Background: Frailty is a health condition preceding impairment and disease, resulting in vulnerability and risk of poor outcomes. Frailty is a multidimensional geriatric syndrome encompassing physical, psychological and cognitive components. Psychological frailty refers to reduced emotional resilience, mood stability, and coping capacity. This paper aims to review the current literature on psychological frailty and mental health outcomes among older adults. Methodology : Four electronic databases, PubMed, Scopus, Science Direct and Web of science were used to systematically search for studies published between January 2019 and December 2023, that examined the effect of psychological frailty on mental health outcomes in older adults, including depression, anxiety, and overall well -being. Results: There were 154 articles screened, with 7 studies meeting inclusion criteria. All included studies assessed psychological frailty using the Tilburg Frailty Indicator (TFI), a multidimensional frailty tool with a psychological domain. Psychological frailty, as measured using the TFI, was consistently associated with depressive symptoms, anxiety, and reduced quality of life. The psychological domain of the TFI demonstrated moderate internal consistency (Cronbach ’s α = 0.712 -0.797). Conclusion: Psychological frailty is a potential risk factor for the development of adverse mental health outcomes in older adults. The use of validated measures, such as the TFI may improve the identification of psychological frailty for early intervention strategies in both community and medical settings to protect older adults ’ mental health

Introduction: Swyer syndrome (46, XY gonadal dysgenesis) is a rare disorder of sex development, characterized by a phenotypic female with streak gonads and hypergonadotropic hypogonadism. It presents with primary amenorrhea and delayed puberty. Overlapping clinical features with Turner syndrome may cause diagnostic uncertainty, highlighting the role of karyotypic evaluation in diagnosis. Case: A 35-year-old phenotypic female was first evaluated at age 27 during admission for an acute viral illness, when incidental findings of primary amenorrhea, short stature (height 131 cm), webbed neck, pectus excavatum, and absent secondary sexual characteristics raised suspicion of Turner syndrome. She had hypertension, with initial imaging suggesting coarctation of the thoracic aorta. CT angiography showed focal narrowing of the descending aorta; multidisciplinary review favored aortic folding, and she was managed conservatively. Endocrine evaluation demonstrated hypergonadotropic hypogonadism, with markedly elevated follicle-stimulating hormone (FSH 108.6 IU/L) and luteinizing hormone (LH 23.16 IU/L) in the presence of low estradiol levels. Pelvic imaging revealed an atrophic uterus with absence of bilateral ovaries, consistent with gonadal dysgenesis. Karyotypic analysis was performed, demonstrating a 46, XY genotype with confirmed SRY gene presence, establishing the diagnosis of Swyer syndrome. DEXA scan demonstrated osteoporosis, in keeping with prolonged hypogonadism. She was commenced on hormone replacement therapy, resulting in the development of secondary sexual characteristics and regular withdrawal bleeding. She remains under structured multidisciplinary follow-up, with endocrine-led management of hypothyroidism and osteoporosis, alongside cardiology follow-up and gynecological surveillance. Conclusion This case highlights the diagnostic complexity of disorders of sex development with overlapping phenotypes and the need for re-evaluation when clinical progression is atypical. Diagnosis enables hormone replacement therapy for induction of secondary sexual characteristics and preservation of bone health. Integration of clinical, biochemical, and genetic data within a multidisciplinary framework is essential to achieve diagnostic accuracy and optimize outcomes.
Turner Syndrome

