胰岛素泵治疗糖尿病酮症酸中毒疗效的荟萃分析

目的评价胰岛素泵治疗糖尿病酮症酸中毒（DKA）的效果。方法计算机检索并筛选关于胰岛素泵在DKA中应用的随机对照试验（RCT）,进行荟萃分析。 结果共纳入19个RCT。与常规胰岛素静脉滴注相比,持续皮下胰岛素泵（CSII）治疗DKA显示出更明显的优势。15个RCT结果显示,CSII治疗DKA血糖达标时间明显缩短;7项研究结果表明,CSII治疗DKA平均胰岛素用量减少;15项研究结果表明,CSII治疗DKA尿酮转阴时间缩短;12项研究结果表明,CSII治疗DKA低血糖发生率明显降低。4项研究结果表明,CSII治疗DKA血酮恢复时间缩短。结论胰岛素泵能模拟胰岛素的生理分泌模式,更快、更有效地纠正代谢紊乱,是一种安全、可靠、方便、灵活、有效的治疗DKA的方法,能提高患者生活质量。     

以酮症酸中毒起病的初发糖尿病临床特点分析

目的：观察以酮症酸中毒起病的初发糖尿病的临床特点。方法选择2010年7月份至2013年12月份在我院治疗的糖尿病酮症酸中毒（ DKA）患者102例,根据患者发病前是否患有糖尿病分为两组,一组为DKA1组（以酮症酸中毒起病,发病前无糖尿病病史）共42例,一组为DKA2组（发病前已确诊有糖尿病）共60例。比较两组患者发病诱因、糖尿病分型特点及误诊率、治愈率、死亡率,并作出分析。结果 DKA1组起病时无明显诱因占42．8％明显高于DKA2组8．3％,差异有统计学意义（P＜0．05）,有明确诱因中感染因素占38．1％;DKA 1组与DKA 2组的糖尿病类型分布不同,差异有统计学意义（P＜0．01）,其中DKA 1组1型糖尿病、未分型糖尿病所占比例高于DKA 2组,2型糖尿病所占比例小于DKA 2组,差异有统计学意义（P＜0．05）,DKA 1组误诊率高于DKA2组差异有统计学意义（P＜0．01）。结论以酮症酸中毒起病的初发糖尿病发病前多无明显诱因,容易误诊,应加强糖尿病及并发症的健康教育,及时监测,尽早进行干预和治疗。     

Flexible,intensive insulin therapy and dietary freedom in adolescents and young adults with Type 1 diabetes: a prospective implementation study

Aims To assess the outcome of a Diabetes Treatment and Teaching Programme (DTTP) on glycated haemoglobin (HbA_1c), severe hypoglycaemia (SH) and severe ketoacidosis (SKA) in adolescents and young adults with Type 1 diabetes. Methods Quality-assurance project with assessment of participants 1 year after participation in a DTTP (5-day inpatient course, groups ≤ 10 patients, fixed curriculum of education/training, introduction of dietary freedom). Before–after analyses of participants aged 12–15, 15–18, 18–21 and 21–24 years. Main outcome measures were HbA_1c, SH and SKA. Results For the 1592 participants, aged 12 to 24 years, mean age at enrolment was 19 ± 3 years, mean duration of diabetes was 7.3 ± 5.4 (range 0.3–24) years, mean baseline HbA_1c declined from 8.8 ± 2.3% to 8.1 ± 2.0%. The incidence of SH was 0.31 vs. 0.11 events/patient/year; the incidence of SKA 0.17 vs. 0.07 events/patient/year. In mixed effects models taking into account effects of centres, age and diabetes duration, the mean difference was −0.64%[P < 0.001, 95% confidence interval (CI) −0.79 to −0.5] for HbA_1c, −0.2 events/patient/year (P < 0.0001, 95% CI −0.28 to −0.12) for SH and −0.1 events/patient/year (P < 0.0001, 95% CI −0.14 to −0.06) for SKA. Conclusions Adolescents and young adults with Type 1 diabetes benefit from participation in a standard DTTP for flexible, intensive insulin therapy and dietary freedom.     

