Assessing the relationship between multimorbidity, NCD configurations, frailty phenotypes, and mortality risk in older adults

BACKGROUND

Older adults are increasingly susceptible to prolonged illness, multiple chronic diseases, and disabilities, which can lead to the coexistence of multimorbidity and frailty. Multimorbidity may result in various noncommunicable disease (NCD) patterns or configurations that could be associated with frailty and death. Mortality risk may vary depending on the presence of specific chronic diseases configurations or frailty.

METHODS

The aim was to examine the impact of NCD configurations on mortality risk among older adults with distinct frailty phenotypes. The population was analyzed from the Costa Rican Longevity and Healthy Aging Study Cohort (CRELES). A total of 2,662 adults aged 60 or older were included and followed for 5 years. Exploratory factor analysis and various clustering techniques were utilized to identify NCD configurations. The frequency of NCD accumulation was also assessed for a multimorbidity definition. Frailty phenotypes were set according to Fried et al. criteria. Kaplan‒Meier survival analyses, mortality rates, and Cox proportional hazards models were estimated.

RESULTS

Four different types of patterns were identified: 'Neuro-psychiatric', 'Metabolic', 'Cardiovascular', and 'Mixt' configurations. These configurations showed a higher mortality risk than the mere accumulation of NCDs [Cardiovascular HR:1.65 (1.07-2.57); 'Mixt' HR:1.49 (1.00-2.22); ≥3 NCDs HR:1.31 (1.09-1.58)]. Frailty exhibited a high and constant mortality risk, irrespective of the presence of any NCD configuration or multimorbidity definition. However, HRs decreased and lost statistical significance when phenotypes were considered in the Cox models [frailty + 'Cardiovascular' HR:1.56 (1.00-2.42); frailty + 'Mixt':1.42 (0.95-2.11); and frailty + ≥ 3 NCDs HR:1.23 (1.02-1.49)].

CONCLUSIONS

Frailty accompanying multimorbidity emerges as a more crucial indicator of mortality risk than multimorbidity alone. Therefore, studying NCD configurations is worthwhile as they may offer improved risk profiles for mortality as alternatives to straightforward counts.

Peptic ulcer as mediator of the association between risk of gastric cancer and socioeconomic status, tobacco smoking, alcohol drinking and salt intake

BACKGROUND

Peptic ulcer disease (PUD) and gastric cancer (GC) are more prevalent in individuals with low socioeconomic status (SES) and share several risk factors. The aim of this study was to investigate the mediating role of PUD in the association between established risk factors and GC.

METHODS

We conducted a pooled analysis of 12 studies from the Stomach Cancer Pooling Project Consortium, including a total of 4877 GC cases and 11 808 controls. We explored the mediating role of PUD in the association between SES, tobacco smoking, heavy alcohol drinking and salt intake, and GC. Also, we assessed the ORs and 95% CIs of the risk factors and both PUD and GC.

RESULTS

PUD mediated 36% of the smoking effect mainly among men. Other risk factors were only slightly mediated by PUD (SES, 5.3%; heavy alcohol drinking, 3.3%; and salt intake, 2.5%). No significant difference was found when excluding PUD diagnosed within 2 years from GC.

CONCLUSIONS

Our study provides innovative information on the mechanism of stomach mucosal damage leading to PUD and GC, with respect to the effect of tobacco smoking in particular.

The utility of the Edmonton Obesity Staging System for the prediction of COVID-19 outcomes: a multi-centre study

BACKGROUND

Patients with obesity have an increased risk for adverse COVID-19 outcomes. Body mass index (BMI) does not acknowledge the health burden associated this disease. The performance of the Edmonton Obesity Staging System (EOSS), a clinical classification tool that assesses obesity-related comorbidity, is compared with BMI, with respect to adverse COVID-19 outcomes.

METHODS

1071 patients were evaluated in 11 COVID-19 hospitals in Mexico. Patients were classified into EOSS stages. Adjusted risk factors for COVID-19 outcomes were calculated and survival analysis for mechanical ventilation and death was carried out according to EOSS stage and BMI category.

