Eruptive xanthomas in a patient with soft-drink diabetic ketosis and apolipoprotein E4/2.

Soft-drink diabetic ketosis, characterized by acute onset ketosis induced by excessive ingestion of sugar-containing drinks, is often seen in obese, young patients, even with undiagnosed type 2 diabetes. We herein report a 15-year-old obese patient with the apolipoprotein E4/2 phenotype, in whom eruptive xanthomas lead to a diagnosis of soft-drink diabetic ketosis. He developed multiple asymptomatic yellowish papules on the auricles, back, buttocks and the extensor surfaces of the elbows and knees. He initially visited a dermatology clinic and his blood triglyceride and HbA1c levels were found to be 6,490 mg/dL and 16.5%, respectively. He was referred to our hospital for treatment of hyperglycemia and hypertyriglyceridemia. On admission, he had ketonuria and increased blood levels of 3-hydroxybutylate and acetoacetate. He habitually drank 1-3 litters of sweet beverages daily to quench his thirst. Therefore, "soft-drink diabetic ketosis" was diagnosed. Severe hypertriglyceridemia was considered to have been a consequence of impaired insulin action and his apolipoprotein E4/2 phenotype. We treated the diabetic ketosis and hypertriglyceridemia with intensive insulin therapy and a fat-restricted diet. At discharge, he no longer required insulin therapy and his blood glucose levels were controlled with metformin and voglibose. Along with amelioration of the hyperglycemia, triglyceride levels decreased to 247 mg/dL without administration of anti-hyperlipidemia agents. The eruptive xanthoma lesions gradually diminished in size and number and eventually disappeared by 12 months. This case provides an instructive example of eruptive xanthomas serving as a sign of severe dysregulation, not only of lipid, but also glucose, metabolism.

Vascular resistance of carotid and vertebral arteries is associated with retinal microcirculation measured by laser speckle flowgraphy in patients with type 2 diabetes mellitus.

AIMS: Evaluation of the retinal microcirculation is key to understanding retinal vasculopathies, such as diabetic retinopathy. Laser speckle flowgraphy (LSFG) has recently enabled us to directly evaluate the vascular resistance in both retinal vessels and capillaries, non-invasively. We therefore assessed whether retinal vessel blood flow and/or the capillary microcirculation are associated with blood flow in the cervical arteries in diabetic patients without severe retinopathy. METHODS: We enrolled 110 type 2 diabetes patients, with no or mild non-proliferative diabetic retinopathy, in this prospective cross-sectional study. We measured the resistivity indices (RIs) of the retinal vessel and capillaries by LSFG and those of cervical arteries by Doppler ultrasonography, followed by analyzing associations. RESULTS: The RIs of not only the carotid but also vertebral arteries were associated with those of retinal vessel blood flow and the retinal capillary microcirculation. Multiple regression analyses revealed these associations to be independent of other explanatory variables including age and diabetes duration. CONCLUSIONS: We obtained novel and direct evidence demonstrating a close association between the retinal microcirculation and cervical artery hemodynamics in diabetic patients. These findings suggest shared mechanisms to underlie micro- and macro-angiopathies. Thus, high vascular resistance of cervical arteries may be a risk of developing retinopathy.

Continuous glucose monitoring in patients with remission of type 2 diabetes after laparoscopic sleeve gastrectomy without or with duodenojejunal bypass.

Bariatric surgery is associated with a high remission rate of type 2 diabetes mellitus. However, it is unclear whether patients showing remission of diabetes actually have normal blood glucose levels throughout the day. We therefore performed continuous glucose monitoring (CGM) in 15 ambulatory patients showing remission of diabetes after laparoscopic sleeve gastrectomy (LSG) without or with duodenojejunal bypass (DJB) at the time of diabetic remission (12.9 ± 1.8 months after bariatric surgery). The definition of remission of diabetes was based on the American Diabetes Association criteria. The mean, SD, and coefficient of variation (CV) of glucose calculated from CGM were 6.2 ± 0.6 mmol/L, 1.5 ± 0.4 mmol/L, and 23.7 ± 6.2%, respectively. These values were higher than those of healthy participants without diabetes previously reported. The percentages of time spent above 10.0 mmol/L and below 3.9 mmol/L were 2.6 (IQR 0-5.0)% and 0 (IQR 0-8.0)%, respectively. Thus, patients with remission of diabetes after LSG or LSG/DJB still had substantial periods of hyperglycemia and hypoglycemia throughout the day. Therefore, we must manage patients with diabetes carefully, even after apparent remission of type 2 diabetes in response to bariatric surgery.

Effect of hybridization on bond strength and adhesive interface after acid-base challenge using 4-META/MMA-TBB resin.

