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Denfeld QE, Turrise S, MacLaughlin EJ, Chang PS, Clair WK, Lewis EF, Forman DE, Goodlin SJ. Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000108. [PMID: 35587567 DOI: 10.1161/hcq.0000000000000108] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.
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Díez-Villanueva P, Jiménez-Méndez C, Bonanad C, García-Blas S, Pérez-Rivera Á, Allo G, García-Pardo H, Formiga F, Camafort M, Martínez-Sellés M, Ariza-Solé A, Ayesta A. Risk Factors and Cardiovascular Disease in the Elderly. Rev Cardiovasc Med 2022; 23:188. [PMID: 39077174 PMCID: PMC11273864 DOI: 10.31083/j.rcm2306188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 07/31/2024] Open
Abstract
Age is associated with increased cardiovascular risk factors and cardiovascular disease, which constitutes the leading cause of morbidity and mortality in elderly population. In this text we thoroughly review current evidence regarding the impact on cardiovascular disease of the most important cardiovascular risk factors, especially prevalent and common in the elderly population. Diagnosis and treatment approaches are also addressed, also highlighting the importance of adequate primary and secondary prevention and management. Also, the relationship between cardiovascular disease and some comorbidities and geriatric conditions, such as frailty, particularly common in the elderly, is reviewed, together with some other issues, less often addressed but closely related to ageing, such as genetics, structural and electrical heart changes and oxidative stress. All such questions are of great importance in the comprehensive approach of risk factors and cardiovascular disease in the elderly.
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Affiliation(s)
| | - César Jiménez-Méndez
- Cardiology Department, Hospital Universitario Puerta del Mar, 11009 Cádiz, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
| | - Sergio García-Blas
- Cardiology Department, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain
| | - Ángel Pérez-Rivera
- Cardiology Department, Hospital Clínico Universitario de Burgos, 09006 Burgos, Spain
- Universidad Isabel I, 09003 Burgos, Spain
| | - Gonzalo Allo
- Endocrinology Department, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain
| | - Héctor García-Pardo
- Cardiology Department, Hospital Universitario Rio Hortega, 47012 Valladolid, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, IDIBELL, 08907 Barcelona, Spain
| | - Miguel Camafort
- Internal Medicine Department, Hospital Clinic, 08036 Barcelona, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, 28007 Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
- School of Biomedical Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Albert Ariza-Solé
- Cardiology Department, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, IDIBELL, 08907 Barcelona, Spain
| | - Ana Ayesta
- Cardiology Department, Hospital Central de Asturias, 33011 Oviedo, Spain
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103
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Haue AD, Armenteros JJA, Holm PC, Eriksson R, Moseley PL, Køber LV, Bundgaard H, Brunak S. Temporal patterns of multi-morbidity in 570157 ischemic heart disease patients: a nationwide cohort study. Cardiovasc Diabetol 2022; 21:87. [PMID: 35641964 PMCID: PMC9158400 DOI: 10.1186/s12933-022-01527-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/18/2022] [Indexed: 12/25/2022] Open
Abstract
Background Patients diagnosed with ischemic heart disease (IHD) are becoming increasingly multi-morbid, and studies designed to analyze the full spectrum are few. Methods Disease trajectories, defined as time-ordered series of diagnoses, were used to study the temporality of multi-morbidity. The main data source was The Danish National Patient Register (NPR) comprising 7,179,538 individuals in the period 1994–2018. Patients with a diagnosis code for IHD were included. Relative risks were used to quantify the strength of the association between diagnostic co-occurrences comprised of two diagnoses that were overrepresented in the same patients. Multiple linear regression models were then fitted to test for temporal associations among the diagnostic co-occurrences, termed length two disease trajectories. Length two disease trajectories were then used as basis for constructing disease trajectories of three diagnoses. Results In a cohort of 570,157 IHD disease patients, we identified 1447 length two disease trajectories and 4729 significant length three disease trajectories. These included 459 distinct diagnoses. Disease trajectories were dominated by chronic diseases and not by common, acute diseases such as pneumonia. The temporal association of atrial fibrillation (AF) and IHD differed in different IHD subpopulations. We found an association between osteoarthritis (OA) and heart failure (HF) among patients diagnosed with OA, IHD, and then HF only. Conclusions The sequence of diagnoses is important in characterization of multi-morbidity in IHD patients as the disease trajectories. The study provides evidence that the timing of AF in IHD marks distinct IHD subpopulations; and secondly that the association between osteoarthritis and heart failure is dependent on IHD. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01527-3.
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Affiliation(s)
- Amalie D Haue
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.,Department of Cardiology, The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jose J Almagro Armenteros
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Peter C Holm
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Robert Eriksson
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.,Department of Infectious Diseases, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Pope L Moseley
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark.,College of Health Solutions, Arizona State University, Arizona State University, 550 N 3rd St., Phoenix, AZ, 85004, USA
| | - Lars V Køber
- Department of Cardiology, The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark. .,Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
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104
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Takeuchi S, Kohno T, Goda A, Shiraishi Y, Kawana M, Saji M, Nagatomo Y, Nishihata Y, Takei M, Nakano S, Soejima K, Kohsaka S, Yoshikawa T. Multimorbidity, guideline-directed medical therapies, and associated outcomes among hospitalized heart failure patients. ESC Heart Fail 2022; 9:2500-2510. [PMID: 35561100 PMCID: PMC9288806 DOI: 10.1002/ehf2.13954] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 03/03/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022] Open
Abstract
Aims Multimorbidity is common among heart failure (HF) patients and may attenuate guideline‐directed medical therapy (GDMT). Multimorbid patients are under‐represented in clinical trials; therefore, the effect of multimorbidity clustering on the prognosis of HF patients remains unknown. We evaluated the prevalence of multimorbidity clusters among consecutively registered hospitalized HF patients and assessed whether GDMT attenuated outcomes. Methods and results We examined 1924 hospitalized HF patients with reduced left ventricular ejection fraction (<50%) in a multicentre registry (West Tokyo HF Registry: WET‐HF). Ten comorbid conditions in the WET‐HF were abstracted: coronary artery disease, atrial fibrillation, stroke, anaemia, chronic obstructive pulmonary disease, renal dysfunction, obesity, hypertension, dyslipidaemia, and diabetes. Patients were divided into three groups (0–2: n = 451; 3–4: n = 787; and ≥5: n = 686) based on the number of comorbid conditions. The primary composite endpoint was all‐cause mortality and HF rehospitalization. The most prevalent comorbidities were renal dysfunction (67.9%), hypertension (66.0%), and anaemia (53.8%). Increased comorbidity was associated with increased adverse outcomes [3–4: hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.13–1.77, P = 0.003; ≥5: HR 2.12, 95%CI 1.69–2.65, P < 0.001; and reference: 0–2] and lower GDMT prescription rate (0–2: 69.2%; 3–4: 57.7%; and ≥5: 57.6%). GDMT was associated with decreased adverse outcomes; this association was maintained even as the comorbidity burden increased but tended to weaken (0–2: HR 0.53, 95%CI 0.35–0.78; P = 0.001; 3–4: HR 0.82, 95%CI 0.65–1.04, P = 0.095; and ≥5: HR 0.81, 95%CI 0.65–1.00, P = 0.053; P for interaction = 0.156). Conclusions Comorbidity clusters were prevalent and associated with poorer outcomes. GDMT remained beneficial regardless of the comorbidity burden but tended to weaken with increasing comorbidity burden. Further research is required to optimize medical care in these patients.
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Affiliation(s)
- Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masataka Kawana
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Saitama, Japan
| | - Yosuke Nishihata
- Department of Cardiology, St. Lukes International Hospital, Tokyo, Japan
| | - Makoto Takei
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, 181-8611, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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105
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Comments on the 2021 ESC guidelines on cardiovascular disease prevention in clinical practice. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:364-369. [PMID: 35165071 DOI: 10.1016/j.rec.2021.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022]
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106
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Comentarios a la guía ESC 2021 sobre la prevención de la enfermedad cardiovascular en la práctica clínica. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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107
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108
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Zhou M, Zhao G, Zeng Y, Zhu J, Cheng F, Liang W. Aging and Cardiovascular Disease: Current Status and Challenges. Rev Cardiovasc Med 2022; 23:135. [PMID: 39076212 PMCID: PMC11274005 DOI: 10.31083/j.rcm2304135] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/10/2022] [Accepted: 03/10/2022] [Indexed: 07/31/2024] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death worldwide. Population aging is becoming the most important driver of the CVD epidemic. With the rapid increase in an aging population, the burden of CVD will continuously increase. Most old people also suffer multimorbidity, which is strongly associated with impaired quality of life, disability, dependence, and mortality. However, few reviews evaluated the CVD burden accompanied by population aging and the challenges of CVD care in elderly individuals with multimorbidity. This review identified and summarized the current status of the CVD epidemic associated with aging and highlighted the challenges and needs of CVD care for the elderly.
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Affiliation(s)
- Mengge Zhou
- Vanke School of Public Health, Tsinghua University, 10084 Beijing, China
- School of Medicine, Tsinghua University, 10084 Beijing, China
| | - Guanqi Zhao
- Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Yuhong Zeng
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), 400038 Chongqing, China
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, 10084 Beijing, China
| | - Feng Cheng
- Vanke School of Public Health, Tsinghua University, 10084 Beijing, China
- School of Medicine, Tsinghua University, 10084 Beijing, China
| | - Wannian Liang
- Vanke School of Public Health, Tsinghua University, 10084 Beijing, China
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109
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Wang L, Qiu H, Luo L, Zhou L. Age- and Sex-Specific Differences in Multimorbidity Patterns and Temporal Trends on Assessing Hospital Discharge Records in Southwest China: Network-Based Study. J Med Internet Res 2022; 24:e27146. [PMID: 35212632 PMCID: PMC8917436 DOI: 10.2196/27146] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 05/06/2021] [Accepted: 01/12/2022] [Indexed: 02/06/2023] Open
Abstract
Background Multimorbidity represents a global health challenge, which requires a more global understanding of multimorbidity patterns and trends. However, the majority of studies completed to date have often relied on self-reported conditions, and a simultaneous assessment of the entire spectrum of chronic disease co-occurrence, especially in developing regions, has not yet been performed. Objective We attempted to provide a multidimensional approach to understand the full spectrum of chronic disease co-occurrence among general inpatients in southwest China, in order to investigate multimorbidity patterns and temporal trends, and assess their age and sex differences. Methods We conducted a retrospective cohort analysis based on 8.8 million hospital discharge records of about 5.0 million individuals of all ages from 2015 to 2019 in a megacity in southwest China. We examined all chronic diagnoses using the ICD-10 (International Classification of Diseases, 10th revision) codes at 3 digits and focused on chronic diseases with ≥1% prevalence for each of the age and sex strata, which resulted in a total of 149 and 145 chronic diseases in males and females, respectively. We constructed multimorbidity networks in the general population based on sex and age, and used the cosine index to measure the co-occurrence of chronic diseases. Then, we divided the networks into communities and assessed their temporal trends. Results The results showed complex interactions among chronic diseases, with more intensive connections among males and inpatients ≥40 years old. A total of 9 chronic diseases were simultaneously classified as central diseases, hubs, and bursts in the multimorbidity networks. Among them, 5 diseases were common to both males and females, including hypertension, chronic ischemic heart disease, cerebral infarction, other cerebrovascular diseases, and atherosclerosis. The earliest leaps (degree leaps ≥6) appeared at a disorder of glycoprotein metabolism that happened at 25-29 years in males, about 15 years earlier than in females. The number of chronic diseases in the community increased over time, but the new entrants did not replace the root of the community. Conclusions Our multimorbidity network analysis identified specific differences in the co-occurrence of chronic diagnoses by sex and age, which could help in the design of clinical interventions for inpatient multimorbidity.
