A 72-year-old man who suddenly felt an excessive thirst and developed pollakisuria and high fever on Sept. 29, 2001. A general practitioner initially diagnosed him as having urinary tract infection on the same day. Vomiting and unconscionsnes occurred on Oct. 3. He was brought to our hospital by ambulance. Laboratory data on admission showed plasma glucose of 1110 mg/dl, blood pH of 7.167 and HCO3- of 7.6mmol/L, and positive urinary ketone bodies, compatible with diabetic ketoacidosis. Serum amylase was elevated, but he had no symptoms of acute pancreatitis. Insulin therapy was started immediately and hyperglyvemia was improved. He has never had diabetes mellitus and his HbA1c was normal (5.3%). His urinary C-peptide was very low (2.4 μg/day) and diabetes-related autoantibodies including anti-GAD, IA-2 antibodies and ICA were negative. So his case was diagnosed as fulminant type 1 diabetes mellitus. Fulminant type 1 diabetes, which has been brought to light by Dr Imagawa’s group, is characterized by near-nomal HbA1c despite diabetic ketoacidosis, rapid loss of insulin secretion and absence of diabetes-related autoantibodies.Great care is needed to recognize the patients with fulminant type 1 diabetes among the elderly with symptoms of urinary tract infection. Here, we reported the case of an aged man who developed aypical fulminant type 1 diabetes.
Diabetes Mellitus, Insulin-Dependent ; Diabetes Mellitus ; symptoms <1> ; Type 1 ; Urinary tract infection

Purpose: Endoscopic submucosal dissection is a promising method for the resection of superficial gastric neoplasms. To date, several institutions have used proton pump inhibitor injections over the perioperative period. However, there is very little evidence regarding their efficacy. To overcome this limitation, we compared procedural outcomes and the prevention of adverse events of proton pump inhibitor injection with an orally administered active potassium-competitive acid blocker alone.Participants and Methods: We enrolled a total of 150 patients treated for superficial gastric neoplasms at a single institution between April 2015 and December 2018. Patients treated for 2 days with proton pump inhibitor injections following 12 days of oral potassium-competitive acid blocker (proton pump inhibitor group=80) were compared with patients treated for 14 days orally with potassium-competitive acid blocker alone (potassium-competitive acid blocker group=70) using propensity score analysis. We evaluated intragastric pH levels prior to endoscopic submucosal dissection, frequency of intraoperative major bleeding, procedure time, en bloc resection rate, curability, ulcer reduction rate 14 days after endoscopic submucosal dissection, and adverse events (including perforation and postoperative bleeding).Results: Propensity score analysis yielded 43 matched pairs. The comparison demonstrated similar values for the outcomes. For all cases, we observed intragastric pH levels >6.4 prior to endoscopic submucosal dissection. Postoperative bleeding rates were 2.3% (1/43) in the proton pump inhibitor group and 0.0% (0/43) in the potassium-competitive acid blocker group (P=0.315).Conclusions: Oral potassium-competitive acid blocker alone was as effective as proton pump inhibitor injection, with a low incidence of adverse events. Based on these results, proton pump inhibitor injection might be omitted during gastric endoscopic submucosal dissection.

In our hospital, we typically perform laparoscopic partial gastrectomy as surgical treatment for extragastric growth type of submucosal tumor (SMT), and laparoscopic intragastric surgery for intragastric growth type. In 2008, laparoscopic and endoscopic cooperative surgery (LECS) was reported for the first time by Hiki et al. Against the background of LECS as laparoscopic local gastric resection with endoscopic resection, we started LECS for gastric SMT from 2015. 　　We performed laparoscopic (LAP) surgery for 15 gastric SMT cases from 2009, and compared 5 cases for which LECS was performed and 10 cases for which LAP was performed. Tumor diameter was 15–21 mm (mean 19.2 mm) in the LECS group, and 20–53 mm (mean 35.5 mm) in the LAP group; the LECS group had a significantly smaller tumor diameter. Operative time was 299 ± 45 min in LECS and 222 ± 25 min in LAP. The volume of blood loss was 24 ± 13 mL in LECS and 33 ± 13 mL in LAP. Hospitalization days was 14.0 ± 3.0 days in LECS and 12.9 ±0.8 days in LAP. There was no significant difference between them.