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I Mühlhauser

Publications and source records attributed to I Mühlhauser.

At least 55 records · Page 3Linked to original sources
PubMed1994

Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow--blood glucose versus urine glucose self-monitoring.

In a prospective controlled trial the effects of a 5-day in-patient treatment and teaching programme for Type 1 (insulin-dependent) diabetes mellitus on metabolic control and health care costs were studied in Moscow. Two different intervention programmes were compared, one based upon urine glucose self-monitoring (UGSM, n = 61) and one using blood glucose self-monitoring (BGSM, n = 60). Follow-up was 2 years. A control group (n = 60) continued the standard treatment of the Moscow diabetes centre and was followed-up for 1 year. Costs and benefits with respect to hospitalizations and lost productivity (according to average wage) were measured in November 1992 rubles (Rb.), with respect to imported drugs and test strips in 1992 German marks (DM). In the intervention groups there were significant decreases of HbA1 values [UGSM: 12.5% before, 9.4% after 1 year, 9.2% after 2 years (p < 0.0001); BGSM: 12.6% before, 9.3% after 1 year, 9.2% after 2 years (p < 0.0001) compared to no change in the control group (12.2% before, 12.3% after 1 year)], and of the frequency of ketoacidosis. The frequency of severe hypoglycaemia was comparable between the UGSM (10 cases during 2 years), BGSM (10 cases during 2 years), and the control group (8 cases during 1 year).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Cigarette smoking and diabetes: an update.

The article provides an overview of recent scientific information on the role of cigarette smoking in the prognosis of diabetes. Data sources included an English-language MEDLINE search for 1989 through 6/1993, supplemented by manual search of bibliographies of pertinent articles. Only studies of humans were considered. Cigarette smoking is related to the development and progression of diabetic nephropathy. Therefore, smoking status has to be taken into account in clinical studies on the course of nephropathy. The association between smoking and retinopathy is less consistent. Evidence is accumulating that cigarette smoking influences insulin action. Several large prospective cohort studies have shown that the relative risk for all-cause mortality is about twice as high for smoking compared to non-smoking diabetic patients. Strong associations are consistently found between cigarette-pack years and complications. It has been calculated that the theoretical benefit of stopping smoking is the most (cost-)effective risk factor intervention for diabetic patients. However, available programmes to help diabetic patients to stop smoking are unsuccessful.

Clinical Trials as Topic↗
PubMed1994

Predictors of glycaemic control in type 1 diabetic patients after participation in an intensified treatment and teaching programme.

The aim of the study was to identify predictors of long-term glycaemic control in Type 1 diabetic patients after participation in an intensified insulin treatment and teaching programme. The study population consisted of 697 Type 1 diabetic patients (mean age 26 +/- 7 (SD) years, duration of diabetes 8 +/- 7 years) who participated in the same structured intensified insulin treatment and teaching programme in 10 hospitals and who were re-examined after 1, 2, and 3 years. Multiple and logistic regression analyses were performed including a set of demographic, disease-related, social, and psychosocial variables as potential predictors. As dependent variables the average HbA1 values during the 3-year follow-up period and a composite variable (average HbA1 values/frequency of severe hypoglycaemia)--dividing patients into three groups with good, moderate or poor metabolic control--were considered. Regression analysis of average HbA1 values revealed significance (p < 0.05) for seven independent predictors in descending order: smoking, age at onset of diabetes, frequency of home blood glucose monitoring, socioeconomic status, diabetes-related knowledge, perceived coping abilities, and sex (R2 (percentage of variation explained by the model) = 17%). In a second regression model, HbA1 values before the intervention programme were added to the model and achieved the highest standardized regression coefficient (0.38), increasing R2 to 29%. In the logistic regression models considering both HbA1 and severe hypoglycaemia as a composite dependent variable, diabetes-related knowledge, HbA1 values before the intervention, smoking, perceived coping abilities, age at onset of diabetes, and C-peptide levels were the strongest predictors of glycaemic control. In conclusion, the relationship between demographic, disease-related, psychosocial, and social variables and metabolic control is complex. Therefore, simplistic concepts of linear causality should be abandoned. In addition to HbA1 values before the intervention, smoking, diabetes-related knowledge, home blood glucose monitoring, age at onset of diabetes, perceived coping abilities and C-peptide levels were the most significant and consistent predictors of glycaemic control.

