Although the current guidelines recommend the use of "individualized" HbA1c goals for patient-centered diabetes care, information regarding the satisfaction of patients with their glycemic control is insufficient. In this study, we aimed to clarify the satisfaction of patients with their glycemic control and to determine the related factors. Outpatients with diabetes were asked to answer questionnaires that included a question about their satisfaction with their glycemic control, and responses were obtained from 254 patients with type 2 diabetes and 22 patients with type 1 diabetes. Twenty-eight percent of the patients answered "satisfied", while 18 % answered "not satisfied". The satisfaction with glycemic control was significantly correlated with HbA1c, adherence to dietary therapy, satisfaction with doctor and clinic, satisfaction with medical cost, intention to drop out and satisfaction with diabetes treatment. Thus, patient satisfaction with glycemic control should be recognized as an important patient-reported outcome, and may be affected by the self-efficacy of dietary therapy and the patient's relationship with medical staff.
The relationship between medical costs and the clinical characteristics of diabetic patients who developed severe hypoglycemia due to antidiabetic agents was investigated. A total of 267 patients (17 type 1 diabetes and 250 type 2 diabetes) diagnosed with hypoglycemia after visiting our hospital via ambulance were included in this study. The direct medical costs were calculated in the non-hospitalization group (n=153) and the hospitalization group (n=114). The mean and median values of medical costs were 14,000 yen and 10,000 yen in the non-hospitalization group and 314,000 yen and 260,000 yen in the hospitalization group, respectively. In the non-hospitalization group, the use of sulfonylureas significantly increased the medical costs. The mean value of medical costs was significantly higher in the patients receiving sulfonylureas (21,000 yen) than in those not receiving such agents (12,000 yen). In the hospitalization group, the medical costs showed a significant positive correlation with the duration of hospitalization. Diabetes treatment to prevent severe hypoglycemia is desirable from the perspective of health economics.
An 80-year-old woman was admitted due to liver dysfunction. She had been treated for type 2 diabetes mellitus by oral anti-diabetic medications. Laboratory examinations findings were as follows: AST 96 IU/L, ALT 134 IU/L, γ-GTP 823 IU/L, fasting serum glucose 204 mg/dL, HbA1c 8.3 %, C-peptide 2.46 ng/mL, anti-GAD antibody 55.8 U/mL, and IgG4 704 mg/dL. Imaging showed marked dilation of bile ducts without swelling of the pancreas or narrowing of the pancreatic ducts. The histological findings of a liver biopsy were compatible with IgG4-related sclerosing cholangitis. Both steroid therapy and insulin therapy were started and led to the amelioration of the liver function and insulin secretion as well as a reduction in anti-GAD antibody. We herein report a case of IgG4-related sclerosing cholangitis associated with diabetes mellitus with positivity for anti-GAD antibody, a situation that is rare to our knowledge.
A 26-year-old man with obesity (body mass index [BMI] 34.6 kg/m2) who had never been diagnosed with diabetes mellitus presented to the emergency department of our hospital via doctor-helicopter after resuscitation from cardiac arrest. He had felt thirsty and shown polydipsia and polyuria the night before admission. On the day of admission, he had felt general malaise in the morning, and he had vomited and shown restlessness around noon. Laboratory findings were as follows: plasma glucose 1060 mg/dL; HbA1c 6.2 %; pH 6.835; HCO3− 6.0 mmol/L; 3-hydroxybutyrate 9685 μmol/L; K 7.5 mEq/L. These findings indicated diabetic ketoacidosis (DKA) and hyperkalemia. His urinary C-peptide reactivity (CPR) was 8.5 μg/day, serum CPR was 0.20 ng/mL before and after a glucagon-loading test, and anti-GAD, anti-IA-2 and anti-insulin antibodies were undetected, indicating a diagnosis of fulminant type 1 diabetes mellitus (FT1DM). The present findings should encourage physicians to consider FT1DM in the differential diagnosis of cardiac arrest and recognize the importance of pre-hospital medicine.
A 57-year-old woman was found to have a high plasma glucose level at a health checkup and visited a diabetes clinic. Unexpectedly, she had a low hemoglobin A1c (HbA1c) of only 4.9 % on high-performance liquid chromatography (HPLC) (HA-8170; Arkray, Kyoto, Japan), while the blood glucose level was 295 mg/dL. High-quality HPLC revealed an extra peak, suggesting the presence of variant hemoglobin. The HbA1c level was 6.6 % when measured by an enzymatic assay. This patient was referred to our hospital with suspected variant hemoglobin but did not attend for one year due to pressure of work. At our initial examination, the postprandial (3 h) blood glucose level was 323 mg/dL, HbA1c (measured by enzymatic assay) was 12.1 %, glycoalbumin was 34.4 %, and urinary ketone bodies were positive. Accordingly, she was urgently hospitalized with a diagnosis of diabetic ketosis. An analysis of the globin gene revealed a heterozygous mutation, and we made a diagnosis of hemoglobin Montfermeil [β130 (H8) Tyr→Cys]. This is the first report to indicate that measurement of HbA1c by HPLC (HA-8170) can show false low values due to hemoglobin Montfermeil.
We conducted a national survey to clarify the characteristics and clinical course of type 1 diabetes related to anti-programmed cell death-1 therapy. We analyzed the detailed data of 22 patients that were collected using a Japan Diabetes Society survey and a literature database search. Among the 22 patients, 11 (50.0 %) met the criteria for fulminant type 1 diabetes and 11 (50.0 %) met the criteria for acute onset type 1 diabetes. The average patient age was 63 years. The mean duration between the date of the first anti-PD-1 antibody injection and development of type 1 diabetes was 155 days and ranged from 13 to 504 days. Flu-like symptoms, abdominal symptoms, and drowsiness were observed in 27.8 %, 31.6 %, and 16.7 % patients, respectively. Mean±standard deviation or median (first quartile-third quartile) glucose levels, HbA1c levels, urinary C-peptide immunoreactivity levels, and fasting serum C-peptide immunoreactivity levels were 617±248 mg/dL, 8.1±1.3 %, 4.1 (1.4-9.4) μg/day, and 0.46 (0.20-0.70) ng/mL, respectively. Seventeen of 20 patients (85.0 %) developed ketosis, and seven of 18 patients (38.9 %) developed diabetic ketoacidosis. Ten of 19 patients (52.6 %) showed at least one elevated pancreatic enzyme level at the onset and two of seven patients showed this elevation before diabetes onset. Only one of 21 patients was anti-glutamic acid decarboxylase antibody positive. In conclusion, anti-programmed cell death-1 antibody-related type 1 diabetes varies from typical fulminant type 1 diabetes to acute onset type 1 diabetes. However, diabetic ketoacidosis was frequently observed at the onset of diabetes. An appropriate diagnosis and treatment should be provided to avoid life-threatening metabolic alterations.