Introduction: Tuberculosis patients with comorbid diabetes face a substantially higher risk of mortal outcomes. The “metainflammation” loop between hyperglycemia and tuberculosis (TB) infection exacerbates systemic severity and increases hazard rates for death. This study aims to quantify the association between baseline hemoglobin A1c (HbA1c) levels and all-cause mortality within a Malaysian cohort. Methodology: This was a retrospective cross-sectional audit analyzing 131 adult TB-DM (diabetes mellitus) patients during their treatment course (2022–2025) in the TB Clinic, Hospital Sungai Buloh. Primary outcomes were all-cause mortality and clinical severity, stratified by baseline HbA1c and diabetes mellitus DM treatment modality (OHA vs. insulin). Results: The overall mortality rate was 17% (22/131). A stark disparity in glycemic control was observed between survivors and deceased patients: those who died presented with extreme mean HbA1c levels of 16.0%, compared to 10.5% in survivors. High HbA1c was also associated with a higher prevalence of pulmonary involvement compared to extrapulmonary disease (10.9% vs 8.9%). Patients requiring insulin therapy experienced significantly higher mortality rates compared to those managed on OHAs, with 25% (12 out of 47) patients requiring insulin therapy having died during TB treatment, compared to only 8.2% (7 out of 84) patients in the OHA-only group. Conclusion Baseline HbA1c is a critical prognostic marker that identifies a high-risk “lethal threshold” at extreme glycemic levels (HbA1c ≥16). Furthermore, the nearly fourfold increase in death risk among insulin-treated patients likely reflects a high-risk phenotype of advanced metabolic failure, which corresponds with a study done in Kelantan (Siti Rohana et al., 2020). The study shows that TB patients with DM had three times higher risk of developing unsuccessful TB treatment outcomes compared to TB patients without DM. Collectively, these data necessitate mandatory early HbA1c screening and aggressive metabolic management to reduce the staggering mortality of this dual epidemic.
Retrospective Studies

Introduction: Steroid cell tumors are rare sex cord-stromal tumors, accounting for <0.1% of ovarian neoplasms. Extraovarian steroid cell tumors are exceptionally rare, often androgensecreting, and pose significant diagnostic challenges. Early recognition is essential to prevent prolonged morbidity from hyperandrogenism. Case: A 60-year-old female, 15 years after total hysterectomy and bilateral salpingo-oophorectomy for a large ovarian mass with massive ascites, presented with deranged liver function tests on routine follow-up. Ultrasonography and computed tomography imaging revealed multiple hypervascular lesions in the liver, retroperitoneum, and peritoneum, suggestive of metastatic disease, with normal-appearing adrenal glands. Biopsy of a liver lesion demonstrated a metastatic neoplasm with morphology and immunoprofile favoring a steroid cell tumor. However, metastasis from the adrenal cortex or an ovarian primary could not be excluded. Given the prior bilateral oophorectomy, metastatic adrenocortical carcinoma was initially suspected, prompting endocrine evaluation. Further history revealed a 1-year history of progressive virilization, including increased facial hair and frontal balding. Hormonal studies demonstrated elevated testosterone (12.2 mmol/L and reference range 0.1–1.42) and dehydroepiandrosterone sulfate (15.9 µmol/L and reference range 0.510–5.560) and the adrenocorticotropic hormone level of 11.7 pmol/L (reference range 1.60–13.9) with suppressed gonadotrophins. Additional workup for catecholamine, cortisol, and aldosterone excess was unremarkable. The discordance between androgen excess and normal adrenal imaging, despite absent ovarian tissue, suggested an extraadrenal androgen-secreting steroid cell tumor. A second histopathology review and multidisciplinary discussion with radiology, gynecologic oncology, and pathology teams were undertaken. As the disease was deemed inoperable, repeat retroperitoneal lesion biopsy confirmed metastatic steroid cell tumor and guided palliative chemotherapy. She was subsequently referred to gynecologic oncology for systemic chemotherapy. Conclusion Extra-adrenal steroid cell tumors, though rare, should be considered in patients with hyperandrogenism long after bilateral oophorectomy, especially when adrenal imaging is normal. Multidisciplinary evaluation and repeat biopsy are often crucial for establishing the diagnosis and guiding treatment.
Hyperandrogenism ; Ovariectomy ; Steroids ; Neoplasms

