Public interest in cognitive enhancement has driven the widespread availability of dietary supplements claiming to support brain health and memory. This comparative cross-sectional study explores the commercial availability and marketing claims of cognitive-enhancing dietary supplements across offline and online retail platforms. A dual-component design was employed in a comparative cross-sectional study. The first component involved assessing the commercial availability and marketing claims of cognitive-enhancing dietary supplements sold through offline retail outlets in Kuala Lumpur using a purposive sampling approach. The second component consisted of a parallel assessment conducted on online platforms, employing a convenience sampling strategy. A total of 13 products were identified on offline retail platforms in Kuala Lumpur, and 117 products were identified on online platforms. Capsules were the most common dosage form, both offline (46.2%) and online (79.5%). Products sold offline most frequently originated from Singapore (69.2%), whereas online products predominantly came from the United States of America (74.4%). The median prices of offline products were RM 190 (55.5), and online products were RM 196 (183), which are comparable, although the online products exhibited a wider price range (RM14–RM1,147). The most frequent claims were “brain health” for offline products and “memory” for online products. Natural or compound extracts were the most common active ingredients. This study’s findings found significant differences between offline and online dietary supplements in terms of availability, country of origin, price and marketing claims. These inconsistent findings underscore the need for stronger regulation and improved transparency in labelling to safeguard consumer health and ensure product credibility. Future research should focus on dosage accuracy, long-term safety, and mechanisms of action for supplements with cognitiveenhancing claims.

Case Report Open Access 15 Primary sternal osteosarcoma is an exceptionally rare entity with a male preponderance. We report a rare case of a 19 -year-old nulliparous female who presented with a two -year history of a progressively enlarging right breast mass. Multimodality imaging —including chest radiography, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) revealed a large mass arising from the sternum extending into the right breast and anterior mediastinum. Biopsy confirmed high - grade osteosarcoma, characterised by multinucleated giant cells and stromal cells with mild atypia. Immunohistochemistry was positive for vimentin and negative for CK7. Surgical resection was planned; however, the patient declined treatment. This case highlights the importance of considering rare diagnoses in atypical presentations of breast masses and underscores the value of imaging and histopathological correlation in diagnosis and management

Case Report Open Access 15 Primary sternal osteosarcoma is an exceptionally rare entity with a male preponderance. We report a rare case of a 19 -year-old nulliparous female who presented with a two -year history of a progressively enlarging right breast mass. Multimodality imaging —including chest radiography, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) revealed a large mass arising from the sternum extending into the right breast and anterior mediastinum. Biopsy confirmed high - grade osteosarcoma, characterised by multinucleated giant cells and stromal cells with mild atypia. Immunohistochemistry was positive for vimentin and negative for CK7. Surgical resection was planned; however, the patient declined treatment. This case highlights the importance of considering rare diagnoses in atypical presentations of breast masses and underscores the value of imaging and histopathological correlation in diagnosis and management

Introduction: Functioning gonadotroph adenomas, also known as follicle-stimulating hormone (FSH)-secreting pituitary adenomas (FSH-omas), are rare pituitary tumors characterized by the secretion of biologically active FSH. Unlike the more common clinically nonfunctioning gonadotroph adenomas, these tumors produce endocrine manifestations due to excessive FSH secretion. Clinical presentation may result from local mass effects such as headache, visual disturbances due to optic chiasmal compression, or from hormonal activity affecting reproductive function. The endocrine manifestations vary between males and females and can lead to diagnostic challenges. Cases: We report two patients with functioning gonadotroph adenomas presenting with distinct clinical manifestations. The first case involved a 23-year-old female who presented with secondary amenorrhea for 4 years, accompanied by personality changes. Abdominal ultrasound demonstrated bilaterally enlarged multicystic ovaries suggestive of ovarian hyperstimulation, which subsequently regressed postoperatively. Biochemical evaluation revealed inappropriately elevated FSH levels (3.5-fold increase), with suppressed luteinizing hormone (LH) and markedly elevated estradiol levels (11-fold increase). Pituitary magnetic resonance imaging (MRI) identified a large sellar–suprasellar mass with mass effect, consistent with a pituitary macroadenoma. The second case involved a 68-year-old male who presented with progressively worsening vision over 2 years. Hormonal evaluation demonstrated elevated FSH levels (4.5-fold increase), with relatively normal LH and low testosterone levels. Pituitary MRI revealed a sellar mass consistent with a pituitary adenoma. Both patients subsequently underwent pterional craniotomy with tumor debulking. Histopathological examination confirmed gonadotroph adenomas, with positive immunohistochemical staining for FSH. Conclusion Functioning gonadotroph adenomas are rare and may present with diverse clinical features related to gonadal hyperstimulation or mass effects. Early recognition of the characteristic hormonal profile and radiological findings is crucial for diagnosis and appropriate management. These cases highlight the importance of considering functioning gonadotroph adenoma in patients presenting with unexplained gonadal hyperstimulation or atypical reproductive hormonal profiles.
Gonadotrophs ; Adenoma

