The inappropriate disposal of insulin needles is becoming a social problem. Similarly, insulin needles are occasionally encountered by staff cleaning Tokaido Shinkansen trains. A cleaning company investigated the actual situation of inappropriate insulin needle disposal on Tokaido Shinkansen trains. The cleaning staff on Tokaido Shinkansen trains found 97 insulin needles from April 2013 to March 2014, 153 insulin needles from April 2014 to March 2015, and 170 insulin needles from April 2015 to March 2016. They investigated the locations of the insulin needles from April 2015 to March 2016. Insulin needles were found in the restrooms (51 %), on floors (32 %), near seats (8 %), and in washrooms (7 %). Although insulin needles were found every other day on Tokaido Shinkansen trains, only 1 case of needlestick accident occurred among the cleaning company staff. We considered that this low incidence was due to employee training. Needlestick accidents cannot be completely prevented as long as the inappropriate disposal of insulin needles continues. We hope that doctors and nurses make good use of the results of our investigation.

A 41-year-old woman was admitted to our hospital because of back pain and a fever. Her laboratory data showed an elevated C-reactive protein level (22.99 mg/dL) and white blood cell count (17630/μL) as well as bacteriuria. Abdominal computed tomography revealed enlargement of the renal pelvis potentially caused by blockage with a ureteral stone, so she was diagnosed with right pyelonephritis. She was found to have uncontrolled diabetes (plasma glucose 249 mg/dL, HbA1c 10.6 % and ketonuria) and be pregnant. Lactobacillus spp. was isolated from the urine and blood cultures. After admission, antibiotics and drip infusion were started intravenously, along with continuous intravenous insulin infusion therapy. A stent for ureter stenosis were performed. The patient was discharged from the hospital 22 days later. Lactobacilli are part of the normal gastrointestinal and female genitourinary flora in humans and rarely but occasionally cause disease. An immunocompromised status due to hyperglycemia and gestational genitourinary flora changes might have contributed to the pathogenesis of this case.

A 23-year-old woman with a body weight of 29 kg (body mass index, 11.3 kg/m²) was diagnosed with anorexia nervosa on X. She was admitted to our department on X+1 due to prolonged hypoglycemia. On admission, her body weight was 50 kg (body mass index, 20.3 kg/m²), and her fasting plasma glucose level was 54 mg/dL. Hypoglycemia occurred frequently early in the morning under fasting conditions. Therefore, a fasting test was performed. After 24 h of fasting, the plasma glucose level was 38 mg/dL, and hypoglycemia unawareness was observed, while plasma immunoreactive insulin was suppressed. There were no increases in the levels of adrenocorticotropic hormone (ACTH) or cortisol in response to the hypoglycemia. Corticotropin-releasing hormone stimulation showed normal responses of ACTH and cortisol. The patient was therefore diagnosed with possible hypoglycemia associated with a reduced hypothalamic response to hypoglycemia. Treatment with oral hydrocortisone 15 mg daily was started and then tapered and discontinued, after which the patient experienced no more episodes of hypoglycemia. The patient in the present study experienced prolonged hypoglycemia even after weight gain. The etiology was considered to be due to possible hypoglycemia associated with a reduced hypothalamic response to hypoglycemia.

Abrupt disease onset and severe metabolic disorders are main characteristics of fulminant type 1 diabetes. Diffusion-weighted magnetic resonance imaging (DWI) is an imaging technique that reflects restricted diffusion in organs and can detect mononuclear cell infiltration into the pancreas at the onset of the disease. Fourteen patients with fulminant type 1 diabetes who underwent abdominal magnetic resonance imaging (MRI) were recruited for the measurement of apparent diffusion coefficient (ADC) values of the pancreas that were compared with those of 21 non-diabetic controls. The ADC values of all parts of the pancreas were significantly lower in fulminant type 1 diabetes than in controls (Head, 1.424±0.382×10⁻³ mm²/s vs. 1.675±0.227×10⁻³ mm²/s; Body, 1.399±0.317×10⁻³ mm²/s vs. 1.667±0.170×10⁻³ mm²/s; Tail, 1.336±0.247×10⁻³ mm²/s vs. 1.561±0.191×10⁻³ mm²/s; Mean, 1.386±0.309×10⁻³ mm²/s vs. 1.634±0.175×10⁻³ mm²/s) (p<0.01). The best cut-off value indicated that the sensitivity was 86 % and the specificity was 71 % when using DWI, which was also efficient in two atypical patients with fulminant type 1 diabetes without elevated levels of exocrine pancreatic enzymes or with high HbA1c levels due to the preexistence of type 2 diabetes. The ADC values were significantly correlated to plasma glucose levels and arterial pH, and tended to increase with the lapse of time. DWI may be an additional tool for making an efficient diagnosis of fulminant type 1 diabetes.