The incidence of depression among diabetes mellitus patients was investigated, along with the effects of intervention using the antidepressant paroxetine. Depression was assessed by the 2-question method and Zung's Self-rating Depression Scale (hereafter: SDS). Among the 107 diabetes mellitus patients examined, 14 patients (13.1 %) were positive for depression in the 2-question screening, and the average SDS score was 38.4 points. The results showed significantly higher SDS scores among patients exhibiting insomnia, changes in appetite and body weight, as well as among males with nephropathy and patients with a known history of coronary artery disease. Patients who were suffering from depression or were in a depressive state were treated with paroxetine for 12 weeks. A significant decrease in the SDS score from the baseline level of 51.0±2 points to 42.0±5 points was observed after 12 weeks of treatment, and significant decreases in the HbA1c (JDS) level was also observed, compared to the pre-treatment levels. These results suggest that the early discovery of depression accompanying diabetes mellitus, together with appropriate intervention, may be beneficial from the standpoint of glycemic control, as well improving the patient's quality of life.

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It is well recognized that the prevalence of peripheral artery disease (PAD) assessed with the ankle-brachial index (ABI) is 3-29 % and that diabetes is a major risk factor. It has been reported that coronary artery disease (CAD) is present in 50-70 % of symptomatic and critical PAD patients. However, little is known about whether CAD is associated with asymptomatic PAD. Therefore, we examined the prevalence of PAD and its association with CAD in asymptomatic type 2 diabetic patients. Two hundred and twenty-eight asymptomatic (Fontaine 1) type 2 diabetic outpatients were recruited (males: 119; Age 66.0±10.8 years; HbA1c 7.6±1.0 %). The ABI was examined in all patients, and those with values less than 0.9 were evaluated with contrast-enhanced CT or MRA. When PAD was suspected, lower extremity and coronary angiography was performed simultaneously. The prevalence of PAD was 7.9 % among all patients, and significant coronary stenosis was demonstrated in 45 % of the PAD patients. These data revealed that the prevalence of coronary stenosis in asymptomatic diabetic PAD patients is as high as that observed in critical PAD patients, as has been previously reported. The ABI is thus considered to be a useful screening test for PAD and CAD.

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A 59-year-old male with type 2 diabetes had been in good glycemic control with intensive insulin therapy. The therapy was switched from insulin to exenatide under continuous glucose monitoring. Hypoglycemia and consecutive hyperglycemia occurred several times soon after the initiation of exenatide and disappeared five days later. Exenatide monotherapy does not generally cause hypoglycemia. However, clinicians should pay attention to the occurrence of abrupt hypoglycemia after the initiation of exenatide, especially in patients with good glycemic control.

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Infected aneurysms in the coronary artery are rare. We herein report a case of a infected aneurysm due to bacteremia caused by a diabetic foot ulcer. A 75-year-old male with type 2 diabetes mellitus and stage 5 chronic kidney disease was admitted to our hospital with an intractable ulcer on his right foot. Cultures of his blood and the wound yielded Methicillin-resistant Staphylococcus aureus (MRSA). On the second day of admission, he had a high fever and developed shortness of breath. His foot ulcer showed improvement, and the presence of other infection foci, including endocarditis, was excluded. Computerized tomography revealed a 60 mm coronary aneurysm in the proximal right coronary artery. Because of the MRSA infection and his poor general condition, surgical excision was not indicated. His inflammatory state persisted despite the treatment with adapted antibiotics, and he died of sepsis on the 30^th day. In the pathological study, the aneurysm was diagnosed as infected aneurysm caused by bacteremia.

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A 26-year-old Japanese male who had polydipsia and consumed 1 l of sugar-containing soft drinks daily was admitted to our hospital with diabetic ketoacidosis with alkalemia. He received standard treatment for DKA with insulin and iv fluids. His plasma C-peptide level remained low after the improvement of glycemic control. His GAD antibody titer was undetectable. He had nephropathy characterized by hypokalemic alkalosis, normotensive hyperreninemic hyperaldosteronism and hypomagnesemia. A renal clearance study revealed that administration of furosemide, but not thiazide, decreased the chloride reabsorption. These are characteristic of Gitelman's syndrome or type III Bartter's syndrome, and may be associated with his polydipsia, which provoked DKA with alkalemia. However, his SLC12A3 and CLCNKB were normal. An abdominal CT showed deletion of the dorsal pancreas and enlargement of the left renal pelvis without an obstruction of the urinary tract. A genetic analysis revealed that he had a heterozygous 1.3-MB deletion mutation on 17q12 involving HNF1B, so he was diagnosed with maturity-onset diabetes of the young type 5 (MODY 5). Because HNF-1β is expressed in human nephrons, mutations of the gene may induce hypokalemia and hypomagnesemia related to inappropriate renal loss. This is the first case of MODY 5 complicated with nephropathy and hypokalemic alkalosis, which resulted in the acute onset of diabetic ketoacidosis with alkalemia.

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