Factitious brittle diabetes mellitus

Five patients are described in whom factitious disease was the cause of brittle type I diabetes mellitus. The patients were referred from throughout the United States because their physicians had been unable to establish the reason for recurrent hospitalizations for diabetic ketoacidosis or coma. In three of the patients, unexplainable signs, symptoms, and/or laboratory results lead to the diagnosis of factitious disease. In the two remaining patients, long-term follow-up was necessary before a factitious cause was established. These five patients exemplify the extraordinary measures that some patients will utilize to continue as a "patient" rather than return to a normal lifestyle.     

Management strategies for brittle diabetes

Type 1 diabetes is an intrinsically unstable condition. However, the term "brittle diabetes" is reserved for those cases in which the instability, whatever its cause, results in disruption of life and often recurrent and/or prolonged hospitalization. It affects 3/1000 insulin-dependent diabetic patients, mainly young women. Its prognosis is poor with lower quality of life scores, more microvascular and pregnancy complications and shortened life expectancy. Three forms have been described: recurrent diabetic ketoacidosis, predominant hypoglycemic forms and mixed instability. Main causes of brittleness include malabsorption, certain drugs (alcohol, antipsychotics), defective insulin absorption or degradation, defect of hyperglycemic hormones especially glucocorticoid and glucagon, and above all delayed gastric emptying as a result of autonomic neuropathy. Psychosocial factors are very important and factitious brittleness may lead to a self-perpetuating condition. The assessment of brittle diabetes requires quantification of the variability of blood glucose levels. To quantify instability, measures which have been developed, include Mean Amplitude of the largest Glycemic Excursions (MAGE), Mean Of Daily Differences (MODD), Lability Index (LI), Low Blood Glucose Index (LBGI), Clarke's score, Hyposcore, and continuous blood glucose monitoring. Once psychogenic problems have been excluded, therapeutic strategies require firstly, the treatment of underlying organic causes of the brittleness whenever possible and secondly optimising standard insulin therapy using analogues, multiple injections and consideration of Continuous Subcutaneous Insulin Infusion. Alternative approaches may still be needed for the most severely affected patients. Isolated islet transplantation (IIT), which restores glucose sensing, should be considered in cases of hypoglycaemic unawareness and/or lability especially if the body mass index is < 25, but with current immunosuppressive protocols patients must have normal renal function and preferably no plans for pregnancy. Implantable pumps have advantages for patients who either weigh more than 80 kgs or have abnormalities of kidney or liver function or are highly sensitised.     

胰岛素泵治疗糖尿病的临床观察

通过比较胰岛素泵组(306例)和多次皮下注射胰岛素组(310例)治疗糖尿病患者高血糖的疗效,结果显示前者控制血糖更为迅速、理想,低血糖发生率低,所需胰岛素少。     

Iatrogenic brittle diabetes: the hold-the-insulin decision

Modern diabetes management often involves multiple daily insulin injections (MDII) for individuals with insulin-dependent diabetes mellitus (IDDM). Such insulin regimens are increasingly composed of a larger percentage of regular insulin and a smaller percentage of intermediate- and long-acting insulin. Withholding insulin in these individuals may precipitate acute metabolic catastrophe and attendant ketosis or, even worse, frank diabetic ketoacidosis. A comprehensive understanding of normal glucose metabolism and the principles of MDII by all health care professionals both in and out of the hospital setting will foster improved metabolic control in the individual with IDDM, reduce health care costs, and have a positive effect on decreasing diabetic complications.     

格列美脲胶囊治疗2型糖尿病的临床观察

格列美脲 (ｇｌｉｍｅｐｉｒｉｄｅ,ＧＭ )是第三代磺酰脲类口服降糖药 ,与其它磺酰脲类药比较 ,其特点为高效、长效、用药量小、副作用少。从 1999年 4月至 1999年 9月 ,本研究对四川普渡制药厂研制的新药ＧＭ胶囊与美国ＨＭＲ公司的ＧＭ (商品名Ａｍａｒｙｌ )进行随机对照研究 ,以评价国产ＧＭ对 2型糖尿病的降糖疗效和安全性。一、对象和方法1.受试对象 :按 1985年ＷＨＯ颁布的标准确诊的 2型糖尿病患者 ,且符合降糖药临床试验条件〔1〕。2 .试验方法 :(1)给药方法 :计算机编程随机 (ＳＰＳＳ软件 )法 ,将门诊的合格受试者随机分为试验…     