Adolescent↗
PubMed1994

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.

Adult↗
PubMed1993

Effective and safe translation of intensified insulin therapy to general internal medicine departments.

Up to now all published experience with intensified insulin therapy has originated from specialized diabetes centres. However, even in diabetes centres and under research conditions intensification of insulin therapy may substantially increase the risk of severe hypoglycaemia. The aim of the present study was to demonstrate the feasibility of effectively and safely transferring intensified insulin therapy based upon a 5-day in-patient treatment and teaching programme from a University diabetes centre to non-specialized general hospitals. A total of nine general hospitals were recruited; the University diabetes centre served as a reference centre. From each general hospital a nurse and a dietitian were trained as diabetes educators, and a diabetes unit with about 10 beds was organized within each department of internal medicine. A total of 697 consecutively admitted Type 1 (insulin-dependent) diabetic patients (age 26 +/- 7 years, duration of diabetes 8 +/- 7 years) who participated in the programme either in one of the general hospitals (n = 579) or in the reference centre (n = 118) were re-examined after 1, 2 and 3 years. Insulin therapy was intensified to a similar extent in the reference centre and the general hospitals; at the 3-year follow-up about 80% of the patients injected insulin at least three times daily or used continuous subcutaneous insulin infusion (10%), and about 70% reported measuring blood glucose levels more than twice per day. HbA1 levels were lowered (p < 0.0001) to comparable levels, i.e. from 10.6% (reference centre) and 9.9% (general hospital), respectively, at baseline to 9.4% and 9.3%, respectively, at the 3-year follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Leucocyte count, proteinuria and smoking in type 1 diabetes mellitus.

A case-control study was carried out to analyse leucocyte counts in relation to proteinuria and smoking in type 1 (insulin-dependent) diabetes. The subjects were 180 smoking (87 women, age 32 +/- 11 years, diabetes duration 14 +/- 6 years) and 188 nonsmoking (88 women, age 32 +/- 11 years, diabetes duration, 14 +/- 6 years) type 1 diabetic patients. Leucocyte counts were higher in smokers than in nonsmokers, both in women (7.6 +/- 2.3 vs 6.8 +/- 1.9 x 10(9)/l, P < 0.01) and in men (8.1 +/- 2.7 vs 6.4 +/- 2.0 x 10(9)/l, P < 0.0001). Leucocyte counts correlated with the number of cigarettes smoked per day (r = 0.32, P < 0.0001), but were unrelated to glycosylated haemoglobin levels. Among nonsmokers, leucocyte counts were comparable between patients with normal proteinuria (6.7 +/- 2.2 x 10(9)/l, n = 106), microproteinuria (6.3 +/- 1.7 x 10(9)/l, n = 66) and macroproteinuria (6.8 +/- 1.1 x 10(9)/l, n = 16). Among smokers, patients with macroproteinuria or microproteinuria had higher leucocyte counts than those with normal proteinuria [8.9 +/- 3.0 x 10(9)/l, (n = 36) vs 8.4 +/- 2.7 x 10(9)/l (n = 61) vs 7.0 +/- 1.9 x 10(9)/l (n = 83); P < 0.0001)], a finding which was not due to differences in the number of cigarettes smoked per day. It is concluded that in these type 1 diabetic patients leucocyte counts were higher in smokers than in nonsmokers. Among nonsmokers leucocyte counts were comparable between patients with normal proteinuria and increased proteinuria, whereas among smokers leucocyte counts were higher in patients with increased proteinuria.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Diabetes education and insulin therapy: when will they ever learn?

