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PubMed2006

The Women's Health Initiative. What is on trial: nutrition and chronic disease? Or misinterpreted science, media havoc and the sound of silence from peers?

The first results of the Women's Health Initiative dietary intervention trial were published in the USA in February. This is a colossal intervention designed to see if diets lower in fat and higher in fruits, vegetables and grains than is usual in high-income countries reduce the incidence of breast cancer, colorectal cancer, heart disease and other chronic diseases, in women aged 50-79 years. As interpreted by US government media releases, the results were unimpressive. As interpreted by a global media blitz, the results indicate that food and nutrition has little or nothing to do with health and disease. But the trial was in key respects not reaching its aims, was methodologically controversial, and in any case has not produced the reported null results. What should the public health nutrition profession do about such messes?

Aged↗
PubMed2004

Pregnancy in patients with rheumatic diseases: psychological implication of a chronic disease and neuropsychological evaluation of the children.

As a consequence of the general improvement in the diagnosis and management of rheumatic diseases, patients achieve a better quality of life, with the possibility of a normal family life including one or more pregnancies. It is important, therefore, to consider the psychological aspects of these mothers' life and the influence of their chronic disease on their children is development. Several papers have reported the impact of systemic lupus erythematosus (SLE) on the quality of life. They found higher incidence of anxiety (from 15 to 45%) and depression (from 25 to 47%) compared to the general population. We have investigated the psychological influence of SLE on family planning, and we observed that it can interfere with physiological phenomena such as parenthood and the upbringing of children. The children of lupus mothers have a normal intelligence level for their age. What is emerging, however, is an increased incidence of learning disabilities compared to the general population. This observation suggests the importance of an early neuropsychological examination, in order to identify the children needing particular care. Therefore, psychological support seems to be an important help in the counseling of patients with rheumatic disease and in the future life of their children.

Adult↗
PubMed1992

Transferrin microheterogeneity in rheumatoid arthritis. Relation with disease activity and anemia of chronic disease.

We studied the relation between disease activity in rheumatoid arthritis (RA) and the microheterogeneity of transferrin. Using crossed immuno isoelectric focusing, transferrin microheterogeneity patterns were analyzed in sera of healthy individuals, nonanemic RA patients, iron deficient RA patients and RA patients with the anemia of chronic disease (ACD). In all RA groups a significant shift in the microheterogeneity pattern was observed, reflecting increased synthesis of transferrins with highly branched glycan chains. Increased disease activity correlated with both the induction of ACD and the change in transferrin glycosylation, which was, therefore, most pronounced in ACD. Generally, an increased synthesis of glycoproteins is accompanied by alterations in their glycosylation pattern. Since transferrin is a negative acute phase protein, our results indicated that changes in synthetic rates and changes in glycosylation induced in the acute phase response are regulated independently.

Anemia↗
PubMed2005

Differences in education, knowledge, self-management activities, and health outcomes for patients with heart failure cared for under the chronic disease model: the improving chronic illness care evaluation.

BACKGROUND: The objective of this study was to determine whether participation in a quality improvement (QI) collaborative for heart failure (HF) was associated with better interpersonal aspects of care and health outcomes. METHODS AND RESULTS: We conducted a cross-sectional telephone survey of patients in 6 organizations who participated in a QI collaborative for HF (participants, n = 387) and 6 comparable control organizations (controls, n = 414) and measured provider-patient communication, education received, knowledge of HF, self-management behaviors, satisfaction, and quality of life. The participant group patients were more likely to report their doctor and nurse discussed treatment options and reviewed self-management (P < .01 for both). A total of 88% of participants were told to weigh themselves daily and record their weight compared with 34% of controls (P < .01). Participants were more likely to know how often to check their weight (P < .01), recognize symptoms of worsening HF (P < or = .01 for all), have a scale (P = .002), and monitor their weight daily (P < .001). Participants had similar quality of life but fewer emergency department visits and hospitalizations. CONCLUSION: Participation in a QI collaborative for HF was associated with better communication, education, and knowledge, and lower health care use. Collaboratives may be a useful method for disseminating quality improvement strategies.

Adolescent↗
PubMed1999

Essential fatty acids in health and chronic disease.

