With the goal of assuring the standardized treatment of diabetic inpatients, we installed an institutional framework to support diabetes care in non-diabetic sections by means of providing regular rounds by an expert team composed of diabetologists, a nurse certified in diabetes nursing and a registered dietician. The team mostly took responsibility for ensuring adequate glucose monitoring, determining the insulin regimen and oral therapy and safeguarding patient safety, including the prevention of hypoglycemia. In order to evaluate the usefulness of these rounds, we conducted a questionnaire survey of nurses and doctors on the non-diabetic wards at one and five years after implementation. The results showed that 98 % of the nurses appreciated the program after one year and gave significantly higher scores for all items of the questionnaire after five years versus the previous survey with respect to efficacy of the rounds in improving the patients' treatment in addition to addressing their own concerns and understanding about diabetes care. After five years, 97 % of the doctors required a commitment for the diabetes team and 90 % observed the program to be highly effective. Therefore, our cross-sectional approach is considered to be useful for improving the hospital-wide quality of diabetes care.

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We herein report a case of a drug eruption suspected to be caused by SGLT2 inhibitors in a patient with type 2 diabetes. The patient was a 63-year-old woman who had been treated with sitagliptin and glimepiride. Her HbA1c level had been approximately 8 %; therefore, luseogliflozin was added to her regimen. On the eighth day of luseogliflozin treatment, she developed erythema on her neck, which later spread to her limbs and trunk. Neither the cessation of luseogliflozin treatment nor administration of steroids by a local physician improved her symptoms, and she was subsequently admitted to our hospital. A dermatologist suspected that luseogliflozin had caused the drug eruption. Consequently, the patient was treated with intravenous prednisolone at a dose of 40 mg per day, which improved the erythema. She was discharged after the steroid dose was gradually reduced (the oral prednisolone dose was tapered to 10 mg per day). Based on the patient's clinical course and biopsy results, the drug eruption was suspected to have been caused by luseogliflozin. Therefore, it is important to inform patients that they should be examined by a dermatologist as soon as possible if they develop a skin rash after taking SGLT2 inhibitors.

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The patient was a 72-year-old woman with type 2 diabetes, paroxysmal atrial fibrillation and renal dysfunction who had received treatment with cibenzoline and sitagliptin. After several days of a reduced appetite, she lost consciousness and was admitted to our hospital. The plasma glucose and HbA1c levels were 31 mg/dl and 5.5 %, respectively. In addition, the serum insulin and C-peptide concentrations were 9.24 μIU/ml and 6.45 ng/ml, respectively, indicating inappropriate insulin secretion, and the serum creatinine level was 2.3 mg/dl, suggesting renal dysfunction. The sitagliptin therapy was suspended, and the plasma glucose levels slightly improved. However, the fasting plasma glucose level remained low at around 60 mg/dl. The blood cibenzoline concentration (1,459 ng/ml) was higher than appropriate; therefore, this medication was also suspended. The fasting plasma glucose level subsequently improved, for a serum insulin concentration of 7.09 μIU/ml and plasma glucose level of 135 mg/dl. Similar to sulfonylurea, cibenzoline has been reported to cause hypoglycemia via the inhibition of ATP-sensitive K channels, particularly at high concentrations. The severe hypoglycemia seen in this case might have been caused by the combination of sitagliptin treatment and the high cibenzoline concentration. The potential for severe hypoglycemia caused by the combination of incretin-related drugs and class Ia antiarrhythmic agents should be recognized, particularly in patients with renal dysfunction.