RESULTS

The risk for intubation was higher in patients with EOSS stages 2 and 4 (HR 1.42, 95% CI 1.02-1.97 and 2.78, 95% CI 1.83-4.24), and in patients with BMI classes II and III (HR 1.71, 95% CI 1.06-2.74, and 2.62, 95% CI 1.65-4.17). Mortality rates were significantly lower in patients with EOSS stages 0 and 1 (HR 0.62, 95% CI 0.42-0.92) and higher in patients with BMI class III (HR 1.58, 95% CI 1.03-2.42). In patients with a BMI ≥ 25 kg/m2, the risk for intubation increased with progressive EOSS stages. Only individuals in BMI class III showed an increased risk for intubation (HR 2.24, 95% CI 1.50-3.34). Mortality risk was increased in EOSS stages 2 and 4 compared to EOSS 0 and 1, and in patients with BMI class II and III, compared to patients with overweight.

CONCLUSIONS

EOSS was associated with adverse COVID-19 outcomes, and it distinguished risks beyond BMI. Patients with overweight and obesity in EOSS stages 0 and 1 had a lower risk than patients with normal weight. BMI does not adequately reflect adipose tissue-associated disease, it is not ideal for guiding chronic-disease management.

Fibroblast growth factor 21 is associated with increased serum total antioxidant capacity and oxidized lipoproteins in humans with different stages of chronic kidney disease

Background and aims

Oxidative stress (OS) induces the production of fibroblast growth factor 21 (FGF21). Previous data have revealed that FGF21 protects cells from OS injury and death, making it a potential therapeutic option for many diseases with increased OS. However, the association of this growth factor with OS markers in humans with chronic kidney disease (CKD) remains unknown. This study aims to evaluate the association of serum FGF21 with serum total antioxidant capacity (TAC) and oxidized low-density lipoproteins (OxLDL) in subjects in different stages of kidney disease.

Methods

This is a cross-sectional study that included 382 subjects with different stages of CKD, irrespective of type 2 diabetes (T2D) diagnosis. Associations of serum FGF21 with OxLDL, TAC, sex, age, body mass index (BMI), fasting plasma glucose, estimated glomerular filtration rate (eGFR), T2D, and smoking, were evaluated through bivariate and partial correlation analyses. Independent associations of these variables with serum FGF21 were evaluated using multiple linear regression analysis.

Results

Serum FGF21 was significantly and positively correlated with age (r = 0.236), TAC (lnTAC) (r = 0.217), and negatively correlated with eGFR (r = -0.429) and male sex (r = -0.102). After controlling by age, sex, BMI, T2D, smoking, and eGFR; both TAC and OxLDL were positively correlated with FGF21 (r = 0.117 and 0.158 respectively, p < 0.05). Using multiple linear regression analysis, eGFR, male sex, T2D, OxLDL, and TAC were independently associated with serum FGF21 (STDβ = -0.475, 0.162, -0.153, 0.142 and 0.136 respectively; p < 0.05 for all) adjusted for age, BMI, smoking, and fasting plasma glucose.

Conclusion

A positive association between serum FGF21 and OS has been found independently of renal function in humans. Results from the present study provide novel information for deeper understanding of the role of FGF21 in OS in humans with CKD and T2D; mechanistic studies to explain the association of serum FGF21 with oxidative stress in CKD are needed.

Desigualdad social en México en el uso de servicios de tamizaje en adultos: un análisis de las encuestas nacionales de salud 2006 y 2012

Objetivo. Medir la desigualdad en el uso de servicios de tamizaje en adultos de 20 a 59 años, a partir de las encuestas nacionales de salud y nutrición 2006 y 2012. Material y métodos. A partir de la selección de cinco indicadores de tamizaje en adultos (detección de diabetes, hipertensión y cánceres de mama, cérvicouterino y de próstata) se estimaron el índice de Kuznets, el índice de desigualdad de la pendiente y el índice de concentración de salud, considerando como indicadores sociales la escolaridad, etnicidad, desempleo, nivel socioeconómico y tipo de protección en salud. Resultados. Las coberturas de las cinco pruebas se incrementaron, sin embargo, la desigualdad observada disminuyó únicamente en las intervenciones en mujeres; en el caso de la detección de cáncer de próstata se incrementó. Conclusión. Si bien es importante monitorear el desempeño de los servicios curativos, persiste el reto de asegurar el acceso efectivo y equitativo a servicios de diagnóstico temprano.