The Diabetes Education Study Group of the European Diabetes Association was founded in 1979 with its major goal to make effective patient training an integral part of any diabetes therapy. However, even today, in many places diabetes education is not an obligatory part of treatment, but is regarded as an optional service to the patient which is frequently fragmentary and haphazard. On the other hand, many physicians still subject their patients to rigid dietary instructions and obedience training, an approach which is mistaken for diabetes education. Several misconceptions about diabetes education keep counteracting the spread and hence the availability of effective treatment and teaching programmes for all Type 1 diabetic patients. One such misconception is that diabetes education could compensate for deficiencies of inappropriate insulin treatment regimens. Studies failing to demonstrate the impact of diabetes education on metabolic control, typically used an insulin treatment regimen with only one or two insulin injections per day, the predominant use of intermediate acting insulin preparations, and without (day-to-day) adjustment of insulin dosages by the patients themselves. A further reason for a lack of success of diabetes education is an unstructured approach which is frequently mistaken for individualized care. The deleterious effects of putting patients on intensified insulin therapy without offering them sufficient and systematic training have manifested themselves at various places by an excessive increase in the risk of severe hypoglycaemia, and of ketoacidosis during therapy with continuous subcutaneous insulin infusion. The effective and safe performance of insulin therapy requires both a rational system of insulin substitution and intensive training of the patients to carry it out. The injection of regular insulin before main meals and the use of intermediate or long-acting insulin preparations for the substitution of basal insulin requirements combined with daily metabolic self-monitoring and (day-to-day) adaptation of insulin dosages by the patients themselves allow a substantial improvement of glycaemic control without an increase in the risk of severe hypoglycaemia and the adoption of a more flexible life style largely freed from forcing and directive dietary and other impositions. Each diabetes centre should continuously evaluate the quality of care offered to their patients as a basis for a specific and systematic improvement of its treatment and education programmes. Such quality control measures must include a recording of the patients' degree of metabolic control and the frequencies of severe hypoglycaemia and ketoacidosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Diabetes Mellitus, Type 1↗
PubMed1993

Behaviour therapy versus doctor's anti-smoking advice in diabetic patients.

OBJECTIVES: To evaluate the efficacy of a structured behaviour therapy programme on smoking cessation in diabetic patients. DESIGN: Prospective, randomized, controlled intervention study. SETTING: University out-patient diabetes clinic. SUBJECTS: A total of 794 consecutive insulin-treated smoking diabetic patients were invited to participate in a smoking cessation programme. Eighty-nine patients agreed to participate and were randomized in two groups. INTERVENTIONS: Forty-four patients were randomized to a structured extensive behaviour therapy anti-smoking intervention and 45 patients to a control group that received a single unstructured anti-smoking advice session given by a physician. MAIN OUTCOME MEASURES: After 6 months, nine patients were confirmed not to be smoking (i.e. urine cotinine concentration below 20 ng ml-1, 2 [5%] in the behaviour therapy intervention group and 7 [16%] in the control group. CONCLUSIONS: In diabetic patients an extensive behaviour therapy intervention for smoking cessation is no more successful than an unstructured physician's advice.

Adult↗
PubMed1993

Evaluation of a structured treatment and teaching programme on hypertension in general practice.

OBJECTIVE: Evaluation of a structured hypertension treatment and teaching programme in general practice. DESIGN: Prospective controlled trial; follow-up period 18 months. SETTING: 10 primary health care practices. PRACTICES AND PATIENTS: From each practice 20 patients (30 to 60 years old, mean of the last two blood pressure measurements at or above 160 and/or 95 mmHg) were randomly selected; in 5 practices these patients were to participate in the treatment and teaching programme; in the remaining 5 practices hypertension care was continued without the availability of such a programme (controls). INTERVENTION: Structured treatment and teaching programme based upon four group sessions for patients mainly conducted by paramedical personnel. MAIN OUTCOME MEASURES: Blood pressure, body weight, prescription of antihypertensive drugs - as documented in the patient's records. MAIN RESULTS: Of the 100 control patients 26 and of the 100 intervention patients 14 were lost to observation; 46 patients had agreed to participate in the programme. The mean number of prescribed antihypertensive agents per patient decreased in the intervention group (1.8 +/- 1.3 at baseline, vs 1.2 +/- 1.2 at follow-up) compared to the control group (1.6 +/- 1.3 vs 1.8 +/- 1.6); difference 0.8 (95% CI 0.4 to 1.1), p < 0.0001. In the control group 9% and in the intervention group 33% of patients had documented reductions of body weight (p < 0.0001). Blood pressure decreased in the intervention group (162 +/- 14/100 +/- 7 mmHg at baseline, vs 154 +/- 16/95 +/- 9 mmHg at follow-up) compared to the control group (161 +/- 13/98 +/- 7 mmHg vs 158 +/- 18/96 +/- 11 mmHg); differences for systolic blood pressure 5 (95% CI 0 to 10) mmHg, p = 0.071; for diastolic blood pressure 4 (1 to 7) mmHg, p = 0.018. CONCLUSIONS: The introduction of a structured hypertension treatment and teaching programme in general practice may lead to significant improvements of hypertension care.

