Using continuous quality improvement to improve diabetes care in populations: the IDEAL model. Improving care for Diabetics through Empowerment Active collaboration and Leadership.

BACKGROUND: The care of patients with chronic diseases, especially those with diabetes mellitus, has been less than ideal. However, despite clear national guidelines, various examples of better care models, and multiple attempts to improve care, an effective process for facilitating and replicating diabetes care improvements in typical primary care practices has been elusive. METHODS: On the basis of the approach and lessons from developmental work at the Minnesota Diabetes Control Program and a trial of continuous quality improvement for clinical preventive services (IMPROVE), a clinic-based intervention processes (IDEAL) has been developed to improve the system and process of care for patients with diabetes as a model for all chronic diseases. The intervention incorporates facilitation of leadership actions in support of change, training for the leader and facilitator of an intraclinic multidisciplinary continuous quality improvement (CQI) team, and consultative and networking support of the change process. Each element of this intervention emphasizes a seven-step process improvement approach and a system for care of patients with diabetes. This model is being developed and tested in a unique partnership between the Minnesota Department of Health and HealthPartners, a large managed care organization (MCO). RESULTS: A prepilot demonstration has succeeded in improving glycemic control, three primary care clinics affiliated with HealthPartners have succeeded in a pilot of the intervention, and an additional 13 clinics are participating in a randomized controlled trial of a refined intervention. CONCLUSIONS: The IDEAL model holds promise for substantial improvements in care, not only for diabetes but for all chronic diseases and for other settings.

Identification of a multifunctional, cell-binding peptide sequence from the a1(NC1) of type IV collagen.

We have previously identified three distinctive amino acid sequences from type IV collagen which specifically bound to heparin and also inhibited the binding of heparin to intact type IV collagen. One of these chemically synthesized domains, peptide Hep-I, has the sequence TAGSCLRKFSTM and originates from the a1(noncollagenous [NC1]) chain of type IV collagen (Koliakos, G. G., K. K. Koliakos, L. T. Furcht, L. A. Reger, and E. C. Tsilibary. 1989. J. Biol. Chem. 264:2313-2323). We describe in this report that this same peptide also bound to intact type IV collagen in solid-phase assays, in a dose-dependent and specific manner. Interactions between peptide Hep-I and type IV collagen in solution resulted in inhibition of the assembly process of this basement membrane glycoprotein. Therefore, peptide Hep-I should represent a major recognition site in type IV collagen when this protein polymerizes to form a network. In addition, solid phase-immobilized peptide Hep-I was able to promote the adhesion and spreading of bovine aortic endothelial cells. When present in solution, peptide Hep-I competed for the binding of these cells to type IV collagen- and NC1 domain-coated substrata in a dose-dependent manner. Furthermore, radiolabeled peptide Hep-I in solution also bound to endothelial cells in a dose-dependent and specific manner. The binding of radiolabeled Hep-I to endothelial cells could be inhibited by an excess of unlabeled peptide. Finally, in the presence of heparin or chondroitin/dermatan sulfate glycosaminoglycan side chains, the binding of endothelial cells to peptide Hep-I and NC1 domain-coated substrates was also inhibited. We conclude that peptide Hep-I should have a number of functions. The role of this type IV collagen-derived sequence in such diverse phenomena as self-association, heparin binding and cell binding and adhesion makes Hep-I a crucial domain involved in the determination of basement membrane ultrastructure and cellular interactions with type IV collagen-containing matrices.

Laminin alterations after in vitro nonenzymatic glycosylation.

Laminin, a basement membrane protein derived from the matrix of the Engelbreth-Holm-Swarm murine tumor, was nonenzymatically glycosylated in vitro in the presence of increasing glucose concentrations. The amount of glucose incorporated per laminin molecule was shown to be proportional to the molarity of glucose used. Nonenzymatic glycosylation resulted in formation of cross-links and alterations of the cruciform shape of laminin molecules; these alterations were dramatic when high concentrations of glucose were used. One of the functions of laminin, the process of self-assembly, was shown to be impaired after in vitro nonenzymatic glycosylation. Glucose incorporation resulted in a dramatic decrease of long-to-long laminin dimers, which normally form during the initial steps of assembly. Furthermore, nonenzymatic glycosylation of laminin reduced its ability to self-associate into complexes larger than dimers, as judged by turbidimetry. The observed decrease of maximal turbidity was proportional to the degree of nonenzymatic glycosylation. Aminoguanidine, which has been suggested to inhibit cross-link formation, was shown to restore to a large extent the shape of laminin, the percentage of long-to-long arm dimers, and the maximal turbidity when included in the mixtures of laminin and glucose. These data suggest that structural and functional alterations of laminin may be primarily due to formation of cross-links. Such modifications of laminin (along with our basement membrane components) may contribute to the morphological and physiological changes observed in basement membranes under diabetic conditions.

