Challenges faced by people with a stoma: peristomal body profile risk factors and leakage

AIM

The Ostomy Life Study 2019 aimed to obtain a better understanding of the challenges faced by people with stoma.

METHODS

Online survey with participants from 17 countries.

FINDINGS

Of the 54 614 individuals invited to take part, 5187 responded; 62% of the respondents avoided physical and social activities because of their stoma and 37% had never consulted their stoma care nurse to have the fit of their stoma product checked. In a subgroup receiving questions on leakage (n=4209), output under the baseplate and leakage onto clothes were experienced within the previous month by 76% and 26% of respondents, respectively. Higher chance of leakage was associated with an irregular stoma shape and peristomal body profile; a stoma level at or below the skin surface; and the presence of creases, folds and other changes in the peristomal area.

CONCLUSION

Leakage and access to a stoma care nurse to provide the necessary care and guidance remain important concerns for individuals with a stoma.

Ostomy Complications and Quality of Life of Ostomy Support Belt/Garment Wearers: A Web-Based Survey

PURPOSE

The purpose of this study was to examine ostomy complications and health-related quality of life (QOL) in individuals with an ostomy who wear an ostomy support belt/garment.

DESIGN

A mixed-methods descriptive study.

SUBJECTS AND SETTING

Two hundred two community-living adults with an ostomy were recruited using an industry distribution list. The target sample had no geographic restrictions.

METHODS

Descriptive analysis was conducted for all outcomes. Participants were separated into groups depending on type of ostomy belt or belt/garment worn or none. All categorical data were summarized using percentages and numerical data using mean ± standard deviation. Association between categorical factors was evaluated using a χ2 test and proportions of occurrences from 2 groups were compared using a 2-proportion z-test. The mean outcomes for 2 or more groups were compared using t tests or analysis of variance (ANOVA), respectively. If ANOVA showed difference among groups, post hoc analysis of group means was conducted using Tukey's Honestly Significant Difference (HSD) test.

RESULTS

Two hundred two respondents completed the survey. Of the 174 participants who responded to the survey question on leakage, 157 (90%) reported experiencing leakage and 135 (77.59%) reported rash or skin irritation. Comparison of whether participants had ever experienced a leakage event was not significantly different across groups (P = .3663). Those who wore an ostomy support belt/garment reported leakage less often (less than once a month) versus respondents who wore other types of belts or no belt (n = 49, 73.13% vs n = 53, 59.55%; P = .0388). Of the 174 participants who responded to the peristomal skin question, 135 (77.59%) participants reported peristomal skin complications. Significantly fewer participants who wore an ostomy support belt/garment reported having peristomal skin irritation compared to those who wore other types of belts or no belt (69.01% vs 84.16%; P = .0080). The mean cumulative total City of Hope Quality of Life (COH QOL) Ostomy score for all participants was 6.45 ± 1.36 out of 10, with the psychosocial domain scoring the lowest at 5.67 ± 1.30 out of 10. No significant differences were observed in mean QOL domain and total scores by those who wore an ostomy support belt/garment, other type of belt/garment, and none. When comparing COH QOL mean scores and leakage frequency of more/less once a month, those who reported leakage more often had significantly worse QOL scores in all 4 domains as well as total scores: physical (P = .0008), psychological (P = .0154), social (P = .0056), spiritual (P = .0376), and total COH QOL score (P = .0018).

CONCLUSION

This study provides important information related to ostomy complications and QOL associated with wearing an ostomy belt or belt/garment. The use of an ostomy support belt/garment may offer an additional intervention to decrease frequency of leakage and peristomal skin irritation and improve QOL.

Risk factors and treatment outcomes of peristomal pyoderma gangrenosum in patients with inflammatory bowel disease

BACKGROUND

Insufficient data exist for peristomal pyoderma gangrenosum (PPG), which primarily affects patients with inflammatory bowel disease (IBD).

AIMS

To evaluate the risk factors and treatment response of PPG in IBD patients in a real-life cohort.

METHODS

Cases of PPG were identified retrospectively using ICD-9/10 codes in patients with IBD who had an ostomy at a tertiary care centre. Disease-specific characteristics were compared between groups with and without PPG, and response to therapy was evaluated in patients with PPG.

