儿童糖尿病酮症酸中毒并发脑水肿临床分析

目的探讨儿童糖尿病酮症酸中毒并发脑水肿的临床特点及危险因素。方法对糖尿病酮症酸中毒并发脑水肿患儿的临床特点及病因进行分析,并与无脑水肿的患儿资料进行对比。结果在47例糖尿病酮症酸中毒患儿中,并发脑水肿4例（8.51%）,均为重度酮症酸中毒。与未并发脑水肿同等程度的酮症酸中毒患儿相比,并发脑水肿者在治疗期间血钠上升缓慢、甚至降低,尿素氮水平较高。4例患儿中有3例应用了碳酸氢盐,用量大于未并发组。结论糖尿病患儿并发重度酮症酸中毒时易并发脑水肿。血钠上升缓慢甚或降低、血尿素氮升高及碳酸氢盐的不适当应用,可增加脑水肿发生的危险。     

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目的探讨儿童糖尿病酮症酸中毒并发脑水肿的临床特征及危险因素。方法对重庆医科大学附属儿童医院1993—2005年住院治疗的糖尿病酮症酸中毒并发脑水肿患儿的临床特征及病因进行分析,并与未并发者进行对照比较。结果在71例酮症酸中毒患儿中,有6例临床表现符合脑水肿的诊断标准,临床确定为并发脑水肿,并发率为8·4%。6例均为重型酮症酸中毒。与未发生脑水肿同等程度的重型酮症酸中毒患儿相比较,并发脑水肿患儿酸中毒更为严重,在治疗期间血钠上升缓慢及持续低钠血症,尿素氮水平升高。6例患儿中有5例应用碳酸氢盐治疗,用量大于未并发者。结论糖尿病儿童并发重型酮症酸中毒易发生脑水肿。严重酸中毒、血钠上升缓慢或持续低钠血症、血尿素氮升高及碳酸氢盐的使用有可能增加脑水肿发生的危险性。     

人白介素18基因启动子多态性与儿童1型糖尿病的相关性研究

目的研究IL-18基因单核苷酸多态性与儿童1型糖尿病（T1DM）的关系。方法应用聚合酶链反应．序列特异性引物（PCR-SSP）和测序的方法,检测118例1型糖尿病患儿和150例正常儿童IL-18基因．137位点C／G和-607位点C／A单核苷酸的多态性。结果①IL-18基因-607位点C／A的-607A等位基因在T1DM和对照组中的发生率分别为41％和53％,差异有统计学意义（P=0．01）,两组间．137位点C／G的等位基因差异无统计学意义（P=0．37）;②IL-18基因．137位点的CC、CG和GG基因型在T1DM和对照组中差异均无统计学意义（P〉0．05）;-607位点的CC基因型T1DM组显著高于正常对照组（P=0．03）,AA基因型T1DM组显著低于正常对照组（P=0．03）;IL-18基因-607位点的CC基因型的新发糖尿病患儿更易发生酮症酸中毒。③IL-18基因的-137G／-607C单体基因型在T1DM和正常对照组间的分布频率差异有统计学意义（P=0．03）。结论IL-18基因-607位点的CC基因型和-137G／-607C单体基因型可能与儿童1型糖尿病的发病有关,而-607位点的AA基因型可能是T1DM的保护性基因型。-607位点的CC基因型与儿童1型糖尿病患者临床表型存在显著的相关性。     

