed high metabolic risk in healthcare workers and highlight the need for targeted workplace health promotion strategies to reduce the risk of developing diabetes.
Tertiary Care Centers ; Health Personnel ; Diabetes Mellitus

Introduction: Severe hypercalcemia is most commonly caused by primary hyperparathyroidism (PHPT) and malignancy. While standard therapies are effective in most cases, a subset of patients have persistent or refractory hypercalcemia. We present a retrospective case series detailing the clinical characteristics, biochemistry, and outcomes of patients treated with denosumab for hypercalcemia. Cases: Seven patients with severe hypercalcemia were identified, comprising five with PHPT and two with malignancyassociated hypercalcemia. The mean age was 70.4 years (range 55–86), with 71% female (n = 5) and 29% male (n = 2). Baseline corrected calcium ranged from 2.92 to 4.59 mmol/L, with a mean of 3.26 mmol/L. In the PHPT cohort, parathyroid hormone (PTH) levels were significantly elevated (16.7–168 pmol/L), while malignancy patients had suppressed PTH (0.6 and 0.9 pmol/L). Prior to denosumab, 4/7 patients (57%) received bisphosphonates, 3/7 (43%) received calcitonin, and 1/7 (14%) was treated with cinacalcet. Denosumab resulted in a mean reduction in corrected calcium of 0.22 mmol/L from 3.26 to 3.03 mmol/L. Biochemical response was observed in 5/7 patients (71%). Of these, 3 patients (43%) achieved normocalcemia, while 2 patients (29%) demonstrated a partial response. The remaining 2/7 patients (29%) showed no significant improvement in calcium levels. Among responders, the mean time to calcium reduction to <3.0 mmol/L was 27 days (range 7–47). Repeat dosing was required in the majority of patients, with a mean of 1.7 doses per patient (range 1–4), indicating variability in both onset and durability of response. Among patients with PHPT, four underwent parathyroidectomy, and one declined surgery. Both patients with malignancy were managed nonsurgically. Conclusion Denosumab achieved normocalcemia in 43% of patients, with additional partial responses. Its effects were variable, with delayed response and frequent need for repeat dosing, supporting its role as an adjunctive or bridging therapy rather than as a definitive treatment.
Denosumab ; Hypercalcemia ; Retrospective Studies

Introduction: Ectopic ACTH secretion (EAS) is a rare cause of Cushing’s syndrome, accounting for 5–15% of cases. Pulmonary neuroendocrine tumors are the most frequent cause. However, primary tumor localization remains a significant diagnostic challenge, delaying effective treatment. Case: A 59-year-old female with diabetes mellitus presented with refractory hypertension and hypokalemia. Initial laboratory findings revealed a baseline cortisol of 1,164 nmol/L and morning adrenocorticotropic hormone (ACTH) of 19.5 pmol/L (normal <10.2 pmol/L), with an overnight dexamethasone suppression test cortisol of 624 nmol/L. Pituitary magnetic resonance imaging (MRI) and computed tomography (CT) scans of the thorax, abdomen, and pelvis were initially unremarkable. A PET scan identified mild hypermetabolism in the left adrenal gland and gastrointestinal tract, though colonoscopy revealed only chronic colitis. An intravenous desmopressin stimulation test demonstrated a 181% rise in ACTH and a 35% rise in cortisol, pointing toward pituitary Cushing’s. However, repeat pituitary MRI remained normal. A high-dose dexamethasone suppression test showed approximately 34% cortisol suppression (cortisol 1,128 nmol/L to 745 nmol/L), suggesting ectopic Cushing’s syndrome. Bilateral inferior petrosal sinus sampling demonstrated a peak central-to-peripheral ACTH ratio of 1.8 on the right and 1.6 on the left, pointing toward ectopic Cushing’s. Localization with DOTATATE PET-CT identified a 7 × 9 × 8 mm nodule in the right middle lobe. A wedge resection was performed. Histopathology confirmed a typical carcinoid tumor with clear resection margins. Immunohistochemistry revealed tumor cells positive for CK AE1/ AE3, synaptophysin, chromogranin, and INSM-1, with weak positivity for ACTH. The latest 8 am cortisol was 117 nmol/L and ACTH 1.74 pmol/L, confirming biochemical cure. Hypokalemia resolved, with improvement in her metabolic profile. Conclusion This case highlights the diagnostic complexities of EAS, particularly when initial imaging is inconclusive and biochemical tests yield conflicting results. Timely, precise localization of the causative tumor is crucial for successful surgical intervention and to prevent severe complications of hypercortisolism, thereby improving patient outcomes.
ACTH Syndrome, Ectopic

