CSII转换为两种MDI方式治疗2型糖尿病的疗效及胰岛素剂量比较

目的2型糖尿病患者经过短期连续皮下胰岛素注射（CSII）强化治疗使血糖平稳后,分别转换为生物合成人胰岛素N联合生物合成人胰岛素R、甘精胰岛素联合门冬胰岛素多次皮下注射（MDI）,比较两种MDI治疗时血糖的变化情况及胰岛素的用量。方法112例2型糖尿病患者应用CSII治疗血糖平稳后,改为生物合成人胰岛素N及生物合成人胰岛素R皮下注射（A组）,86例2型糖尿病患者应用CSII治疗血糖平稳后,改为甘精胰岛素及门冬胰岛素皮下注射（B组）,观察A、B两组治疗时的日内血糖波动情况、胰岛素用量及低血糖的发生率。结果两组患者经CSII治疗转换为MDI治疗后均能有效控制血糖,B组血糖波动较A组平稳,每日胰岛素用量较A组更少[（0．62±0．28）U／kg],低血糖发生率更低。结论两种MDI方法均能有效控制血糖,甘精胰岛素联合门冬胰岛素皮下注射降糖更加安全、有效：     

Association between early glycemic management and diabetes complications in type 1 diabetes mellitus: A retrospective cohort study

AimsTo investigate the association between early HbA1c levels near diagnosis and future glycemic management, and analyzed risk factors of complications in people with T1DM.MethodsThis retrospective cohort study included 201 children and adolescents with T1DM. Patient data including sex, age at diagnosis, duration of disease, HbA1c levels, HbA1c variability during the follow-up period, and diabetes complications and comorbidities were collected.ResultsThe mean follow-up period of patients was 16.4 years. HbA1c levels in all three examined time points after diagnosis (first year, second year, and first two years) were significantly associated with recent HbA1c level, and second-year HbA1c was most closely correlated with recent HbA1c level. Elevated second-year HbA1c was a risk factor of diabetic ketoacidosis (DKA) and retinopathy, and increased variability of HbA1c was significantly related to various microvascular complications. When HbA1c is stratified into quartiles, the subjects of each quartile trend to stay within that quartile over the follow-up period.ConclusionsEarly HbA1c levels were closely associated with recent HbA1c levels and diabetes complications in patients with T1DMs. Strict glucose management after diagnosis and reducing variability of HbA1c may prevent future diabetes complications and comorbidities.     

Pregnancy outcome in type 2 diabetes mellitus: a retrospective analysis from the Netherlands

MAIN OBJECTIVES: The objective was to describe pre-gestational history and the maternal, fetal and neonatal outcome in pregnancies in women with pre-gestational type 2 diabetes during the period between 1992 and 2006 from one center in the Netherlands. METHODS: Patients attending the obstetric-diabetology outpatient clinic of a tertiary referral center were studied. This center also has a regular diabetes clinic and a community midwifery service. Patients were identified from the database. Maternal outcome (pre-eclampsia, pre-term delivery, Cæsarean section) and fetal and neonatal outcome (macrosomia, congenital malformations, perinatal mortality, neonatal hypoglycemia) were analyzed as well HbA1c levels, planning of pregnancy, gestational age at first antenatal visit and ethnic background. RESULTS: Sixty-six singleton pregnancies from 48 women were analyzed. Their age was 34 ± 5 yr, the BMI 31.7 ± 7.4 and the median duration of diabetes was 3 yr. 52% were Caucasian and 35% were of Moroccan descent. 49% did not complete secondary school. Moroccan descent was associated with a lower educational level and a BMI comparable with the whole study group. The proportion of planned pregnancies was approximately 70%. The mean HbA1c in the first trimester was 6.4 ± 1.1% and the gestational age at first visit was 10 ± 5 wk, in one-quarter before 6 wk. The prevalences of variables related to maternal and neonatal outcome were as follows: spontaneous abortion 13.6%, pre-eclampsia 8.9%, pre-term delivery 21.4%, spontaneous labor 25.0%, induced labor 48.2%, Cæsarean section 42.9%, macrosomia (≥90th percentile) 41.1%, severe hypoglycemia 41.5% and major congenital malformations 5.1%. CONCLUSIONS: Pre-gestational type 2 diabetes is associated with an increased incidence of adverse pregnancy outcome despite reasonable mean HbA1c level and despite a high frequency of planned pregnancies. Many women report relatively late. Improvement in the outcome requires more active peri-gestational specialist care and a tailored approach is required towards migrant communities.     