Insulin glargine supplementation during early management phase of diabetic ketoacidosis in children

Objective To study the effect of subcutaneous administration of insulin glargine on the rate of resolution of acidosis and intravenous insulin infusion requirement in children with moderate and severe diabetic ketoacidosis (DKA). Study design Retrospective cohort study. Setting Pediatric intensive care unit of a university-based children's hospital. Patients Children with moderate to severe DKA admitted between March 2001 and February 2003. Results The outcomes of children who received 0.3 units/kg of subcutaneous insulin glargine in the first 6 h of management in addition to the standard treatment (n = 12) were compared with those of children who received standard treatment alone (n = 59). Measured outcomes included dose of intravenous insulin required, duration of insulin infusion and acidosis correction time. The two groups were similar in demographics and severity of illness. The mean time for acidosis correction (venous pH ≥ 7.3) in the insulin glargine group was shorter than the standard therapy group (12.4 ± 2.9 h and 17.1 ± 6.2 h respectively, p < 0.001). The insulin infusion time was shorter in the insulin glargine group (14.8 ± 6.0 h vs 24.4 ± 9.0 h, p < 0.001). There was a trend towards shorter total hospital stay in the glargine group (3.2 ± 1.0 days vs 3.72 ± 1.06 days). Conclusions In our small series of children with moderate and severe DKA, supplementing with subcutaneous insulin glargine led to a faster resolution of acidosis without any adverse effects. This could potentially lead to a shorter need for insulin infusion and a shorter ICU length of stay.     

糖尿病酮症酸中毒兔血-脑脊液屏障的变化

目的　探讨糖尿病酮症酸中毒的血脑脊液屏障损伤机制。方法　新西兰家兔随机分模型组(n=6 )和生理盐水对照组 (n=6 )。模型组从耳缘静脉注射四氧嘧啶和链脲佐菌素各 15 0 mg/ kg,对照组给予等量生理盐水 ,72 h后检测血糖、尿酮体。两组静脉内均注射伊文氏蓝 ,6 h后检测动脉血气 ;处死动物 ,取脑组织用紫外分光光度计测定伊文氏蓝吸光度 (A) ,并观察光镜、超微结构、碱性磷酸酶细胞化学及诱导型一氧化氮合酶 (i NOS)免疫组织化学结果。结果　 72 h后模型组 :血糖全部大于 17mm ol/ L,尿中出现酮体 ;伊文氏蓝 A值略增高 ,和对照组相比无显著性差异。组织学和超微结构观察模型组脑血管周围水肿 ,内皮细胞损伤 ,神经元变性、坏死。碱性磷酸酶细胞组化显示血管内皮上酶活性明显弱于对照组。免疫组化可见脑实质内血管壁上 i NOS染色阳性。结论　在四氧嘧啶和链脲佐菌素诱发的糖尿病酮症酸中毒动物模型中出现脑水肿 ,其产生与血脑脊液屏障的破坏及一氧化氮 (NO)参与有关。     

Comparison of capillary blood ketone measurement by electrochemical method and urinary ketone in treatment of diabetic ketosis and ketoacidosis in children