RESULTS

The cohort included 41 IBD patients with PPG and 123 IBD controls with an ostomy who never developed PPG. Patients with PPG were more likely to be female (76% vs 51%, P = 0.006), had higher BMIs (29.78 ± 0.89 vs 23.53 ± 0.51, P < 0.0001) and had increased usage of pouch belts (97% vs 71%, P = 0.0008) compared to controls. There were no differences in age at surgery (41.76 ± 2.60 vs 43.49 ± 1.50, P = 0.57) or IBD diagnosis (63% vs 54% Crohn's disease, P = 0.28) between PPG and controls. 85% of PPG patients achieved complete resolution with different treatments, including surgery. Complete resolution with topical corticosteroids and calcineurin inhibitors alone were low (14% and 13% respectively). Higher rates of complete resolution were reported with anti-tumour necrosis factor (TNF) agents (63%) and surgical interventions (80%).

CONCLUSIONS

Female gender, higher BMI and pouch belts were associated with increased risk of developing PPG. Most PPG cases resolved after treatment with the highest rates of complete resolution seen with anti-TNF agents and surgical intervention.

Stress Management Competency Framework in English policing

Background

The UK Health and Safety Executive’s Stress Management Competency Framework and associated questionnaire, the Stress Management Competency Indicator Tool (SMCIT), address line managers’ behaviours across four competency areas. The application in policing remains unexplored.

Aims

This study profiled English police officers’ perception of their line managers’ competencies in the framework areas. The odds of experiencing poor mental wellbeing and work attitudes associated with having a line manager with a development need on each competency area were tested.

Methods

Two hundred and sixty-three police officers completed a survey comprising the SMCIT and measures of psychological distress, resilience and work engagement. Bivariate correlations were calculated to identify patterns of relationships between variables. Binary logistic regression analyses tested the odds of psychological distress caseness, low resilience and low work engagement being associated with officers’ perception of their line manager having a development need on the SMCIT criteria.

Results

Approximately half the participants reported their line manager had a development need on the ‘Managing and Communicating Existing and Future Work’, ‘Managing the Individual Within the Team’ and ‘Reasoning and Managing Difficult Situations’ competencies, and one quarter on the ‘Respectful and Responsible: Managing Emotions and Having Integrity’ competency. Officers’ rating of their line manager having a development need on the four competency areas was associated with up to four-fold elevated odds of each undesirable state.

Conclusions

The framework competency areas are relevant to English policing and offer a basis for stress reduction interventions targeted at line managers’ behaviours.

Creating consensus-based practice guidelines with 2000 nurses

Medical professionals follow evidence-based practice guidelines to achieve effective patient outcomes. Traditionally, to develop guidelines, a small group of experts examine evidence then agree on a set of statements, which are then published in journals. However, more than 7000 primary care journal articles are published monthly. This study examined a different way of drawing up practice guidelines, which involved large numbers of nurses from different countries directly in developing then disseminating the guidelines to speed up acceptance and the implementation of best practice. The results were consensus-based best practice guidelines for the treatment of patients with ostomies, which have received a high level of acceptance and enthusiasm from practitioners in 27 countries.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Costs of an ostomy self-management training program for cancer survivors

OBJECTIVE

To measure incremental expenses to an oncologic surgical practice for delivering a community-based, ostomy nurse-led, small-group, behavior skills-training intervention to help bladder and colorectal cancer survivors understand and adjust to their ostomies and improve their health-related quality of life, as well as assist family caregivers to understand survivors' needs and provide appropriate supportive care.

METHODS

The intervention was a 5-session group behavior skills training in ostomy self-management following the principles of the Chronic Care Model. Faculty included Wound, Ostomy, and Continence Nurses (WOCNs) using an ostomy care curriculum. A gender-matched peer-in-time buddy was assigned to each ostomy survivor. The 4-session survivor curriculum included the following: self-management practice and solving immediate ostomy concerns; social well-being; healthy lifestyle; and a booster session. The single family caregiver session was coled by a WOCN and an ostomy peer staff member and covered relevant caregiver and ostomate support issues. Each cohort required 8 weeks to complete the intervention. Nonlabor inputs included ostomy supplies, teaching materials, automobile mileage for WOCNs, mailing, and meeting space rental. Intervention personnel were employed by the University of Arizona. Labor expenses included salaries and fringe benefits.

