Construction of a simulation model and evaluation of the effect of potential interventions on the incidence of diabetes and initiation of dialysis due to diabetic nephropathy in Japan.

BACKGROUND: The prevalence of diabetes mellitus is a growing public health concern in Japan. We developed a simulation model to predict the number of people with diabetes and those on dialysis due to diabetic nephropathy. In addition, we used the model to simulate the impact of possible interventions on the number of people with diabetes and those on dialysis due to diabetic nephropathy in the near future. METHODS: A simulation model with aging chains for diabetes management was built using system dynamics. The model was calibrated to population data from 2000 to 2015 (sex- and age category-specific population, the prevalence of diabetes, and the number of patients on dialysis due to diabetic nephropathy). We extrapolated the model up to 2035 in order to predict future prevalence of diabetes and related dialysis (base run). We also ran the model, hypothesizing that incidence of diabetes and/or related dialysis would be reduced by half from 2015 to 2025 and that this rate would be maintained until 2035, in order to investigate the effects of hypothetical interventions on future prevalence. RESULTS: The developed model forecasted the population with diabetes to increase until 2028 (5.58 million males and 3.34 million females), and the population on dialysis due to diabetic nephropathy to increase until 2035 (113,000 males and 48,000 females). Simulation experiments suggested that diabetes prevention interventions would decrease the number of patients on dialysis in 2035 by 13.8% in males and 12.6% in females compared to the base run. In contrast, interventions aiming to avoid dialysis initiation for patients with diabetes would decrease the number of patients on dialysis by 37.8% in males and 38.1% in females. CONCLUSIONS: We successfully developed a simulation model to project the number of patients with diabetes and those on dialysis due to diabetic nephropathy. Simulation experiments using the model suggested that, as far as the perspective of the next 20 years, intervention to prevent dialysis is an important means of bending the increasing curve of dialysis in the population with diabetes. Simulation analysis may be useful when making and evaluating health policies related to diabetes and other chronic diseases.

Insulinoma Presenting with Reactive Hypoglycemia: Evaluating the Effect of Tumor Resection via Continuous Glucose Monitoring.

A 71-year-old woman previously diagnosed with reactive hypoglycemia was transferred to our emergency unit because of loss of consciousness. Her plasma glucose level was 27 mg/dL, and continuous glucose monitoring (CGM) revealed postprandial asymptomatic hypoglycemia. A hypervascular tumor was identified via computed tomography in the distal pancreas, and the diagnosis of insulinoma was confirmed using the selective arterial calcium stimulation test. Although no episodes of hypoglycemia were observed during CGM after resection, a pathological examination identified regional lymph node metastasis. It is important to consider insulinoma as a cause of postprandial hypoglycemia, and CGM is useful for evaluating treatment outcomes.

Acute Multiple Arteriovenous Thromboses in a Patient with Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is one of the most serious acute complications of diabetes mellitus. An arterial thrombotic tendency from DKA is relatively common; however, the occurrence of acute multiple arteriovenous thromboses is rare. We herein report the case of a 49-year-old man with DKA complicated by multiple thromboses. After transfer to our emergency room with DKA, the patient developed sudden abdominal pain. Contrast-enhanced computed tomography revealed near-complete occlusion of the superior mesenteric artery, superior mesenteric vein, splenic artery, and right femoral artery. This occurrence highlights the need for considering the risk of thrombosis during the initial treatment for DKA.

Effect of body mass index and intra-abdominal fat measured by computed tomography on the risk of bowel symptoms.

BACKGROUND: This study aims to investigate the association between body mass index (BMI) or intra-abdominal fat measured by computed tomography (CT) and bowel symptoms. METHOD: A cohort of 958 Japanese adults who underwent colonoscopy and CT and completed questionnaires after excluding colorectal diseases was analyzed. Six symptoms (constipation, diarrhea, loose stools, hard stools, fecal urgency, and incomplete evacuation) using a 7-point Likert scale were evaluated between baseline and second questionnaire for test-retest reliability. Associations between BMI, visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), and symptom score were analyzed by a rank-ordered logistic model, adjusting for age, sex, smoking, and alcohol consumption, hypertension, diabetes mellitus, and dyslipidemia. RESULTS: Some bowel symptom scores were significantly (p<0.05) different between the age groups, sexes, smoking, and alcohol consumption. In multivariate analysis, constipation was associated with low BMI (p<0.01), low VAT area (p = 0.01), and low SAT area (p<0.01). Moreover, hard stools was associated with low BMI (p<0.01) and low SAT area (p<0.01). The remaining symptoms were not significantly associated with BMI or intra-abdominal fat. Test-retest reliability of bowel symptom scores with a mean duration of 7.5 months was good (mean kappa, 0.672). CONCLUSIONS: Both low BMI and low abdominal fat accumulation appears to be useful indicators of increased risk for constipation and hard stools. The long-term test-retest reliability of symptom score suggests that bowel symptoms relevant to BMI or visceral fat remain consistent over several months.

