Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study

Associated factors of frailty among community-dwelling older adults with multimorbidity from a health ecological perspective: a cross-sectional study

BACKGROUND

As the global aging process accelerates, the older population is increasing annually, with the majority suffering from one or more chronic diseases. Due to the influence of chronic disease comorbidity, frailty among the older is widespread. Therefore, early identification of frailty in older adults with comorbidities from a comprehensive perspective, along with proactive measures for prevention and timely intervention, becomes an inevitable requirement for healthy aging. This study aimed to identify the entry point of frailty management in the older with multimorbidity in the community and clarify the focus of frailty management.

METHODS

A national cross-sectional survey of 1056 older adults with comorbidities in 148 cities across China was conducted. Frailty was assessed using the Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight (FRAIL) scale. Based on the health ecological model, the factors which may influence frailty were collected from five levels. Univariate and multivariate analysis were utilized to determine the factors influencing frailty. The STROBE checklist was used preparing the manuscript.

RESULTS

A total of 417 patients (39.5%) reported having frailty, while 613 patients (58.0%) were in the pre-frail state. Multivariate logistic regression analysis indicate that compared with robust patients, number of comorbidities, self-efficacy, sleep quality and perceived social support are associated with frailty in older patients with comorbidities (P < 0.05). Compared to pre-frail group, factors such as number of comorbidities, gender (female), cognitive status of diseases, anxiety, having four or more comorbidities, smoking, eating habits, taking three or more different types of medication and perceived social support are associated with frailty (P < 0.05).

CONCLUSIONS

The prevalence of frailty among older adults with comorbidities is exceptionally high, influenced by various dimensions from health ecology perspective. Psychological care and daily behavior management should be strengthened for the frail older with multimorbidity. Precise and individualized care interventions need to be developed to help promote healthy aging.

Epidemiology of multimorbidity in childhood cancer survivors: a matched cohort study of inpatient hospitalisations in Western Australia

BACKGROUND

Childhood cancer survivors (CCS) experience an elevated burden of health complications, underscoring the importance of understanding the patterns of multimorbidity to guide the management of survivors with complex medical needs.

METHODS

We examined the patterns of hospitalisations with multimorbidity in 5-year CCS (n = 2938) and age- and sex-matched non-cancer comparisons (n = 24,792) using statewide records of inpatient admissions in Western Australia from 1987 to 2019.

RESULTS

Multimorbidity rates were higher for CCS (10.6, 95%CI 10.2-10.9) than for non-cancer comparisons (3.2, 95%CI 3.2-3.3). CCS exhibited a significantly higher adjusted hazard ratio of multimorbidity, particularly when admitted for neoplasms (14.6, 95%CI 11.2-19.1), as well as blood (7.3, 95%CI 4.9-10.7), neurological and sensory (5.2, 95%CI 4.2-6.6), and cardiovascular (3.6, 95%CI 2.6-4.8) diseases. By the age of 55 years, chronic multimorbidity was more prevalent in survivors than in comparisons (14.5% vs. 5.3%). Psychiatric disorders were common comorbidities, particularly in those admitted for neurological and sensory (71.1%), endocrine (61.5%), and digestive (59.3%) diseases. Multimorbidity during hospitalisation increased the length of hospital stay (p < 0.05). Key condition clusters included (1) psychoactive substance  dependence, alcohol misuse, and other mental disorders; (2) hypertension, diabetes, kidney disease, and musculoskeletal diseases; (3) epilepsy, hypothyroidism, and other liver diseases; and (4) hypertension, kidney disease, and other liver diseases.

CONCLUSIONS

These findings suggest that exposure to cancer in childhood elevates the risk of multimorbidity. The reconfiguration of healthcare delivery to enhance personalised care and clinical integration is essential for effectively managing multimorbidity in this population.

Suboptimal antidepressant use among inpatients and outpatients with symptoms of depression: a cross-sectional analysis of the POKAL core data set

We present a cross-sectional analysis of 1391 outpatients and 280 inpatients participating in subprojects of the Research Training Group POKAL, of whom 1609 had a PHQ-9 score ≥ 5 and 62 reported depression with antidepressant use. Antidepressant use was lower among outpatients than inpatients (28.5% vs. 82.5%), with higher levels of SSRI monotherapy (44.1% vs. 25.5%). Of antidepressant users, 80.1% had potentially inadequate treatment response, 21.7% high-risk use and of those with severe symptoms, 42.1% were potentially undertreated. Key risk factors were higher anxiety levels (for inadequate treatment response) and polypharmacy (for high-risk use), while previous depressive episode was protective against potential undertreatment.

Understanding hospital activity and outcomes for people with multimorbidity using electronic health records

As the prevalence of multimorbidity grows, provision of effective healthcare is more challenging. Both multimorbidity and complexity in healthcare delivery may be associated with worse outcomes. We studied consecutive, unique emergency non-surgical hospitalisations for patients over 50 years old to three hospitals in Scotland, UK between 2016 and 2024 using linked primary care and hospital records to define multimorbidity (2 + long-term conditions), and timestamped hospital electronic health record (EHR) contacts with nursing and rehabilitation providers to describe intensity of inpatient care. The primary outcome was emergency hospital readmission within 30 days of discharge, analysed using multivariable logistic regression. Across 98,242 consecutive admissions, 84% of the study population had multimorbidity, 50% had 4 + long-term conditions, and 37% had both physical and mental health conditions. Both higher condition count and contacts (nursing and rehabilitation) were independently associated with the primary outcome in fully adjusted models (example adjusted odds ratio [aOR] 1.62, 95% CI 1.52 to 1.73 for 4 + conditions compared to no multimorbidity, p < 0.001; aOR 1.35, 95% CI 1.28 to 1.42 for > 8 nursing contacts compared to 1-3, p < 0.001). While multimorbidity was associated with longer hospital stays with more nursing and rehabilitation contacts, the distribution of contacts and activity did not differ by multimorbidity or subsequent emergency readmission status. Higher count multimorbidity was associated with an increased risk of readmission, but we observed uniformity in care despite differential outcomes across multimorbidity groups. This may suggest that EHR data-driven approaches could inform person-centred care and improve hospital resource allocation.

Survival and parenteral nutrition dependence in patients aged 65 y and older with short bowel syndrome: a retrospective observational cohort study

BACKGROUND

Home parenteral support (PS) is the standard treatment of chronic intestinal failure (CIF) with short bowel syndrome (SBS) as the leading cause. However, outcomes of PS in older patients remain poorly studied.

METHODS

This retrospective observational study evaluated patients with newly diagnosed SBS-CIF initiating PS between 2015 and 2020 at a national French CIF referral center. Patients were stratified into 2 groups: 65 y or older (older group) and younger than 65 y (younger group). Multivariate Cox regression identified predictors of mortality and PS dependence in older patients.

RESULTS

We included 175 patients [median age: 61 y (IQR: 46-70 y); 58% female]. Mesenteric ischemia was the primary cause of CIF (32%). Surgical anatomy included jejunostomy (47%), jejunocolic (39%), and ileocolic anastomosis (14%). Older patients [n = 73 (42%); median age: 72 y; IQR: 68-76 y] had higher rates of arterial hypertension, dyslipidemia, cancer, and SBS-CIF caused by radiation enteritis, but fewer cases attributed to Crohn disease. After a median follow-up of 27 mo (95% confidence interval [CI]: 22, 32 mo), the probability of survival was 92% (95% CI: 88%, 97%), and the probability of PS dependence was 68% (95% CI: 60%, 785), with no significant difference between age groups. In older patients, the presence of a jejunostomy (hazard ratios [HR]: 3.4; 95% CI: 1.1, 10.6) was an independent predictor of PS dependence, and BMI of <22 kg/m2 (HR: 10.9; 95% CI: 1.4, 87.4) was an independent predictor of mortality. Fourteen patients (8%) were treated with teduglutide, with no significant difference between age groups.

CONCLUSIONS

Nearly half of patients with SBS-CIF on PS are aged 65 y or older, with PS dependence and survival rates comparable with those of younger patients. These findings suggest that age should not be a barrier to PS initiation.