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Affiliation(s)
- Liya Wang
- Big Data Research Center, University of Electronic Science and Technology of China, Chengdu, China
| | - Hang Qiu
- Big Data Research Center, University of Electronic Science and Technology of China, Chengdu, China.,School of Computer Science and Engineering, University of Electronic Science and Technology of China, Chengdu, China
| | - Li Luo
- Business School, Sichuan University, Chengdu, China
| | - Li Zhou
- Health Information Center of Sichuan Province, Chengdu, China
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110
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[The new ESC guidelines 2021 on prevention of cardiovascular diseases : Appeal for prevention]. Herz 2022; 47:55-62. [PMID: 35029736 DOI: 10.1007/s00059-021-05094-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/04/2022]
Abstract
This article summarizes the innovations and most important points of the recently published and updated ESC guidelines 2021 on the prevention of cardiovascular diseases. Developments in risk stratification and further developments with respect to targets and options for the treatment of risk factors necessitated an update of the guidelines from 2016. The innovations incorporate a staged and individualized approach to the prevention targets, an implementation of the systematic coronary risk evaluation 2 (SCORE 2 update) and the SCORE 2‑older persons (OP) systems on risk stratification, including age-dependent estimations for young (<50 years old) and older people (≥70 years old) as well as for patients with diabetes mellitus and atherosclerotic cardiovascular diseases. Furthermore, specific recommendations are given for coronary heart disease, heart failure and chronic kidney insufficiency. In addition to recommendations on individualized treatment, the relevance of cardiovascular prevention at the population level, including environmental protection is underlined.
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111
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Cheng X, Ouyang F, Ma T, Luo Y, Yin J, Li J, Zhang G, Bai Y. Association of Healthy Lifestyle and Life Expectancy in Patients With Cardiometabolic Multimorbidity: A Prospective Cohort Study of UK Biobank. Front Cardiovasc Med 2022; 9:830319. [PMID: 35757322 PMCID: PMC9218816 DOI: 10.3389/fcvm.2022.830319] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background The prevalence of cardiometabolic multimorbidity (CMM), which significantly increases the risk of mortality, is increasing globally. However, the role of healthy lifestyle in the secondary prevention of CMM is unclear. Methods In total, 290,795 participants with CMM, which was defined as coexistence of at least two of hypertension (HTN), diabetes mellitus (DM), coronary heart disease (CHD), and stroke (ST), and those without these four diseases at baseline were derived from UK Biobank. The associations between specific CMM patterns and mortality, and that between healthy lifestyle (including physical activity, smoking, alcohol consumption, and vegetable and fruit consumption) and mortality in patients with specific CMM patterns were calculated using the flexible parametric Royston-Parmar proportion-hazard model. Hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were calculated. Results During a median 12.3-year follow up period, 15,537 (5.3%) deaths occurred. Compared with participants without cardiometabolic diseases, the HRs for all-cause mortality were 1.54 [95% confidence interval (CI): 1.30, 1.82] in participants with HTN + DM, 1.84 (95% CI: 1.59, 2.12) in those with HTN + CHD, 1.89 (95% CI: 1.46, 2.45) in those with HTN + ST, and 2.89 (95% CI: 2.28, 3.67) in those with HTN + DM + CHD. At the age of 45 years, non-current smoking was associated with an increase in life expectancy by 3.72, 6.95, 6.75, and 4.86 years for participants with HTN + DM, HTN + CHD, HTN + ST, and HTN + DM + CHD, respectively. A corresponding increase by 2.03, 1.95, 2.99, and 1.88 years, respectively, was observed in participants with regular physical activity. Non-/moderate alcohol consumption and adequate fruit/vegetable consumption were not significantly associated with life expectancy in patients with specific CMM patterns. Conclusion Cardiometabolic multimorbidity was associated with an increased risk of mortality. Regular physical activity and non-current smoking can increase life expectancy in patients with specific CMM patterns.
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Affiliation(s)
- Xunjie Cheng
- Department of Geriatric Medicine, Center of Coronary Circulation, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Feiyun Ouyang
- Department of Social Medicine and Health Management, Central South University, Changsha, China
| | - Tianqi Ma
- Department of Geriatric Medicine, Center of Coronary Circulation, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Luo
- Department of Geriatric Medicine, Center of Coronary Circulation, Xiangya Hospital, Central South University, Changsha, China
| | - Jinghua Yin
- Department of Geriatric Medicine, Center of Coronary Circulation, Xiangya Hospital, Central South University, Changsha, China
| | - Jinchen Li
- Department of Geriatric Medicine, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Guogang Zhang
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, China.,Department of Cardiovascular Medicine, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yongping Bai
- Department of Geriatric Medicine, Center of Coronary Circulation, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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113
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Lopes Lima M, Bordin D, Fernandes Furquim RC, Andreani Cabral LP, Muller EV, Berger Fadel C. Caminho na rede formal de cuidado em saúde de pacientes pós-alta hospitalar segundo multimorbidade. REVISTA CUIDARTE 2022. [DOI: 10.15649/cuidarte.1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introdução: A gestão de informações associadas à multimorbidade na atenção hospitalar é relevante para o planejamento de estratégias de prevenção de agravos à saúde em pacientes de maior risco, a fim de oportunizar a organização de sistemas de saúde de modo eficiente. Objetivo: O presente trabalho objetivoudelinear o caminho formal percorrido por pacientes com e sem multimorbidade, considerando o uso da rede pública de saúde após a internação hospitalar. Materiais e métodos: Realizou-se um estudo quantitativo, transversal, descritivo, utilizando dados primários de 445 pacientes internados em um hospital universitário, no ano de 2018. Os dados foram coletados através de análise do prontuário médico e entrevista telefônica. Os resultados foram analisados por meio de frequência absoluta e relativa. Resultados: Desenvolveu-se um fluxograma, representando os pontos da rede de saúde utilizados pelo paciente após a alta hospitalar, segundo multimorbidade. Verificou-se uma alta prevalência de encaminhamento (com multimorbidade (CM) 93,52%; sem multimorbidade (SM) 97,71%) e comparecimento na atenção secundária à saúde (CM 86,15%; SM 89,63%), um baixo encaminhamento (CM 42,45%; SM 36,27%) e comparecimento na atenção primária à saúde (CM 61,29%; SM 64,81%), e considerando os 3 níveis de atenção juntos, houve um baixo comparecimento (CM 17,98%; SM 21,89%) para ambos os grupos investigados. Discussão: Entende-se que a semelhança de comparecimento em todos os pontos da rede por ambos os grupos é um problema, por tratar de forma igual populações desiguais e consequentemente com necessidades diversas. Conclusões: Sinaliza-se a importância de maior incentivo ao acompanhamento de pacientes com multimorbidade na rede primária de saúde, especialmente no período de pós-alta hospitalar, e a necessidade de fortalecimento da Rede de Atenção à Saúde.
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114
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Möllmann HL, Apeltrath L, Karnatz N, Wilkat M, Riedel E, Singh DD, Rana M. Comparison of the Accuracy and Clinical Parameters of Patient-Specific and Conventionally Bended Plates for Mandibular Reconstruction. Front Oncol 2021; 11:719028. [PMID: 34900674 PMCID: PMC8660676 DOI: 10.3389/fonc.2021.719028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives This retrospective study compared two mandibular reconstruction procedures-conventional reconstruction plates (CR) and patient-specific implants (PSI)-and evaluated their accuracy of reconstruction and clinical outcome. Methods Overall, 94 patients had undergone mandibular reconstruction with CR (n = 48) and PSI (n = 46). Six detectable and replicable anatomical reference points, identified via computer tomography, were used for defining the mandibular dimensions. The accuracy of reconstruction was assessed using pre- and postoperative differences. Results In the CR group, the largest difference was at the lateral point of the condyle mandibulae (D2) -1.56 mm (SD = 3.8). In the PSI group, the largest difference between preoperative and postoperative measurement was shown at the processus coronoid (D5) with +1.86 mm (SD = 6.0). Significant differences within the groups in pre- and postoperative measurements were identified at the gonion (D6) [t(56) = -2.217; p = .031 <.05]. In the CR group, the difference was 1.5 (SD = 3.9) and in the PSI group -1.04 (SD = 4.9). CR did not demonstrate a higher risk of plate fractures and post-operative complications compared to PSI. Conclusion For reconstructing mandibular defects, CR and PSI are eligible. In each case, the advantages and disadvantages of these approaches must be assessed. The functional and esthetic outcome of mandibular reconstruction significantly improves with the experience of the surgeon in conducting microvascular grafts and familiarity with computer-assisted surgery. Interoperator variability can be reduced, and training of younger surgeons involved in planning can be reaching better outcomes in the future.
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Affiliation(s)
- Henriette L Möllmann
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Laura Apeltrath
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Nadia Karnatz
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Max Wilkat
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Erik Riedel
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Daman Deep Singh
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Majeed Rana
- Department of Oral and Maxillofacial Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
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Clustering Inflammatory Markers with Sociodemographic and Clinical Characteristics of Patients with Diabetes Type 2 Can Support Family Physicians' Clinical Reasoning by Reducing Patients' Complexity. Healthcare (Basel) 2021; 9:healthcare9121687. [PMID: 34946413 PMCID: PMC8700975 DOI: 10.3390/healthcare9121687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 01/08/2023] Open
Abstract
Diabetes mellitus type 2 (DM2) is a complex disease associated with chronic inflammation, end-organ damage, and multiple comorbidities. Initiatives are emerging for a more personalized approach in managing DM2 patients. We hypothesized that by clustering inflammatory markers with variables indicating the sociodemographic and clinical contexts of patients with DM2, we could gain insights into the hidden phenotypes and the underlying pathophysiological backgrounds thereof. We applied the k-means algorithm and a total of 30 variables in a group of 174 primary care (PC) patients with DM2 aged 50 years and above and of both genders. We included some emerging markers of inflammation, specifically, neutrophil-to-lymphocyte ratio (NLR) and the cytokines IL-17A and IL-37. Multiple regression models were used to assess associations of inflammatory markers with other variables. Overall, we observed that the cytokines were more variable than the marker NLR. The set of inflammatory markers was needed to indicate the capacity of patients in the clusters for inflammatory cell recruitment from the circulation to the tissues, and subsequently for the progression of end-organ damage and vascular complications. The hypothalamus–pituitary–thyroid hormonal axis, in addition to the cytokine IL-37, may have a suppressive, inflammation-regulatory role. These results can help PC physicians with their clinical reasoning by reducing the complexity of diabetic patients.