Stature in adults as an indicator of socioeconomic inequalities in Mexico

OBJECTIVE

To estimate the association between stature in Mexican adults and some sociodemographic factors.

METHODS

We studied a sample of 30 970 subjects, using anthropometric data from the 2012 National Health and Nutrition Survey (ENSANUT 2012). The first quartile was used as the cutoff to define short stature. We analyzed differences among stature strata for sociodemographic variables by using the Kruskal-Wallis test. We estimated odds ratios to measure the association between stature and sociodemographic variables, controlling for potential confounders.

RESULTS

Persons from the southern region of the country were some three times as likely to be of short stature than were subjects in the northern region. The stature difference between the Mexican states with the highest and the lowest average stature was larger than the average difference in stature between Mexico and the United States of America. Adults who had had less than six years of schooling presented the highest prevalence of short stature, regardless of sex, region of the country, place of residence (rural or urban), or the proportion of indigenous language speakers in a state. In addition, the stratum with the highest marginalization (percentage of the population lacking education and services, with a low income, and living in a small community) showed the highest prevalence of short stature.

CONCLUSION

In Mexico, adults who are of short stature have unequal living conditions when compared to those of average or high stature, and this could drive increases in health inequity.

Terremotos y salud en México: atención de la emergencia en el Istmo de Tehuantepec

 El día 7 de septiembre del 2017 se registró un sismo de intensidad 8.2 grados en la escala de Richter, con mayor afec­tación en la región del Istmo de Tehuantepec. El mecanismo de respuesta por parte del sector salud fue implementado de manera inmediata a través del Operativo para la Seguridad en Salud. Las acciones prioritarias estuvieron enfocadas en el restablecimiento de la capacidad local de atención médica, en la identificación de enfermedades prevalentes y en llevar a cabo acciones de salud pública. Sin embargo, pese a las experiencias obtenidas en 1985, aún se vislumbra escasez de planeación y asignación de responsabilidades.

Analysis of spatial mobility in subjects from a Dengue endemic urban locality in Morelos State, Mexico

INTRODUCTION

Mathematical models and field data suggest that human mobility is an important driver for Dengue virus transmission. Nonetheless little is known on this matter due the lack of instruments for precise mobility quantification and study design difficulties.

MATERIALS AND METHODS

We carried out a cohort-nested, case-control study with 126 individuals (42 cases, 42 intradomestic controls and 42 population controls) with the goal of describing human mobility patterns of recently Dengue virus-infected subjects, and comparing them with those of non-infected subjects living in an urban endemic locality. Mobility was quantified using a GPS-data logger registering waypoints at 60-second intervals for a minimum of 15 natural days.

RESULTS

Although absolute displacement was highly biased towards the intradomestic and peridomestic areas, occasional displacements exceeding a 100-Km radius from the center of the studied locality were recorded for all three study groups and individual displacements were recorded traveling across six states from central Mexico. Additionally, cases had a larger number of visits out of the municipality´s administrative limits when compared to intradomestic controls (cases: 10.4 versus intradomestic controls: 2.9, p = 0.0282). We were able to identify extradomestic places within and out of the locality that were independently visited by apparently non-related infected subjects, consistent with houses, working and leisure places.

CONCLUSIONS

Results of this study show that human mobility in a small urban setting exceeded that considered by local health authority's administrative limits, and was different between recently infected and non-infected subjects living in the same household. These observations provide important insights about the role that human mobility may have in Dengue virus transmission and persistence across endemic geographic areas that need to be taken into account when planning preventive and control measures. Finally, these results are a valuable reference when setting the parameters for future mathematical modeling studies.

