Hemoglobin AIa, b, c as components of the HbA_I fraction, are known to arise by post-translational, non-enzymatic glycosylation of HbA at the β-chain-N-terminal amino group. Although HbA_Ia, b, c increase quantitatively in many cases with diabetes mellitus, the modes of attachment of monosaccharides to these subfractions remain unknown. We attempted to clarify this problem by utilizing a GC-MS system for monosaccharide analysis of glycosylated hemoglobins. The HbAIa, b, c and HbAo from normal controls, diabetics, and thyrotoxic patients with or without carbohydrate intolerance were fractionated by Bio-Rex 70 column chromatography, according to Trivelli's method. Each sample from the fractions of HbAIa, b, c and HbAo was treated to form TMSi monosaccharide derivatives, according to Bunn's method. Then, GC-MS (Shimadzu LKB 9000) mass fragmentography was performed to identify the monosaccharides. The following results were obtained.
1) In normal controls, diabetics, and thyrotoxic patients, each fraction of HbAIa, b, c and HbAo was demonstrated to contain α-, β-mannose, glucose, and galactose. It seems likely therefore that glycosylation exists in HbAIa, b with several monosaccharides as it does in HbAIc but that HbA_Ia, b are at least glycosylated in different ways in both quantity and quality, so contributing to the differences in separation patterns of each of the HbA_Ia, b, c and HbAo. It is suggested that HbA_Ia, b may be in an intermediary position among the HbA which would be further glycosylated in HbA_Ic.
2) As a whole, the percent HbAIc appears to represent a more significant index than that of HbA_I (a+b+c) in reflecting the long-term state of glucose metabolism but individual cases are not always in accordance with this result.
3) The hexose moieties of the HbAo fraction may show a relation with the percent HbA_Ic and percent HbA_I (a+b+c) and also reflect the state of glucose metabolism.
4) There was no correlation between the hexose contents of HbAo (or HbA_I+HbAo) and the percent HbA_I (a+b+c)(or percent HbA_Ic). The findings were at variance with previous results describing a significant correlation between the TBA colour value and percent HbA_I (a+b+c).
5) Qualitative and quantitative analyses of the sugar components of HbA_I and HbAo may provide one means of elucidating the glucose metabolism.

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A second survey of deliveries in pregnant diabetics through-out Japan during 1976-4980 was performed in December 1980 by questionnaire. The results of the first study, carried out in 1976 by the same method, about such deliveries during 1971-4975 have been reported previously.
A total of 693 deliveries (694 offspring) in 645 diabetics was observed with regard to the age of diabetic onset, pre-delivery duration of diabetes, treatment of diabetes during pregnancy, perinatal mortality, and morbidity in newborns.
The incidence of delivery by diabetics in 1975 was 0.15%, and in 1979, 0.17%. Most of the diabetics involved were classified as White class B. The mean pre-delivery duration of diabetes was four years. While the duration did not tend to become longer, pregnant diabetics with a duration of diabetes of over 11 years were significantly increased compared to the figures in the first survey.
During pregnancy, 265 of the 693 diabetics (38.2%) were treated mainly with insulin, while 5 of the 693 (0.7%) received oral hypoglycemic agents, showing an apparent decrease.
The perinatal mortality in fetuses or newborns was 7.2%, or 50 of 694-an apparent decrease compared to the 10.8%, or 41 of 378, observed in the first survey.
Concerning the morbidity in newborns, hypoglycemia appeared in 20.8% and respiratory distress syndrome in 8.9%. The incidence of respiratory distress syndrome was highest in the untreated group in the third trimester.
Since both the respiratory distress syndrome and severe congenital malformation are principal causes of death in newborns, the importance of strict control of diabetes mellitus in pregnant diabetics cannot be overemphasized.

