Steven B. Leichter

Diabetes patient education in hospital settings.

Most American hospitals apparently do not offer formal programs of diabetes-related patient education. In many in stitutions, patient educa tion consists only of the provision of written materials or is assumed to be an informal respon sibility of the primary care nurse. Both of these instructional arrangements are inadequate: many written materials are too difficult for patients to read, and most floor nurses lack the training to carry out diabetes patient education. As a result, substantial gaps exist in patient knowledge and performance of essential aspects of self-care. These gaps appear unrecognized in many institutions.

National standards for diabetes patient education programs: pilot study results and implementation plan. A report by the National Standards Steering Committee of the National Diabetes Advisory Board.

National Standards for Diabetes Patient Education Programs and a plan to implement them have been developed and pilot tested by the diabetes community in a four-year process conducted under the auspices of the Na tional Diabetes Advisory Board. The pilot study demonstrated the feasibil ity of implementing a na tional quality assurance process for diabetes pa tient education programs. Evidence from the pilot study also suggested that a national quality assur ance plan will foster third-party reimbursement for ambulatory diabetes patient education. The National Coalition for Recognition has been established to conduct for mal review and recogni tion of programs seeking to meet the National Standards.

Flexible Diets For Diabetes Care

The nutritional aspect of diabetes treatment is often the most difficult component of care for the patient and the health professional. The demands imposed by major alter ations in lifestyle, the artificiality of therapeutic eating pro grams, and the lack of available and proven counseling are possible causes of poor patient compliance. Diets may also be socially stigmatic to patients with diabetes. While advances have been made in many areas of nutrition and diabetes, there has been relatively little change in the traditional nutritional counseling methods, intended to lead to an understanding and adherence to a sound nutritional program. The evolving definition of the general goals of nutri tional therapy and the lack of success with traditional ap proaches to nutritional care of diabetes have recently stimu lated the search for alternate nutritional regimens. These programs have been called flexible diets. They all base food selection upon the quality of food content rather than food group as in the exchange diet. Indiuidual counseling is important and is directed primarily to modify present eat ing habits rather than radical changes. The continued de velopment of flexible diets may be an exciting area of nutri tional development in the future.

Third party reimbursement: an alternate approach.

active in this field. A recent study suggests that adequate patient education is available in less than ten percent of American hospitals.2 Less than ten percent of diabetic Americans may receive comprehensive instruction in selfcare.3 A lack of recognition of the importance of preventive care services (including patient education), and the lack of insurance reimbursement have been cited as two reasons for the rela-

The effects of nonsuppressible insulin-like protein (NSILP) on cyclic nucleotide metabolism in rat liver

Abstract Nonsuppressible insulin-like protein (NSILP), 100 ng/ml, inhibited cyclic AMP accumulation in rat liver, as stimulated by glucagon, 10 −7 M, from 493 ± 12 to 183 ± 7 pmoles/gm tissue (p −4 M, from 387 ± 12 to 233 ± 9 pmoles/gm tissue. With 1 μM as substrate, NSILP, 100 ng/ml, increased cAMP-dependent phosphodiesterase activity in liver slices from 19.08 ± 0.18 to 24.94 ± 0.38 pmoles cAMP hydrolyzed/mg protein/min (p

The Kentucky Diabetes Control Program and the Feasibility of the Pyramidal Model for Public Health Intervention in Diabetes Mellitus

The Kentucky Diabetes Control Program was the first statewide program to use an indirect, pyramidal model to achieve desired changes in health care delivery for diabetes. This model leverages the expertise of sub- specialists through regional sub specialty teams (RDTs) of allied health professionals to primary health professionals for use with their patients. It has the advantage of yielding geometric increases in the numbers of patients affected while utilizing the existing primary care system. The model was implemented throughout Kentucky over four years and now includes an admin istrative core, two subspecialty resource centers, and 18 RDTs, with a registered nurse and dietitian in each. During its first five years of operation, the program providedformal, continuing education in diabetes to 16, 035 health professionals. They, in turn, provided formal patient education to 20, 866 patients and family members. These results suggest the feasi bility of the indirect, pyramidal model as afunctional public health intervention in diabetes.

Third party reimbursement for diabetes care. II. The effects of DRGs.

There is increasing recognition of both the validity and the restricted availability of diabetes patient education as an integral component of diabetes care (Krall & Joslin, 1971; NDAB, 1981; Schoenrich, 1974; Geller & Butler, 1981). The delivery of patient education in both inpatient and outpatient settings is inadequate, when assessed by accepted standards (Leichter, 1982; Essig & Thielen, 1982). Reports of various recognized committees and confer-

Exogenous, but not endogenous, cyclic GMP reduces hepatic pyruvate kinase activity

We investigated the effects of exogenous cyclic GMP and stimulants of endogenous cyclic GMP accumulation on L-form (hepatic) pyruvate kinase (ATP: pyruvate 2-O-phosphotransferase, EC 2.7.1.40) activity in isolated rat hepatocytes. Exogenous cyclic GMP (200 muM) reduced pyruvate kinase activity, but was less potent than exogenous cyclic AMP (50 muM) (Ki congruent to 120 muM vs. 30 muM, respectively), had a slower onset of action (1.0 vs. 0.3 min, respectively) and a less rapid maximal effect (5.0 vs. 1.0 min, respectively). Similar results were noted with dibutyryl cyclic GMP or dibutyryl cyclic AMP. 1.0 muM acetylcholine increased cyclic GMP concentrations in isolated hepatocytes from 233 +/- 16 to 447 +/- 3 pmol/g cell protein (P less than 0.001), but did not alter pyruvate kinase activity. Similar results were noted with carbamylcholine, NaN3 or acetylcholine plus eserine sulfate. The results suggest a differential effect of exogenous vs. endogenous cyclic GMP on L-form pyruvate kinase activity, and question the physiological relevance of observations with exogenous cyclic GMP in this system.

Lack of effect of cholinergic agents or endogenous guanosine 3':5'-monophosphate on renin release by slices of rat renal cortex in vitro.

Abstract Cyclic GMP, in concentrations exceeding 50 μM, and cyclic AMP, in concentrations exceeding 1 μM, significantly increased the release of renin by slices of rat renal cortex. Stimulants of cyclic AMP accumulation, such as epinephrine or norepinephrine, 1 μM, produced a significant increase of renin release but did not alter cyclic GMP levels. In contrast, acetylcholine, carbamylcholine, bethanachol, methachol and NaN 3 increased cyclic GMP accumulation without modifying renin release. These results suggest that exogenous cyclic GMP acts as a weak agonist of cyclic AMP on renin release in renal cortex. The effects observed with exogenous cyclic GMP, however, may not represent a physiological action since various stimulants of endogenous cyclic GMP accumulation did not alter renin secretion.