Introduction: Diabetic ketoacidosis (DKA) is a life-threatening complication associated with significant morbidity and healthcare burden. Despite advances in diabetes care, recurrent DKA remains common, often reflecting gaps in treatment adherence and patient education. Identifying predictors of recurrence is crucial for risk stratification and targeted intervention. Methodology: We conducted a retrospective observational study of all adult DKA admissions to a tertiary centre between 2001 and 2025. Electronic medical records were reviewed for demographic data, biochemical parameters, precipitating factors, and clinical outcomes. DKA was defined using standard biochemical criteria. Recurrent DKA was defined as ≥2 admissions during the study period. Factors associated with recurrent DKA admissions were analyzed. Patients under the age of 18 years and those with missing vital information were excluded. Results: A total of 667 DKA admissions, comprising 566 patients, were identified, of which 101 admissions (15.1%) were recurrent, involving 65 patients. Among recurrent DKA episodes, the most common precipitating factors were infection (64.4%) and insulin omission (62.4%). After multivariate analyses, patients with type 1 diabetes mellitus (T1DM) were more likely to develop recurrent DKA compared to those with type 2 diabetes mellitus (aOR 4.16; 95% confidence interval [CI] 2.58–6.70; p <0.001). Insulin omission was strongly associated with recurrent DKA (aOR 2.29; 95% CI 1.46–3.60; p <0.001). In contrast, baseline glycated hemoglobin and chronic kidney disease were not significantly associated with recurrence. Diabetic counseling during the first DKA admission did not reduce recurrent DKA. There were no significant differences in mortality (3.9% vs 6.2%, p = 0.524) or critical care admission rates (40.6% vs 38.7%, p = 0.718) between recurrent and first DKA episodes. Conclusion Recurrent DKA accounts for a substantial proportion of DKA admissions and is strongly associated with insulin omission and T1DM. Our findings suggest that recurrent DKA is driven predominantly by behavioral and adherencerelated factors, indicating the need for multidisciplinary interventions beyond standard inpatient counseling.
Diabetic Ketoacidosis ; Retrospective Studies

Introduction: The rising incidence of diabetic ketoacidosis (DKA) in type 2 diabetes mellitus (T2DM) represents a paradigm shift from its traditional recognition as a hallmark complication of type 1 diabetes mellitus (T1DM). However, contemporary data comparing clinical presentation, precipitating factors, and outcomes between these two populations remain limited. Methodology: In this retrospective observational study, all adult DKA admissions with T1DM or T2DM at a tertiary centre between 2001 and 2025 were studied. DKA was defined according to standard biochemical criteria. Electronic medical records were reviewed to extract demographic data, biochemical parameters, precipitating factors, management details, and clinical outcomes of all adult DKA admission in T1DM and T2DM. Patients aged <18 years or those with incomplete data were excluded. Results: A total of 601 DKA episodes were analyzed, comprising 130 (21.6%) in patients with T1DM and 471 (78.4%) in those with T2DM. Mean age was 26.9 ± 0.71 years for T1DM and 52.1 ± 0.7 years for T2DM. Gender distribution was balanced (male 48.3%, female 51.7%). Mean hemoglobin A1c (HbA1c) was 11.3 ± 0.3% in T1DM and 12.1 ± 0.2% in T2DM. Infection was the most common precipitating factor overall (69.0%), occurring more frequently in T2DM than in T1DM (74.7% vs. 56.2%), followed by medication non-adherence (62.4% vs. 43.8%). Significant differences were observed between groups in admission pH, bicarbonate (both p <0.001), blood ketones (p = 0.028), and HbA1c (p = 0.010), whereas anion gap (p = 0.056) and blood glucose levels (p = 0.755) did not differ significantly. Clinical outcomes were comparable with respect to intensive care unit (ICU) admission rates (40.0% in T1DM vs. 39.0% in T2DM, p = 0.779) and median resolution time (p = 0.462). However, the median length of hospital stay was significantly longer in T2DM (8.2 ± 0.32 vs. 5.4 ± 0.4 days; p <0.001). Overall mortality was 6.0%, with substantially higher mortality in T2DM compared to T1DM (7.4% vs. 0.8%, p = 0.013). Conclusion In this large regional series of adult DKA, most episodes occurred in T2DM. Despite similar ICU admission rates and time to resolution, T2DM was associated with more frequent infection-related precipitants, longer hospital stays, and higher mortality, underscoring the need for targeted preventive strategies in this population.
Adult ; Diabetes Mellitus, Type 1 ; Diabetic Ketoacidosis ; Diabetes Mellitus, Type 2

