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Much of chronic disease management depends on active partnership of consumer and provider. Our system promotes diabetes management through profiling and adaptive support of both consumer and provider. We use a University Podiatry Clinic and diabetes consumer information portal as inter-related contexts that share profile information.
The anemia of chronic disease (ACD) is a hypoproliferative anemia defined by a low serum or plasma iron concentration in the presence of adequate reticuloendothelial iron stores. It is been established that ACD results from the effects of cytokines that mediate the immune or inflammatory response. During the past 3 years, the clinical scope of this syndrome has been expanded beyond the traditional chronic infectious, inflammatory, or neoplastic diseases to include other, often acute, syndromes in which the same pathogenetic mechanisms are operating. An improved understanding of the use of the soluble transferrin receptor concentration in clinical medicine has enhanced the ability to diagnose ACD, and further experience with the use of recombinant human erythropoietin in the management of severely affected patients with ACD has provided a basis for rational and effective management. Ongoing studies of the mechanisms contributing to the development of ACD continue to elucidate the pathogenesis of this common and clinically significant syndrome.
For many progressive chronic diseases, there exist useful prognostic indicators for the course of the disease and the survival of the patient. The evolution of such an indicator is modelled as a monotone transformation of a pure birth process with killing. Explicit formulas are derived for the probability distribution of this process at an arbitrary time, the distribution of the first-passage times, the joint distribution of the survival time and the maximum of the process, and the marginals of this joint distribution. In two examples, the general formulas are evaluated in closed form.
BACKGROUND: A steady increase in chronic obstructive pulmonary disease (COPD) admissions was addressed by enhancing primary care to provide intensive chronic disease management. AIM: To compare the effect of a disease management programme, including a COPD management guideline, a patient-specific care plan and collaboration between patients, general practitioners, practice nurses, hospital physicians and nurse specialists with conventional care, on hospital admissions and quality of life. METHODS: One hundred and thirty-five patients with a clinical diagnosis of moderate to severe COPD were identified from hospital admission data and general practice records. General practices were randomized to either conventional care (CON), or the intervention (INT). Pre- and post-study assessment included spirometry, Shuttle Walk Test, Short Form-36, and the Chronic Respiratory Questionnaire (CRQ). Admission data were compared for 12 months prior to and during the trial. RESULTS: For respiratory conditions, mean hospital bed days per patient per year for the INT group were reduced from 2.8 to 1.1, whereas those for the CON group increased from 3.5 to 4.0 (group difference, P = 0.030) The INT group also showed an improvement for two dimensions of the CRQ, fatigue (P = 0.010) and mastery (P = 0.007). CONCLUSIONS: A chronic disease management programme for COPD patients that incorporated a variety of interventions, including pulmonary rehabilitation and implemented by primary care, reduced admissions and hospital bed days. Key elements were patient participation and information sharing among healthcare providers.
Patients with chronic diseases fail to comply with the regimen prescribed by the physician for a variety of reasons. Physicians must be aware of the likelihood of noncompliance in the individual patient and make strong efforts to detect problems and persuade patients with the importance of adherence to a program designed to reach and maintain stated, and often negotiated, therapeutic goals. It is the physician's responsibility to teach, motivate, and strengthen the patient to maximize compliance in a largely unsupervised setting. This can best be accomplished by a process of "therapeutic partnership."
Most patients with chronic disease can benefit from rehabilitation efforts to optimize their functioning within the limitations placed on them by the disease and/or treatment and to increase their responsibility in their health care. Rehabilitation should include education and counseling in nutrition, behavioral change, exercise conditioning, and clinical concerns. The exercise portion can be accomplished in a supervised or unsupervised setting, depending on the patient's clinical status and needs. The exercise prescription must be modified to meet the clinical needs of the patient. Supervised settings may increase compliance and provide the primary care physician with valuable follow-up information that will assist in long-term medical care. The primary care physician has the responsibility of carefully screening patients, referring them into the appropriate exercise setting, and incorporating the rehabilitation results into the patient's long-term care. Physician support can dramatically enhance the success of the rehabilitation efforts.
