Acute-on-chronic liver failure (ACLF) is a complex syndrome characterized by acute hepatic decompensation superimposed on pre-existing chronic liver disease or cirrhosis that is associated with acute worsening of portal hypertension, increased risk of infection, organ dysfunction and high short-term mortality. This Review provides a comprehensive update on definitions, pathophysiological mechanisms, clinical presentation and management of ACLF. The severe hepatic injury in ACLF triggers systemic inflammation, which is driven by damage-associated molecular patterns, gut-derived microbial products, and immunometabolic and functional dysregulation. Immune dysfunction can range from hyperinflammation and hypercytokinaemia to immune paresis, which in turn predisposes patients to infection and organ failure. The principles of ACLF management prioritize ameliorating the acute hepatic insult, managing portal hypertension, preventing organ failure and optimizing patients who are eligible for liver transplantation. Emerging options include novel therapies targeting immune modulation and liver regeneration, therapeutic plasma exchange and artificial liver support systems. Well-defined criteria for prompt interventions and selection of patients for transplantation within the first week after diagnosis — the ‘golden window’ — have improved outcomes of liver transplantation in patients with ACLF. The Kyoto ACLF Consensus reflects global efforts on unifying definitions, simplifying treatment end points, refining prediction tools, and filling the void of targeted non-transplantation interventions to improve outcomes in patients with ACLF; however, large knowledge gaps remain and further research is needed. Acute-on-chronic liver failure (ACLF) is a complex syndrome characterized by acute hepatic decompensation superimposed on pre-existing chronic liver disease or cirrhosis. This Review provides an update on definitions, pathophysiological mechanisms, clinical presentation and management of ACLF.
Hidradenitis suppurativa (HS) is a chronic, relapsing inflammatory skin disorder, affecting intertriginous areas and characterized by painful nodules, abscesses, fistulae, and scarring. Despite its impact on patients’ quality of life (QoL), HS remains underdiagnosed and mismanaged due to its heterogeneous clinical presentation. A panel of 14 Malaysian dermatologists, HS special interest group, developed a set of consensus-based recommendations on diagnosis, disease assessment, comorbidities, treatment, and follow-up care to improve HS management. A modified Delphi process was utilized to draft and finalize statements based on evidence sourced from literature between 2013 and 2023. The consensus highlights the importance of early recognition of HS clinical signs, differential diagnosis, and the use of validated tools such as Hurley staging, International HS Severity Score System, and Dermatology Life Quality Index to assess disease severity and QoL. Treatment recommendations for HS were stratified by disease severity, including topical, systemic, and biologic therapies, and surgical interventions for advanced cases. Adalimumab and secukinumab are currently the only approved biologics in Malaysia, showing sustained efficacy in moderate-to-severe HS. Adjunctive therapies such as zinc supplementation, lifestyle modifications, and wound care are also recommended. The consensus emphasizes a multidisciplinary approach to address the multifaceted nature of HS and optimize long-term outcomes, and aims to standardize HS care in Malaysia, promote early intervention, and enhance QoL for affected patients.
Purpose:Palliative care patients experience symptoms and concerns in the physical, psychological, social, and spiritual domains, which can negatively affect their quality of life. Understanding the prevalence of symptoms and problems is crucial in the face of increasing palliative care needs to tailor individualized patient-centered care plans. This study aimed to examine the prevalence and severity of symptom burden and explore the factors associated with high symptom burden in palliative care patients. Methods:This multicenter cross-sectional study included adult palliative care patients at the beginning of an episode of care across four palliative care units in Malaysia between July and September 2024. Demographic data, functional status, and the Integrated Palliative Care Outcome Scale (IPOS) were extracted from medical records and clinical databases. Results:This study recruited 405 patients with a mean age of 65.4±14.1 years and a slight predominance of men (53%) and cancer diagnoses (58%). Most patients were in the unstable phase of illness (62%), with 8.5±4.8 symptoms per patient. The most prevalent symptoms/concerns were family anxiety (86%), poor mobility (82%), and lethargy (80%). At least 50% of the patients had ≥5 items with an IPOS score ≥2. Cancer diagnosis (adjusted OR 2.350; 95% CI 1.030, 5.358) and unstable phase (4.272; 1.657, 11.011) were factors associated with severe overall and physical symptom burdens (≥1 item with IPOS score ≥2), after adjusting for other possible confounders. Conclusion:The prevalence and severity of symptoms and concerns among palliative care patients were high, suggesting complex needs.
Uncorrected refractive errors are a significant cause of preventable vision impairment in children, particularly in urban regions with high rates of myopia. Cycloplegic refraction is the clinical gold standard for accurately assessing pediatric refractive errors, but it remains inconsistently used in practice. This qualitative study examines the perspectives and experiences of eye care professionals (ECPs) in Kuala Lumpur to understand the practical, regulatory, and systemic barriers that influence the use of cycloplegia, complementing prior quantitative findings on practice disparities. A descriptive qualitative design was used. Semi-structured interviews were conducted with 20 ECPs (ophthalmologists, optometrists, and opticians) from both the public and private sectors. Interviews were transcribed verbatim and thematically analysed using an inductive–deductive approach with independent coding and AI-assisted verification. Five descriptive themes were synthesised and conceptually mapped into four higher-order domains: Environmental Institutional Factors, Family Socioeconomic Factors, Clinical Case-Based Practices, and Communication Collaboration. Participants described pediatric refraction as operationally complex and time-intensive, particularly for children under six. Use of cycloplegia varied according to patient age, case complexity, and practitioner confidence, with pragmatic decisions often replacing formal protocols. Regulatory ambiguity—especially the interplay between the Optical Act 1991 and the Poisons Act 1952—limits access to diagnostic drugs, particularly in the private sector. Some ECPs considered cycloplegia unnecessary in routine cases. Fragmented care pathways, multiple referrals, and out-of-pocket costs further constrained timely access for families, especially those on lower incomes. This study examines the underlying factors driving disparities in pediatric cycloplegic refraction observed in related quantitative research. Addressing regulatory ambiguities, strengthening inter-professional collaboration, and developing integrated “one-stop” pediatric vision care models may enhance access, continuity, and equity of care. Policy action is needed to reduce avoidable childhood visual impairment through earlier and more accurate refractive correction.