Improvement of both fasting and postprandial glycemic control by the two-step addition of miglitol and mitiglinide to basal insulin therapy: a pilot study.

BACKGROUND: Combination therapy consisting of basal insulin and oral hypoglycemic agents (OHAs) is effective for the treatment of type 2 diabetes (T2DM) that cannot be adequately controlled using OHAs alone. Though basal insulin with metformin or sulfonylurea is an effective therapy, it cannot reduce postprandial glycemia without the risk of hypoglycemia. We examined a two-step regimen consisting of the addition of postprandial hypoglycemic agents (an alpha-glucosidase inhibitor and a glinide) in patients whose T2DM was poorly controlled using basal insulin therapy. METHODS: Inpatients between the ages of 30-79 years who had T2DM and an HbA1c level of more than 7.0% were recruited. The patients were treated with once-daily insulin glargine with or without metformin, depending on the patient's age and renal function. Insulin glargine was titrated to achieve a target fasting glucose level of 70-130 mg/dL as a first step (STEP0). If the 2-hour postprandial glucose (PBG) level was higher than the target of 180 mg/dL, miglitol treatment (150 mg/day) was initiated, with dose adjustments (75-225 mg) allowed depending on abdominal symptoms and the PBG (STEP1). If the PBG of the patients remained higher than the target after 3 days of treatment, mitiglinide (30 mg/day, titrated up to 60 mg) was added (STEP2). We then evaluated the proportion of patients who achieved the target PBG before and after the two-step regimen. Continuous Glucose Monitoring (CGM) was performed throughout the two-step protocol in most of the patients. RESULTS: Of the 16 patients who were recruited (median age, 67.0 [58.0-71.0] years; body mass index, 25.0 [22.0-27.9] kg/m(2); HbA1c level at admission, 9.1% [8.35-10.4%]), 1 patient (6.25%) achieved the target PBG at STEP 0 and 14 patients (87.5%) had achieved the target PBG at the end of the treatment protocol (P = 0.002). CGM showed a significant decrease in the glucose level at each step of the protocol. The standard deviations in the CGM glucose levels for 24 hours, MAGE, and M-value also improved. CONCLUSIONS: The two-step addition of postprandial hypoglycemic agents to basal insulin therapy is potentially effective and safe for decreasing both the fasting and postprandial glucose levels.

Successful treatment of chronic intractable itching using oral pregabalin in a patient with diabetes and systemic prurigo nodularis: a case report of an iliopsoas muscle abscess.

A 73-year-old Japanese man developed chronic intractable itching due to prurigo nodularis. High-dose glucocorticoid ointment failed, and the treatment resulted in poor glycemic control. Repeated scratching caused hematogenous bacterial dissemination via cutaneous injuries, resulting in the formation of iliopsoas and spinal epidural abscesses that required long-term antibiotic treatment. Pregabalin was administered to treat the pruritus, and a considerable improvement was observed. A reduction in the dose and intensity of the topical corticosteroids improved the patient's glycemic control, resulting in the complete resolution of the abscesses. Pregabalin significantly improved the patient's pruritus and decreased the risk of infection.

A morbid obese Japanese woman with a body mass index of 83.2 kg/m2: before and after sleeve gastrectomy.

A 34-year-old Japanese woman presented at our institution weighing 182.7 kg, 148.2 cm tall, and with a body mass index of 83.2 kg/m(2). She had been overweight since childhood, but no abnormality was found to explain her obesity. Treatments, including mazindol, bofu-tsusho-san, dietary restriction, and BioEnterics Intragastric Balloon, did not result in improvement of her obesity. Finally, we performed sleeve gastrectomy, and she has maintained her weight within 130-140 kg without rebounding for 2 and a half years. We followed the clinical changes before and after the operation. This case provides potentially interesting information regarding operative treatment for morbid obesity in Japanese.