RESULTS

The total incremental expense per intervention cohort of 4 survivors was $7246 or $1812 per patient.

CONCLUSIONS

A WOCN-led group self-help ostomy survivorship intervention provided affordable, effective, care to cancer survivors with ostomies.

Intestinal Stomas-Postoperative Stoma Care and Peristomal Skin Complications

Intestinal stomas are necessary for several colon and rectal conditions and represent a major change in the new ostomate's daily life. Though dehydration is the most frequent etiology requiring readmission, irritant contact dermatitis and a host of other peristomal skin conditions are more common complications for ostomates. Wound, ostomy, and continence nurses are invaluable resources to both ostomy patients and providers. A few simple interventions can prevent or resolve most common peristomal complications. Good stoma care is possible in a resource-poor environment.

Enceladus' Water Vapor Plume

The Cassini spacecraft flew close to Saturn's small moon Enceladus three times in 2005. Cassini's UltraViolet Imaging Spectrograph observed stellar occultations on two flybys and confirmed the existence, composition, and regionally confined nature of a water vapor plume in the south polar region of Enceladus. This plume provides an adequate amount of water to resupply losses from Saturn's E ring and to be the dominant source of the neutral OH and atomic oxygen that fill the Saturnian system.

Pathogenesis of vascular disease

Only recently are we beginning to understand the complex interplay of factors involved in vascular disease and diabetes. Insulin resistance provides a starting point to explain the many factors that lead to the more severe vascular disease characteristic of diabetes. Insulin resistance syndrome comprises insulin resistance and compensatory hyperinsulinaemia as well as hypertension, dyslipidaemia, macrovascular disease, and increased plasminogen activator inhibitor-1 activity. The development of type 2 diabetes may be viewed as the inability of the pancreas to continue to overcome insulin resistance, even with excessive insulin production.

Negative correlates of computer game play in adolescents

There is some concern that playing computer games may be associated with social isolation, lowered self-esteem, and aggression among adolescents. Measures of these variables were included in a questionnaire completed by 204 year eight students at a North London comprehensive school. Principal components analysis of a scale to assess needs fulfilled by game play provided some support for the notion of 'electronic friendship' among boys, but there was no evidence that game play leads to social isolation. Play was not linked to self-esteem in girls, but a negative relationship was obtained between self-esteem and frequency of play in boys. However, self-esteem was not associated with total exposure to game play. Aggression scores were not related to the number of games with aggressive content named among three favourite games, but they were positively correlated with total exposure to game play. A multiple regression analysis revealed that sex and total game play exposure each accounted for a significant but small amount of the variance in aggression scores. The positive correlation between playing computer games and aggression provides some justification for further investigation of the causal hypothesis, and possible methodologies are discussed.

The ability to detect unseen staring: a literature review and empirical tests

There is evidence to suggest that individuals not only believe in their ability to detect an unseen gaze, but may genuinely be able to do so. The present study reviewed past research and sought to determine whether such a phenomenon was empirically demonstrable. In Expt 1, 12 participants responded to 12 sequences (with feedback in the last nine) of 20 trials each, with staring or non-staring episodes based on Sheldrake's random number sequences. No effects were obtained when no feedback was given. With feedback, more accurate than mean chance expectation (MCE) results were obtained on staring, but no difference on non-staring trials. However other 'normal' explanations of ESP phenomena discuss the possibility of matching in bias between experimental sequences and participants' representations of randomness. Tests of the sequences found more alternations than expected, a feature typical of subjective randomness, but the increase in accuracy found on staring trials only was not consistent with this explanation. It was concluded that the improvement in accuracy with feedback is likely to be due to implicit learning, given the structure in non-random sequences. This hypothesis was supported in Expt 2 where 12 participants responded to 12 'genuinely random' sequences, and no differences in accuracy from MCE were obtained.