Human beings evolved consuming a diet that contained about equal amounts of n-3 and n-6 essential fatty acids. Over the past 100-150 y there has been an enormous increase in the consumption of n-6 fatty acids due to the increased intake of vegetable oils from corn, sunflower seeds, safflower seeds, cottonseed, and soybeans. Today, in Western diets, the ratio of n-6 to n-3 fatty acids ranges from approximately 20-30:1 instead of the traditional range of 1-2:1. Studies indicate that a high intake of n-6 fatty acids shifts the physiologic state to one that is prothrombotic and proaggregatory, characterized by increases in blood viscosity, vasospasm, and vasoconstriction and decreases in bleeding time. n-3 Fatty acids, however, have antiinflammatory, antithrombotic, antiarrhythmic, hypolipidemic, and vasodilatory properties. These beneficial effects of n-3 fatty acids have been shown in the secondary prevention of coronary heart disease, hypertension, type 2 diabetes, and, in some patients with renal disease, rheumatoid arthritis, ulcerative colitis, Crohn disease, and chronic obstructive pulmonary disease. Most of the studies were carried out with fish oils [eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)]. However, alpha-linolenic acid, found in green leafy vegetables, flaxseed, rapeseed, and walnuts, desaturates and elongates in the human body to EPA and DHA and by itself may have beneficial effects in health and in the control of chronic diseases.

Chronic Disease↗
PubMed2004

Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review.

PURPOSE: To assess the clinical and economic effects of disease management in patients with chronic diseases. METHODS: Electronic databases were searched for English-language articles from 1987 to 2001. Articles were included if they used a systematic approach to care and evaluated patients with chronic disease, reported objective measurements of the processes or outcomes of care, and employed acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organization of Care Group. RESULTS: Two reviewers evaluated 16,917 titles and identified 102 studies that met the inclusion criteria. Identified studies represented 11 chronic conditions: depression, diabetes, rheumatoid arthritis, chronic pain, coronary artery disease, asthma, heart failure, back pain, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Disease management programs for patients with depression had the highest percentage of comparisons (48% [41/86]) showing substantial improvements in patient care, whereas programs for patients with chronic obstructive pulmonary disease (9% [2/22]) or chronic pain (8% [1/12]) appeared to be the least effective. Of the outcomes more frequently studied, disease management appeared to improve patient satisfaction (71% [12/17]), patient adherence (47% [17/36]), and disease control (45% [33/74]) most commonly and cost-related outcomes least frequently (11% to 16%). CONCLUSION: Disease management programs were associated with marked improvements in many different processes and outcomes of care. Few studies demonstrated a notable reduction in costs. Further research is needed to understand how disease management can most effectively improve the quality and cost of care for patients with chronic diseases.

Cardiovascular Diseases↗
PubMed1988

Quality of life in chronic diseases: perceptions of elderly patients.

Quality of life is an important consideration in medical decisions involving elderly patients and a clinical outcome measure of health care. Elderly outpatients (N = 126) with five common chronic diseases (arthritis, ischemic heart disease, chronic pulmonary disease, diabetes mellitus, and cancer) and their physicians were interviewed to better characterize patient quality of life. Patients generally perceived their quality of life to be slightly worse than "good, no major complaints" in each chronic disease. Physicians' ratings were generally worse than and only weakly associated with the patients' ratings of quality of life in each chronic disease. Significant independent correlates of patients' ratings of quality of life included the patients' perceptions of their health, interpersonal relationships, and finances. These results suggest that quality of life in elderly outpatients with chronic disease is a multidimensional construct involving health, as well as social and other factors. Physicians may misunderstand patients' perceptions of their quality of life.

Aged↗
PubMed1978

The surgical aspects of chronic mucosal inflammatory bowel disease (chronic ulcerative colitis).

The surgical aspects of chronic mucosal inflammatory bowel disease were reviewed by comparing the experience at our institution between two periods, one a decade later than the other (1961-1965 and 1971-1975). The striking findings were a marked decrease in the incidence of carcinoma and toxic megacolon and a marked increase in use of one-stage proctocolectomy with either Brooke ileostomy or Kock pouch. There was, in addition, a corresponding decrease in the operative mortality for elective cases, from 2.4 to 1.3%; yet the operative mortality for emergency cases remained relatively stable at about 25%. The reason for the decrease in the incidence of carcinoma and toxic megacolon appears to be on the basis of selection outside of our institution, in that fewer of these cases are being referred.

Adult↗
PubMed1988

Pulmonary aspergillosis appearing as chronic nodular disease in chronic granulomatous disease.

Chronic nodular pneumonia is unusual in children. Three children are described who presented with diffuse nodular pulmonary disease and in whom lung biopsy demonstrated Aspergillus infection. One child was known to have chronic granulomatous disease of childhood (CGD) and further investigation demonstrated CGD in the other two patients as well. These cases indicate that Aspergillus infection and CGD should be considered in the differential diagnosis in children who present with chronic diffuse nodular pneumonia.

Aspergillosis↗
PubMed2006

Assessing risk factors for chronic disease--Jordan, 2004.

