Ingrid Mühlhauser

Smoking Is Associated With Progression of Diabetic Nephropathy

OBJECTIVE To investigate the association between cigarette smoking and the progression of diabetic nephropathy. RESEARCH DESIGN AND METHODS A prospective, follow-up study over one year was conducted in a sequential sample of 34 smokers, 35 nonsmokers, and 24 ex-smokers with type I diabetes, hypertension, and diabetic nephropathy. Progression of renal disease was defined according to the stage of nephropathy as an increase in proteinuria or serum creatinine or a decrease in the glomerular filtration rate. RESULTS Progression of nephropathy was less common in nonsmokers (11%) than in smokers (53%) and patients who had quit smoking (33%), P > 0.001. In a stepwise logistic regression analysis, cigarette pack years, 24-h sodium excretion, and GHb were independent predictive factors for the progression of diabetic nephropathy. Because blood pressure (BP) was well controlled in these patients and most values were within a normotensive range, neither standing, sitting, nor supine BP values were associated with progression of nephropathy. CONCLUSIONS Cigarette smoking represents an important factor associated with progression of nephropathy in treated hypertensive type I diabetic patients.

Patient education as the basis for diabetes care in clinical practice and research

Despite the obvious improvements made in the field of diabetes therapy during this century [1] the quality of diabetes care has, in general, remained poor. The widespread failure to acknowledge the impact of patient education appears to evolve as the primary reason for this unsatisfactory situation. Despite the firm and well founded recommendations put forward by some of the pioneers of modem diabetology, e.g. Drs. E.P.Joslin and R.D. Lawrence in the 1920s, it has taken almost 50 years for the beneficial effects of patient education to have finally and unequivocally been proven. The recently developed strategies for a global approach to diabetes therapy which combines biomedical, psychosocial and educational elements represents an exemplary therapeutic model for the care of many chronic diseases.

Evaluation of an intensified insulin treatment and teaching programme as routine management of Type 1 (insulin-dependent) diabetes

SummaryIt has been questioned whether aiming at near-normoglycaemia by intensified insulin treatment regimens is feasible and safe for the majority of patients with insulin-dependent diabetes. In this study, intensified insulin injection therapy (including blood glucose self-monitoring and multiple insulin injections) based upon a 5-day inpatient group teaching programme was evaluated in Type 1 (insulin-dependent) diabetes mellitus in the centralised health care system of Bucharest. One hundred patients (group A, initial HbA1 12.5%) were followed for 1 year on their standard therapy (individual teaching, no metabolic self-monitoring), and thereafter for 1 year on intensified therapy. Another 100 patients (group B, HbA1 12.3%) were followed for 2 years on intensified therapy. A third 100 patients (group C, HbA1 11.7%) were assigned to a basic 4-day inpatient group teaching programme with conventional insulin therapy (including self-monitoring of glucosuria and acetonuria) and followed for 1 year. Mean HbA1 remained unchanged after standard treatment (group A: 12.8% at 12 months), but decreased during intensified therapy (group A: 10.1% at 24 months; group B: 9.3% at 12 months, 9.5% at 24 months; p<0.0001). In group C, no change was found compared to standard treatment (i.e. group A at 12 months). Incidence rates of ketoacidosis were 0.16 episodes per patient per year during standard treatment, 0.01 during intensified treatment (p<0.01) and 0.04 in group C (p<0.025). Hospitalisation rates were reduced by 60% during intensified therapy and by 40% in group C. Frequency of severe hypoglycaemia was not significantly different between the three treatment regimens. Thus, under the condition that insulin treatment is based upon a structured and comprehensive training of the patient, intensified insulin injection therapy performed as routine treatment of Type 1 diabetes significantly lowers HbA1 levels without increasing the risk of severe hypoglycaemia.

Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study

Aims/hypothesisThe aim of this study was to evaluate the implementation of a course teaching flexible, intensive insulin therapy on glycaemic control and severe hypoglycaemia in routine care.MethodsThis is a continuous quality-assurance project involving hospital diabetes centres. Every third year each centre re-examines 50 consecutive patients (evaluation sample) 1 year after participation in the course. Ninety-six diabetes centres in Germany participated and 9,583 patients with type 1 diabetes (190 evaluation samples) were re-examined between 1992 and 2004. The intervention was a 5-day inpatient course for groups of up to ten patients with a fixed curriculum of education and training for dietary flexibility and insulin adjustment. The main outcome measures were HbA1c and severe hypoglycaemia.ResultsMean baseline HbA1c was 8.1%, and had decreased to 7.3% at follow-up; incidence of severe hypoglycaemia was 0.37 events per patient per year prior to intervention and 0.14 after intervention. In mixed-effects models adjusted for effects of centres, age and diabetes duration, the mean difference was −0.7% (95% CI −0.9 to −0.6%, p<0.0001) for HbA1c and −0.21 events per patient per year (95% CI −0.32 to −0.11, p=0.0001) for severe hypoglycaemia, with similar results for evaluation samples, with a maximum of 10% of patients lost to follow-up. Before intervention, the incidence of severe hypoglycaemia was three-fold higher in the lowest quartile than in the highest quartile of HbA1c, whereas the risk was comparable across the range of HbA1c values after intervention.Conclusions/interpretationImplemented as part of a continuous quality-assurance programme the self-management programme is effective and safe in routine care. Improvement of glycaemic control can be achieved without increasing the risk of severe hypoglycaemia.

