2003--2005项目管理试卷

GlobalGuidelineforType2DiabetesGlobalGuidelineforType2Diabetes内容概括1.背景资料2.糖尿病危害性3.诊断及监测4.治疗概论5.住院病人治疗原则GlobalGuidelineforType2Diabetes1.背景资料GlobalGuidelineforType2Diabetes•1.根据循证医学原则制定,内容参考近5年来国际上出版的指南、meta分析、及相关刊物。•2.根据不同地区、不同医疗资源制定3个等级标准。GlobalGuidelineforType2Diabetes三个等级医疗标准StandardCareMinimalCareComprehensiveCareGlobalGuidelineforType2Diabetes2.糖尿病危害性GlobalGuidelineforType2Diabetes•1.发病人数日益增长。无论是在发达国家还是在发展中国家，均明显增加。其中90%为2型糖尿病。（见下图）•2.发展中国家增长的速度超过了发达国家。（200%比45%），21世纪DM将在中国、印度等发展中国家流行。•3.DM的主要并发症已经成为病人致残和早亡的主要原因，每年全球约3000000人口因糖尿病而死亡。•4.2型糖尿病占我国糖尿病人群的90%以上，它的血管并发症使人们丧失劳动能力,预期寿命缩短8-12年。GlobalGuidelineforType2DiabetesP.Zimmetetal.BulletinoftheInternationalDiabetesFederation48:13,2003GlobalGuidelineforType2DiabetesAmuchquotedpaperbyHaffneretal,suggestedthatpeoplewithType2diabeteshaveaCVriskequivalenttonon-diabeticpeoplewithpreviousCVD。HaffnerSM,LehtoS,R鰊nemaaT,PyoralaK,LaaksoM.Mortalityfromcoronaryheartdiseaseinsubjectswithtype2diabetesandinnondiabeticsubjectswithandwithoutpriormyocardialinfarction.NEnglJMed1998;339:229-34.GlobalGuidelineforType2Diabetes糖尿病急性并发症及大血管和微血管等慢性并发症，致死、致残率高，一旦发生，难以逆转，降低病人的生活质量，缩短寿命。GlobalGuidelineforType2Diabetes3.诊断及监测GlobalGuidelineforType2Diabetes提倡早期诊断•早期诊断的意义；Type2diabeteshasalongasymptomaticpre-clinicalphasewhichfrequentlygoesundetected.Atthetimeofdiagnosis,overhalfhaveoneormorediabetescomplications.Retinopathyratesatthetimeofdiagnosisrangefrom20%to40%.OfpeoplewithType2diabetes,theproportionwhoareundiagnosedrangesfrom30%to90%.SM,MeyerLC,NeilHAW,RossIS,TurnerRC,HolmanRR.Complicationsinnewlydiagnosedtype2diabeticpatientsandtheirassociationwithdifferentclinicalandbiochemicalriskfactors.UKPDS6.DiabetesRes1990;13:1-11.HarrisMI,KleinR,WelbornTA,KnuimanMW.OnsetofNIDDMoccursatleast4-7yrbeforeclinicaldiagnosis.DiabetesCare1992;15:815-19.UKPDSGroup.UKProspectiveDiabetesStudy30:Diabeticretinopathyatdiagnosisoftype2diabetesandassociatedriskfactors.ArchOphthalmol1998;116:297-303.GlobalGuidelineforType2Diabetes早期诊断•早期诊断的方法----目前全球根据各地区约有30%-90%糖尿病漏诊率.Fordiagnosis,anoralglucosetolerancetest(OGTT)shouldbeperformedinpeoplewithafastingplasmaglucose≥5.6mmol/l(≥100mg/dl)and7.0mmol/l(126mg/dl);Wherearandomplasmaglucoselevel≥5.6mmol/l(≥100mg/dl)and11.1mmol/l(200mg/dl)isdetectedonopportunisticscreening,itshouldberepeatedfasting,oranOGTTperformed.GlobalGuidelineforType2Diabetes诊断标准:WHO-1999criteriaHealthOrganization.Definition,DiagnosisandClassificationofDiabetesMellitusanditsComplications.ReportofaWHOConsultation.Part1:DiagnosisandClassificationofDiabetesMellitus.Geneva:WHOGlobalGuidelineforType2Diabetes•诊断标准的解释:•糖尿病诊断是依据空腹、任意时间或OGTT中2小时血糖值•空腹指至少8小时内无任何热量摄入•任意时间指一日内任何时间，无论上次进餐时间及食物摄入量•OGTT是指以75克无水葡萄糖为负荷量，溶于水内口服(如用1分子结晶水葡萄糖，则为82.5克。