DIABETES MELLITUS (diabetes mellitus; grech, diabetes, from diabaino to pass through; synonym: sugar mocheiznureniye, diabetes mellitus) — the disease, to-rogo is the cornerstone the absolute or relative insufficiency of insulin in an organism causing disbolism, hl. obr. carbohydrate.
- 1 History
- 2 Statistics
- 3 The etiology and a pathogeny
- 4 Pathological anatomy
- 5 Classification
- 6 A clinical picture
- 7 The diagnosis
- 8 Treatment
- 9 The forecast
- 10 Prevention
- 11 Pregnancy and disturbances of sexual function at women at a diabetes mellitus
- 12 The diabetes mellitus
D. is known to page since ancient times. The disease proceeding with allocation of a large amount of urine it is mentioned in Ebers's papyrus (about 17 century BC). In 1756 Mr. Dobson (M. of Dobson) found at this disease in urine sugar that formed the basis for the existing name of a disease. The role of a pancreas in D.'s pathogeny of page was for the first time established in 1889 by J. Mehring and O. Minkowski who caused experimental D. of page in dogs by removal of a pancreas. L. V. Sobolev in 1901 showed that production of the antidiabetic substance called afterwards insulin (see), occurs in islets of Langerhans. In 1921 F. Banting and Best (Ch. Best), having applied the methods recommended by L. V. Sobolev received native insulin. Introduction to a wedge, practice in the middle of 20 century of peroral antidiabetic drugs was an important stage in treatment of patients with a diabetes mellitus.
D. of page — extended hron, a disease. In the majority of the countries of the world occurs at 1 — 2% of the population, in the countries of Asia — is slightly more rare. Usually at active identification the patient who was not knowing about existence at it this disease is the share of each famous patient. Of page at mature and advanced age meets considerably more often than in children's and youthful. In all countries the progressing increase in incidence is noted; in GDR sick D.' number of page in 10 years (from 1960 to 1970) was tripled approximately [V. Schliack, 1974].
The wide spread occurance, growth of incidence, frequent development of vascular complications put D. of page on the level of the leading problems of medicine and demand its deep studying.
The cause of death of sick D. of page of advanced age — defeat of cardiovascular system, at persons of young age is a renal failure as a result of a diabetic glomerulosclerosis. During the period from 1965 to 1975 the lethality from a diabetic coma decreased from 47,7 to 1,2%; the complications connected with defeat of cardiovascular system considerably increased.
The etiology and a pathogeny
In D.'s development by page is of great importance hereditary predisposition. But the nature of inborn defect and the nature of inheritance at D. are definitely not established to page. There are data on autosomal and recessive, autosomal and dominant ways of inheritance; the possibility of multifactorial inheritance is allowed, at Krom predisposition to D. of page depends on a combination of several genes.
A number of the factors influencing D.'s development by page is revealed. However because of the big frequency of hereditary predisposition and impossibility of the accounting of distribution of genetic defect it is not possible to solve, these factors are primary in D.'s development by page or they only promote manifestation of hereditary predisposition.
The main page in D.'s pathogeny — the relative or absolute insulinny insufficiency which is a consequence of defeat of the insular device of a pancreas or caused by the extra pancreatic reasons, leading to disturbance of different types of exchange and patol, to changes in bodies and fabrics.
Among factors, provocative or defiant D. of page, it is necessary to point to infectious diseases, it is preferential at persons of children's and youthful age. However specific defeat of the insulinprodutsiruyushchy device at them it is not established. At some people D.'s symptoms of page appear soon after mental and physical. injuries. Quite often D.'s development by page is preceded by an overeating with consumption of a large number of products, carbohydrate-rich. D. is frequent the page arises at patients with chronic pancreatitis (see). The question of an etiological role of atherosclerosis of the arteries feeding a pancreas in D.'s development by page is not solved. Of page is observed more often at patients with an idiopathic hypertensia, than at the persons having normal the ABP.
It is established what is of great importance in D.'s emergence by the village obesity (see). By data A. M. Sitnikova, L. I. Konradi (1966), in an age group of 45 — 49 years at women a lot of weight more than for 20% of D. of page is noted by 10 times more often than at women with normal body weight.
At D. women of page can come to light for the first time during pregnancy in connection with the hormonal reorganization strengthening effect of kontrinsulyarny hormones.
In a stage of potential diabetes of disturbance of reaction of the insulyarny device to stimulation by glucose consist in weaker, than at healthy, rise in level of immunoreactive insulin in blood and come to light only at big loadings per os glucose — 200 g or intravenous, especially at long injection of glucose.
At patients with the hidden D. of page delay of rise in level of immunoreactive insulin is more expressed, than at persons with potential diabetes, and comes to light already at standard test on tolerance to glucose. While at healthy after peroral loading the peak of immunoreactive insulin is observed by glucose in 30 — 60 min., at patients with the hidden D. of page it is noted later — in 90 — 120 min.; in size it is not less, than at healthy. However increase in level of immunoreactive insulin at patients with the hidden D. of page is insufficient in relation to rise in level of sugar in blood, especially within the first hour after reception of glucose.
At patients with explicit D. of page insulyarny reaction in response to stimulation with glucose is reduced in all terms of a glucose tolerance test, and at a heavy stage of D. of page with vyso-them in figures of a hyperglycemia on an empty stomach, existence acetonemias (see) and acidosis (see) insulyarny reaction usually is absent. Also decrease in level of immunoreactive insulin on an empty stomach is observed.
Long hyperglycemia (see) inevitably leads to decrease in insulinprodutsiruyushchy ability of the insular device, and noncompensated D.'s current of page is characterized by transition of relative insulinny insufficiency to absolute.
At sick D. the page with obesity observe the same stages in development of insulinny insufficiency that at patients with a normal weight: relative and absolute. At obesity during the period preceding emergence of insulinny insufficiency resistance to insulin is noted, hyper dysinsulinism (see) on an empty stomach and after loadings glucose, a hypertrophy and a hyperplasia of beta cells of islands of a pancreas. Lipoblasts are increased in sizes and rezistentna to insulin that is defined by reduction of number of receptors to insulin. At weight reduction all these changes at persons with obesity are exposed to involution. Decrease in tolerance to glucose at increase in fatty deposits happens, it is obvious because beta cells are not capable to further increase in products of insulin for overcoming resistance to insulin. Existence of a hyper dysinsulinism and insulin resistance at persons with obesity to glucose allows to count up to disturbance of tolerance that obesity, on extreme to a measure at a part of patients, is etiol, a factor of development of D. of page. Existence of a hypertrophy and a hyperplasia of beta cells at obesity, perhaps, is the reason of slower development of absolute insulinny insufficiency at D. the page proceeding with obesity.
A number of hormonal and non-hormonal antagonists of insulin is known, but their primary role in development of insulinny insufficiency at D. is not proved to page. The antiinsulinny factors of blood serum connected with alpha and beta lipoproteids, albumine are described. The antagonist of insulin concerning muscular tissue connected with albumine — sinalbumin was studied. It is improbable that antiinsulinny factors matter in development of insulinny insufficiency since at potential D.'s stage of page it is not established an insulinrezistentnost and a hyper dysinsulinism which would have to take place with antagonism to to insulin (see).
It is known that free fat to - you interfere with effect of insulin on muscular tissue. Their level in blood is increased at D. by page. But this increase is a consequence of insulinny insufficiency since is eliminated at achievement of a normoglikemiya.
At D. the page is noted disturbance of transformations of pro-insulin into insulin; the inactivation of insulin is not accelerated in comparison with healthy faces. The hypothesis of the increased binding of insulin serum proteins did not receive convincing confirmation put forward by Antoniadis (H. N. Antoniades, 1965). There are no also indisputable data on development of autoimmune process as the reasons of formation of insulinny insufficiency.
Insulin — the anabolic hormone promoting utilization of glucose, biosynthesis of a glycogen, lipids, proteins. It suppresses a glycogenolysis, a lipolysis, a gluconeogenesis. Primary place of its action — a membrane of insulinchuvstvitelny fabrics.
At the developed insulinny insufficiency when influence of insulin decreases or drops out, effects of hormones antagonists begin to prevail even if their concentration in blood is not increased. At - the page compensated to D. the content in blood of a growth hormone, catecholamines, glucocorticoids, a glucagon increases. Increase in their secretion is reaction to intracellular insufficiency of glucose, edge takes place in insulinchuvstvitelny fabrics at D. of page. Content of these hormones in blood is also increased at hypoglycemia (see). Having arisen as compensatory reaction, increase in level of hormones antagonists in blood leads to increase of diabetic disturbances of exchange and an insulinrezistentnost.
The Antiinsulinny effect of a growth hormone is connected with increase in a lipolysis and increase in level free fat to - t in blood, development of an insulinrezistentnost and decrease in utilization of glucose by muscular tissue. Under action glucocorticoid hormones (see) the catabolism of proteins and a gluconeogenesis in a liver amplifies, the lipolysis increases, capture of glucose insulinchuvstvitelny fabrics decreases. Catecholamines (see) suppress secretion of insulin, raise a glycogenolysis in a liver and muscles, strengthen a lipolysis. Action, antagonistic in relation to insulin glucagon (see) consists in stimulation of a glycogenolysis, lipolysis, catabolism of proteins.
At insulinny insufficiency intake of glucose in cells of muscular and fatty fabrics is reduced that reduces utilization of glucose. Thereof in fatty tissue the speed of synthesis free fat to - t and triglycerides decreases. Along with it there is strengthening of processes of a lipolysis. Free fat to - you come to blood in a large number.