Cigarette-smoking as a risk factor for macroproteinuria and proliferative retinopathy in type 1 (insulin-dependent diabetes)

SummaryIn a case control study 192 cigarette-smoking patients with Type 1 (insulin-dependent) diabetes were compared with 192 non-cigarette-smoking patients pair-matched for sex (90 females), duration of diabetes (mean 14 years), and age (mean 32 years). Macroproteinuria was found in 19.3% of the smoking and in 8.3% of the non-smoking patients (p < 0.001). Proliferative retinopathy was present in 12.5% of the smoking and in 6.8% of the non-smoking patients (p < 0.025). The percentages of patients with normal proteinuria or without retinopathy were comparable between the two groups. In addition, glycosylated haemoglobin values and the prevalence of hypertension were similar between smoking and non-smoking patients. Thus, cigarette-smoking appears to be a risk factor for the progression of incipient to overt nephropathy and of background to proliferative retinopathy in Type 1 diabetes.

Intensified insulin therapy and the risk of severe hypoglycaemia

Summary The objectives of the present analyses were to assess the association between HbA1 c levels and severe hypoglycaemia (SH, treatment with glucose i. v. or glucagon injection) and to identify predictors of SH in a prospective multicentre trial. The study population consisted of 636 insulin-dependent diabetic patients who had participated in a structured 5-day in-patient group treatment and teaching programme for intensification of insulin therapy (ITTP) in one of 10 hospitals and who were re-examined after 1, 2, 3, and 6 years including assessment of demographic, disease and treatment related parameters, diabetes-related knowledge, behaviour, and emotional coping. At baseline, age (mean ± SD) was 27 ± 7 years, diabetes duration 9 ± 7 years and HbA1 c 8.3 ± 1.9 %. During the 6-year follow-up, the mean HbA1 c value improved to 7.6 %, and in patients with a diabetes duration of more than 1 year at entry into the study (n = 538) the incidence of SH decreased from 0.28 cases/patient/year during the year preceding the ITTP to 0.17 cases/patient/year. The patient group was divided into decile groups according to mean follow-up HbA1 c values. In each group more than 230 patient years could be analysed. Groups with mean HbA1 c values of 5.7, 7.0, 7.4, 7.7 and 8.9 % had comparable risks of SH (0.15–0.19 cases/patient/year). In a logistic regression analysis, mean HbA1 c during follow-up, a history of SH during the year preceding the ITTP, C-peptide level, emotional coping, carrying emergency carbohydrates (as assessed at the 1-year follow-up), and age at onset of diabetes were significant independent predictors of SH. The incidence of SH between centres varied between 0.05 and 0.27 cases/patient/year. In conclusion, in the present analyses no linear or exponential relationship between HbA1 c and severe hypoglycaemia could be identified by using simple group comparisons. Applying complex regression analyses, various patient-related predictors of severe hypoglycaemia were identified. [Diabetologia (1997) 40: 926–932]

Effect on hip fractures of increased use of hip protectors in nursing homes: cluster randomised controlled trial

Abstract Objective: To assess the effects of an intervention programme designed to increase use of hip protectors in elderly people in nursing homes. Design: Cluster randomised controlled trial with 18 months of follow up. Setting: Nursing homes in Hamburg (25 clusters in intervention group; 24 in control group). Participants: Residents with a high risk of falling (459 in intervention group; 483 in control group). Intervention: Single education session for nursing staff, who then educated residents; provision of three hip protectors per resident in intervention group. Usual care optimised by brief information to nursing staff about hip protectors and provision of two hip protectors per cluster for demonstration purposes. Main outcome measure: Incidence of hip fractures. Results: Mean follow up was 15 months for the intervention group and 14 months for the control group. In total 167 residents in the intervention group and 207 in the control group died or moved away. There were 21 hip fractures in 21 (4.6%) residents in the intervention group and 42 hip fractures in 39 (8.1%) residents in the control group (relative risk 0.57, absolute risk difference −3.5%, 95% confidence interval −7.3% to 0.3%, P=0.072). After adjustment for the cluster randomisation the proportions of fallers who used a hip protector were 68% and 15% respectively (mean difference 53%, 38% to 67%, P=0.0001). There were 39 other fractures in the intervention group and 38 in the control group. Conclusion: The introduction of a structured education programme and the provision of free hip protectors in nursing homes increases the use of protectors and may reduce the number of hip fractures. What is already known on this topic Nursing home residents are at particularly high risk of fracturing a hip Hip protectors can effectively prevent hip fractures Adherence to the use of hip protectors is poor What this study adds The use of hip protectors in nursing homes can be substantially increased by a single session education targeted at nursing staff and residents and provision of free hip protectors Increasing the use of hip protectors resulted in a relative reduction of hip fractures of about 40%