Adiposity and Blood Pressure in 110 000 Mexican Adults

Previous studies have reached differing conclusions about the importance of general versus central markers of adiposity to blood pressure, leading to suggestions that population-specific adiposity thresholds may be needed. We examined the relevance of adiposity to blood pressure among 111 911 men and women who, when recruited into the Mexico City Prospective Study, were aged 35 to 89 years, had no chronic disease, and were not taking antihypertensives. Linear regression was used to estimate the effects on systolic and diastolic blood pressure of 2 markers of general adiposity (body mass index and height-adjusted weight) and 4 markers of central adiposity (waist circumference, hip circumference, waist:hip ratio, and waist:height ratio), adjusted for relevant confounders. Mean (SD) adiposity levels were: body mass index (28.7±4.5 kg/m²), height-adjusted weight (70.2±11.2 kg), waist circumference (93.3±10.6 cm), hip circumference (104.0±9.0 cm), waist:hip ratio (0.90±0.06), and waist:height ratio (0.60±0.07). Associations with blood pressure were linear with no threshold levels below which lower general or central adiposity was not associated with lower blood pressure. On average, each 1 SD higher measured adiposity marker was associated with a 3 mm Hg higher systolic blood pressure and 2 mm Hg higher diastolic blood pressure (SEs <0.1 mm Hg), but for the waist:hip ratio, associations were only approximately half as strong. General adiposity associations were independent of central adiposity, but central adiposity associations were substantially reduced by adjustment for general adiposity. Findings were similar for men and women. In Mexican adults, often overweight or obese, markers of general adiposity were stronger independent predictors of blood pressure than measured markers of central adiposity, with no threshold effects.

Diabetes and Cause-Specific Mortality in Mexico City

BACKGROUND

Most large, prospective studies of the effects of diabetes on mortality have focused on high-income countries where patients have access to reasonably good medical care and can receive treatments to establish and maintain good glycemic control. In those countries, diabetes less than doubles the rate of death from any cause. Few large, prospective studies have been conducted in middle-income countries where obesity and diabetes have become common and glycemic control may be poor.

METHODS

From 1998 through 2004, we recruited approximately 50,000 men and 100,000 women 35 years of age or older into a prospective study in Mexico City, Mexico. We recorded the presence or absence of previously diagnosed diabetes, obtained and stored blood samples, and tracked 12-year disease-specific deaths through January 1, 2014. We accepted diabetes as the underlying cause of death only for deaths that were due to acute diabetic crises. We estimated rate ratios for death among participants who had diabetes at recruitment versus those who did not have diabetes at recruitment; data from participants who had chronic diseases other than diabetes were excluded from the main analysis.

RESULTS

At the time of recruitment, obesity was common and the prevalence of diabetes rose steeply with age (3% at 35 to 39 years of age and >20% by 60 years of age). Participants who had diabetes had poor glycemic control (mean [±SD] glycated hemoglobin level, 9.0±2.4%), and the rates of use of other vasoprotective medications were low (e.g., 30% of participants with diabetes were receiving antihypertensive medication at recruitment and 1% were receiving lipid-lowering medication). Previously diagnosed diabetes was associated with rate ratios for death from any cause of 5.4 (95% confidence interval [CI], 5.0 to 6.0) at 35 to 59 years of age, 3.1 (95% CI, 2.9 to 3.3) at 60 to 74 years of age, and 1.9 (95% CI, 1.8 to 2.1) at 75 to 84 years of age. Between 35 and 74 years of age, the excess mortality associated with previously diagnosed diabetes accounted for one third of all deaths; the largest absolute excess risks of death were from renal disease (rate ratio, 20.1; 95% CI, 17.2 to 23.4), cardiac disease (rate ratio, 3.7; 95% CI, 3.2 to 4.2), infection (rate ratio, 4.7; 95% CI, 4.0 to 5.5), acute diabetic crises (8% of all deaths among participants who had previously diagnosed diabetes), and other vascular disease (mainly stroke). Little association was observed between diabetes and mortality from cirrhosis, cancer, or chronic obstructive pulmonary disease.

CONCLUSIONS

In this study in Mexico, a middle-income country with high levels of obesity, diabetes was common, glycemic control was poor, and diabetes was associated with a far worse prognosis than that seen in high-income countries; it accounted for at least one third of all deaths between 35 and 74 years of age. (Funded by the Wellcome Trust and others.).

[Inequality in primary care interventions in maternal and child health care in Mexico]

OBJECTIVE

To analyze the principal indicators associated with maternal mortality and mortality in children under 1 year of age and evaluate coverage levels and variability among the federative entities of Mexico.

