To study the relation between diurnal blood pressure variations and common carotid atherosclerosis, we performed both 24-hour ambulatory blood pressure monitoring (ABPM) and common carotid arterial imaging by ultrasonography in 60 type 2 diabetic patients. We further classified the patients into dippers (nocturnal reduction of systolic blood pressure (SBP) by≥10% to<20% of daytime SBP; n=13), non-dippers (reduction by≥0% to<10%; n=35), and inverted-dippers (reduction by<0%; n=12). There were no differences in background factors, such as age, sex, body mass index, duration of diabetes mellitus, Brinkman index, blood lipids, uric acid and HbA₁c levels, daily urinary C-peptide reactivity, CV% of the R-R interval, and daytime BR The carotid arterial wall thickness was significantly higher in the inverted-dippers group than in the dippers or non-dippers group (p<0.05). A logistic regression analysis using the carotid arterial wall thickness (defined as hypertrophic if greater than 1.0mm) as the object variable and various risk factors including ABPM parameters, as the explanatory variables revealed that a pattern of a nighttime fall in SBP (dipper, non-dipper or inverted dipper) or nighttime SBP were significant independent contributing factors. These results suggest that nocturnal SBP elevation is an important risk factor for the thickening of the carotid arterial walls.

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Oral glucose tolerance tests in gastrectomized subjects often reveal an oxyhperglycemia-type glucose tolerance curve. However, when diabetes mellitus is diagnosed according to the 1999 diagnostic criteria of the Japan Diabetes Society, the results often disagree with the diagnostic criteria. In the present study, such problems were reinvestigated using 75 g-OGTT and other parameters of glycemic control in 60 gastrectomized subjects selected from 2257 subjects examined during periodic medical check-ups. The mean plasma glucose levels at 0 minutes (FPG), 60 minutes (PG-1), and 120 minutes (PG-2) were 96.9mg/dl, 179.1mg/dl and 86.6mg/dl, respectively. According to the 1999 diagnostic criteria (JDS 1999), 6 subjects were classified as diabetics, 6 as borderline diabetics, and 47 as normal. The mean HbA₁c level was 6.8%, which is higher than normal. Mean levels of fructosamine (FRA) and 1, 5-anhydro-D-glucitol (1, 5-AG) were 256μmol/l and 16.2μg/ml, respectively. Both of these values are within their normal ranges. In spite of the marked changes in plasma glucose levels (FPG, PG-1 and PG-2), the plasma glucose level was significantly correlated with the HbA₁c, FRA, and 1, 5-AG levels. Before making a final diagnosis of diabetes mellitus, a thorough study of the patient's past history, especially when a gastrectomy has been undergone, together with a detailed analysis of laboratory data should be performed.

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A 54-year-old man with poorly controlled type 2 diabetes was admitted to our hospital because of persistent lumbago accompanied by a fever. Laboratory data showed leucocytosis (12, 800/μl), a positive CRP (17.6 mg/dl) and an elevated ESR (115 mm/h). A lateral X-ray of the lumbar spine revealed a narrowing of the L 2/3 intervertebral disk space. T₂-weighted magnetic resonance imaging revealed high signal intensity lesions in the posterior portion of the vertebral bodies of the L 2 and L 3 vertebrae and the L 2/3 intervertebral disk. Gallium and bone scintigraphies showed a markedly increased uptake in the L 2/3 area. Streptococcus intermedius was isolated from the venous blood. We diagnosed the patient as having pyogenic vertebral osteomyelitis as a result of a Streptococcus intermedius infection associated with diabetes. Clinical symptoms improved following treatment with insulin and antibiotics. Streptococcus intermedius is a rare causative organism in osteomyelitis, but the incidence of infections resulting from Streptococcus intermedius may increase in the near future. Diabetic patients infected with Streptococcus intermedius should be treated with antibiotics and a strict control regimen for thier diabetes.

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A 31-year-old man with inpaired consciousness and urinary and fecal incontinence was admitted to hospital. Based on his low blood glucose (BG) levels (29 mg/dl), he was diagnosed as being in a hypoglycemic coma. The patient recovered after receiving an intravenous infusion of glucose.Although insulinoma was suspected as a cause of the hypoglycemia, hyperinsulinemia was never demonstrated.In other words, the patient's immunoreactive insulin (IRI) levels were always lower than 10μU/ml, and his IRI/BGratio was never higher than 0.5.However, the patient's plasma proinsulin levels were markedly elevated at 89.3 pmol/L (the normal range is 2.9-13.1 pmol/L).An intra-arterial calcium infusion was performed to determine if a pancreatic islet cell tumor was present.The calcium was infused into the celiac artery, and a sample was taken through the portal vein by percutaneous transhepatic portal catheterization.During this test, a marked rise in IRI levels was observed at the confluent point of the portal-splenic vein.Moreover, a selective celiac angiography revealed a tumor stain at the pancreatic uncus. The patient was diagnosed as having insulinoma, and surgery was performed to enucleate the tumor. After surgery, the patient's plasma proinsulin levels fell to a normal value of 6.4pmol/L and the hypoglycemic symptoms disappeared.The low IRI and high proinsulin levels observed this case are relatively rare among cases of insulinomas.Intra-arterial calcium infusion with venous sampling can be a useful procedure for the detection of insulinoma.

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A 47-year-old man with increasing shortness of breath was admitted to our hospital. Bilateral sensorineural deafness was diagnosed at 21 years of age, and diabetes mellitus was diagnosed at 32 years of age. Proteinuria developd at 38 years of age, and chronic renal failure was diagnosed at 45 years of age. Because of the sensorineural deafness, mitochondrial diabetic and deafness syndrome (MIDD) was suspected. An A to G substitution at nucleotide 3243 in the mitochondrial tRN^{ALeu (UUR)}gene was identified. An echocardiography revealed severe diffuse hypertrophy and asynergy in the left ventricle. Histological examination of the left ventricular wall revealed morphological abnormalities in the mitochondria, leading to a diagnosis of mitochondrial cardiomyopathy. The quadriceps muscle was positive for ragged red fiber, and diffuse cerebral atrophy was detected by brain CT. We then performed ²⁰¹Tl and ¹²³I-BMIPP scintigraphy examinations and discovered a discrepancy, indicating that fatty acid metabolism in the cardiomyocytes had deteriorated but that the perfusion defect was not prominent. These findings were consistent with a diagnosis of mitochondrial cardiomyopathy. The patient's elder brother exhibited a similar clinical phenotype. Sibling cases of mitochondrial cardiomyopathy and diabetes seem to be uncommon.

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Clinical infomations on 1, 408 patients-46 with insulin-dependent diabetes mellitus (IDDM) and 1362 with non-insulin-dependent diabetes mellitus (NIDDM)-who visited a diabetes mellitus clinic were registered into using software “CoDiC^®”, a modification of “NovoNet^®” for outcome reseach. Titers of autoantibodies against glutamic acid decarboxylase (GAD) were measured in all IDDM and 74.3% of NIDDM patients. Those found positive to GAD antibody numbered 45.7% of IDDM and 1.8% of NIDDM patients. Based on this data and a clinical course of GAD antibody positive patients with impaired glucose tolerance, we discuss the clinical significance of measuring GAD antibodies.

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[in Japanese]

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