Validation of a Diabetes-Specific Quality-of-Life Scale for Patients With Type 1 Diabetes

OBJECTIVE To validate a diabetes-specific quality-of-life scale and to assess its psychometric properties in a large sample of patients with type 1 diabetes. RESEARCH DESIGN AND METHODS To assess the quality of diabetes care in a population-based study, a representative sample of 684 patients with type 1 diabetes was examined. A total of 657 patients (42% female; mean age 36 years; mean diabetes duration 18 years) completed the diabetes-specific quality-of-life scale (DSQOLS), which comprised 64 items on individual treatment goals (10 items), satisfaction with treatment success (10 items), and diabetes- related distress (44 items). Statistical examinations covered factor analysis, internal consistency of subscales, and construct and discriminant validity. RESULTS Factor analysis of the 44 items on diabetes-specific burdens revealed six reliable components (Cronbachs α): social relations (0.88), physical complaints (0.84), worries about future (0.84), leisure time flexibility (0.85), diet restrictions (0.71), and daily hassles (0.70). All six subscales were significantly correlated with a validated well-being scale (r = -0.35 to -0.53, P < 0.001) and treatment satisfaction (r = 0.28 to 0.43, P < 0.001). Physical complaints (r = 0.24) and worries about future (r = 0.17) showed the highest correlations with HbA1c (P < 0.001). A flexible insulin therapy, a liberalized diet, the absence of late complications, and a higher social status were significantly associated with more favorable scores in different domains. CONCLUSIONS The DSQOLS is a reliable and valid measure of diabetes-specific quality of life. The scale is able to distinguish between patients with different treatment and dietary regimens and to detect social inequities. Use of the DSQOLS for assessment of individual treatment goals as defined by the patients may be helpful to identify motivational deficits and to tailor individual treatment strategies.

What constitutes evidence-based patient information? Overview of discussed criteria

OBJECTIVE To survey quality criteria for evidence-based patient information (EBPI) and to compile the evidence for the identified criteria. METHODS Databases PubMed, Cochrane Library, PsycINFO, PSYNDEX and Education Research Information Center (ERIC) were searched to update the pool of criteria for EBPI. A subsequent search aimed to identify evidence for each criterion. Only studies on health issues with cognitive outcome measures were included. Evidence for each criterion is presented using descriptive methods. RESULTS 3 systematic reviews, 24 randomized-controlled studies and 1 non-systematic review were included. Presentation of numerical data, verbal presentation of risks and diagrams, graphics and charts are based on good evidence. Content of information and meta-information, loss- and gain-framing and patient-oriented outcome measures are based on ethical guidelines. There is a lack of studies on quality of evidence, pictures and drawings, patient narratives, cultural aspects, layout, language and development process. CONCLUSION The results of this review allow specification of EBPI and may help to advance the discourse among related disciplines. Research gaps are highlighted. PRACTICE IMPLICATIONS Findings outline the type and extent of content of EBPI, guide the presentation of information and describe the development process.

EVALUATION OF A STRUCTURED TREATMENT AND TEACHING PROGRAMME ON NON-INSULIN-DEPENDENT DIABETES

A structured treatment and teaching programme for non-insulin-treated non-insulin-dependent (type 2) diabetes was evaluated prospectively in general practice. The four group sessions were mainly conducted by paramedical personnel. 65 patients from five general practices were assessed at the start of the programme and 50 (mean age 65 years, diabetes duration 7 years) completed the 1 year follow-up (intervention group). The control group consisted of 49 patients (mean age 63 years, diabetes duration 7 years) from three other general practices without the programme. In the intervention group the percentage of patients receiving sulfonylureas fell from 68% at the start of the study to 38% after 1 year (mean difference 30%, 95% confidence interval [CI] 16-44%); the mean weight loss was 2.7 kg (95% CI 1.6-3.8 kg), and non-fasting triglycerides were reduced by 0.77 mmol/1 (95% CI 0.35-1.19 mmol/l); and glycosylated haemoglobin remained unchanged (7.1% of total haemoglobin). In the control group none of these indices was changed during the study year, and 10% of patients started insulin treatment. The structured treatment and teaching programme improved the overall quality of patient care in elderly non-insulin-dependent diabetic patients treated by general practitioners.