Pregnancy outcomes in women with type 1 diabetes in China during 2004 to 2014: A retrospective study (the CARNATION Study)

BackgroundWe aimed to report pregnancy outcomes of women with type 1 diabetes (T1D) in China, on which data were sparse.MethodsThis is a nationwide retrospective study conducted in 11 general medical centers in 8 cities across China. We investigated the clinical data of all women who attended these centers with a singleton pregnancy and whose pregnancy ended between 1 January 2004 and 31 December 2014. Pregnancies of women with pregestational T1D were ascertained and compared with those of women without T1D.ResultsFrom over 300 000 pregnancies over the 11‐year study period, we identified 265 singleton pregnancies of women with T1D. One maternal death was documented among 265 (0.37%) women with T1D and 83 among 318 486 (0.03%) women without T1D. Women with T1D suffered from higher rates of pregnancy loss (13.21% vs 2.92%, crude risk ratio [cRR] 5.08 [95% CI, 3.56‐7.26]) and preeclampsia (17.74% vs 4.20%, cRR 4.94 [95% CI, 3.60‐6.77]) compared with those without T1D. Infants of these women with T1D had elevated rates of neonatal death (5.65% vs 0.16%, cRR 37.36 [95% CI, 21.21‐65.82]) and congenital malformation(s) (8.26% vs 3.53%, cRR 2.46 [95% CI, 1.54‐3.93]) compared with those of women without T1D. No significant improvement in pregnancy outcomes in women with T1D was observed over the period 2004 to 2014.ConclusionsPregnancy outcomes were persistently poor in women with T1D during 2004 to 2014 in China. Pregnancy care needs to be improved to reduce adverse pregnancy outcomes among Chinese women with T1D.     

Characteristics of children with type 1 diabetes and persistent suboptimal glycemic control

Objective: This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement.Methods: A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children’s National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥10% after the first year since the initial visit (n=151). Medical records of patients with subsequently improved glycemic control were reviewed (n=39).Results: Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively. Each additional visit with HbA1c ≥10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively. Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥2 years. Multiple contributing factors for improved control were identified, but no one factor explained improved control in >25% of patients.Conclusion This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management. Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical. Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention. Conflict of interest:None declared.     

Postprandial glycemic control with biphasic insulin aspart in patients with type 1 diabetes

We sought to investigate the ability of biphasic insulin aspart 30 (BIAsp 30) to control postprandial hyperglycemia and hyperlipidemia in a meal-test comparison with biphasic human insulin 30 (BHI 30). In this randomised crossover trial, 50 patients with type 1 diabetes (mean age, 35.7 +/- 9.4 years; body mass index [BMI], 24.0 +/- 2.6 kg/m(2); HbA(1c), 8.6% +/- 1.1%) were studied on 3 separate days, where the following treatments were given in random order: BIAsp 30 injected immediately before a standard breakfast, BHI 30 injected 30 minutes before breakfast (BHI 30(t=-30)), and BHI 30 injected immediately before breakfast (BHI 30(t=0)). The dose was 0.40 U/kg for all 3 treatments. BIAsp 30 reduced the area under the baseline adjusted 4-hour postprandial serum glucose curve (AUC(0-4h)) by 23% compared with BHI 30(t=0) (P <.0001) and by 9% compared with BHI 30(t=-30) (P =.013). Maximum serum glucose concentration (C(max)) was lower for BIAsp 30 compared with BHI 30(t=0) (14.0 +/- 2.4 v 16.5 +/- 2.8 mmol/L, P <.0001), and time to maximal serum glucose concentration (t(max)) was approximately 20 minutes shorter for BIAsp 30, irrespective of timing of BHI 30 injection (P <.0001). There were no significant differences among the 3 treatments with respect to postprandial levels of free fatty acids or triglycerides. The pharmacokinetic results were consistent with the above observations, ie, significantly larger insulin AUC(0-4h), higher C(max) and shorter t(max) were observed for BIAsp 30 compared with BHI 30, irrespective of timing of BHI 30 injection. We conclude that postprandial glycemic control was more effective with BIAsp 30 than with BHI 30, irrespective of timing of BHI 30 injection.     