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Forman DE, Racette SB, Toto PE, Peterson LR, Glynn NW, Pruskowski J, Byard T, Delligatti A, Lolley R, Mulkareddy V, Allsup K, Perera S, Lenze EJ, Rich MW. Modified Application of Cardiac Rehabilitation in Older Adults (MACRO) Trial: Protocol changes in a pragmatic multi-site randomized controlled trial in response to the COVID-19 pandemic. Contemp Clin Trials 2021; 112:106633. [PMID: 34823001 PMCID: PMC8648552 DOI: 10.1016/j.cct.2021.106633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/18/2021] [Accepted: 11/19/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Older adults are at higher risk for cardiovascular disease and functional decline, often leading to deterioration and dependency. Cardiac rehabilitation (CR) provides opportunity to improve clinical and functional recovery, yet participation in CR decreases with age. Modified Application of CR in Older Adults (MACRO) is a National Institute on Aging (NIA)-funded pragmatic trial that responds to this gap by aiming to increase enrollment of older adults into CR and improving functional outcomes. This article describes the methodology and novel features of the MACRO trial. METHODS Randomized, controlled trial of a coaching intervention (MACRO-I) vs. usual care for older adults (age ≥ 70 years) eligible for CR after an incident cardiac hospitalization. MACRO-I incorporates innovations including holistic risk assessments, flexible CR format (i.e., helping patients to select a CR design that aligns with their personal risks and preferences), motivational prompts, nutritional emphasis, facilitated deprescription, enhanced education, and home visits. Key modifications were necessitated by the COVID-19 pandemic, including switching from a performance-based primary endpoint (Short Physical Performance Battery) to a patient-reported measure (Activity Measure for Post-Acute Care Computerized Adaptive Testing). Changes prompted by COVID-19 maintain the original intent of the trial and provide key methodologic advantages. CONCLUSIONS MACRO is exploring a novel individualized coaching intervention to better enable older patients to participate in CR. Due to COVID-19 many aspects of the MACRO protocol required modification, but the primary objective of the trial is maintained and the updated protocol will more effectively achieve the original goals of the study.
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Affiliation(s)
- Daniel E Forman
- University of Pittsburgh, Divisions of Geriatrics and Cardiology, and Pittsburgh Veteran Affairs, GRECC, Pittsburgh, PA, United States of America.
| | - Susan B Racette
- Washington University, School of Medicine, Program in Physical Therapy and Department of Medicine, Washington University, St. Louis, MO, United States of America
| | - Pamela E Toto
- University of Pittsburgh Department of Occupational Therapy, Pittsburgh, PA, United States of America
| | - Linda R Peterson
- Washington University, Department of Medicine, St. Louis, MO, United States of America
| | - Nancy W Glynn
- University of Pittsburgh, Center for Aging and Population Health, Department of Epidemiology, Graduate School of Public Health, Pittsburgh, PA, United States of America
| | - Jennifer Pruskowski
- Pittsburgh Veteran Affairs, GRECC, University of Pittsburgh, University of Pittsburgh, Division of Geriatrics, Pittsburgh, PA, United States of America
| | - Thomas Byard
- University of Pittsburgh, Division of Geriatrics, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Amanda Delligatti
- Veterans Health Foundation, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Rebecca Lolley
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, United States of America
| | - Vinaya Mulkareddy
- University of Pittsburgh Medical Center, Heart and Vascular Institute, Pittsburgh, PA, United States of America
| | - Kelly Allsup
- VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Subashan Perera
- University of Pittsburgh, Division of Geriatrics, Pittsburgh, PA, United States of America
| | - Eric J Lenze
- Washington University, Department of Psychiatry, St Louis, MO, United States of America
| | - Michael W Rich
- Washington University, Department of Medicine, St. Louis, MO, United States of America
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da Silva RC, Gondim MC, Cavalcante AMRZ, Bachion MM, da Silva VM, de Oliveira Lopes MV. Ineffective health management: A systematic review and meta-analysis of related factors. J Nurs Scholarsh 2021; 54:376-387. [PMID: 34811891 DOI: 10.1111/jnu.12747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/13/2021] [Accepted: 10/29/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE A standardized language system can support the elaboration of clinical guidelines by matching information from similar patterns of response to people. To identify the factors that are related to a higher likelihood of an ineffective health management nursing diagnosis. METHODS We conduct a systematic review and meta-analysis. An electronic search was conducted in MEDLINE databases via PubMed, Web of Science, SciELO, CINAHL, SCOPUS, and Embase between October and November 2020. Descriptive data were extracted from each article. The odds ratios for each etiological factor related to ineffective health management were directly extracted from the articles or calculated from the data described in the articles. The analysis of the measurements of exposure and the magnitude of the effect was performed using the statistical software R, and a forest plot was constructed for each etiological factor. FINDINGS Ten studies were included, and 15 related factors were recovered from the primary studies. The factors that significantly increased the likelihood of an ineffective health management nursing diagnosis were insufficient knowledge of the therapeutic regimen, perceived barriers, powerlessness, economic disadvantage, and difficulty managing complex treatment regimens. No effect was verified with the following factors: decision conflict, family pattern of healthcare, and inadequate number of cues to action. CONCLUSION Factors related to a higher likelihood of ineffective health management may be the focus of early and targeted nursing interventions, contributing to an improved quality of care. CLINICAL RELEVANCE Understanding exposure to these factors can improve diagnostic reasoning at different population levels.
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Bordin D, Gonçalves D, Cabral LPA, Lima ML, Grden CRB. Factors associated to multimorbidity in inpatient elderly according to sociodemographic characteristics, lifestyle and use of services. ABCS HEALTH SCIENCES 2021. [DOI: 10.7322/abcshs.2020061.1508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Introduction: Aging is a physiological process associated to decreased functional capacity and the presence of diseases, especially chronic noncommunicable diseases. Objective: To analyze the prevalence and factors associated to the multimorbidity of elderly in a teaching hospital, according to sociodemographic characteristics, lifestyle and use of services in the health care network. Methods: Descriptive and inferential cross-sectional study, conducted with 144 hospitalized patients 60 years of age or more, from January to June 2018, in a university hospital in the state of Paraná. Data were collected 30 days after hospital discharge by telephone interview. The dependent variable was the occurrence of multimorbidity and the independent variables were: sociodemographic characteristics, lifestyle and use of hospital health services. Logistic regression analysis was performed. Results: It was found that 55% of the elderly had multimorbidity. The elderly who were more chances to have multimorbidity where there low education (OR=16.29; CI:2.75-96.42), non-white (OR=2.34; CI:1.00-5.50) hospitalized longer (4 to 7 days: OR=6.91; CI:2.40-19.96; more than 7 days: OR=3.03; CI:1.00-9.22), who scheduled to return to the hospital (OR=18.99; CI: 1.30-277.87), and that after discharge they needed help from someone to follow the medical recommendations (OR=3.16; CI:1.38-7.22). Conclusion: It was identified a high prevalence of multimorbidity, and important factors associated to multimorbidity in hospitalized elderly, with emphasis on education; color; hospitalization time; scheduling of return to hospital after discharge; need for help from someone (family member/caregiver), without post-discharge, to follow medical recommendations.
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Kanwar A, Roger VL, Lennon RJ, Gharacholou SM, Singh M. Poor quality of life in patients with and without frailty: co-prevalence and prognostic implications in patients undergoing percutaneous coronary interventions and cardiac catheterization. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:591-600. [PMID: 32821905 DOI: 10.1093/ehjqcco/qcaa065] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/29/2020] [Accepted: 08/17/2020] [Indexed: 11/14/2022]
Abstract
AIMS We hypothesize that poor quality of life (QOL) is highly prevalent in frail older adults and is associated with worse prognosis. METHODS AND RESULTS Predismissal standardized tests for frailty and QOL were prospectively administered to patients included in two cohorts. In Cohort 1, 629 patients ≥65 years who underwent percutaneous coronary intervention (PCI) from 2005 to 2008, frailty (Fried criteria), and QOL [SF-36 and Seattle Angina Questionnaires (SAQ)] were ascertained. Cohort 2 included 921 patients ≥55 years who underwent cardiac catheterization (535 had PCI) from 2014 to 2018 and frailty was determined by Rockwood criteria and QOL by single-item, self-reported health questionnaire. In Cohort 1, 19% were frail and 20% patients in Cohort 2 were frail with a frailty index >0.30. The median SAQ for physical limitation (58.9 vs. 82.2, P < 0.001), physical (29.5 vs. 43.9, P < 0.001), and mental (49.2 vs. 57.4, P < 0.001) component scores of SF-36 in Cohort 1 were lower and self-rating of fair/poor health (56% vs 18%, P < 0.001) in Cohort 2 was significantly higher in frail patients. As compared to patients without frailty, frail patients were five times more likely (59% vs. 11%, P < 0.001) in Cohort 1 and seven times more likely (56% vs. 8%) in Cohort 2 to be classified with poor QOL. Age- and gender-adjusted 3-year all-cause death and death or myocardial infarction (MI) was significantly higher for patients undergoing PCI with frailty; [hazard ratio (95% confidence interval) death, 4.20 (2.63-6.68, P < 0.001) and death or MI hazard ratio (HR) 2.72 (1.91-3.87, P < 0.001)] and with poor QOL [HR death 2.47 (1.59-3.84, P < 0.001)] and death or MI 1.61 (1.16-2.24, P < 0.001). There was no significant interaction between frailty and QOL (P = 0.64) and only modest attenuation was observed when considered together indicating their independent prognostic influence. CONCLUSION In elderly patients undergoing cardiac catheterization or PCI, poor QOL is seen more frequently in frail patients. Both frailty and poor QOL had significant and independent association with long-term survival.