Joint assessment of abdominal obesity and non-traditional lipid parameters for primary prevention of cardiometabolic multimorbidity: insights from the China health and retirement longitudinal study 2011-2018

BACKGROUND

Obesity and abnormal lipid metabolism increase the risk of various cardiometabolic diseases, including diabetes, heart disease, and stroke. However, the impact of abdominal obesity (AO) and non-traditional lipid parameters on the risk of cardiometabolic multimorbidity (CMM) remains unclear. This study aims to investigate the separate and combined effects of AO and non-traditional lipid parameters on the incidence risk of CMM.

METHODS

This study enrolled 7,597 eligible participants from the China health and retirement longitudinal study (CHARLS). Cox proportional hazards models were used to perform adjusted regression analyses and mediation analyses, with Kaplan-Meier analysis used for cumulative hazards. Restricted cubic splines were utilized to evaluate the nonlinear relationship between non-traditional lipid parameters and the risk of CMM among participants with AO. Subgroup analyses were conducted with stratification by age, gender, BMI, smoking status, drinking status, and hypertension to investigate interaction effects across different populations. Additionally, sensitivity analyses were further performed to evaluate the impact of various subgroups on diabetes, heart disease, and stroke.

RESULTS

During the 7-year follow-up period, a total of 699 participants (9.20%) were newly diagnosed with CMM. Kaplan-Meier curves revealed that the subgroup with both AO and high levels of non-traditional lipid parameters had the highest cumulative hazard for developing CMM. In the fully adjusted model, Cox regression analysis revealed that participants with both high levels of non-traditional lipid parameters and AO exhibited the highest risk of developing CMM. Subgroup and sensitivity analyses further confirmed the robustness of these findings, showing consistent results across different demographic groups and under various analytical conditions. Furthermore, AO was found to significantly mediated the associations between non-traditional lipid parameters and the risk of developing CMM.

CONCLUSION

The separate and combined effects of AO and non-traditional lipid parameters were significantly associated with the risk of developing CMM. Notably, AO may induce CMM by partially mediating the effects of serum lipids in human metabolism. The findings highlighted the importance of joint evaluation of AO and non-traditional lipid parameters for primary prevention of CMM.

Disproportionately raised risk of adverse outcomes in patients with COPD and comorbid type 2 diabetes or depression: Swedish register-based cohort study

BACKGROUND

We aimed to examine if patients with COPD and comorbid type 2 diabetes, or COPD with comorbid depression or anxiety, had disproportionally raised excess risks of subsequent cardiovascular disease and mortality.

METHODS

This general population-based cohort study used data from Swedish national registers, with follow-up during 2005-2018. Cox regression estimated risks of cardiovascular disease or mortality, producing hazard ratios (HR) with (95% confidence intervals). Interaction testing quantified disproportionally increased excess risks.

RESULTS

Among 5,624,306 individuals, 332,549 had a COPD diagnosis. Compared with individuals who did not have COPD or type 2 diabetes, all-cause mortality risk was higher for individuals who had either COPD or type 2 diabetes, with HR 2.68 (2.66-2.69) and 1.70 (1.69-1.71), respectively. Having both conditions produced an HR of 3.72 (3.68-3.76). Among cardiovascular outcomes, the highest risks were found for chronic heart failure: COPD only, HR 2.87 (2.84-2.90); type 2 diabetes only, 1.86 (1.84-1.88); and both, 4.55 (4.46-4.64). Having both COPD and type 2 diabetes was associated with disproportionally higher excess risks than expected from the sum of the individual diseases, except for cerebrovascular disease or ischemic heart disease. For COPD and depression/anxiety, all-cause mortality risk was associated with COPD only, HR 2.74 (2.72-2.76); depression/anxiety only, 2.39 (2.38-2.40); and both 4.72 (4.68-4.75). Chronic heart failure was associated with COPD only, HR 2.74 (2.71-2.78); depression/anxiety only, 1.31 (1.30-1.32); and both, 3.45 (3.40-3.50). This disease combination was associated with disproportionally higher excess risks than expected, except for atrial fibrillation.

CONCLUSIONS

Type 2 diabetes or depression/anxiety in COPD patients were associated with disproportionally excess risks for cardiovascular disease and mortality. It is important for clinicians to be aware of these greater than expected risks, to prevent further cardiovascular morbidity and mortality.

Health conditions in adults with atrial fibrillation compared with the general population: a population-based cross-sectional analysis

BACKGROUND

Atrial fibrillation (AF) prevalence is rising due to population ageing and comorbidity is an increasing problem. The aim of this study was to examine the prevalence and association of coexisting health conditions among adults with AF in the general population.

METHODS

Cross-sectional analysis of Clinical Practice Research Datalink (CPRD) primary care electronic medical records in England linked to hospital admissions as of 30 November 2015. CPRD is broadly representative of the UK general population in terms of age, sex and ethnicity. We estimated prevalence and used logistic regression examining risk factors of age, sex and socioeconomic status (SES) to compare prevalence of 252 physical and mental health conditions and 23 higher level health condition groups in adults with AF compared with adults without AF.

RESULTS

34 338 adults with AF (57% male; 83% ≥65 years) and 907 739 without AF (49% male; 23% ≥65 years) were identified. Adjusted for age and sex, adults with AF were significantly more likely to have 20/23 (87%) health condition groups than adults without AF. The most prevalent health condition groups in adults with AF were cardiovascular (prevalence of 89% in adults with AF vs 26% in adults without AF, adjusted OR (aOR) 5.82, 95% CI 5.60 to 6.05), gastrointestinal (62% vs 37%, aOR 1.34, 95% CI 1.31 to 1.38) and orthopaedic (58% vs 24%, aOR 1.32, 95% CI 1.29 to 1.35). 151/252 individual conditions were significantly more common in adults with AF including cardiovascular conditions such as cardiomyopathy (4.5% vs 0.3%, aOR 9.58, 95% CI 8.88 to 10.35) and heart failure (18% vs 0.7%, aOR 9.07, 95% CI 8.70 to 9.46), and non-cardiovascular conditions such as pleural effusion (16% vs 1.8%, aOR 3.55, 95% CI 3.42 to 3.67) and oesophageal malignancy (0.3% vs 0.0%, aOR 2.14, 95% CI 1.69 to 2.70). Associations were similar after SES adjustment.

CONCLUSIONS

While cardiovascular conditions are highly prevalent and strongly associated with AF, a wide spectrum of non-cardiovascular conditions were also strongly associated, requiring a greater understanding of managing comorbid conditions with management principles contradictory to AF.

Frailty as a Prognostic Indicator for In-Hospital Mortality and Clinical Outcomes in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Frailty is a significant predictor of adverse outcomes in patients with acute coronary syndrome (ACS). However, its impact on short-term clinical outcomes remains unclear. We conducted a systematic review and meta-analysis to investigate the associations between frailty and adverse clinical outcomes in patients with ACS.

METHODS

We systematically searched the Embase, MEDLINE, and CENTRAL databases from inception to 1 August 2023 for observational cohort studies, cross-sectional studies, or clinical trials involving hospitalised adults with ACS. Studies utilising validated frailty screening tools and examining the associations between frailty and clinical endpoints, such as in-hospital mortality, length of hospital stay, major bleeding, and stroke, were included. The meta-analysis was performed via random effects models and meta-regression analyses.

RESULTS

Among the 4,458 records identified, 42 were deemed eligible, and data from 14 studies were included in the analysis. Frailty was significantly associated with increased in-hospital all-cause mortality (relative risk [RR] 2.89; 95% confidence interval [CI] 2.49-3.34) and prolonged length of hospitalisation (standardised mean difference [SMD] 2.01; 95% CI 1.48-2.46), with frail patients with ACS spending an average of 3.5 more days in the hospital. Furthermore, frail patients with ACS presented a significantly greater risk of adverse outcomes than non-frail patients with ACS did (RR 1.86; 95% CI 1. 41-2.46). Subgroup analysis revealed a significant increase in major bleeding events (RR 2.03; 95% CI 1.51-2.73) among frail patients with ACS, whereas the incidence of stroke showed a nonsignificant trend towards elevation (RR 1.23; 95% CI 0.56-2.72).