OBJECTIVE: To identify demographic predictors of hospital admission for chronic disease. METHODS: Hospital morbidity records were extracted from the WA Data Linkage System for the period 1994-99 for specific chronic diseases based on national priorities. Poisson regression was used to estimate the effects of Aboriginal and Torres Strait Islander (ATSI) descent, co-morbidity, geography, socio-economic status and possession of health insurance on hospital admission rates. RESULTS: This study has identified some of the main demographic risk factors for hospitalisation in patients with chronic disease as the following: being male, of ATSI descent, living in a relatively disadvantaged Census Collection District and having multiple co-morbidities. Depending on the disease, locational disadvantage and possession of private health insurance were also risk factors. CONCLUSIONS: The study indicates that a crucial component in keeping patients with chronic disease out of hospital is ensuring quality primary care for all members of the community, equipping patients with the necessary skills to self-manage their chronic condition. Particular attention must be given to developing programs that are accessible to the more disadvantaged members of the community. IMPLICATIONS: Programs aimed at keeping patients with chronic disease out of hospital must be targeted at the most vulnerable groups of the population if they are to be effective.
To determine the role marrow-adherent cells may play in the anemia of chronic diseases, marrow samples were collected from ten patients with the anemia of chronic disease, seven control patients with cancer but without the anemia of chronic disease, and five normal volunteers. Marrow was either cultured directly or first depleted of adherent cells and then cultured. Plasma clots containing 6 X 10(4) nonadherent marrow cells were cocultured with marrow-adherent cells prepared by incubating 6 X 10(4)-6 X 10(2) unfractionated marrow cells in microtiter plates and removing the nonadherent cells. Adherent cell depletion of marrow from patients with anemia of chronic disease significantly increased erythroid colony formation. Coculture of adherent cells from anemic patients with autologous nonadherent marrow cells inhibited erythroid colony-forming unit (CFU-E) proliferation in patients with the anemia of chronic disease. In contrast, adherent cells from control patients did not affect autologous erythroid colony formation, and adherent cells from normal volunteers stimulated autologous erythroid colony formation. Coculture of adherent cells from anemia patients with nonadherent marrow from control patients failed to inhibit allogeneic erythroid colony formation. Media conditioned by adherent cells from patients with the anemia of chronic disease failed to suppress consistently the formation of allogeneic erythroid colonies. These data suggest that marrow-adherent cells normally stimulate erythropoiesis, but suppress erythroid progenitors, in patients with the anemia of chronic disease and may in part be responsible for their anemia.
The anemia of chronic disease (ACD) is defined as a mild anemia associated with a chronic inflammatory, infectious or neoplastic illness and with a characteristic disturbance of iron metabolism. Many of the findings in ACD can be accounted for by release of a monokine called leukocyte endogenous mediator (LEM), endogenous pyrogen, or interleukin-1. This substance is released from "activated" monocytes. Bacterial endotoxins, certain lymphokines and phagocytic challenges are among the factors stimulating its biosynthesis. LEM induces fever, leukocytosis, biosynthesis. LEM induces fever, leukocytosis, and a variety of biochemical changes, including hypoferremia and alterations in plasma protein synthesis, collectively known as the "acute phase response." It is proposed that ACD results from the long-term elaboration of LEM and that release of this material is the common pathogenetic factor found in the illnesses that are associated with ACD. Some suggestions are made for testing the hypothesis. The hypoferremia associated with ACD is probably caused by defective release of iron from cells--particularly from macrophages, but also from hepatocytes and intestinal epithelium. Two possible mechanisms for this abnormality have been proposed: liberation of lactoferrin from neutrophilic leukocytes and induction of apoferritin synthesis. Neither mechanism has been established. Erythrokinetic studies in ACD have detected a modest reduction of erythrocyte survival without an adequate compensatory increase in the rate of red cell production. The reduced erythrocyte survival is probably related to an increase in phagocytic activity by activated macrophages. Impaired bone marrow response is partly related to the restricted iron supply, but there is substantial evidence for an additional defect in erythropoietin secretion. In some malignant diseases, there is evidence of an additional abnormality: impaired marrow response to a normal amount of erythropoietin. The nature of the erythropoietic defects and the relation of LEM to them remain to be established.
