QUESTION 1:
Chronic diseases are the leading cause of the death and disability worldwide. For every 10 people, 7 deaths are attributed to chronic disease, such as heart disease, cancer, and stroke (CDC, 2012). In 2005 nearly one out of every two adults had a chronic disease. It accounts for nearly 75% of direct healthcare cost in the United States (Thrall, 2005). The prevalence of chronic disease increases with age, and with the increased longevity of the population the costs of care are rising. Diseases that were once considered to be fatal are now considered to be chronic diseases, such as certain forms of cancer.
Heart disease and stroke are the first and third leading cause of death in the United States respectively; together they account for nearly 30% of deaths (CDC, 2009). Diabetes as a systemic disease is the leading cause of kidney failure, amputations, and blindness in patients 20-74 years old. $92 billion dollars a year are spent on the healthcare costs associated with diabetes, that is nearly 1.5x the cost spent on stroke or heart disease (Swartz, 2010). Arthritis is the most common cause of disability and afflicts nearly 1 in every 5 Americans. Arthritis limits daily activities, which are usually necessary to improve the pain. The consequence of the resulting severe pain is missed working days (CDC, 2009).
Interventions such as, immunization in childhood, efforts to curb smoking trends, screenings, weight loss and healthy eating programs could save as much as $4 billion annually and as many as 2 million lives (Sorrel, 2012).
Works Cited
Thrall J., 2005. Prevalence and Cost of Chronic Disease in a Health Care System Structured for Treatment of Acute Illness. Radiology. 235, p. 9-12
Swartz K., 2010. Projected Costs of Chronic Disease. Health Care Cost Monitor. Available at: http://healthcarecostmonitor.thehastingscenter.org/kimberlyswartz/projected-costs-of-chronic-diseases/
Sorrel, L., 2012. States Target Chronic Disease to Trim Health Care Cost. American Medical News. Available at: http://www.amednews.com/article/20120319/government/303199958/6/
CDC, 2012. Chronic Disease and Health Promotion (web). National Center for Chronic Disease Prevention and Health Promotion. Available at: http://www.cdc.gov/chronicdisease/overview/index.htm
CDC, 2009. The Power of Prevention: Chronic diseasethe Public Health Challenge of the 21st Century. Available at: http://www.cdc.gov/chronicdisease/pdf/2009-Power-of-Prevention.pdf
QUESTION 2:
A patient with diabetes mellitus and coronary artery disease should be treated in the same manner as a person who only suffers from coronary artery disease. The problem lies in that when they do get treatment, for example PCI, they are more likely to have restenosis and have lower long-term survival rates following the procedure. Dyslipidemia in a diabetic patient is usually hypertriglyceridemia and low HDL, a “protective” lipoprotein. A patient with diabetes does not make more LDL cholesterol, but their LDL is defective in that it is more easily glycated and susceptible to oxidation leading to plaque formation (Harrison’s, 2008). The key to successful treatment is the reduction of LDL, which decreases the number of cardiovascular events and the morbidity. The American Diabetes Association (ADA) recommends that patients reduce their LDL cholesterol, increase their HDL, and decrease triglyceride levels. Studies have shown that exercise increases HDL, as well as eating fish that are rich in omega 3 fatty acids, and a glass of red wine per day may also increase HDL. Other lifestyle modifications include, changing the diet, quitting smoking, and weight loss. Target levels for a patient’s lipoprotein profile who has diabetes but no cardiovascular disease are <100mg/dL for LDL, ≥40mg/dL for HDL, and triglyceride levels should be <100mg/dL (American Heart Association, 2012). However, if the diabetic patient has a history of cardiovascular disease LDL levels should try and be below 70 mg/dL. Dietary modifications include increased monounsaturated fats and carbohydrates and reduced saturated fats and cholesterol. Besides modifications to the person’s lifestyle medication should be used to lower cholesterol levels such as HMG-CoA reductase inhibitors, as well as drugs that put less strain on the heart such as the use of β- blockers.
Hypertension must also be controlled in a patient with diabetes as it can precipitate problems with cardiovascular disease. A person who has “healthy” blood pressure is considered to have a BP <120/80 mmHg. Hypertension is considered in patients with a BP of >140/90 mmHg (American Diabetes Association, 2013). In the diabetic patient the goal is to get the patients BP <130/80 (Harrison’s, 2008). First step in the treatment of hypertension is lifestyle changes, for example weight loss, dietary changes such as a reduction in the intake of sodium, exercise, and stress management. These are similar to the lifestyle changes that reduce the risk of coronary artery disease. If the lifestyle changes do not help medication can be used. ACE inhibitors or angiotensin receptor blockers, should be used in all diabetic patients that have hypertension. Cardiovascular agents should also be used, for example β- blockers and calcium channel blockers (Harrison’s, 2008).
