In Advances in Diabetology, The 49^th Annual Post Graduate Course, a 'Special Lectures on History of Diabetes' was held. Dedicated researchers, Frederick Grant Banting, who discovered insulin, Priscilla White, who developed clinical practice in diabetes and pregnancy, Paul Langerhans, who identified the pancreatic islets, and Paul Kimmelstiel, who established the clinical entity of diabetic nephropathy, were introduced and discussed in the lectures.

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The aim of this study was to evaluate the influence of dapagliflozin on glycemic control, body weight and quality of life (QOL) of Japanese patients with type 2 diabetes. The study included 55 patients with type 2 diabetes administered 5 mg of dapagliflozin daily. The change in the HbA1c value, body weight and QOL of the patients was compared using DTR-QOL questionnaires before and 6 months after the administration of dapagliflozin. We confirmed a significant improvement in the QOL according to the DTR-QOL questionnaires as well as a significant decrease in the HbA1c value (8.3±1.6 % vs. 7.7±1.4 %,P<0.0001) and weight (78.7±18.4 kg vs. 76.0±18.4 kg, P<0.0001) after 6-months administration of dapagliflozin. We witnessed cases that resulted in an unexpected improvement following the administration of a SGLT2 inhibitor, which triggered behavioral changes, together with the involvement of intensified activity from the medical workers. We also recognized the importance of patient-centered care and medical treatment support, which is essential in diabetic treatment.

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We examined the relationship between lower extremity muscle strength, the amount of physical activity and diabetic neuropathy (DN) in patients with diabetes. The present study included 61 patients with type 2 diabetes who were over 60 years of age (male, n=35; female, n=26: mean age 71.7±6.1 years). The survey items were as follow: lower extremity muscle strength, amount of physical activity, the presence of DN, and the patient's background factors. From the results of a multiple regression analysis, gender, physical activity and age were extracted as factors that were related to the knee extensor force (R²=0.47). In addition, DN (R²=0.15) was extracted as the sole factor to be related to the ankle dorsal flexor force. In the type 2 diabetes patients over 60 years of age, the ankle dorsal flexor force was associated with DN, as previous studies have reported. On the other hand, the knee extensor force was associated with physical activity. From these results, it is suggested that the promotion of physical activity might not only lead to the improvement of the blood glucose level but also preserve or strengthen the muscle power of the lower extremities.

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A 58-year-old woman who had been treated with prednisolone for microscopic polyangiitis since 2 years previously, experienced thirst, impaired consciousness and general fatigue after the excessive intake of soft-drinks. Her consciousness level corresponded to JCS I-1. Laboratory studies showed a plasma glucose level of 867 mg/dl, an HbA1c level of 10.3 %, and elevated ketone body counts in her blood and urine. An arterial blood gas analysis showed that the serum anion gap was 15.1, indicating metabolic acidosis. However, the pH of 7.680 and the HCO₃^- level of 30.0 mmol/l suggested concomitant metabolic alkalosis. Her plasma potassium level was 3.4 mEq/l. She was diagnosed with diabetic ketoacidosis (DKA) and metabolic alkalosis and admitted to hospital. Her alkalosis and hyperglycemia improved with fluid administration and a continuous intravenous insulin infusion. It is assumed that metabolic alkalosis was induced by hypokalemia related to the administration of a diuretic agent and prednisolone and by secondary hyperaldosteronism. Several reports have described rare occurrences of mixed acid-base disorder in patients with diabetic ketoasidosis. The association of other acid-base disturbances with DK should be kept in mind in clinical practice.

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A 17-year old female with Prader-Willi syndrome (PWS) was referred to our hospital for examination and treatment of diabetes. Her fasting blood glucose and HbA1c level were 259 mg/dl and 11.8 %, respectively. Intensive insulin therapy was initiated, resulting in the marked improvement of her fasting and postprandial glucose levels. Thereafter, treatment with daily injections of exenatide (10 μg) and metformin (500 mg/day) was initiated to replace the insulin therapy, resulting in the control of her glycemic level. The metformin treatment was discontinued 3 months after discharge, after her glycemic control showed substantial improvement (HbA1c 6.1 %). Over a 6 month period, her body weight decreased from 71.1 kg to 64.6 kg with the suppression of her appetite. For 2 years after discharge, her HbA1c levels were maintained to within 6.1-6.6 %, despite an increase in her body weight, which returned to 72.5 kg with the return of her appetite. We report a case of a diabetic patient with PWS who was treated with exenatide for 2 years, in whom glycemic status, but not body weight, was kept under control.