Effect of mild exercise on glycemic and bodyweight control in Japanese type 2 diabetes patients: A retrospective analysis

We retrospectively evaluated the effects of mild physical exercise (P) in a routine clinical setting on glycemic and bodyweight control in Japanese type 2 diabetes patients with and without individualized nutritional therapy (D). We analyzed 49 patients who participated in P that measured 2.5 metabolic equivalents and was held once every 2 weeks, compared with 83 non‐participant controls, followed over a period of approximately 1.6 years. With a Cox model, the adjusted hazard ratio for improved glycated hemoglobin by numerical count of P was 1.03 (95% confidence interval [CI] 1.00–1.07; P = 0.025). Among four categories – with neither P nor D, only P, only D, and both P and D – the hazard ratios for reduced body mass index were 1.0, 0.87 (95% CI 0.46–1.67), 0.58 (95% CI 0.25–1.30) and 2.17 (95% CI 1.03–4.59), respectively. Even mild physical exercise contributed to glycemic control. The combination of P and D exerted beneficial effects on bodyweight control.     

Comorbidity and glycemic control in patients with type 2 diabetes

BACKGROUND: It is commonly believed that good glycemic control is hard to achieve in patients with diabetes mellitus and concurrent chronic illnesses. OBJECTIVE: To determine the impact of comorbidity on glycemic control at presentation and subsequent follow-up in patients with type 2 diabetes. METHODS: We studied 654 consecutive patients who presented to a diabetes clinic in 1997. Comorbidity was rated using the Chronic Disease Score (CDS) index, which is a validated, weighted score that takes into account the patient's age, sex, and classes of medications. Univariate and multivariate linear regressions were used to determine the contribution of age, body mass index (calculated as weight in kilograms divided by the square of height in meters), diabetes duration, type of therapy, and CDS to initial hemoglobin A(1c) (HbA(1c)) level. A similar analysis was performed for the 169 patients with follow-up HbA(1c) levels 6 months after presentation. RESULTS: Patients were 90% African American, and 66% female, with average age of 53 years. Average diabetes duration was 5 years; body mass index, 33; HbA(1c) level, 8.8%; and CDS, 1121 (range, 232-7953). At presentation, patients with higher CDSs tended to be older and to have a lower HbA(1c) level, but multivariate linear regression showed that receiving pharmacological therapy, younger age, and having a lower C-peptide level were the only significant contributors to HbA(1c) level. In the 169 follow-up patients, presenting characteristics were not significantly different from those of the full cohort: average initial HbA(1c) level was 8.8%; CDS, 1073. Their HbA(1c) level at 6 months averaged 7.5% and the CDS had no significant impact on their follow-up HbA(1c) level. CONCLUSION: Comorbidity does not appear to limit achievement of good glycemic control in patients with type 2 diabetes.     

Association between vitamin D status and glycemic profile in postmenopausal women with type 2 diabetes

The aim of this study is to evaluate the association between vitamin D status and glycemic profile in postmenopausal women with type 2 diabetes. A cross-sectional study was carried out with 70 (59.47 ± 6.47 years; 1.56 ± 0.05 m; 73.56 ± 13.01 kg; 30.30 ± 5.00 BMI kg/m²) postmenopausal women with type 2 diabetes (T2D). The blood samples were collected after fasting for 12 h and the main outcome parameters were serum follicle-stimulating hormone (FSH), estradiol; 25-OH vitamin D; insulin; C-Reactive Protein; cholesterol total (CT), triglycerides (TG), high density lipoprotein (HDL-cholesterol), glucose; calcium, HDL-cholesterol. The average serum 25(OH)D level in this study was 28.45 ± 8.26 ng/mL. The prevalence of hypovitaminosis D was 60%. Table 1 displays mean and standard deviation values for participants’ characteristics. The postmenopause status of the women studied was confirmed by FSH and estradiol measurement. All the clinical and anthropometric characteristics did not show difference (p > 0.05) between the groups (Table 2). Triglycerides level was highest (p < 0.0391) in the hypovitaminosis D group. The other serum markers did not show statistical differences (p > 0.05) between the groups. In conclusion, our results suggest that only TG level shows a negative correlation with vitamin D status in postmenopausal women with type 2 diabetes.     

Conjugated equine estrogen improves glycemic control and blood lipoproteins in postmenopausal women with type 2 diabetes

