Chronic Disabling Disease Research Articles

Trajectories of care and outcomes of Veterans receiving home-based primary care.

Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described. We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps. We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care. HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.

The effect of the emotion regulation training on the resilience of caregivers of patients with schizophrenia: a parallel randomized controlled trial

BackgroundSchizophrenia is the most severe mental chronic disabling disease that the majority of the patients need constant care in a variety of aspects. Regarding the role of family caregivers in taking care of these patients, caregivers need to be resilient, in addition to other psychological traits, to adapt to the circumstance. This study aimed to investigate the effect of the emotion regulation training on the resilience of caregivers of patients with schizophrenia in southeastern Iran.MethodsThe study was a parallel randomized controlled trial. Seventy caregivers of patients with schizophrenia were selected by convenience sampling method and randomly assigned to an emotion regulation training group and a control group. The intervention group received eight 90-min training sessions (one session weekly) about emotion regulation. The participants completed the Conner–Davidson resilience scale before and one month after the intervention.ResultsThe mean scores of the resilience increased in the control and intervention groups at the end of the study. A significant difference was found between the two groups (p < 0.001). At the beginning of the study, the mean score of the resilience was 59.94 in the control group and 51.97 in the intervention group. However, the mean score of the resilience in the control group was 61.28 after the intervention, which was not significant, but it was 69.08 in the intervention group, which was significant. A significant difference was observed between two groups in the mean scores (p = 0.01).ConclusionsAccording to the results of this study, cognitive and metacognitive skills of emotion regulation can be suggested as one of the methods for increasing the psychological well-being of schizophrenia patients’ caregivers. The increase of mental well-being and resilience of caregivers can help them better manage a patient with schizophrenia.Trial registration IRCT registration number: IRCT2017061733997N2, Registration date: 2017-08-16, 1396/05/25, Registration timing: prospective, https://en.irct.ir/trial/26116

High Risk Subgroups Sensitive to Air Pollution Levels Following an Emergency Medical Admission.

For three cohorts (the elderly, socially deprived, and those with chronic disabling disease), the relationship between the concentrations of particulate matter (PM10), sulphur dioxide (SO2), or oxides of nitrogen (NOx) at the time of hospital admission and outcomes (30-day in-hospital mortality) were investigated All emergency admissions (90,423 episodes, recorded in 48,035 patients) between 2002 and 2015 were examined. PM10, SO2, and NOx daily levels from the hospital catchment area were correlated with the outcomes for the older admission cohort (>70 years), those of lower socio-economic status (SES), and with more disabling disease. Adjusted for acuity and complexity, the level of each pollutant on the day of admission independently predicted the 30-day mortality: for PM10–OR 1.11 (95% CI: 1.08, 1.15), SO2–1.20 (95% CI: 1.16, 1.24), and NOx–1.09 (1.06–1.13). For the older admission cohort (≥70 years), as admission day pollution increased (NOx quintiles) the 30-day mortality was higher in the elderly (14.2% vs. 11.3%: p < 0.001). Persons with a lower SES were at increased risk. Persons with more disabling disease also had worse outcomes on days with higher admission particulate matter (PM10 quintiles). Levels of pollutants on the day of admission of emergency medical admissions predicted 30-day hospital mortality.

Chronic disabling disease--impact on outcomes and costs in emergency medical admissions.

Chronic disabling disease is present in nearly 90% of emergency medical admissions. We have examined its impact on outcomes and costs in one institution, using a database of episodes collected prospectively over 12 years. All emergency admissions (66,933 episodes; 36,271 patients) to St James' Hospital over a 12-year period (2002-13) were evaluated in relation to 30-day in-hospital mortality, length of stay (LOS) and hospital costs. Predictor variables (identified univariately) were entered into a multi-variable logistic regression model to predict 30-day in-hospital mortality. The data were also modelled as count data (absolute LOS, total cost) using zero-truncated Poisson regression. Acute illness severity was the best independent predictor of mortality; chronic disabling disease was an independent predictor (P < 0.001) for patients with 4+ disabling conditions. Age, adjusted for other predictors, was only independently predictive of mortality for patient 85+ years. Chronic disabling disease was an independent predictor of LOS increasing linearly with incidence rate ratios of 1.35 (95% CI: 1.29, 1.42), 1.59 (95% CI: 1.51, 1.66), 1.73 (95% CI: 1.65, 1.83) and 1.74 (95% CI: 1.65, 1.84) for those with 1, 2, 3 or 4+ disabling conditions, respectively. Age, as a predictor of LOS was strongly correlated with the presence of disabling disease. Chronic disabling disease independently predicted costs non-linearly; those with 2 or more disabling conditions had particularly high total hospital costs. Chronic disabling disease is an independent predictor of hospital LOS and costs in unselected emergency admissions; adjusted for illness severity, it is only a mortality predictor for those with multiple disabling conditions.