Adult↗
PubMed1993

Improvement of hypertension care by a structured treatment and teaching programme.

Despite the availability of multiple nonpharmacological and pharmacological antihypertensive regimens large scale control of BP on a population basis is still unsatisfactory. To achieve a better quality in hypertension care we have developed and evaluated a structured outpatient hypertension treatment and teaching programme. This programme aims at improving of patients' compliance to antihypertensive therapy and is based on four groups sessions mainly conducted by paramedical personnel. This programme was evaluated in three different settings: in patients with hypertension, diabetes mellitus and poor compliance to antihypertensive drug therapy; in blind patients with diabetic nephropathy and severe hypertension; and in patients with essential hypertension as treated by primary healthcare physicians in general practice. In all three studies a significant improvement in compliance to antihypertensive therapy and, hence, in BP control was demonstrated leading to preservation of renal function in diabetic nephropathy and fewer drug prescriptions in essential hypertension. In conclusion, studies evaluating the effect of large scale implementation of such structured treatment and teaching programmes on the quality of hypertension care in the community should be carried out.

Antihypertensive Agents↗
PubMed1992

Quality assessment of diabetes care according to the recommendations of the St. Vincent Declaration: a population-based study in a rural area of Austria.

Using a mobile ambulance the quality of diabetes care was evaluated, according to the recommendations of the St. Vincent Declaration, in 95% of all known diabetic patients (n = 395) in a geographically defined rural area of Austria with 7871 inhabitants. Fourteen of the 395 patients had Type 1 (insulin-dependent) diabetes with age at onset of diabetes below 30 years. Of the 375 patients examined (women 61%, age 66 +/- 13 years, median diabetes duration 6 years) 16% were treated with insulin and 47% with oral agents; HbA1c levels were 7.3 +/- 1.7%. Prevalence of known hypertension was 54%; 68% of these patients had their blood pressure uncontrolled (systolic greater than or equal to 160 and/or diastolic greater than or equal to 95 mmHg); a further 15% of patients with previously unknown hypertension had blood pressure values of greater than or equal to 160 and/or greater than or equal to 95 mmHg. Urinary albumin concentrations of greater than 200 mg/l were found in 15% of patients, 2% had a serum creatinine level of greater than 177 mumol/l, no patient had renal replacement therapy. Six patients (1.5%) were blind. Screening for retinopathy identified six patients (out of 317 in whom the retina could be evaluated) for whom consultation with an ophthalmologist as soon as possible was recommended. Of the total patient group (n = 395) 20 patients (5%) had foot complications (amputations and/or ulcers): 14 patients had a total of 21 lower limb amputations (eight above knee, six below knee, seven below ankle); eight of these 14 patients lived in a nursing home; 11 patients had a total of 13 foot ulcers.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Evaluation of a structured treatment and teaching programme on asthma.

The objective of this study was to evaluate a structured treatment and teaching programme for adult patients with moderate to severe asthma. The design consisted of a prospective, before-after trial: the same consecutive patients were studied before and after intervention with observation periods 1 year before and 1 year after intervention. The investigation took place within a tertiary care centre (university hospital). A total of 142 consecutive patients were referred for in-patient treatment of their asthma, of whom 132 (93%) patients participated in the follow-up examination. The intervention consisted of a structured 5-d in-patient treatment and teaching programme presented by a specialized nurse educator. The aim of the programme was for the patient to assume greater responsibility for disease management, including self-monitoring of peak expiratory flow and qualified self-adaptation of drug therapy. The main outcome measures were the frequency of severe asthma attacks, hospitalization, and absenteeism from work (data provided by health insurance companies), patients' compliance and management skills. During the year before and the year after the intervention 71% and 36%, respectively of patients had one or more severe asthma attacks (mean difference 35%, 95% CI: 25-45%, P less than 0.0001). The percentage of patients who were hospitalized because of asthma decreased from 39% to 22% (mean difference 17%, 95% CI: 7-27%, P less than 0.002). The percentage of employed patients (n = 67) who were absent from work because of asthma decreased from 60% to 43% (mean difference 17%, 95% CI: 4-30%, P less than 0.04). The patients' adherence to maintenance drug therapy and their management skills improved significantly. It was concluded that the participation of patients with moderate to severe asthma in a structured treatment and teaching programme resulted in a substantial reduction in asthma morbidity in the year following the intervention.