1型糖尿病患儿血清干扰素γ诱导蛋白10水平的变化及其意义

目的观察趋化因子干扰素γ诱导蛋白10（IP-10）在儿童1型糖尿病（T1DM）发病中的变化。方法用ELISA法检测50例T1DM患儿和30例健康儿童的血清IP-10水平,根据自身抗体存在与否、自身抗体阳性种类数及不同病程对IP-10进行分组比较。结果T1DM患儿血清IP-10水平[（367±131）ng／L]显著高于对照组[（133±43）ng／L],差异有统计学意义（t=9．49,P〈0．01）。其中自身抗体阳性组IP-10[（385±147）ng／L]和自身抗体阴性组IP-10[（311±101）ng／L]均高于对照组（t=8．99,P〈0．01;t=8．67,P〈0．01）,但该两组间差异无统计学意义。1种、2种和3种自身抗体阳性患儿血清IP-10水平差异无统计学意义（F=1．46,P〉0．05）。初发组和病程〉12年组的T1DM患儿血清IP-10均高于对照组（t=10．34,P〈0．01;t=4．36,P〈0．01）,而病程〉12年组血清IP-10水平低于初发组（t=4．30,P〈0．01）。结论T1DM患儿血清IP-10水平高于对照组,血清IP-10水平不受自身抗体阳性存在与否、自身抗体阳性种类多少的影响,随病程延长,血清IP-10水平逐渐下降。     

儿童糖尿病酮症酸中毒的急救

酮症酸中毒是儿童糖尿病最重要的并发症,也是糖尿病患儿死亡的主要原因。50～70％的糖尿病病儿发生过1次或多次酮症酸中毒,约有1/3的儿童糖尿病患者以酮症酸中毒为首发症状。我科近15年来共收治糖尿病患儿20例,占同期住院人数之1.3‰,其中17例(85％)有酮尿,8例(40％)有酸中毒,4例     

婴儿捂热综合征死亡的危险因素

目的探讨婴儿捂热综合征（IMS）死亡的危险因素。方法回顾性分析2002年1月-2007年2月63例IMS患儿的临床资料，按照是否并代谢性酸中毒、高血糖、低血钙、超高热，及儿童危重病例评分（PCIS）、脏器衰竭数目对患儿进行分组，对各项危险因素行χ^2检验，比较组间患儿的病死率。结果63例患儿住院期间病死率为22．1％。并代谢性酸中毒与未并代谢性酸中毒患儿病死率比较差异有统计学意义（RR=3．20，95％CI=1．0～10．24，χ^2=4．76P〈0．05），且病死率随着血pH降低而升高（Pearson列联系数=0．49，χ^2=9．80P〈0．05）。存活48例与15例死亡患儿PCIS评分相比有显著差异（t=7．798P〈0．05）。PCIS≤80分与〉80分患儿的病死率相比有显著差异（RR=12．73，95％CI=1．78～91．04，χ^2=13．24P〈0．05）。血糖〉12mmol／L的患儿与血糖〈12mmol／L的患儿相比差异有统计学意义（RR=3．73，95％CI=1．46～9．54，χ^2=8．73P〈0．05）。并低血钙与未并低血钙的患儿病死率相比有显著差异（RR=3．0,95％CI=1．23—7．31，χ^2=6．30P〈0.05）。体温≥41℃与体温〈41℃的患儿病死率相比有显著差异（RR=3．0，95％CI=1．34～6．74，χ^2=3．97P〈0．05）。脏器衰竭≥3个与脏器衰竭〈3个的患儿病死率相比有显著差异（RR=7．88，95％a=2．85～21．78，χ^2=17．66P〈0．05）。结论代谢性酸中毒、高血糖、低血钙、超高热、低PCIS评分及多脏器衰竭可能是IMS的死亡危险因素。     

儿童1型糖尿病28例临床分析

目的 了解糖尿病儿童血糖及中远期并发症控制情况;探讨胰岛自身免疫性抗体在儿童1型糖尿病诊断中的作用。方法 用追踪调查法观察28例儿童1型糖尿病患儿。结果 糖尿病组与对照组谷氨酸脱羧酶抗体（GADA）,胰岛素自身抗体（IAA）,胰岛细胞抗体（ICA）三者联合检测阳性率比较均差异显著（P均＜0．05）;饮食控制组和一般控制组糖化血红蛋白值比较差异不显著（P＞0．05）,两者与不控制组比较有显著差异（P＜0．05）;三者空腹血糖值比较差异不显著（P均＞0．05）。结论 GADA、IAA、ICA均可作为儿童1例糖尿病诊断的指标。联合检测更具互补性。饮食控制能降低糖尿病患儿中远期并发症的发生。糖化血红蛋白则更能反映饮食控制情况。     