The binding of heparin to type IV collagen: domain specificity with identification of peptide sequences from the alpha 1(IV) and alpha 2(IV) which preferentially bind heparin.

Three distinctive heparin-binding sites were observed in type IV collagen by the use of rotary shadowing: in the NC1 domain and at distances 100 and 300 nm from the NC1 domain. Scatchard analysis indicated different affinities for these sites. Electron microscopic analysis of heparin-type IV collagen interaction with increasing salt concentrations showed the different affinities to be NC1 greater than 100 nm greater than 300 nm. The NC1 domain bound specifically to chondroitin/dermatan sulfate side chains as well. This binding was observed at the electron microscope and in solid-phase binding assays (where chondroitin sulfate could compete for the binding of [3H]heparin to NC1-coated substrata). The triple helix-rich, rod-like domain of type IV collagen did not bind to chondroitin/dermatan sulfate side chains. In solid-phase binding assays only heparin could compete for the binding of [3H]heparin to this domain. In order to more precisely map potential heparin-binding sites in type IV collagen, we chemically synthesized 17 arginine- and lysine-containing peptides from the alpha 1(IV) and alpha 2(IV) chains. Three peptides from the known sequence of the alpha 1(IV) and alpha 2(IV) chains were shown to specifically bind heparin: peptide Hep-I (TAGSCLRKFSTM), from the alpha 1(NC1) chain, peptide Hep-II (LAGSCLARFSTM), a peptide corresponding to the same sequence in peptide Hep-I from the alpha 2 (NC1) chain, and peptide Hep-III (GEFYFDLRLKGDK) which contained an interruption of the triple helical sequence of the alpha 1(IV) chain at about 300 nm from the NC1 domain, were demonstrated to bind heparin in solid-phase binding assays and compete for the binding of [3H]heparin to type IV collagen-coated substrata. Therefore, each of these peptides may represent a potential heparin-binding site in type IV collagen. The mapping of the binding of heparin or related structures, such as heparan sulfate proteoglycan, to specific sequences of type IV collagen could help the understanding of several structural and functional properties of this basement membrane protein as well as interactions with other basement membrane and/or cell surface-associated macromolecules.

Heparin type IV collagen interactions: equilibrium binding and inhibition of type IV collagen self-assembly.

Interactions between type IV collagen and heparin were examined under equilibrium conditions with rotary shadowing, solid-phase binding assays, and affinity chromatography. With the technique of rotary shadowing and electron microscopy, heparin appeared as thin, short strands and bound to the following three sites: the NC1 domain, and in the helix, at 100 and 300 nm from the NC1 domain. By solid-phase binding assays the binding of [3H]heparin in solution to type IV collagen immobilized on a solid surface was found to be specific, since it was saturable and could be displaced by an excess of unlabeled heparin. Scatchard analysis indicated three classes of binding sites for heparin-type IV collagen interactions with dissociation constants of 3, 30, and 100 nM, respectively. Furthermore, by the solid-phase binding assays, the binding of tritiated heparin could be competed almost to the same extent by unlabeled heparin and chondroitin sulfate side chains. This finding indicates that chondroitin sulfate should also bind to type IV collagen. By affinity chromatography, [3H]heparin bound to a type IV collagen affinity column and was eluted with a linear salt gradient, with a profile exhibiting three distinct peaks at 0.18, 0.22, and 0.24 M KCl, respectively. This suggested that heparin-type IV collagen binding was of an electrostatic nature. Finally, the effect of the binding of heparin to type IV collagen on the process of self-assembly of this basement membrane glycoprotein was studied by turbidimetry and rotary shadowing. In turbidity experiments, the presence of heparin, even in small concentrations, drastically reduced maximal aggregation of type IV collagen which was prewarmed to 37 degrees C. By using the morphological approach of rotary shadowing, lateral associations and network formation by prewarmed type IV collagen were inhibited in the presence of heparin. Thus, the binding of heparin resulted in hindrance of assembly of type IV collagen, a process previously described for interactions between various glycosaminoglycans and interstitial collagens. Such regulation may influence the assembly of basement membranes and possibly modify functions. Furthermore, qualitative and quantitative changes of proteoglycans which occur in certain pathological conditions, such as diabetes mellitus, may alter molecular assembly and possibly permeability functions of several basement membranes.

