Background: Euglycemic diabetic ketoacidosis is a critical clinical presentation that can occur during treatment with sodium-glucose cotransporter 2 inhibitors. However, little is known regarding how a low-carbohydrate diet in combination with this treatment can increase the risk for this condition. Here, we report a case of euglycemic diabetic ketoacidosis in a patient treated with sodiumglucose cotransporter 2 inhibitors after initiation of a low-carbohydrate diet. Case Presentation: A 54-year-old woman who was taking canagliflozin was transferred to our hospital with severe dyspnea. She had been started on a strict low-carbohydrate diet for 6 days before admission. Laboratory evaluation revealed severe ketoacidosis and a blood glucose level of 196 mg/dL. After her symptoms improved, she was diagnosed with type 1 diabetes mellitus. Conclusion: Although low-carbohydrate diets are recommended for patients with diabetes mellitus, physicians should exercise great caution in recommending low-carbohydrate diets to patients undergoing treatment with sodium-glucose cotransporter 2 inhibitors.

Background In the diagnosis of pulmonary embolism (PE), the d -dimer threshold is based on studies conducted in Western countries, where the incidence rate is 5 times higher than that in Asian countries, including Japan. If we could elevate the d -dimer threshold based on the low pre-test probability in the Japanese population, we could omit the computed tomography pulmonary angiography (CTPA) which might lead to radiation exposure and contrast-induced nephropathy. Therefore, we aimed to determine a new d -dimer threshold specific to Japanese individuals. Methods We conducted a retrospective cohort study at an emergency department in Japan, using medical charts collected from January 2013 to July 2017. We included patients whose d -dimer were measured for suspicion of PE with low or intermediate probability of PE and CTPA were performed. The primary outcome was failure rate of the new d -dimer threshold, defined as the rate of PE detected by CTPA among patients with d -dimer under the new threshold ranging from 1000 to 1500 μg/L by 100. The new d -dimer threshold was appropriate if the upper limit of 95% confidence interval of the failure rate of PE was approximately 3%. Results In 395 patients included, the number of patients with PE was 24 (the prevalence was 6.1%). If the d -dimer threshold was 1100 μg/L, the failure rate was 0% (0/119), the upper limit of the 95% confidence interval of the failure rate was 3.1%, and 30% (119/395) of the CTPA might be omitted. Conclusion The new d -dimer threshold could safely exclude PE. This result can be generalized to other Asian populations with a lower incidence of PE. Further prospective studies will be needed.

Obturator hernia (OH) is a relatively rare abdominal wall hernia with a high mortality rate. The diagnosis of OH is challenging because of symptomatic variations and spontaneous reduction in hernia on imaging. An 89‐year‐old woman presented to our emergency department with pain in the abdomen and right groin. Computed tomography (CT) revealed an incarcerated small bowel in the gap between the obturator externus and pectineus (OE‐P gap). Symptoms disappeared after manual reduction. She experienced these same symptoms intermittently during the past year and underwent abdominal CT 4 times after disappearance of symptoms. The CT scans at each previous visit showed an enlarged OE‐P gap (an average of 80 mm) compared with the asymptomatic side (an average of 34 mm). An enlarged OE‐P gap on CT images taken after disappearance of symptoms could be a sign of spontaneously reduced OH.

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