The effects of intensive glycemic control on neuropathy in the VA cooperative study on type II diabetes mellitus (VA CSDM)

To determine whether a difference in HbA(1c) could be safely sustained between a standard therapy (STD) arm and an intensive therapy (INT) arm, while maintaining HbA(1c) levels in both arms within a range acceptable in community practice. The effects of intensive treatment on various parameters were studied in this feasibility trial. We report here the results of 24 months of INT on peripheral and autonomic neuropathy.A prospective trial was conducted in five medical centers in 153 men of 60 +/- 6 years of age who had a known diagnosis of diabetes for 7.8 +/- 4 years. They were randomly assigned to a standard insulin treatment group (one morning injection per day) or to an intensive therapy group designed to attain near-normal glycemia and a clinically significant separation of glycohemoglobin from the standard arm. A four-step plan was used in the intensive therapy group along with daily self-monitoring of glucose: (1) an evening insulin injection, (2) the same injection adding daytime glipizide, (3) two injections of insulin alone, and (4) multiple daily injections. Peripheral neuropathy was diagnosed clinically by a history and physical examination, and by abnormal autonomic neuropathy Valsalva ratio (VR < 1.2) and RR variation (RRV < 10). An average HbA(1c) separation of 2.07% was achieved with INT, having HbA(1c) at or below 7.3% (p = 0. 001 versus STD). Baseline prevalence of peripheral neuropathy was 53% in STD, and 48% in INT. By 24 months, the prevalence increased to 69% in STD (p = 0.005 versus baseline), and to 64% in INT (p = 0. 008 versus baseline, but no different than STD). Though INT did not reverse all elements of peripheral neuropathy, there was a decreased prevalence of cranial neuropathy (p = 0.053 versus STD) and more frequent preservation of touch sensation in the upper extremities (p = 0.03 versus STD) in INT. At baseline, an abnormal Valsalva ratio and/or RR variation was seen in 38% of STD and 31% of INT. By 24 months in STD, the prevalence rose to 55% (p = 0.0067 versus baseline), and in INT, to 48% (p = 0.012 versus baseline and no different from STD). The prevalence of erectile dysfunction increased from 53% at baseline to 73% at 2 years, p = 0.002 in STD, and from 51% to 73% at 2 years (p = 0.003 versus baseline) and no different from STD. There was no change in the frequency of abnormal gastrointestinal or sweating symptoms. Our conclusion was that 2 years of meticulous glycemic control did not decrease overall prevalence of peripheral or autonomic neuropathy. In fact, the prevalence rose equivalently and significantly in both treatment arms. There was some benefit, however, in decreased frequency of cranial neuropathy and better preservation of touch sensation in INT.

Effect of intensive glycemic control on fibrinogen, lipids, and lipoproteins: Veterans Affairs Cooperative Study in Type II Diabetes Mellitus

BACKGROUND

The Veterans Affairs Cooperative Study in Type II Diabetes Mellitus prospectively studied insulin-treated patients with type 2 (non-insulin-dependent) diabetes mellitus, achieving 2.1% glycosylated hemoglobin separation between intensive- and standard-treatment arms (P<.001) for 2 years.

OBJECTIVE

To assess the effect of intensive therapy on serum fibrinogen and lipid levels, compared with standard treatment.

METHODS

One hundred fifty-three male subjects with type 2 diabetes mellitus and who required insulin treatment were recruited from 5 Veterans Affairs medical centers. The subjects were divided into intensive- and standard-treatment arms for a randomized prospective study. Dyslipidemia was managed identically in both arms (diet, drugs). Fibrinogen levels and lipid fractions were measured in the full cohort. Lipid fractions are separately reported in patients not treated with hypolipidemic agents.