Synthesis of triglycerides in fatty tissue at D. of page decreases, in a liver it is not broken and even amplifies because of the increased receipt free fat to - t. The liver is capable to phosphorylate glycerin and to form the alpha glycerophosphate necessary for synthesis of triglycerides while in muscular and fatty fabrics alpha glycerophosphate is formed only as a result of utilization of glucose. The page leads increase in synthesis of triglycerides in a liver at D. to their increased receipt in blood, and also to fatty infiltration of a liver. Because of partial oxidation free fat to - the t in a liver happens increase in products of ketone bodies beta and hydroxy-butyric, acetoacetic to - t, acetone) and cholesterol that leads to their accumulation (see. Acetonemia ) also causes a toxic state — a so-called ketosis. As a result of accumulation of acids acid-base balance is broken — there is metabolic acidosis (see). This state called by ketoacidosis characterizes a decompensation of exchange disturbances at D. by page. Considerably receipt in blood milk to - you from skeletal muscles, a spleen, walls of intestines, kidneys and lungs increases (see. Lactacidemia ). At bystry development of ketoacidosis the organism loses a lot of water and salts that leads to disturbance of water and electrolytic balance (see. Water salt metabolism, pathology ; Mineral metabolism, pathology ).
At D. the page breaks also protein metabolism with decrease in synthesis of protein and increase in its disintegration in this connection formation of glucose from amino acids (a gluconeogenesis — increases see. Glycolysis ).
Increase in products of glucose by a gluconeogenesis is one of the main disturbances of exchange in a liver at insulinny insufficiency. Products of interstitial exchange of proteins, fats and carbohydrates with short carbon chains become a source of formation of glucose. As a result of decrease in utilization of glucose and increase in its products the hyperglycemia develops.
Intake of glucose in cells of a liver, a P-cell of islands of a pancreas, a crystalline lens, nervous tissue, seed bubbles, erythrocytes, a wall of an aorta happens without influence of insulin and depends on concentration of glucose in blood. But insulinny insufficiency leads to disturbances of exchange and in these bodies and fabrics. As a result of a hyperglycemia the content of glucose in cells of «non-insulin-dependent» fabrics exceeds their ability to phosphorylation and processes of its turning into sorbitol and fructose amplify. Increase in concentration of these osmotically active agents in cells is considered as a probable cause of damage of fabrics, in particular the beta cells which are not needing insulin for transmembrane transport of glucose.
At D. synthesis in a liver of glycoproteins in which carbohydrate part the important place is occupied by glucose and the glycosamine which is formed of it is not broken by page. As a result of a hyperglycemia this synthesis can even be accelerated. Significance in development of a diabetic mikroangiopatiya is attached to disturbance of their exchange.
Morfol, changes pancreas (see) reflect functional reorganization of the insular device (tsvetn. fig. 7 and 8) also define pathogenetic mechanisms D. of page. Changes in vascular system of an organism are secondary, they are caused by the disturbances of exchange connected with damage of a pancreas.
Macroscopic changes of a pancreas are not specific. Reduction of volume and weight of body, lipomatoz and cirrhosis (a so-called granular atrophy) in itself are not the proof of presence of D. of page, are not connected with progressing of a disease. The changes developing at an inflammation, injuries, disturbances of blood circulation, tumors of a pancreas can result in secondary insulinny insufficiency.
For D. of page with primary insulinny insufficiency morfol. criterion is ratio distortion between alpha and beta cells of islands which reflect morfol, and funkts, disorganization in system a glucagon — insulin, being a basis of relative or absolute insulinny insufficiency.
The ratio of alpha cells and beta cells making at healthy people from 1:3 to 1:5 can change to 1: 2 or 1:1. Change of this index can be connected with reduction of quantity of beta cells (for 7 — 10%) that especially accurately comes to light at youthful D. of page. At the same time in the remained beta cells symptoms of a hyperplasia and hyperfunction (increase in mitochondrions, an enlightenment of a matrix, swelling of an ergastoplazmatichesky reticulum, increase in amount of the cosecreted insulin) are found. At the same time in such cells signs of alteration are quite often noted. At youthful D. of page often there is an infiltration of islands macrophages and lymphocytes leading to gradual death of beta cells. Similar changes are observed in an experiment at introduction by an animal of insulin. Other form of disorganization of the insular device — increase in quantity of alpha cells at not changed quantity of beta cells. In response to it the compensatory hypertrophy of beta cells develops, edges also comes to an end with functional exhaustion. Gistokhim, researches reveal reduction of maintenance or disappearance of zinc from cytoplasm of beta cells.
Relative or absolute insufficiency of beta cells is inherent to children's, youthful and adult forms D. of page, increases in process of duration of a disease, finding direct dependence on its weight.
Accumulation of a glycogen in an epithelium of distal tubules of kidneys is characteristic of D. of page (tsvetn. fig. 5, 6 and 9); in a liver the glycogen can come to light not only in cytoplasm, but also in kernels of hepatocytes and cells of reticuloendothelial system that usually is followed by krupnokapelny fatty dystrophy of peripheral departments of segments (fatty infiltration of a liver).
At D. the page proceeding 5 — 10 years there is a generalized defeat of vessels — a diabetic angiopatiya, edges are represented by the response of a vascular bed to a complex of the endocrine, exchange and fabric disturbances inherent to a disease and is divided into two look: mikroangiopatiya and macrovascular disease.
Defeat of capillaries and venules consists in a thickening of their basal membranes, damage, proliferation of an endothelium and pericytes and adjournment in vessels of glikoproteidny substances. Mikroangiopatiya especially often develops in kidneys, a retina of an eye (fig. 1), skin (fig. 3), muscles and perineural spaces. Sometimes it arises a wedge earlier, D.'s manifestations by the village and gradually progresses. At the same time degree of manifestation of changes of a microcirculator bed is defined not so much by D.'s duration of page, how many extent of its compensation at treatment. Damage, an uneven thickening of basal membranes, Mucoid swelling of the main substance are followed by disturbance of vascular permeability. In an endothelium active comes to light Pinotsitoz (see), alteration and desquamation of cells. Reactive changes consist in proliferation of an endothelium and pericytes, accumulation of mast cells in perivascular spaces. Synthesis of substance of basal membranes an endothelium and pericytes, activation of synthesis of tropocollagen is led to irreversible changes in a type of a hyalinosis and an angiosclerosis (fig. 2).
The major wedge. - morfol, manifestations of a mikroangiopatiya at D. pages are connected first of all with severe defeats of vessels of a retina of an eye and kidneys. Defeat of vessels went. - kish. a path can bring to hron, to gastritis and development of erosion of a mucous membrane went. - kish. path. Sometimes there is heavy diarrhea, the cut is the cornerstone defeat of vessels and the nervous device of intestines. Mikroangiopatiya of a myocardium leads to difficulties of collateral circulation at vasomotor spasms and burdens the forecast at a myocardial infarction at sick D. of page. In arteries of average caliber calcification (Makenberg's sclerosis) can develop.
Arteriolosclerosis (see) is an obligatory component of generalized defeat of a vascular bed, but morphologically has no essential differences from those types of defeat of arterioles which develop at a hypertensive vasculopathy. Most often vessels of a retina of an eye and kidneys are surprised. Arterioles of a brain at sick D. of page are surprised less often whereas the arteriolosclerosis in skin and cross-striped muscles is found much more often.
Atherosclerosis (see) at D. the page meets more often, develops earlier and proceeds much heavier, than usually. For atherosclerosis at D. big extent of distribution of defeats which in combination with mikroangiopatiya lead to development is inherent to page trophic ulcers (see) can also become complicated gangrene (see). Atherosclerosis of arteries of heart at D. page is followed by increase of dismetabolichesky cardiosclerosis (see). The microscopic picture characteristic of atherosclerosis is supplemented at D. with page more expressed changes of subendothelial and muscular basal membranes, big accumulation of glycoproteins. In the centers of lipoid infiltration and an atheromatosis a large amount of phospholipids, cholesterol and mucopolysaccharides comes to light.
Despite inherent D. generalized defeat of vessels, in a wedge, a picture of a disease is defined by page this or that organ localization connected with extent of defeat of vessels.
various classifications of D. of page are given In literature. It is the most reasonable to classify D. of page taking into account absence or existence of clinical signs of a disease, and also idea of this disease as genetically caused. The Soviet endocrinologists apply the following classification: a potential diabetes mellitus (prediabetes), the hidden diabetes mellitus (according to the nomenclature of WHO — latent, symptomless, subclinical chemical) and an explicit diabetes mellitus (on WHO — clinical).
A clinical picture
Potential and hidden D. pages are the stages preceding clinically expressed disease.
The potential diabetes mellitus proceeds without wedge, manifestations. It is considered to be that such diabetes is available for all children who were born from patients with diabetes of parents. It is established that potential D. of page is found: a) persons with hereditary predisposition to D. have a page — enzygotic twins of sick D. of page; at persons whose both parents are sick with D. page; at persons, one of parents of which is sick with D. page and there are sick D. of page on other hereditary line; b) at the women who gave birth to the living or dead child weighing 4,5 kg and more, and also gave birth to the dead child with a hyperplasia of islets of Langerhans in the absence of an eritroblastoz at it. D.'s development by page approximately at 60 — 100% of people is more senior than 50 years which have both parents or enzygotic twins D. are sick with page, allows many researchers to consider that in the period of not diagnosed stage they had potential D. of page. It is unknown whether this stage begins from the moment of conception or the birth, or develops in the next years lives, but, undoubtedly, at this stage there are already disbolism. Their indirect indicators — disturbances of a course of pregnancy and fetation at women with potential diabetes, a hyperplasia of islets of Langerhans at a fruit, etc.
Hidden diabetes mellitus. Patients have no wedge, signs. Of page comes to light by means of a glucose tolerance test. In this stage of a disease a sugar content in blood on an empty stomach and within a day normal; the glucosuria is absent (if there is no decrease in a renal threshold of passability for sugar). At some patients the hidden D. of page the cortisone (Prednisolonum) - glucosic test comes to light only with the help.
At the hidden D. the page at some patients notes a skin and genital itch, a furunculosis, periodontosis. But at most of patients in this stage of a disease of the complaint are absent.
