Hospital Kuala Lumpur

Despite treatment, many hypertensive patients with coronary heart disease (CHD) have blood pressure (BP) that remains above guideline targets. However, less is known about patients in whom on-treatment BP is below target and major European guidelines differ substantially in their recommendations for such patients. Specifically, 2023 European Society of Hypertension (ESH) guidelines provide a Class 3 recommendation to proactively avoid BP below target whereas 2024 European Society of Cardiology (ESC) guidelines do not. Between 2020 and 2023, adults hospitalised in the previous 6-24 months with incident or recurrent CHD were sampled in 14 countries from all six WHO regions and invited for a standardised interview and examination as part of the International Action on Secondary and Primary Prevention by Intervention to Reduce Events (INTERASPIRE) study. We measured seated BP twice using an automated oscillometric device after 5 min of rest. We defined participants as having BP above target (BP ≥130/80 mm Hg), at target (BP 120-129/70-79 mm Hg) or below target (<120/70 mm Hg); according to both 2023 ESH and 2024 ESC guidelines. Among 4548 participants (21.1% female), the mean age (±SD) was 60.0 (±10.3) years. At a median (IQR) of 1.05 (0.76-1.45) years after index CHD hospitalisation, 10.3% of patients had BP readings within the target range of 120-129/70-79 mm Hg, with 53.9% above target and 35.7% below target. Patients with below-target BP were more likely to have heart failure (13.6% vs 10.0%, p=0.041) and estimated glomerular filtration rate <60 mL/min/1.73 m² (18.9% vs 10.7%, p<0.001), when compared with those at target. They were also statistically more likely to be severely frail (p=0.030). The median number of BP-lowering medications did not differ significantly between the 3 BP target groups. Cumulative dosing of BP-lowering medications in the below-target group was also not more intensive than that in the at-target group. More than one-third of INTERASPIRE patients with CHD presented with BP <120/70 mm Hg, which is below target per current European hypertension guidelines. Further research is needed in this population to resolve discordant guideline recommendations and determine whether de-escalation of BP-lowering therapies is beneficial or even harmful in this setting.

Background/Objectives: Isolated methylmalonic acidemia (iMMA) is a rare autosomal recessive metabolic disorder caused by defects in methylmalonyl-CoA mutase (MCM) activity or in the biosynthesis of its cofactor, adenosylcobalamin. Mutations in five genes-MMUT, MMAA, MMAB, MMADHC, and MCEE-are known to underlie this condition. This study aimed to characterize the clinical features and molecular spectrum of iMMA in Malaysian patients of diverse ethnic backgrounds. Material and Methods: Patients with biochemical evidence suggestive of iMMA, including elevated propionylcarnitine (C3), increased C3/C2 ratio, and raised urine methylmalonic acid levels in the absence of hyperhomocysteinemia, were selected for genetic testing. Sanger sequencing was performed to identify pathogenic variants in the MMUT, MMAA, MMAB, MMADHC, or MCEE genes. Results: The cohort consisted predominantly of Iban patients (n = 5), with the remaining cases comprising one Malay and one Thai-Malay individual. Age at diagnosis ranged from Day 1 of life to 6 years. All 7 patients were confirmed to have iMMA through molecular analysis. A total of seven pathogenic or likely pathogenic variants were identified, including two novel MMUT variants (c.246_250delinsGA and c.1358G>C), four known MMUT variants (c.560C>G, c.693C>G, c.982C>T, c.1106G>A), and one known MMAB variant (c.644+1G>A). Clinical presentation and disease severity varied across cases, reflecting underlying genotypic heterogeneity. Conclusions: This study highlights the molecular diversity and clinical variability of iMMA in Malaysia. Our findings reinforce the importance of integrating metabolic screening with molecular diagnostics to identify disease-causing variants and guide patient management strategies effectively.

Previous studies of antidepressant prescribing patterns largely were limited to a single location or time, and very few involved Asia. This Asian Psychotropic Prescription Patterns Consortium study investigated pharmacoepidemiologic trends and factors associated with use and dosing of newer antidepressants across 12 Asian sites in 2003, 2013, and 2023. Data from each site included demographic, treatment setting, clinical features, and type and dosage of antidepressants prescribed. Sociodemographic and clinical variables were examined using univariate methods, followed by multivariable logistic and linear modeling. Of 8357 adult participants (59.8% female), 82.8% received at least one modern antidepressant. Use of these drugs was strongly associated with more recent year, younger age, inpatient status, and affective or anxiety-related disorders. Higher daily antidepressant doses were associated with inpatient status, male gender, more recent year, and younger age. This large, multisite study provides a two-decade overview of evolving antidepressant-prescribing patterns in 12 Asian sites and highlights patient characteristics associated with prescription of newer antidepressants and their dosage. Needed are further studies of psychotropic prescribing practices related to specific illness subtypes and their impact on psychosocial functioning over time among Asian patients.

Pulmonary tuberculosis (PTB) remains a major global health challenge, particularly in low- and middle-income countries where it contributes significantly to morbidity and mortality. Hemoptysis is a common complication of PTB and may result from a variety of mechanisms, including vascular involvement. Rasmussen aneurysm, a pseudoaneurysm of the pulmonary artery adjacent to a tuberculous cavity, represents a rare but potentially fatal cause of hemoptysis. We report a Malaysian patient with smear-positive PTB complicated by Rasmussen aneurysm, successfully managed with selective pulmonary artery embolization. This case highlights the importance of early recognition and advanced imaging with CT pulmonary angiography to establish diagnosis and guide therapy. In addition, we performed a comprehensive review of published reports and studies on Rasmussen aneurysm to emphasise the diagnostic challenges, summarise management strategies, and highlight why this entity remains underdiagnosed, particularly in resource-limited settings.