OBJECTIVE: To evaluate the effectiveness of the Shanghai Chronic Disease Self-Management Program (CDSMP). METHODS: A randomized controlled trial with six-month follow-up compared patients who received treatment with those who did not receive treatment (waiting-list controls) in five urban communities in Shanghai, China. Participants in the treatment group received education from a lay-led CDSMP course and one copy of a help book immediately; those in the control group received the same education and book six months later. FINDINGS: In total, 954 volunteer patients with a medical record that confirmed a diagnosis of hypertension, heart disease, chronic lung disease, arthritis, stroke, or diabetes who lived in communities were assigned randomly to treatment (n = 526) and control (n = 428) groups. Overall, 430 (81.7%) and 349 (81.5%) patients in the treatment and control groups completed the six-month study. Patients who received treatment had significant improvements in weekly minutes of aerobic exercise, practice of cognitive symptom management, self-efficacy to manage own symptoms, and self-efficacy to manage own disease in general compared with controls. They also had significant improvements in eight indices of health status and, on average, fewer hospitalizations. CONCLUSION: When implemented in Shanghai, the CDSMP was acceptable culturally to Chinese patients. The programme improved participants' health behaviour, self-efficacy, and health status and reduced the number of hospitalizations six months after the course. The locally based delivery model was integrated into the routine of community government organizations and community health services. Chinese lay leaders taught the CDSMP courses as successfully as professionals.
OBJECTIVE: To establish the prevalence of chronic diseases reported by parents among a random population of Dutch children. Furthermore, to establish how often these children visited a physician because of a chronic disease, and used drugs for its treatment. SETTING: Dordrecht and environs. DESIGN: Descriptive. METHOD: In the school year 1990-1991, all 8689 parents of school children summoned for a periodical health check by the school doctor or school nurse were sent a questionnaire together with the notification. With the aid of a list of criteria it was determined for every child during the periodical health check if the diseases, if any, were serious, if the children were being treated for them and if they used medication. RESULTS: The response to the questionnaire amounted to 98.3%. Of the children examined, 21.3% according to the parents suffered from one or more chronic diseases, 3.7% to a major extent. Of the group with one or more chronic diseases, 25.2% were monitored by the family doctor, 10.5% by the paediatrician, 18.6% by various other specialists and 4.5% by a homeopathist. Of the population as a whole, 10.1% used medication because of one or several of the chronic diseases; this accounted for 47.4% of the group with one or several chronic diseases. CONCLUSION: The prevalence of chronic diseases in school children reported by the parents is so high that it should be given attention in post-graduate education and public health information.
Patients with chronic disease typically become severely deconditioned, which often leads to physical disability. Every effort should be made to recommend and encourage patients to adopt and maintain a program of physical activity. Although there are no specific exercise guidelines for many chronic conditions, patients should be instructed to start a routine of physical activity that is gradual for most (if not all) days of the week, working up to 30 minutes per session at an exertion level that is easily tolerated. It is critical that assessment of physical functioning and recommendations for physical activity be included as a part of routine medical care. In doing so, we change the expectations of patients and family members, and work toward optimizing physical functioning and quality of life.