•OGTT的方法:•早餐空腹取血(空腹8-14小时后），取血后于5分钟内服完溶于250-300ml水内的无水葡萄糖75克（如用1分子结晶水葡萄糖，则为82.5克）•试验过程中不喝任何饮料、不吸咽、不做剧烈运动，无需卧床•从口服第一口糖水时计时，于服糖后30分钟、1小时、2小时及3小时取血（用于诊断可仅取空腹及2小时血）GlobalGuidelineforType2Diabetes控制指标水平•血糖控制水平；•HbA1c6.5%•Equivalenttargetlevelsforcapillaryplasmaglucoselevelsare6.0mmol/l(110mg/dl)beforemeals,and8.0mmol/l(145mg/dl)1-2haftermeals.•血脂控制水平•Reassessatallroutineclinicalcontactstoreviewachievementoflipidtargets:•LDLcholesterol2.5mmol/l(95mg/dl),•triglyceride2.3mmol/l(200mg/dl),•HDLcholesterol1.0mmol/l(39mg/dl).•血压控制水平•Aimtomaintainbloodpressurebelow130/80mmHg•Acceptthateven140/80mmHgmaynotbeachievablewith3to5antihypertensivedrugsinsomepeople.•Reviseindividualtargetsupwardsifthereissigni.cantriskofposturalhypotensionandfalls.GlobalGuidelineforType2Diabetes每年全面检测一次GlobalGuidelineforType2Diabetes检测原则及目的•Generalprinciplesinclude:annualreviewofcontrolandcomplications;anagreedandcontinuallyupdateddiabetescareplan;andinvolvementofthemultidisciplinaryteamindeliveringthatplan,centredaroundthepersonwithdiabetes.GlobalGuidelineforType2Diabetes临床血糖监测方法•HbA1cperformedevery2to6monthsdependingonlevelandstabilityofbloodglucosecontrol,andchangeintherapy.•Site-of-carecapillaryplasmaglucosemonitoringatrandomtimesofdayisnotgenerallyrecommended.GlobalGuidelineforType2Diabetes自我血糖监测方法•Self-monitoringofbloodglucose(SMBG)shouldbeavailabletothose;•ForallnewlydiagnosedpeoplewithType2diabetes;•thoseoninsulintreatment;•toprovideinformationonhypoglycaemia;•toassessglucoseexcursionsduetomedicationsandlifestylechanges•tomonitorchangesduringintercurrentillness.•SMBGcanbeconsideredinrelationto:•outcomes(adecreaseinHbA1cwiththeultimateaimofdecreasingriskofcomplications)•safety(identifyinghypoglycaemia)•process(education,self-empowerment,changesintherapy).GlobalGuidelineforType2Diabetes对尿糖监测的评价•Urineglucosetestingischeapbuthaslimitations.Urinefreeofglucoseisanindicationthatthebloodglucoselevelisbelowtherenalthreshold,whichusuallycorrespondstoabloodglucoselevelofabout10.0mmol/l(180mg/dl).•Positiveresultsdonotdistinguishbetweenmoderatelyandgrosslyelevatedlevels,andanegativeresultdoesnotdistinguishbetweennormoglycaemiaandhypoglycaemia.GlobalGuidelineforType2Diabetes4.治疗概论GlobalGuidelineforType2Diabetes生活方式干预治疗•目的：通过调整生活方式，如饮食、运动等更好地控制血糖、血压、血脂等危险因素。•关于饮食；•专家指导下制定个体营养需求方案;•严格限制高热量、高脂食物、食盐及酒