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The combined effects of glucagon and cortisol on insulin-induced hypoglycemia were studied in beagle dogs.
Insulin (0.1-0.4 U/kg) and glucagon (10 μg/kg) were injected to the animals subcutaneously, and cortisol (50 mg/kg) was given intravenously. Blood samples were collected at appropriate intervals and the blood glucose and c-AMP concentration were measured. The blood glucose levels of dogs receiving glucagon and cortisol simultaneously, or glucagon at 15, 30 or 60 min after the cortisol injection at 30 min after administration of insulin, were significantly higher than those in dogs injected with glucagon or cortisol alone at 30 min after insulin injection.
When the area under the blood glucose concentration time-curve was calculated, it was clear that the combined effects of glucagon and cortisol were of potentiation and not additive, and especially the effect of glucagon was potentiated by cortisol. It is assumed that this action is due to an increase of c-AMP in the organs based on inhibition of phosphodiesterase activity by cortisol.

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Some characteristics of the HDL subfractions in diabetics were studied. Serum HDL₂ and HDL₃ cholesterol (HDL₂·C and HDL₃·C) levels were measured by a new method using high performance liquid chromatography (HPLC) in 58 diabetics without atherosclerotic disease, 23 patients with ischemic heart disease (IHD), and 24 normal subjects.
(1) The serum total HDL cholesterol (T-HDL·C), HDL₂·C and HDL₃·C were significantly lower in patients with IHD than in normal subjects, but there were no significant differences between the diabetics and normal subjects.
(2) The relationship between the HDL subfractions and diabetic complications was studied. The serum HDL₃·C in males and serum HDL₂·C in females were significantly lower in diabetics with retinopathy than in those without retinopathy. The serum HDL₃·C in males was significantly lower in diabetics with neuropathy than in those without neuropathy.
(3) The relationship of HDL₂·C and HDL₃·C to T-HDL·C was studied in all the subjects. HDL₂·C showed a tendency to decrease in parallel with T-HDL·C. On the other hand, there were no apparent changes in HDL₃·C except in cases of a concentration of less than 30mg/dl of T-HDL·C. In the range of less than 30mg/dl of T-HDL·C, HDL₃·C also showed a decrease in accordance with the decrease in T-HDL·C.
(4) The relationship of HDL₂·C and HDL₃·C to T-HDL·C was studied in diabetics, patients with IHD, and normal subjects. HDL₂·C showed a strong positive correlation with T-HDL·C in each group. HDL₃·showed no correlation with T-HDL·C in normal subjects; however, a positive correlation was found in diabetics and patients with IHD.
In conclusion, our study indicates that in diabetics, the HDL₃·C level decreased in parallel with T-HDL·C even over the range of 30mg/dl of T-HDL·C.

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Quantitative analysis of pupillary light reflexes was performed in 60 diabetic patients using computerized infrared videopupillography and the “open loop” stimulatory technique. The visual acuity of all patients studied was at least 0.8 and there were no ophthalmoscopic signs of retinopathy in the area stimulated by the light, thereby ensuring roughly uniform retinal sensitivity.
Pupillographic analysis revealed a normal latency time and abnormalities such as miotic pupil area (PA), reduced constriction area, reduced maximum velocities of constriction (VCmax) and dilatation (VDmax) compared to sex and age matched controls. These changes resembled the findings obtained in the pupil of normal subjects topically instilled with dilute pilocarpine, indicating the pupil of the diabetics to be cholinergic. We could estimate the degree of pupillary abnormalities only by determination of PA, since the reduction of PA correlated closely with the reduction of VCmax or VDmax.
Such abnormal responses were obtained from 8 (67%) fo 12 patients without peripheral neuropathy (PN), 21 (81%) of 26 patients with mild PN, and all of 18 patients with severe PN. The degree of the abnormalities appeared to parallel the progression of PN. The pupillary abnormalities were more closly correlated to the development of paresthesia or the reduction of vibratory sensation and less related to the reduction of deep tendon reflexes or motor nerve conduction velocity. A correlation was also found between the degree of pupillary abnormalities and the duration of diabetes, but not between the degree of pupillary abnormalities and the control of FBS.
Furthermore, a close correlation existed between the degree of pupillary abnormalities and the severity of retinopathy. Abnormal responses were obtained from 20 (69%) of 29 patients without retinopathy, and all of 27 patients with retinopathy. These findings suggest the possibility that autonomic neuropathy may play a role in the pathogenesis of retinopathy.
It is concluded that a reduction of PA represents a useful warning for the development of diabetic neuropathy and even retinopathy. Incorporation of such tests of pupillary functions into routine examinations should be beneficial.