CONCLUSIONS

Frailty is strongly associated with in-hospital all-cause mortality, prolonged length of hospitalisation, and adverse clinical outcomes such as major bleeding in patients with ACS.

Comprehensive care processes for substance use disorders in adult mental health services: A systematic review

BACKGROUND AND OBJECTIVES

Assessment and care of substance use disorder within mental health services are essential due to the high prevalence and harms associated with comorbidity. Substance use disorder assessment and care are routinely recommended in clinical guidelines; however, processes are not agreed. This systematic review of routine clinical practice in relation to substance use disorders in adult mental health service aims to identify routine assessment and diagnosis processes, the proportion of patients and service episodes in which they occur and their outputs.

METHODS

We searched MEDLINE, PsycINFO, Embase and relevant Cochrane databases for articles until July 2024 reporting on substance use assessment, diagnosis or treatment in adults receiving routine mental health service and locating additional articles by snowballing. Variables including setting, study method, period, cohort, substances, clinical assessment type, diagnosis and care pathways were compared.

RESULTS

In 137 heterogeneous studies reporting routine practice within a wide variety of adult mental health service from 29 nations, 44 (32%) expected or reported on substance use assessment in domains of pattern or impact. However, 23 studies (17%) reported structured approaches to substance use disorder assessment, while 67 (49%) reported a diagnostic structure, including classification system. Diagnostic prevalence varied markedly. Treatment was reported in 16 studies (12%) and no substance use disorder outcomes were reported.

CONCLUSION

This systematic review shows marked variation in routine practice in mental health service across a range of substance use disorder assessment and diagnosis processes. To better identify substance use disorder, enhance its care and reduce associated morbidity, adult mental health service may benefit from standardising expectations and systematically monitoring the performance of substance use assessment and diagnosis.

Managing medication in very old age: A qualitative study among Faroese nonagenarians

BACKGROUND

Currently, people generally live longer, and consequently, the number of older people experiencing periods of multimorbidity and the need for medication will increase. Managing multiple medications can be a complex and challenging task, especially for older people who may experience a decline in their cognitive and physical abilities. The aim of this study was to gather knowledge on how home-dwelling people who are 90 years or older manage their daily medication, what strategies they use, and what challenges they experience regarding medication. This knowledge is necessary for providing support and care for the oldest old regarding their medication management in daily living.

METHOD

Semi-structured interviews were conducted with 10 men and women aged 91-97 years who were part of the Faroese Nonagenarian Study conducted in 2021. The analysis was conducted by using thematic analysis as suggested by Braun and Clarke.

RESULTS

We identified three important themes for understanding how the oldest-old citizens manage medication and the challenges and worries that they sometimes experience. These themes were managing medication in daily living, challenges regarding medication management, and worries among the participating older people and their relatives. The majority of the participants received automated dose dispensing (ADD) services, which they considered a great help. In addition, they developed personal strategies to manage their medication. However, the changing colour and shape of tablets caused concern among the participants, and concern about side effects were not always taken seriously by their general practitioners.

CONCLUSION

In addition to personal strategies, ADD services helped the participants manage medications in daily living. However, user involvement and regular counselling with their doctors appeared to be insufficient and, in some cases, absent. This study points to the necessity of strengthening user involvement by providing sufficient and regular counselling about medication between healthcare providers and people of very old age.

Health inequalities in incidence of bacteraemias: a national surveillance and data linkage study, England, 2018 to 2022

BackgroundHealth inequalities exist globally, but limited data exist on this topic for bacteraemia.AimIn this study we investigated health inequalities surrounding bacteraemia in England, to identify high-risk population groups and areas of intervention.MethodsWe retrospectively analysed English surveillance data between 2018 and 2022 for Escherichia coli, Klebsiella species, Pseudomonas aeruginosa, and both meticillin-sensitive and resistant Staphylococcus aureus (MSSA, MRSA) bacteraemia. Crude incidence rates stratified by index of multiple deprivation and ethnic groups were calculated; age-adjusted rate ratios were estimated using negative binomial regression models.ResultsWe identified 342,787 bacteraemia cases. Across all pathogens, as the level of deprivation rose, so did the age-adjusted bacteraemia incidence rate ratio. Compared with residents of the 20% least deprived areas of England, residents of the 20% most deprived areas had a 2.68-fold increased bacteraemia rate for MRSA (95% CI: 2.29-3.13) and 1.95-fold for E. coli (95% CI: 1.84-2.05), and 15% higher odds of dying within 30 days of any bacteraemia (95% CI: 1.13-1.19). After age adjustment, the incidence of all bacteraemia was higher in the Asian and Black groups compared with the White group: for MRSA, 79% higher in the Asian (95% CI: 1.51-2.10) and 59% higher in the Black (95% CI: 1.29-1.95) groups. The exception was MSSA, whose incidence was highest in the White group.ConclusionDisproportionately higher age-adjusted incidence of bacteraemia occurred in deprived areas and ethnic minorities. These disparities are likely multifactorial, possibly including socioeconomic, cultural, and systemic risk factors and different burden of comorbidities. Better understanding these factors can enable targeted interventions.

Impact of Multimorbidity on Mortality in Heart Failure With Mildly Reduced and Preserved Ejection Fraction

BACKGROUND

How different combinations of comorbidities influence risk at the patient level and population level in patients with heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction is unknown. We aimed to investigate the prevalence of different combinations of cardiovascular and noncardiovascular comorbidities (ie, multimorbidity) and associated risk of death at the patient level and population level.

METHODS

Using patient-level data from the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) and PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction), we investigated the 5 most common cardiovascular and noncardiovascular comorbidities and the resultant 45 comorbidity pairs. Cox proportional hazard models were used to calculate the population-attributable fractions for all-cause mortality and the relative excess risk due to interaction for each comorbidity pair.

RESULTS

Among 6504 participants, 95.2% had at least 2 of the 10 most prevalent comorbidities. The comorbidity pair with the greatest patient-level risk was stroke and peripheral artery disease (adjusted hazard ratio, 1.88 [95% CI, 1.27-2.79]), followed by peripheral artery disease and chronic obstructive pulmonary disease (1.81 [95% CI, 1.31-2.51]), and coronary artery disease and stroke (1.67 [95% CI, 1.33-2.11]). The pair with the highest population-level risk was hypertension and chronic kidney disease (CKD; adjusted population-attributable fraction, 14.8% [95% CI, 9.2%-19.9%]), followed by diabetes and CKD (13.3% [95% CI, 10.6%-16.0%]), and hypertension and diabetes (11.9% [95% CI, 7.1%-16.5%). A synergistic interaction (more than additive risk) was found for the comorbidity pairs of stroke and coronary artery disease (relative excess risk due to interaction, 0.61 [95% CI, 0.13-1.09]), diabetes and CKD (relative excess risk due to interaction, 0.46 [95% CI, -0.15 to 0.77]), and obesity and CKD (relative excess risk due to interaction, 0.24 [95% CI, 0.01-0.46]).

CONCLUSIONS

The risk associated with comorbidity pairs differs at the patient and population levels in heart failure with mildly reduced ejection fraction/heart failure with preserved ejection fraction. At the population level, hypertension, CKD, and diabetes account for the greatest risk, whereas at the patient level, polyvascular disease and chronic obstructive pulmonary disease are the most important.

Multimorbidity Patterns and Rheumatoid Arthritis Disease Outcomes: Findings From a Multicenter, Prospective Cohort

OBJECTIVE

To determine whether unique multimorbidity patterns are associated with long-term rheumatoid arthritis (RA) disease severity.

METHODS

We conducted a cohort study within the Veterans Affairs Rheumatoid Arthritis registry. We applied previously derived multimorbidity patterns based on the presence of diagnostic codes for relevant conditions prior to enrollment using linked administrative data. Disease activity and functional status were assessed longitudinally up to 5 years after enrollment. The association of multimorbidity patterns with disease activity and functional status were assessed using generalized estimating equations models adjusting for relevant confounders.

