Severe Chronic Illness Research Articles

Role of stress in the exacerbation of chronic illness: Effects of clonidine administration on blood pressure and plasma norepinephrine, cortisol, growth hormone and prolactin concentrations

Systolic blood pressure (SBP), diastolic blood pressure (DBP), and plasma norepinephrine (NE), cortisol (CRT), growth hormone (GH) and prolactin (PRL) were studied before and after clonidine (2.5 μg/kg i.m.) administration in 193 chronic severely ill patients and 193 normal subjects matched by age and sex. During exacerbation periods (positive manifestations of impairment and progressive disease), the patients showed higher NE, CRT and DBP than the normals or when they were investigated during non-exacerbation periods (92 of the 193). Clonidine induced sharp, marked reductions of NE, CRT and DBP, plus a sudden increase of GH, in all the patients during exacerbation periods. Non-significant reductions of NE, CRT and DBP were observed in normals and in patients during non-exacerbation periods. On the other hand, the GH increase registered during exacerbation periods was of an order of magnitude higher than that registered in normals and in patients during non-exacerbation periods. Significant reduction of SBP was registered both in normals and patients (exacerbation and non-exacerbation periods). Some tendency to PRL lowering was observed during exacerbation periods only. A high positive correlation between NE and DBP (pre- and post-clonidine values) was obtained during exacerbation periods in patients, but not in normals or during non-exacerbation periods in the patients. Similarly, a close negative correlation was obtained between CRT and GH (postclonidine values) during exacerbation periods, but not in normals or during non-exacerbation periods. No significant correlation was found between NE and SBP in any group of subjects. The clonidine-induced changes in GH and CRT observed in the patients during exacerbation periods were in striking contrast to the absence of these changes in depressed patients. This finding is consistent with the low rate of depression (6.7%) registered among our patients during exacerbation periods. The high plasma NE and CRT levels registered in chronic severely ill patients during exacerbation periods reflect a central and peripheral sympathetic hyperactivity, accompanied by an overactivity of the pituitary — adrenocortical axis. The strong reduction of DBP, NE and CRT, along with the sharp and great increase of GH, might be useful as indicators in assessing the exacerbation and progression of severe chronic illnesses.

Reducing Deaths Caused by Bronchial Asthma-Reply

In Reply.— Dr Rubenstein has raised some of the same questions that we have asked ourselves both during the collection of the data for our study and on an ongoing basis. National Jewish Center has had long experience with the care of children and adults with severe asthma. Physicians from all 50 states and several foreign countries refer patients who have not been able to be controlled in their home community despite expert primary care and allergy-pulmonary consultation. The reasons for referral are severe medical illness and the psychosocial problems that accompany severe chronic illness. Therefore, the patients usually represent a small percentage of patients at the most extreme end of the illness spectrum. Patients admitted to the center are cared for by a team consisting of pulmonary-psychiatric nurses, pediatric psychiatrists, psychologists and social workers in consultation with psychiatrists, and rehabilitation specialists. The team is directed either by a full-time,

Chronically III Children

Increasing numbers of children are surviving with long-term and severe chronic illnesses. Approximately 10% to 15% of children have some chronic health condition; 2% of children in the United States have severe chronic illnesses. Despite the differences in medical and surgical treatments for these varied diseases, the fact of chronicity creates certain problems common to most families with a chronically ill child: high financial costs, heavy daily care burden, conflicting professional advice, and social isolation. New findings about the developmental and emotional impact of childhood chronic illness suggest opportunities for early intervention to diminish handicaps from chronic illness.

Young adults with disabilities: health, employment and financial costs for family carers.

In this paper, the health and employment of mothers with a severely disabled young adult are compared with those of women in the general population. Mothers in the sample were much more likely to suffer from a severe chronic illness and to experience symptoms of psychiatric disturbance. Their workforce participation, hours of work and earnings were all lower than for women in general. Variations in mothers' health status and employment patterns could not be explained by aspects of their sons' or daughters' disablement. It seemed that mothers of all disabled young adults, not only mothers of the more severely disabled, experienced adverse effects of providing care in the family. Implications of these findings are discussed.

Conference on the Care of Patients with Severe Chronic Pain and Terminal Illness

Conference on the Care of Patients with Severe Chronic Pain and Terminal Illness

The impact of severe illness on the individual and family: an overview.

The course and outcome of severe chronic illness are decisively affected by social and emotional variables. The conceptual approach of this article emphasizes an understanding of the individual, the family, and health care personnel as all facing a series of adaptive tasks in relation to the illness. Each of the three phases of the illness--the diagnostic, chronic, and end stage--poses special tasks and requires different defenses and coping capacities from the patient, family, and health care personnel. These are discussed as interdependent factors in a holistic framework.