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Affiliation(s)
- Amrit Kanwar
- Department of Internal Medicine, Loma Linda University, Loma Linda, California
| | - Veronique L Roger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Ryan J Lennon
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | | | - Mandeep Singh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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López-Fernández T, de Castro Carpeño J. Cancer and acute cardiovascular diseases: team work to transform the clinical practice. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:840-842. [PMID: 34491315 DOI: 10.1093/ehjacc/zuab079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Teresa López-Fernández
- Cardio-Oncology Unit, Cardiology Department, La Paz University Hospital, IdiPAZ Research Institute, Planta 1, Paseo de la Castellana 261, 28043 Madrid, Spain
| | - Javier de Castro Carpeño
- Cardio-Oncology Unit, Oncology Department, La Paz University Hospital, IdiPAZ Research Institute, Planta 1, Paseo de la Castellana 261, 28043 Madrid, Spain
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Aging and Women's Health: An Update from the National Institute on Aging. Clin Geriatr Med 2021; 37:533-541. [PMID: 34600720 DOI: 10.1016/j.cger.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Older women outnumber older men in the United States and may experience a range of physical, cognitive, social, and emotional challenges. The "Geriatric 5 Ms"-Multicomplexity, Mind, Mobility, Medications, and What Matters Most-provide a useful framework for understanding and addressing the health and wellness needs of older women in the clinic. The National Institute on Aging, a component of the US National Institutes of Health, supports a vibrant program of aging research with many immediately implementable findings and useful resources for the busy clinician.
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Strandberg TE, Lindström L, Jyväkorpi S, Urtamo A, Pitkälä KH, Kivimäki M. Phenotypic frailty and multimorbidity are independent 18-year mortality risk indicators in older men : The Helsinki Businessmen Study (HBS). Eur Geriatr Med 2021; 12:953-961. [PMID: 33661507 PMCID: PMC8463371 DOI: 10.1007/s41999-021-00472-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/12/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE Multimorbidity, prefrailty, and frailty are frequent in ageing populations, but their independent relationships to long-term prognosis in home-dwelling older people are not well recognised. METHODS In the Helsinki Businessmen Study (HBS) men with high socioeconomic status (born 1919-1934, n = 3490) have been followed-up from midlife. In 2000, multimorbidity (≥ 2 conditions), phenotypic prefrailty and frailty were determined in 1365 home-dwelling men with median age of 73 years). Disability was assessed as a possible confounder. 18-year mortality follow-up was established from registers and Cox regression used for analyses. RESULTS Of the men, 433 (31.7%) were nonfrail and without multimorbidity at baseline (reference group), 500 (36.6%) and 82 (6.0%) men had prefrailty or frailty, respectively, without multimorbidity, 84 (6.2%) men had multimorbidity only, and 201 (14.7%) and 65 (4.8%) men had prefrailty or frailty together with multimorbidity. Only 30 (2.2%) and 86 (6.3%) showed signs of ADL or mobility disability. In the fully adjusted analyses (including ADL disability, mental and cognitive status) of 18-year mortality, frailty without multimorbidity (hazard ratio 1.62, 95% confidence interval 1.13-2.31) was associated with similar mortality risk than multimorbidity without frailty (1.55, 1.17-2.06). The presence of both frailty and multimorbidity indicated a strong mortality risk (2.93, 2.10-4.07). CONCLUSION Although multimorbidity is generally considered a substantial health problem, our long-term observational study emphasises that phenotypic frailty alone, independently of disability, may be associated with a similar risk, and a combination of multimorbidity and frailty is an especially strong predictor of mortality.
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Affiliation(s)
- Timo E Strandberg
- University of Helsinki, Clinicum, and Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029, Helsinki, Finland.
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.
| | | | | | | | - Kaisu H Pitkälä
- University of Helsinki, Clinicum, and Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029, Helsinki, Finland
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Sturmberg JP, Getz LO, Stange KC, Upshur REG, Mercer SW. Beyond multimorbidity: What can we learn from complexity science? J Eval Clin Pract 2021; 27:1187-1193. [PMID: 33588522 DOI: 10.1111/jep.13521] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022]
Abstract
Multimorbidity - the occurrence of two or more long-term conditions in an individual - is a major global concern, placing a huge burden on healthcare systems, physicians, and patients. It challenges the current biomedical paradigm, in particular conventional evidence-based medicine's dominant focus on single-conditions. Patients' heterogeneous range of clinical presentations tend to escape characterization by traditional means of classification, and optimal management cannot be deduced from clinical practice guidelines. In this article, we argue that person-focused care based in complexity science may be a transformational lens through which to view multimorbidity, to complement the specialism focus on each particular disease. The approach offers an integrated and coherent perspective on the person's living environment, relationships, somatic, emotional and cognitive experiences and physiological function. The underlying principles include non-linearity, tipping points, emergence, importance of initial conditions, contextual factors and co-evolution, and the presence of patterned outcomes. From a clinical perspective, complexity science has important implications at the theoretical, practice and policy levels. Three essential questions emerge: (1) What matters to patients? (2) How can we integrate, personalize and prioritize care for whole people, given the constraints of their socio-ecological circumstances? (3) What needs to change at the practice and policy levels to deliver what matters to patients? These questions have no simple answers, but complexity science principles suggest a way to integrate understanding of biological, biographical and contextual factors, to guide an integrated approach to the care of people with multimorbidity.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia.,Foundation President, International Society for Systems and Complexity Sciences for Health, Waitsfield, Vermont
| | - Linn O Getz
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kurt C Stange
- Department of Family Medicine & Community Health, Epidemiology & Biostatistics, Oncology and Sociology, Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ross E G Upshur
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stewart W Mercer
- Department of Primary Care and Multimorbidity, Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Chen J, Wijesundara JG, Patterson A, Cutrona SL, Aiello S, McManus DD, McKee MD, Wang B, Houston TK. Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses' and patients' perspectives. BMC Health Serv Res 2021; 21:1021. [PMID: 34583702 PMCID: PMC8480104 DOI: 10.1186/s12913-021-07031-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND After hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients' post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers. METHODS Guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model. RESULTS Participants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI). CONCLUSIONS Strategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.
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Affiliation(s)
- Jinying Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Jessica G Wijesundara
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Angela Patterson
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Sarah L Cutrona
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | | | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - M Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Thomas K Houston
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Higuchi S, Kohno T, Kohsaka S, Shiraishi Y, Takei M, Goda A, Shoji S, Nagatomo Y, Yoshikawa T. Different Impact of Beta-Blockers on Long-Term Mortality in Heart Failure Patients with and without Chronic Obstructive Pulmonary Disease. J Clin Med 2021; 10:jcm10194378. [PMID: 34640396 PMCID: PMC8509631 DOI: 10.3390/jcm10194378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 09/17/2021] [Accepted: 09/22/2021] [Indexed: 12/04/2022] Open
Abstract
The administration of beta-blockers is challenging and their efficacy is unclear in heart failure (HF) patients with chronic obstructive pulmonary disease (COPD). This study aimed to investigate the association of beta-blockers with mortality in such patients. This multicenter observational cohort study included hospitalized HF patients with a left ventricular ejection fraction <50% and evaluated them retrospectively. COPD was diagnosed based on medical records and/or the clinical judgment of each investigator. The study endpoints were two-year all-cause, cardiac, and non-cardiac mortality. This study included 83 patients with COPD and 1760 patients without. Two-year all-cause, cardiac, and non-cardiac mortality were observed in 315 (17%), 149 (8%), and 166 (9%) patients, respectively. Beta-blockers were associated with lower all-cause mortality regardless of COPD (COPD: hazard ratio [HR] 0.39, 95% CI 0.16–0.98, p = 0.044; non-COPD: HR 0.62, 95% CI 0.46–0.83, p = 0.001). This association in HF patients with COPD persisted after multivariate analysis and inverse probability weighting and was due to lower non-cardiac mortality (HR 0.40, 95% CI 0.14–1.18. p = 0.098), not cardiac mortality (HR 0.37, 95% CI 0.07–2.01, p = 0.248). Beta-blockers were associated with lower all-cause mortality in HF patients with COPD due to lower non-cardiac mortality. This may reflect selection biases in beta-blocker prescription.
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Affiliation(s)
- Satoshi Higuchi
- Department of Emergency and General Medicine, Kyorin University School of Medicine, Tokyo 181-8611, Japan
- Correspondence: (S.H.); (T.K.)
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo 181-8611, Japan;
- Correspondence: (S.H.); (T.K.)
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.K.); (Y.S.); (S.S.)
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.K.); (Y.S.); (S.S.)
| | - Makoto Takei
- Department of Cardiology, Saiseikai Central Hospital, Tokyo 108-0073, Japan;
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Tokyo 181-8611, Japan;
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (S.K.); (Y.S.); (S.S.)
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan;
| | - Tsutomu Yoshikawa
- Department of Cardiology, Sakakibara Heart Institute, Tokyo 183-0003, Japan;
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur J Prev Cardiol 2021; 29:5-115. [PMID: 34558602 DOI: 10.1093/eurjpc/zwab154] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA).,International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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Beil M, Flaatten H, Guidet B, Sviri S, Jung C, de Lange D, Leaver S, Fjølner J, Szczeklik W, van Heerden PV. The management of multi-morbidity in elderly patients: Ready yet for precision medicine in intensive care? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:330. [PMID: 34507597 PMCID: PMC8431262 DOI: 10.1186/s13054-021-03750-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/27/2021] [Indexed: 11/16/2022]
Abstract
There is ongoing demographic ageing and increasing longevity of the population, with previously devastating and often-fatal diseases now transformed into chronic conditions. This is turning multi-morbidity into a major challenge in the world of critical care. After many years of research and innovation, mainly in geriatric care, the concept of multi-morbidity now requires fine-tuning to support decision-making for patients along their whole trajectory in healthcare, including in the intensive care unit (ICU). This article will discuss current challenges and present approaches to adapt critical care services to the needs of these patients.
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Affiliation(s)
- Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care Medicine, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Service de Reanimation, Hopital Saint-Antoine, Paris, France
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- Department of Adult Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hadassah University Hospital, Hebrew University of Jerusalem, Jerusalem, Israel.