Introduction: Central diabetes insipidus (CDI) is characterized by impaired arginine vasopressin secretion, resulting in hypotonic polyuria and hypernatremia. In patients with coexisting diabetes mellitus, persistent polyuria may be misattributed to hyperglycemia, delaying recognition of a concurrent water balance disorder. CDI without identifiable structural abnormalities may be overlooked, leading to delayed diagnosis and complications. Case: We report a 30-year-old Malay female with underlying type 2 diabetes mellitus and premorbid obesity who presented with hyperosmolar hyperglycemic state, accompanied by persistent polyuria, polydipsia, weight gain, and amenorrhea. Despite resolution of hyperglycemia, she had ongoing polyuria with hypernatremia, raising suspicion of a concomitant water balance disorder. Biochemical evaluation demonstrated a hyperosmolar state with serum osmolality 334 mOsm/kg and inappropriately dilute urine (urine osmolality 254 mOsm/kg), supporting impaired vasopressin activity. A modified water deprivation test showed a >50% rise in urine osmolality following desmopressin, consistent with CDI. Diabetes autoantibody screening was negative. Anterior pituitary function was preserved, with normal thyroid and adrenal axes (thyroidstimulating hormone 3.30 mIU/L, cortisol 290.6 nmol/L), and gonadotropins not suggestive of hypopituitarism (luteinizing hormone 6.8 IU/L, follicle-stimulating hormone 24.6 IU/L). Neuroimaging with computed tomography brain showed no structural hypothalamic–pituitary lesion. Magnetic resonance imaging of the pituitary demonstrated absence of the posterior pituitary bright spot, with preserved gland morphology and no focal lesion, supporting CDI without an identifiable structural cause. Her clinical course was complicated by severe hospitalacquired infection leading to septic shock, requiring intensive care support, mechanical ventilation, and renal replacement therapy. She was commenced on desmopressin, with subsequent clinical and biochemical improvement, alongside multidisciplinary management. Conclusion In patients with type 2 diabetes mellitus, persistent polyuria may obscure an underlying water balance disorder. This case highlights the importance of considering alternative causes of polyuria and a systematic endocrine approach to ensure accurate diagnosis and appropriate management.
Diabetes Mellitus, Type 2 ; Hyperglycemic Hyperosmolar Nonketotic Coma ; Diabetes Insipidus

Objectives: The integration of large language models (LLMs), particularly those based on the generative pre-trained transformer (GPT) architecture, has begun to revolutionize various fields, including dentistry. Despite these promising applications, the use of GPT in dentistry presents several challenges. Ongoing research and the development of robust ethical frameworks are essential to mitigate these issues and enhance the responsible deployment of GPT technologies in clinical settings. Hence, this systematic review aims to explore the trends, applications, strengths, and challenges associated with the use of GPT in dentistry. Methods: Articles were selected if they contained detailed information on the application of GPT in dentistry. The search strategy used in systematic reviews follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search of databases and other sources yielded a total of 704 studies. After removing duplicates and conducting a full-text screening, 16 articles were included in the review. The methodological quality of the research was evaluated using the Critical Appraisal Skills Programme (CASP) checklist. Results: Out of a total of 91 articles published on GPT in dentistry, 20 were editorials and 11 were narrative reviews; these were excluded, leaving 60 original research articles for further analysis. The articles were assessed based on the type of results they provided. Ultimately, 16 articles that reported positive findings with robust methodology were included in this review Conclusions The results highlight mixed responses; therefore, further research on integration into clinical workflows must be conducted with extensive methodological rigor.