RESULTS

We studied 2,956 participants, of which 88.2% were male, 76.9% reported white race, and 79.3% had a smoking history. Mental health and substance abuse (β 0.12 [95% confidence interval {CI} 0.00, 0.23]), cardiovascular (β 0.25 [95% CI 0.12, 0.38]), and chronic pain (β 0.21 [95% CI 0.11, 0.31]) multimorbidity were associated with higher Disease Activity Score in 28 joints (DAS28) scores. Mental health and substance abuse (β 0.09 [0.03, 0.15]), cardiovascular (β 0.11 [95% CI 0.04, 0.17]), and chronic pain multimorbidity (β 0.15 [95% CI 0.10, 0.20]) were also associated with higher Multidimensional Health Assessment Questionnaire (MDHAQ) scores. The metabolic pattern of multimorbidity was not associated with DAS28 or MDHAQ. The number of multimorbidity patterns present was highly associated with DAS28 and MDHAQ (P trend < 0.001), and patients with all four multimorbidity patterns had the highest DAS28 (β 0.59 [95% CI 0.36, 0.83]) and MDHAQ (β 0.27 [95% CI 0.16, 0.39]) scores.

CONCLUSION

Mental health and substance abuse, chronic pain, and cardiovascular multimorbidity patterns are associated with increased RA disease activity and poorer functional status. Identifying and addressing these multimorbidity patterns may facilitate achieving RA treatment targets.

Digital Medicine Tools and the Work of Being a Patient: A Qualitative Investigation of Digital Treatment Burden in Patients With Diabetes

Objective

To understand the contribution of digital medicine tools (eg, continuous glucose monitoring systems, scheduling, and messaging applications) to treatment burden in patients with diabetes.

Patients and Methods

Between October and November 2023, we invited patients with type 1 or type 2 diabetes to participate in semistructured interviews. The interviewees completed the Treatment Burden Questionnaire as they reflected on how digital medicine tools affect their daily routines. A published taxonomy of treatment burden guided the qualitative content analysis of interview transcripts.

Results

In total, 20 patients agreed to participate and completed interviews (aged 21-77 years, 55% female, 60% living with type 2 diabetes). We found 5 categories of tasks related to the use of digital medicine tools that patients had to complete (eg, calibrating continuous glucose monitors), 3 factors that made these tasks burdensome (eg, cost of device replacements), and 2 categories of consequences of burdensome tasks on patient wellbeing (eg, fatigue from device alarms).

Conclusion

Patients identified how digital medicine tools contribute to their treatment burden. The resulting digital burden taxonomy can be used to inform the design, implementation, and prescription of digital medicine tools including support for patients as they normalize them in their lives.

amVAE: Age-aware multimorbidity clustering using variational autoencoders

Multimorbidity, the co-occurrence of multiple chronic conditions within the same individual, is increasing globally. This is a challenge for the single patients, as these individuals are subject to a heavy disease and treatment burden, yet evidence on the epidemiology and consequences of multimorbidity remains underexplored. Historically, studies aiming to understand multimorbidity patterns predominantly utilized cross-sectional data, neglecting the essential temporal dynamics which shape multimorbidity progression. Other studies based their analyses on small datasets, or populations only targeting certain sectors of the healthcare system. In this study, we (1) introduce a novel two-step multimodal Variational Autoencoder-based approach for temporal disease-based clustering (i.e. discovering age-aware multimorbidity clusters); (2) provide quantitative experiments for the robustness of our approach and the extracted temporal clusters; and (3) demonstrate how the temporal disease clusters obtained from our model can provide novel understanding of the development of multiple conditions over time and thus generate new hypotheses for different stages of multimorbidity and their associations. We trained and evaluated our models on a dataset containing the entire adult population of Denmark in the period 1995-2015, focusing on individuals suffering from chronic heart disease, including 766,596 individuals.

The association between total social exposure and incident multimorbidity: A population-based cohort study

Background

Multimorbidity, the co-occurrence of two or more chronic conditions, is associated with the social determinants of health. Using comprehensive linked population-representative data, we sought to understand the combined effect of multiple social determinants on multimorbidity incidence in Ontario, Canada.

Methods

Ontario respondents aged 20-55 in 2001-2011 cycles of the Canadian Community Health Survey were linked to administrative health data ascertain multimorbidity status until 2022. Additive total social exposure (TSE) was generated by summing 12 measures of social disadvantage captured from the survey. Weighted-additive TSE included 15 measures of social disadvantage summed across 5 equally weighted domains. Hazard ratios for the association between each TSE measure and multimorbidity were estimated using competing risk Cox-proportional hazards models. All analyses were sex-stratified.

Results

Both additive and weighted-additive TSE were associated with an increased risk of multimorbidity among females and males. A social gradient was observed for multimorbidity risk in all models. While adjusted models were attenuated, an increased risk of multimorbidity was observed among those experiencing the most social disadvantage, compared to those with the least social disadvantage in additive (HR Females = 2.16; 95%CI = 1.63, 2.86; HR Males = 1.90; 95%CI = 1.52, 2.38) and weighted-additive (HR Females = 1.94; 95%CI = 1.49, 2.53; HR Males = 1.72; 95%CI = 1.41, 2.10) models. The observed social gradient was retained.

Conclusions

These findings demonstrate the importance of considering the cumulative effects of multiple social determinants of health on multimorbidity.

A systematic analysis of the contribution of genetics to multimorbidity and comparisons with primary care data

BACKGROUND

Multimorbidity, the presence of two or more conditions in one person, is common but studies are often limited to observational data and single datasets. We address this gap by integrating large-scale primary-care and genetic data from multiple studies to interrogate multimorbidity patterns and producing digital resources to support future research.

METHODS

We defined chronic, common, and heritable conditions in individuals aged ≥65 years, using two large primary-care databases [CPRD (UK) N = 2,425,014 and SIDIAP (Spain) N = 1,053,640], and estimated heritability using the same definitions in UK Biobank (N = 451,197). We used logistic regression to estimate the co-occurrence of pairs of conditions in the primary care data. Linkage disequilibrium score regression was used to estimate genetic similarity between pairs of conditions. Meta-analyses were conducted across databases, and up to three sources of genetic data, for each pair of conditions. We classified pairs of conditions as across or within-domain based on the international classification of disease.

FINDINGS

We identified 72 chronic conditions, with 43.6% of 2546 pairs showing higher co-occurrence than chance in primary care and evidence of shared genetics. Many across-domain pairs exhibited substantial shared genetics (e.g., iron deficiency anaemia and peripheral arterial disease: genetic correlation Rg = 0.45 [95% Confidence Intervals 0.27:0.64]). 33 pairs displayed negative genetic correlations, such as skin cancer and rheumatoid arthritis (Rg = -0.14 [-0.21:-0.06]), due to potential adverse drug effects. Discordance between genetic and primary care data was also observed, e.g., abdominal aortic aneurysm and bladder cancer co-occurred in primary care but were not genetically correlated (Odds-Ratio = 2.23 [2.09:2.37], Rg = 0.04 [-0.20:0.28]) and schizophrenia and fibromyalgia were less likely to co-occur together in primary care but were positively genetically correlated (OR = 0.84 [0.75:0.94], Rg = 0.20 [0.11:0.29]).

INTERPRETATION

Most pairs of chronic conditions show evidence of shared genetics, and co-occurrence in primary care, suggesting shared mechanisms. The identified patterns of shared genetics, negative correlations and discordance between genetic and observational data provide a foundation for future multimorbidity research.

FUNDING

UK Medical Research Council [MR/W014548/1].

Physical frailty, genetic predisposition, and type 2 diabetes mellitus

AIM

To examine the association between frailty and incident type 2 diabetes mellitus (T2DM), considering the joint effect of multimorbidity and genetic risk.

METHODS

The study included 429,022 individuals in the UK Biobank. We used Cox regression with hazard ratio (HR) and 95 % confidence interval (CI) to 1) evaluate the associations of frailty with incident T2DM, 2) explore whether frailty and multimorbidity would have a joint effect, and 3) assess whether the associations were modified by genetic risk.