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Visseren FLJ, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FDR, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J 2021; 42:3227-3337. [PMID: 34458905 DOI: 10.1093/eurheartj/ehab484] [Citation(s) in RCA: 2271] [Impact Index Per Article: 757.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Alessandro Biffi
- European Federation of Sports Medicine Association (EFSMA)
- International Federation of Sport Medicine (FIMS)
| | | | | | | | | | | | | | | | | | | | - F D Richard Hobbs
- World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) - Europe
| | | | | | | | | | | | | | | | | | | | | | - Christoph Wanner
- European Renal Association - European Dialysis and Transplant Association (ERA-EDTA)
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129
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Sanchis J, García Acuña JM, Raposeiras S, Barrabés JA, Cordero A, Martínez-Sellés M, Bardají A, Díez-Villanueva P, Marín F, Ruiz-Nodar JM, Vicente-Ibarra N, Alonso Salinas GL, Rigueiro P, Abu-Assi E, Formiga F, Núñez J, Núñez E, Ariza-Solé A. Carga de comorbilidad y beneficio de la revascularización en ancianos con síndrome coronario agudo. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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130
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Coughlin SS, Datta B, Berman A, Hatzigeorgiou C. A cross-sectional study of financial distress in persons with multimorbidity. Prev Med Rep 2021; 23:101464. [PMID: 34258176 PMCID: PMC8254038 DOI: 10.1016/j.pmedr.2021.101464] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/04/2021] [Accepted: 06/17/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Financial distress among persons with multimorbidity is an important topic which has been inadequately addressed to date. OBJECTIVE We examined the extent of financial distress among persons with multimorbidity, using data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS). DESIGN Cross-sectional, population-based study. PARTICIPANTS Adults ages ≥ 18 years with multimorbidity. MAIN MEASURES Low income and selected social determinants of health that are indicators of financial distress. KEY RESULTS Multimorbidity was more common among those with a household income of less than $15,000 per year (P < 0.001) and among those who were 65 years of age or older (P < 0.001). There was an approximately linear increase in the percentage of individuals who had a household income of less than $15,000 or $25,000 per year with increasing number of morbidities. About one-quarter of individuals who had five or more morbidities had a household income of less than $15,000 per year as compared with 4.49% of individuals with no morbidities (P < 0.001). For all of the social determinants of health examined (Couldn't pay bills, didn't have money for food, didn't have money for balanced meals, didn't have enough money to make ends meet, and felt this kind of stress), there was an approximately linear increase in the percentage of individuals with an indicator of financial distress with increasing number of morbidities. Further research is needed examining the prevalence and correlates of financial distress in this population as well effective strategies for ameliorating its impact on the health and wellbeing of these persons.
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Affiliation(s)
- Steven S. Coughlin
- Department of Population Health Sciences, Augusta University, 1120 15 Street, Augusta, GA 30912, USA
- Institute of Public and Preventive Health, Augusta University, Augusta, GA, USA
| | - Biplab Datta
- Department of Population Health Sciences, Augusta University, 1120 15 Street, Augusta, GA 30912, USA
- Institute of Public and Preventive Health, Augusta University, Augusta, GA, USA
| | - Adam Berman
- Department of Population Health Sciences, Augusta University, 1120 15 Street, Augusta, GA 30912, USA
- Division of Cardiology, Augusta University, 1120 15th Street, Augusta, GA 30912, USA
| | - Christos Hatzigeorgiou
- Division of General Internal Medicine, Augusta University, 1120 15 Street, Augusta, GA 30912, USA
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131
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Abstract
Age is an independent risk factor for cardiovascular disease. With the accelerated growth of the population of older adults, geriatric and cardiac care are becoming increasingly entwined. Although cardiovascular disease in younger adults often occurs as an isolated problem, it is more likely to occur in combination with clinical challenges related to age in older patients. Management of cardiovascular disease is transmuted by the context of multimorbidity, frailty, polypharmacy, cognitive dysfunction, functional decline, and other complexities of age. This means that additional insight and skills are needed to manage a broader range of relevant problems in older patients with cardiovascular disease. This review covers geriatric conditions that are relevant when treating older adults with cardiovascular disease, particularly management considerations. Traditional practice guidelines are generally well suited for robust older adults, but many others benefit from a relatively more personalized therapeutic approach that allows for a range of medical circumstances and idiosyncratic goals of care. This requires weighing of risks and benefits amidst the patient's aggregate clinical status and the ability to communicate effectively about this with patients and, where appropriate, their care givers in a process of shared decision making. Such a personalized approach can be particularly gratifying, as it provides opportunities to optimize an older patient's function and quality of life at a time in life when these often become foremost therapeutic priorities.
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Affiliation(s)
| | - Daniel E Forman
- University of Pittsburgh, University of Pittsburgh Medical Center and VA Pittsburgh Geriatric, Research, Education and Clinical Center (GRECC), Pittsburgh, PA, USA
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Chen J, Kiefe CI, Gagnier M, Lessard D, McManus D, Wang B, Houston TK. Non-specific pain and 30-day readmission in acute coronary syndromes: findings from the TRACE-CORE prospective cohort. BMC Cardiovasc Disord 2021; 21:383. [PMID: 34372783 PMCID: PMC8351351 DOI: 10.1186/s12872-021-02195-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/27/2021] [Indexed: 12/26/2022] Open
Abstract
Background Patients with acute coronary syndromes often experience non-specific (generic) pain after hospital discharge. However, evidence about the association between post-discharge non-specific pain and rehospitalization remains limited. Methods We analyzed data from the Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE) prospective cohort. TRACE-CORE followed patients with acute coronary syndromes for 24 months post-discharge from the index hospitalization, collected patient-reported generic pain (using SF-36) and chest pain (using the Seattle Angina Questionnaire) and rehospitalization events. We assessed the association between generic pain and 30-day rehospitalization using multivariable logistic regression (N = 787). We also examined the associations among patient-reported pain, pain documentation identified by natural language processing (NLP) from electronic health record (EHR) notes, and the outcome. Results Patients were 62 years old (SD = 11.4), with 5.1% Black or Hispanic individuals and 29.9% women. Within 30 days post-discharge, 87 (11.1%) patients were re-hospitalized. Patient-reported mild-to-moderate pain, without EHR documentation, was associated with 30-day rehospitalization (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.14–3.62, reference: no pain) after adjusting for baseline characteristics; while patient-reported mild-to-moderate pain with EHR documentation (presumably addressed) was not (OR: 1.23, 95% CI: 0.52–2.90). Severe pain was also associated with 30-day rehospitalization (OR: 3.16, 95% CI: 1.32–7.54), even after further adjusting for chest pain (OR: 2.59, 95% CI: 1.06–6.35). Conclusions Patient-reported post-discharge generic pain was positively associated with 30-day rehospitalization. Future studies should further disentangle the impact of cardiac and non-cardiac pain on rehospitalization and develop strategies to support the timely management of post-discharge pain by healthcare providers. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02195-z.
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Affiliation(s)
- Jinying Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | | | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - David McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
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133
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Ansari S, Muhammad T, Dhar M. How Does Multi-Morbidity Relate to Feeling of Loneliness among Older Adults? Evidence from a Population-Based Survey in India. JOURNAL OF POPULATION AGEING 2021. [DOI: 10.1007/s12062-021-09343-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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134
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Bekić S, Babič F, Pavlišková V, Paralič J, Wittlinger T, Majnarić LT. Clusters of Physical Frailty and Cognitive Impairment and Their Associated Comorbidities in Older Primary Care Patients. Healthcare (Basel) 2021; 9:healthcare9070891. [PMID: 34356270 PMCID: PMC8304880 DOI: 10.3390/healthcare9070891] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Objectives: We aimed to identify clusters of physical frailty and cognitive impairment in a population of older primary care patients and correlate these clusters with their associated comorbidities. (2) Methods: We used a latent class analysis (LCA) as the clustering technique to separate different stages of mild cognitive impairment (MCI) and physical frailty into clusters; the differences were assessed by using a multinomial logistic regression model. (3) Results: Four clusters (latent classes) were identified: (1) highly functional (the mean and SD of the “frailty” test 0.58 ± 0.72 and the Mini-Mental State Examination (MMSE) test 27.42 ± 1.5), (2) cognitive impairment (0.97 ± 0.78 and 21.94 ± 1.95), (3) cognitive frailty (3.48 ± 1.12 and 19.14 ± 2.30), and (4) physical frailty (3.61 ± 0.77 and 24.89 ± 1.81). (4) Discussion: The comorbidity patterns distinguishing the clusters depend on the degree of development of cardiometabolic disorders in combination with advancing age. The physical frailty phenotype is likely to exist separately from the cognitive frailty phenotype and includes common musculoskeletal diseases.
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Affiliation(s)
- Sanja Bekić
- General Medical Practice, 31000 Osijek, Croatia;
- Faculty of Medicine, University Josip Juraj Strossmayer, 31000 Osijek, Croatia
| | - František Babič
- Department of Cybernetics and Artificial Intelligence, Faculty of Electrical Engineering and Informatics, Technical University of Košice, 04201 Košice, Slovakia; (V.P.); (J.P.)
- Correspondence:
| | - Viera Pavlišková
- Department of Cybernetics and Artificial Intelligence, Faculty of Electrical Engineering and Informatics, Technical University of Košice, 04201 Košice, Slovakia; (V.P.); (J.P.)
| | - Ján Paralič
- Department of Cybernetics and Artificial Intelligence, Faculty of Electrical Engineering and Informatics, Technical University of Košice, 04201 Košice, Slovakia; (V.P.); (J.P.)
| | - Thomas Wittlinger
- Department of Cardiology, Asklepios Hospital, 38642 Goslar, Germany;
| | - Ljiljana Trtica Majnarić
- Department of Internal Medicine, Family Medicine and the History of Medicine, Faculty of Medicine, University Josip Juraj Strossmayer, 31000 Osijek, Croatia;
- Department of Public Health, Faculty of Dental Medicine and Health, University Josip Juraj Strossmayer, 31000 Osijek, Croatia
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135
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Abstract
Within the last decade, clustering of comorbidities has become an increasing health problem on a global scale and will continue to challenge healthcare professionals in the coming years. People with multiple diseases find difficulties in managing their daily lives due to the implications each disease brings; attending and keeping up to date with hospital appointments, being prescribed and taking various medications, the effects of mental health and quality of life, and the impact it has on their families. Most research in clinical trials often exclude individuals with multimorbidity and observational studies mainly focus on single disease outcomes, therefore there is an opportunity to encourage future research in an area which could help prevent further cases and improve the lives of those already living with multimorbidity. This review aims to summarise the rising prevalence and most common clusters, highlight the challenges faced in healthcare, and explore ways to improve future research.
