Team Approach with Diabetes Patients

The team approach is optimal for working with patients with diabetes.
Assessing the psychological and physiological effects of stress, stress
management, and biofeedback on blood glucose control are necessary. In
addition to a physician with special expertise in diabetes, the team consists of
at least a certified biofeedback practitioner, a certificate diabetes practitioner,
a certified diabetes educator, and the patient. The team works together in
evaluating the effects of treatment on the physiological and psychological
aspects of glycemic control. Most biofeedback practitioners do not have
expertise in diabetes education and management. However, when they treat
patients with diabetes, they need to know the basic physiology of diabetes
and the fundamentals of diabetes management.

The psychologist practitioner carries out an initial interview with the diabetic
to determine stress -related physical and emotional symptoms. One assesses
the patient's perception of the effects of the stress on his or her blood glucose
and his or her perceived capabilities and management strategies.
Psychological testing also may be used to assess the person's level of
depression, anxiety, anger, and current stress.

The practitioner also conducts a psychophysiological assessment.

Practitioners differ on the specifics of this assessment but often monitor
multiple modalities. These often include muscle tension, skin conductance,
and blood flow in the hands (via skin temperature), heart rate, and breathing
during the resisting baseline, and during and after various standard office
stressors. Our laboratory measures frontal electromyography (EMG), heart
rate, blood pressure, and finger temperature while patients sit quietly with their
eyes closed. The practitioner provides biofeedback, relaxation therapies, and
stress management. Relaxation and biofeedback can help patients feel more
in control of their physiology, psychological state, and their illness.
Furthermore, decreased plasma levels of stress hormones and sympathetic
activity mediate lowered arousal and diminished hyperglycemia.

The diabetes educator (and or physician) can interpret blood glucose values
because he or she understands the effects of hypoglycemic medications, diet,
and exercise on blood glucose. This person also obtains information about the
person's diabetes care regime.

The diabetes educator studies:

History
1. Family history of diabetes
2. Other medical problems
3. Use of prescription and nonprescription medication
Medical Treatment Regimen for Diabetes, Knowledge, and Management
1. Diet: usual caloric intake, restrictions , time of meals , types and
amounts of food eaten, meal- planning skills, , compliance problems
2. Activity /exercise. Types.
Acute / Chronic Complications of Diabetes, Knowledge and Management
1. Hypoglycemia: frequency of episodes , signs and symptoms , and
usual causes

With this information, one identifies the patient's knowledge, current self,
management, self - care deficits and problems, and capabilities to make
appropriate decisions and manage his or her disease. This information
provides the basis for instructing the patient about diabetes care and
addressing problems with daily management during later session

Starting at the time of diagnosis, patients with diabetes need to adjust their
life-style and behavior significantly. They must incorporate diabetes
management behavior into their daily routine. Psychological adjustment to
IDDM and NIDDM often is problematic. Therefore, counseling and supportive
psychotherapy can be useful during the early weeks and months after
diagnosis. However, beginning a biofeedback -assisted relaxation program
may not be appropriate. Adding the clinic appointment for biofeedback and
home practice requirements necessary to learn relaxation techniques might
overload the resources of the patient. Furthermore, it would be difficult to
attribute improving in glycemic control to the biofeedback and relaxation
because the patient is starting multiple new behaviors concurrently.

Another reason for deferring biofeedback during the fist year after diagnosis
is the so -called diabetic "honeymoon period". This phenomenon is the partial
or complete remission of the signs and symptoms of diabetes soon after the
onset of IDDM when the pancreas temporarily produces insulin. The blood
glucose level may stabilize at close to normal, and the need for exogenous
insulin may decrease significantly or completely. This period may last one,
several, or, rarely, 12 months (Krall&Baser, 1989). One could mistakenly
attribute a decrease need for exogenous insulin to the biofeedback and stress
management treatment instead of to temporary pancreatic insulin production.
When the honeymoon period ends and the patient's beta cells are not longer
capable of producing insulin, the patient could misattribute the renewed need
for exogenous insulin as a total failure of the self-regulation process.

Within a stepped -care model consider starting more conservative relaxation

therapy or office-based biofeedback -assisted relaxation sooner than 12
months after diagnosis for selected patients. For example, one could start with
audio cassette relaxation instructions and printed patient education about
relaxation. The material should include information to avoid misattributions
about the honeymoon period.