Introduction: Diabetic ketoacidosis (DKA) in pregnancy is an uncommon yet life-threatening emergency, with disproportionate risks to both mother and fetus. Pregnancy-specific physiological changes predispose patients to rapid metabolic decompensation, often with atypical presentations. Despite this, local data remain limited. We describe the clinical profile, precipitating factors, and outcomes of DKA in pregnancy in a tertiary centre, with emphasis on potentially preventable triggers. Cases: Nine pregnant patients with DKA were identified from a retrospective review of all cases admitted for DKA from 2002 to 2025. Mean age was 31.67 ± 5.20 years; all were Malay. The majority had type 2 diabetes mellitus (55.6%), followed by type 1 diabetes (33.3%) and latent autoimmune diabetes in adults (11.1%). The mean period of amenorrhea was 19.67 ± 12.62 weeks. Infection was the leading precipitant (44.4%), with additional triggers including insulin omission (22.2%), hyperemesis gravidarum, preterm labor, steroid exposure, and perioperative fasting. Most diagnoses were made in the emergency department (55.6%). Biochemical parameters reflected significant severity (mean bicarbonate 7.89 ± 2.98 mmol/L; anion gap 25.00 ± 5.81), with 88.9% classified as severe DKA. Intensive Care Unit (ICU) care was required in 77.8% of cases. The majority (77.8%) were admitted to the ICU unit, with a median time to resolution of 13.00 ± 12.00 hours (interquartile range [IQR]), and the median hospital length of stay was 7.00 ± 5.00 days (IQR). Complications during treatment included hypokalemia (33.3%), acute kidney injury (22.2%), and hypoglycemia (11.1%). Rebound DKA occurred in one-third of patients. All patients were discharged clinically stable. Outcome data demonstrated pregnancy loss in three cases and one preterm birth. Conclusion DKA in pregnancy remains a severe and resource-intensive condition. This series highlights missed opportunities in prevention, with modifiable precipitants such as infection and insulin omission commonly identified. The high severity at presentation suggests delays in recognition. Early detection, optimized metabolic care, and targeted preventive strategies are crucial to improving maternal and fetal outcomes.
Female ; Pregnancy ; Diabetic Ketoacidosis

A series of comprehensive focus group discussions with active firefighters revealed that inconsistencies in incorporating a rigorous physical training program during work hours contributed significantly to the challenges of maintaining functional fitness, particularly strength. This article outlines a process for identifying the specific exercises required to enhance strength, drawing on the expertise and experience of physical trainers. Modified nominal group technique (mNGT) sessions were conducted to identify and rank exercises for five functional strengths (i.e., pushing, pulling, lifting, carrying, and dragging). A total of six physical trainers from the firefighter academy were interviewed to 1) identify the skeletal muscles involved in the functional movements using a visual aid; 2) generate ideas for exercises via brainstorming; 3) privately rank the displayed list of exercises for each muscle group involved in each functional movement; and 4) design a physical training programme for beginner, intermediate and advanced levels by manipulating loads. Males dominated the expert group (66.7%) and had a mean of 11.50 (SD 5.20) years of experience in physical training. The mNGTs yielded three top-ranking exercises for each functional strength: 1) Pushing: the push-up, sit-up, and jumping jack; 2) pulling: the push-up, jumping jack, and sit-up; 3) lifting: the jumping jack, push-up, and jumping squat; 4) carrying: the push-up, plank, and sit -up; and 5) dragging: the jumping jack, sit-up, and jumping squat. Then each exercise was designed for the beginner, intermediate, and advanced levels by manipulating loads (i.e. additional weight or number of repetitions). This study demonstrated that mNGT is an effective tool for identifying the three top-ranking exercises that address firefighter recruits’ functional strength. The experts chose multi-joint exercises targeting agonist and antagonist skeletal muscle groups and mimicking movements of daily work life. The exercises, corroborated by previous empirical evidence, provide opportunities for common skeletal muscle groupings to be targeted simultaneously to increase cardiovascular adaptations over a shorter period. The physical exercise is now ready to be implemented for piloting purposes among firefighter recruits.