We aimed to compare the recent practical method of capillary β-hydroxy butyrate (βOHB) measurement with the widely used urinary ketone measurement in monitoring metabolic status of the patient during treatment of diabetic ketoacidosis (DKA) and diabetic ketosis (DK). Patients with DKA and DK admitted to the hospital were followed with simultaneous measurements of capillary βOHB by electrochemical method (Medisense Optium, Abbott), and urinary ketone by semi-quantitative method. Blood gases were measured in 2–4 h intervals. Fourteen patients with DKA/DK (7 males and 7 females, age: 9.2 ± 4.2 years) were included with 50 simultaneous measurements of capillary and urinary ketone. No correlation was detected between urinary ketone and blood pH (P = 0.06) and HCO₃ (P = 0.79), whereas a significant negative correlation was found between capillary βOHB and blood pH (r = −0.41, P < 0.05) and HCO₃ (r = −0.35, P < 0.05). Capillary βOHB and urinary ketone levels did not correlate at the beginning and 3.3 ± 1.4 h after treatment, but did correlate in the third samples taken 7.8 ± 2.0 h after treatment (r = 0.8, P < 0.05). Capillary βOHB levels show good correlation with the degree of acidosis (pH and HCO₃). Capillary βOHB measurement is more sensitive than urinary ketone measurement in reflecting the patient’s metabolic status and improvement during treatment.     

胰岛素泵入法在糖尿病伴冠心病患者酮症治疗中的应用

目的：观察门冬胰岛素泵入法在糖尿病酮症伴冠心病患者治疗中的应用价值。方法：糖尿病酮症伴冠心病患者60例,随机分为门冬胰岛素泵入组（治疗组）和常规治疗对照组,治疗组采用门冬胰岛素24h持续皮下输注基础量（根据24h胰岛素分泌特点设定每时间段的输入量）,三餐前给予负荷量;总量根据公式精确计算,基础量：占总量一半;负荷量：按血糖水平调整。对照组小剂量普通胰岛素24h持续静脉点滴,三餐前门冬胰岛素皮下注射,睡前合成胰岛素皮下注射,剂量从小剂量开始,以后随血糖水平调整。结果：两组病人酮体均转阴,但治疗组酮体转阴所需时间短（P〈0.05）,胰岛素用量少、低血糖发生率明显减低（P〈0.05）,心绞痛、心衰发生率低（P均〈0.05）。结论：胰岛素泵入法在糖尿病酮症伴冠心病患者治疗中不失为一种安全有效的好方法。     

Factors associated with discontinuing insulin therapy after diabetic ketoacidosis in adult diabetic patients.

AIMS: To assess the factors associated with successful discontinuation of insulin therapy after diabetic ketoacidosis (DKA) in adult patients. METHODS: Patients (>or= 18 years) attending the Endocrine and Metabolism Clinic at a major hospital in southern Taiwan were recruited. After recovery from the acute stage, those with no contraindications to oral antidiabetic agents, with adequate beta cell reserve, and with no antiglutamic acid decarboxylase (GAD) antibody were treated with oral agents. RESULTS: Sixty-six patients (38 males, 28 females, aged 18-76 years) were included, and 21 qualified for treatment with oral agents. These 21 patients were older at diagnosis of diabetes (45.5 +/- 14.0 vs. 40.0 +/- 13.8 years, P = 0.047), had shorter diabetes duration (median 0 vs. 5.5 months, P = 0.040), higher BMI (median 23.4 vs. 19.5 kg/m2, P < 0.001), higher serum osmolality during DKA (352.1 +/- 40.7 vs. 318.0 +/- 16.4 mmol/kg, P = 0.005), and lower insulin dose following recovery (median 0.49 vs. 0.83 unit/kg/d, P < 0.001) than those patients that had to continue insulin therapy. Thirteen patients (8 males, 5 females; 62%) successfully discontinued insulin for at least one year without recurrence of DKA. Multiple logistic regression analyses showed that BMI >or= 25 kg/m2 (adjusted relative risk (ARR) 8.85, 95% CI 1.05, 8.39), diabetes onset age >or= 40 years (ARR 8.08, 95% CI 1.16, 6.95), and undiagnosed diabetes before DKA (ARR 8.90, 95% CI 1.19, 7.51) were significant factors associated with successful discontinuation of insulin therapy. CONCLUSION: We identified three independent clinical factors associated with successful discontinuation of insulin therapy after DKA.