RESULTS

Compared with non-frail individuals, prefrail and frail individuals were at higher risk of T2DM: HR[95 %CI] = 1.42 [1.38;1.47] for prefrailty and 1.81[1.70;1.92] for frailty. Five frailty components were associated with increased risk of T2DM: HR[95 %CI] = 1.21[1.17;1.26] for weight loss, 1.35[1.30;1.40] for exhaustion, 1.31[1.26;1.37] for low physical activity, 1.27[1.20;1.33] for low grip strength, and 1.47[1.41;1.52] for slow gait speed. The increased risks were more pronounced among frail individuals with more than three morbidities: HR[95 %CI] = 4.10[3.76;4.46]. Frail individuals at high genetic risk had a four and a half-fold greater risk of T2DM compared with non-frail individuals at low genetic risk: HR[95 %CI] = 4.54[4.14;4.97].

CONCLUSION

Frailty was associated with increased risk of T2DM, especially in individuals with higher number of morbidities and high genetic risk. Frailty may be an independent risk factor for T2DM and targeted strategies to prevent and manage frailty would contribute to reducing the risk of T2DM.

Approaches to characterising multimorbidity in older people accessing hospital care: a scoping review

PURPOSE

An increasing proportion of older adults accessing hospital care are living with multimorbidity, with a high degree of complexity of multimorbidity in older hospital populations expected. We aimed to assess approaches taken to characterise multimorbidity in older adults accessing hospital care, including how complexity is considered.

METHODS

Following established scoping review guidelines, all published studies that characterised multimorbidity in a hospital population, with average age ≥ 65 years, were identified via a prespecified search strategy. Six electronic databases were searched to identify peer-reviewed literature published to September 2023 meeting eligibility criteria. Screening was undertaken by two independent reviewers, and data extracted using a standard proforma.

RESULTS

Of 5305 titles and abstracts screened, 75 papers, reporting on 72 unique study populations across 24 countries, met inclusion criteria. There was heterogeneity in most aspects of characterisation. Multimorbidity was defined in 43% (n = 31/72) of studies; most (n = 59/72, 82%) aimed to describe a multimorbidity-outcome association. Number of conditions considered ranged from 2 to 285 and weighted indices were used as a measure of multimorbidity in 75% (n = 54/72) of studies, with 56% (n = 40/72) using a version of the Charlson Comorbidity Index. Complexity was explicitly studied in 17% (n = 12/72) of studies.

DISCUSSION

Our review highlights heterogeneity in characterisation of multimorbidity in older adults accessing hospital care, with limited consideration of complexity. As the proportion of older adults accessing hospital care who are living with multimorbidity increases, better characterisation of their multiple conditions and associated complexity is a priority to ensure delivery of appropriately tailored care.

Quadratic associations between sleep and multimorbidity among the older population in China: Evidence from CLHLS 2011 to 2018

OBJECTIVES

To investigate the relationship between sleep and multimorbidity, including the associations between sleep duration and multimorbidity, as well as between sleep quality and multimorbidity.

METHODS

Using data from the three latest waves of the Chinese Longitudinal Health Longevity Study (2011, 2014, and 2018), a binary panel regression was conducted to investigate the quadratic relationship between sleep duration and multimorbidity. Subsequently, quadratic fitting and robustness analysis were further utilized to strengthen the verification of this relationship.

RESULTS

From 2011 to 2018, the prevalence of multimorbidity increased, with average rates of 0.309, 0.345, and 0.367, respectively. Meanwhile, sleep duration was 7.45, 7.34, and 7.39, but sleep quality showed a declining trend with scores of 3.70, 3.63, and 3.47, respectively. Furthermore, the regression analysis revealed that the odds ratios (OR) for the relationship between sleep duration and multimorbidity, and between the square of sleep duration and multimorbidity were 0.734, with 95 % CI = [0.6272, 0.8582] and 1.016, with 95 % CI = [1.0058, 1.0262], respectively. From the quadratic relationship, it is evident that the multimorbidity among older Chinese adults initially decreases and then increases with long sleep durations.

CONCLUSIONS

The multimorbidity was significantly different among individuals with different sleep duration. A U-shaped relationship was observed between sleep duration and multimorbidity, whereby both short and excessive sleep durations were associated with higher rates of multimorbidity. Additionally, a negative association was found between sleep quality and multimorbidity, indicating that higher sleep quality was linked to lower rates of multimorbidity.

Analysis and Distribution of Emergency Cases at One of Mexico's Largest Hospitals and Trauma Centers

Objective This study aims to identify the most common emergencies among the population in the metropolitan area of Monterrey, Mexico - one of the largest cities in the country - and compare these emergencies and their characteristics with those in other countries and geographical regions. Methods This cross-sectional study included all patients (n = 14,744) treated in the emergency department of Hospital Universitario Dr. José Eleuterio González between September and December 2023. The analysis encompassed all patients registered in the triage census by nurses, excluding those with incomplete records. Since all patients with sufficient data were included, sample size calculation was not required. Statistical analyses included the chi-square test and logistic regression for categorical variables. Results A total of 14,744 emergency department patients were reviewed. Among them, 54.7% were women, with a mean age of 39.07 years (±19.62). Of the total, 92% were from the Monterrey metropolitan area. Traumatic emergencies accounted for 27.5%, with limb injuries being the most common (10.5%). Nontraumatic emergencies made up 72.5%, with abdominal/pelvic pain being the most frequent complaint (13%). The internal medicine department received the highest number of patients (36.1%). The busiest day was Saturday (15.2%), with peak hours at 1:00 p.m. (5.8%). Conclusions The majority of patients were women aged 21-30 years from the metropolitan area, primarily presenting with nontraumatic conditions such as abdominal pain. The highest patient influx occurred on Saturdays at 1:00 p.m., with most cases managed by the internal medicine department. These findings may help authorities and clinicians optimize emergency care resources by anticipating the most common emergencies and peak demand times.

Chronic pain in multiple sites is associated with depressive symptoms in US adults: A cross-sectional study

BACKGROUND

Chronic pain poses a significant public health challenge, yet its manifestation in multiple body areas remains insufficiently studied. This study seeks to explore the relationship between chronic pain affecting multiple sites and depression.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (NHANES) from 2009 to 2010 regarding chronic pain and depression, employing weighted univariate and multivariate logistic regression analyses to explore the relationship between the number of body sites impacted by chronic pain and depression rates. Furthermore, subgroup analyses were performed to identify possible confounding factors that could affect this relationship.

RESULTS

There is a correlation between chronic pain and higher risk of depression (OR 3.821, 95% CI 3.138-4.646, P < 0.001). The multivariable-adjusted observational study indicates that, compared to individuals without chronic pain, the risk of depression is significantly associated with an increasing number of body sites affected by chronic pain. Specifically, when a person experiences chronic pain in five different areas, the risk of depression peaks (OR 16.050, 95% CI 8.723-29.905, P < 0.001).

CONCLUSION

The findings of this study indicate a significant correlation between chronic pain in multiple sites and depressive symptoms.

Association between Multimorbidity and End-of-Life Outcomes among Middle-Aged and Older Adults: Evidence from 28 Countries

OBJECTIVES

Multimorbidity poses significant challenges to the well-being of middle-aged and older adults, but its impact on end-of-life experiences remains relatively underexplored and inconsistent. This study aims to investigate the association between the number of chronic conditions and 6 end-of-life outcomes across 28 countries.

DESIGN

Longitudinal analyses.

SETTING AND PARTICIPANTS

Data were drawn from 6625 participants in the Survey of Health, Ageing, and Retirement in Europe (SHARE).

METHODS

Information on 12 chronic non-communicable conditions was self-reported by participants in core interviews and categorized into 4 groups: 0, 1, 2, and ≥3 chronic conditions. Six end-of-life outcomes were reported by proxy respondents during end-of-life interviews after participants' deaths. These outcomes included the place of death, duration of hospital stays in the last year of life, hospice or palliative care utilization, and symptoms such as pain, breathlessness, and anxiety or sadness in the last month of life. Mixed-effects logistic regression models were conducted to examine the association between the number of chronic conditions and end-of-life outcomes.