Menawan Gunung Kinabalu: Penyakit Altitud Tinggi dan Langkah-Langkah Pencegahan PengenalanGunung Kinabalu, puncak tertinggi di Malaysia dengan ketinggian 4095 meter, merupakan destinasi popular bagi pendaki tetapi boleh mendatangkan risiko penyakit berkaitan altitud kepada para pendaki. Artikel ini bertujuan untuk membincangkan penyakit altitud tinggi dan langkah-langkah pencegahan yang boleh diambil oleh pendaki sebelum, semasa dan selepas pendakian dari segi perubahan mekanisme fisiologi.MetodologiSatu kajian literatur secara komprehensif telah dijalankan, dengan fokus kepada simptom, gejala, dan pencegahan penyakit altitud dalam kalangan pendaki. Maklumat dikumpulkan dari jurnal yang disemak oleh rakan sejawat, laporan teknikal pendakian, dan kajian lapangan berkaitan dengan Gunung Kinabalu dan pendakian di altitud tinggi.Hasil KajianPenyakit altitud tinggi seperti penyakit ketinggian akut, high-altitude cerebral oedema, high-altitude pulmonary oedema, dan beberapa penyakit lain dikupas dengan lebih mendalam. Selain itu, faktor risiko penyakit altitud tinggi turut dikenal pasti. Strategi pencegahan yang dibahagikan kepada sebelum, semasa, dan selepas pendakian kemudian dibincangkan. Antara langkah pencegahan yang berkesan termasuk persediaan fizikal badan, konsultasi dan penilaian kesihatan komprehensif pra-pendakian, aklimatisasi secara beransur-ansur, mengekalkan hidrasi, dan penggunaan ubat profilaksis seperti acetazolamide dan dexamethasone..KesimpulanSetiap pendaki yang ingin menawan gunung altitud tinggi seperti Gunung Kinabalu perlu fahami risiko penyakit altitud tinggi. Langkah pencegahan yang bersesuaian dan mencukupi bukan sahaja mampu mengurangkan risiko penyakit altitud tinggi, tetapi berjaya menawan puncak Gunung Kinabalu dan pulang dengan selamat.

The orbital tubercle, also known as Whitnall’s tubercle, was first described by S.E. Whitnall in 1911 and is a significant anatomical landmark on the zygomatic bone that serves various structural and clinical functions. Understanding its anatomy is essential for protecting adjacent soft tissues during surgical procedures and its role in forensic studies. This study aims to assess the prevalence, precise location, and morphological characteristics of Whitnall’s tubercle in adult human skulls. A cross-sectional observational study was conducted on 108 orbital fossae of 54 well-preserved adult human skulls.Whitnall’s tubercle was classified as apparent if visible or non-apparent if detectable only by palpation. Its dimensions and distances from nearby anatomical landmarks were measured. Statistical analyses were performed to compare measurements between sides. Whitnall’s tubercle was present in 106 (98.1%) out of 108 examined orbital fossae, with 67 classified as apparent and 39 as non-apparent. The mean longitudinal length was 6.59±0.99 mm on the right and 6.86±1.30 mm on the left (P=0.025), while the transverse lengths showed no significant difference (P=0.63). The majority of Whitnall’s tubercle presented an oval shape (92.5%), with no significant difference between sides (P=0.63). The distances between Whitnall’s tubercle and selected anatomical landmarks showed minor variations, but none reached statistical significance. This study provides valuable insights into the anatomical characteristics of Whitnall’s tubercle, emphasizing its clinical relevance in orbital surgery and forensic applications. Understanding these features can enhance surgical precision and improve patient outcomes.