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A needle-type glucose sensor has been developed using a hydrogen peroxide electrode covered with immobilized glucose oxidase. In vitro experiments revealed that the noise and drift of sensitivity were less than 1 % and 1 % per hr, respectively. The residual current was less than 6 %, and the temperature coefficient was less than 5 % per 1°C in the range of 33-42°C. Linearity to glucose concentration was observed in the range of 0-500 mg/100 ml. The response was rapid (T_90% was less than 20 sec). The current output was constant when the oxygen tension was more than 25 mm Hg. The sensor showed no change in its sensitivity during continuous monitoring in vitro for 60 days.
A wearable-type artificial endocrine pancreas (18×17×8 cm in size and 700g in weight) was developed, consisting of a needle-type glucose sensor, a microcomputer system, and pump-driving mechanisms.
Treatments of depancreatized dogs with the system were conducted for up to 7 days. Appropriate amounts of insulin were delivered by the device to maintain the daily glycemic excursions in diabetic dogs within the normal range.
The following conclusions were drawn. 1) The glucose sensor was successfully miniaturized in the form of a needle preserving sensor-characteristics sufficient to allow application as a glucose monitor for a closed-loop control system. 2) The 7-day perfect glycemic controls obtained in depancreatized dogs with the wearable-type artificial endocrine pancreas, indicated the feasibility of its long-term application to diabetic patients.

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In some cases, proliferative diabetic retinopathy is progressive during pregnancy. However, the effect of pregnancy on background retinopathy has not yet been clearly established.
We report a case in which background retinopathy, Scott Ia, II, was observable at the 15th week of pregnancy and whose retinal lesion progressed dramatically to Scott IIIb, IIIb, during pregnancy in spite of the best possible diabetic control. At the 31st week of pregnancy, the patient received photocoagulation in the right eye and the retinopathy improved, but only temporarily. After termination of the pregnancy, the proliferative retinopathy showed a further improvement.
The patient was a 38-year-old office worker. She was diagnosed as diabetic at the age of 26, and since that time had been administering a single daily injection of insulin. In July 1970 (at age 30), she had a Caesarean section. The baby weighed 3, 800 g and was normal. In September 1970 (at age 30), she developed hyperthyroidism and was treated with an antithyroidal agent for two years. In November 1978 (at age 38), she visited our hospital for consideration of termination of pregnancy, although she hoped to continue the pregnancy. Later, at the 15th week of pregnancy, she was admitted to our hospital because her house was very distant.
Efficient diabetic control was established by giving four injections of insulin and six small meals daily throughout her pregnancy. From 22 weeks to 25 weeks, the early retinopathy progressed to Scott IIIb, IIIb. At 31 weeks of pregnancy, she underwent photocoagulation, after which the retinopathy improved. From 35 weeks, the retinal lesion again worsened. At 37 weeks, because of progressing retinopathy, she had a Caesarean section and a healthy girl, weighing 2, 310 g was born. After delivery, her retinopathy improved and up to the present has remained at the Scott IIIa stage. Even now it is unclear why the background retinopathy was progressive during her pregnancy in spite of the best possible control.