RESULTS

There were no baseline differences between arms. Fibrinogen levels rose in the intensive-treatment arm at 1 year (from 3.34+/-0.12 to 3.75+/-0.15 g/L; P<.001) but returned to baseline at 2 years (3.47+/-0.12 g/L). There was no change in the standard-treatment arm. Triglyceride levels decreased in the intensive-treatment arm from 2.25+/-0.27 to 1.54+/-0.14 mmol/L (199+/-24 to 136+/-12 mg/ dL) at 1 year (P = .004) and to 1.74+/-0.18 mmol/L (154+/-16 mg/dL) at 2 years (P = .03); there was no change in the standard-treatment arm. Cholesterol levels decreased in the intensive-treatment arm at 1 year from 5.4+/-0.21 to 4.99+/-0.13 mmol/L (207+/-8 to 193+/-5 mg/dL) (P = .02); there was no change in the standard-treatment arm. Levels of low- and high-density lipoprotein cholesterol decreased in the standard-treatment arm only by 2 years, from 3.44+/-0.13 to 3.16+/-0.10 mmol/L (133+/-5 to 122+/-4 mg/ dL) (P =.02) and from 1.10+/-0.03 to 1.00+/-0.03 mmol/L (42+/-1 to 38+/-1 mg/dL) (P<.001) for low-density and high-density lipoprotein cholesterol, respectively. Levels of apolipoprotein B decreased in both treatment arms (P<.001), and apolipoprotein A1 levels decreased in the standard-treatment arm (P<.01). Lipoprotein (a) levels did not change in either treatment arm. Lipid results were essentially identical whether examined in the full cohort or excluding those patients receiving hypolipidemic agents.

CONCLUSIONS

Intensive insulin therapy led to a potentially beneficial reduction in serum triglyceride levels and preservation of high-density lipoprotein cholesterol and apolipoprotein A1 levels. However, it caused transient elevation in plasma fibrinogen levels, a possible thrombogenic effect.

Cardiovascular events and correlates in the Veterans Affairs Diabetes Feasibility Trial. Veterans Affairs Cooperative Study on Glycemic Control and Complications in Type II Diabetes

BACKGROUND

The risks and benefits of intensive therapy in non-insulin-dependent diabetes mellitus (NIDDM) need to be defined. In preparation for a long-term trial, a feasibility study of 153 men in 5 medical centers compared standard vs intensive insulin therapy.

OBJECTIVE

To assess the rate of development of new cardiovascular events and their correlates.

METHODS

Patients with a mean +/- SD age of 60 +/- 6 years and diagnosis of NIDDM for 7.8 +/- 4.0 years were randomly assigned to a standard (1 insulin injection every morning) or to an intensive treatment arm (stepped plan from 1 evening injection of insulin, alone or with glipizide, to multiple daily injections) designed to attain near-normal glycemia levels. A 2.07% separation of glycosylated hemoglobin (HbA1c) was sustained for a mean follow-up of 27 months (P < .001). Predefined cardiovascular events were assessed by a committee unaware of treatment assignment.

RESULTS

Mild and moderate hypoglycemic events were more frequent in the intensive than in the standard treatment arm (16.5 vs 1.5 per patient per year, respectively). Mean insulin dose was 23% lower in the standard treatment arm (P < .001). There were 61 new cardiovascular events in 24 patients (32%) in the intensive treatment arm and in 16 patients (20%) in the standard treatment arm (P = .10). There was no difference in total and cardiovascular mortality (n = 5 and n = 3 in the intensive and standard treatment arms, respectively) or in new events in patients with cardiovascular history (n = 10 in each arm). In Cox regression analysis, the only significant correlate for new cardiovascular events was previous cardiovascular disease (P = .04). Entering in the analysis any baseline cardiovascular abnormality, the regression model indicated a lower HbA1c level prior to the event as the only correlate for new cardiovascular events (P = .05).

CONCLUSION

A long-term prospective trial is needed to assess the risk-benefit ratio of intensive insulin therapy for NIDDM in patients who require it.

Evaluations of retinopathy in the VA Cooperative Study on Glycemic Control and Complications in Type II Diabetes (VA CSDM). A feasibility study

OBJECTIVE

The main goal of the study of 153 male veterans was to determine whether a statistically and clinically significant difference in HbA1c could be achieved between a standard therapy and an intensively treated group of patients with type II diabetes. A second major goal was to assess the feasibility of collecting reliable high-quality endpoint data, including microvascular and macrovascular events. Retinopathy was defined as a key microvascular endpoint.