A novel synthetic peptide from the B1 chain of laminin with heparin-binding and cell adhesion-promoting activities.

Recent studies using solid-phase-binding assays and electron microscopy suggested the presence of a heparin-binding domain between the inner globule of a lateral short arm and the cross region of laminin. Using the information from the amino acid sequence of the B1 chain of laminin, several peptides were synthesized from areas with a low hydropathy index and a high density of lysines and/or arginines. One of these, peptide F-9 (RYVVLPRPVCFEKGMNYTVR), which is derived from the inner globular domain of the lateral short arm, demonstrated specific binding to heparin. This was tested in direct solid-phase binding assays by coating the peptide either on nitrocellulose or on polystyrene and in indirect competition assays where the peptide was in solution and either laminin or heparin was immobilized on a solid support. The binding of [3H]heparin to peptide F-9 was dramatically reduced when heparin but not other glycosaminoglycans other than heparin (dextran sulfate, dermatan sulfate) were used in competition assays. Modification of the free amino groups of peptide F-9 by acetylation abolished its ability to inhibit the binding of [3H]heparin to laminin on polystyrene surfaces. Peptide F-9 promoted the adhesion of various cell lines (melanoma, fibrosarcoma, glioma, pheochromocytoma) and of aortic endothelial cells. Furthermore, when peptide F-9 was present in solution, it inhibited the adhesion of melanoma cells to laminin-coated substrates. These findings suggest that peptide F-9 defines a novel heparin-binding and cell adhesion-promoting site on laminin.

Molecular mechanisms in basement membrane complications of diabetes. Alterations in heparin, laminin, and type IV collagen association.

We report alterations in the ligand-binding properties of laminin, the major noncollagenous protein of basement membranes, resulting from nonenzymatic glycosylation in vitro. Mouse laminin was incubated in vitro with 500 mM glucose, and the level of nonenzymatically glycosylated amino acids increased 2-, 6.2-, and 12-fold after incubation for 1, 3, and 12 days, respectively. Ligand binding assays conducted in solution with varying concentrations of [3H]heparin and a constant amount of control or nonenzymatically glycosylated laminin showed a reduction in heparin binding proportional to laminin glycosylation. An analysis of the stoichiometry of [3H]heparin binding to control and nonenzymatically glycosylated laminin at saturating levels of heparin was performed. The results indicated that the total number of heparin binding sites on laminin decreased 4.7- and 14.7-fold due to nonenzymatic glycosylation of laminin for 1 and 3 days, respectively. [3H]heparin binding to 12-day nonenzymatically glycosylated laminin was abolished. Scatchard analyses of the binding data for heparin and laminin gave a dissociation constant (Kd) of 3.4 X 10(-8) M. The data for nonenzymatic glycosylation of laminin for 1 day in vitro resulted in a biphasic heparin binding curve. Both high- and low-affinity binding was observed (Kd values of 3.3 x 10(-8) and 2.6 x 10(-7) M, respectively). Similar high- and low-affinity binding sites were seen on 3-day nonenzymatically glycosylated laminin (Kd values of 2.1 x 10(-8) and 3.9 x 10(-7) M, respectively). [3H]heparin binding at a fixed concentration to a constant amount of control or 12-day nonenzymatically glycosylated laminin and type IV collagen was also studied.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of nonenzymatic glucosylation on the binding of the main noncollagenous NC1 domain to type IV collagen.