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Werner's syndrom characterized by accelerating aging is often associated with insulin-resistant diabetes mellitus. The diabetes is usually mild and can be controlled by diet therapy and/or oral hypoglycemic agents. We report a case of Werner's syndrome associated with insulin-dependent diabetes mellitus. A 33-year-old woman with a three-year history of diabetes revealed typical signs and symptoms of Werner's syndrome such as a senile appearance, emaciation, amenorrhea, loss of hair, and cataract. Routine laboratory findings were almost normal except for glycosuria, ketonuria and hyperglycemia. CT scan of the brain revealed generalized brain atrophy. An oral glucose tolerance test demonstrated 573mg/dl at time 0, 615mg/dl at 60 min and 732 mg/dl at 120 min. A tolbutamide tolerance test revealed neither a fall of plasma glucose nor elevation of C-peptide. Insulin sensitivity tests were performed twice four months apart. The insulin binding to red blood cells of the patient increased gradually in association with an improvement of the fasting plasma glucose by insulin therapy, although the sensitivity to insulin was essentially unchanged. Endocrine function tests revealed low responses of GH to L-Dopa and arginine administration. The responses of LH and FSH to LH-RH were also low. The functions of the thyroid and adrenal glands were normal.
These results suggested that the insulin resistance in this case was due to a defect of the postreceptor steps rather than of the receptor itself. Abnormality of the hypothalamopituitary axis may be related to the symptoms of emaciation and amenorrhea.

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A 50-year-old woman was admitted to hospital in May 1981 because of hypoglycemic episodes. Her fasting blood glucose, immunoreactive insulin and C-peptide immunoreactivity levels were 30-55mg/dl, 8-20μU/ml and 1.25-2.13ng/ml, respectively. Positive results were not obtainedby provocative tests on insulin secretion (glucose tolerance, tolbutamide, leucine, glucagon and calcium infusion tests).
Angiography of the celiac and superior mesenteric arteries, endoscopic retrograde pancreatography and ultrasonic examination of the pancreas, failed to reveal any tumor. Computed tomography demonstrated a slightly dense lesion measuring 1 cm in diameter in the tail of the pancreas.
The insulin levels in the portal and splenic venous blood obtained by percutaneous transhepatic catheterization showed a prominent peak (58μU/ml) in the splenic vein which suggested an insulinsecreting tumor in the tail. A tumor (1×1×0.7cm) was subsequently found in the tail of the pancreas at operation.
This study indicates that computed tomography and percutaneous transhepatic portal vein catheterization can be important in the preoperative localization of insulinoma.

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A 47-year-old woman developed permanent insulin dependent diabetes mellitus during an attack of infectious mononucleosis. The clinical features of the patient are reported.
On 13 Aug. 1980, she complained of fever and sore throat, and was found to have lymphadenopathy, hepatic dysfunction, atypical lymphocytes in a peripheral blood smear, and a positive Paul-Bunnell test. Infectious mononucleosis was confirmed by a 16-fold gain in anti-VCA (IgG) titer and a positive anti-EA titer.
On 24 Sept. 1980, she suddenly developed diabetic ketosis and insulin therapy was started. In Feb. 1981, the conventional insulin therapy was changed to continuous subcutaneous insulin infusion therapy, because the patient's diabetes mellitus was severely unstable. Her ketonuria and hypoglycemia disappeared with about 30 units of monocomponent actrapid insulin, and fair control was achieved.
Several tolerance tests revealed no C-peptide response in 50g OGTT, a low glucagon response in the arginine tolerance test (0.5 g/kg) and no glucagon response in hypoglycemia induced by intravenous insulin infusion (0.2 U/kg). These results suggested that not only B cell but also A cell function was damaged, and this could be related to the unstable diabetes of the patient.
In April 1981, slight diffuse goiter was noticed and the patient's titer of thyroid microsome antibody was 25, 600. Anti-thyroglobulin antibody was negative and the serum levels of T₃, T₄, TSH were within normal limits.
The HLA type of the patient was A2, A10/ B15, B40/ Cw3, Cw7/ DR4, DRw9.
Isletcell surface antibody could not be detected at 2, 6 and 9 months after the onset of diabetes mellitus.

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