RESEARCH DESIGN AND METHODS

This was a randomized prospective trial of 153 men between the ages of 40 and 69 years, with type II diabetes for 15 years or less. Of the patients, 78 were assigned to the standard therapy arm and 75 to the intensive therapy arm. The goal of standard therapy was good general medical care and well-being and avoiding excessive hyperglycemia, glycosuria, ketonuria, or hypoglycemia. This was generally accomplished with one shot of insulin per day. The goal of intensive therapy was to obtain an HbA1c within two standard deviations of the mean of nondiabetic subjects (4.0-6.1%). This was obtained by a four-step management technique, with patients moving to the next step only if operational goals were not met. The steps were as follows: step 1: evening intermediate or long-acting insulin only; step 2: evening insulin with daytime glipizide; step 3: insulin, twice a day, no glipizide; and step 4: more than two injections of insulin, no glipizide. Retinopathy was assessed at baseline, 12, and 24 months by seven-field stereo fundus photography done at each of the five participating VA medical centers and read at the Central Reading Center at the Department of Ophthalmology, University of Wisconsin Medical School, Madison. Visual acuity was determined by ophthalmologists at each of the participating hospitals.

RESULTS

After the 6th month of the 24-month study, an average HbA1c of approximately 7.1% in the intensively treated group was sustained for the full study and was significantly lower than that seen in the standard group (9.2%, P < 0.001). Compliance in obtaining fundus photographs was excellent. Near normalization of glycemia did not cause transient worsening of retinal morphology nor did it prevent the onset or delay the progression of retinopathy. There was no effect on visual acuity.

CONCLUSIONS

1) A glycemic control intervention study in people with type II diabetes is feasible and safe; 2) intensive control did not cause transient deterioration of retinopathy; and 3) although no improvement was seen in retinopathy, the follow-up was 24 months, an interval shorter than the 3 years or more of intensive therapy before improvement is seen in type 1 diabetic studies. This does not rule out the possibility that longer periods of intensive therapy would have improved retinopathy. A full-scale intervention trial in type II diabetes is needed to resolve this issue.

Glycemic control and complications in type II diabetes. Design of a feasibility trial. VA CS Group (CSDM)

OBJECTIVE

To determine, after 1 yr of follow-up in type II diabetes patients, whether a statistically and clinically significant difference can be achieved in HbA1c between a standard therapy group and an intensively treated group, while maintaining HbA1c levels in both groups within ranges acceptable in regular community practice. Secondary objectives include assessment of patient adherence to protocol, side effects, and accuracy of data collection.

RESEARCH DESIGN AND METHODS

This is a prospective, randomized, controlled VA CS conducted with 151 patients at five VAMCs. Patients are males, age 40-69 yr, treated at entry with a maximum dose of sulfonylurea or with insulin, exhibiting an HbA1c level > 3 SDs above the normal mean (5.05 + 3 x 0.50 = > 6.55%). Standard control is achieved with insulin and intensive control with a step-up regimen including insulin alone or insulin/glipizide combinations. Education and management of cardiovascular risk factors are handled similarly in both groups. Primary macrovascular end points are nonfatal myocardial infarction, congestive heart failure, stroke, amputation, and cardiovascular death. Primary microvascular end points are appearance and progression of retinopathy, documented by centrally read seven-field-stereo fundus photographs. Other measured indicators include resting and ambulatory ECGs, ventricular function (MUGA scan), serum lipid and apolipoprotein levels, plasma fibrinogen, nonsymptomatic peripheral vasculopathy, neuroautonomic status by heart-beat variation on Valsalva maneuver, and microalbuminuria.

CONCLUSIONS

This study may be the basis for a long-term trial, involving 1400 patients, to assess the long-term effects of metabolic control on macro- and microvascular end points.

Platelet aggregation and release of ATP after incubation with soluble immune complexes purified from the serum of diabetic patients

Human platelets are known to have Fc receptors that are able to recognize soluble immune complexes and to respond to that stimulation by aggregating and releasing soluble factors. In diabetes, enhanced platelet aggregation has been proposed as one of the factors contributing to the development of microangiopathy. Soluble immune complexes isolated from seven diabetic patients were found to enhance ADP-induced platelet aggregation and release of ATP. This enhancement was proven not to be an artifact due to the isolation protocol, by comparison of purified immune complexes with nonspecific protein purified from normal sera by identical or slightly modified isolation protocols. Soluble immune complex appear to be the first well-characterized platelet aggregating factors form the sera of diabetic patients. The natural of the antigen involved in their formation does not appear relevant, since very similar results were obtained whether soluble immune complexes were purified from patients with insulin-anti-insulin complexes in their serum, or from those without such complexed but with positive results in nonspecific screening techniques.