Works Cited
Fauci A., Braunwald E., Kasper D., Hauser S., Longo D., Jameson J., Loscalzo J., eds. (2008) Harrison’s Principles of Internal Medicine (17th edition) New York: McGraw Hill Medical. 2717-2720
American Diabetes Association (2013) High Blood Pressure. Retrieved from: http://www.diabetes.org/diabetes-basics/prevention/checkup-america/bloodpressure.html
American Heart Association. (2012) Cholesterol Abnormalities & Diabetes. Retrieved from: http://www.heart.org/HEARTORG/Conditions/Diabetes/WhyDiabetesMatters/Cholesterol-Abnormalities-Diabetes_UCM_313868_Article.jsp
QUESTION 3:
Chronic obstructive pulmonary disease (COPD) is due to chronic airflow obstruction that is not full reversible. COPD is an umbrella term that encompasses emphysema, chronic bronchitis, and small airway disease (Harrison’s, 2008). Risk factors for the development of COPD include both inherent and environmental causes; they include smoking, increased airway responsiveness, respiratory infections, occupational exposure such as dust, and air pollution especially in large urban areas. Genetic factors for the development of COPD, specifically emphysema, is a deficiency in α1 antitrypsin, a protease inhibitor; other genetic factors have been tested to try and link them to the development of COPD, but no definitive connection has been found. The underlying pathophysiology of COPD results from, airflow obstruction where the measure FEV1/ FVC is chronically reduced, lung hyperinflation due to “air trapping”. Hyperinflation is a compensatory mechanism that tries to preserve expiratory flow in the patient. As the lungs increase in volume, elastic recoil increases, leading to airway enlargement and a decrease in airway resistance (Harrison’s, 2008). Gas exchange is also impaired due to a ventilation/ perfusion mismatch. The pathogenesis of COPD can be explained in four steps that are interrelated and coexist; 1) Chronic exposure to air pollutants, such as smoke leads to the recruitment of inflammatory cell infiltrates, 2) these inflammatory cell infiltrates lead to damage due to the release of elastolytic proteinases, 3) because of the destruction, structural cells of the lung undergo apoptosis, and 4) the inability of the lungs to undergo repair leads the classic appearance of enlarged airways seen in COPD.
The appearance and functional capacity of a patient with COPD are at two opposite ends of the spectrum; a patient can be considered to be a pink puffer or a blue bloater. Pink puffers have an increase in alveolar ventilation, and their PaCO2 and PaO2 are near normal. The patient appears thin and is breathless but is not cyanotic. As the disease progresses they can progress to type 1 respiratory failure. Blue bloaters on the other hand have decreased alveolar ventilation, a low PaO2, and a high PaCO2. The respiratory centers in these patients brains are insensitive to CO2 and therefore rely on hypoxic drive to keep breathing, therefore supplemental oxygen must be given with care (Oxford, 2012).
Works Cited
Fauci A., Braunwald E., Kasper D., Hauser S., Longo D., Jameson J., Loscalzo J., eds. (2008) Harrison’s Principles of Internal Medicine (17th edition) New York: McGraw Hill Medical. 1635-1643
Longmore M., Wilkinson I., Davidson E., Foulkes A., Mafi A., eds. (2010) .Oxford Handbook of Clinical Medicine (8th edition) New York: Oxford University Press Inc. 176
Question 4
The word iatrogenesis comes from the Greek word iatro meaning surgeon or physician and the Roman word genesis meaning production. Iatrogenic disease can be described as any disorder, or problem, that may occur to a patient due to a visit, investigation or treatment by a medical professional (Somerville A., 1972). While malpractice is also part of this term, iatrogenic disease can be due to the unavoidable consequences associated with treatment.
In the past the doctor that was most likely to cause iatrogenic disease was the surgeon. Nowadays, however all doctors can be implicated because of the numerous risk factors for developing iatrogenic disease. All patients at high risk for developing iatrogenic disease include those that have multiple chronic diseases, visit multiple doctors, have a high number of hospitalization, increased number of medical and/ or surgical procedures, and take several medications, also known as poly-pharmacy. Poly-pharmacy is a major problem, with an increase in the number of chronic diseases and the number of concurrent drugs to treat those illnesses there are multiple drug-drug interactions that could potentially occur (Somerville A., 1972). The risk for drug interactions to occur increases in the malnourished and those suffering from renal disease (Permpongkosol S., 2011). Risk factors due to medical or surgical intervention include hospital-acquired infections, poly-pharmacy and transfusion reactions. Generally the patients that fall into these categorizes are the elderly. One study suggests that the incidence of iatrogenic disease in the elderly population is between 3.4% and 33.9% (Atiqi R, van Bommel E, Cleophas TJ, Zwinderman AH, 2010). Preventative care is the best method to avoid iatrogenic disease in the elderly. Prevention entails identifying the elderly at high risk, early recognition and treatment of chronic diseases, and minimization of the drugs they use. Besides the methods of prevention mentioned above, there also needs to be cooperation between the patients doctors as-well as a trusted pharmacist who could help minimize complications associated with the number of drugs elderly patients are generally on (Permpongkosol S., 2011).
Works Cited
Somerville A. (1972). Iatrogenic Disease. The College of Family Physicians. 18(6), 85, 87, 89-91
Permpongkosol S. (2011). Iatrogenic Disease in the Elderly: Risk Factors, consequences, and prevention. NCBI. http://dx.doi.org/10.2147%2FCIA.S10252. Available through: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066256/
Atiqi R, van Bommel E, Cleophas TJ, Zwinderman AH. Prevalence of iatrogenic admissions to the Departments of Medicine/Cardiology/Pulmonology in a 1,250 bed general hospital. Int J Clin Pharmacol Ther. 2010;48(8):517–524.
