Improvement of glucose variability by continuation of Low-Carbo meal

Background: For years, there have been various discussion of Calorie Restriction (CR) and low carbohydrate diet (LCD). We have continued clinical research of CR and LCD so far. Patient and Method: The patient was 72-year-old female with type 2 diabetes mellitus (T2DM). At first visit, she showed BMI 29.5, postprandial 120 min of blood glucose 548 mg/dl, HbA1c 18.0%, Hb 11.4 g/dL, GOT 29 IU/mL, r-GTP 36 IU/mL, Cre 1.0 mg/dL, TG 194 mg/dL, LDL 161 mg/dL. Serum C-peptide radioimmunoactivity (CPR) 5.4 ng/mL, urinary protein 24 mg/dL. Results: We have treated her by standard LCD meal, including 26% of carbohydrate with 1400kcal per day. She could continue LCD successfully and showed the decreased data as follows: HbA1c 18.0% to 7.8%, blood glucose 548 mg/dL to 154 mg/dL, proteinuria 24 mg/dL to 3 mg/dL, weight 72 kg to 65 kg for some months. Discussion and Conclusion: LCD showed clinical efficacy in several biomarkers. Patient applied standard-LCD method, including 26% of carbohydrate with 1400 kcal per day, which would bring decreased HbA1c, glucose, proteinuria and weight to the actual degree. These data would become basal reference and would bring further research development in the future

Satisfactory Control for Glucose Profile by Combined Agents of Xultophy with A Small Dose

The patient was a 74-year-old female with type 2 diabetes mellitus (T2DM) treated on Humalog mix 25 twice a day. As social history, she has worked long years for growing and harvesting lotus roots. It gives physically heavy loading, which brings unstable glycemic daily control. She had to titrate minute regulation every time. For stable glucose variability, the treatment was changed to Xultophy, which is a specific combined agent of Insulin Degludec and Liraglutide (IDeg/Lira) once a day. Then, detailed glucose monitoring showed a better daily profile of blood glucose, irrespective of heavy or light work. It showed the bio-psycho-social benefit of Xultophy

Improved Hypertension by Investigating Circadian Rhythm of Blood Pressure

Case: The case is 86-year-old male hypertensive patient with anti-hypertensive drug for 5 years. He has been provided Amlodipine besilate 5mg at 0800h and doxazosin mesylate 2mg at 2300h for long. In June 2020, he noticed unstable fluctuation of Blood Pressure (BP) during morning, afternoon and night. Results: Then, he checked the circadian rhythm of BP, which showed higher BP in early morning, decreasing BP 0800-1000h, minimum BP during 1000-1400h, increasing BP during 1400-1800h and stable BP during 1800-2400h. Due to the result, he changed to take amlodipine at 2300h. Consequently, his BP gradually became stable during 24 hours after 2 weeks. Discussion: Some factors may exist for contributing improved BP fluctuation. They include a) pathophysiological characteristics of BP circadian rhythm, b) effective time for anti-hypertensive drug, c) accuracy of the obtained BP data and d) the social and psychological reliability of the patient. Regarding d) he was engaged in research and development work as a senior researcher at a chemical company. He has been also a member of New Elderly Association (NEA), which was established by Shigeaki Hinohara. He lives on the philosophy of Hinohara-ism for long, associated with stable mind and body

The importance of continuing adequate lifestyle including exercise, daily activity and low carbohydrate diet (LCD) for type 2 diabetes mellitus (T2DM)

The case was 71-year-old male patient with type 2 diabetes mellitus (T2DM). He was diagnosed T2DM at the age of 61 associated with thirsty, polydipsia and fatigue. HbA1c value was 12.5% and blood glucose profile was 150-300 mg/dL. Just after starting low carbohydrate diet (LCD), his blood glucose kept under 150 mg/dL all day long. He continued good diabetic control as HbA1c 5.8-6.8% for 10 years. Some beneficial points are found: i) keeping LCD with the feeling not stressful but pleasant for observing the normal glucose level, ii) walking daily for 2 hours, iii) continuing educational activity in the walking association for DM and health care. iv) writing the diary for years every day, including exercise, meal, medicine, activities and so on, v) checking post-prandial hyperglycemia by meal tolerance test (MTT). For details of v), HbA1c was 6.5% in May 2021 and fasting glucose was 107mg/dL. Glucose values 45-min and 60-min after 3 meals showed 210-201-177mg/dL and 195-213-172mg/dL, respectively. His various continuing behaviors contributed satisfactory glycemic control. This article becomes reference in the diabetic practice and research

Detail Investigation of Frequent Nocturia and its Improvement by the Administration of Diuretic

Background: For elderly people, nocturia has been often found associated with other diseases. Case presentation: The case is 88-year-old male with hypertension, Cardiovascular Disease (CVD), Diabetes, Chronic Kidney Disease (CKD). He developed nocturia and insomnia, and then checked daily water balance by himself. Results: Basic situation showed water intake/urine volume were 750mL/1030mL/day, in which urine ratio of day/night was 27%/73% with waking up twice during night. He was given furosemide 20mg, per os at 1500h. Same study showed 960mL/1090 mL, and urine ratio as 77%/23% with no waking up. Discussion and Conclusion: From some reports, Odds Ratio (OR) for combination of nocturia shows 1.25 for hypertension, 1.23/1.74 for CVD (mild/severe). Consequently, current treatment would contribute adequate managements for nocturia problem

Improved Insulin Resistance and Glucose Variability by Super-Low Carbohydrate Diet