RESULTS

Among the included participants, having 3 or more chronic conditions was positively associated with dying in a hospital [odds ratio (OR), 1.31; 95% CI, 1.15-1.49)], staying in hospitals for 3 months or more during the last year of life (OR, 1.36; 95% CI, 1.04-1.78), and experiencing symptoms such as pain (OR, 1.67; 95% CI, 1.34-2.08), breathlessness (OR, 1.32; 95% CI, 1.08-1.60), and anxiety or sadness (OR, 1.43; 95% CI, 1.12-1.83) in the last month of life after adjusting for covariates. In addition, each additional chronic condition was associated with 6% to 12% increases in the odds of these end-of-life outcomes, except for hospice or palliative care utilization.

CONCLUSIONS AND IMPLICATIONS

Our findings underscore the significant impact of multimorbidity on end-of-life experiences and highlight the importance of coordinated care strategies to address the complex needs of patients with multimorbidity and alleviate their symptom burden.

Burden, trends, and predictions of low physical activity-related diseases in China: analysis from the Global Burden of Disease Study, 1990-2021, with projections to 2035

Objective

To evaluate the burden of disease related to low physical activity in China, examine its trends over time, and predict future trends up to 2035 to inform preventive actions.

Methods

Using Global Burden of Disease Study 2021 (GBD2021) data, we analyzed the burden of disease associated with low physical activity, employing Deaths and Disability-Adjusted Life Years (DALYs) as indicators. Trends from 1990 to 2021 were examined using the Estimated Annual Percentage Change (EAPC) method, and future projections were made using the BAPC model.

Results

The number of deaths attributable to low physical activity rose from 48,882 in 1990 to 148,152 in 2021, with the age-standardized death rate decreasing slightly from 8.39 to 8.18 per 100,000 (EAPC = 0.07). DALYs increased from 1,246,888 to 3,254,644, while the age-standardized DALYs rate fell from 168.93 to 162.52 per 100,000 (EAPC = -0.08). The DALY rate for diabetes increased from 30.12 to 36.54 per 100,000 (EAPC = 0.42); ischemic heart disease death rate rose from 2.86 to 3.52 per 100,000 (EAPC = 1.12), and the DALY rate increased from 40.72 to 46.05 per 100,000 (EAPC = 0.8). The highest death and DALY rates were observed in individuals over 95 years old. Females had higher death and DALY rates than males, with a death rate of 8.29 per 100,000 and a DALY rate of 197.98 in 2021. The BAPC model predicts that by 2035, deaths will reach 161,280 and DALYs will reach 3,523,135.

Conclusion

From 1990 to 2021, the age-standardized death and DALY rates associated with low physical activity in China declined, yet the absolute number of deaths and DALYs increased due to population growth and aging. Special attention is needed for diabetes and ischemic heart disease, as their burdens have significantly risen. Although females are more affected by low physical activity than males, the increase in the burden among males has been more pronounced in recent years. The impact of low physical activity intensifies with age, particularly among the older adult. Thus, targeted strategies are essential to mitigate the burden of low physical activity in China.

Multifactorial Prediction of the Risk of Hospital Mortality in Patients With Acute Coronary Syndrome

Aim      To identify predictors for the risk of in-hospital death and to develop a prognostic scale for individual risk of death in patients with acute coronary syndrome (ACS) at the hospital stage of treatment.Material and methods  A sequential retrospective analysis was conducted, including 225 patients with ACS (n=101, main group of patients who died in hospital; n=124, control group) hospitalized in the Regional Vascular Center #2 of the Semashko Nizhny Novgorod Regional Clinical Hospital from January, 2021 through July, 2022. Clinical, demographic, laboratory and instrumental characteristics of patients were studied. Statistical analysis was performed using the Statistica version 10.0 and MedCalc version 20.0 software. The cutoff threshold for quantitative variables was determined by ROC analysis. Potential outcome predictors were identified by a univariate logical regression analysis followed by the construction of a multivariate model for predicting in-hospital mortality using the stepwise analysis with backward inclusion. The prognostic degree of a predictor was expressed as an odds ratio (OR) with a 95% confidence interval (CI). Differences were considered statistically significant at p<0.05. For each variable of the multivariate regression model, an individual score was calculated using a linear transformation of the beta coefficients of each variable.Results Seven independent predictors of hospital death were identified in patients with ACS: Killip class II or higher acute heart failure (AHF) (OR 5.96; 95% CI 1.82-19.48; p=0.0031), low hemoglobin ≤127 g/l (OR 3.75; 95% CI 1.39-10.07; p=0.0087), elevated blood glucose on admission ≥9.7 mmol/l (OR 4.86; 95% CI 1.55-15.21; p=0.0065), high body mass index (BMI) ≥32 kg/m2 (OR 7.18; 95% CI 2.65-19.42; p=0.0001), high pulmonary artery systolic pressure (PASP) ≥38 mmHg (OR 3.95; 95% CI 1.48-10.51; p=0.0059), reduced left ventricular ejection fraction (LVEF) according to Simpson (%) ≤42% (OR 5.80; 95% CI 2.15-15.68; p=0.0005), reduced glomerular filtration rate (GFR) according to CKD-EPI ≤55 ml/min (OR 5.75; 95% CI 2.16-15.28; p=0.0005). An individual score was calculated for each predictor. The total score of all predictors formed a scale that was ranged from score 0 to 43 with a cutoff threshold of 14, where a result >14 indicated a high probability of in-hospital death. This scale has a high prognostic potential with the sensitivity 93.07%, specificity 86.29%, and the area under the curve (AUC) 0.957.Conclusion      Based on the obtained multifactorial model that included 7 major predictors, a scale (scoring system) was developed for predicting the risk of death for ACS patients at the hospital stage of treatment. This scale allows fast identification of patients with a high risk of in-hospital death with a high prognostic accuracy in real clinical practice.

Prognostic factors influencing implant survival and marginal bone loss in patients with osteoporosis or osteopenia medication

Objectives

To evaluate the factors that influence the survival of dental implants and marginal bone loss (MBL) in patients taking osteoporosis or osteopenia medication.

Materials and Methods

This study included patients who underwent dental implant treatment after taking medication for osteoporosis or osteopenia. Electronic medical records were used to collect data of patient age, sex, age at osteoporosis or osteopenia diagnosis, types of medications, age at medication initiation, duration of medication before implant surgery, whether the medication was paused before surgery, paused duration of medication, implant survival status, and MBL before and after prosthetic treatment. Firth's logistic regression was used to analyze the relationships between each variable and implant survival as well as between MBL before and after prosthetic treatment.

Results

Of the 267 patients, 111 with 209 implants were included in the study. The mean observation period was 57.9 months. The survival rate was 92.8% at the patient level and 96.2% at the implant level. No significant associations were found between implant survival and any of the variables examined. MBL before prosthetic treatment was significantly associated with use of receptor activator of nuclear factor-κB ligand (RANKL) inhibitors (P=0.032) and bone formation stimulators (P=0.022). Comparing the concurrent and single use of bisphosphonates and RANKL inhibitors, only the use of RANKL inhibitors alone was significantly associated with MBL before prosthetic treatment (P=0.039). MBL after prosthetic treatment was significantly associated with injection method among the routes of drug administration (P=0.011).

Conclusion

The implant survival rate in patients undergoing medical treatment for osteoporosis or osteopenia was comparable to the general implant survival rate. MBL before prosthetic treatment was associated with type of anti-osteoporotic medication, whereas MBL after prosthetic treatment was correlated with drug administration route. Further studies with larger sample sizes are required.

How do people with multimorbidity prioritise healthcare when faced with tighter financial constraints? A national survey with a choice experiment component

BACKGROUND

People with multimorbidity (i.e., two or more chronic conditions) experience increased out-of-pocket healthcare costs and are vulnerable to cost-related non-adherence to recommended treatment. The aim of this study was to understand how people with multimorbidity prioritise different healthcare services when faced with tighter budget constraints and how they experience cost-related non-adherence.

METHODS

A national cross-sectional online survey incorporating a choice experiment was conducted. Participants were adults aged 40 years or over with at least one chronic condition, recruited in Ireland (December 2021 to March 2022). The survey included questions about real-life experiences of cost-related non-adherence and financial burden. The choice experiment element involved participants identifying how they would prioritise their real-world healthcare utilisation if their monthly personal healthcare budget was reduced by 25%.