儿童糖尿病酮症酸中毒的诊断和治疗

糖尿病酮症酸中毒（DKA）是儿童糖尿病的急性并发症，发生率为每年0．5％～0．8％，通常见于1型糖尿病患儿，但高达25％的病例为新诊断的糖尿病，大多为感染所诱发。据国外报道，DKA的病死率为2％～5％，主要死因为延误诊治。目前糖尿病的发病率正逐年上升，因此DKA的诊断和治疗已引起高度关注。[第一段]     

不同体重指数糖尿病患儿胰岛自身抗体检测意义初探

通过对儿童糖尿病患儿检测谷氨酸脱羧酶抗体（GADA）、胰岛素自身抗体（IAA）、胰岛细胞抗体（ICA），旨在了解其在不同体重指数（BMI）糖尿病患儿中的差异，并初步探讨其意义。应用酶联免疫吸附法（ELISA）测定32例糖尿病患儿血清GADA、IAA、ICA。结果显示，132例糖尿病儿童中肥胖占31．2％，正常体重占6．3％，体重减轻占62．5％；肥胖儿GADA、ICA阳性率与体重减轻儿比较差异有显著性（P＜0．05），而IAA差异不显著（P＞0．05）；病程1年内的初发糖尿病中，肥胖儿GADA、ICA阳性率明显低于体重减轻儿。提示肥胖儿童糖尿病具有2型糖尿病的免疫学特征，随儿童糖尿病中肥胖儿的增多，2型糖尿病有增多趋势；相对IAA，检测GADA、ICA更适用于1、2型糖尿病的分型。     

儿童1型糖尿病的10年回顾及白介素-10在糖尿病酮症酸中毒中的临床意义

目的：回顾浙江大学医学院附属儿童医院10年来住院儿童 1 型糖尿病的发病状况并探讨白介素-10（IL-10）在儿童 1 型糖尿病酮症酸中毒（DKA）中的临床意义。方法：对1999年1月至2009年2月在该院住院的263例334例次1型糖尿病患儿的临床资料进行回顾性分析;并对其中48例1型糖尿病患儿进行血脂、细胞因子等检查,根据有无酮症酸中毒分为 DKA组和非DKA组,24例正常健康儿童作为对照组,比较各组间血脂、细胞因子等参数的差异。结果：儿童1型糖尿病患儿中,女性多见（56.3%）,发病年龄以6~11.9岁多见。32.7% 的患儿以酮症酸中毒为就诊表现。DKA组血脂、血糖及糖化血红蛋白均高于非DKA组,二分类logistic 回归分析示上述指标水平的升高均为酮症酸中毒的危险因素。IL-10水平在DKA组明显升高,余细胞因子在DKA组和非DKA组无明显差异。糖尿病组各细胞因子水平明显高于正常对照组。结论：1型糖尿病患儿酮症酸中毒发生率较高,糖、脂代谢紊乱是酮症酸中毒的危险因素。IL-10可能为酮症酸中毒的敏感指标。［中国当代儿科杂志,2010,12（11）：849-854］     

Predicting diabetic ketoacidosis in children by measuring end-tidal CO2 via non-invasive nasal capnography

AIM: To determine if nasal capnography can be used as a screening tool to predict diabetic ketoacidosis (DKA) in children with Type 1 diabetes mellitus (T1DM) presenting to the emergency department. METHODS: Cross-sectional, prospective, observational study of children with T1DM who presented to the Emergency Department of Princess Margaret Hospital for Children, Western Australia, over a 12-month period from June 2003 to June 2004. Information on demographic data and T1DM was recorded. Nasal capnography, venous blood gases and urinary analysis were performed on patients. Data were analysed using chi(2) tests and receiver operating characteristic curve analysis. Sensitivities and specificities were calculated at different end-tidal carbon dioxide (ETCO(2)) levels to predict presence of DKA. RESULTS: Fifty-eight patients aged 1-18 years (mean 10.7, SD 4.7) were analysed. Thirty-three (57%) were male and 30 (52%) presented with new onset of T1DM. Of the 58 cases, 15 (26%) had DKA, and 11 of these were new T1DM patients. No patients with an ETCO(2) > 30 mmHg had DKA (sensitivity 1.0, specificity 0.86). Six patients with an ETCO(2) < 30 mmHg did not have DKA. CONCLUSIONS: Nasal capnography in conjunction with clinical assessment is predictive of DKA. Further research into this area with larger numbers could help validate ETCO(2) as a screening tool for DKA in the emergency department.     