The objective of this study was to determine the metabolic effects of estrogen replacement therapy in postmenopausal women with type 2 diabetes. Twenty-five postmenopausal, type 2 diabetic women completed a randomized, blinded, cross-over trial of conjugated equine estrogen, 0.625 mg/day, vs. placebo for 8 weeks, separated by a 4-week washout period. When compared with 8 weeks of placebo, estrogen reduced fasting serum glucose (7.2 +/- 0.3 vs. 8.4 +/- 0.4 mmol/L, P = 0.0003), glycated hemoglobin (8.7 +/- 0.4% vs. 9.3 +/- 0.4%, P = 0.04), total cholesterol (5.27 +/- 0.20 vs. 5.50 +/- 0.21 mmol/L, P = 0.04), low-density lipoprotein cholesterol (2.47 +/- 0.13 vs. 2.69 +/- 0.14 mmol/L, P = 0.02), serum apolipoprotein B (114 +/- 6 vs. 121 +/- 5 mg/dL, P = 0.03), and postprandial glucose area under the curve (by 12%, P = 0.015). Estrogen replacement therapy also increased high-density lipoprotein (HDL) cholesterol (1.27 +/- 0.08 vs. 1.1 +/- 0.07 mmol/L, P = 0.0002), high-density lipoprotein(2) cholesterol (0.41 +/- 0.04 vs. 0.30 +/- 0.03 mmol/L, P = 0.0001), and fasting triglyceride (2.17 +/- 0.21 vs. 1.94 +/- 0.16 mg/dL, P = 0.02) concentrations but not postprandial triglyceride area under the curve (P = not significant). We conclude that estrogen replacement therapy improves glycemic control, blood lipoproteins, and apolipoprotein B concentrations while modestly increasing triglyceride levels in postmenopausal, type 2 diabetic women.     

Predictors of glycemic control in children with type 1 diabetes: the importance of race

Diabetes is a common cause of kidney failure and blindness among young adults, particularly of African-American descent. Since glycemic control is a predictor of diabetes complications, we evaluated the impact of multiple factors including a special multidisciplinary management program on glycosylated hemoglobin in children with Type 1 diabetes.Data was collected from pediatric diabetes clinics in New Orleans, LA and Baltimore, MD. In New Orleans, hemoglobin A(1c) was higher in African-American patients 12. 5+/-3.3% (n=71) vs. 10.7+/-2.1% (n=80) in Caucasian children, p<0. 0001. Longer duration of diabetes was also associated with higher hemoglobin A(1c) in both races. The effect of race on hemoglobin A(1c) was independent of the influence of sex, insurance status, body mass index (BMI) z-score, and number of clinic visits. Covariate analysis with mean blood glucose levels indicated that higher hemoglobin A(1c) was attributable to higher mean blood glucose levels in African-American children. From the Baltimore data, a multidisciplinary intervention program led to improved total glycosylated hemoglobin for Caucasian patients but not for African-American children.Poorer glycemic control of African-American children is likely to predispose them to a higher likelihood of developing microvascular complications as they mature. Standard hospital-based multidisciplinary programming for diabetes management may have limited effectiveness in improving glycemic control of African-American children with diabetes. Innovative intervention programs are needed for these high-risk patients.     

Association between glycemic control and birthweight with glycated albumin in Chinese women with gestational diabetes mellitus

Aims/Introduction

To assess glycated albumin (GA) as a potential glycemic index in managing gestational diabetes mellitus (GDM).

Materials and Methods

Eligible pregnant women were divided into the GDM group with abnormal result on a 75‐g oral glucose tolerance test (OGTT) and the control (normal) group. GA measurements, Pearson''s correlation analysis, multiple logistic regression and receiver operating characteristic curve analysis were obtained at the follow‐up examination of participants in the two groups.

Results

A total of 2,118 women were assigned to the GDM group (n = 639) and control group (n = 1,479). The mean level of serum GA in GDM group was significantly greater than that in the control group at both 24–28 and 36–38 weeks of gestation (P < 0.05). The area under the receiver operating characteristic curve for GA defining good glycemic control in GDM was 0.874 (95% confidence interval 0.811–0.938). The cut‐off point for the GA levels derived from the receiver operating characteristic curve was 11.60%, which had sensitivity and specificity for detecting a poor glycemic status of 75.93% and 86.36%, respectively. The risk of birthweight ≥3,500 g and macrosomia increased significantly with GA levels ≥13.00% at 24–28 weeks and ≥12.00% at 36–38 weeks of gestation.

Conclusions

GA might be an appropriate and conveniently measured index that can detect poor glycemic control and predict birthweights in GDM women.     

Self-reported factors that affect glycemic control in college students with type 1 diabetes

PURPOSE: This study examined the self-reported impact of different factors on the overall diabetes care of college students with type 1 diabetes. METHODS: An 18-item questionnaire was mailed to 164 students with type 1 diabetes attending college away from home; results from 42 students fulfilled study criteria and were analyzed. Metabolic control was assessed by relative changes in glycosylated hemoglobin (HbA1c) levels from medical records. RESULTS: HbA1c levels did not change significantly between high school and college, yet most college students reported that diabetes was more difficult to manage in college. Commonly reported barriers to diabetes control included diet, irregular schedules, lack of parental involvement, peer pressure, drugs and alcohol, fear of hypoglycemia, and finances. Factors identified as improving diabetes control were an increased sense of responsibility, increased frequency of blood glucose testing, exercise, contact with healthcare providers, fear of hyperglycemia, and knowledge of the results of the Diabetes Control and Complications Trial. Many students reported testing their blood more frequently and taking more injections than in high school; most were on intensive insulin regimens. CONCLUSIONS: Despite the perception that diabetes management was more difficult in college, metabolic control was maintained during college, possibly due to a more intensive treatment approach.     