The purposes of this study were twofold, namely to evaluate: (1) the effect of hybridization on microtensile bond strength (microTBS) to dentin, and (2) the ultrastructure of the dentin-adhesive interface with 4-META/MMA-TBB resin after acid-base challenge. Dentin surfaces, which received no treatment (NT), 65% phosphoric acid (PA), or 10% citric acid-3% ferric chloride (10-3), were bonded with a 4-META/MMA-TBB resin. To evaluate dentin bond strength, microTBS test was performed at a crosshead speed of 1 mm/min. For ultrastructural evaluation of the adhesive interfaces, SEM was used to examine the interfaces of the bonded specimens after acid-base challenge. The microTBS of NT was not determined, while that of 10-3 was significantly higher than that of PA (p < 0.05). With PA and 10-3, the hybrid layer was clearly observed, but no so for the acid-base resistant zone. Wall lesion was found in NT only. In conclusion, hybridization is vital to improving microTBS to dentin and enhancing resistance at the adhesive interface against acid-base challenge.

Morphological and mechanical characterization of the acid-base resistant zone at the adhesive-dentin interface of intact and caries-affected dentin.

This study examined the ultrastructure of both intact and caries affected dentin-adhesive interface after artificial secondary caries formation, using scanning electron microscopy and nanoindentation testing. Half of the prepared specimens were bonded with Clearfil SE Bond (Kuraray Medical, Japan) and a resin composite (Metafil Flo, Sun Medical, Japan) for the nanoindentation test. The other specimens were stored in a buffered demineralizing solution for 90 minutes, then observed using SEM. An acid-base resistant zone (ABRZ) was observed beneath the hybrid layer, distinguished by argon-ion etching. The ABRZ of caries-affected dentin was thicker than that of normal dentin, while its nanohardess was lower than normal dentin (p<0.05). It is suggested that the monomer of Clearfil SE Bond penetrated deeper than previously reported, creating a so-called "hybrid layer." However, its physical properties depended on the condition of the dentin.

Confocal laser scanning microscopic observations of secondary caries inhibition around different types of luting cements.

PURPOSE: To analyze in vitro artificial secondary caries inhibition around conventional luting cements and resin cements using a confocal laser-scanning microscope (CLSM). METHODS: Box shape cavities (approximately 3 mm long, 4 mm wide, and 1.5 mm deep) were prepared in bovine root dentin. One of five cements: Elite Cement 100 (EL) zinc phosphate cement, HY-Bond Carbo Cement (CA) polycarboxylate cement, Fuji I (FI) glass-ionomer cement, Fuji Luting (FL) GIC-based resin cement and Panavia F (PA) fluoride-releasing resin cement, was placed in the cavity. After polishing, the center of the cement surface was covered with an adhesive to preserve the original cement solubility. The specimens were stored in distilled water at 37 degrees C for 1 week, and stored in an artificial demineralizing solution for 3.5 days. Following this, each specimen was sectioned into two halves, trimmed, and polished. Thickness of inhibition zone, depth of outer lesion and cement solubility around each cement were determined by a CLSM. RESULTS: Inhibition zones were not seen in EL and CA, while they were found in FI, FL and PA. The depths of the outer lesions of CA and FI were significantly lower than those of EL, FL and PA (P< 0.05). The highest and the second-highest cement solubility were obtained in EL and CA, respectively. FI and FL indicated significantly lower cement solubility than EL and CA. PA tended to show the lowest cement solubility.

Ultrastructure of the dentin-adhesive interface after acid-base challenge.

PURPOSE: To observe the ultrastructure of the dentin-adhesive interface after in vitro sequential challenge by acidic and basic chemicals around adhesive restorations. MATERIALS AND METHODS: Box-shaped cavities were prepared in bovine root dentin and restored as follows: Reactmer Bond and Reactmer Paste (RB/RP), Clearfil SE Bond and Clearfil AP-X (SE/APX), ABF (experimental) and APX (ABF/APX), Single Bond and APX (SB/APX). After the specimens were stored in water for 1 week, the integrity of the bonds tested by sequential immersion were placed in an artificial demineralizing solution (pH 4.5) for 20 min and in 5% NaOCl for 20 min. The specimens were sectioned, polished, then argon-ion etched for 7 min, and gold sputter coated for SEM examination of the dentin-adhesive interface. RESULTS: The morphological results indicated tight bonding between the cavity wall dentin and the adhesive. For the fluoride-releasing restoration, RB/RP, a thick acid-resistant zone was clearly observed adjacent to the restoration; however, the bonding resin, RB, was partially degraded by the acid-base challenge. For SE/APX, ABF/APX and SB/APX, the bonding resins were resistant to the acid-base challenge. With the self-etching adhesive systems, SE and ABF, a thin band of acid-base resistant dentin less than 1 microm thick was observed beneath the hybrid layer. With the wet bonding system, SB, the hybrid layer was partially degraded by the acid-base challenge. CONCLUSION: SEM observation is useful for observing the reactions of adhesives to acid-base challenge. Prevention of secondary caries around a restoration may be influenced by the physical properties of the restorative and adhesive materials, quality of the hybrid layer, and fluoride-release.