The explicit diabetes mellitus has a characteristic wedge, symptoms: polydipsia (see), polyuria (see), weight loss (or obesity), decrease in working capacity, hyperglycemia (see) on an empty stomach and during the day and glycosuria (see). Identification acetonemias (see), acidosis (see) and acetonurias (see) points to more expressed diabetic disturbances of exchange. Quite often the disease develops slowly and gradually, in other cases of D. of page begins violently and quickly progresses.
Distinguish three severity.
I degree (easy current) — absence of ketoacidosis, level of sugar in blood does not exceed on an empty stomach 140 mg of % (during the definition of true glucose). Compensation (preservation of a normoglikemiya within a day and an aglyukozuriya, preservation of working ability of the patient) is reached only by a diet, without drug treatment.
II degree (moderately severe current) — the glycemia on an empty stomach does not exceed 220 mg of %, and compensation is reached by purpose of drugs of sulfanylurea or insulin.
III degree (heavy current) — the glycemia is on an empty stomach higher than 220 mg of %, there is a big tendency to development of ketoacidosis, an insulinrezistentnost. Often labile current. Quite often the retinopathy and a glomerulosclerosis develops. Such patients need a dietotherapy and administration of insulin higher than 60, and sometimes and it is higher than 120 PIECES in day for achievement of compensation.
Distinguish two types D. of page — youthful and adult. Youthful D. of page usually comes to light at the age of 15 — 20 years, is more often characterized by the acute beginning and bystry progressing, is frequent — a labile current, in the adult period of life — development of a retinopathy and a glomerulosclerosis. The hypodermic fatty tissue at patients with youthful type is often developed insufficiently, body weight is normal. The adult type D. of page comes to light at mature or advanced age, is often combined with obesity, well compensated by the antihyperglycemic means applied orally in combination with a diet; proceeds is more good-quality, ketoacidosis develops seldom. However it is often difficult to differentiate these two types — D. of page and at advanced age can proceed on youthful type, and at young men — on adult type.
Explicit D.'s symptoms of page at most of patients develop gradually. Patients do not notice them in the beginning and see a doctor only in several weeks and even months after emergence of the first symptoms of a disease.
Characteristic symptoms of explicit D. of page — thirst, dryness in a mouth, a lose of weight, weakness and a polyuria. The amount of urine can make per day 2 — 6 l and more. Both increase in appetite, and its decrease is noted. Thirst is connected with dehydration of an organism, oppression of function of sialadens, dryness of mucous membranes of a mouth and throat.
At dekompensirovanny D. the page at patients notes strengthening of thirst, a polyuria, dehydration of skin, bad healing of wounds. Patients are inclined to pustulous and fungus diseases of skin. Furuncles and an anthrax constitute danger because at purulent processes the need for insulin increases and thereof development diabetic is possible coma (see).
The lipoid necrobiosis belongs to damages of skin at D. of page. It is shown in the form of the educations which are slightly towering over skin not disappearing during the pressing moderately erythematic, with a scaly peeling in the beginning. The hl is surprised. obr. skin of shins (see. Necrobiosis lipoid ).
As a result of disturbance of lipidic exchange the xanthomas representing papules of yellowish color which arise usually on skin of forearms, in elbows and knees (see can develop. Xanthoma ). Are often observed ulitis (see), periodontosis (see).
At patients with severe forms the rubeosis — a dermahemia in the field of malars, superciliary arches, a chin is observed that it is connected with expansion of skin capillaries and arterioles.
At the page is long dekompensirovanny D. increase in processes of disintegration and decrease in synthesis of protein lead to atrophic changes in muscles. Reduction of their weight, flabbiness at a palpation is observed, muscular weakness and increased fatigue. The muscular atrophy can be connected with a diabetic polyneuropathy, disturbances of blood circulation. At some patients develops diabetic amyotrophy (see. Atrophy muscular ) — asymmetric damage of muscles of a pelvic girdle, hips, is more rare than a shoulder girdle. At the same time thinning of separate muscle fibers with a simultaneous thickening of a sarcolemma is observed. Diabetic amyotrophy is connected with changes of peripheral motor-neuron.
At sick D. of page the pulmonary tuberculosis often joins. In the period of a decompensation, especially at a diabetic coma, there is an increased bent to development of focal pneumonia.
Defeat of cardiovascular system at D. by the village is characterized by the progressing development of atherosclerosis of large arteries and specific changes of small vessels — a mikroangiopatiya. Clinical displays of atherosclerosis at sick D. to page are similar to displays of atherosclerosis at the patients who are not suffering from D. page. Features consist only that at sick D. of page atherosclerosis develops, as a rule, at younger age, quickly progresses, equally often strikes men and women. Especially often there is a disturbance of blood circulation of the lower extremities.
One of the first symptoms of atherosclerosis of vessels of the lower extremities is the alternating lameness.
During the progressing of process gastrocnemius muscle pains develop, they become resistant, paresthesias, a cold snap and blanching of feet develop. Further crimson and cyanochroic coloring of foot, most often in a thumb and a heel develops. The pulsation on a. dorsalis pedis, a. tibialis post, and, as a rule, is already not defined on a. poplitea on early a wedge, stages of disturbance of blood circulation, but at some patients in the absence of pulse on these arteries trophic disturbances do not arise owing to development of collateral circulation. The heaviest display of atherosclerosis of arteries of the lower extremities — dry or wet gangrene (see).
Decrease in contents or absence salt to - you in a gastric juice is rather often observed. The peptic ulcer meets seldom. At the elderly patients who especially have obesity inflammatory processes in bilious ways and in a gall bladder are quite often observed.
Diarrhea can be connected with an akhiliya, the accompanying gastroenterocolitis, defective food, with consumption of a large number of vegetables, fruit, fats, and also with existence of a diabetic polyneuropathy. At dekompensirovanny D. of page quite often there is an increase in a liver caused by its fatty infiltration. Functional trials of a liver at the same time are usually not broken.
The heavy current of D. of page is characterized by development and progressing of a diabetic glomerulosclerosis (see. Glomerulosclerosis diabetic ); its most precursory symptom is small proteinuria (see), able to remain the only symptom for a number of years. Further the picture of insufficiency of kidneys with hypostases, transition develops in uraemia (see). Inflammatory processes in urinary tract are frequent acute and hron. Along with a usual current of a pyelitis the erased and its asymptomatic forms are observed. The medullary necrosis proceeding with a picture of a serious septic condition, a hamaturia, severe pains like renal colic, the accruing azotemia belongs to more rare damages of kidneys at D. of page.
The most frequent and severe damage of eyes is diabetic retinopathy (see), edges it is clinically shown in the progressing decrease in sight with development of a total blindness. Besides, tranzitorny change of a refraction, weakness of accommodation, a depigmentation of an iris of the eye can be observed. More bystry maturing senile is noted cataracts (see). At young age the metabolic cataract can develop, at a cut the phacoscotasmus beginning in subkapsulyarny area has an appearance of snow flakes. At persons with D. the page develops more often glaucoma (see).
At sick D. the page in the period of a decompensation observes passing increase in function of a number of hemadens (increase in secretion of a growth hormone, catecholamines, glucocorticoids) with the corresponding laboratory symptomatology.
Approximately at 10% of patients with youthful type D. of the village receiving treatment by insulin the labile course of a disease is observed. At these patients the decompensation of disturbances of exchange even is periodically noted at strict observance of a diet, there are fluctuations of a glycemia with bystry transitions from a hypoglycemia to a hyperglycemia. It is more often observed at patients with a normal weight, is long ill, from the beginning of a disease at children's and young age. Consider that the complete dependence of patients from the entered insulin is the cornerstone of lability, concentration to-rogo in blood changes slowly and does not correspond to changes of a glycemia (an insulin-dependent form).
Insufficiently adequate treatment, physical and mental overstrain, infectious diseases, purulent inflammation can quickly worsen D.'s current of page, lead to a decompensation and a prekomatozny state. There is a sharp weakness, strong thirst, a polyuria, weight loss; skin is dry, flabby, visible mucous membranes dry, a pungent smell of acetone from a mouth. The speech which is slowed down, muffled. Patients go hardly, are disabled; consciousness is kept. The sugar content in blood on an empty stomach usually exceeds 300 mg of %. Such state in a wedge, practice is called also diabetic ketoacidosis. If urgent medical measures are not taken, diabetic develops coma (see). At labile D. of page also the hypoglycemic coma can develop (see. Hypoglycemia ).
At some patients the insulinrezistentnost is noted, under a cut usually understand the need for insulin exceeding 120 PIECES a day for achievement of compensation. The Insulinrezistentnost is observed at patients in a condition of diabetic ketoacidosis and a coma.
The reasons of an insulinrezistentnost at most of patients are not clear. It is noted at obesity. At a part of patients the insulinrezistentnost can be connected with a high antiserum capacity to insulin in blood.
Defeats of a nervous system are a component a wedge, displays of diabetes. At the same time they can be observed in an initial stage (hidden) of a disease and in a nek-swarm to a measure to shade other early symptoms of D. of page.
From them the neurotic syndrome and a diabetic polyneuropathy which occur approximately at a half of patients, especially at elderly people are most often observed, it is long the page suffering from D. The clinic of a neurotic syndrome (a headache, a sleep disorder, fatigue, irritability) as well as a syndrome of a diabetic polyneuropathy (extremity pain, disorder of skin sensitivity, etc.), is not strictly specific. At a diabetic neurasthenia asthenic symptoms — slackness, weakness, the lowered mood, indifference to surrounding are slightly more often observed. At the same time dominance of the phenomena of irritation or block depends to a large extent and on premorbidal features of the identity of the patient.
Numbness of extremities, paresthesias, the polyneuritis which is characterized by pains are observed, and at a severe form — decrease and disappearance of tendon jerks, there can occur atrophic changes in muscles. Trophic frustration are characteristic of D. of page (dryness and a peeling of skin on feet and shins, fragility of nails, a hypotrichosis). Motive disturbances in extremities are noted not often, tendon jerks decrease or drop out eventually; paresis of separate nerves, napr, taking away, oculomotor, front, femoral is observed.
