儿童1型糖尿病应用动态血糖监测系统的效能分析

目的评价动态血糖监测系统(CGMS)在儿童1型糖尿病血糖监测中的效能。方法应用CGMS监测17例1型糖尿病患儿的血糖,与指血血糖值比较,应用相关分析、血糖误差分析表格(EGA)等方法评价其效能。结果在总体、高、正常血糖水平,相匹配的CGMS血糖值与指血血糖值相关系数分别为0.96、0.92、0.94(P均<0.01);在低血糖水平,两者相关性下降(r=0.73,P<0.01)。CGMS血糖值在指血血糖值±20%和±30%范围的总体比例为88.5%、93.8%;在高、正常、低血糖水平,CGMS血糖值在指血血糖值±20%和±30%范围的比率分别为94.1%、96.5%,81.8%、90.3%,50.0%、80.0%。结论CGMS的血糖监测结果与血糖仪一致,能较准确地监测儿童1型糖尿病患儿的血糖情况,更全面地反映患儿的血糖波动特征。     

A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency

Helgeson VS, Honcharuk E, Becker D, Escobar O, Siminerio L. A focus on blood glucose monitoring: relation to glycemic control and determinants of frequency. Objective: To re‐examine the relation of blood glucose monitoring to glycemic control among adolescents with type 1 diabetes and to evaluate the relation of demographic, behavioral, and psychosocial characteristics of adolescents who monitor more and less frequently. Research design and methods: Participants were 132 adolescents with type 1 diabetes (average age = 12 yr) and their parents, recruited from Children's Hospital of Pittsburgh. Adolescents were interviewed annually for five consecutive years after routine clinic appointments. At each assessment, data from blood glucose meters were downloaded and glycosylated hemoglobin A1c was recorded from medical records. Results: More frequent blood glucose monitoring was related to better glycemic control. Adolescents who monitored more frequently were younger, from higher social status families, on insulin pumps, and had higher self‐efficacy. Age‐related declines in blood glucose monitoring occurred among adolescents with low self‐esteem, high stressful life events, and lower parental support. Conclusions: Given the importance of blood glucose monitoring for good glycemic control, future research should enhance adolescents' self‐efficacy for monitoring and intervene with those who are at risk for age‐related declines in blood glucose monitoring.     

Predictors of glucose control in children and adolescents with type 1 diabetes mellitus

AIMS: To evaluate the glucose control [(as measured by hemoglobin A1c (HbA1c)], the factors associated with glycemic control, and possible explanations for these associations in a sample of children and adolescents with type 1 diabetes. METHODS: Data were collected on 155 children and adolescents, with type 1 diabetes mellitus, attending a multidisciplinary diabetes clinic in Portland, OR. Patients' hospital charts were reviewed to determine demographic factors, disease-related characteristics, and HbA1c level. RESULTS: Mean percent HbA1c was 9.3. Adolescents between the ages of 14 and 18 yr were in poorer metabolic control (adjusted mean percent HbA1c 0.56 higher than children 2-8 yr). Children who attended the clinic three to four times in the previous year were in better control (adjusted mean percent HbA1c 0.46 lower than those who visited two or fewer times and 1.11 lower than those who attended five or more times). Children with married parents were in better glycemic control than those of single, separated, or divorced parents (adjusted mean percent HbA1c 0.47 lower for children of married parents). This effect appeared to be mediated, in part, by the number of glucose checks performed per day. CONCLUSIONS: This study suggests that adolescents should be targeted for improved metabolic control. Diabetes team members need to be aware of changing family situations and provide extra support during stressful times. Regular clinic attendance is an important component of intensive diabetes management. Strategies must be developed to improve accessibility to the clinic and to identify patients who frequently miss appointments.     