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A 40-year-old woman, who had a history of obesity from 20 years of age, was diagnosed with type 2 diabetes at 28 years of age. At 30 years of age, she was started on insulin therapy for strict metabolic control before pregnancy. Despite increasing the maximum dose of metformin up to 2,250 mg and a total insulin dose of 100 U/day (1.07 U/kg/day), her glycemic control remained unstable with a HbA1c value of 9.8 % and a fourth admission to our hospital. She was treated with diet and exercise therapy and administered 50 mg of ipragliflozin from the third to 13th hospital day. At discharge from the hospital, her total insulin dose was decreased to 53 U/day (0.60 U/kg/day). She lost weight, her BMI decreased from 38.7 kg/m² to 36.3 kg/m², the area of visceral fat decreased from 365.6 cm² to 246.9 cm² and the visceral/subcutaneous fat ratio decreased from 0.88 to 0.66 after a 10-day short-term administration of ipragliflozin. An analysis of the body composition report indicated that the weight loss was nearly entirely due to body fat loss. We herein report a successful case of a patient who was able to become pregnant after the short-term administration of ipragliflozin and the observed improvement of her metabolic abnormality through select indices.

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We evaluated the efficacy of weekly caregiver-administered subcutaneous exenatide in elderly and obese type 2 diabetic (T2D) patients in whom hypoglycemic agents alone were ineffective and who had difficulty with self-administration. Case 1 was a 75-year-old woman with an 8-year history of T2D who had been treated with basal supported oral therapy and whose HbA1c level had deteriorated to 11.5 %. After 9 months of weekly caregiver-administered subcutaneous exenatide supplemented with oral hypoglycemic agents (OHA), her HbA1c level improved to 6.7 %. Case 2 was a 67-year-old woman with a 20-year history of T2D treated with OHA, including sulfonylurea, with a HbA1c level of 7.3 %. After 6 months of weekly caregiver-administered subcutaneous exenatide supplemented with OHA, her HbA1c level improved to 5.9 %. Case 3 was a 79-year-old woman with a 30-year history of T2D treated with a premix insulin injection and whose HbA1c level had deteriorated to 9.1 %. After 4 months of weekly caregiver-administered subcutaneous exenatide supplemented with OHA, her HbA1c level improved to 7.5 %. Our results indicate that weekly caregiver-administered subcutaneous exenatide may be an alternative therapeutic option for elderly and obese T2D patients in whom treatment with hypoglycemic agents alone is ineffective and who have difficulty with self-administration.

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A 46-year-old woman presented to a nearby clinic with a 2-day history of abdominal pain and a fever and was diagnosed with gastroenteritis. The abdominal pain subsided, however, a slight fever persisted. Four days after the initial presentation, the patient revisited the clinic due to exacerbation of the upper abdominal pain and development of dry mouth and nausea. A qualitative urinalysis revealed glycosuria and ketonuria, which had not been detected at the first presentation. The patient was emergently transferred to our hospital and admitted, presenting with increased anion gap metabolic acidosis. According to her condition the patient was diagnosed with diabetic ketoacidosis. Laboratory tests at presentation showed casual blood glucose of 955 mg/dl and HbA1c of 6.0 % and there was a decrease in her insulin secretion capacity, leading to the diagnosis of fulminant type I diabetes. On hospital day 9, pain and swelling localized to the right ankle joint developed. The patient was diagnosed with deep-vein thrombosis (DVT) and immediately underwent anticoagulant therapy with a favorable result. The onset of DVT is a potential complication in diabetic patients and must be treated as soon as possible.

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The Department of Diabetic Dialysis Prevention Guidance Management has been newly established and early active team intervention is being implemented with the aim of preventing the shift to dialysis treatment in diabetic patients. We conducted two surveys of Saiseikai hospitals throughout in Japan regarding the current status after introducing diabetic dialysis prevention guidance and investigated potential future issues. The most common reason for team intervention not being implemented at the facilities was the inability to secure staff members. Teams were primarily composed of physicians, nurses, and dietitians, and certified diabetes educators were included in the team at 91 % of the hospitals. Having nurses and dietitians offer guidance at the same site was believed to lead to shared patient information and unified guidance content among medical professionals, thereby leading to a reduced guidance time. Although the responses indicated that the effects of guidance were felt at over 80 % of the facilities, the proportion of nurses and dietitians who responded that they had some misgivings about the guidance increased in the second survey, and 62 % of the teams overall felt that the guidance activities were burdensome. These issues therefore must be improved in the future.

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[in Japanese]

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