The syndrome of acute encephalopathy can develop at disturbance of treatment by insulin. It is shown by a sharp headache, concern, the general weakness, nausea, vomiting, a soporous state, sometimes focal symptoms (paresis, aphasia, a gemigipesteziya). The muscle tone is lowered, pupils narrow. Level of sugar in blood rather low, and in cerebrospinal liquid — is raised and almost equal to the level of sugar in blood.
The syndrome hron, encephalopathies develops usually at patients with frequent hyper glycemic and hypoglycemic states and koma in the anamnesis. Gradually memory, attention, working capacity, in nevrol decrease, the status there are moderately expressed pseudobulbar frustration — tearfulness, cough during food, the speech with a nasal shade, hypersalivation, increase in reflexes of oral automatism and a muscle tone on plastic type, patol, reflexes. There are also some features of a course of disturbances of cerebral circulation at D. of page: netrombotichesky ischemic prevail strokes (see), hemorrhages are rare, frequent long soporous comas. Sometimes circulatory disturbances are presented by a peculiar alternating syndrome: within several weeks on one party partial paresis of third cranial nerves, on opposite — small pyramidal and sensitive disturbances develops. At a syndrome myelipathies (see) — the aching pains and slight paresis of the lower extremities, muscular atrophies. Occasionally there are cases to preferential involvement of back columns (pseudotabes diabetica).
Mental disorders can take place; their clinical picture is very various. Various asthenic states which in mild cases are shown by an acrimony, tearfulness, persuasive fears, sleeplessness, and in heavier — the general adynamia, drowsiness, apathy, an exhaustion of attention are most frequent. Decrease in working capacity of various degree is continuous.
Affective disturbances are more often observed in the form of superficial alarming depressions, sometimes with the ideas of self-accusation. Less often the condition of the increased mood meets a shade of fussiness. Psychoses at D. of page happen seldom. There can be a condition of acute psychomotor excitement against the background of the changed consciousness. The motive concern with visual and auditory hallucinations can reach considerable intensity. The condition of excitement can accept wavy, discontinuous character of a current. At especially severe forms of D. of page acute psychoses in the form of an amentia or amental and delirious stupefaction are possible.
At D.'s combination of page to an idiopathic hypertensia or cerebral atherosclerosis there are symptoms of weak-mindedness: decrease in criticism, memory against the background of complacent mood.
Disturbances of sexual function at men, sick D. of page, at the age of 25 — 55 years are observed approximately in 25% of cases. Sometimes it happens the first symptom of D. of page. Distinguish acute, or temporary, impotence and chronic. Temporary impotence arises owing to sharp disturbances of metabolism at an aggravation of a current of D. of page and is shown by weakening of sexual desire. The libido is recovered at effective antidiabetic treatment. Hron, impotence is characterized by the progressing weakening of erections, is more rare — a premature ejaculation, decrease in a libido and an orgasm. This form of impotence does not depend on D.'s duration of page, level of a hyperglycemia and arises usually as a result of interaction of metabolic, innervatsionny, vascular and hormonal disorders. The role of metabolic disturbances is confirmed by emergence of a temporary form of impotence, very frequent disturbance of sexual functions at the patients who transferred repeated diabetic and especially hypoglycemic comas. The hypoglycemia influences the spinal sexual centers that is characterized by disappearance of spontaneous erections, and later weakening of adequate erections, frustration of an ejaculation. Damages of the peripheral autonomic and somatic nerves innervating generative organs often have character of the mixed polyneuritis. At some patients sensitivity of skin of a balanus is reduced, it is reduced or there is no bulbokavernozny reflex, various signs of visceral neuropathies among which the dysfunctions of a bladder established by a tsistografiya are most natural are found. Natural communication between expressiveness of nefroangiopatiya, retinopathies, decrease in permeability of capillaries of skin, thermolability of vessels of extremities and frequency of impotence is noted. In the presence of atherosclerosis there can be an obliteration of sexual arteries, bifurcations of an aorta. In the latter case impotence is combined with the alternating lameness (Lerish's syndrome). From hormonal disturbances insufficiency of androgenic function of testicles sometimes is found, but concentration of testosterone in plasma is more often and the response to stimulation by a gonadotrophin at sick D. pages do not change. Decrease in maintenance of gonadotrophins is more natural that speaks morfol, changes in system a hypothalamus — a hypophysis.
To lead the complications able to a lethal outcome — the severe defeat of cardiovascular system (observed at youthful type D. of page), a glomerulosclerosis and the diabetic coma which is characterized by increase in a sugar content in blood (more than 300 mg of %), increase in maintenance of ketone bodies in blood (it is higher than 25 mg of %) and acetonuria; it is followed by development of noncompensated acidosis, increase psikhonevrol, symptoms, a loss of consciousness — see. Coma .
D.'s Diagnosis of page establish on the basis a wedge, symptoms and laboratory indicators: thirst, a polyuria, weight loss, a hyperglycemia on an empty stomach or during the day and a glycosuria taking into account the anamnesis (existence in sick D.' family of page or disturbances during pregnancy — the birth of large fruits more than 4,5 kg, still births, toxicosis, a hydramnion). Sometimes D. page is diagnosed by the oculist, the urologist, the gynecologist and other specialists.
At detection of a glycosuria it is necessary to be convinced that it is caused by a hyperglycemia. Usually the glycosuria appears at a sugar content in blood within 150 — 160 mg of %. The glycemia on an empty stomach at healthy people does not exceed 100 mg of %, and its fluctuations within a day are in limits of 70 — 140 mg of % by a glyukozooksidazny method. By Hagedorn's method — Janszen the normal sugar content in blood on an empty stomach does not exceed 120 mg of %, and its fluctuations during the day make 80 — 160 mg of %. If the sugar content in blood on an empty stomach and during the day slightly exceeds normal amounts, then repeated researches and carrying out a glucose tolerance test are necessary for confirmation of the diagnosis.
The most widespread is the glucose tolerance test with single administration of per os glucose. Within three days before capture of test investigated shall be on the diet containing 250 — 300 g of carbohydrates. Within 15 min. prior to a research and throughout all glucose tolerance test it shall be in a quiet situation, in a comfortable position sitting or lying. After capture of blood to on an empty stomach investigated allow to drink the glucose dissolved in 250 ml of water then take blood every 30 min. within 21 2—3 hour. Standard loading are 50 g of glucose (WHO recommendation).
Cortisone (Prednisolonum) - glucosic test is carried out the same as usual, but in 8,5 and 2 hours prior to it investigated accepts a cortisone on 50 mg or Prednisolonum on 10 mg. The patient weighing more than 72,5 kg Conn and Fayans (J. Conn, S. Fajans, 1961) recommend to appoint a cortisone in a dose of 62,5 mg. Respectively the dose of Prednisolonum shall be increased to 12,5 mg.
The criteria of a normal and diabetic glucose tolerance test accepted in the USSR are close to Conn and Fayans's criteria. The glucose tolerance test is considered diabetic if the level of sugar in the blood taken from a finger on an empty stomach, more than 110 mg of % in 1 hour after reception of glucose — more than 180 mg of %, in 2 hours — more than 130 mg of % (during the use of a glyukozooksidazny method and method of Shomodyi — Nelson).
The cortisone (Prednisolonum) - glucosic test is considered diabetic if the hyper glycemic level of sugar in blood on an empty stomach more than 110 mg of %, in 1 hour after reception of glucose — more than 200 mg of %, in 2 hours — more than 150 mg of %. Existence of a glycemia in 2 hours after reception of glucose more than 180 mg of % is especially convincing.
During the definition of sugar in blood by Hagedorn's method — Janszen all indicators on 20 mg of % are higher. If sugar in blood reaches hyper glycemic level only in 1 or 2 hours after reception of glucose, then the glucose tolerance test is regarded as doubtful concerning D. by page (see. Carbohydrates, methods of definition ).
the Philosophy of treatment of D. of page is normalization of the broken metabolism. This situation in the USSR was put forward by V. G. Baranov in 1926 and developed in a number of the subsequent works. The main indicators of compensation of disturbances of exchange are: normalization of level of sugar in blood within a day and elimination of a glycosuria.
Treatment is directed to compensation of the page of a metabolism broken at D. and recovery of working capacity, and also the prevention vascular, Ophthalmolum., renal, nevrol, and other frustration.
Treatment of patients with the hidden D. of page is carried out by a diet; at obesity — a diet in combination with guanyl guanidines. Treatment only a diet can be applied by page, also sick with an easy form of explicit D.
The patient with normal body weight in an initiation of treatment appoints a diet, protein-rich, with the normal content of fats and restriction of carbohydrates (tab. 1).
Table 1. Approximate initial structure of a diet for patients with a diabetes mellitus with a normal weight
- The weight of crude products is specified.
This diet has the caloric content of 2260 kcal. It includes 116 g of proteins, 136 g of fats, 130 g of carbohydrates.
Replacement of one products with others can be made taking into account the caloric value of food and content of carbohydrates in it. By amount of carbohydrates of 25 g of black bread 70 g of potatoes or 15 g of grain are approximately equivalent. But from white flour, the fast-soaked-up carbohydrates, and replacement of black bread with them contain such products as rice, semolina, products it is undesirable. It can be made in the presence of associated diseases went. - kish. path. Sugar is excluded completely. Use of sorbite, xylitol in number of no more than 30 g a day is recommended. In case of deviations from an approximate diet it is impossible to allow reduction in food of proteins since it can cause negative nitrogenous balance and lead to disturbance of health and working capacity. At purpose of a diet it is necessary to take the nature of work, age, sex, weight, growth and other factors into account.