RESULTS

Among the 962 participants, 64.9% (n = 624) had multimorbidity. Over one third (34.5%, n = 332) of participants reported cost-related non-adherence in the previous 12 months, which included not attending a healthcare appointment and/or not accessing medication. Similar findings on prioritisation were observed on the choice task. When presented with the hypothetical tighter budget constraint, participants reduced expenditure on 'other healthcare (hospital visits, specialist doctors, etc.)' by the greatest percentage (50.2%) and medicines by the lowest percentage (24.8%). Participants with multimorbidity tended to have a condition they prioritised over others. On average, they reduced expenditure for their top-priority condition by 71% less than would be expected if all conditions were valued equally, while they reduced expenditure for their least prioritised condition by 60% more than would be expected. Independence, symptom control and staying alive were rated as the most important influencing factors when making prioritisation decisions (median score = 5 out of 5).

CONCLUSION

When faced with tighter financial constraints, people with multimorbidity tended to have a condition they prioritised over others. Participants were also more likely to prioritise medicines over other aspects of healthcare. Researchers, policymakers and clinicians should take greater consideration of the different ways people respond to tighter financial constraints. This could involve reducing the payment barriers to accessing care or clinicians discussing healthcare costs and coverage with patients as part of cost-of-care conversations.

Multimorbidity characteristics in older adults and their associated factors in complex networks: a cross-sectional study

Background

Multimorbidity of chronic diseases has become an increasingly serious public health problem. However, the research on the current situation of multimorbidity in the older adults in Jiangsu, China is relatively lacking.

Methods

We surveyed a total of 229,926 inpatients aged above 60 and with two or more chronic diseases in the First Affiliated Hospital with Nanjing Medical University from January 1, 2015 to December 31, 2021. The Apriori algorithm was used to analyze the association rules of the multimorbidity patterns in old adults.

Results

The mean age of these patients was 72.0 ± 8.7 years, and the male-to-female ratio was 1: 1.53. These patients during the COVID-19 period (from 2020 to 2021) displayed younger, higher male rate, shorter median length of hospital stay, higher ≥6 multimorbidities rate and lower median cost than those not during the COVID-19 period (from 2015 to 2019). In all of these patients, the top 5 chronic diseases were "Hypertensive diseases (I10-I15)," "Other forms of heart disease (I30-I52)," "Diabetes mellitus (E10-E14)," "ischaemic heart diseases (I20-I25)" and "Cerebrovascular diseases (I60-I69)." The complex networks of multimorbidity showed that Hypertensive diseases had a higher probability of co-occurrence with multiple diseases in all these patients, followed by diabetes mellitus, other forms of heart disease, and ischaemic heart diseases (I20-I25).

Conclusion

In conclusion, the patterns of multimorbidity among the aged varied by COVID-19. Our results highlighted the importance of control of hypertensive diseases, diabetes, and heart disease in most periods. However, during the pandemic period, we should pay more attention to diseases that require urgent treatment, such as malignant tumors. For different periods, the spectrum of diseases we focus on should change accordingly.

The impact of family socioeconomic status on adolescent mental and physical health: the mediating role of parental involvement in youth sports

Introduction

The physical and mental health of adolescents is a crucial cornerstone for social development. Therefore, this study aimed to examine whether family socioeconomic status made a difference in Chinese teenage mental and physical health and to disentangle the mediating role of parental involvement in youth sports in the process in which family socioeconomic status influenced adolescent health.

Methods

A quantitative analysis used a sample of approximately 11,000 adolescents from Chinese middle schools. The research employed structural equation modelling (SEM) to explore the relationships among family socioeconomic status, parental involvement in youth sports, and adolescent mental and physical health.

Results

The findings indicated that both family socioeconomic status and parental involvement in youth sports significantly positively predict levels of adolescents' physical health and mental health. Further analysis revealed that parental involvement in youth sports mediated the relationship between family socioeconomic status and adolescent health.

Discussion

It is evident that parental involvement in youth sports plays a crucial role in adolescent mental and physical health. Regardless of family socioeconomic status, parents should actively engage in sports activities with their children, which is not only an important way to promote adolescents' health but also a manifestation of realizing health equity.

The Role of Nutrition and Other Lifestyle Patterns in Mortality Risk in Older Adults with Multimorbidity

Background: Limited research has examined how older adults' lifestyles intersect with multimorbidity to influence mortality risk. Methods: In this community-dwelling prospective cohort, the Sydney Memory and Ageing Study, principal component analysis was used to identify lifestyle patterns using baseline self-reported data on nutrition, lifestyle factors, and social engagement activities. Multimorbidity was defined by self-reported physician diagnoses. Multivariable logistic regression was used to estimate odds ratios (ORs) for multimorbidity cross-sectionally, and Cox proportional hazards models were used to assess hazard ratios (HRs) for mortality risk longitudinally. Results: Of 895 participants (mean age: 78.2 years; 56.3% female) with complete lifestyle data, 597 had multimorbidity. Two distinct lifestyle patterns emerged: (i) a nutrition pattern characterised by higher intakes of protein, fibre, iron, zinc, magnesium, potassium, and folate, and (ii) an exercise-sleep-social pattern marked by weekly physical activities like bowling, bicycling, sleep quality (low snoring/sleepiness), and high social engagement. Neither pattern was associated with multimorbidity cross-sectionally. Over a median 5.8-year follow-up (n = 869; 140 deaths), participants in the upper tertiles for combined lifestyle pattern scores had a 20% lower mortality risk than those in the lowest tertile [adjusted HR: 0.80 (95% CI: 0.65-0.97); p-trend = 0.02]. This association was stronger in participants with multimorbidity, with a 29% lower risk [0.71 (0.56-0.89); p-trend = 0.01], likely due to multimorbidity modifying the relationship between nutrition and mortality risk (p-interaction < 0.05). While multimorbidity did not modify the relationship between the exercise-sleep-social pattern and risk of mortality, it was consistently associated with a 19-20% lower risk (p-trend < 0.03), regardless of the multimorbidity status. Conclusions: Older adults with multimorbidity may particularly benefit from adopting healthy lifestyles focusing on nutrition, physical activity, sleep quality, and social engagement to reduce their mortality risk.

Frailty during polymyalgia rheumatica, giant cell arteritis and other inflammatory rheumatic diseases

Recent data suggest a pathophysiological role of aging and immunosenescence during polymyalgia rheumatica (PMR) and giant cell arteritis (GCA), by definition rheumatic disease of the elderly. During aging, there is a decline in major physiological functions (immune system, muscle, cognitive, endocrine, cardiovascular, respiratory and renal functions), which combined with multimorbidity, environmental factors and polypharmacy can lead to frailty. Frailty is a clinical syndrome and dynamic concept including a pre-frailty stage; it reflects a reduction in physiological reserve capacities which alters the mechanisms of adaptation to stress. It results in the inability of a vulnerable subject to return to baseline homoeostasis after minor stress, increasing the risk of hospitalization, loss of autonomy and death. To date, there are no consensual criteria for frailty and its assessment in clinical practice remains difficult, based either on physical criteria including weight loss, fatigue, reduction in muscular strength and walking, inactivity or on a multidimensional geriatric assessment. The impact on morbidity and mortality and quality of life, the possibility of detecting reversible stages of pre-frailty and of implementing preventive measures justify interest in rheumatology as the number of patients aged 65 years and older with inflammatory rheumatic diseases is increasing. If there are no specific recommendations for the management of frailty or pre-frailty, recommendations for exercises, physical activity and nutrition to limit sarcopenia and comorbidities can be applied. The association with multimorbidity and its additive effect reinforces the need for screening, prevention and specific management of comorbidities, particularly infections, osteoporosis, cardiovascular diseases, during chronic inflammatory rheumatic diseases, PMR and GCA.