Introduction: Air pollution and air quality are growing concerns among urban citizens of Southeast Asia, especially the University students who devote most of their days to the vicinity of campus. However, there is limited data available on the extent of the problem, as well as an understanding of the knowledge of and perceptions of people who may be exposed to poor air quality. Methods: This focused study evaluated University students’ opinions, perceptions, and behavioral responses to local air quality in the Iskandar Puteri, Johor region of Malaysia using an online questionnaire, and measurements of NO2, SO2, formaldehyde, and particulate matter levels in the area using diffusion tubes. All air quality parameters were within the standards recommended by the local environmental authority, however, NO2 levels exceeded the recommended World Health Organization (WHO) standards at all sites. Results: Questionnaire findings indicate that students most commonly suffered from respiratory diseases, and were very concerned about air pollution and its impacts. Respondents perceived the situation to be worse in the afternoons and weekends, corroborated by the PM2.5 readings in the area. Preferred preventive measures included wearing masks and limiting active time outdoors. Conclusions The evidence from this study highlighted the need to improve air quality in Iskandar Puteri as the NO2 level exceeded international standards for human health at all study sites. This could be supported by educational programs for industry, limitations on traffic emissions, and general awareness of air quality issues present locally.

Objectives: Type 2 diabetes mellitus (T2DM) shares a complex relationship with bone metabolism and few studies investigated the effect of impaired bone health on the risk of T2DM. This study was conducted to investigate the association between hip fractures and the risk of incident T2DM. Methods: This is a retrospective cohort study using data from the real-world hip fracture cohort. Hong Kong Chinese patients aged ≥ 65 years without T2DM who were admitted to public hospitals due to a fall between 2008 and 2015 were included in the study. Patients who sustained falls with and without hip fractures were matched by propensity score (PS) at a 1:1 ratio. Competing risk regression was used to evaluate the association between hip fracture and incident T2DM, with death being the competing event. Results: A total of 23,314 hip fracture cases were matched to 23,314 controls. The median follow-up time was 5.09 years. The incidence rate of T2DM was 11.947 and 14.505 per 1000 person-years for the hip fracture and control group respectively. After accounting for the competing risk of death, the hip fracture group had a significantly lower risk of developing T2DM (HR: 0.771, 95% CI: 0.719–0.827). Similar results were observed in all subgroups after stratification by age and sex. Conclusions Hip fracture was found to be associated with a reduced risk of T2DM. These findings provide insight into the topic of bone and glucose metabolism and prompt further research in evaluating the role of bone health in the management of T2DM.

INTRODUCTION: Studies of concordance between patients' self-report of diseases and a criterion standard (e.g. chart review) are usually conducted in epidemiological studies to evaluate the agreement of self-reported data for use in public health research. To our knowledge, there are no published studies on concordance for highly prevalent chronic diseases such as diabetes and pre-diabetes. The aims of this study were to evaluate the concordance between patients' self-report and their medical records of diabetes and pre-diabetes diagnoses, and to identify factors associated with diabetes concordance. METHOD: A cross-sectional, interviewer-administered survey was conducted on patients with chronic diseases after obtaining written consent to assess their medical notes. Interviewers were blinded to the participants' profiles. Concordance was evaluated using Cohen's kappa (κ). A multivariable logistic regression model was used to identify factors associated with diabetes concordance. RESULTS: There was substantial agreement between self-reported and medical records of diabetes diagnoses (κ=0.76) and fair agreement for pre-diabetes diagnoses (κ=0.36). The logistic regression model suggested that non-Chinese patients had higher odds of diabetes concordance than Chinese patients (odds ratio [OR]=4.10, 95% confidence interval [CI] 1.19-14.13, P=0.03). Patients with 3 or more chronic diseases (i.e. multimorbidity) had lower odds of diabetes concordance than patients without multimorbidity (OR=0.21, 95% CI 0.09-0.48, P<0.001). CONCLUSION Diabetes concordance was substantial, supporting the use of self-report of diabetes by patients with chronic diseases in the primary care setting for future research. Pre-diabetes concordance was fair and may have important clinical implications. Further studies to explore and improve health literacy and patient-physician communication are needed.
Humans ; Prediabetic State ; Singapore/epidemiology* ; Cross-Sectional Studies ; Diabetes Mellitus/epidemiology* ; Medical Records ; Self Report