��ͯ1�����򲡶�̬Ѫ�Ǽ����ٴ�����

目的应用动态血糖监测系统(CGMS)观察1型糖尿病患儿血糖控制情况,寻找评价和改善血糖控制的方法。方法收集复旦大学附属儿科医院2003年10月至2004年6月内分泌科门诊随访的儿童1型糖尿病患者28例,男16例,女12例,年龄(13.1±4.5)岁,病程(5.5±3.4)年,其中21例采用每天多次胰岛素注射(MDI),另7例使用胰岛素泵连续胰岛素输注(CSII)治疗。动态监测血糖3d,同时指尖血糖监测≥4次/d。结果(1)研究对象体重指数(BMI)为(19.4±3.0)kg/m2,糖化血红蛋白(HbA1c)为(8.4±1.6)%。CSII组HbA1c(8.2±1.0)%,MDI组HbA1c(8.5±1.8)%,差异有显著性意义(P<0.05);(2)CGMS发现22例77次餐后2h高血糖,CSII组4例(57.1%),每例出现1次,MDI组18例(85.7%),每例出现(4.1±2.5)次,差异显著(P<0.01);(3)CGMS发现17例79次低血糖,持续时间(76.6±92.8)min,而指尖血糖监测仅发现19次低血糖;白天低血糖持续时间(41.5±39.1)min,夜间(112.4±117.1)min,夜间低血糖持续时间显著长于白天(P<0.01)。(4)HbA1c≤8%组餐后高血糖发生率低于HbA1c>8%组(P<0.05),而低血糖的发生率显著升高(P<0.01)。结论1型糖尿病患儿多数存在低血糖和餐后高血糖;动态血糖监测系统是发现血糖异常波动的有效工具。动态血糖监测对指导1型糖尿病治疗,调整胰岛素剂量,从而改善血糖控制有着重要的临床意义。     

Use of continuous glucose monitoring in young children with type 1 diabetes: implications for behavioral research

Patton SR, Williams LB, Eder SJ, Crawford MJ, Dolan L, Powers SW. Use of continuous glucose monitoring in young children with type 1 diabetes: implications for behavioral research. Objective: This study presents data on the use of continuous glucose monitoring (CGM) in young children with type 1 diabetes mellitus (T1DM). CGM provides moment‐to‐moment tracking of glucose concentrations and measures of intra‐ and interday variability, which are particularly salient measures in young children with T1DM. Methods: Thirty‐one children (mean age = 5.0 yr ) with T1DM wore the Medtronic Minimed CGM for a mean of 66.8 h. The CGM was inserted in diabetes clinics, and parents were provided brief training. Results: Few difficulties were experienced and families cited the acceptability of CGM. Participants' CGM data are compared with self‐monitoring blood glucose (SMBG) data as well as data from older children with T1DM to illustrate differences in methodology and variability present in this population. CGM data are used to calculate glucose variability, which is found to be related to diabetes variables such as history of hypoglycemic seizures. Conclusions: CGM is an acceptable research tool for obtaining glucose data in young children with T1DM and has been used previously in older children and adults. CGM may be particularly useful in young children who often experience more glucose variability. Data obtained via CGM are richer and more detailed than traditional SMBG data and allow for analyses to link blood glucose with behavior.     

Effectiveness of sensor-augmented pump therapy in children and adolescents with type 1 diabetes in the STAR 3 study

