OBJECT: We assessed the clinical characteristics and long-term prognoses of diabetic patients with foot ulcers. We also analyzed the factors affecting the prognosis. METHODS: Study 1: We assessed the clinical characteristics of diabetic foot ulcer patients hospitalized in our hospital from January 2008 to December 2009. Study 2: We investigated the mortality, cause of death, and recurrence rate of these patients in May 2014. RESULTS: A total of 70 % of patients had recurrent foot ulcers, and 30 % and 10 % were hospitalized for heart disease and stroke, respectively. The 1-, 3-, and 5-year survival rates were 75 %, 65 %, and 55 %, respectively, and 27 % and 27 % died from heart disease and sepsis, respectively. The 5-year survival rate was lower in patients with recurrent foot ulcers than in those without such ulcers (33 % vs. 64 %) and in those living alone than in those living with others (0 % vs. 73 %). A multivariate analysis of these results using a proportional hazard model showed that recurrent foot ulcers in diabetic patients were an independent risk factor of a poor prognosis (hazard ratio 9.3, P=0.03). DISCUSSION: Diabetic foot ulcer patients were associated with high recurrence rate and a poor prognosis. This is the first report demonstrating that diabetic foot ulcer patients with recurrence and living alone had lower survival rates than others.

Autoimmune Polyglandular Syndrome (APS) type III is defined by autoimmune thyroid disease and autoimmune diseases other than autoimmune adrenal gland disease, such as type 1 diabetes, vitiligo. We herein report the case of 66-year-old male patient with APS III. The patient had vitiligo and was diagnosed with diabetes mellitus at 47 years. The patient was initially treated with an oral hypoglycemic agent; this was changed to insulin therapy at 54 years of age. At 58 years of age the patient was negative for anti-GAD antibodies. However, at 62 years of age, anti-GAD antibodies were detected and the patient's urine C-peptide level declined. This indicated that type 1 diabetes had occurred during type 2 diabetes. In addition, a blood test revealed Basedow disease. At 66 years of age, the patient's endogenous insulin secretion was depleted, and the patient was found to be negative for anti-adrenal antibodies, which indicated APS III.

A 29-year-old woman was admitted to our hospital due to unconsciousness. She was diagnosed with insulinoma, and distal pancreatectomy was performed. However, her serum chromogranin A (CgA) levels increased after surgery. We therefore examined the patient for metastasis and recurrent insulinoma; but they were not detected. According to previous reports, the serum CgA level in the serum is useful as a diagnostic and follow-up biomarker in cases involving neuroendocrine tumors other than insulinoma. It is more important for clinicians to ask patients about hypoglycemic symptoms and to perform imaging studies when recurrence or metastasis of insulinoma is suspected.

We experienced an obese patient with type 1A diabetes that was difficult to distinguish from soft-drink ketosis. A 45-year-old man whose uncle had type 2 diabetes visited our clinic due to general fatigue, thirst and polydipsia (soft drink>1 L per day) for the past 10 days. His BMI was 25.7 kg/m² on admission. He was diagnosed with diabetic ketoacidosis based on the following findings: blood glucose, 1,260 mg/dL; HbA1c, 12.4 %; blood gas pH, 7.156; and positive urine ketone bodies, and he was treated with continuous insulin infusion therapy. Based on the medical history and the presence of obesity, soft-drink ketosis was suspected, but he was ultimately diagnosed with acute-onset type 1A diabetes because of the presence of GAD autoantibodies, IA-2 autoantibodies, and IAA. His serum C-peptide reactivity (CPR) was low (0.37 ng/mL) on admission but recovered to a fasting/postprandial CPR of 1.41/8.39 ng/mL by 3 months later. His insulin requirement also decreased from 1.23 to 0.37 U/kg/day. The differential diagnosis of obese patients who develop diabetic ketoacidosis is often difficult. This case should provide valuable information on the role of obesity in the development of type 1 diabetes.

We experienced two cases in which type 2 diabetes patients developed HPVG during treatment with a dipeptidyl peptidase (DPP)-4 inhibitor. Case 1 was an 85-year-old man who underwent aortic valve replacement for aortic valve stenosis. Sitagliptin (50 mg) was restarted on the first postoperative day. On the 8th postoperative day, he complained of upper abdominal pain, and was diagnosed with HPVG based on the abdominal CT findings. Sitagliptin was terminated immediately and the HPVG was found to have disappeared on an abdominal CT scan that was performed the following day. Case 2 was 82-year-old man who underwent coronary artery bypass for effort angina pectoris. After restarting linagliptin (5 mg) on the second postoperative day, he complained abdominal fullness. HPVG was incidentally detected by coronary CT scan on the 10th postoperative day. The patient's abdominal symptom improved following the termination of linagliptin and the HPVG was found to have disappeared on an abdominal CT scan that was performed on the 18th postoperative day. Although there are reports of HPVG due to the administration of α-GIs, there are no reports on HPVG during DPP-4 inhibitor treatment. Physicians should thus be aware of the possibility of HPVG in patients with diabetes who complain of abdominal pain after restarting a DPP-4 inhibitor in the early postoperative period.