トクシマケン ノ トウニョウビョウ ニオケル ケンコウ ホジ ゾウシン タイセイ : キカン ビョウイン カラ ノ トウニョウビョウ チイキ レンケイ ノ ジッシレイ トウニョウビョウ レンケイ テチョウ ノ カツヨウ

Patients with diabetes are increasing in Japan. In２００７,８．９million persons were estimated to have diabetes in Japan. Forty four ％ of them were not treated, and only３０％ achieved good glycemic controls. On the other hand, there are only３７diabetes specialists in Tokushima（January２０１１）. To break away the worst mortality rate, we needed to use limited medical resources, effectively. From April２００８, we created a critical pathway to regional medical network for diabetes. Unfortunately, this critical pathway adapted very limited patients, because it was inconvenient to carry to several hospitals. Next, we used diabetes network notebook published by Japan Association for Diabetes Education and Care. To evaluate its usefulness as a tool for regional network,３５patients who were treated by general practitioner and diabetes specialist, introduced this diabetes network notebooks. Thirty two patients（９１．４％）carried the notebooks at their second visit. HbA１c levels did not change between before and after. Therefore we suggest this notebook may be useful to promote diabetes regional network

ドウジキ ニ 1ガタ トウニョウビョウ オ ハッショウシ タセンセイ ジコ メンエキ ショウコウグン IIIガタ ト シンダンシ エタ コウキ コウレイシャ ノ ドウホウ ショウレイ

We herein presented a case of a ７９-year-old woman who was referred to our hospital with dry mouth and polyuria that had persisted for three months prior to her admission. She developed Hashimoto disease at ７３ years old and pernicious anemia at ７８ years old. Her blood glucose level was ６８２ mg/dl, HbA１c １４．６％, and urinary ketone was positive ; therefore, she was diagnosed with diabetic ketosis. Acute-onset autoimmune type １ diabetes mellitus was diagnosed based on the diagnostic criteria for acute-onset type １ diabetes mellitus （２０１２） by the committee of the Japan Diabetes Society. Autoimmune polyglandular syndrome was subsequently diagnosed based on the complications of type １ diabetes and Hashimoto’s thyroiditis. Her ８７-year-old brother had developed acute-onset autoimmune type １ diabetes ２ months before his sister was hospitalized. Autoimmune polyglandular syndrome type III was also diagnosed because he had autoimmune thyroid disease. No epidemiological data are currently available for late elderly with acute-onset type １ diabetes in Japan. To the best of our knowledge, this is the first case of acute-onset autoimmune type １ diabetes mellitus that developed around the same time period in an elderly brother and sister who were diagnosed with autoimmune polyglandular syndrome type III. Common genetic and environmental factors were etiologically implicated in the almost simultaneous onset between these siblings

Treatment algorithm of ACTH deficiency

Objective : To examine diagnostic performance of corticotropin-releasing hormone (CRH) test combined with baseline dehydroepiandrosterone sulfate (DHEA-S) in patients with a suspect of central adrenal insufficiency. Methods : Patients (n=215) requiring daily or intermittent hydrocortisone replacement, or no replacement were retrospectively checked with their peak cortisol after CRH test and baseline DHEA-S. Results : None of 106 patients with the peak cortisol ≥ 17.5 μg / dL after CRH test required replacement, and all 64 patients with the peak cortisol < 10.0 μg / dL required daily replacement. Among 8 patients with 10.0 μg / dL ≤ the peak cortisol < 17.5 μg / dL and baseline DHEA-S below the reference range, 6 patients required daily replacement and 1 patient was under intermittent replacement. Among 37 patients with 10.0 μg / dL ≤ the peak cortisol < 17.5 μg / dL and baseline DHEA-S within the reference range, 10 and 6 patients were under intermittent and daily replacement, respectively. Conclusions : No patients with the peak cortisol ≥ 17.5 μg / dL required hydrocortisone replacement, and all patients with the peak cortisol below 10.0 μg / dL required daily replacement. Careful clinical evaluation was required to determine requirement for replacement in patients with 10.0 μg / dL ≤ the peak cortisol < 17.5 μg / dL even in combination with baseline DHEA-S

糖尿病患者の在宅ケア向上をめざしたTCDS育成の試み

The Tokushima City Medical Association has cultivated the talented persons of nursing care profession by both the education of diabetes and the instruction of medical treatments to secure the quality of home care for increasing diabetic patients. They are certified to be the Tokushima City Certified Diabetes Supporter（TCDS）. In Tokushima Prefecture, the rate of aging and the certification rate of care need are ranked high in Japan, and the medical measures should be provided for the aged diabetic patients utilizing team nursing care as well as team medical care, because many of these patients are obliged to receive home medical care owing to the introduction of community-based integrated care systems. Tokushima Prefecture kept the worst of age-adjusted diabetes mortality and also the worst of crude diabetes mortality in recent years. Therefore, the program for the TCDS was arranged by the staffs composed of board certified fellows of the Japan Diabetes Society, certified diabetes physicians of Tokushima, and Tokushima local certified diabetes educators （Tokushima LCDEs）. The program includes the lectures of diabetes and medical treatments, the practical training, and the group work by the World Café system collaborated with the medical staffs across many different fields, using the dramatic skit presented by the medical doctors and the LCDE staffs after narrating the scenario for the blood glucose control of diabetic patients to be treated. The persons who have completed the training course are certified as the TCDS by The Tokushima City Medical Association. The workshop is held twice a year and the certification is renewed every three years without examination. In conclusion, it is suggested that the development of TCDS leads to the improvement of the ability of nursing care staffs to support diabetic treatments and the advancement of the quality of home medical care for the aged diabetic patients

トクシマシ イシカイ ノ トウニョウビョウ タイサク

Tokushima City Medical Association has founded the committee for the means to prevent diabetesmellitus, because the mortality rate by diabetes mellitus in Tokushima Prefecture remainedranked first for 14 years from 1993 to 2006. It has enlightened a large number of people, such asdiabetic patients and candidates for diabetes, and also healthy citizens in Tokushima for preventingdiabetes mellitus. For this aim, Tokushima City Medical Association has made the home pagenamed Tokushima City Diabetic Network to show clearly the means to prevent diabetes mellitusfor the citizens. By this Web site, the citizens can get a correct knowledge about diabetes mellitus,a useful information about the treatments including exercises, diets and medications, and an informationabout medical institutions by utilizing the search page to receive a proper diabetic treatment.Tokushima City Medical Association held several events, such as Tokushima citizens’extension courses and diabetes forums for the citizens to understand diabetes mellitus clearly.Fortunately, in 2007, Tokushima got out of the first rank of diabetic mortality rate. TokushimaCity Medical Association will continue efforts to prevent diabetes mellitus by approaching the citizensof all ages from various aspects

Pulmonary-Renal Syndrome with Negative ANCAs and Anti-GBM Antibody

We report the case of a 76-year-old woman who was referred to our hospital for a gradually worsening cough and renal dysfunction. Although pneumonia was initially suspected, imaging findings of the lungs revealed diffuse alveolar hemorrhage at a later date. Renal failure developed and hemodiafiltration was performed on the 9th day. Rapidly progressive glomerulonephritis with crescent formation was diagnosed by renal biopsy. This case presentation has important clinical implications because uncategorizable pulmonary-renal syndrome (PRS) without the presence of ANCAs and anti-GBM antibody is extremely rare and has high rates of morbidity and mortality. No treatment has been established