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136
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Vanassche T, Verhamme P, Anand SS, Shestakovska O, Leong DP, Fox KAA, Bhatt DL, Avezum A, Alings M, Aboyans V, Maggioni AP, Widimsky P, Muehlhofer E, Berkowitz SD, Yusuf S, Connolly SJ, Eikelboom JW, Bosch J. Low-dose rivaroxaban plus aspirin in patients with polypharmacy and multimorbidity: an analysis from the COMPASS trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:462-473. [PMID: 34191011 DOI: 10.1093/ehjcvp/pvab050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/09/2021] [Accepted: 06/28/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND In patients with coronary or peripheral arterial disease, adding low dose rivaroxaban to aspirin reduces cardiovascular events and mortality. Polypharmacy and multimorbidity are frequent in such patients. AIMS To analyze whether the benefits and risks of rivaroxaban plus aspirin varies in patients with comorbidities and receiving multiple drugs. METHODS AND RESULTS We describe ischemic events (cardiovascular death, stroke, or myocardial infarction) and major bleeding in participants from the randomised, double-blind COMPASS study by number of cardiovascular medications and concomitant medical conditions. We compared event rates and hazard ratios (HR) for rivaroxaban plus aspirin versus aspirin alone by the number of medications and concomitant conditions, and tested for interaction between polypharmacy or multimorbidity and the antithrombotic regimen.The risk of ischemic events was higher in patients with more concomitant drugs (HR 1.7, 95%CI 1.5-2.1 for >4 vs 0-2) and with more comorbidities (HR 2.3, 1.8-2.1 for >3 vs 0-1). Multimorbidity, but not polypharmacy, was associated with a higher risk of major bleeding. The relative efficacy, safety, and net clinical benefit of rivaroxaban were not affected by the number of drugs or comorbidities. Patients taking more concomitant medications derived the largest absolute reduction in the net clinical outcome with added rivaroxaban (1.1% vs 0.4% reduction with >4 vs 0-2 cardiovascular drugs, NNT 91 vs 250). CONCLUSION Adding low-dose rivaroxaban to aspirin resulted in benefits irrespective of the number of concomitant drugs or comorbidities. Multiple comorbidities and/or polypharmacy should not dissuade the addition of rivaroxaban to aspirin in otherwise eligible patients.
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Affiliation(s)
- Thomas Vanassche
- University Hospitals Leuven, Dept. of Cardiovascular Sciences, Leuven, Belgium
| | - Peter Verhamme
- University Hospitals Leuven, Dept. of Cardiovascular Sciences, Leuven, Belgium
| | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Olga Shestakovska
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Darryl P Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, United States
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brasil
| | - Marco Alings
- Amphia Ziekenhuis and Werkgroep Cardiologische Centra Nederland, Utrecht, the Netherlands
| | - Victor Aboyans
- Dept. of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, Limoges University, Limoges, France
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy
| | - Petr Widimsky
- Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | | | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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137
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Rodríguez-Sánchez E, Navarro-García JA, Aceves-Ripoll J, González-Lafuente L, Corbacho-Alonso N, Baldan-Martín M, Madruga F, Alvarez-Llamas G, Barderas MG, Ruilope LM, Ruiz-Hurtado G. Analysis of Global Oxidative Status Using Multimarker Scores Reveals a Specific Association Between Renal Dysfunction and Diuretic Therapy in Older Adults. J Gerontol A Biol Sci Med Sci 2021; 76:1198-1205. [PMID: 33423057 DOI: 10.1093/gerona/glab012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Indexed: 01/29/2023] Open
Abstract
Aging and chronic kidney disease (CKD) are important interrelated cardiovascular risk (CVR) factors linked to oxidative stress, but this relationship has not been well studied in older adults. We assessed the global oxidative status in an older population with normal to severely impaired renal function. We determined the oxidative status of 93 older adults (mean age 85 years) using multimarker scores. OxyScore was computed as index of systemic oxidative damage by analyzing carbonyl groups, oxidized low-density lipoprotein, 8-hydroxy-2'-deoxyguanosine, and xanthine oxidase activity. AntioxyScore was computed as index of antioxidant defense by analyzing catalase and superoxide dismutase (SOD) activity and total antioxidant capacity. OxyScore and AntioxyScore were higher in subjects with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 than in peers with eGFR >60 mL/min/1.73 m2, with protein carbonyls, catalase, and SOD activity as major drivers. Older adults with a recent cardiovascular event had similar OxyScore and AntioxyScore as peers with eGFR >60 mL/min/1.73 m2. Multivariate linear regression analysis revealed that both indices were associated with decreased eGFR independently of traditional CVR factors. Interestingly, AntioxyScore was also associated with diuretic treatment, and a more pronounced increase was seen in subjects receiving combination therapy. The associations of AntioxyScore with diuretic treatment and eGFR were mutually independent. In conclusion, eGFR is the major contributor to the imbalance in oxidative stress in this older population. Given the association between oxidative stress, CKD, and CVR, the inclusion of renal function parameters in CVR estimators for older populations, such as the SCORE-OP, might improve their modest performance.
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Affiliation(s)
- Elena Rodríguez-Sánchez
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - José Alberto Navarro-García
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jennifer Aceves-Ripoll
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Laura González-Lafuente
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Nerea Corbacho-Alonso
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Montserrat Baldan-Martín
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Felipe Madruga
- Departament of Geriatrics, Hospital Virgen del Valle, SESCAM, Toledo, Spain
| | - Gloria Alvarez-Llamas
- Departament of Immunology, IIS-Fundación Jimenez Diaz, Madrid, Spain.,REDINREN, Madrid, Spain
| | - María G Barderas
- Department of Vascular Physiopathology, Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Luis M Ruilope
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain.,European University of Madrid, Spain
| | - Gema Ruiz-Hurtado
- Cardiorenal Translational Laboratory, Institute of Research i+12, Hospital Universitario 12 de Octubre, Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain
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138
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Breen KM, Finnegan L, Vuckovic KM, Fink AM, Rosamond W, DeVon HA. Multimorbidity phenotypes in patients presenting to the emergency department with possible acute coronary syndrome. Heart Lung 2021; 50:648-653. [PMID: 34098234 DOI: 10.1016/j.hrtlng.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Multimorbidity (> 2 conditions) increases the risk of adverse outcomes and challenges health care systems for patients with acute coronary syndrome (ACS). These complications may be partially attributed to ACS clinical care which is driven by single-disease-based practice guidelines; current guidelines do not consider multimorbidity. OBJECTIVES To identify multimorbidity phenotypes (combinations of conditions) with suspected ACS. We hypothesized that: 1) subgroups of patients with similar multimorbidity phenotypes could be identified, 2) classes would differ according to diagnosis, and 3) class membership would differ by sex, age, functional status, family history, and discharge diagnosis. METHODS This was a secondary analysis of data from a large multi-site clinical study of patients with suspected ACS. Conditions were determined by items on the Charlson Comorbidity Index and the ACS Patient Information Questionnaire. Latent class analysis was used to identify phenotypes. RESULTS The sample (n = 935) was predominantly male (68%) and middle-aged (mean= 59 years). Four multimorbidity phenotypes were identified: 1) high multimorbidity (Class 1) included hyperlipidemia, hypertension (HTN), obesity, diabetes, and respiratory disorders (COPD or asthma); 2) low multimorbidity (Class 2) included only obesity; 3) cardiovascular multimorbidity (Class 3) included HTN, hyperlipidemia, and coronary heart disease; and 4) cardio-oncology multimorbidity (Class 4) included HTN, hyperlipidemia, and cancer. Patients ruled-in for ACS primarily clustered in Classes 3 and 4 (OR 2.82, 95% CI 1.95-4.05, p = 0.001 and OR 1.76, 95% CI 1.13-2.74, p = 0.01). CONCLUSION Identifying and understanding multimorbidity phenotypes may assist with risk-stratification and better triage of high-risk patients in the emergency department.
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Affiliation(s)
- Katherine M Breen
- Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA 30322, United States.
| | - Lorna Finnegan
- Loyola University Chicago, Marcella Niehoff School of Nursing, Chicago, IL, United States
| | - Karen M Vuckovic
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, Chicago, IL, United States
| | - Anne M Fink
- University of Illinois at Chicago, College of Nursing, Department of Biobehavioral Health Science, Chicago, IL, United States
| | - Wayne Rosamond
- University of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC, United States
| | - Holli A DeVon
- University of California Los Angeles School of Nursing, Los Angeles, CA, United States
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139
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He K, Zhang W, Hu X, Zhao H, Guo B, Shi Z, Zhao X, Yin C, Shi S. Relationship between multimorbidity, disease cluster and all-cause mortality among older adults: a retrospective cohort analysis. BMC Public Health 2021; 21:1080. [PMID: 34090390 PMCID: PMC8180153 DOI: 10.1186/s12889-021-11108-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/20/2021] [Indexed: 11/18/2022] Open
Abstract
Background Previous studies have evaluated the association of multimorbidity with higher mortality, but epidemiologic data on the association between the disease clusters and all-cause mortality risk are rare. We aimed to examine the relationship between multimorbidity (number/ cluster) and all-cause mortality in Chinese older adults. Methods We conducted a population-based study of 50,100 Chinese participants. Multiple logistic regression analysis was used to estimate the impact of long-term conditions (LTCs) on all-cause mortality. Results The prevalence of multimorbidity was 31.35% and all-cause mortality was 8.01% (50,100 participants). In adjusted models, the odds ratios (ORs) and 95% confidence intervals (CIs) of all-cause mortality risk for those with 1, 2, and ≥ 3 LTCs compared with those with no LTCs was 1.45 (1.32–1.59), 1.72 (1.55–1.90), and 2.15 (1.85–2.50), respectively (Ptrend < 0.001). In the LTCs ≥2 category, the cluster of chronic diseases that included hypertension, diabetes, CHD, COPD, and stroke had the greatest impact on mortality. In the stratified model by age and sex, absolute all-cause mortality was higher among the ≥75 age group with an increasing number of LTCs. However, the relative effect size of the increasing number of LTCs on higher mortality risk was larger among those < 75 years. Conclusions The risk of all-cause mortality is increased with the number of multimorbidity among Chinese older adults, particularly disease clusters. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11108-w.
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Affiliation(s)
- Kun He
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, People's Republic of China
| | - Wenli Zhang
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, People's Republic of China
| | - Xueqi Hu
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, People's Republic of China
| | - Hao Zhao
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, People's Republic of China
| | - Bingxin Guo
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, People's Republic of China
| | - Zhan Shi
- Department of Pharmacy, Zhengzhou People's Hospital, Zhengzhou, Henan, People's Republic of China
| | - Xiaoyan Zhao
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Chunyu Yin
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, People's Republic of China
| | - Songhe Shi
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, Henan, 450001, People's Republic of China.