Antiplatelet Agents In Diabetic Lower Extremity Vascular Disease. A Va Cooperative Study

Peripheral vascular disease is a devastating complication of diabetes mellitus. Post-operative vascular death rates are 10% or more following amputation for gangrene in diabetic patients, and three year mortality approaches 30%. An additional 20-30% of patients require subsequent amputation for diabetic gangrene. In view of these statistics, and because of the postulated role of the blood platelet in diabetic vascular disease, a collaborative study on antiplatelet agents was begun in 10 VA medical centers in 1977. In a double-blinded study, aspirin (325 mg tid) plus dipyridamole (75 mg tid) or placebos are given to adult diabetic males who had suffered a recent amputation for diabetic lower extremity vascular disease. End points are major vascular events after at least 3 years of follow-up.

Recruitment of 231 subjects was completed by May, 1980. Baseline characteristics are well matched in both groups. Mean age is 59.6 years, duration of diabetes 12.7 years, smoking history 33.3 pack years, and treatment with insulin 68%. Previous myocardial infarction, congestive heart failure, and/or cerebrovascular disease is present in 17-18% and retinopathy is present in 40% at entry. About 43% have more than one vascular complication at baseline.

Mean duration of follow-up is now 18 months. Major vascular events in separate patients are: 40 amputations, 31 deaths, 5 myocardial infarctions. Numerous less serious vascular events have also occurred, as have multiple events in single patients. Therapy has been stopped in 17% of patients, but rarely due to drug side effects. Compliance with therapy has been good.

We conclude that this study will provide important new information on the natural history of lower extremity vascular disease in diabetes. It will also provide definitive data about the efficacy of antiplatelet agents in diabetic vascular disease.

Simplified method for detecting anti-insulin antibodies and insulin-anti-insulin immune complexes

A simplified approach for estimating free and total anti-insulin antibodies and soluble insulin-anti-insulin immune complexes in serum has been developed and evaluated. For determination of free anti-insulin antibodies, a binding ratio for 125I-labeled insulin at fivefold serum dilution is calculated; the binding ratios obtained are reproducible (run-to-run coefficient of variation, 7.3%) and correlate well with titration of anti-insulin antibodies by other techniques (correlation coefficient, 0.9327). Total anti-insulin antibody concentrations are determined by calculating the [125I]insulin binding ratio for a sample previously acidified, adsorbed with acid dextran-coated charcoal, and neutralized. The difference in binding ratios between two aliquots of the same serum, one diluted 10-fold without manipulation and the second studied at an identical dilution after acidification and removal of free insulin, is taken as an index of the presence of soluble insulin-anti-insulin immune complexes. Because the tests can be performed at a single dilution, both time and materials are conserved without apparent loss of discrimination between sera with high antibody titers and high concentrations of insulin-anti-insulin immune complexes and sera with negative titers or low concentrations.

Simplified method for detecting anti-insulin antibodies and insulin-anti-insulin immune complexes

A simplified approach for estimating free and total anti-insulin antibodies and soluble insulin-anti-insulin immune complexes in serum has been developed and evaluated. For determination of free anti-insulin antibodies, a binding ratio for 125I-labeled insulin at fivefold serum dilution is calculated; the binding ratios obtained are reproducible (run-to-run coefficient of variation, 7.3%) and correlate well with titration of anti-insulin antibodies by other techniques (correlation coefficient, 0.9327). Total anti-insulin antibody concentrations are determined by calculating the [125I]insulin binding ratio for a sample previously acidified, adsorbed with acid dextran-coated charcoal, and neutralized. The difference in binding ratios between two aliquots of the same serum, one diluted 10-fold without manipulation and the second studied at an identical dilution after acidification and removal of free insulin, is taken as an index of the presence of soluble insulin-anti-insulin immune complexes. Because the tests can be performed at a single dilution, both time and materials are conserved without apparent loss of discrimination between sera with high antibody titers and high concentrations of insulin-anti-insulin immune complexes and sera with negative titers or low concentrations.