Y-39983, a Selective Rho-Kinase Inhibitor, Attenuates Experimental Autoimmune Encephalomyelitis via Inhibition of Demyelination

Objective: Rho-associated kinase (ROCK) is a serine/threonine kinase and a major downstream effector of the small GTP-binding protein, Rho. Rho-ROCK triggers an intracellular signaling cascade that controls actin cytoskeleton and is essential for cell motility and adhesion, neurite outgrowth and retraction. In chronic disabling disease, multiple sclerosis (MS) and its animal model experimental autoimmune encephalomyelitis (EAE), demyelination and axonal damage are the major pathological changes contributing to neurological disability. We investigated the protective effect of a specific ROCK inhibitor, Y-39983, on demyelination and axonal damage in chronic EAE. Methods: Western blotting for myelin proteins, electron microscopy and solochrome cyanine staining was performed to evaluate demyelination while neurofilament proteins and cytoskeletal proteins including β-actin and β-tubulin were used to determine axonal damage in a chronic mouse model of EAE treated with Y-39983. Results: Y-39983 significantly suppressed clinical symptoms of EAE and prevented its relapse while increasing the amount of myelin proteins. No significant changes in neurofilaments and cytoskeletal proteins were observed compared with control EAE mice. The inhibition of demyelination by Y-39983 was confirmed by solochrome cyanine staining and electron microscopy. To further study the effect of Y-39983 on demyelination in EAE, we tested three major ROCK substrates, including myosin light chain phosphorylation, LIMK2 and collapsin response mediator protein-2. The activity of these molecules was decreased in EAE animals treated with Y-39983. Conclusion: The inhibitory effect of Y-39983 on demyelination is probably due to the inactivation of ROCK substrates, which are important for neurite outgrowth, growth cone collapse and demyelination of oligodendrocytes.

Associations between diagnoses, impairments, disability and handicap in a population of elderly people.

'Handicap' is the disadvantage for an individual that results from ill-health. It represents an important outcome in chronic disabling disease, but has proved difficult to measure until recently. The strength of association between handicap and other health status measures, and the relative contributions of health and socioeconomic variables to handicap have not been studied previously. We undertook a cross-sectional survey of all people > 65 years old in a defined geographical area of North London. The interview was based on the short-CARE psychiatric survey tool, and in addition included measures of physical health and disability, the London Handicap Scale, income, social support and housing. In all, 654 residents (74%) from a register of 889 were interviewed. A random sample of 225 had additional data collected which are reported in this analysis. Strength of association with handicap scores increased progressively from diagnosis to impairment to disability. Variation in handicap with diagnosis was explained by impairment, and variation with impairment was mostly explained by disability. Age, housing quality, social support and income were associated with handicap score, but confounding by these did not explain the association between handicap and other aspects of disablement. Disease-associated variables explained quantitatively much more variation in handicap than socioeconomic variables. The most potent influences on handicap are disease and disability, justifying the high priority given by health services to detection, treatment and rehabilitation. Where this is not possible handicap may be reduced to some extent through socioeconomic intervention.

The reality of continuing care

The need for multidisciplinary collaboration, cooperation and communication has never been greater as larger numbers of disabled, dependent, individuals with chronic disease are supported in our communities. Chronic disabling disease is frequently accompanied by distressing symptoms that are difficult to control. Individuals and their carers may require multidisciplinary assessment and ongoing support to maximize independence. However, support mechanisms for dealing with such patients are not necessarily well defined.

The Cook County Hospital emergency department. New methods to meet changing needs.

Today the emergency departments of hospitals are providing more medical care than ever before for a vast number of persons with nonurgent, chronic disabling disease. This has resulted in acute over...