Lipid profile correlates with glycemic control in young patients with type 1 diabetes mellitus

Data on dyslipidemia in type 1 diabetes is scarce. The authors aimed to evaluate the lipid profile in patients with type 1 diabetes and its correlation to glycemic control. Ninety-four subjects (53.2% males), aged 15.4+/-4.7 (3.6-21.9 years), with disease duration of 5.0+/-3.6 years (0.3-17 years) were evaluated for heart rate, blood pressure, height, and weight. Laboratory data included total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TGs), glycemia, glycosylated hemoglobin (HbA1c), creatinine, thyroid-stimulating hormone, antithyroid antibodies, and 24-hour microalbuminuria. Correlations were performed by the Spearman rank correlation test, and the significance level was <0.05. Mean values were TC, 168.6+/-46.6 mg/d; HDL, 43.1+/-15.3 mg/dL; LDL, 110.9+/-40.6 mg/dL; TGs, 78.3+/-48.6 mg/dL; glycemia, 204.6+/-116.7 mg/dL; and HbA1c, 11.2%+/-2.9%. High TC (43.9% vs. 10.7%; p<0.002) and LDL (51.5% vs. 10.7%; p<0.01) were more prevalent in patients 19 years and younger (n=66). HbA1c correlated with TC (r=0.30; p=0.004), LDL (r=0.28; p=0.008), TG (r=0.31; p=0.003), and TG/HDL ratio (r=0.25; p=0.01). Duration of diabetes correlated with LDL (r=0.21; p=0.04) and insulin daily doses with TG (r=0.23; p=0.04) and body mass index expressed as z scores (r=-0.28; p=0.007). There was a high prevalence of hypercholesterolemia (54.6%) in these diabetic patients, and lipid fraction levels were correlated with HbA1c. Good management of diabetes seems to be of paramount importance in controlling dyslipidemia.     

The association between intensive glycemic control and vascular complications in type 2 diabetes mellitus: A meta-analysis

Background and AimIn patients with type 2 diabetes mellitus, the relationship between lowering glycated hemoglobin (HbA_1c) and macrovascular complications is not clear and therefore lowering the level of HbA_1c is controversial.Methods and ResultsWe searched for all randomized controlled trials comparing the effects of intensive and standard glycemic control on vascular events in patients with type 2 diabetes mellitus. The primary endpoint was combined macrovascular complications, including cardiac events, stroke and peripheral vascular disease. Fixed and random effect models were used to analyze the results.Eight studies were included according to selection criteria. The results showed no benefits of intensive glycemic control on macrovascular and microvascular complications (P > 0.1), but a higher rate of severe hypoglycemia (P < 0.00001) in the intensive control group when the target HbA_1c level was <7.0%. When the target HbA_1c level was lowered to 7.0–7.9%, intensive glycemic control showed benefits on the reduction of microvascular events (P < 0.05) without increasing the risk of severe hypoglycemia (P = 0.74), but no influence on macrovascular complications (P > 0.1).ConclusionThe results of this analysis suggest that a target HbA_1c level of 7.0–7.9% may be a better glycemic control target than that of <7.0% in patients with established type 2 diabetes mellitus.     

Pregnancy in women with type 2 diabetes: an uncertain prognosis

The increasing prevalence of type 2 diabetes in women of childbearing age leads to an increasing number of pregnant women with type 2 diabetes. Pregnancy complicated by type 2 diabetes is a high-risk pregnancy, associated with birth defects and high perinatal mortality to the same extent as in type 1 diabetes. Until now, most attention was directed toward women with type 1 diabetes. Recent data stresses the urgent need to develop better screening and efficient care strategies in women with type 2 diabetes, who also display many risk factors for adverse fetal outcome. Family physicians, diabetologists and gynaecologists must be aware of this growing concern. Improvement of pregnancy planning, adequate metabolic control from conception to delivery and a multi-disciplinary team approach to care should improve fetal and maternal outcomes. Furthermore, diabetes screening in high-risk women prior to pregnancy is warranted.