Patients must at least partially accept the idea that stress can negatively
impact on glycemic control. Increased average blood glucose, a wider range
of values, an increase in fasting blood glucose, and sometimes more frequent
hypoglycemia are common stress effects reported by patients. If a patient is
unaware of or rejects the correlation between stress and blood glucose, then
perhaps stress is not affecting that person's blood glucose. However, if he or
she does not understand stress and is unaware of the potential or its effects,
the person may misunderstand its impact. In this case, educate the patients
about stress and its relationship to blood glucose. This can improve the
chance for treatment to help normalize blood glucose levels.

The goals of biofeedback-assisted are to:

1) Increase the person's ability to perceive and effectively manage stress.

2) Decrease the neural and endocrine systems' effect s on blood glucose and
insulin.
3) Reduce average blood glucose and increase the percentage of fasting
blood glucose values at target range.
4) reduce dosage of hypoglycemic medication if blood glucose levels are well
controlled at entry.

Relaxation therapies involve slow, diaphragmatic breathing, meditation,

autogenic phrases, and/or progressive muscle relaxation. One also may use
"positive imagery" with other relaxation therapies. Measure the person's blood
glucose before and after at least the first relaxation session. In our program,
most sessions include instruction and practice of autogenic phrases. About
one -fourth of the sessions include progressive relaxation.

There are no long term follow-up studies with diabetic population treated with
biofeedback or relaxation. However, we suggest periodic refresher sessions
as is common practice when treating other chronic disorders. The practitioner
and the patient determine the timing of the follow-up office sessions. One
periodically evaluates control described earlier.

1. Los miembros del equipo que participaron en este estudio

A. se han certificado como expertos en endocrinología.
B. realizan diferentes funciones acorde a sus conocimientos.
C. profundizan en los fundamentos fisiológicos de la diabetes.

2. Uno de los miembros del grupo que realice la retroalimentación al

paciente
A. debe percibir los efectos fisiológicos que produce y agrava la enfermedad en el paciente.
B. valora los diferentes estados emocionales del paciente antes de proporcionar el
medicamento adecuado.
C. evalúa la percepción que tiene el paciente sobre los efectos de la tensión en su
enfermedad.

3. La relajación con apoyo de la retroalimentación

A. favorece la reducción de los niveles plasmáticos de las hormonas del stress y la glicemia.
B. incluye siempre el estudio pormenorizado de las mismas modalidades fisiológicas
C. se lleva a cabo con el paciente en estado basal durante varias e intensas sesiones.

4. El educador en diabetes
A. debe, dentro de sus funciones y en primer lugar, educar al paciente en todos los aspectos
de su enfermedad y manejo diario.
B. analiza la enfermedad en forma global en relación al paciente, indaga sobre sus
conocimientos de la enfermedad y lo instruye en su manejo.
C. debe recibir un curso que lo instruya sobre la enfermedad antes de poder evaluar los
problemas que pueda presentar el paciente.

5. En el párrafo 5 el autor dice que en algunos casos iniciar un

programa de relajación asistida puede no ser apropiado para el
paciente.
A. debido a que el médico no sabría asignar el valor debido a las diferentes terapias que
recibe el paciente que tendría saturada su capacidad de adaptación.
B. porque este programa entraría en conflicto con la psicoterapia de apoyo que se aplica
durante las primeras semanas o meses después del diagnóstico.
C. por la serie de dificultades que se presentan, pues el paciente debe incorporar su
entendimiento y manejo de su diabetes a la rutina diaria.

6. La utilización de la relajación asistida durante los primeros meses

después del diagnóstico
A. evita la remisión parcial o completa de los síntomas del paciente durante el periodo llamado
"luna de miel".
B. interfiere con la disminución de la necesidad de insulina exógena del paciente diabético.
C. puede enmascarar la producción de la insulina pancreática temporal del periodo "luna de
miel".

7. La expresión a stepped-care model significa:

A. empezar poco a poco con el plan de relajación terapéutica.
B. tomar medidas más enérgicas para continuar con el modelo de atención.
C. dar los pasos necesarios para que el paciente adquiera la información necesaria.