Introduction: Normotensive pheochromocytomas in Von Hippel-Lindau (VHL) syndrome present unique perioperative challenges. Standard alpha-blockade may induce intolerable orthostatic hypotension, making calcium channel blockers (CCB) a practical alternative. Furthermore, the primary intraoperative danger in these specific phenotypes may not be a hypertensive crisis, but profound vasoplegia. We report a VHL patient undergoing synchronous robotic surgery exhibiting this paradoxical hemodynamic response. Case: A 37-year-old female with VHL syndrome presented with an incidental 3.5-cm left adrenal mass and bilateral renal masses. Biochemistry confirmed a normotensive, noradrenergic pheochromocytoma (24-hour urine normetanephrines 4.2x upper limit of normal). Renal biopsy revealed a clear cell papillary renal cell tumor. Due to prior severe intolerance to Prazosin (hypotension/dizziness with low-dose Prazosin 0.5 mg ON), we utilized amlodipine for preoperative optimization. She was only able to tolerate low-dose 2.5 mg OD alongside oral sodium chloride and ample oral fluid loading. She underwent a synchronous robotic-assisted left adrenalectomy and left midpole renal tumor excision. Strikingly, tumor manipulation did not precipitate a hypertensive crisis. Instead, she developed hypotension requiring an intravenous noradrenaline infusion prior to adrenal vein ligation and tumor removal. Vasopressor support was successfully weaned 12 hours postoperatively, and she was discharged well. Conclusion Normotensive, noradrenergic pheochromocytomas in VHL are hemodynamically fragile. Chronic catecholamine excess induces homologous desensitization and downregulation of alpha-1 adrenergic receptors. This physiological adaptation explains the normotensive presentation and highlights the intraoperative vasoplegia experienced once sympathetic tone is altered by anesthesia. While CCB monotherapy with volume expansion safely facilitates prolonged, synchronous robotic surgeries, clinicians must anticipate and combat refractory hypotension rather than classical hypertensive spikes.

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

Introduction: Pituitary apoplexy is a rare but potentially life-threatening endocrine emergency caused by hemorrhage or infarction of the pituitary gland. Its presentation often mimics other acute neurological conditions, posing diagnostic and management challenges. We report a case series of three patients presenting with similar neuro-ophthalmic complaints but differing in symptom onset and radiological features. Cases: The first case was a 25-year-old obese female who presented with acute headache, fever, and right eye ptosis with complete ophthalmoplegia for 2 days. Imaging demonstrated a heterogeneous pituitary macroadenoma with superimposed hemorrhage. Cortisol, prolactin, and insulin-like growth factor-1 levels were low. She received hydrocortisone replacement and underwent left pterional craniotomy with tumor debulking, resulting in marked visual improvement. The second case involved a 59-year-old male who presented with headache and bilateral blurred vision for 1 week, followed by acute right-sided ptosis. Imaging showed a heterogeneous sellar-suprasellar mass compressing the optic chiasm. He had central hypocortisolism, hypothyroidism, and hyponatremia. Surgical intervention was declined, and outpatient follow-up showed stable neuro-ophthalmic findings. The third case was a 30-year-old female who presented with a 2-week history of headache and right-sided blurred vision with temporal hemianopia. Imaging revealed a sellar-suprasellar mass with fluid-fluid levels compressing the optic chiasm. She had central hypocortisolism, hypothyroidism, and hypogonadism. Hydrocortisone replacement was initiated, followed by transsphenoidal surgery with tumor debulking. Her vision improved after the surgery. Conclusion Pituitary apoplexy may present with similar clinical features despite differing onset and radiological characteristics. Early corticosteroid therapy is essential, while surgical intervention should be reserved for patients with severe or progressive neuro-ophthalmic deficits. This case series highlights the importance of individualized, multidisciplinary management to achieve favorable outcomes.
Pituitary Apoplexy