25-羟维生素D与儿童1型糖尿病及酮症酸中毒的相关性研究

目的探讨血清25-羟维生素D[25-(OH)D]水平与儿童1型糖尿病(T1DM)及酮症酸中毒(DKA)的相关性。方法选取2006年1月—2009年12月期间152例住院患儿,其中52例为首次发病的T1DM患儿,包括酮症酸中毒(DKA组)21例,以及非酮症酸中毒(非DKA组)31例,其余100例为非T1DM组。检测并比较三组患儿的血清25-(OH)D水平,分析血清25-(OH)D水平与儿童T1DM及DKA的相关性。结果 DKA组患儿的血清25-(OH)D平均为(53.6±27.8)nmol/L,显著低于非DKA组的(69.7±27.9)nmol/L和非T1DM组的(81.8±28.3)nmol/L(P<0.05);非DKA组患儿的血清25-(OH)D水平显著低于非T1DM组(P<0.05)。结论 T1DM患儿的血清25-(OH)D水平低,尤以DKA患儿最为明显,维生素D在儿童T1DM发病中的潜在保护效应值得关注。     

1型糖尿病并低三碘甲状腺氨酸综合征201例

目的探讨1型糖尿病(T1DM)及糖尿病酮症酸中毒(DKA)患儿并低三碘甲状腺氨酸(T3)综合征的临床特点。方法采用放射免疫分析法检测91例T1DM并DKA患儿(DKA组)及110例单纯T1DM患儿(非DKA组)血清T3、甲状腺素(T4)、促甲状腺激素(TSH)水平,观察2组T3、T4下降例数及水平,并将DKA组分为轻、中、重3个亚组,观察不同组别中甲状腺激素变化特点。结果 DKA组易发生T3、T4下降,DKA组T3[(0.54±0.51)μg.L-1]、T4[(5.65±2.80)μg.L-1]与非DKA组T3[(1.02±0.38)μg.L-1]、T4[(9.28±2.85)μg.L-1]比较,差异均有统计学意义(Pa<0.000 1)。中、重度DKA组与非DKA组T3比较,差异有统计学意义(Pa<0.000 1),轻、中、重度DKA组与非DKA组T4比较,差异均有统计学意义(Pa<0.000 4,0.000 1)。DKA组与非DKA组TSH比较,差异无统计学意义(P>0.05)。结论 T1DM患儿甲状腺激素检测的结果主要表现为T3降低,部分伴T4降低,其疾病的严重程度与甲状腺激素降低程度一致,T1DM并DKA患儿的T3、T4水平均有明显下降,提示T1DM患儿需重视甲状腺激素的检测,利于早期防治。     

Serum interleukin-18 levels are raised in diabetic ketoacidosis in Chinese children with type 1 diabetes mellitus

OBJECTIVE: To investigate the role of serum interleukin (IL-18) in children with type 1 diabetes mellitus (T1DM) and diabetic ketoacidosis (DKA). DESIGN: Case-control study. SUBJECTS: Sixty-one children with T1DM including 28 with DKA and 33 without DKA and 30 age - and sex-matched healthy controls were recruited. METHODS: Serum IL-18, IL-12, and IFN-gamma levels were measured in all subjects by enzyme linked immunosorbent assay. RESULTS: Serum IL-18 levels were significantly higher in patients with DKA than those in patients without DKA (759.2 +/- 353.8 pg/mL vs. 634.9 +/- 399.7 pg/mL, P = 0.001) and healthy controls (310.0 +/- 265.3 pg/mL). The serum IL-12 and IFN-gamma levels were not different between patients and controls (277.5 +/- 207 pg/mL vs. 351.4 +/- 223.4 pg/mL, P = 0.45 and 7.02 +/- 7.53 pg/mL vs. 5.59 +/- 5.34 pg/mL, P = 0.21, respectively). CONCLUSION: Serum IL-18 levels are increased in children with type 1 diabetes mellitus and could be a predictor of diabetic ketoacidosis.     

Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics

Abdul‐Rasoul M, Al‐Mahdi M, Al‐Qattan H, Al‐Tarkait N, Alkhouly M, Al‐Safi R, Al‐Shawaf F, Mahmoud H. Ketoacidosis at presentation of type 1 diabetes in children in Kuwait: frequency and clinical characteristics. Background: Diabetic ketoacidosis (DKA) has significant morbidity and mortality, and is common at diagnosis in children. Objective: Describe the frequency and severity of DKA at diagnosis of type 1 diabetes mellitus (T1DM) in children in Kuwait. Methods: Hospital records of 677 diabetic children less than 12 yr of age, diagnosed during the period of 2000–2006 were reviewed. DKA was defined as blood glucose > 11 mmol/L, pH < 7.3, and/or bicarbonate < 15 mmol/L with ketonuria. Results: Of all patients diagnosed with T1DM, 255 (37.7%) presented with DKA. The frequency of DKA was constant between 2000 and 2002 (42.7–41.5%), but decreased in the following years to 30.7% in 2006 (p < 0.005). The majority had either mild or moderate DKA (74.1%). Fifty‐one (36.7%) of all children in the 0–4 yr had severe DKA compared to ten (2.9%) in the 5‐ to 8‐yr‐old group, and three (1.5%) in 9‐ to 12‐yr‐old patients (p < 0.0001). Moreover, 83% of children with severe DKA were in the 0–4 yr age group. One child (0.15%) died and twenty‐seven (4%) needed intensive care unit (ICU) care. Conclusion: Our study provides recent data on Middle Eastern population, for whom data are sparse. Although it has significantly decreased, the frequency of DKA at presentation of T1DM in children in Kuwait is still high, secondary to the high prevalence of diabetes in the community. Young children, especially those less than 2 yr old remain at high risk. Increasing the general awareness of the public as well as of pediatricians to the disease may lead to early diagnosis before the development of acidosis.     

交感神经皮肤反应在糖尿病患儿周围神经病早期诊断中的应用

目的探讨交感神经皮肤反应(SSR)在儿童糖尿病周围神经病交感神经纤维病变早期诊断的应用价值。方法对35例1型糖尿病(T1DM)儿童和30例健康儿童四肢分别进行电刺激SSR检测,测量每个肢体的平均起始潜伏期和峰-峰波幅,并比较2组各肢体的SSR起始潜伏期及峰-峰波幅差异。同时对T1DM组儿童进行神经传导速度(NCV)的检测,并对NCV检测异常率与SSR检测异常率进行比较。另外,还对有酮症酸中毒(DKA)史和无DKA史的2组患儿SSR检测异常结果进行比较。结果 T1DM组患儿各肢体SSR起始潜伏期均较健康对照组明显延长(Pa<0.05)。健康对照组30例四肢均可引出SSR波形,T1DM组31例患儿四肢均可引出SSR波形;4例患儿至少有一肢不能引出SSR波形(11.4%),其中2例患儿四肢均未引出SSR波形(5.7%);21例(60%)患儿至少有一肢SSR缺失或起始潜伏期异常,其中15例(71.4%)有DKA史,高于无DKA患儿异常检出率(6例,42.9%),但2组比较无统计学差异。T1DM组患儿NCV检测异常10例(28.6%),较SSR起始潜伏期的检出异常率低,两者比较差异无统计学意义(P>0.05)。结论 SSR检测可早期发现糖尿病周围神经病交感神经小纤维病变,较NCV敏感。     

Prevalence and characteristics of type 2 diabetes mellitus in 9-18 year-old children with diabetic ketoacidosis