Introduction: The incidence of angiotensin-converting enzyme inhibitors (ACEi)-induced cough has been reported between 5% and 30% but is unknown in Malaysia. This study aimed to determine the incidence of ACEi-induced cough and its associated factors in a public primary care clinic in Malaysia. Methods: A retrospective review of electronic medical records of patients who were initiated ACEi between January 1, 2015, and December 31, 2015, and reviewed until July 31, 2016. A total of 1,091 patients were newly prescribed ACEi, and 394 patients were eligible for this study. We excluded patients who defaulted follow-ups with no further clinic visits before July 31, 2016, were transferred to the clinic without the recorded date of ACEi initiation, were transferred to other clinics during the study period, were followed up at other clinics and attended the study clinic for a short period, or were given only a stat dose of ACEi. Results: Among the 394 patients initiated on ACEi, 225 (57.1%) were male, 369 (93.7%) were Malay, 376 (95.4%) had hypertension, and 192 (48.7%) had diabetes. The incidence of ACEi-induced cough was 24.1%, and 42 (10.7%) patients developed cough on the day of therapy initiation. There was no association between age, gender, ethnicity, type of ACEi, and cough. Conclusion Approximately one quarter of patients developed cough after ACEi initiation, and approximately half of them developed cough within 1 week of ACEi initiation. Doctors should consider early follow-up for patients initiated on ACEi therapy to ensure adherence, quality of life, and minimise unnecessary treatment.
Angiotensin-Converting Enzyme Inhibitors ; Cough ; Incidence

Major depressive disorder (MDD) is a common but complex illness that is frequently presented in the primary care setting. Managing this disorder in primary care can be difficult, and many patients are underdiagnosed and/or undertreated. The Malaysian Clinical Practice Guidelines (CPG) on the Management of Major Depressive Disorder (MDD) (2nd ed.), published in 2019, covers screening, diagnosis, treatment and referral (which frequently pose a challenge in the primary care setting) while minimising variation in clinical practice.
Depression ; Depressive Disorder, Major ; Primary Health Care ; Therapeutics

Introduction: Sarawak has a population that is geographically and characteristically widely varied. This study aimed to determine the demographic profile of patients in Sarawak, Malaysia. Materials and Methods – A cross-sectional study was conducted in 2019 at four major haemophilia treatment centres in Kuching, Sibu, Bintulu and Miri Hospitals, Sarawak. Demographic and clinical data were collected with consents from patients. Results and Discussion: Ninety-six haemophilia patients were identified - 79(82.3%) haemophilia A(HA) and 17(17.7%) haemophilia B(HB). Severe haemophilia patients were noted in 45.6% (36/79) of HA and 64.7% (11/17) of HB. In all 44.3% of the HA and 52.9% of the HB population had no identifiable family history of haemophilia. Two-thirds of the patients with severe HA were on prophylaxis [24/36 (66.7%)] and only onethird [4/11 (36.4%)] in severe HB. Inhibitors developed in 9/79 (11.4%) of the HA population [3/79 (3.8%) high responders]. The median inhibitor titre was not significantly different between the different treatment groups – on demand versus prophylaxis (1.0BU versus 2.0BU; z statistic -1.043, p-value 0.297, Mann-Whitney test). None of the patients developed inhibitory alloantibodies to factor IX. Four HA patients (5.1%) underwent immune tolerance induction where one case had a successful outcome. Three severe HA patients received emicizumab prophylaxis and showed remarkable reduction in bleeding events with no thromboembolic events being reported. One female moderate HA patient received PEGylated recombinant anti-haemophilic factor. Eleven patients underwent radiosynovectomy. One mild HB patient succumbed to traumatic intracranial bleeding. Our data reported a prevalence (per 100,000 males) of 5.40 cases for all severities of HA, 2.46 cases for severe HA; 1.16 cases for all severities of HB, and 0.75 cases for severe HB. The overall incidence of HA and HB was 1 in 11,500 and 1 in 46,000, respectively. Conclusion: This study outlines the Sarawakian haemophilia landscape and offers objective standards for forward planning. Shared responsibilities among all parties are of utmost importance to improve the care of our haemophilia population.