Absenteeism↗
PubMed1991

Severe hypoglycemia in type I diabetic patients with impaired kidney function.

OBJECTIVE: To assess the frequency and possible risk indicators of severe hypoglycemia in insulin-dependent (type I) diabetic patients with impaired kidney function. RESEARCH DESIGN AND METHODS: Retrospective follow-up examination of case subjects and control subjects with mean follow-up periods of 2.9 and 1.3 yr, respectively. The setting was the diabetes center at the Düsseldorf University hospital. Subjects were consecutive type I diabetic patients. Case subjects consisted of 44 patients with initial serum creatinine levels of greater than or equal to 133 microM and pathological proteinuria. Control subjects consisted of 46 patients with normal serum creatinine levels matched for age, duration of diabetes, and hypertension; 57% of case subjects and 67% of control subjects were being treated with beta-blockers. Incidence of severe hypoglycemia (cases/patient-yr) was assessed through an interviewer-administered questionnaire. RESULTS: At comparable levels of HbA1c (7.9 +/- 1.8 vs. 7.6 +/- 1.1%), case subjects had a fivefold higher incidence of severe hypoglycemic episodes (1.28 vs. 0.25 cases/patient-yr, P less than 0.02) than control subjects. Within the group with impaired kidney function, patients with severe hypoglycemic episodes had lower HbA1c levels (7.4 +/- 1.6 vs. 8.7 +/- 2.0%, P less than 0.03) and a lower body mass index (22.0 +/- 3.4 vs. 24.4 +/- 3.8 kg/m2, P less than 0.04) than those without severe hypoglycemic episodes, whereas serum creatinine levels, body weight-related insulin dosage (U x kg-1 x day-1), prevalence of blindness, autonomic neuropathy, and treatment with beta-blockers were comparable. CONCLUSIONS: Type I diabetic patients with impaired kidney function are at an excessively high risk of severe hypoglycemia. In addition to low HbA1c levels, a low body mass index appears to be a risk indicator for this adverse effect of insulin therapy.

Adult↗
PubMed1991

Hypoglycemic symptoms and frequency of severe hypoglycemia in patients treated with human and animal insulin preparations.

OBJECTIVES: To compare hypoglycemic warning symptoms (main objective) and incidence of severe hypoglycemia (secondary objective) between patients treated with animal and human insulin preparations. RESEARCH DESIGN AND METHODS: Two hundred forty-seven patients on treatment with animal insulin preparations and 276 patients on human insulins, matched for duration of diabetes (16 +/- 11 vs. 15 +/- 10 yr), were recruited for the study. Patients were interviewed with a standardized questionnaire. RESULTS: When asked which symptom usually occurs first during hypoglycemia, 19% of the animal insulin group and 22% of the human insulin group answered "sweating," 19 and 17%, respectively, answered "trembling," and 15 and 11%, respectively, answered "unrest." According to the patients' perception, in both groups, their most reliable hypoglycemic warning symptoms were "trembling" (26 and 22%) and "sweating" (15 and 18%). Six and eight percent of patients, respectively, reported hypoglycemia unawareness and 17 and 18%, respectively, impaired awareness of hypoglycemia. The incidence of severe hypoglycemia was 0.45 cases/patient-yr in patients treated with animal insulins and 0.46 cases/patient-yr in patients treated with human insulin preparations. The differences were not statistically significant. CONCLUSIONS: This study shows that hypoglycemic warning symptoms and the incidence of severe hypoglycemia are comparable between patients on treatment with human and animal insulin preparations.

Adult↗