Type IV collagen has the ability to self-assemble by amino end, carboxyl end, and lateral associations to complex network-like structures which can be visualized by rotary shadowing. The main noncollagenous NC1 domain which is located at the carboxyl end of type IV collagen molecules binds to itself to form dimers and also binds along the length of type IV collagen. The latter binding initiates lateral assembly. Following in vitro nonenzymatic glucosylation of the isolated NC1 domain, binding to the helix-rich domain of type IV collagen was impaired. In turbidity experiments, the nonenzymatically glucosylated NC1 domain minimally suppressed the development of turbidity of collagen solutions when compared to control NC1 domain. In rotary shadowing experiments nonenzymatically glucosylated NC1 domain did not significantly inhibit lateral associations or networks formed by type IV collagen, whereas control NC1 domain caused a drastic decrease in laterally assembled structures. These data suggest that nonenzymatic glucosylation of the NC1 domain may interfere with normal assembly of type IV collagen in diabetes mellitus and may be related to abnormal functions of basement membranes in this pathological condition.

Decreased interaction of fibronectin, type IV collagen, and heparin due to nonenzymatic glycation. Implications for diabetes mellitus.

The nonenzymatic glycation of basement membrane proteins, such as fibronectin and type IV collagen, occurs in diabetes mellitus. These proteins are nonenzymatically glycated in vivo and can also be nonenzymatically glycated in vitro. After 12 days of incubation at 37 degrees C with 500 mM glucose, purified samples of human plasma fibronectin and native type IV collagen showed a 13.0- and 4.2-fold increase, respectively, in glycated amino acid levels in comparison to control samples incubated in the absence of glucose. Gelatin (denatured calfskin collagen) was glycated 22.3-fold under the same conditions. Scatchard analyses were performed on the binding of radiolabeled fibronectin to gelatin or type IV collagen. It was found that there is a 3-fold reduction in the affinity of fibronectin to type IV collagen due to the nonenzymatic glycation of fibronectin. The dissociation constant (KD) for the binding of control fibronectin to type IV collagen was 9.6 X 10(-7) M while the KD for glycated fibronectin and type IV collagen was 2.9 X 10(-6) M. This was similar to the 2.7-fold reduction in the affinity of fibronectin for gelatin found as a result of the nonenzymatic glycation of fibronectin (KD of 4.5 X 10(-7) M for the interaction of control fibronectin with gelatin vs. KD of 1.2 X 10(-6) M for the interaction of nonenzymatically glycated fibronectin with gelatin). The molecular association of control fibronectin or its glycated counterpart with [3H]heparin was also determined. Scatchard analyses of this interaction showed no difference between control fibronectin and glycated fibronectin in [3H]heparin binding.(ABSTRACT TRUNCATED AT 250 WORDS)

Developmental analysis of Drosophila position-specific antigens.

The distributions of three position-specific (PS) antigens have been examined in different Drosophila tissues and at various developmental times, using both immunofluorescence and affinity purification procedures. In the imaginal discs the PS antigens show nonuniform and nonhomologous distributions, and the expression of the antigens in a particular disc region can vary during development. In general, PS antigen expression appears to correlate with morphogenetic events in the disc epithelia, suggesting that the antigens are involved in cell-cell recognition and/or adhesion processes. PS antigens are also found in many other tissues, and in embryos as early as the cellular blastoderm stage. Affinity-purified PS antigens from different tissues or stages appear to be similar, as judged by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The results are discussed in relation to Drosophila developmental events, with particular regard to the dorsoventral cell lineage restriction in the wing disc.

Related cell-surface antigens expressed with positional specificity in Drosophila imaginal discs.

We have isolated three classes of monoclonal antibodies against Drosophila cell-surface antigens that are expressed with positional specificity in imaginal discs. Comparison of immunofluorescence patterns with the wing-disc fate map reveals that expression of the antigens is not directly related to the specific type of cuticular structure that a cell will make upon differentiation but depends on the position of the cell in the undifferentiated disc epithelium. On mature wing discs, each class of position-specific (PS) antibody binds nonuniformly with respect to the dorso-ventral compartment boundary, with PS1 antibodies binding primarily to dorsal cells and PS2 antibodies, to ventral cells. Antibodies of the different PS classes extract similar but nonidentical sets of large glycoproteins from cell lysates, and antibodies of the most general class, PS3, recognize the PS1 and PS2 antigens in addition to PS3-specific components. Thus, the distributions and molecular characteristics of the PS antigens suggest that the molecules are structurally and functionally related to one another.