Objectives: The integration of large language models (LLMs), particularly those based on the generative pre-trained transformer (GPT) architecture, has begun to revolutionize various fields, including dentistry. Despite these promising applications, the use of GPT in dentistry presents several challenges. Ongoing research and the development of robust ethical frameworks are essential to mitigate these issues and enhance the responsible deployment of GPT technologies in clinical settings. Hence, this systematic review aims to explore the trends, applications, strengths, and challenges associated with the use of GPT in dentistry. Methods: Articles were selected if they contained detailed information on the application of GPT in dentistry. The search strategy used in systematic reviews follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search of databases and other sources yielded a total of 704 studies. After removing duplicates and conducting a full-text screening, 16 articles were included in the review. The methodological quality of the research was evaluated using the Critical Appraisal Skills Programme (CASP) checklist. Results: Out of a total of 91 articles published on GPT in dentistry, 20 were editorials and 11 were narrative reviews; these were excluded, leaving 60 original research articles for further analysis. The articles were assessed based on the type of results they provided. Ultimately, 16 articles that reported positive findings with robust methodology were included in this review Conclusions The results highlight mixed responses; therefore, further research on integration into clinical workflows must be conducted with extensive methodological rigor.

Objectives: The integration of large language models (LLMs), particularly those based on the generative pre-trained transformer (GPT) architecture, has begun to revolutionize various fields, including dentistry. Despite these promising applications, the use of GPT in dentistry presents several challenges. Ongoing research and the development of robust ethical frameworks are essential to mitigate these issues and enhance the responsible deployment of GPT technologies in clinical settings. Hence, this systematic review aims to explore the trends, applications, strengths, and challenges associated with the use of GPT in dentistry. Methods: Articles were selected if they contained detailed information on the application of GPT in dentistry. The search strategy used in systematic reviews follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search of databases and other sources yielded a total of 704 studies. After removing duplicates and conducting a full-text screening, 16 articles were included in the review. The methodological quality of the research was evaluated using the Critical Appraisal Skills Programme (CASP) checklist. Results: Out of a total of 91 articles published on GPT in dentistry, 20 were editorials and 11 were narrative reviews; these were excluded, leaving 60 original research articles for further analysis. The articles were assessed based on the type of results they provided. Ultimately, 16 articles that reported positive findings with robust methodology were included in this review Conclusions The results highlight mixed responses; therefore, further research on integration into clinical workflows must be conducted with extensive methodological rigor.

Objective: The adoption of minimally invasive spine surgery techniques has increased globally over the past decade. These techniques are primarily used for percutaneous pedicle screw insertion. Surgeons in low socioeconomic settings often depend on fluoroscopy for accurate placement of percutaneous pedicle screws. Precise medial and sagittal angulation of the Jamshidi needle is essential to prevent misplacement during screw insertion. Here, we present a technique based on trigonometric calculations that allows the accurate determination of the medial angulation of the Jamshidi needle, using intraoperative measurement of the pedicle width at the targeted vertebral body. Methods: All patients who underwent percutaneous pedicle screw insertion using the described method between August 2023 and July 2024 were evaluated by 2 independent observers using computed tomography scan images. Pedicle violations were graded according to the Gertzbin-Robbins scale. The rates of pedicle perforation, significant errors in pedicle cannulation, and postoperative complications were analysed. Interrater reliability and the correlation between intraoperative pedicle width measurements and the medial angulation value of the Jamshidi needle were assessed statistically. Results: The mean age of the patients was 44.5 years. A total of 112 percutaneous pedicle screws were analysed. Among the 15 identified pedicle breaches, 9 were medial and 6 were lateral. The pedicle perforation rate was 13.4%. None of the patients with pedicle breaches developed significant postoperative complications. Interobserver agreement between the 2 evaluators was moderate (kappa coefficient, 0.597; p<0.001). There was a strong and statistically significant positive correlation between pedicle width measurement and the medial angulation value of the Jamshidi needle (r = +0.974, p<0.001). Conclusion The medial angulation of the Jamshidi needle for percutaneous pedicle screw insertion under fluoroscopy can be predicted using intraoperative pedicle width measurements. As the intraoperative pedicle width increases, the medial angulation required for the Jamshidi needle also increases.