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The patient was a 79-year-old woman who had been diagnosed with type 2 diabetes at 64 years of age and subsequently treated with oral agents. Nevertheless, her glycemic control remained poor, and her HbA1c level was around 8-9 %. At 73 years of age, she complained of a fever, lumbago, lower abdominal pain, general fatigue and appetite loss. She was thus admitted to our hospital to undergo a further examination and was diagnosed with pyometra. In addition to strict blood glucose control with insulin, surgical resection, irrigation and drainage were performed. These treatments resolved the inflammation and enabled her to be insulin-independent. However, she developed a series of bilateral psoas abscesses (PA), including a right side PA (two months later), left side PA (one year later), right side PA (four years later) and left side PA (six years later). The number of reports on diabetic patients with PA has recently been increasing, and some reports have shown that 30-60 % of patients with PA have diabetes with poor glycemic control. However, to our knowledge, there have been no case reports of bilateral PAs, and only three cases of PA secondary to pelvic inflammatory disease have been reported.

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A 36-year-old woman was admitted to our hospital with complaints of vomiting and drowsiness after a one-week history of drinking only alcohol, without any meal intake. We diagnosed her with diabetic ketoacidosis and started a continuous intravenous insulin infusion, which resulted in severe hypokalemia, from 2.7 mEq/l to 1.3 mEq/l, requiring discontinuation of the insulin infusion. A total of 660 mEq of potassium infusion for the first 72 hours was required to maintain a normal serum K level. The ketoacidosis recovered; however, severe acidemia remained. Using a Stewart's physicochemical acid-base analysis, we found that the main cause of the acidosis was strong ion-derived acidosis brought about by the presence of excess free water, massive saline infusion, tubular damage and excessive loss of ketone bodies. The primary cause of the severe hypokalemia in the present case was the depletion of total body potassium, which may have been closely related to the patient's eating disorder. Furthermore, these conditions caused the depletion of other electrolytes, including calcium, phosphorus and magnesium. A more detailed analysis of acid-base abnormalities and electrolyte disturbances is required in such patients, including physicochemical analyses.

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In our hospital, a local health care link program for diabetes has been used since 2008. Patients receiving treatment using this program are usually examined by their primary care physician and undergo medical consultation and treatment every six months as well as screening for complications annually in the hospital. During the 6-year period from the initiation of the program to April 2014, a total of 168 patients were treated using this program, among whom nine malignant tumors and 12 cases of macroangiopathy were observed. Of the nine malignant tumors, seven were asymptomatic and six were diagnosed as stage IV on identification. As of April 2014, the number of patients using the program was 110, and their mean HbA1c level was 7.4 %. In contrast, among 105 age-, sex- and disease duration-matched controls, extracted from 115 patients who underwent a consultation at our hospital during the same period of time but were not treated using the program, the number of malignant tumors and macroangiopathies was 1 and 7, respectively. The results of this study support the usefulness of the local health care link program for diabetes for regularly and securely conducting multiple screenings for major complications of diabetes, such as malignant tumors and macroangiopathy.

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The JDCP study is a large-scale observational study to investigate the current status of management of people with diabetes in recent years, and to clarify the risk factors for the onset/progression of diabetes complications. This study includes a total of 6,338 patients aged 40~<75 years old who had received regular outpatient treatment from 2007~2009 at medical facilities nationwide specializing in diabetes. The primary endpoints for the study include occurrence/progression of nephropathy, retinopathy, neuropathy, macroangiopathy, and periodontal disease, and the secondary endpoints include occurrence of malignancy and mortality. The current report describes an outline of the study, and a summary of baseline data for the participating patients with type 2 diabetes (n=5,944). The baseline characteristics were as follows: males 60.1 %; mean age 61.4 years-old; duration of diabetes 10.8 years; family history of diabetes 52.8 %; BMI 24.5 kg/m²; HbA1c 7.4 % (achievement of<7.0 %, 40.6 %); blood pressure 129.8/74.8 mmHg; non-HDL-C 137.6 mg/dl. Treatment includes diet therapy alone 10.4 %, oral hypoglycemic agents 62.1 %, and insulin therapy 27.5 %. The cohort is to be followed up for at least 5 years, with a high follow-up rate. The study keeps focusing on making registry reliable and versatile, as well as bringing resulting research findings and insights to bear on treatment guide for diabetes.

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