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: Euglycemic diabetic ketoacidosis (EDKA) is an uncommon but potentially life-threatening complication of diabetes, characterized by significant ketoacidosis in the absence of marked hyperglycemia. The increasing use of sodiumglucose co-transporter-2 inhibitors (SGLT2i) has contributed to its rising incidence; however, data describing its clinical spectrum remain limited. Methodology: We conducted a retrospective observational study of 19 patients admitted for EDKA between 2002 and 2025. EDKA was defined as metabolic acidosis with ketosis in the presence of blood glucose <11 mmol/L. Demographic characteristics, comorbidities, biochemical parameters, triggers, and clinical outcomes were analyzed. Continuous variables were reported as mean (SD) or median (interquartile range [IQR]), and categorical variables as frequencies and percentages. Results: The cohort displayed a mean age of 52 (SD 22.2) years, with a slight female predominance (52.6%). The majority had underlying type 2 diabetes mellitus (89.5%). Other comorbidities include hypertension (63.2%) and chronic kidney disease (31.6%). Despite severe metabolic derangement, the mean blood glucose at presentation was modest at 9.3 (SD 3.38) mmol/L. Median pH was 7.1 (IQR 0.35) and bicarbonate 9.1 mmol/L, with a markedly elevated median anion gap of 25.3 mmol/L. SGLT2i exposure was identified in 47.4% of patients, predominantly empagliflozin, with most initiated within 6 months. Nevertheless, infection was still the leading precipitant (68.4%), while 31.6% were adjudicated as having SGLT2i as the primary precipitating factor, probably due to underreporting during the diagnosis. Nearly half of the patients required intensive care (47.4%). The mean time to DKA resolution was 19 (SD 10.1) hours. Overall outcomes were favorable, with 89.5% of patients discharged and a mortality rate of 10.5%. Conclusion EDKA presents with severe metabolic acidosis despite deceptively normal glucose levels, increasing the risk of delayed recognition. Early assessment of ketones and acid– base status is essential in patients with diabetes presenting with unexplained metabolic acidosis, particularly among those receiving SGLT2 inhibitors, to facilitate timely diagnosis and management.
Diabetic Ketoacidosis

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

Objectives: To evaluate study designs and citation counts of original research published in the Medical Journal of Malaysia (MJM). Methods: The bibliographic data of the MJM for the period 1980-2016 were retrieved from PubMed and analysed using Endnote bibliographic software. Study designs of original journal articles were analysed according to whether the articles were diagnostic study, prognostic study or clinical trial (collectively known as “evidence papers”). The citation counts of the original articles and case reports for the period 2012-2016 were compared in a sub-study using a case-control design. Results: A total of 3952 MJM journal items were retrieved from PubMed for the period 1980-2016; of these, 58.9% were original articles and 29.5% were case reports. Among the original articles, 14.6% were “evidence papers”; 2.3% were diagnostic studies, 7.7% were prognostic studies, 4.6% were clinical trials. In the study period 2012-2016, “other types of original articles” had statistically significantly more citations than case reports. However, there is no difference between “evidence papers” and case reports. Conclusion Our analysis shows the distribution of the types of articles appearing in the MJM for the period of study and serves as a reference for improving citations counts in the local context.
Bibliometrics