The dilemma of self-monitoring of blood glucose.
The dilemma of self-monitoring of blood glucose.
复制标题
血糖自我监测的困境。
DOI：
10.1007/s00125-006-0582-z
复制
发表时间：
2007
期刊：
影响因子：
8.2
通讯作者：
Davidson,MB
中科院分区：
文献类型：
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作者：
Davidson,MB
Martin等人在去年发表于《糖尿病学》（Diabetologia）的一篇论文中报道，在观察性回顾性队列研究“2型糖尿病患者的血糖自我监测和结局”（ROSSO）中，自我监测血糖（SMBG）与显著降低糖尿病相关发病率和全因死亡率相关，即使在调整了年龄、性别、糖尿病诊断时的合并症（高血压、冠心病和卒中史）后也是如此。空腹血糖浓度、甘油三酯水平和治疗。这些发现对于不服用胰岛素的患者仍然适用。相反，在本期《糖尿病学》杂志上，Davis等人报道，在观察性、前瞻性Fremantle研究中，调整混杂因素后，SMBG与糖尿病相关发病率、心脏性死亡或全因死亡率的改善结果无关。在Fremantle研究中调整的混杂因素包括年龄、性别、糖尿病病程、既往冠心病、既往外周动脉疾病、神经病变、视网膜病变、微量白蛋白尿、收缩压、血清总胆固醇和当前吸烟。令人惊讶的是，在那些不服用胰岛素但进行SMBG的患者中，心血管死亡风险显著增加了79%。如何解释这两项大型研究的完全不同的结果，我们能从中学到什么教训？首先，有许多因素可能影响结果，特别是大血管，考虑所有适当的混杂因素可能是有问题的。其次，对于推荐谁进行SMBG，以及实施SMBG的患者，医生可能有一个自我选择的过程。支持前者的证据是，进行SMBG的患者血糖水平高于未进行SMBG的患者[1,3]。一项大型观察性回顾性健康计划研究提供了后者的证据，在该研究中，更频繁进行SMBG的患者的HbA1c水平较低。然而，对计划成员进行的自我管理问卷或计算机辅助电话访谈（83%的人回答）显示，自我保健实践和健康的生活方式行为在更频繁进行SMBG的患者中更为常见。根据定义，观察性研究不是实验性研究，即干预措施是选择的而不是随机分配的。这导致了选择偏倚的可能性，这反过来意味着结果可能不是由研究中的干预措施引起的。虽然在分析数据时可以考虑到可识别的差异，但不能肯定这些调整是充分的，因为所有相关差异可能都不是充分的
In a paper published in Diabetologia last year, Martin et al.[1] reported that self-monitoring of blood glucose (SMBG) in the observational retrospective cohort Retrolective Study ‘Self-monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes’(ROSSO) was associated with significantly decreased diabetes-related morbidity and all-cause mortality even after adjusting for age, sex, comorbidities at diagnosis of diabetes (hypertension, CHD and history of stroke), fasting plasma glucose concentrations, triacylglycerol levels and treatment. These findings remained true for patients not taking insulin. In contrast, in the present issue of Diabetologia, Davis et al.[2] report that, in the observational, prospective Fremantle study, SMBG was not associated with improved outcomes of diabetes-related morbidity, cardiac death or all-cause mortality after adjustment for confounders. The confounders adjusted for in the Fremantle study were age, sex, duration of diabetes, prior CHD, prior peripheral arterial disease, neuropathy, retinopathy, microalbuminuria, systolic blood pressure, total serum cholesterol and current smoking. Surprisingly, there was a significant 79% increased risk of cardiovascular mortality in those patients who were not taking insulin but were performing SMBG. How can the disparate results of these two large studies be explained and what lessons can we learn from them? First, there are many factors that might impinge on the outcomes, especially the macrovascular ones, and taking all the appropriate confounders into account may be problematic. Second, there may be a self-selection process for physicians in terms of who is recommended for, and patients who perform, SMBG. Evidence for the former is the finding that those who perform SMBG have higher glycaemia than those who do not [1, 3]. Evidence for the latter was supplied by a large observational retrospective health plan study in which patients who performed SMBG more frequently had lower HbA1c levels [4]. However, a self-administered questionnaire or a computer-assisted telephone interview administered to plan members (83% of whom responded) revealed that self-care practices and healthy lifestyle behaviours were significantly more common in patients who performed SMBG more frequently. By definition, an observational study is not an experimental one, ie interventions are chosen rather than randomly assigned. This leads to the possibility of selection bias which, in turn, means that outcomes may not be caused by the intervention under study [5]. Although identifiable differences can be taken into account when the data are analysed, one cannot be certain that these adjustments are adequate because all of the relevant differences may not be