The Hypoglycemic Confidence Scale (HCS) is a unique scale that assesses confidence in staying safe from hypoglycemia-related problems. In this study, the Japanese version of the HCS (HCS-J) was developed and validated. A questionnaire survey including the HCS and three other psychological tests (Diabetes Treatment Satisfaction Questionnaire [DTSQ], The Problem Areas in Diabetes scale [PAID-5], and Generalized Anxiety Disorder [GAD]) was conducted in 121 adults with type 1 diabetes. Psychometric analyses included internal consistency reliability, a confirmatory factor analysis (CFA), convergent validity, and hierarchical regression analyses. Cronbach's α was 0.86. The CFA proved a generally good model (GFI: 0.935, CFI: 0.975, RMSEA: 0.056) in a 1-factor, 9-item structure, which was the same as the original version. The HCS showed a positive correlation with the DTSQ but a negative correlation with the PAID-5, GAD, and number of severe hypoglycemia. In conclusion, the HCS-J is a reliable and valid scale.

The patient was a 62-year-old woman with an 18-year history of type 2 diabetes mellitus who had discontinued treatment for 2 years due to interrupted to hospital visits. She was brought to the emergency department of our hospital with a fever of 39.6°C and impaired consciousness (JCS 300). She was diagnosed with a hyperosmolar hyperglycemic condition (HHS) and acute pyelonephritis of the right kidney due to Klebsiella aerogenes infection. Her severe sepsis was treated with multidisciplinary care in the ICU from the time of admission, and although the HHS improved, there was a flare-up of inflammation on the 7th day. Reevaluation by contrast-enhanced CT revealed findings of acute focal bacterial nephritis (AFBN), and suggested possible progression to renal abscess in some parts. Surgical treatment was considered for AFBN and renal abscess refractory to medical treatment. Percutaneous drainage was difficult due to the location of the abscess; thus, right nephrectomy was performed on the 10th day, and her general condition improved promptly thereafter. We should reevaluate acute pyelonephritis refractory to medical treatment with contrast-enhanced CT and consider surgical treatment in cases with progression to AFBN or renal abscess.

A 69-year-old man receiving insulin therapy for type 2 diabetes mellitus was treated with nivolumab for lung adenocarcinoma. During 3 years of nivolumab treatment, his insulin requirement increased and his glycemic control worsened. After 59 courses of nivolumab, he presented to the hospital with anorexia and fatigue and was admitted with a diagnosis of diabetic ketoacidosis. His endogenous insulin secretory capacity was significantly reduced, despite negative test results for islet-related autoantibodies. Imaging studies revealed that his pancreas had atrophied in comparison to before the start of nivolumab. Recently, in addition to new-onset type 1 diabetes, pancreatic atrophy has been reported in some patients treated with immune checkpoint inhibitors. The present case suggests a potential association between severe pancreatic atrophy observed during immune checkpoint inhibitor treatment and exacerbations of type 2 diabetes, including the onset of diabetic ketoacidosis.

We herein report a 61-year-old man with diabetes and primary bilateral macronodular adrenal hyperplasia (PBMAH) associated with an ARMC5 variant who developed thyroid and pancreatic cancer. The patient was diagnosed with diabetes and obesity at 41 years old. At 48 years old, PBMAH complicated with subclinical Cushing syndrome was detected during hospitalization for diabetic ketoacidosis. Afterwards, the patient developed bilateral papillary thyroid cancer, so we suspected a genetic mutation. Pathogenic germline mutations in ARMC5, a major tumor suppressor gene detected in PBMAH, may play an important role in extra-adrenal tumorigenesis in PBMAH. In our patient, a heterozygous mutation[c.1855C>T (p.R619^*) ]of the gene was confirmed. The patient was treated with liraglutide and insulin, and hemoglobin A1c was maintained at 6 % to 7 %. Unfortunately, however, the patient died of pancreatic cancer at 61 years old. To our knowledge, this is the first report of a case of PBMAH and concomitant pancreatic cancer. Both PBMAH and diabetes are assumed to increase the risk of cancer. Furthermore, approximately half of patients with PBMAH develop glucose intolerance. Thus, strict screening for neoplastic diseases should be recommended in patients with PBMAH complicated with diabetes.

Prader-Willi syndrome (PWS) is a congenital anomaly of the hypothalamus that leads to overeating and severe obesity, and is associated with a high rate of type 2 diabetes. In this case, a patient with PWS who had repeated hospitalizations for heart failure with a preserved ejection fraction due to severe obesity (BMI 43.8 kg/m²) and poor glycemic control was started on semaglutide (0.25 mg, subcutaneous injections, once a week). After 4 months of treatment, the patient's body weight had decreased 19 kg from 108 kg (before treatment) to 89 kg, and their HbA1c value had decreased 2.5 % from 8.2 % to 5.7 %. Although there are some reports on the use of glucagon-like peptide-1 receptor agonist (GLP-1RAs) for PWS because of its weight loss effect, no reports have demonstrated a significant effect of low-dose semaglutide, as was observed in this case. The present case suggests that GLP-1RA treatment may have the potential to improve the symptoms associated with heart failure.

A 74-year-old man was admitted to our hospital for the evaluation of bilateral leg weakness and a fever. Blood culture studies showed growth of Klebsiella pneumoniae (KP), and the patient received standard-dose ceftriaxone therapy. Liver abscess, urinary tract infection, pulmonary infection, vertebral osteomyelitis and discitis, as well as endocarditis were ruled out. Contrast-enhanced abdominal computed tomography revealed dilatation of the abdominal aorta and perivascular effacement and intramural abscess, which led to the diagnosis of infectious abdominal endoaortitis. Following confirmation on antibiotic sensitivity testing, the patient received high-dose cefazolin therapy, which resulted in resolution of endoaortitis. Serum glycosylated hemoglobin was 6.5 %, and insulin was administered to the patient. Although the aorta is resistant to infection, severe atheroma may serve as a focus of endovascular infection. Infectious endoaortitis should therefore be included in the differential diagnosis of bacteremia in diabetic patients who demonstrate susceptibility to infection and atherosclerosis.

Differentiating between alcoholic ketoacidosis (AKA) and euglycemic diabetic ketoacidosis (euDKA) is difficult, as both feature metabolic acidosis with an increased anion gap without hyperglycemia. A 51-year-old man who had been a heavy drinker was admitted to our hospital because of thirst and palpitations. He had regularly consumed more than 50 g of alcohol per day for a number of years. He also had a history of type 2 diabetes, which was being treated with empagliflozin, a sodium-glucose co-transporter-2 (SGLT2) inhibitor. At admission, his blood pH was 7.261, and his HCO3⁻ level was 14.0 mmol/L. The anion gap was elevated (25.2 mmol/L), as were lactate levels (5.1 mmol/L), but blood glucose was not (79 mg/dL). Initially, AKA was suspected, and treatment was started with fluid transfusion and thiamine. However, eight hours after admission, although the lactate level had normalized, metabolic acidosis persisted. After the patient was transferred to our department, we diagnosed him with euDKA because of the history of SGLT2 inhibitor treatment. The general condition of the patient improved after continuous intravenous administration of insulin and glucose. Even in heavy alcohol drinkers with metabolic acidosis without hyperglycemia, early administration of insulin and glucose should be considered for those being treated with SGLT2 inhibitors.