Chronic diseases are the leading cause of death and disability worldwide. An ageing population in prosperous countries has led to an increase in the number of people living with one or more chronic conditions; a trend which is predicted to worsen. Other 'new' epidemics such as obesity, combined with scarce economic resources, have provided impetus for a review of care provision for those living with chronic diseases in the UK. The new 'National Health Service (NHS) and Social Care Long Term Conditions Model' represents a cultural shift as patient and carer are scripted as central in managing their chronic disease, supported rather than directed by a health and social care team. The patient as a passive recipient of care is no longer viable in this approach to care delivery. It has been acknowledged that cultural shift within the NHS is required for these initiatives to be successful. Nurse educators have the potential to play a key role in supporting nurses to fully engage in the modernised chronic disease management initiative. This paper outlines the main features of the contemporary approach to chronic disease management, together with relevant UK policy changes. The implications of these changes for nurse education will be considered.
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BACKGROUND: Implementing programs that target primary prevention of chronic diseases is critical for at-risk populations. Pasos Adelante, or "Steps Forward," is a curriculum aimed at preventing diabetes, cardiovascular disease, and other chronic diseases in Hispanic populations. Pasos Adelante is adapted from the National Heart, Lung, and Blood Institute's cardiovascular disease prevention curriculum, Su Corazon, Su Vida, and includes sessions on diabetes and community advocacy and incorporates walking clubs. CONTEXT: The Pasos Adelante curriculum was implemented in two Arizona, United States-Sonora, Mexico border counties. Key issues in these communities are safety, access to recreational facilities, climate, and cultural beliefs. METHODS: Pasos Adelante is a 12-week program facilitated by community health workers. The program includes interactive sessions on chronic disease prevention, nutrition, and physical activity. Evaluation of the program included precurriculum and postcurriculum questionnaires with self-reported measures of physical activity and dietary patterns. Approximately 250 people participated in the program in Yuma and Santa Cruz counties. CONSEQUENCES: Postprogram evaluation results demonstrate a significant increase in moderate to vigorous walking among participants and shifts in nutritional patterns. INTERPRETATION: The Pasos Adelante program demonstrates that an educational curriculum in conjunction with the support of community health workers can motivate people in Arizona/Sonora border communities to adopt healthy lifestyle behaviors.
OBJECTIVE: To assess the associations between having had a fall and chronic diseases and drug use in elderly women. DESIGN: Cross sectional survey, using data from the British women's heart and health study. SETTING: General practices in 23 towns in Great Britain. PARTICIPANTS: 4050 women aged 60-79 years. MAIN OUTCOME MEASURE: Whether women had had falls in the previous 12 months. RESULTS: The prevalence of falling increased with increasing numbers of simultaneously occurring chronic diseases. However, no such relation with falling was found in the fully adjusted data for the number of drugs used. Circulatory disease, chronic obstructive pulmonary disease, depression, and arthritis were all associated with an increased odds of falling. The fully adjusted, population attributable risk of falling associated with having at least one chronic disease was 32.2% (95% confidence interval 19.6% to 42.8%). Only two classes of drugs (hypnotics and anxiolytics, and antidepressants) were independently associated with an increased odds of falling. Each class was associated with an increase of about 50% in the odds of falling, and each had a population attributable risk of < 5%. CONCLUSION: Chronic diseases and multiple pathology are more important predictors of falling than polypharmacy.
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35 million people will die in 2005 from heart disease, stroke, cancer, and other chronic diseases. Only 20% of these deaths will be in high-income countries--while 80% will occur in low-income and middle-income countries. The death rates from these potentially preventable diseases are higher in low-income and middle-income countries than in high-income countries, especially among adults aged 30-69 years. The impact on men and women is similar. We propose a new goal for reducing deaths from chronic disease to focus prevention and control efforts among those concerned about international health. This goal-to reduce chronic disease death rates by an additional 2% annually--would avert 36 million deaths by 2015. An additional benefit will be a gain of about 500 million years of life over the 10 years from 2006 to 2015. Most of these averted deaths and life-years gained will be in low-income and middle-income countries, and just under half will be in people younger than 70 years. We base the global goal on worldwide projections of deaths by cause for 2005 and 2015. The data are presented for the world, selected countries, and World Bank income groups.