Only a diet it is necessary to refuse treatment if during the first 5 — 7 days there is no decrease in level of sugar in blood and sugar contents in urine and if for 10 days of treatment normalization of a glycemia and disappearance of sugar in urine is not reached. At the datum level of sugar in blood on an empty stomach which is strongly keeping during 2 — 3 weeks it is possible to pass to training expansion of a diet — add every 5 days 25 g of black bread (either 70 g of potatoes, or 15 g of grain). Before each new increase of products, carbohydrate-rich, it is necessary to check daily urine for sugar and to define a sugar content in blood on an empty stomach. Usually it is required to make 4 — 6 such increases in a diet. Expansion of a diet is made under control of body weight — it is necessary to achieve its stabilization at the level corresponding normal to growth, gender and age (see. Body weight ).
Sick D. of page with obesity shall have a low-calorie diet, with restriction of fats and carbohydrates. Oil quantity decreases to 5 g a day, black bread — less than 100 g a day.
Success of treatment in many respects depends on whether it is possible to lose weight. In view of the fact that sick D.' diet of page with obesity contains few liposoluble vitamins, it is necessary to appoint vitamins A and D in the quantities providing daily requirement. It is important that food was eaten at least 4 times a day at regular intervals. Liquid is not limited if there are no indications to its restriction.
If body weight is lost, then in 1 month it is possible to add 50 g of black bread and 5 g of oil and at the continuing weight reduction to make two more such increases at an interval of 1 month. After that the structure of a diet should be kept before receiving desirable weight reduction. Further increase in a diet of products, carbohydrate-rich and fats, is made under control of weight of the patient and blood tests and urine on sugar.
In the absence of indications to an insulin therapy at sick D. easy and moderate severity usually treatment by a diet is combined by page using orally antidiabetic means — sugar-lowering drugs of sulfanylurea (see. Sulfanamide drugs ) and guanyl guanidines (see).
Sugar-lowering drugs of sulfanylurea stimulate beta cells, increase secretion of insulin and exponentiate its action. They are inefficient at patients with a severe form of D. of page at absolute insulinny insufficiency. These drugs possible to compensate disturbances of exchange preferential at sick D. to the pages revealed aged 35 years are more senior. At treatment by drugs of sulfanylurea normalization of a glycemia is reached within the first week, but at some patients — in 2 — 3 weeks.
Drugs lasting action up to 12 hours — Tolbutamidum (Butamidum), Carbutamidum (bukarban), a cycle amide — are applied 2 times a day (usually in 7 — 8 and 17 — 18 hours, in 1 hour prior to food). In the beginning drugs appoint in a dose 1 g 2 times a day, then the dose can be reduced to 1 g in the morning and 0,5 g in the evening, and at preservation of normal indicators of sugar in blood — to 0,5 g in the morning and 0,5 g in the evening. If there are no hypoglycemic states, then this dose remains within a year and more.
Drugs with duration of antihyperglycemic action about one days — Chlorproramidum, hlotsiklamid — apply once a day in the morning. They can be appointed also in two steps, but the main part of a daily dose shall be accepted in the morning. Effective medical doses of Chlorproramidum, a hlotsiklamid make 0,25 — 0,5 g a day. Chlorproramidum possesses the strongest antihyperglycemic action. Tolbutamidum works more weakly, but also its toxicity is less.
At treatment hypoglycemic states which usually do not happen heavy arise sugar-lowering drugs of sulfanylurea sometimes. All sugar-lowering drugs of sulfanylurea can cause skin and allergic and dispeptic disturbances (rash, a skin itch, a loss of appetite, nausea, vomiting). Occasionally they have toxic effect on marrow, a liver, kidneys. At diseases of marrow, parenchymatous damage of a liver and kidneys treatment by these drugs contraindicated. They are contraindicated also at pregnancy (get through a placenta!), at inflammatory processes and existence of concrements in urinary tract. Their use is not shown at severe forms of D. of page with a decompensation and exhaustion.
Treatment by sugar-lowering drugs of sulfanylurea should be carried out at monthly control of composition of peripheral blood and researches of urine on protein, urobilin and uniform elements. If drugs do not eliminate a hyperglycemia and a glycosuria), then their combined use with guanyl guanidines can be tried. At inefficiency it is necessary to pass to an insulin therapy.
Development of nonsensitivity to sugar-lowering drugs of sulfanylurea is result, as a rule, of D.'s progressing by the village.
Treatment by insulin is shown to sick D. by page with existence of an acetonemia, acidosis, acetonuria, decline of food, with associated diseases, napr, pyelonephritis, pneumonia, an anthrax, etc., in the absence of sufficient effect of treatment by a diet and peroral antidiabetic drugs or at contraindications to use of these drugs. If it is possible to lower doses of insulin to 2 — 8 PIECES a day at preservation of compensation of D. of page, transition to peroral drugs is possible.
Adult patients in the presence of a glycemia have on an empty stomach 250 mg of % and it is reasonable to begin treatment with insulin above at once that does not exclude a possibility of transition in the subsequent to drugs of sulfanylurea.
The attempt of transition to treatment by drugs of sulfanylurea at adult patients can be made at a daily dose of insulin to 20 PIECES, and in the presence of obesity and at higher dose. After purpose of these drugs insulin is not cancelled at once, and gradually reduce its dose under control of blood tests and urine by a sugar content.
There are drugs of insulin short, the average duration and long action. At treatment drugs of the prolonged action shall be used generally. Insulin of short action is applied only according to special indications — at the expressed ketoacidosis, a coma, immediate surgeries and some other states. Insulin is entered subcutaneously, at a diabetic coma — as well intravenously.
The diet at treatment by insulin on structure shall be full. Approximate contents about dukt, carbohydrate-rich: 250 — 400 g of black bread, 50 — 60 g of grain, except rice and a manna, 200 — 300 g of potatoes. Sugar is excluded. At treatment by sick D.' insulin of page with obesity the caloric content of a diet shall be reduced due to restriction of carbohydrates and fats the same as at treatment of these patients with one diet.
At most of patients the sugar-lowering effect of water solution of crystal insulin at hypodermic introduction is shown in 15 — 20 min., reaches a maximum in 2 hours, duration of action no more 6th hour. Longer action is sometimes noted. Products, carbohydrate-rich, appoint in 1 and 3,5 hours after its introduction.
The best modern drugs of insulin of long action are the suspension insulin-protamin (SIP) and drugs of group of the insulin-zinc-suspension (IZS). Action the VULTURE reaches a maximum in 8 — 12 hours and 18 — 30 hour proceed. The vulture is close on action to foreign drugs — to neutral protamin of Hagedorn (NPH insulin). If action the VULTURE is developed a little in a slowed-up way and there is a hyperglycemia during the first hours after his introduction, then it is possible to add to it in one syringe simple insulin. If its action does not last for days, pass to treatment of ITsS, edges are represented by mix of two drugs — ITsS of amorphous (ITsS-A) and ITsS of crystal (ITsS-K) in the ratio 3:7. It is similar to foreign Lente insulin.
ITsS-A: action begins in 1 — 1,5 hour, continues 10 — 12 hours, the maximum effect is observed in 5 — 8 hours of ITsS-K: action begins in 6 — 8 hours, reaches a maximum in 16 — 20 hours, 30 — 36 hour proceed.
The Protamin-tsink-insulin (PTI) — the drug containing more than protamin, than previous. Its effect begins in 2 — 4 hours, in 6 — 12 hours, duration of action as much as possible works 16 — 20 hour. Quite often it is required to add simple insulin to it (but in other syringe!). This drug is used less often.
The prolonged drugs of insulin enter once a day, in the morning. Products, carbohydrate-rich, at their use are distributed evenly during the day — each 4 hours and it is obligatory before going to bed. Doses of insulin select under control of researches of sugar in urine in 4 portions (the first portion — after administration of insulin to 17 hours, the second portion — from 17 to 23 hours, the third — from 23 to 7 hours of morning, the fourth — from 7 to 8 hours) if insulin is entered into 8 hours, however also other options are possible. More exact selection of doses of insulin is made under control of day fluctuations of sugar in blood.
Drugs of insulin of average duration of action — ITsS-A, globulin-insulin — apply at D. moderately severe page once a day in the morning, at more severe forms of a disease 2 times a day can be applied.
Complications of an insulin therapy — a hypoglycemia and allergic reactions to administration of insulin.
Of page is not a contraindication for surgical interventions, but before planned operations it is necessary to achieve compensation of disturbances of exchange. If earlier sulfanylurea used drugs, then at small interventions does not cancel them, and in case of D.'s decompensation of page adds insulin to them.
Big surgical interventions at all sick D. the page should be carried out with administration of insulin. If the patient received insulin of long action, then in the morning before operation enter a half of a usual dose and kapelno intravenously appoint 5% solution of glucose. Further under control of repeated researches of urine on sugar and acetone and blood on sugar resolve an issue of additional administration of simple insulin during the day and amount of the poured glucose. At immediate surgeries repeated additional injections of simple insulin during the day can be also required. The diet is appointed according to recommendations of the surgeon; allow reception of easily acquired carbohydrates. Use of guanyl guanidines during surgical interventions and in the postoperative period is contraindicated.
Treatment of patients at ketoacidosis and in a prekomatozny state is carried out by insulin which is entered fractionally 3 — 4 times a day and more; at the same time constant control behind indicators of a sugar content in blood and an acetonuria is necessary. At the same time enter isotonic solution of sodium chloride into a vein, give alkaline drink. The diet in these cases can be expanded at the expense of carbohydrates, fats are limited.
At nevrol, frustration treatment shall be directed first of all to compensation of carbohydrate metabolism. At focal defeats of c. N of page, as a rule, appoint insulin; at the same time the sugar content in blood shall be not lower than 140 — 160 mg of % (by Hagedorn's method — Janszen). Use of oxygen, drugs of anabolic hormones, cocarboxylase, glutaminic to - you, a routine, vitamins of group B is shown. At a diabetic polyneuropathy the physical therapy is shown (massage, ultrasound, an electrophoresis with novocaine). At hron, encephalopathy and disturbance of cerebral circulation appoint an Euphyllinum, depot Padutinum, Aminalonum, drugs of Clofibratum.
Treatment at mental disorders: at asthenic and depressive syndromes apply tranquilizers, at acute psychotic states — aminazine.