In 2003, chronic diseases were the leading cause of mortality in Jordan; 38.2% of deaths were attributed to cardiovascular disease and 14.3% to cancer (Jordan Ministry of Health [MOH], unpublished data, 2004). In 2002, MOH, with assistance from CDC and the World Health Organization (WHO), established a behavioral risk factor surveillance program to monitor risk factors associated with chronic diseases. This report summarizes the findings of the second Behavioral Risk Factor Survey, which was conducted in Jordan in 2004. The findings indicated that the prevalence of obesity had increased by 52.3% in Jordan since 2002. In addition, cancer screening rates among women and seatbelt use rates overall were low compared with U.S. rates. Development and implementation of a national plan to prevent and control chronic diseases is needed.

Behavioral Risk Factor Surveillance System↗
PubMed2006

Adolescents' perception of epilepsy compared with other chronic diseases: "through a teenager's eyes".

Adolescent perception of physical and social impact of chronic illness was assessed to determine (1) if there is greater prejudice toward epilepsy than other chronic disease and (2) if adolescents with chronic disease have less prejudice toward similarly affected peers with all types of chronic disease or just their specific chronic disease. Cognitively normal teens aged 13 to 18 years without chronic disease (n = 41) and with epilepsy (n = 32), asthma (n = 38), diabetes (n = 21), and migraine (n = 17) were interviewed in the outpatient clinics of a tertiary care pediatric center regarding their perceptions of the physical and social impact of eight chronic diseases (epilepsy, asthma, diabetes, Down syndrome, arthritis, migraine, leukemia, human immunodeficiency virus [HIV] infection). Epilepsy was perceived to have a more adverse physical impact than all chronic illnesses except Down syndrome. The perception was that it more frequently caused mental handicap, injured the afflicted individual and bystanders, and led to death. Epilepsy was also perceived to have a more negative social impact, particularly on behavior, honesty, popularity, adeptness at sports, and fun. Significantly more adolescents expressed reluctance to befriend peers with epilepsy, both from their own and their perceived parental perspectives. Having a chronic disease did not generally alter the adolescents' perceptions of peers with chronic disease. However, cases with epilepsy ranked this disease to have less social impact than teens with other chronic diseases. In conclusion, adolescents consider epilepsy to have a greater physical and social impact than most chronic diseases. Educational efforts should focus on the "normality" of most persons with epilepsy and emphasize the low risk of injury when proper first aid is followed.

Adolescent↗
PubMed2003

2002 E. Mead Johnson Award for Research in Pediatrics Lecture: the molecular biology of the anemia of chronic disease: a hypothesis.

The anemia of chronic disease is a common disorder that afflicts patients with a wide variety of inflammatory conditions including arthritis, malignancies, infections, and inflammatory bowel disease. It results in significant morbidity and may be severe enough to require blood transfusions. The pathogenesis of anemia of chronic disease is not fully understood, but poor maintenance of red blood cell mass has been observed at three levels: 1) iron is not efficiently recycled from reticuloendothelial macrophages to erythroid precursors, 2) erythroid precursors respond poorly to erythropoietin, and 3) red blood cell survival is decreased. Whether each of these changes is related to the same effector of the inflammatory process is unknown. We have had the opportunity to investigate severe anemia of chronic disease in an unusual group of patients with glycogen storage disease type 1a. We found that anemia was directly related to the presence of large hepatic adenomas that inappropriately produced a new peptide hormone, hepcidin. Hepcidin has recently been identified as part of the innate immune response and is a key regulator of cellular iron egress. Based on our findings in this patient group, we propose a central role for hepcidin in anemia of chronic disease, linking the inflammatory process with iron recycling and erythropoiesis. We present a hypothesis based on our findings.

Adenoma↗
PubMed2005

Declining cell-mediated immunity and increased chronic disease burden.

BACKGROUND: The effects of chronic disease have been proposed as an explanation for conflicting results in studies of age effects on cell-mediated immunity. OBJECTIVE: To examine the hypothesis that declining cell-mediated immunity is more closely linked to chronic disease burden than to chronological age. METHODS: Fifty-eight elderly individuals were tested for delayed-type hypersensitivity (DTH) responses to Candida and tetanus antigens. Disease burden was quantified using the Cumulative Illness Rating Scale (CIRS). Higher CIRS scores reflect greater disease burden. Mean DTH response by age group (<71, 71-78, and >78 years) was compared with mean DTH response by CIRS score (<11, 11-15, >15). Total serum IgE levels were measured and similarly stratified by age and CIRS score. RESULTS: Mean Candida DTH responsiveness declined progressively with increasing disease burden (increasing CIRS score). Mean DTH responses were 7.78, 3.05, and 0.0 mm for CIRS scores less than 11, 11 to 15, and greater than 15, respectively. Candida DTH responses showed no progressive decline with advancing age. Mean DTH responses were 4.7, 3.5, and 5.0 mm in participants younger than 71, 71 to 78, and older than 78 years, respectively. Total serum IgE levels increased with advancing age. Mean total IgE levels were 182, 249, and 342 IU/mL in participants younger than 71, 71 to 78, and older than 78 years, respectively. No correlation was observed between mean total IgE levels and CIRS scores. CONCLUSIONS: An inverse relationship between Candida DTH response and CIRS score suggests that increased chronic disease burden is associated with diminished cell-mediated immune response. Advancing age did not predict a diminished DTH response in our patients. No relationship was observed between chronic disease burden and total serum IgE level.