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Arsanjani R, Khera N. Financial Toxicity in Cancer and Cardiovascular Disease: A Threat to Access and Quality of Care. JACC CardioOncol 2021; 3:247-249. [PMID: 34396330 PMCID: PMC8352244 DOI: 10.1016/j.jaccao.2021.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Feldman DR, Romashko MD, Koethe B, Patel S, Rastegar H, Zhan Y, Resor CD, Connors AC, Kimmelstiel C, Allen D, Weintraub AR, Wessler BS. Comorbidity Burden and Adverse Outcomes After Transcatheter Aortic Valve Replacement. J Am Heart Assoc 2021; 10:e018978. [PMID: 33960198 PMCID: PMC8200712 DOI: 10.1161/jaha.120.018978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for symptomatic patients with aortic stenosis and elevated procedural risk. Many deaths following TAVR are because of noncardiac causes and comorbid disease burden may be a major determinant of postprocedure outcomes. The prevalence of comorbid conditions and associations with outcomes after TAVR has not been studied. Methods and Results This was a retrospective single‐center study of patients treated with TAVR from January 2015 to October 2018. The association between 21 chronic conditions and short‐ and medium‐term outcomes was assessed. A total of 341 patients underwent TAVR and had 1‐year follow‐up. The mean age was 81.4 (SD 8.0) years with a mean Society of Thoracic Surgeons predicted risk of mortality score of 6.7% (SD 4.8). Two hundred twenty (65%) patients had ≥4 chronic conditions present at the time of TAVR. There was modest correlation between Society of Thoracic Surgeons predicted risk of mortality and comorbid disease burden (r=0.32, P<0.001). After adjusting for Society of Thoracic Surgeons predicted risk of mortality, age, and vascular access, each additional comorbid condition was associated with increased rates of 30‐day rehospitalizations (odds ratio, 1.21; 95% CI, 1.02–1.44), a composite of 30‐day rehospitalization and 30‐day mortality (odds ratio, 1.20; 95% CI, 1.02–1.42), and 1‐year mortality (odds ratio, 1.29; 95% CI, 1.05–1.59). Conclusions Comorbid disease burden is associated with worse clinical outcomes in high‐risk patients treated with TAVR. The risks associated with comorbid disease burden are not adequately captured by standard risk assessment. A systematic assessment of comorbid conditions may improve risk stratification efforts.
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Affiliation(s)
| | | | - Benjamin Koethe
- Institute for Clinical Research and Health Policy Studies Biostatistics, Epidemiology, and Research Design (BERD) Center Tufts Medical Center Boston MA
| | - Sonika Patel
- Department of Internal Medicine University of Maryland Baltimore MD
| | - Hassan Rastegar
- Division of Cardiothoracic Surgery Tufts Medical Center Boston MA
| | - Yong Zhan
- Division of Cardiothoracic Surgery Tufts Medical Center Boston MA
| | | | | | | | - David Allen
- Department of Interventional Radiology Tufts Medical Center Boston MA
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Li Z, Zhao H, Wang J. Metabolism and Chronic Inflammation: The Links Between Chronic Heart Failure and Comorbidities. Front Cardiovasc Med 2021; 8:650278. [PMID: 34026868 PMCID: PMC8131678 DOI: 10.3389/fcvm.2021.650278] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022] Open
Abstract
Heart failure (HF) patients often suffer from multiple comorbidities, such as diabetes, atrial fibrillation, depression, chronic obstructive pulmonary disease, and chronic kidney disease. The coexistance of comorbidities usually leads to multi morbidity and poor prognosis. Treatments for HF patients with multi morbidity are still an unmet clinical need, and finding an effective therapy strategy is of great value. HF can lead to comorbidity, and in return, comorbidity may promote the progression of HF, creating a vicious cycle. This reciprocal correlation indicates there may be some common causes and biological mechanisms. Metabolism remodeling and chronic inflammation play a vital role in the pathophysiological processes of HF and comorbidities, indicating metabolism and inflammation may be the links between HF and comorbidities. In this review, we comprehensively discuss the major underlying mechanisms and therapeutic implications for comorbidities of HF. We first summarize the potential role of metabolism and inflammation in HF. Then, we give an overview of the linkage between common comorbidities and HF, from the perspective of epidemiological evidence to the underlying metabolism and inflammation mechanisms. Moreover, with the help of bioinformatics, we summarize the shared risk factors, signal pathways, and therapeutic targets between HF and comorbidities. Metabolic syndrome, aging, deleterious lifestyles (sedentary behavior, poor dietary patterns, smoking, etc.), and other risk factors common to HF and comorbidities are all associated with common mechanisms. Impaired mitochondrial biogenesis, autophagy, insulin resistance, and oxidative stress, are among the major mechanisms of both HF and comorbidities. Gene enrichment analysis showed the PI3K/AKT pathway may probably play a central role in multi morbidity. Additionally, drug targets common to HF and several common comorbidities were found by network analysis. Such analysis has already been instrumental in drug repurposing to treat HF and comorbidity. And the result suggests sodium-glucose transporter-2 (SGLT-2) inhibitors, IL-1β inhibitors, and metformin may be promising drugs for repurposing to treat multi morbidity. We propose that targeting the metabolic and inflammatory pathways that are common to HF and comorbidities may provide a promising therapeutic strategy.
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Affiliation(s)
- Zhiwei Li
- Department of Pathophysiology, State Key Laboratory of Medical Molecular Biology Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Hongmei Zhao
- Department of Pathophysiology, State Key Laboratory of Medical Molecular Biology Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Jing Wang
- Department of Pathophysiology, State Key Laboratory of Medical Molecular Biology Institute of Basic Medicine, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
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Miller PE, Thomas A, Breen TJ, Chouairi F, Kunitomo Y, Aslam F, Damluji AA, Anavekar NS, Murphy JG, van Diepen S, Barsness GW, Brennan J, Jentzer J. Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality. Am J Med 2021; 134:653-661.e5. [PMID: 33129785 PMCID: PMC8079541 DOI: 10.1016/j.amjmed.2020.09.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population. METHODS We analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression. RESULTS The prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all). CONCLUSIONS In 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn; Yale National Clinicians Scholar Program, New Haven, Conn.
| | - Alexander Thomas
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Thomas J Breen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Fouad Chouairi
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Yukiko Kunitomo
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Faisal Aslam
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Va; Division of Cardiology, Johns Hopkins Hospital, Baltimore, Md
| | | | - Joseph G Murphy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Joseph Brennan
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minn
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Pati S, Mahapatra P, Dwivedi R, Athe R, Sahoo KC, Samal M, Das RC, Hussain MA. Multimorbidity and Its Outcomes Among Patients Attending Psychiatric Care Settings: An Observational Study From Odisha, India. Front Public Health 2021; 8:616480. [PMID: 33968863 PMCID: PMC8096979 DOI: 10.3389/fpubh.2020.616480] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Multimorbidity, the presence of two or more chronic health conditions is linked to premature mortality among psychiatric patients since the presence of one can further complicate the management of either. Little research has focused on the magnitude and effect of multimorbidity among psychiatric patients in low-and middle-income settings. Our study, provides the first ever data on multimorbidity and its outcomes among patients attending psychiatric clinics in Odisha, India. It further explored whether multimorbidity was associated with higher medical expenditure and the interaction effect of psychiatric illness on this association. Methods: This cross-sectional study included 500 adult patients presenting to the psychiatric clinic of a medical college hospital in Odisha over a period of 6 months (February 2019–July 2019). A validated structured questionnaire, “multimorbidity assessment questionnaire for psychiatric care” (MAQ-PsyC) was used for data collection. We used multinomial logistic model for the effect estimation. Odds ratios (OR) and 95% confidence intervals (CI) for high healthcare utilization and expenditure were calculated by number and pattern of multimorbidity. Data was analyzed by STATA 14. Results: Half (50%) of the psychiatric outpatients had multimorbidity. The relative probabilities of having one additional condition were 5.3 times (RRR = 5.3; 95% CI: 2.3, 11.9) and multiple morbidities were 6.6 times (RRR = 6.6; 95%CI: 3.3, 13.1) higher for patients in 60+ age group. Healthcare utilization i.e., medication use and physician consultation was significantly higher for psychiatric conditions such as mood disorders, schizophrenia, schizotypal and delusional disorders, and for hypertension, cancer, diabetes, among somatic conditions. Out of pocket expenditure (OOPE) was found to be highest for laboratory investigations, followed by medicines and transport expenditure. Within psychiatric conditions, mood disorders incurred highest OOPE ($93.43) while hypertension was the most leading for OOPE in physical morbidities ($93.43). Psychiatric illnesses had a significant interaction effect on the association between multimorbidity and high medical expenditure (P = 0.001). Conclusion: Multimorbidity is highly prevalent in psychiatric patients associated with significantly high healthcare utilization and medical expenditure. Such disproportionate effect of psychiatric multimorbidity on healthcare cost and use insinuates the need for stronger financial protection and tailor-made clinical decision making for these vulnerable patient subgroups.
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Affiliation(s)
- Sanghamitra Pati
- Indian Council of Medical Research (ICMR)-Regional Medical Research Centre, Bhubaneswar, India
| | - Pranab Mahapatra
- Department of Psychiatry, Kalinga Institute of Medical Sciences, Kalinga Institute of Industrial Technology (KIIT) University, Bhubaneswar, India
| | - Rinshu Dwivedi
- Department of Humanities and Science (Economics), Indian Institute of Information Technology, Tiruchirappalli, India
| | - Ramesh Athe
- Department of Humanities and Science (Mathematics), Indian Institute of Information Technology, Dharwad, India
| | - Krushna Chandra Sahoo
- Indian Council of Medical Research (ICMR)-Regional Medical Research Centre, Bhubaneswar, India
| | - Mousumi Samal
- Indian Council of Medical Research (ICMR)-Regional Medical Research Centre, Bhubaneswar, India
| | - Ram Chandra Das
- Department of Psychiatry, Kalinga Institute of Medical Sciences, Kalinga Institute of Industrial Technology (KIIT) University, Bhubaneswar, India
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Bjarnason-Wehrens B, Tamulevičiūtė-Prascienė E. The benefit of the use of short physical performance battery test in elderly patients in cardiac rehabilitation. Eur J Prev Cardiol 2021; 29:1005-1007. [PMID: 33846736 DOI: 10.1093/eurjpc/zwab063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Birna Bjarnason-Wehrens
- Department of Preventive and Rehabilitative Sport and Exercise Medicine, Institute of Cardiology and Sports Medicine, German Sport University Cologne, Am Sportpark Muengersdorf 6, Cologne 50933, Germany
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Krishnaswami A, Liu TI, Harris J, Prentice HA, Paxton EW, Masoudi FA. The association of multimorbidity to mortality in older adults after permanent pacemaker placement. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:919-928. [PMID: 33825225 DOI: 10.1111/pace.14238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 03/02/2021] [Accepted: 03/28/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND In the United States 2018 bradycardia guideline, the current class III recommendation that patients with permanent pacemaker (PPM) indications and high multimorbidity burden may not have meaningful clinical benefit from PPM therapy is based on limited data. METHODS Observational study (January 1, 2008-December 31, 2015) of adults ≥65 years (N = 16,678) who underwent PPM implantation. Exposure variable: Elixhauser comorbidity number (ECN, 29 well-validated conditions). PRIMARY OUTCOME ≤1-year mortality; secondary outcome: > 1-year mortality. RESULTS Those who died ≤1-year were older, had a lower body mass index (BMI), and higher ECN (p < .001). Cumulative survival at 1-year was 92.3% (95% confidence interval [CI]: 91.9-92.7). One-year survival decreased by increasing ECN-with a difference at 1-year between lowest and highest ECN category of 17.3% (ECN 0-1: 97.1% [95% CI: 96.3-97.7]; ECN ≥8: 79.8% [95% CI: 77.9-81.5]). For those who survived the first year, cumulative survival at 8-years was 51.2% (95% CI = 49.8-52.6) with a difference between ECN 0-1 and ≥8 of 43.4%. Increasing ECN was associated equally with ≤1-year (HR 1.28 [95% CI: 1.25-1.30]) and >1-year (HR 1.19 [95% CI: 1.17-1.20]) mortality. A predictive model including age, sex, BMI, PPM type, race, and ECN had greater discriminative ability (p < .0001) than a bedside model (age, sex) for the primary outcome. CONCLUSION Across the heterogeneity of indications for PPM placement, multimorbidity is increasingly common. The association of multimorbidity to mortality (≤1-year, >1-year) should be routinely discussed during the shared decision-making process as an important prognostic geriatric domain variable.