胰岛素泵治疗老年2型糖尿病的疗效观察

目的对比应用胰岛素泵(CSII)与多次皮下注射胰岛素(MSII)对血糖控制不佳的老年2型糖尿病(T2DM)患者的治疗效果及安全性。方法将58例老年T2DM患者随机分为CSII组(30例)和MSII组(28例),进行胰岛素治疗。分别检测2组治疗前后的三餐前后及睡前血糖、血糖控制时间、每日胰岛素用量、低血糖发生的次数以及治疗后的糖化血红蛋白(HbA1c)水平并进行统计分析。结果2组均能达到目标血糖值,但CSII组血糖控制达标时间、胰岛素用量及低血糖发生率均明显少于MSII组(P<0.01),CSII治疗后HbA1c水平显著低于MSII组(P<0.01)。结论CSII有效模拟人体生理胰岛素分泌,用于老年T2DM患者能更快、更有效地控制高血糖,减少低血糖的发生率,并且效果能持续较长时间。     

Hypoglycaemic brittle diabetes successfully managed by social worker intervention

The case is presented of a 39-year-old Type 1 diabetic patient of 22 years duration with recurrent hypoglycaemic comas. He was of unusual personality and had bizarre ideas on self-regulation of his diabetes, resulting in wide variations of insulin dosage. In one 12-month period he had 88 separate admissions to an emergency department with severe hypoglycaemic coma requiring intravenous glucose administration. The cycle of admissions was eventually broken by the intervention of a social worker, who provided structured non-medical support. The patient's diabetic misconceptions remained, but he appeared to gain sufficient insight to prevent recurrent hypoglycaemia.     

磷酸西格列汀治疗新诊断2型糖尿病的临床观察

目的 观察用磷酸西格列汀治疗新诊断T2DM的有效性和安全性. 方法 139例新诊断T2DM患者,按照HbA1 c水平分为A、B、C3组,采用二肽基肽酶-4（DPP-4）抑制剂磷酸西格列汀100 mg,1次/d口服治疗,持续治疗52周. 结果 治疗52周后,3组HbA1c分别由12.0％、8.4％、6.8％降至7.1％、6.9％、6.5％.FBG、2hBG、胰岛素释放水平与治疗前比较差异均有统计学意义（P＜0.05）.肝肾功能、血脂、UAlb、BMI与治疗前比较差异无统计学意义（P＞0.05）.有3例发生低血糖事件,未发生其他不良反应. 结论 用磷酸西格列汀治疗新诊断T2DM患者,可安全有效地降低HbA1c及7个时点（三餐前后、睡前）血糖.     

短期应用胰岛素泵治疗老年人2型糖尿病的临床观察

目的　对比短期应用胰岛素泵与多次皮下注射胰岛素对血糖控制不佳的老年 2型糖尿病患者的治疗效果及安全性。　方法　老年 2型糖尿病患者 5 8例 ,分为胰岛素泵治疗组和胰岛素多次皮下注射治疗组 ,泵治疗组给予胰岛素泵持续皮下注射短效胰岛素加餐前大剂量 ;注射治疗组 3餐前注射短效胰岛素和睡前注射中效胰岛素。泵治疗组治疗 1个月后换用多次皮下注射方法继续治疗。对比两组血糖水平、血糖达标时间、血糖波动值、胰岛素用量、低血糖发生率以及治疗 3个月后糖化血红蛋白和胰岛素用量。　结果　在第 1个月内 ,泵治疗组和注射治疗组血糖达标时间〔( 7 3±3 6 )d和 ( 12 1± 5 8)d〕、血糖波动值〔( 4 4± 1 6 )mmol/L和 ( 6 9± 2 7)mmol/L、胰岛素用量〔( 33 7± 6 3)U/d和 ( 4 2 8± 7 9)U/d〕、低血糖发生率 ( 2次和 14次 )均有明显差别 (P <0 0 1及P <0 0 5 ) ;3个月后糖化血红蛋白和胰岛素用量差异仍有显著性。　结论　短期应用胰岛素泵强化治疗能更快、更有效、更安全的控制血糖 ,并且具有较好的中长期效果。     