Aged↗
PubMed1992

Biological complexity and strategies for finding DNA variations responsible for inter-individual variation in risk of a common chronic disease, coronary artery disease.

Most common chronic diseases of humans aggregate, but do not segregate, in families. The segregation-linkage research paradigm has not provided great insights into their genetic etiology. In this paper, using coronary artery disease as an example, we discuss hierarchical organization, coherence, emergent properties and dynamism as features that characterize the complexity of genotype-phenotype relationships. We summarize a research strategy for evaluating the contribution of genetic and environmental factors to the prediction of inter-individual variation in risk of disease. We then review a statistical strategy that employs cladistic theory to identify individuals carrying mutant DNA sequences responsible for an observed association between marker variation in a gene and inter-individual variation in biological traits that determine risk of a common multifactorial disease. Finding these DNA sequences is a necessary step in our search for an understanding of the nature of the mapping of genetic variation into variation in risk of a disease like coronary artery disease.

Coronary Disease↗
PubMed1995

Erythropoietin and the anaemia of chronic disease.

The anaemia of chronic disease is the second most common anaemia in the world and is an underproduction anaemia with relatively low erythropoietin (EPO) values for the degree of the anaemia. This anaemia occurs with inflammation, infection, or malignancy and a principle question has been whether it would respond to recombinant human EPO (r-HuEPO). Several studies are now available to answer this question. In one study 12 of 16 patients with rheumatoid arthritis receiving r-HuEPO increased their haematocrits 6 percentage points or more and 11 of 12 reached normal haematocrits. Investigations of the effect of r-HuEPO on the anaemia of AIDS showed that patients with EPO levels of 500 U/L or less had an increase in the mean haematocrit of 4.6 percentage points with a decrease in red cell transfusions from 5.3 to 3.2 units per patient. Quality of life indices significantly improved in responders. When 413 patients with anaemia due to a wide variety of malignancies were randomized to r-HuEPO treatment, 58% of those receiving chemotherapy increased their haematocrits by at least 6 points over 12 weeks. Quality of life parameters of responders also significantly improved. Anaemia in three patients with inflammatory bowel disease also responded in 8-14 weeks to r-HuEPO and two of the three reached normal haemoglobin levels. It is clear that r-HuEPO can correct the anaemia of chronic disease and can improve the quality of life of responders.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Randomised controlled trial of a lay-led self-management programme for Bangladeshi patients with chronic disease.

BACKGROUND: Reducing the impact of chronic disease in minority ethnic groups is an important public health challenge. Lay-led education may overcome cultural and language barriers that limit the effectiveness of professionally-led programmes. We report the first randomised trial of a lay-led self-management programme - the Chronic Disease Self-Management Programme (CDSMP) (Expert Patient Programme) - in a south Asian group. AIM: To determine the effectiveness of a culturally-adapted lay-led self-management programme for Bangladeshi adults with chronic disease. DESIGN OF STUDY: Randomised controlled trial. SETTING: Tower Hamlets, east London. METHOD: We recruited Bangladeshi adults with diabetes, cardiovascular disease, respiratory disease or arthritis from general practices and randomised them to the CDSMP or waiting-list control. Self-efficacy (primary outcome), self-management behaviour, communication with clinician, depression scores, and healthcare use were assessed by blinded interviewer-administered questionnaires in Sylheti before randomisation and 4 months later. RESULTS: Of the 1363 people invited, 476 (34%) agreed to take part and 92% (439/476) of participants were followed up. The programme improved self-efficacy (difference: 0.67, 95% confidence interval [CI] = 0.08 to 1.25) and self-management behaviour (0.53; 95% CI = 0.01 to 1.06). In the 51% (121/238) of intervention participants attending three or more of the 6-weekly education sessions the programme led to greater improvements in self-efficacy (1.47; 95% CI = 0.50 to 1.82) and self-management behaviour (1.16; 95% CI = 0.50 to 1.82), and reduced HADS depression scores (0.64; 95% CI = 0.07 to 1.22). Communication and healthcare use were not significantly different between groups. The programme cost pound123 (181) per participant. CONCLUSION: A culturally-adapted CDSMP improves self-efficacy and self-care behaviour in Bangladeshi patients with chronic disease. Effects on health status were marginal. Benefits were limited by moderate uptake and attendance.

Adult↗