Background Diabetes mellitus (DM) has been more prevalent. American Diabetes Association (ADA) proposed the Standards of Medical Care in Diabetes-2022. For nutritional therapy, low carbohydrate diet (LCD) has been recognized for its benefits. Authors have continued diabetic research concerning LCD and meal tolerance test (MTT). Case Presentation The case is 61-year-old male with type 2 diabetes mellitus (T2DM) for years. His hemoglobin A1c (HbA1c) increased to 7.8% in autumn 2021, and further evaluation and treatment was conducted including LCD, daily check of meal and carbohydrate amount, 75 g OGTT, glucagon stimulation test (GST) and others. Results He was on super-LCD method including 12% of carbohydrate. His carbohydrate intake amount and 45-minutes post-prandial blood glucose showed significant correlation. The results of 75 g OGTT twice in May 2020 and December 2021 showed that similar pattern of glucose and insulin responses and insulinogenic index (IGI). In contrast, they showed decreased fasting immuno-reactive insulin (IRI) and Homeostasis model assessment insulin resistance (HOMA-R). For GST, C-peptide showed normal response. Discussion and Conclusion Judging from the results of MTT, OGTT, GST and IGI, he seems to show rather decreased insulin resistance by LCD associated with preserved insulin secretion ability to some degree. Further investigation would be required from pathophysiological point of view

Attenuated Efficacy of Dulaglutide in Elder Type 2 Diabetes Mellitus (T2DM) Cases

Acute increase of type 2 diabetes mellitus (T2DM) is a serious medical problem. Recently, an agent known as Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) was developed for T2DM which has remarkable efficacy and safety profile. In this article, we reported 2 T2DM cases with dulaglutide treatment, showing interesting clinical course. Case 1 is an 88-year-old man with hypertension, arteriosclerosis and mild cognitive impairment (MCI) without difficulties of Quality of Life (QOL)/Activities in Daily living (ADL) in daily life. He has been rather stable on liraglutide with HbA1c 7.2%. After switching from liraglutide to dulaglutide, HbA1c decreased to 6.7% in 2 months, but later increased to 11.3% in 3 months. C-peptide index (CPI) decreased from 2.5 to 0.8. Case 2 is an 83-year-old man and was treated by degludec with CPI 1.35. After switching to dulaglutide, HbA1c decreased to 7.6% in 2 months, but later increased to 10.3% in 2 months. These two cases revealed similar clinical course. Some possibilities might be speculated, including antibody production, differences of GLP-1 RAs from man-origin or lizard-origin, changes in body weight, a possible complication of renal, hepatic inflammatory influences and the subacute decreased ability of insulin secretion in the β cells. The current report would be useful for treatment of GLP-1 RAs in the future

HER2-Positive Metaplastic Breast Cancer with Resistance to Neoadjuvant Chemotherapy: Case Report

Introduction: Metaplastic breast carcinoma (MBC) is a rare histologic subtype of breast carcinoma, which is usually negative for estrogen receptor, progesterone receptor, and HER2. HER2-positive MBC is therefore extremely rare. Most MBCs have poor response to chemotherapy. HER2-targeted neoadjuvant chemotherapy (NAC) is widely performed and has high efficacy in treating HER2-positive breast cancer. We report an atypical case of HER2-positive breast cancer that had poor response to NAC and was diagnosed with MBC after the surgery. Case Presentation: A 73-year-old woman noticed a mass in her right breast and visited our hospital. The mass was diagnosed as hormone receptor-negative, HER2-positive invasive ductal carcinoma, T2N0M0 stage IIA. She received HER2-targeted NAC comprising trastuzumab + pertuzumab + docetaxel. Despite three courses, we observed disease progression. The next NAC regimen was composed of two courses of epirubicin + cyclophosphamide, but the cancer continued to grow. She stopped receiving NAC and underwent a unilateral mastectomy and sentinel lymph node biopsy. Although the preoperative pathological result of core needle biopsy specimen showed invasive ductal carcinoma, the postoperative pathological result of the surgical specimen was MBC. Conclusion: In this case, when the patient had undergone three courses of trastuzumab + pertuzumab + docetaxel, it would have been appropriate to review the result of the core needle biopsy with pathologists or to perform vacuum-assisted breast biopsy. This case suggests the importance of considering the possibility of special histologic subtypes such as MBC when a tumor with the diagnosis of invasive ductal carcinoma is resistant to NAC

Enhancing the Therapeutic Efficacy of Bone Marrow-Derived Mononuclear Cells with Growth Factor-Expressing Mesenchymal Stem Cells for ALS in Mice.

Several treatments have been attempted in amyotrophic lateral sclerosis (ALS) animal models and patients. Recently, transplantation of bone marrow-derived mononuclear cells (MNCs) was investigated as a regenerative therapy for ALS, but satisfactory treatments remain to be established. To develop an effective treatment, we focused on mesenchymal stem cells (MSCs) expressing hepatocyte growth factor, glial cell line-derived neurotrophic factor, and insulin-like growth factor using human artificial chromosome vector (HAC-MSCs). Here, we demonstrated the transplantation of MNCs with HAC-MSCs in ALS mice. As per our results, the progression of motor dysfunction was significantly delayed, and their survival was prolonged dramatically. Additional analysis revealed preservation of motor neurons, suppression of gliosis, engraftment of numerous MNCs, and elevated chemotaxis-related cytokines in the spinal cord of treated mice. Therefore, growth factor-expressing MSCs enhance the therapeutic effects of bone marrow-derived MNCs for ALS and have a high potential as a novel cell therapy for patients with ALS