Emerging vocational rehabilitation strategies for people with diabetes mellitus

BACKGROUND: People with diabetes mellitus constitute an emerging vocational rehabilitation (VR) consumer population. OBJECTIVE: The objective of this article is to (a) describe the characteristics and needs of Americans with diabetes mellitus, (b) examine the often devastating effects that this highly prevalent disease of the endocrine system has on employment and career development, and (c) suggest strategies that rehabilitation professionals can use to improve VR services and outcomes. METHOD: Following an overview of the etiology, incidence, prevalence, and impact of this high incidence endocrinological disease, the authors present strategies to meet the service and support needs of Americans with diabetes mellitus across the phases of the VR process. RESULTS: The importance of individualized case planning, employer consultation, workplace accommodations, interface with medical and mental health professionals, and adherence to self-care and symptom management regimens is emphasized throughout the article. CONCLUSION: Diabetes mellitus is an emerging disability that can affect people of any age, one that disproportionally affects people of color and people who live in poverty. Rehabilitation professionals must be prepared to meet the service needs of this growing clientele.

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.

Pulse-spray pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts: long-term experience and comparison of original and current techniques

OBJECTIVE

Pulse-spray pharmacomechanical thrombolysis is an evolving method for the treatment of vascular occlusions in which a highly concentrated fibrinolytic agent is injected as a high-pressure spray directly into thrombus. The purpose of this retrospective study was to analyze our long-term experience with this technique for the treatment of clotted hemodialysis grafts and to compare the efficacy and safety of the original and current methods.

SUBJECTS AND METHODS

Over 6 years, 284 cases of dialysis graft thrombosis were considered suitable for treatment with pulse-spray thrombolysis. The original technique involved the injection of highly concentrated urokinase directly into a clot through two crisscross catheters with multiple side holes. The current technique includes early fragmentation of residual clot with a balloon catheter, intrathrombic injection of heparin, mechanical treatment of a lysis-resistant clot at the arterial anastomosis, and routine administration of aspirin. After thrombolysis, underlying obstructions were treated with balloon angioplasty, atherectomy, or stents. The technical success, immediate clinical success, and frequency of complications for the entire population were analyzed. In addition, the results for 36 cases treated with the original technique were compared with the results for 37 recent cases treated with the current technique.

RESULTS

Of 284 cases considered suitable for treatment, thrombolysis was not done in eight cases because the venous anastomosis could not be crossed. Thrombolysis was discontinued in two cases because of extravasation of contrast material. The technical success for all grafts considered for treatment was 96%; 92% of treated grafts remained patent for at least 24 hr. Major complications occurred in 1% of cases, and minor complications occurred in 9% of cases. The clinical efficacies of the original and current techniques were 86% and 92%, respectively. The mean thrombolytic agent infusion time was reduced from 44 +/- 20 min to 23 +/- 13 min (p < .001). The overall procedure time for the recently treated subgroup was 67 +/- 26 min. There was no significant difference in the frequencies of major and minor complications between the treatment subgroups.

CONCLUSION

Pulse-spray pharmacomechanical thrombolysis is a reliable, rapid, and safe method for recanalization of occluded dialysis grafts. The current technique has been proven as safe and effective as the original technique but offers the advantage of a significant reduction in the time required for the infusion of thrombolytic agent.