Comprehensive examination (nevrol., biochemical, Urals., rentgenol.) allows to perform pathogenetic reasonable therapy of disturbances of sexual function at men at D. of page. Careful correction of disturbances of carbohydrate metabolism, vitamin therapy is necessary (B1? B12) and physical therapy. Low level of testosterone of plasma is compensated by purpose of androgens. At datum level of testosterone the chorionic gonadotrophin is shown. Drug is recommended also in cases of the infertility caused at D. by page a hypospermatogenesis, disturbance of exchange of fructose.
Sanatorium treatment of sick D. of page is included into a complex of therapeutic actions. It is reasonable to send the patients receiving insulin to local sanatoria. In the USSR sick D. pages accept on treatment sanatoria in Yessentuki, Borjomi, Pyatigorsk, Truskavets, etc. The direction of patients in sanatorium in a condition of a decompensation is contraindicated, especially at ketoacidosis.
Specially picked up physical. exercises, involving a musculoskeletal system and muscular system in work, increase oxidizing processes in an organism, promote assimilation and consumption of glucose muscles, strengthen effect of insulin. At a combination of an insulin therapy to physical. exercises at sick D. by the village observe the expressed decrease in sugar in blood. Physical. exercises, besides, well influence a functional condition of c. the N of page and cardiovascular system, increase body resistance, detain development of obesity and atherosclerosis.
At occupations to lay down. physical culture physical. loading shall correspond to a condition of cardiovascular system of the patient and his subjective reaction (fatigue, decrease in working capacity, etc.)*. At a severe form of D. of page and exhaustion to lay down. the physical culture is contraindicated.
Duration of occupation to lay down. gymnastics usually makes 25 — 30 min. Physical. loading shall accrue gradually due to increase in number of exercises and their repeatability, change of initial positions (from a prone position to a sitting position and standing). In a complex physical. exercises surely it is necessary to include several breathing exercises.
At a big exercise stress the hypoglycemic state can develop. At emergence of an asthma it is necessary to interrupt exercises and 30 — * 60 sec. slowly to resemble about the room.
Physical. exercises, especially at beginners, can sometimes cause a feeling of fatigue, muscular pains, strengthening of perspiration, pain in heart. In such cases it is necessary to lower loading — each movement to repeat a smaller number of times and to do breaks for rest. It is better to carry out exercises in the morning and later 1 — 1,5 hour after an afternoon snack.
Are useful to the persons occupied with intellectual and slow-moving work morning a gigabyte. gymnastics, circulation on foot for work and after it, sports pauses in operating time, moderate physical. work in a garden, on the house, on a kitchen garden, pedestrian walks.
In the conditions of sanatorium treatment walks on the flat area, walking tours, playings badminton, towns, volleyball, but are shown no more than 30 min. Directly later physical. loading for the purpose of increase in oxidizing processes if there are no contraindications, it is possible to use rubdown, a shower, short-term bathing. Massage and self-massage is allowed.
Moderate physical. work renders to lay down. action — prevents accumulation of excess fat, maintains normal vitality and increases the general body resistance.
For life the forecast at D. of page favorable, especially at early detection of a disease. However a diet and, depending on a form of a disease, the appointed treatment of the patient shall observe all life. Timely correct treatment, observance of the appointed mode lead to compensation of disturbances of exchange even at a severe form of a disease, working capacity is recovered. At certain patients permanent remission with normalization of tolerance to glucose is reached. In the started cases, in the absence of adequate therapy, at various extreme states there is a decompensation of process, the diabetic coma, severe damage of kidneys can develop; at youthful type D. of page — a hypoglycemic coma, severe defeat of cardiovascular system. In these cases the forecast for life adverse.
Major factors in D.'s prevention by the village are a balanced diet, regular physical. exercises, correct organization of work and rest. Special attention shall be paid on identification of the persons which are «in a zone of risk»: the having relatives, sick D. of the pages having obesity, atherosclerosis, a hypertension, the women who gave birth to the children weighing more than 4,5 kg who had still births, persons with the «doubtful» tolerance test to glucose. The persons which are «in a zone of risk» need to carry out the tolerance test to glucose once a year or i of times in 2 years.
Pregnancy and disturbances of sexual function at women at a diabetes mellitus
Before use of an insulin therapy were often observed the atrophic phenomena in a reproductive system in this connection, by data A. M. Ginevich, ability to conceive was kept only by 5 of 100 sick D. of page of women. On condition of a rational insulino-and a dietotherapy the vast majority of women, sick D. the page, keeps genital function. The exception, according to G. v. Knorre, is made by the pages hurting children's and youthful D. at which duration of the genital period is considerably reduced.
The hormonal reorganization inherent to pregnancy strengthening effect of kontrinsulyarny hormones promotes transition is hidden the proceeding diabetes mellitus in explicit.
D.'s current of page in the first half of pregnancy significantly does not change or observed decrease in need for insulin. Since 24 — 28th week at most of pregnant women tendency to ketoacidosis increases, the need for insulin considerably increases. By the end of pregnancy at a part of patients depreciation in sugar in blood and urine is observed.
D.'s current of page at childbirth is caused by influence of such factors as an emotional stress, considerable muscular work, disturbance of a diet, exhaustion. Therefore along with development of acidosis and a hyperglycemia in women in labor also falling of level of sugar in blood can be observed.
After the delivery, especially after Cesarean section, the need for insulin sharply falls, then gradually rises to initial level before pregnancy. All this demands careful control of pregnant women and performing adequate insulin therapy.
D.'s influence by the village on the course of pregnancy is shown by increase in frequency of late toxicoses of pregnant women (see), hydramnions (see), pyelonephritis (see) which will difficult respond to treatment also considerably worsen the forecast of pregnancy.
At the time of delivery at D, the page is often observed untimely izlity amniotic waters, weakness of patrimonial forces, asphyxia of a fruit, the complicated extraction of a shoulder girdle. The large sizes of children quite often are the reason of the increased traumatism in labor. Maternal mortality in labor not high; from complications of a puerperal period the hypogalactia most often meets (see. Lactation ).
In the absence of systematic control of pregnant women and D.'s treatment by the village perinatal mortality of children high. According to H. Daweke's observations perinatal mortality at a heavy diabetic nephropathy makes up to 40%, at pyelonephritis at pregnant women — to 32,5%, and at a hydramnion along with high perinatal mortality malformations are often observed.
At the children who are given rise from mothers, sick D. by page the deviation in development is quite often observed; children differ in the large size and can have the characteristic appearance reminding patients with Itsenko's syndrome — Cushing, the expressed immaturity of functions. At some children disturbances of proteinaceous, carbohydrate and fatty exchanges are established, the bilirubinemia, hron, a hypoxia is found; atelectases of lungs, atelectatic pneumonia come to light; all this can be combined with symptoms of an intracranial injury. These children, as a rule, of a gipotonichna, with reduced reflexes, quickly lose flesh and slowly take him. They considerably lag behind by adaptation opportunities healthy children of the same age; disturbance of normal dynamics of phases of a dream testifies to functional immaturity of a nervous system.
Frequency of malformations of the children who were born from sick D. page of mothers fluctuates within 6,8 — 11%. Inborn heart diseases, an underdevelopment of caudal department of a backbone, etc. are most often observed.
The organization of specialized obstetric care of page to sick D., careful overseeing by pregnant women, strict compensation of disturbances of exchange allowed to reduce quantity of complications of pregnancy and to reduce adverse influence of these disturbances on a fruit, and also it is very considerable to reduce perinatal mortality.
Carlson and Kyellmer's researches (To. Karlsson, J. Kjellmer) showed that the minimum perinatal mortality and incidence of children are observed in group of mothers who during pregnancy had permanent compensation of diabetes and the average level of glucose in blood did not exceed 100 mg of %. Thus, for preservation of a fruit criteria of compensation of D. of page of mother during pregnancy shall be considerable more strict, than at nonpregnant.
Pregnant, sick D.' treatment by the village, and preservation of life of a fruit are based on the following philosophy: maximum compensation of D. of page, prevention and treatment of complications of pregnancy, rational choice of time and method of delivery, careful nursing of newborns.
Apply a combination of drugs of high-speed insulin and insulin of the prolonged action to sick D.' treatment by the village of pregnant women. The necessary dose of insulin is calculated generally according to indications and within a day since glikozurichesky indicators at pregnant women in connection with change of a threshold of passability of kidneys for glucose not always reflect a true glycemia. Use of drugs of sulfanylurea during pregnancy is contraindicated. The diet at D. of page shall have the stable content of carbohydrates. Approximate daily layout: carbohydrates — 200 — 250 g, proteins — 1,5 — 2,0 g, fats — to 70 g on 1 kg of weight at the maximum saturation by vitamins and lipotropic substances. The adequate insulin therapy based on perhaps more frequent research of glycemic and glikozurichesky indicators; prevention of complications of pregnancy dictates need of constant overseeing of the sick obstetrician and endocrinologist during all pregnancy. Hospitalization is obligatory in early durations of gestation and for 2 — 3 weeks before childbirth; out-patient control in the 1st half of pregnancy is necessary each 2 weeks, and in the 2nd — weekly.
The question of term and a method of childbirth is solved depending on a condition of mother, a fruit and an obstetric situation. The frequency of complications increasing by the end of pregnancy and threat of antenatal death of a fruit force many obstetricians to carry out sick D.' delivery by the village to 36 weeks. Under control of the tests defining a functional condition and a maturity of a fruit in a number of clinics aim to bring closer a delivery time to timely, than decrease in incidence and mortality of children is provided. Preference is given to delivery in natural patrimonial ways, but in the presence of obstetric complications indications to Cesarean section extend.
Indications to early delivery by stimulation of patrimonial activity or to Cesarean section is development or weighting of a diabetic retinopathy and a diabetic glomerulosclerosis, heavy toxicosis of the second half of pregnancy, signs of disturbance of life activity of a fruit. The indication to early deliveries) emergence of a decompensation of D. of page which is not giving in to treatment, bystry progressing of a diabetic retinopathy, a glomerulosclerosis is.