OBJECTIVE: To estimate the prevalence of type 2 diabetes mellitus (DM2) in 9-18 year-old children with diabetic ketoacidosis (DKA) and to describe the presenting biochemical characteristics and response to standardized DKA treatment. METHODS: Data were collected from a consecutive sample of 9-18 year-old children presenting with DKA. DKA was defined as hyperglycemia and ketosis with an initial pH <7.3, or bicarbonate <15 mmol/l. Patients were classified as having DM2 if they had negative autoantibody status and normal or elevated fasting C-peptide. RESULTS: The prevalence of DM2 in patients with DKA was 13.0% (6.1-23.3%). There was no significant difference in the presenting pH (7.14 vs 7.15), but blood glucose was higher (735 vs 587 mg/dl) in patients with DM2, than in patients with type 1 DM (DM1). The duration of insulin infusion until resolution of acidosis (17.3 vs 13.2 h) and intensive care unit stay (2.4 vs 1.6 days) were longer in patients with DM2. Seven of the nine patients with DM2 did not require insulin at 1-year follow-up. CONCLUSIONS: Children with DM2 can present with DKA and constitute a significant percentage in the above 9-year age group. The need for insulin must be carefully re-evaluated as DKA resolves in these patients. Adolescents with DM2 and their families need to be educated about DKA.     

Delayed diagnosis in type 1 diabetes mellitus

Children with suspected type 1 diabetes mellitus (T1DM) should have same day referral to a paediatric diabetes team. 99 children (54 male; median age 10.5 years, range 0.9-15.9 years) were diagnosed with T1DM at our hospital between January 2004 and June 2007. 27 (27.2%) presented in diabetic ketoacidosis (DKA). 37 (37.3%) required hospital admission, while the rest had ambulatory management. In 21 (21.2%) children, diagnosis was delayed >24 h (median 3.0 days, range 1-14 days) due to missed diagnosis at the local hospital (four) or by the general practitioner (seven), arranging a fasting blood glucose test (nine) and outpatient appointment requested via fax (one). Children with delayed diagnosis presented more frequently in DKA (52.3% vs 20.5%, p<0.01), with a higher median presenting HbA1c (12.3% vs 10.9%, p<0.05). There were no differences in age and sex between the delayed diagnosis and immediate referral groups. Healthcare providers need to be aware of the importance of immediate referral of children newly diagnosed with T1DM.     

Pediatric stroke associated with new onset type 1 diabetes mellitus: case reports and review of the literature

Neurological deterioration in children with diabetic ketoacidosis (DKA) is commonly caused by cerebral edema. However, stroke should also be suspected when focal neurological deficits are apparent, because children with hyperglycemia and DKA are prone to thrombosis. We report three cases of pediatric stroke associated with new onset type 1 diabetes mellitus (T1DM). The first case presented with sinovenous thrombosis, and the other two cases presented in DKA and had a late diagnosis of ischemic stroke following neurological deterioration. Our recent experiences and review of the literature emphasize the importance of early diagnosis, investigation, and treatment for patients that present with new onset T1DM and stroke.     

Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus

OBJECTIVES: (a) To determine the incidence and severity of diabetic ketoacidosis (DKA) and (b) to stratify according to insurance status at the initial diagnosis of type 1 diabetes (T1DM). RESEARCH DESIGN AND METHODS: Subjects included children <18 yr who presented with new-onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. Insurance status and initial venous pH were obtained. RESULTS: Overall, 383 subjects presented with new-onset T1DM and 359 (93.7%) were enrolled. Forty-three (12.0%) of these children were uninsured and 40 (11.1%) had Medicaid. One hundred and two (28.4%) subjects presented with DKA. When compared to the insured subjects, uninsured subjects had a significantly increased risk of presenting with DKA [odds ratios (OR): 6.19, 95% CI 3.04-12.60, p < 0.0001], as well as presenting with severe DKA, defined as venous pH <7.10 (OR: 6.09, 95% CI 3.21-11.56, p < 0.0001). There were no differences, however, between the insured and Medicaid subjects in their probability of presenting with DKA or severe DKA. The risk of presenting with DKA (as well as with severe DKA) was the highest among patients <4 yr old. CONCLUSIONS: At the time of initial diagnosis, uninsured patients were more likely to present with DKA than insured patients. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening. A potential explanation is that uninsured subjects may delay seeking timely medical care, thereby presenting more critically ill, whereas insured subjects may have their T1DM diagnosed earlier.