8. Es esencial que el paciente conozca

A. el tratamiento médico que le ayude a normalizar sus valores glicémicos.
B. la relación que existe entre las situaciones tensas y los niveles de glucosa.
C. el impacto del aumento de la glucosa en el organismo y el manejo de la diabetes.

9. Parte de los objetivos de la relajación

A. es aminorar los efectos de los sistemas endócrino y nervioso en la glucosa y en la insulina.
B. es reducir la medicación hipoglicémica del paciente de acuerdo a controles establecidos de
antemano.
C. incrementar la habilidad del paciente para tratar de reducir su medición de glucosa en
ayunas.

10. La terapia de relajación involucra, entre otras cosas,

A. la relajación muscular y el uso de videos con imágenes agradables.
B. la medición de la glucosa en sangre antes y después de cada sesión.
C. la respiración diafragmática y una serie de frases auto-concebidas.

11. La terapia de relajación

A. ha sido estudiada en poblaciones de diabéticos crónicos desde hace mucho tiempo.
B. y sus sesiones de seguimiento se realizan de mutuo acuerdo entre el médico y el paciente.
 C. para diabéticos se practica por largos periodos puesto que la enfermedad es crónica.

Genetics: The Beginnigs

In 1865, Gregor Mendel presented two lectures in the Brno Natural Science
Society that summarized the results of his experiments on heredity in the
garden pea, Pisum sativum. Until the rediscovery of his work in 1900, the
material basis of inheritance was thought to be fluid in nature, and terms such
as "true blood" and "half blood" were thought to be scientifically correct. One
result was a general perception that ___1___ materials that were mixed could
not be separated. ___2___ was thought to alter the hereditary units or genes.
Mendel's major intellectual ___3___ was his demonstration that the
material ___4___ of inheritance was a particulate and that mixing did not alter
genes. His ___5___ in support of this conclusion was based on the second
generation reappearance of ___6___ present in one of the grandparental
peas used for his ___7___ . For example, he crossed round peas and
wrinkled peas to ___8___ a progeny generation that consisted entirely of
round peas. The ___9___ characteristics were not seen in the children. The
grandchild peas were, however, both ___10___ and wrinkled. The results
(round children and round and wrinkled ___11___ ) were clearly at variance
with the ___12___ of a fluid basis of inheritance that suggested that
the ___13___ and grandchildren should have been sort of wrinkled and sort
of round - fluid ___14___ of both parents' characteristics.
Today we can ___15___ a reasonably complete explanation of Mendel's
results with peas, ___16___ , and the inheritance of characters controlled by
single genes, in general. The ___17___ of wrinkled peas in the second
generation meant that the ___18___ (gene deoxyribonucleic acid [DNA]) to
produce wrinkles was ___19___ in the first generation plants, but was
not ___20___ . Since it was expressed in the second generation plants, the
information or DNA was ___21___ unchanged. The genetic information was
shown to be particulate rather than fluid. It is the particulate
unchanging ___22___ of the DNA molecule that allows DNA fingerprint.

1.
A. domineering
B. hereditary
C. characteristic

2.
A. Mixing
B. Melting
C. Growing

3.
A. behaviour
B. contribution
C. pattern

4.
A. equivalent
B. norm
C. basis

5.
A. evidence
B. technique
C. experience
6.
A. responses
B. characteristics
C. relationships

7.
A. studies
B. sequences
C. series

8.
A. avoid
B. repeat
C. produce

9.
A. flat
B. wrinkled
C. inconsistent

10.
A. round
B. harsh
C. distinct

11.
A. twins
B. sibilings
C. grandchildren

12.
A. hypothesis
B. system
C. sequence

13.
A. parents
B. children
C. relatives

14.
A. mixtures
B. figures
C. patterns

15.
A. avoid
B. persuade
C. provide

16.
A. for instance
B. in particular
C. for example

17.
A. vanishing
B. reappearance
C. fading

18.
A. election
B. probability
C. information

19.
A. present
B. connected
C. possible

20.
A. rejected
B. distinguished
 C. expressed

21.
A. transmitted
B. combined
C. supported

22.
A. supply
B. inheritance
C. nature