Treatment of newborns is carried out by the principles of treatment of premature children. Depending on indicators of a hemodynamics and the nature of metabolic disturbances apply effective resuscitation actions, administration of glucose in critical terms, continuous oxygenation in combination with administration of the enzymes improving tissue respiration. According to indications carry out dehydrational therapy (see), correction of disturbances of electrolytic exchange, anticonvulsant and sedative treatment, etc.
The increased requirements imposed to inspection and sick D.' treatment by the village of women and their children can be fully carried out only at the accurate organization of the specialized help.
Specialized obstetric departments are the centers concentrating all medical, advisory, methodical and the research directed to development of effective measures for health protection of sick mother and her child.
At the address of spouses to the doctor with a question of a possibility of pregnancy it is necessary to warn them about a high risk for the child (a still birth, malformations) and dangers of hereditary transfer of a disease. At desire sick D. can interrupt with page pregnancy, but if she wishes to keep pregnancy and to it there are no contraindications, then all shall be provided to lay down. actions for preservation of life and health of the child.
The diabetes mellitus
the Diabetes mellitus at children occurs at children in the entire periods of children's age, including at chest age and in the period of a neonatality, however with the largest frequency incidence of diabetes is observed at prepubertatny age. Among all diseases at D. children of page makes, according to M. M. Bubnov, M. I. Martynov (1963), from 3,8 to 8%.
The etiology and a pathogeny
In most cases D. of page is genetically caused disease. Assessment of genetic defect is complicated by variability a wedge, displays of a disease. Mutant gays it is widespread widely, is available apprx. 4 — 5% of homozygotes with penetrance of a gene for women apprx. 90% and for men — 70%. D.'s gene of page (d) is available for 20 — 25% of people in population, the general frequency of the pages predisposed to D. — apprx. 5%. Apprx. 20% of people 5% — homozygotes (dd), 75% — healthy are heterozygotes (Dd) on a diabetic gene, (DD). Among homozygotes of 0,9% pages, 0,8% — the hidden D. page are ill explicit D., at 3,3% «diabetic readiness» (predisposition) does not give in to modern diagnosis. At children of D. the page meets in the families having obesity, a glycogenosis, renal diabetes, a mucoviscidosis more often. D. of page can sometimes develop as a result of pancreatitis, an injury, hemorrhage, and also a malformation of fabrics — hamartias (see).
D.'s inheritance by the village as a wedge, a syndrome can be autosomal and recessive, polygenic; pseudo-domination of a sign is observed. At D. of page there is a hereditary transfer of inferiority as a part of DNA or damage of ability of information to the coding DNA mechanism.
Development of a disease is caused by influence of several genes which are in various loci and not always being «spetsificheskikhm» concerning diabetes, but their action under the influence of a number of factors can be summed up and lead to emergence diabetic a wedge, a syndrome. The genetic defects leading to D.'s development by page can be various. It disturbances of synthesis and release of insulin (mutation of a structural gene; the mutation of a regulator gene leading to reduced synthesis of insulin; the gene defect causing synthesis of abnormal insulin; the defects causing an abnormal structure of membranes of beta cells or defects of their power), the gene defects resulting in nonsensitivity of peripheral fabrics to insulin, neutralization of insulin owing to a mutation of the regulator gene causing the high content of insulin antagonists, etc. Hereditary transfer of gene defects happens in various ways.
The factors provoking D.'s beginning of page at children are infectious diseases, intoxications, vaccination, physical and mental injuries, the excess use of fats and carbohydrates with food.
Absolute or relative insufficiency insulin (see) plays the leading role in D.'s pathogeny of page at children. There is an assumption that at D. pages at children a certain value have kontrinsulyarny factors of an adenohypophysis among which the first place is allocated to somatotropic hormone. Apparently, acceleration of growth at children during the period preceding developing of a disease is also explained by it.
A clinical picture
Distinguish potential, hidden and explicit D. of page. The disease most often comes to light sharply, quite often suddenly (from a diabetic coma), and is sometimes atypical (with an abdominal syndrome or a hypoglycemia). Anorexia occurs at children more often than a polyphagia. Night incontience of urine (see) — one of the most frequent symptoms of the beginning of a disease.
The disease is characterized by a peculiar progressing current which is caused by gradual decrease in products of insulin a pancreas and influence of kontrinsulyarny factors at the long course of a disease. Special lability of exchange processes with considerable fluctuations of level of a glycemia (from a hypoglycemia to excessively high hyperglycemia) with violently developing decompensation from insignificant provocative factors is characteristic. The reason of such lability consists in excessive sensitivity to endogenous insulin, decrease in a glycogen in a liver and muscles (immaturity of nervnoregulyatorny mechanisms of carbohydrate metabolism and high energy level of processes in the developing children's organism). The accessory factors promoting lability of level of sugar in blood at children are insulin therapy, muscular work, various a stress situation, accompanying a disease, hron, infections, etc.
Establishment of degree of a decompensation of metabolic disturbances and determination of criteria of compensation at D. first of all is necessary for page at children for the solution of questions of therapeutic tactics. Speaking about a decompensation or D.'s compensation by the village at children, it must be kept in mind set a wedge, displays of a disease and metabolic disturbances.
Compensation of processes — full a wedge, wellbeing of the sick child in the absence of a glycosuria or existence of traces of sugar in urine, datum level of ketone bodies and sugar in blood and lack of acetonuria. Against the background of a usual motive and dietary regimen, the picked-up dose of insulin in a phase of compensation there should not be hypoglycemic conditions and sharp fluctuations of a glycemia within a day. Any deviations from the specified criteria shall be considered as a decompensation.
According to expressiveness patofiziol. shifts distinguish three degrees of a decompensation.
The decompensation of the I degree (D1) is characterized by instability of a glycemia (periodic increase in level of sugar in blood on an empty stomach to 200 mg of %) and a glycosuria (more than 30 g per day), the emergence in morning portions of urine of traces of acetone moderated by increase in a night diuresis, small thirst. In this stage of a decompensation activation of sympathoadrenal system begins; increase in release of kortikoidny substances that can be considered as manifestation of the general syndrome of adaptation. Insulinny activity of blood at initial diabetes with gradual development of a decompensation decreases slightly or remains normal. The I degree of D. of page is easily removable correction of a diet or doses of insulin.
Decompensation of the II degree (D2): resistant hyperglycemia, considerable glycosuria, acetonuria, acetonemias, polyuria, polydipsia, polyphagia, syndrome of the accruing eksikoz. The compensated metabolic acidosis. Along with decrease in insulinny activity of blood influence of kontrinsulyarny closed glands which hormones deepen metabolic disturbances amplifies and promote formation of inhibitors of insulin and enzymes, increasing, thus, deficit of insulin. Compensatory and adaptive mechanisms begin to develop into pathological.
The decompensation of the III degree (D3) is characterized by increase of a hyperglycemia, glycosuria, acetonemia, decrease in standard bicarbonate (shifts of pH of blood to 7,3 can be observed); the expressed acetonuria, smell of acetone from a mouth, the polyuria, thirst expressed by symptoms of dehydration, a hepatomegalia. Against the background of a metabolic acidosis and a secondary respiratory alkalosis substantial increase of lung ventilation due to increase and deepening of breath is noted.
Insulinny activity of blood falls to traces, excretion with urine 17 of oxycorticosteroids increases, considerable changes in a range of the catecholamines excreted with urine are observed. The expressed hyper aldosteronuria is noted, in blood the maintenance of the free and connected with protein forms 11 of hydroxycorticosteroids increases. Rhythms of excretion with urine of electrolytes, glucocorticoids, promineralokortikoid, Aldosteronum, catecholamines are perverted.
The decompensation of the III degree can easily pass into a diabetic coma and therefore demands acute management.
Côme I of degree (KK1): consciousness is darkened by times, a hyporeflexia, noisy breath, tachycardia, the pungent smell of acetone from a mouth expressed eksikoz, a hyperglycemia, an acetonemia, a sharp decompensated metabolic acidosis and a secondary respiratory alkalosis. The polyuria is replaced by an oliguria therefore relative reduction of a glycosuria at increase in percentage of glucose in urine is observed. Repeated vomiting. Acetonuria. There are paradoxical mechanisms of regulation of the main homeostatic functions, the transmineralization accrues.
At a coma of the II degree (KK2) the symptoms and metabolic disturbances stated above become even more expressed: the sharpest decompensated acidosis, cellular eksikoz, potassium deficit, secondary respiratory alkalosis and circulator hemodynamic frustration, areflexia and dead faint. Only emergency treatment can save the child.
Some biochemical, indicators of dynamics of a decompensation and a coma are presented in table 2.
Table 2. Some biochemical indicators at a decompensation of a diabetes mellitus and a diabetic coma at children
Hypoglycemic; states shall be considered as D.'s decompensation of page. The hypoglycemia meets in the initial, labile stage of diabetes, at selection of a diet and an insulin therapy, at increase in a dose of insulin, after starvation or physical more often. tension. If initial values of sugar in blood at the child are very high and sharply fall, then heavy hypoglycemic symptoms can appear even at datum level of sugar in blood. The long, often repeating hypoglycemic states at children can become the reason of cerebral frustration.
Of page at children proceeds hard, easy forms and remissions are observed seldom. At insufficiently careful treatment processes of growth and development of the child are slowed down, the increase in a liver caused by accumulation of fat and a glycogen in a liver is observed. In such cases tendency to a ketosis is especially big, and treatment of similar patients is complicated. Children, sick D. have a page, caries of teeth meets less often, and periodontosis more often than on average at children»
the Lipoid necrobiosis of skin at children's age is observed extremely seldom. Changes from vessels of a retina of an eye at children a long time can have reversible character. The leading role in development and progressing of vascular changes is played by weight of a current of D. of page, depth of exchange disturbances. Influence of duration of a disease on development of vascular defeats is expressed vaguely and is probably connected with the fact that in process of increase of prescription of a disease its weight progresses.