METHODS

Eight interventions in maternal and child primary health care (variables) were studied: complete vaccination series, measles vaccine, and pentavalent vaccine in children under 1 year of age; early breast-feeding; prenatal care with at least one check-up by trained staff; prevalence of contraceptive use among married women of reproductive age; obstetric care in delivery by trained staff; and the administration of tetanus toxoid (TT) to pregnant women. The average and standard deviation of national coverage for each variable was calculated. Within each federative entity the proportion of municipalities with high, medium, and low marginalization was determined. States were ranked by the proportion of municipalities with high marginalization (highest to lowest) and divided into quintiles. Absolute inequality was measured using the observed difference and relative inequality, using the ratio of each variable studied.

RESULTS

The average national coverage for the eight variables studied ranged from 86.5% to 97.5%, with administration of TT to pregnant women the lowest and administration of measles vaccine to children under 1 year of age the highest. Obstetric care in delivery, prevalence of contraceptive use, and prenatal checkup were the variables with less equitable coverage. In states with higher levels of marginalization, activities dependent on a structured health system-e.g., obstetric care in delivery-showed lower levels of coverage compared to preventive activities not requiring costly inputs or infrastructure-e.g., early breast-feeding.

CONCLUSIONS

Interventions exhibiting greater inequity are associated with the lack of medical infrastructure and are more accentuated in federative entities with higher levels of marginalization. Greater public health expenditure is urgently needed to implement feasible, effective alternatives in terms of access and health care. Intersectoral policies and activities should be implemented to create synergies that will equitably improve the health of Mexican mothers and children.

Modernización académica de la Escuela de Salud Pública de México: 1983-1995

Este artículo discute los esfuerzos por modernizar la Escuela de Salud Pública de México (ESPM). En la primera parte se abordan las condiciones en las que operaba la Escuela a principios de la década de los ochenta. En la segunda parte se describen los cambios introducidos entre 1983 y 1986, hasta  antes de la incorporación de la ESPM al Instituto Nacional de Salud Pública (INSP). En la tercera parte se revisa, sobre todo,  a renovación conceptual que dio sustento a los nuevos programas docentes que se implantaron a finales de los años ochenta y las iniciativas implantadas entre 1987 y 1995. En la cuarta parte se discute la construcción de la nueva sede del INSP y la mudanza a Cuernavaca. Este ensayo busca comunicar la importancia de las transformaciones por las que atravesó la ESPM y que la convirtieron en una institución verdaderamente académica que utiliza la investigación como motor de la formación de los recursos humanos en salud pública.

[Academic modernization of Mexican School of Public Health: 1983-1995]

In this paper we discuss the recent efforts to modernize the School of Public Health of Mexico (ESPM). In the first part we analyze the conditions in which the ESPM operated at the beginning of the 1980s. In part two we describe the changes introduced in the ESPM between 1983 and 1986, up until its incorporation into the National Institute of Public Health (INSP). In part three we discuss the conceptual renovation which built the platform for the new academic programs introduced by the School between 1987 and 1995. In the fourth part we discuss the construction of the new facilities of INSP and the process of moving to the city of Cuernavaca. The main message of this paper is that the transformations witnessed by the ESPM in the final decades of the past century turned it into a true academic institution which uses research as the motor for training of human resources in public health.

[Some observations on high specialty medical care in Mexico]

OBJECTIVES

To put forth the concept of highly specialized medical care, in agreement with the nature of its practice, and evaluate the feasibility of creating a support service network.

METHODS

Qualitative study of the current practice and requirements for 39 selected medical specialties, using the technique of focused groups of experts in each specialty. In accordance with the "Grounded Theory", variables were systematized and categorized and then compared in order to identify relationships between categories and link them to consensus testimonial references. On the basis of the characteristics of each kind of practice, one key expert integrated and validated service portfolios.

RESULTS

We developed an integrated a concept for highly specialize medical care with 39 operational catalogs of those diagnoses that belong to each specialty, along with catalogs of the resources required by each specialty.

CONCLUSIONS

Highly specialized care is a desirable model for clinical practice, but does not constitute a different level of care. Currently, medical practice is constrained by the lack of well-defined boundaries and scarcity of resources in order to be conceptualized as high specialty. It is therefore more convenient to strengthen the concept of third level of care in order to identify opportunities for the establishment of high specialty areas that will in turn serve as the focal points for medical innovation.