Introduction: A common diagnostic error is the tendency to attribute new symptoms directly to the most obvious laboratory abnormality. In pregnancy, a suppressed thyroidstimulating hormone (TSH) with elevated free T4 is frequently presumed to indicate primary hyperthyroidism, overlooking the possibility of benign gestational transient thyrotoxicosis (GTT). We report a case where this pattern led to the misattribution of acute flaccid paralysis to thyrotoxic periodic paralysis, critically delaying the diagnosis of Guillain-Barré syndrome (GBS). Case: A 21-year-old female Malay primigravida at 19 weeks and 5 days presented with a 2-week history of progressive, descending bilateral lower limb weakness culminating in paralysis, associated with vomiting and 5 kg weight loss. On admission, she was febrile (38.0°C) and tachycardic (150 bpm). Neurological examination revealed proximalpredominant flaccid paralysis and hyporeflexia with intact sensation, without thyroid eye signs or goiter. Thyroid function tests showed profound thyrotoxicosis (TSH <0.005 mIU/L, free thyroxine 4 20.16 pmol/L) with hypokalemia (2.9 mmol/L). A neck ultrasound was normal. A provisional diagnosis of thyrotoxic periodic paralysis with impending storm was made, leading to treatment with potassium replacement, propylthiouracil, and hydrocortisone. Despite biochemical improvement, her paralysis persisted. On day 5, she developed acute bulbar palsy and respiratory failure requiring intubation. A subsequent comprehensive workup for infectious, autoimmune (including thyroid antibodies), and nutritional causes was unremarkable. Nerve conduction studies confirmed the acute motor axonal neuropathy (AMAN) variant of GBS. Treatment with a 5-day course of intravenous immunoglobulin resulted in neurological improvement and successful extubation. Conclusion This case highlights the critical pitfall of prematurely attributing acute neurological deficits to abnormal thyroid function tests in pregnancy. Biochemical thyrotoxicosis, including GTT, should not preclude urgent evaluation for life-threatening neurological conditions such as GBS, particularly when weakness is progressive or refractory to metabolic correction.
Female ; Pregnancy ; Thyroid Function Tests

Introduction: Nephrogenic syndrome of inappropriate antidiuresis (NSIAD) is an uncommon X-linked genetic condition marked by euvolemic hyponatremia, which arises from a gain-of-function mutation in the arginine vasopressin receptor type 2 (AVPR2) gene. In contrast to the classic syndrome of inappropriate antidiuretic hormone secretion (SIADH), NSIAD is characterized by urine that is inappropriately concentrated even when arginine vasopressin (AVP) levels are low or undetectable. Failure to recognize NSIAD may result in recurrent hyponatremia and neurological morbidity. Case: A 2-year-old male was referred to us after recurrent vomiting and subsequently developed generalized tonicclonic seizures due to hyponatremia (with a sodium level of 115 mmol/L). He needed sodium replacement through an intravenous drip of 3% saline and was stabilized with oral sodium chloride 20%. Urine osmolality was elevated, serum osmolality remained normal, and copeptin levels were low. He was discharged after a 10-day hospital stay. During follow-up, hyponatremia recurred despite his typical fluid intake of 1,200 mL/day. He was instructed to limit his fluid intake to 600–700 mL, which successfully normalized his serum sodium levels. Serum levels of adrenocorticotropic hormone, the aldosterone-to-renin ratio, thyroid function tests, and serum cortisol were all within normal ranges. Plasma AVP was unusually low (4.0 pmol/L). Whole exome sequencing (WES) confirmed a likely pathogenic hemizygous variant in AVPR2 gene located on chromosome Xq28, which was inherited from his mother. He is the only child, born from a non-consanguineous marriage, with no other significant family medical history. Conclusion Nephrogenic syndrome of inappropriate antidiuresis (NSIAD), is an uncommon, yet clinically significant condition. This case highlights the importance of considering a broad range of differential diagnoses when a patient presents with hyponatremic seizure. Furthermore, obtaining a detailed family history is essential to identify potential hereditary factors that could contribute to the condition and for genetic counseling.
Child ; Nephrogenic Syndrome of Inappropriate Antidiuresis

Purpose: This study was performed to evaluate the antiadhesive effect and safety of a novel adhesion barrier device (ABD) in comparison to other commercially available anti-adhesion products. Methods: A 4-arm, controlled, blinded, experimental, and murine model study design was used. Forty male Sprague Dawley rats were randomly allocated to Interceed, Seprafilm, ABD, and control groups (n = 10/group). Abdominal cavity trauma was induced in all rats. Interceed, Seprafilm, or the ABD were applied to the injury site of each rat according to their respective groups, the control group received no intervention. Results: Twenty-one days after the operation, surgical adhesion severity and area scores were significantly reduced in the Interceed, Seprafilm, and ABD groups compared to the control group (P = 0.016, P < 0.001, P < 0.001, respectively), and in the ABD group compared to the Interceed group (P = 0.036). No significant difference was observed between the ABD and Seprafilm groups (P = 0.070). Additionally, in the ABD group, no remnants of the ABD were observed at the injury site, and no hematological abnormalities were present. Conclusion The ABD has the potential to improve postsurgical peritoneal adhesions compared to Interceed and has comparable effectiveness compared to Seprafilm. The ABD may be a valuable option to reduce surgical failure. Further studies in human subjects are warranted to determine the clinical application and safety of the ABD for commercialization.