Relationship of the Actions of Neuroleptic Drugs to the Pathophysiology of Tardive Dyskinesia

Publisher Summary This chapter surveys and synthesizes the adaptive responses to the neuroleptic drugs that may bear on the mechanisms underlying the late and persistent or tardive dyskinesias associated with their use in the treatment of patients with severe chronic neuropsychiatric illnesses. The chapter provides an overview of the current use of the neuroleptic drugs, their neurological side effects, and their currently suspected mechanisms of action. There is a need for carefully controlled neuropathologic studies in animals and man following prolonged exposure to neuroleptic agents, using classical neurohistology and newer techniques such as chemical assays of transmitters and their metabolites, as well as biochemical and immunohistologic assays of neuron-specific enzymes, and the new labeling assays for neurotransmitter and drug receptors. Such methods are applicable to postmortem human brain tissue for a more direct evaluation of the current pathophysiologic hypotheses concerning the response of the brain to prolonged exposure to neuroleptic drugs, and the development of tardive dyskinesia. The precise pathophysiology of tardive dyskinesia remains uncertain. The study of neurological, behavioral, and endocrinological effects of the neuroleptic agents on the CNS has contributed to an improved understanding of their actions, which is at least equal to that of many other drugs used in medicine.

Thyroid function in non-thyroidal illness.

SERUM total and non-protein-bound (“free”) fraction of thyroxine and triiodothyronine together with the urinary unconjugated concentrations of these hormones have been measured in normal subjects and in a group of hospital in-patients suffering from a variety of moderately severe subacute or chronic non-thyroidal illness. Significantly higher concentrations of serum free thyroxine and even more striking increases in renal excretion of thyroxine were found in sick subjects. No such changes were apparent in the case of triiodothyronine. It is suggested that these findings are best explained by the presence in sick individuals of circulating small molecular weight compounds which competitively inhibit thyroxine binding to serum proteins and its active reabsorption by renal tubules.

The pathology of experimental yersiniosis in guinea pigs

Yersinia pseudotuberculosis infection was produced experimentally in guinea pigs by the oral, intraperitoneal and subcutaneous routes. Dose levels varied from 20 000 × 10 6 to 6·25 × 10 6 viable organisms per 100 g body weight. All doses used for oral and intraperitoneal infections were lethal while a dose of 6·25 × 10 6 organisms per 100 g body weight killed 50 per cent of subcutaneously infected animals. The larger doses produced an acute fatal illness, while the lower doses were associated with a less severe chronic illness. The main pathological findings were miliary focal necrosis and abscess formation. Caseous lymphadenitis occurred in chronically infected animals. The distribution of lesions associated with the different routes of inoculation is recorded.

Osteoporosis and Smoking

To the Editor.— I wish to respond to Dr. Daniell's letter published in the July 31, 1972, issue ofThe Journalregarding the relationship between osteoporosis and smoking. In his study of 17 patients with severe idiopathic, presenile osteoporosis, 15 smoked 20 or more cigarettes per day for many years. Several possible mechanisms were discussed regarding smoking and osteoporosis. I believe another needs mentioning. As is well known, severe immobility can lead to osteoporosis. Decreased osteoblastic and increased osteoclastic activity occurs as a result of immobilization and lack of proper mechanical stress on bones. In Dr. Daniell's study, the group with idiopathic presenile osteoporosis included many subjects with severe chronic respiratory illnesses. Two of the patients died subsequently of chronic obstructive pulmonary disease. Thus, in this study, heavy smoking seems as likely to be related to osteoporosis via severe respiratory illness causing immobility as via the other mechanisms proposed to

STUDIES IN DEPRESSION: 1. CINGULO‐TRACTOTOMY IN THE TREATMENT OF SEVERE AFFECTIVE ILLNESS

Fifty cases of selective anterior cingulotomy (cingulo-tractotomy) are reviewed. The application of this psychosurgical procedure to patients suffering from severe chronic depressive illness is considered. Criteria for the selection of cases for the operation are discussed, and a plea is made for consideration of the operation as a potentially life-saving therapeutic measure.

Psychological practices with the physically disabled.

The editors have attempted to examine the psychological aspects of the problems that accompany the various physical disabilities. In having done so, they have emphasized, justly, the individual adjustment of the disabled person to his physical deficit and his total life situation. The presentation comprises 12 groups of physical disabilities, each presented by a different author. Amputation, hemiplegia, cerebral palsy, and cardiovascular disabilities are considered, as are auditory, visual, and language disorders, and deafness and blindness. Also, there are chapters on cancer, facial disfigurement, severe chronic illness, and arthritis and rheumatism. The most prominent problems connected with a disability, but not limited to it, are discussed. The selection of disabilities to be considered was made on the basis of incidence in the population, difficulty of psychological appraisal and of vocational rehabilitation, and the availability of psychological literature on the subjects. Since all of the contributors are recognized figures in the