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Affiliation(s)
- Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California, USA
| | - Taylor I Liu
- Division of Cardiac Electrophysiology, Kaiser Permanente Santa Clara, Santa Clara, California, USA
| | - Jessica Harris
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California, USA
| | - Heather A Prentice
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California, USA
| | - Elizabeth W Paxton
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California, USA
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Perry CA, Van Guilder GP, Hossain M, Kauffman A. Cardiometabolic Changes in Response to a Calorie-Restricted DASH Diet in Obese Older Adults. Front Nutr 2021; 8:647847. [PMID: 33816541 PMCID: PMC8017169 DOI: 10.3389/fnut.2021.647847] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 02/24/2021] [Indexed: 12/13/2022] Open
Abstract
Objective: To examine the response of a calorie-restricted Dietary Approaches to Stop Hypertension diet on indicators of cardiometabolic health in a cohort of sedentary obese older adults. Design: This was a controlled-feeding trial with a parallel design. Each participant consumed either 3 oz (85 g; n = 15) or 6 oz (170.1 g; n = 13) of lean fresh beef within a standardized calorie-restricted DASH-like diet for 12-weeks. Fasted blood samples were collected and used to measure conventional biomarkers of cardiovascular, metabolic and inflammatory health. Participants: Caucasian older (70.8 years), obese (BMI: 32 ± 6.9 kg/m2; WC: 101 ± 16.4 cm) females (n = 17) and males (n = 11) from the rural community of Brookings, South Dakota. Results: 28 participants completed the 12-week feeding trial, with no differences (p > 0.05) among the biomarkers of cardiometabolic health between the 3 and 6 oz beef intake groups. However, when the beef intake groups were combined, all biomarkers changed concentration in response to the intervention diet. Total cholesterol (p < 0.001), LDL-C (p = 0.004), HDL-C (p < 0.0001), insulin (p = 0.014), glucose (p = 0.008), HOMA-IR (p < 0.05), IL-12 (p < 0.001), and CRP (p = 0.006) all decreased in response to the study diet. IGF-1 (p < 0.001) and IL-8 (p = 0.005) increased in response to the intervention. Correlations among cardiometabolic biomarkers and body composition measures were observed. By study end, the decrease in insulin (R 2 = 0.22; P = 0.012) and HOMA-IR (R 2 = 0.22; P = 0.01) was positively correlated with the decrease in waist circumference. The increase in IGF-1 was significantly correlated with the decrease in waist circumference (R 2 = 0.21; p = 0.014). The increase in IGF-1 was significantly correlated with the increase in sit-to-stand (R 2 = 0.21; p = 0.016). The increase in IL-8 was significantly correlated with decreases in total cholesterol (R 2 = 0.24; P = 0.008), LDL-C (R 2 = 0.17; P = 0.031) and glucose (R 2 = 0.44; P = 0.0001). Conclusions: These findings suggest that a DASH-like diet with restricted calories may potentially improve biomarkers of cardiometabolic health in sedentary obese older adults. These results also point to interrelationships between body composition changes and changes in cardiometabolic biomarkers. Lastly, regardless of meat intake amount, positive impacts on cardiometabolic biomarkers were observed in this cohort of older adults with an obese phenotype.
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Affiliation(s)
- Cydne A Perry
- Department of Applied Health Science, Indiana University Bloomington School of Public Health, Bloomington, IN, United States
| | - Gary P Van Guilder
- High Altitude Exercise Physiology Department, Western Colorado University, Gunnison, CO, United States
| | - Mosharraf Hossain
- Department of Health and Nutritional Sciences, South Dakota State University, Brookings, SD, United States
| | - Alyssa Kauffman
- Department of Health and Nutritional Sciences, South Dakota State University, Brookings, SD, United States
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Estimating the Economic Burden of Low Health Literacy in the Blacktown Community in Sydney, Australia: A Population-Based Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052303. [PMID: 33652730 PMCID: PMC7956806 DOI: 10.3390/ijerph18052303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/19/2021] [Accepted: 02/23/2021] [Indexed: 11/24/2022]
Abstract
Evidence shows that inadequate or low health literacy (LHL) levels are significantly associated with economic ramifications at the individual, employer, and health care system levels. Therefore, this study aims to estimate the economic burden of LHL among a culturally and linguistically diverse (CALD) community in Blacktown: a local government area (LGA) in Sydney, Australia. This study is a secondary analysis of cross-sectional data from publicly available datasets, including 2011 and 2016 census data and National Health Survey (NHS) data (2017–2018) from the Australian Bureau of Statistics (ABS), and figures on Disease Expenditure in Australia for 2015–2016 provided by the Australian Institute of Health and Welfare (AIHW). This study found that 20% of Blacktown residents reported low levels of active engagement with health care providers (Domain 6 of the Health Literacy Questionnaire (HLQ)), with 14% reporting a limited understanding of the health information required to take action towards improving health or making health care decisions (Domain 9 of the HLQ). The overall extra/delta cost (direct and indirect health care costs) associated with LHL in the Blacktown LGA was estimated to be between $11,785,528 and $15,432,239 in 2020. This is projected to increase to between $18,922,844 and $24,191,911 in 2030. Additionally, the extra disability-adjusted life year (DALY) value in 2020, for all chronic diseases and age-groups—comprising the extra costs incurred due to years of life lost (YLL) and years lived with disability (YLD)—was estimated at $414,231,335. The findings of our study may enable policymakers to have a deeper understanding of the economic burden of LHL in terms of its impact on the health care system and the production economy.
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Castañeda-Avila MA, Lapane KL, Jesdale BM, Crawford SL, Epstein MM. Variation in Colorectal Cancer Screening Practices According to Cardiovascular Disease Status and Race/Ethnicity. J Racial Ethn Health Disparities 2021; 8:166-173. [PMID: 32383046 PMCID: PMC7647945 DOI: 10.1007/s40615-020-00768-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To assess current estimates of colorectal cancer (CRC) screening practices in relation to cardiovascular disease (CVD) status and whether this association varies by race/ethnicity. METHODS Cross-sectional analysis of the Behavioral Risk Factor Surveillance System data from 2012, 2014, 2016, and 2018 among US adults aged 50-75 years (n = 807,937). Participants' self-reported CRC screening practices were categorized as being up-to-date, not up-to-date, or never screened. Multinomial logistic regression was used to assess whether self-reported prevalent CVD was associated with CRC screening practices after adjusting for several potentially confounding variables; additional analyses were stratified by race/ethnicity. RESULTS One-quarter of US adults had never been screened for CRC, while 67.0% reported being up-to-date with CRC screening. The proportion of Hispanics who had never been screened (35.3%) was higher than non-Hispanic Whites (23.5%) and Blacks (20.6%). Adults with CVD were less likely to never have been screened (adjusted odds ratio (aOR), 0.92; 95% confidence interval (CI), 0.88-0.95) or not to be up-to-date (aOR, 0.90; 95% CI, 0.86-0.94) on CRC screening than those without CVD. CONCLUSION The presence of CVD is associated with better adherence to CRC screening guidelines. Poor CRC screening utilization in Hispanics should be a priority for further investigation and intervention.
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Affiliation(s)
- Maira A Castañeda-Avila
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Road North, Worcester, MA, 01655, USA.
| | - Kate L Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Road North, Worcester, MA, 01655, USA
| | - Bill M Jesdale
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Road North, Worcester, MA, 01655, USA
| | - Sybil L Crawford
- Graduate School of Nursing, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mara M Epstein
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 55 Lake Road North, Worcester, MA, 01655, USA
- Meyers Primary Care Institute and the Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Yiaslas TA, Sood A, Ono G, Rogers-Soeder TS, Kitazono RE, Embree J, Spann C, Caputo CA, Taylor J, Schaefer S. The Design and Implementation of a Heart Disease Reversal Program in the Veterans Health Administration: Before and During the COVID-19 Pandemic. Fed Pract 2021; 37:558-565. [PMID: 33424214 DOI: 10.12788/fp.0074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background Heart disease continues to be the leading cause of death in the US, and the number of people with cardiovascular disease (CVD) is rising. CVD is more prevalent among military veterans than nonveterans, and veteran status is associated with higher risk of incident heart disease after controlling for socioeconomic status, other medical diseases, depression, and lifestyle. Many patients seeking care in the Veterans Health Administration, including those who undergo cardiac catheterization, meet the criteria for multimorbidity (defined as ≥ 2 chronic diseases). Observations The Heart Disease Reversal Program (HDRP) is a novel interdisciplinary, multicomponent lifestyle program at the US Department of Veterans Affairs (VA) Sacramento VA Medical Center. This program is a streamlined adaptation of behavioral/lifestyle interventions aimed at promoting partial reversal (regression) of atherosclerotic heart disease and achievement of comprehensive cardiovascular risk reduction. HDRP was developed and implemented within a VA behavioral medicine clinic and successfully adapted for delivery through videoconferencing during the COVID-19 pandemic. Patient satisfaction survey data indicate a very high level of patient acceptability. We found direct-to-patient clinical outreach an effective method for launching a disease reversal program. Conclusions Beyond the clinical benefits to patients, there is significant value and benefit added to the health care system by offering an intervention within the disease reversal paradigm. Efforts of the health care team to reverse a disease can be considered the highest aim of medicine and health care.
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Affiliation(s)
- Themis A Yiaslas
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Ajay Sood
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Gregory Ono
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Tara S Rogers-Soeder
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Rachel E Kitazono
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Janelle Embree
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Cynthia Spann
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Carrie A Caputo
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - June Taylor
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
| | - Saul Schaefer
- is a Psychologist in the Behavioral Medicine Clinic; is Chief, Endocrine Section; and are Clinical Pharmacists; , and are Dietitians, Nutrition and Food Service; is a Nurse Educator; all at the Sacramento Veterans Affairs Medical Center in California. is a Psychologist, Behavioral Medicine Service, Kaiser Permanente, in Sacramento. Themis Yiaslas is an Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, Ajay Sood is Professor, Division of Endocrinology; and is a Professor and Director of Medical Student Research; all at the University of California Davis School of Medicine in Sacramento
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