Bloodstream infections in older persons are associated with greater morbidity and mortality. Older individuals often present with atypical symptoms, such as lethargy, poor oral intake, or falls, rather than classical signs like fever or localized symptoms. This study aims to evaluate the clinical characteristics of older persons admitted with bacteraemia and identify predictors of in-hospital mortality. A retrospective observational cohort study was conducted at a tertiary hospital. Patients admitted to the geriatric ward with bacteraemia over a 1.5-year study period were included in the study. Demographic, clinical, and laboratory data were collected and analyzed to identify independent predictors for in-hospital mortality. A total of 185 older patients were included in this study. Presentations were frequently non-specific, with 33.5% of the patients not fulfilling Systemic Inflammatory Response Syndrome (SIRS) criteria on admission. Advanced age (≥ 76 years old), hypalbuminaemia (< 20 g/L), elevated lactate (> 2 mmol/L), delirium, and absence of SIRS criteria were independently associated with increased in-hospital mortality of the older patients with bacteraemia. Due to immunosenescence and age-related physiological changes, older persons often present atypically and may have normal vital signs or laboratory values despite severe infection. Clinicians should maintain a high index of suspicion for sepsis in older patients, even in the absence of classical symptoms, to enable timely diagnosis and management.

Autism spectrum disorder (ASD) prevalence estimates vary widely across countries and over time, partly due to differences in the screening and diagnostic tools used. This study combined bibliometric analysis and systematic review methods to examine global publication trends and evaluate the use of standardized assessment tools in ASD prevalence studies involving school-aged children (typically 6-12 years). A bibliometric search of the Scopus database (2015-2025) identified 107 publications, which were analyzed for citation patterns, research themes, and geographic distribution. Of these, 18 studies met systematic review inclusion criteria, reporting ASD prevalence in the general population and high-risk samples across diverse regions. The most frequently used screening tools were the Social Communication Questionnaire (SCQ) and Childhood Autism Spectrum Test (CAST), while gold-standard diagnostic tools such as the Autism Diagnostic Observation Schedule (ADOS/ADOS-2) and Autism Diagnostic Interview-Revised (ADI-R) were common for diagnostic confirmation. However, psychometric performance and cultural adaptation processes varied, and many tools were not validated for the study population. Tool selection and adaptation were found to directly influence prevalence estimates, with implications for research comparability and policy planning. Findings highlight the need for culturally validated instruments, standardized sampling approaches, and increased representation of low- and middle-income countries in ASD prevalence research to ensure equitable and accurate identification.

We performed a comprehensive systematic review and meta-analysis of repetitive transcranial magnetic stimulation (rTMS) to explore its use as an adjunctive therapy for adult patients with drug-resistant epilepsy (DRE). Following PRISMA guidelines, PubMed and Ovid MEDLINE databases were searched until January 2025 for English-language studies reporting pre- and post-rTMS seizure frequencies and detailed protocols in adult patients with DRE. Random-effects meta-analyses pooled standardized mean differences in weekly seizure frequency at immediate, 4-week, and 8-week follow-ups. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools, and evidence certainty was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Oxford Centre for Evidence-Based Medicine (OCEBM) frameworks. 12 studies involving 150 participants were included, with seven contributing to the meta-analysis. Meta-analysis demonstrated a small but statistically significant reduction in seizure frequency at 4 and 8 weeks following rTMS (pooled SMD -.49 [95% CI -.98 to -.01, p = .46] and -.19 [95% CI -.35 to -.02, p = .91]), with insignificant heterogeneity (I2 = 0%). In contrast, no statistically significant difference was observed immediately after rTMS (pooled SMD .19 [95% CI -1.69 to 1.31, p = .38]). Common adverse effects included headaches (14%-33%) and hearing problems (9%-14%). Quality of life improved significantly in two of three studies, and one study reported depression improvement in 67% of participants. Risk of bias was low in three studies, moderate in five, and high in four. rTMS use as adjunctive therapy for DRE demonstrated moderate (GRADE level 2) and low-quality (OCEBM level 3) evidence. rTMS was associated with modest reductions in seizure frequency in selected populations. However, effect sizes were small and heterogeneous. Larger, prospective, multicenter studies are needed to further evaluate its efficacy. International Prospective Register of Systematic Reviews (PROSPERO) (ID #CRD42024553998).

Abstract Kuala Lumpur has taken bold steps to embed sustainability within its urban planning policies and development frameworks, aiming for a 70% reduction in CO 2 emissions by 2030 and near-zero emissions by 2050 (DBKL, 2021), in line with the KL Low Carbon Society Blueprint, one of the most recent innovations supporting this agenda is the KL Low Carbon Building Checklist (KLLCBC), introduced by DBKL as a structured tool for assessing compliance with low-carbon design principles. This paper presents a comprehensive review of the KLLCBC, examining its origin, structure, application, and future roadmap toward digital implementation. Findings from policy reviews, case study applications, and stakeholder interviews indicate that the KLLCBC plays a vital role in supporting sustainable development and offers a scalable model for other municipalities. The paper further explores the checklist’s relevance to the UN Sustainable Development Goals (SDGs), particularly SDG 11 and SDG 13, and outlines recommendations to support its evolution into a web-based decision-support platform.