Slover RH, Welsh JB, Criego A, Weinzimer SA, Willi SM, Wood MA, Tamborlane WV. Effectiveness of sensor‐augmented pump therapy in children and adolescents with type 1 diabetes in the STAR 3 study. Objective: Maintenance of appropriate A1C values and minimization of hyperglycemic excursions are difficult for many pediatric patients with type 1 diabetes. Continuous glucose monitoring (CGM) sensor‐augmented pump (SAP) therapy is an alternative to multiple daily injection (MDI) therapy in this population. Research design and methods: Sensor‐augmented pump therapy for A1C reduction (STAR 3) was a 1‐yr trial that included 82 children (aged 7–12) and 74 adolescents (aged 13–18) with A1C values ranging from 7.4 to 9.5% who were randomized to either SAP or MDI therapy. Quarterly A1C values were obtained from all subjects. CGM studies were carried out at baseline, 6 months, and 12 months to quantify glycemic excursions [calculated as area under the glucose concentration‐time curve (AUC)] and variability. In the SAP group, sensor compliance was recorded. Results: Baseline A1C values were similar in subjects randomized to the SAP (8.26 ± 0.55%) and MDI groups (8.30 ± 0.53%). All subsequent A1C values showed significant (p < 0.05) treatment group differences favoring SAP therapy. Compared with the MDI group, subjects in the SAP group were more likely to meet age‐specific A1C targets and had lower AUC values for hyperglycemia with no increased risk of hypoglycemia. Glucose variability improved in the SAP group compared to the MDI group. Children wore CGM sensors more often and were more likely to reach age‐specific A1C targets than adolescents. Conclusions: SAP therapy allows both children and adolescents with marginally or inadequately controlled type 1 diabetes to reduce A1C values, hyperglycemic excursions, and glycemic variability in a rapid, sustainable, and safe manner.     

1型糖尿病青少年患者血糖控制和糖尿病微血管并发症

为了解1型糖尿病青少年患者的血糖控制情况、糖尿病微血管并发症的发生率及其危险因素 ,调查病程5年以上的1型糖尿病患者76例 ,平均年龄17.2±3.9岁 ,平均病程9.0±3.4年 ,检测餐后2小时血糖、糖化血红蛋白 (HbA1C)、尿微量白蛋白 ,眼底荧光造影等。结果显示 ,HbA1C 平均水平为 (9.7±1.7) % ;糖尿病肾病发生率为9.2% ,微量白蛋白尿 (UAER :20～200μg/min)和大量蛋白尿 (UAER>200μg/min)分别占7.9 %和1.3 %;糖尿病视网膜病变发生率为23.7% ,非增殖型16例占21.1% ,增殖型2例占2.6 % ,其中3例合并白内障。提示目前1型糖尿病青少年患者的血糖控制不理想 ,仅有18.4 %的患者HbA1C <8 % ;长病程、女性、血糖控制差是1型糖尿病青少年发生糖尿病视网膜病变、糖尿病肾病的危险因素     

Continuous glucose monitoring system during physical exercise in adolescents with type 1 diabetes

Aim: Continuous glucose monitoring system (CGMS) provides detailed information on glucose fluctuations. The aim was to establish whether CGMS could be used during physical exercise and whether it detects more episodes of hypoglycaemia and hyperglycaemia than frequent blood glucose measurements. Methods: Adolescents with type 1 diabetes (12 girls and 47 boys) participated in three annual sports camps that lasted for 3–4 days and included different types of exercise: soccer, floorball + cross‐country skiing and golf. During the study, blood glucose values, mean 8.7 ± 3.3 per day, were obtained with Hemocue in parallel with the CGMS. Results: Ninety‐eight per cent of the participants used the sensor at all times during the camps. Eighty‐seven per cent of the sensors gave adequate signals for 24 h and 66% for 48 h. Median durations of hypoglycaemia and hyperglycaemia were 1.7 h per day and 3.8 h per day, respectively. The CGMS identified significantly more episodes of hypoglycaemia (p < 0.005) and hyperglycaemia (p < 0.005) during the day and night than frequent blood glucose tests. Conclusion: We demonstrate that, even during days that included episodic strenuous physical exercise, CGMS could provide useful information on glucose fluctuations during day and night, albeit with significant failure rates.     