[Direct cost analysis of hemodialysis units]

OBJECTIVE

To estimate and compare direct costs per hemodialysis session in public and private units in Mexico City.

MATERIAL AND METHODS

PAATI, a microcosting strategy, was used to determine total costs of four public and two private health hospitals in Mexico City. A "shadow study" approach was employed to collect the needed data. Charts containing the "PAATI" information for each session were developed in Microsoft Excel.

RESULTS

The average annual cost per patient undergoing hemodialysis in public units is $158 964.00 MX. The estimated cost for the care of all population estimated in need of renal replacement therapy (via hemodialysis) was estimated to be $10 921 788 072.00 MX.

CONCLUSION

Human resources and infrastructure availability in México are very limited for nephrology, and in consequence for offering hemodialysis services.

[The need of transforming the health system in Mexico]

In this article we review the need for the transformation of the Mexican health care system given the deformities that the system developed in the last 60 years. We start by the discussion of two main deformities: the segmented answer to the health right, and the development of a segmented health care system based on the method of payment (formal workers contributions); and the development of a health care model based on specialties and hospital care. These deformities have resulted in a health care system characterized by high costs and low effectiveness. Even though the correction of the deformities imply complex modifications that involve political economic and legal aspects, in the short term we have the conditions in Mexico for the creation of a universal primary health care system, given the human and financial resources available in the country.

[Calculating the optimum size of a hemodialysis unit based on infrastructure potential]

OBJECTIVE

To estimate the optimum size for hemodialysis units to maximize production given capital constraints.

MATERIALS AND METHODS

A national study in Mexico was conducted in 2009. Three possible methods for estimating a units optimum size were analyzed: hemodialysis services production under monopolistic market, under a perfect competitive market and production maximization given capital constraints.

RESULTS

The third method was considered best based on the assumptions made in this paper; an optimal size unit should have 16 dialyzers (15 active and one back up dialyzer) and a purifier system able to supply all. It also requires one nephrologist, five nurses per shift, considering four shifts per day.

CONCLUSION

Empirical evidence shows serious inefficiencies in the operation of units throughout the country. Most units fail to maximize production due to not fully utilizing equipment and personnel, particularly their water purifier potential which happens to be the most expensive asset for these units.

Modelling of the influenza A(H1N1)v outbreak in Mexico City, April-May 2009, with control sanitary measures

We use a time dependent modification of the Kermack and McKendrick model to study the evolution of the influenza A(H1N1)v epidemic reported in the Mexico City area under the control measures used during April and May 2009. The model illustrates how the sanitary measures postponed the peak of the epidemic and decreased its intensity. It provides quantitative predictions on the effect of relaxing the sanitary measures after a period of control. We show how the sanitary measures reduced the maximal prevalence of the infected population from 10% to less than 6% of the total population. We also show how the model predicts the time of maximal prevalence and explains the effect of the control measures.

On the spread of the novel influenza A (H1N1) virus in Mexico

A novel influenza A H1N1 virus of swine origin is responsible for the influenza epidemic affecting Mexico, the United States of America (USA), and 39 other countries. While the origin of this emerging pathogen remains uncertain, an increase in the reported incidence of respiratory diseases was noted during March 2009 at the town of La Gloria, in the southeastern state of Veracruz, Mexico. So far, this is the first community in which a case of novel influenza A H1N1 virus has been identified. Further cases were rapidly detected in other areas of Mexico and elsewhere. Initially, the atypical respiratory disease outbreak caused great uncertainty posing a challenge to the Mexican health system. Control measures such as social distancing, timely medical care, and personal hygiene have so far proven effective in containing the outbreak, resulting in a decline of the number of new cases. To the best of our knowledge, it appears that the virus might not be as virulent or contagious as previously thought. Here we provide a description of the influenza epidemic spread in Mexico. As the virus disseminates worldwide, there is concern about the possibility of a new reassortment resulting in a more pathogenic strain that will pose a threat for every country. The influenza epidemic provided lessons that underscore the importance of epidemiologic surveillance and preparedness. Further investigation to address questions about this new virus and conditions for its spread is warranted.