初探健康管理与我国糖尿病的预防与控制

近年来,我国糖尿病发展的势头迅速,成为糖尿病患病率增长最快的国家之一,给社会和经济带来了巨大的负担。文章针对我国的糖尿病的流行现状及其带来的经济负担,分析了实施糖尿病健康管理的现实意义,并借鉴美国健康管理的经验,构思了我国社区的促进糖尿病防制的健康管理模式。     

糖尿病防治的策略转变——从关注糖化血红蛋白到着眼心血管事件

通过对2型糖尿病心血管终点事件的观察,更多的临床证据提示,糖尿病的治疗目标应该以减少心血管事件为主。糖尿病防治从策略上发生了两个转变,即以血糖为中心转向以防治心血管事件为中心的多危险因素综合防治策略;以糖化血红蛋白检测作为血糖评价的金标准转向以血糖量、质、时程控制的全面评价策略。     

糖尿病的免疫抑制治疗

淡化糖尿病的分型为我们提供了一个全新的思维空间。即传统的1型和至少部分2型糖尿病可能都是一种自身免疫性疾病,而目前流行的炎症学说可能是对认可免疫损伤是糖尿病发病理论的一个过渡,我们应该重新审视糖尿病的早期治疗和研究其慢性并发症的发病机理。我们则采用小别量、长时间的治疗理念,早期接受这种免疫治疗的患者出现低血糖的症状,遂减少胰岛素的剂量;再次出现低血糖,我们就继续减少胰岛素的剂量。结果,有部分患者完全摆脱了胰岛素。我们对糖尿病的再认识是建立在对多脏器活检的基础之上。我们的活检结果表明,糖尿病肾病存在着免疫损伤。糖尿病眼底病变是使患者致盲的主要病因,糖尿病患者的眼底病变是一种自身免疫损伤的结果。我们尝试用小剂量的免疫抑制剂环孢菌素A（25mgbid）治疗糖尿病眼底出血,取得了不错的疗效,也证实糖尿病眼底病变是一种血管炎,与自身免疫病变有关。其他的器官还包括垂体、大脑的血管、糖尿病足、冠心病、皮肤的病变和肌肉活检的免疫组化也均有证据表明,免疫损伤是导致多种慢性并发症的罪魁祸首,是一种多器官免疫损伤的结果无论是1型糖尿病,还是2型糖尿病,肌细胞表面或多或少均有免疫复合物沉积。这些免疫复合物的存在势必会影响胰岛素与肌肉细胞表面的胰岛素受体结合,即胰岛素抵抗的存在。为此,我们在临床上广泛采用了免疫抑制治疗的理念治疗糖尿病。应用小剂量胰岛素和小剂量环孢素A治疗早期发现的糖尿病取得了不错的疗效。唯一担心的副作用发生在肝脏,即部分糖尿病患者会出现总胆红素升高,而也有一部分患者总胆红素不升高。     

针对T细胞介导的胰岛自身免疫的治疗策略

1A型糖尿病是由T细胞所介导的器官特异性自身免疫性疾病。人们利用转基因技术、自身抗原疫苗接种、单克隆抗体治疗等新兴技术通过诱导自身免疫耐受,改变免疫调节因子,调节细胞凋亡等途径阻止了自身免疫反应对胰岛的攻击。这些针对其发病机制所提出的新型治疗策略让人们看到了治疗自身免疫型糖尿病的希望。     

心理性胰岛素抵抗及应对策略

糖尿病易导致严重的慢性并发症,已成为影响人们生活质量的一种常见疾病。早期应用胰岛素是使2型糖尿病患者血糖得到良好控制、减少并发症发生的有效手段。但许多患者不愿接受或延迟胰岛素治疗。本文旨在探讨胰岛素应用过程中患者及医护人员存在的心理障碍,即心理性胰岛素抵抗,并进一步阐述其应对策略。     

应激对中国地鼠糖尿病发生的影响

研究实验性应激、情绪性、笼架水平在中国地鼠糖尿病发生中的作用强度及其交互作用,以确定中国地鼠糖尿病发生危险因素。结果表明实验性应激(震动、旋转合并限制)能促使中国地鼠血糖水平显著升高,糖尿病发病率增加,发病年龄提前;高情绪性中国地鼠,随着实验时间延长,其发病率也逐渐升高,并稳定在一定水平;析因方差分析提示,实验性应激与动物情绪性的交互作用对实验后中国地鼠的血糖变化起主要作用。     

Evidence of Impaired Glucose Tolerance and Insulin Resistance in Patients With Alzheimer’s Disease

Alzheimer’s disease (AD) and diabetes rarely occur together, a finding that provides a possible clue as to the development of AD. Abnormal glucose metabolism is not limited to diabetes, but also can include impaired glucose tolerance, insulin resistance, and hyperinsulinemia. AD patients have significantly varying insulin levels after drinking sugared sodas and thus may be classified as insulin resistant. After reviewing the literature on impaired glucose tolerance and insulin production in AD, we present several hypotheses as possible explanations for the relationship between insulin resistance and AD. Finally, we suggest future studies, including studies on use of thiazolidinediones (currently used in the treatment of diabetes) in AD.     

Self-appraisal and coping in out-patients with chronic disease

Self-appraisal, coping efforts, muscle function, and activity and severity of disease were examined in out-patients with rheumatoid arthritis, osteoarthrosis or diabetes mellitus. Factor analysis of a 31-item self-appraisal and coping questionnaire yielded eight factors (self-appraisal, acceptance, minimization, planful problem-solving, avoidance, persistence, attribution of responsibility, and support seeking). For the factors of avoidance, minimization, and persistence, as well as for measures of activity and severity of disease, significant differences between the diagnostic groups were found. For patients with rheumatic arthritis, hierarchical regression analysis indicated disease duration to be associated with acceptance and with attribution of responsibility, and disability measures to be associated with self-appraisal. For patients with osteoarthrosis, they showed disability in muscle function to be associated with avoidance, and more negative self-appraisal as well as lower levels of support seeking to be associated with long disease duration. Results are discussed in terms of structural and adaptive defence forms and of adherence to a coping model ("medical model") which tends to foster acceptance and dependency.     

A general index of self-reported sleep: the sleep quotient

Utilizing multiple sleep measures, a practice common to virtually all sleep assessments, poses problems both for statistical analyses in the form of inflated Type I error rate and for interpretation by the inability to specify general sleep change. A sleep quotient (SQ) is proposed that appears to overcome these problems. The paper presents archival norms for self-report sleep data, demonstrates the use of these norms in transforming novel data to standardized units, and casts the standardized score in the form of an intelligence quotient, now called a SQ, with a mean of 100 and a standard deviation of 15. Previously published data are reanalyzed by use of SQ scores, methods of interpreting SQ data are demonstrated, and advantages of SQ analyses are described. The SQ appears to be a valid, useful composite sleep index permitting the measurement of general sleep.     

从胰腺移植到胰岛干细胞移植

糖尿病学家在胰腺及胰岛细胞移植领域进行了不懈的探索。胰腺移植和胰岛细胞移植的两大制约因素是可供移植的胰腺来源少且诱发受体免疫排斥反应而需应用免疫抑制剂。胰岛细胞制备、纯化技术以及免疫隔离技术的应用在一定程度上克服了上述两大制约因素，人们期待胰岛干细胞技术及其相关的基因技术的深入将这一技术趋于完善。