In early terms after the beginning of a disease at children the functional condition of kidneys changes: increase in glomerular filtering and canalicular reabsorption. Functional changes in kidneys appear before changes of vessels of eyes.
The general atherosclerosis with D. of page occurs at children very seldom. Emergence of an arteriolosclerosis depends on duration of existence of D. of page and therefore can take place and at children's age.
The diabetic polyneuropathy is most often observed. The current of a polyneuritis, frustration of a nervous system quite persistent, and only with approach of puberty quite often comes permanent remission.
D.'s Diagnosis by the village at children's age does not differ from that at adults. If the child comes to clinic in coma, then at diagnosis it is necessary to differentiate a diabetic coma with encephalitis, a hematencephalon, a hypoglycemia, a heavy eksikoz, with a circulatory unefficiency, an uremic coma. At the same time researches of urine and blood on a sugar content are decisive.
the Main objective of treatment consists in achievement of long compensation by means of a diet, insulin and a gigabyte. mode. For providing the correct physical. development of sick children appoints a full-fledged diet according to age. Limit only the sugar and products prepared on sugar (the need for them becomes covered at the expense of the sugar which is contained in milk and fruit). The general daily caloric content of food is distributed as follows: 60% of kcal make carbohydrates, 16% are proteins, 24% — fats. The breakfast makes 30% of a daily diet, a lunch — 40%, an afternoon snack — 10%, a dinner — 20%. At the expressed acetonuria limit amount of fats and increase amount of carbohydrates, appoint lipotropic substances and products, them containing (low-fat cottage cheese, oat and rice porridges, etc.), alkaline mineral waters, etc.
Therapy insulin is appointed if daily excretion of glucose with urine exceeds 5% of the sugar value of food (contents in food of all carbohydrates and 50% of proteins). As the indication for an insulin therapy serves also the level of sugar in blood exceeding 200 mg of % not korrigiruyemy a diet, existence of a ketosis, dystrophy and associated diseases.
To children with the occult diabetes or with slowly developing disease at small expressiveness a wedge, symptoms, and also to children in a condition of remission after an initial course of treatment of insulin under careful a wedge, and laboratory control it is possible to recommend reception of glucose-lowering drugs and guanyl guanidines.
Ground rules of purpose of an insulin therapy to children correspond to that at adults (control of a glycemia and a glycosuria). At children with the easy course of diabetes good compensation of exchange processes can be reached by a single injection of crystal insulin. At children with the long course of a disease resort to a combination: usual insulin and insulin of the prolonged action. At the heavy course of diabetes (especially in the pubertal period), except mix of the above-named drugs, for temporary correlation of the broken metabolism appoint (in the evening or at 6 o'clock in the morning) a small dose of usual insulin.
Treatment of a diabetic coma and ketoatsidotichesky state is directed to elimination of acidosis, toxicosis and eksikoz, caused by deficit of insulin and shifts of exchange processes. Therapeutic actions at a coma shall be bystry. In a condition of ketoacidosis and a coma the child needs to begin immediately an insulin therapy). The initial dose of insulin at the children who were earlier not receiving insulin makes 0,45 — 0,5 PIECES on 1 IS of weight, at KK1 — 0,6 PIECES on 1 kg of weight, at KK2 — 0,7 — 0,8 PIECES on 1 kg of weight. At a coma of / z doses of insulin enter intravenously, other part of the appointed dose — intravenously kapelno within 2 — 3 hour. To the children who were earlier receiving insulin irrespective of its look, in coma enter simple insulin taking into account earlier entered dose of the insulin and time which passed from the moment of an injection.
For fight against dehydration, ketoacidosis and circulator frustration administration of liquid is obligatory (intravenously and enterally). Enter intravenously struyno isotonic solution of sodium chloride at the rate of 8 — 10 ml on 1 kg of weight with addition 100 — 200 mg of cocarboxylase, 2 ml of 5% of solution ascorbic to - you. Then adjust intravenous drop administration of liquid in structure: isotonic solution of sodium chloride, Ringer's solution — Locke, 5% solution of glucose in the ratio 1:1:1 (on the first 6 hours); further the players of liquid are changed towards the increase in content of glucose and solutions containing potassium. Daily requirement of the liquid entered intravenously on 1 kg of weight shall make at the III degree of a decompensation 45 — 50 ml, at K K of j — 50 — 60 ml, at To Kg — 60 — 70 ml. Duration of intravenous administration of liquid shall make at the III degree of a decompensation to 35 hours, at KK1 — to 37 hours, at KK2 — 38 — 40 hour.
Sick it is necessary to enter 4% into the first 3 — 6 hours solution of sodium bicarbonate. The amount of bicarbonate is calculated on Mellemgard's formula — Siggarda — Andersen: 0,3 X deficit of the bases (in mekv/l) the X body weight (in kg). In very hard cases it is necessary to control several times a day results of treatment by definition of pH, deficit of the bases, standard bicarbonate. To increase the content of bicarbonate in plasma, follows at a decompensation of the III degree into the first 3 — 6 hours to enter 140 — 160 ml, at KK1 — 180 — 200 ml, at KK2 — 210 — 250 ml of 4% of solution of sodium bicarbonate.
Rate of administration of liquids following: in the first 6 hours — 50% of daily quantity, for the subsequent 6 hours — 25%, in the remained time — 25%.
The second injection of insulin in quantity x / 2 — 2/z an initial dose is done in 2 — 3 hours, further insulin is entered in 3 — 4 hours. Administration of insulin in 6 hours from an initiation of treatment shall be provided with adequate amount of glucose (2 g of glucose on 1 PIECE of insulin) for prevention of a hypoglycemia. The need for glucose per day at D3 — 170 — 200 g, at KK1 — 165 — 175 g, at KK2 — 155 — 165 g.
For the prevention of a hypopotassemia in the course of removal of the patient from coma and the III degree of a decompensation drop administration of liquid and insulin it is necessary to begin treatment with drugs of potassium not later than the 2nd hour from the beginning of therapy, and 80% of necessary potassium shall be entered into the first 12 — 15 hours of treatment. The daily need for drugs of potassium increases in process of increase of weight of a condition of patients. At the III degree of a decompensation it makes 3,0 — 3,2 g, at KK1 — 3,5 — 3,8 g, at KK2 — 3,8 — 4,5 g.
For elimination hypopotassemias (see) intravenously enter 1% solution of potassium chloride and enterally 5 — 10% solution of acetate or potassium chloride. Also administration of potassium phosphate since loss by a cell of phosphates is expressed stronger, than loss of chlorides can be recommended.
In connection with considerable circulator frustration at a coma introduction of 0,05% of solution of strophanthin (in the absence of an anury) in an age dose in 10% solution of glucose is recommended (introduction slow).
At pernicious vomiting before intravenous administration of liquids it is necessary to make a gastric lavage and a cleansing enema.
For prevention of consecutive infection (pneumonia, phlebitis and so forth) after removal from coma appoint antibiotics (parenterally).
In the first days food the child is not given. After the termination of vomiting and at improvement of a state sweet tea, kissel, compote, alkaline mineral waters, orange, lemon, carrot juice is recommended. On second day the diet is expanded due to introduction of semolina porridge, a beef-infusion broth with crackers, mashed potatoes, the wiped meat, skim cheese, in the next days limit fats.
Complex therapy of ketoacidosis and a coma includes appointment glutaminic to - you (1,5 — 3,0 g a day) for the purpose of binding of ketone bodies and reduction of acidosis, lipotropic means and polyvitamins.
One of complications at the wrong therapy of ketoacidosis and a coma is the late gipokaliyemichesky syndrome which is observed in 3 — 4 — 6 hours after the beginning of an insulin therapy. It is characterized by gray pallor, a considerable hypomyotonia, disorder of breath, change of an ECG (gipokaliyemichesky type), a cardiac disturbance (cyanosis, tachycardia, low the ABP, imperceptible pulse), paresis of intestines and bladder (the prevention and treatment of a syndrome — see above).
Children, sick D. of page, demand constant dispensary observation. Medical examination shares to be performed at least once in 1 — 2 month with a control research of level of sugar and ketone bodies of blood. It is necessary to conduct researches of urine on sugar and ketone bodies daily, bulk analysis of urine — at least 1 time a month. Watch the general state, physical development, a day regimen, a diet, an insulin therapy. Consultation of the doctor-oculist — once in 3 — 6 months, consultation of the otolaryngologist and other specialists — according to indications. All children with D. of page are inspected on tuberculosis.
Children with D. of page shall use in the additional day off in a week or reduced school day; they are exempted from physical. work at school and, according to indications, from school examinations.
Sick D. of page are subject to obligatory hospitalization for purpose of the correct treatment. At a satisfactory general condition hospitalization of children is performed 1 — 2 time a year for repeated inspection and dose adjustment of insulin. All children with a diabetic and hypoglycemic coma, the expressed symptoms of a decompensation are subject to obligatory hospitalization.
Forecast depends on timeliness of the made diagnosis. At dispensary observation, careful treatment, observance of the mode of study and rest physical and mental development of the child proceeds normally. At a severe form with a decompensation and a coma, and also at renal complications and infectious diseases the forecast less favorable.
Prevention Of page consists in dispensary observation for children from families where there are sick D. of page. To them conduct a research of urine and blood on sugar, in some cases — the tolerance test to glucose. At identification at children of predisposition to D. of page it is necessary to pay attention to a diet, to avoid an overfeeding, especially carbohydrates (candies, flour products, etc.).
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V. G. Baranov; K. A. Velikanov (yp), V. G. Vtorova (gin.), T. B. Zhuravleva (stalemate. An.), V. P. Illarionov (to lay down. physical.), Yu. A. Knyazev, L. F. Marchenko (ped.), Yu. S. Martynov (not BP.), T. A. Nevzorova (psikhiat.).