The coronavirus disease 2019 pandemic has fundamentally reshaped anatomy education, offering invaluable insights to guide the future of anatomy pedagogy. As we transition into a post-pandemic era, it is crucial to integrate the lessons learned to create a more resilient, flexible, and effective educational environment. This paper examines the transformative strategies implemented at Universiti Sains Malaysia during the pandemic, focusing on the empowerment of blended learning, technology-enhanced tools, student-centered learning practical sessions, and enhancement of formative assessment. These strategies include integrating digital learning resources, such as the Virtual Anatomy Museum and online histology quizzes, with in-person instruction, fostering a supportive and interactive learning environment. Additionally, practical sessions were redesigned to emphasize collaborative learning, peer teaching, and developing critical thinking and communication skills. Formative assessments were integrated to provide continuous feedback and support ongoing learning. This comprehensive approach not only enhanced students’ understanding of anatomical concepts but also improved their emotional well-being and overall learning experience. The lessons learned from the pandemic have paved the way for a more innovative and adaptive anatomy education that is well-prepared for future challenges.

The coronavirus disease 2019 pandemic has fundamentally reshaped anatomy education, offering invaluable insights to guide the future of anatomy pedagogy. As we transition into a post-pandemic era, it is crucial to integrate the lessons learned to create a more resilient, flexible, and effective educational environment. This paper examines the transformative strategies implemented at Universiti Sains Malaysia during the pandemic, focusing on the empowerment of blended learning, technology-enhanced tools, student-centered learning practical sessions, and enhancement of formative assessment. These strategies include integrating digital learning resources, such as the Virtual Anatomy Museum and online histology quizzes, with in-person instruction, fostering a supportive and interactive learning environment. Additionally, practical sessions were redesigned to emphasize collaborative learning, peer teaching, and developing critical thinking and communication skills. Formative assessments were integrated to provide continuous feedback and support ongoing learning. This comprehensive approach not only enhanced students’ understanding of anatomical concepts but also improved their emotional well-being and overall learning experience. The lessons learned from the pandemic have paved the way for a more innovative and adaptive anatomy education that is well-prepared for future challenges.

The coronavirus disease 2019 pandemic has fundamentally reshaped anatomy education, offering invaluable insights to guide the future of anatomy pedagogy. As we transition into a post-pandemic era, it is crucial to integrate the lessons learned to create a more resilient, flexible, and effective educational environment. This paper examines the transformative strategies implemented at Universiti Sains Malaysia during the pandemic, focusing on the empowerment of blended learning, technology-enhanced tools, student-centered learning practical sessions, and enhancement of formative assessment. These strategies include integrating digital learning resources, such as the Virtual Anatomy Museum and online histology quizzes, with in-person instruction, fostering a supportive and interactive learning environment. Additionally, practical sessions were redesigned to emphasize collaborative learning, peer teaching, and developing critical thinking and communication skills. Formative assessments were integrated to provide continuous feedback and support ongoing learning. This comprehensive approach not only enhanced students’ understanding of anatomical concepts but also improved their emotional well-being and overall learning experience. The lessons learned from the pandemic have paved the way for a more innovative and adaptive anatomy education that is well-prepared for future challenges.

BACKGROUND: Mesenchymal stem cells (MSCs) have undergone extensive investigation for their potential therapeutic applications, primarily attributed to their paracrine activity. Recently, researchers have been exploring the therapeutic potential of extracellular vesicles (EVs) released by MSCs. METHODS: MEDLINE/PubMed and Google scholar databases were used for the selection of literature. The keywords used were mesenchymal stem cells, extracellular vesicles, clinical application of EVs and challenges EVs production. RESULTS: These EVs have demonstrated robust capabilities in transporting intracellular cargo, playing a critical role in facilitating cell-to-cell communication by carrying functional molecules, including proteins, RNA species, DNAs, and lipids. Utilizing EVs as an alternative to stem cells offers several benefits, such as improved safety, reduced immunogenicity, and the ability to traverse biological barriers. Consequently, EVs have emerged as an increasingly attractive option for clinical use. CONCLUSION From this perspective, this review delves into the advantages and challenges associated with employing MSC–EVs in clinical settings, with a specific focus on their potential in treating conditions like lung diseases, cancer, and autoimmune disorders.