应用胰岛素泵治疗儿童及青少年1型糖尿病对糖代谢的影响

为观察应用胰岛素泵治疗儿童及青少年1型糖尿病(T1DM)对糖代谢的影响 ,随访10例胰岛素泵治疗的T1DM患儿 ,分别观察胰岛素泵治疗前、后6个月的糖化血红蛋白值(HbA1c)、胰岛素用量、严重低血糖及酮症酸中毒发生次数的变化情况。结果显示 ,胰岛素泵治疗6个月后HbA1c 显著下降 ,治疗前为8.97 %±1.69 %,治疗后为7.51 %±1.17 % (t=2.52 ,P<0.05) ;胰岛素用量无显著下降 ;未发生严重低血糖和酮症酸中毒。表明胰岛素泵治疗可有效控制血糖 ,明显降低HbA1c,减少低血糖及酮症酸中毒的发生 ,是儿童及青少年T1DM常规治疗的较好选择。     

Missed bolus doses: devastating for metabolic control in CSII-treated adolescents with type 1 diabetes

Objective: To investigate the management of continuous subcutaneous insulin infusion (CSII) in adolescents with type 1 diabetes including their administration of bolus doses and to study relationships between insulin omission and metabolic control, body mass index, daily frequency of self‐monitoring of blood glucose (SMBG) and bolus doses, health‐related quality of life (HRQOL), the burden of diabetes and treatment satisfaction. Methods: Ninety CSII‐treated (≥6 months) adolescents aged 12–18 yr, from four diabetes clinics in Sweden, participated in the study. The adolescents recorded their meal intake the previous day, which was compared with downloaded pump data, and the frequency of missed boluses was stated. Haemoglobin A1c (HbA1c) and diabetes‐related data were recorded. HRQOL and treatment satisfaction were measured with questionnaires. Results: Thirty‐eight per cent of the adolescents had missed >15% of the doses the previous day, those had higher HbA1c (7.8 ± 1.0 vs. 7.0 ± 1.2%, p = 0.001), took fewer daily boluses (3.8 ± 1.7 vs. 5.3 ± 1.7, p < 0.001) and SMBG (2.4 ± 1.8 vs. 3.6 ± 1.8, p = 0.003), were less satisfied with their treatment (4.8 vs. 5.3, scale 0–6, p = 0.029) and perceived the medical treatment more negatively (72.1 vs. 79.7, scale 0–100, p = 0.029). Multiple linear regression analysis showed that the variations in HbA1c could be explained by the frequency of bolus doses (p = 0.013) and SMBG per day (p < 0.0001) adjusted for duration and age (r² = 0.339, p < 0.0001). Conclusion: Insulin omission was common. Those who missed doses were less satisfied and perceived more impact with the treatment. The frequencies of daily boluses and SMBG were associated with metabolic control. Diabetes teams need strategies to guide adolescents on how to avoid insulin omission.     

Telemedical support to improve glycemic control in adolescents with type 1 diabetes mellitus

Introduction In this paper, we evaluated the feasibility of a telemedical (TM) support program and its effect on glycemic control in adolescents with type 1 diabetes mellitus (T1DM). Thirty-six adolescents (m=20, median age at the start of the study: 15.3 years (range: 10.7–19.3 years), median age at diagnosis: 9.3 years (2.1–13.8 years), median duration of disease: 6.4 years (1.0–12.8 years), HbA1c>8%, all on intensified insulin therapy) were randomized in a crossover trial over 6 months (3 months with TM, 3 months with conventional support and paper diary (PD)). During the TM phase, the patients sent their data (date, time, blood glucose, carbohydrate intake, insulin dosage) via mobile phone, at least daily, to our server and diabetologists sent back their advice via short message service (SMS) once a week.Results Glycemic control improved during the TM phase, while it deteriorated during the PD phase: TM-PD group HbA1c (%, median (range)): 9.05 (8–11.3) (at 0 months), 8.9 (6.9–11.3) (at 3 months), and 9.2 (7.4–12.6) (at 6 months), and PD-TM group: 8.9 (8.3–11.6), 9.9 (8.1–11), and 8.85 (7.3–11.7) (p<0.05). Patients rated the TM support program to be a good idea. Technical problems with General Packet Radio Service (GPRS) data transmission led to data loss and decreased patient satisfaction.Conclusion Our telemedical support program, VIE-DIAB, proved to be feasible in adolescents and helped to improve glycemic control.