Exercise: the brittle cornerstone of type 2 diabetes treatment

Regular exercise has been recommended for diabetes patients for many years; however, it is not widely used clinically. This may be because of high costs, lack of reimbursement, low compliance and/or absence of proper infrastructure. Alternatively, structured exercise therapy may be underutilised because current guidelines do not include detailed information on the preferred type and intensity of exercise that should be applied to maximise the benefits of exercise for different subgroups of patients with type 2 diabetes. Based on available evidence and our own clinical research experience this article proposes that exercise therapy in type 2 diabetes might be more effective if (1) cardiac rehabilitation programmes served as a model for ‘pre-cardiac diabetes rehabilitation’; (2) resistance exercise were prescribed for sarcopenic or severely deconditioned type 2 diabetes patients; and (3) a multidisciplinary approach and continued exercise training under personal supervision became standard therapy. Nevertheless, more clinical research is warranted to establish the efficacy of an approach that takes into account type 2 diabetes subpopulations at different stages of the disease and with different levels of comorbidity.     

Muscle infarction in a young woman with brittle type 1 diabetes

We present the first case of muscle infarction in a 30-year-old woman who had a 5-year history of type 1 diabetes mellitus that was not complicated by nephropathy, retinopathy or neuropathy. All common causes of muscle infarction were excluded, particularly microangiopathy and a hypercoagulable state. The differential diagnosis included infection (pyomyositis, necrotic fasciitis), focal inflammatory myositis, vascular events, trauma, tumor and diabetic amyotrophy, all of which were excluded. In spite of good glycaemic control, her diabetes remained brittle; alternating states of transient acute hypoglycaemia and hyperglycaemia may have been responsible for the infarction. Brittleness resumed after treatment with subcutaneous insulin infusion using a portable pump. No recurrence of muscle infarction was observed during a 18-month follow-up.     

糖尿病患者心率变异性的临床观察及评价

用心率变异性（ＨＲＶ）分析技术，观察糖尿病患者ＨＲＶ时域的六项指标变化：①ａｖｇＲＲ：ＲＲ间期平均值；②ＳＤＡＮＮ：４分钟ＲＲ平均值的标准差；③ＣＶ：变异系数；④ＳＤ：每４分钟ＲＲ间期标准差的平均值；⑤ＳＤＳＤ：ＳＤ的标准差；⑥ｒｍＳＡＳＤ：每４分钟内相邻ＲＲ间期差值作均方根后的平均值。Ⅱ型糖尿病患者２５例，正常对照组１８例，两组年龄相似。结果表明，糖尿病组的ＳＤ，ＳＤＡＮＮ及ｒｍＳＡＳＤ显著低于对照组，而ａｖｇＲＲ无显著变化。为分析记录时间上的差异性，选择８１例正常人，分成上午组（４５例）与下午组（３６例），除ＳＤＡＮＮ外，其余五项指标在上午组与下午组之间无显著差别。结论认为糖尿病患者的ＨＲＶ显著减小，说明ＨＲＶ对糖尿病有一定的临床应用价值。     

老年2型糖尿病患者血清瘦素含量的临床观察

目的　观察老年 2型糖尿病患者血清瘦素含量及其有关指标的临床意义。方法　将 15 2例受检者按照病情和年龄分为老年 2型糖尿病组 (ED组 )、非老年 2型糖尿病组 (NED组 )和健康老年人组 (C组 ) ,测定空腹血清瘦素(F Lp)含量及其他有关指标。结果　ED组和C组男性F Lp含量高于NED组男性 (P<0 .0 5 ) ,女性低于NED组女性 (P<0 .0 5 ) ;ED组和C组男性睾酮含量低于NED组男性 (P<0 .0 5 ～ 0 .0 1) ,女性雌二醇含量低于NED组女性(P <0 .0 5 )。ED组男性F Lp及睾酮含量与C组男性比较以及ED组女性F Lp及雌二醇含量与C组女性比较差异均无显著性意义 (P >0 .0 5 )。体重指数、睾酮、雌二醇与F Lp含量独立相关。结论　老年 2型糖尿病患者血清瘦素含量与老年健康者比较差异无显著性意义 ,与非老年 2型糖尿病患者比较差异有显著性意义。