Implementation of hospital-initiated complex interventions for adult people with multiple long-term conditions: a scoping review

BACKGROUND

The increasing prevalence of multiple long-term conditions (MLTC) presents significant challenges to healthcare delivery globally. Although interventions for long-term conditions have predominantly been designed and evaluated in primary care settings, there is a growing recognition of the need to address the management of MLTC within secondary care. This scoping review aims to comprehensively evaluate hospital-initiated complex interventions for people with MLTC.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL Plus and Cochrane Library to identify published studies from Jan 1, 2010, evaluating hospital-initiated interventions initiated for adults (aged ≥ 18 years) with MLTC (PROSPERO: CRD42024498448). Studies reporting patients with frailty only, one long-term condition or orthogeriatric studies that did not focus solely on people with MLTC were excluded. The primary outcome measures were the characteristics of these complex interventions measured as: (i) intervention components, (ii) stakeholders involved; and (iii) implementation strategies, reported according to a theoretical framework (Expert Recommendations for Implementing Change). Secondary outcome measures were clinical and cost implications of these complex interventions, feasibility and sustainability, defined according to the World Health Organisation implementation framework.

FINDINGS

This scoping review identified 70 studies (56,111 participants). Twelve intervention components were identified in 52 combinations; the most common were medication review and optimisation (n = 39), chronic disease management (n = 34) and providing detailed care plans (n = 23). Majority of studies included two or more interventions components (n = 49) delivered by multiple stakeholders (n = 38). Of eleven implementation strategies reported, training and educating stakeholders, establishing integrated wards or clinics and regular multidisciplinary team meetings were the most common. Majority of combinations of intervention groups were associated with improved clinical outcomes for patients with MLTC (n = 43/70, 61.4%), yet eight studies reported on costs. However, embedding training and education or integrated clinics in delivering these intervention groups were associated with improved clinical outcomes, irrespective of the number of healthcare professionals involved. Majority of studies were evaluated in single centre settings, with limited evaluation of broader implementation measures.

INTERPRETATION

Hospital-initiated complex interventions that involve multiple stakeholders may be feasible and appear to be clinically useful for people with MLTC. To strengthen impact and support wider scale-up across health systems, closing knowledge gaps around cost-implications and strategies to improve implementation of these complex interventions through training and education or integrated clinics will be crucial.

Multimorbidity patterns and influencing factors in older Chinese adults: a national population-based cross-sectional survey

Background

This study aims to develop specific multimorbidity relationships among the elderly and to explore the association of multidimensional factors with these relationships, thereby facilitating the formulation of personalised strategies for multimorbidity management.

Methods

Cluster analysis identified chronic conditions that tend to cluster together, and then association rule mining was used to investigate relationships within these identified clusters more closely. Stepwise logistic regression analysis was conducted to explore the relationship between influencing factors and different health statuses in older adults. The results of this study were presented by network graph visualisation.

Results

A total of 15 045 individuals were included in this study. The average age was 73.0 ± 6.8 years. The number of patients with multimorbidity was 7426 (49.4%). The most common binary disease combination was hypertension and depression. The four major multimorbidity clusters identified were the tumour-digestive disease cluster, the metabolic-circulatory disease cluster, the metal-psychological disease cluster, and the age-related degenerative disease cluster. Cluster analysis by sex and region revealed similar numbers and types of conditions in each cluster, with some variations. Gender and number of medications had a consistent effect across all disease clusters, while aging, body mass index (BMI), waist-to-hip ratio (WHR), cognitive impairment, plant-based foods, animal-based foods, highly processed foods and marital status had varying effects across different disease clusters.

Conclusions

Multimorbidity is highly prevalent in the older population. The impact of lifestyle varies between different clusters of multimorbidity, and there is a need to implement different strategies according to different clusters of multimorbidity rather than an integrated approach to multimorbidity management.

Association of early and late onset of chronic diseases with physical frailty among older Indian adults: study based on a population survey

BACKGROUND

There is a limited understanding of the age at onset of chronic diseases linked to an increased risk of physical frailty among older persons, despite the well-established link between chronic diseases and frailty. This study aimed to examine the prevalence of early- and late-onset chronic diseases and their association with physical frailty and its components in older adults in India.

METHODS

Data from the Longitudinal Aging Study in India (LASI), wave 1 (2017-2018), were used with a sample of 31,386 older adults aged 60 years and above, including 15,043 males and 16,343 females. Physical frailty was assessed by using an adapted version of the frailty phenotype developed by Fried et al.. The main explanatory variable was self-reported age at the onset of chronic diseases, and a cutoff of 50 years was considered to define the early and late onset of chronic disease. Multivariable logistic regression models were used to examine the association between early and late onset of chronic diseases and physical frailty and its components.

RESULTS

Overall, 30.65% of the sample population was physically frail, and frailty was much higher in the 80 years and aboveage group (54.23%). Compared to individuals without any morbidity, those with late onset of single morbidity (AOR: 1.22, CI: 1.09-1.36) and multimorbidity (AOR: 1.49, CI: 1.29-1.71) had higher odds of physical frailty. Similarly, multimorbidity was significantly associated with most components of physical frailty, with the exception of weight loss. Older adults with late-onset hypertension (AOR: 1.22, CI: 1.09-1.36), stroke (AOR: 1.75, CI: 1.35-2.27), and heart disease (AOR: 1.58, CI: 1.21-2.06) had higher odds of physical frailty than those without any morbidity. The odds of being physically frail were higher in those with early onset arthritis (AOR: 1.55, CI: 1.15-2.08) and late-onset of arthritis (AOR: 1.35, CI: 1.13-1.61) than in those without any morbidity. Additionally, the odds of physical frailty were higher among those with late-onset chronic diseases, particularly heart disease (AOR: 3.39, CI: 1.31-8.77) and psychiatric disease (AOR: 3.00, CI: 1.19-7.61), compared to individuals with early onset of these conditions.

CONCLUSIONS

This study found significant positive associations between early and late onset chronic diseases and physical frailty and its components among older Indians. These findings underscore the importance of managing late-onset chronic diseases, especially heart diseases and psychiatric conditions, to mitigate frailty in older adults. These findings also emphasize the critical role of age at onset of specific chronic conditions and multimorbidity in the development of frailty, suggesting that targeted disease-specific interventions could help delay or prevent frailty.

Adherence to a healthy dietary pattern mitigates the detrimental associations between osteosarcopenic adiposity and both all-cause mortality and life expectancy: a cohort study

Background and aims: To determine the associations between osteosarcopenic adiposity (OSA) and both all-cause mortality and life expectancy, and to investigate whether adherence to a healthy diet can modify these associations. Methods: Utilizing data obtained from 201 223 UK Biobank participants, we assessed body composition for OSA and a healthy diet score was used to assess dietary quality. Results: Compared to participants with no body composition abnormality, the adjusted HRs (95% CIs) of all-cause mortality for those with 1, 2, and 3 (OSA) abnormalities were 1.13 (1.08, 1.18), 1.28 (1.21, 1.35), and 2.01 (1.58, 2.56) after adjustments, respectively. Compared with participants with no body composition abnormality, OSA patients with poor dietary patterns had a higher risk of all-cause mortality (HR = 2.92, 95% CI: 1.96, 4.36) than those with medium (HR = 1.73, 95% CI: 1.27, 2.37) and healthy dietary patterns (HR = 1.39, 95% CI: 0.34, 5.60). Specifically, a lower intake of fish and a higher intake of processed meat contributed to such different associations. Compared with participants without body composition abnormality, those with 1, 2, and 3 (OSA) body composition abnormalities had 0.31 (95% CI: -0.07, 0.69), 0.62 (95% CI: 0.16, 1.09) and 3.03 (95% CI: 1.05, 5.00) years of reduced life expectancy at age 45 years. Conclusions: Body composition abnormality, particularly OSA, is associated with both increased risk of all-cause mortality and reduced life expectancy. Nevertheless, it is noteworthy that adopting a healthy dietary pattern appears to mitigate these associations.

Multiple long-term conditions as the next transition in the global diabetes epidemic

Several transitions, or new patterns and dynamics in the contributors and health outcomes, have altered the character and burden of the multi-decade, worldwide growth in prevalence of type 2 diabetes (T2DM). These changes have led to different needs for prevention and care. These dynamics have been driven by diverse demographic, socio-economic, behavioural, and health system response factors. In this Perspective, we describe these transitions and how their attributes have set the stage for multimorbidity, or multiple long-term conditions (MLTCs), to be the next major challenge in the diabetes epidemic. We also describe how the timing and character of these stages differ in high-, middle-, and low-income countries. These challenges call for innovation and a stronger focus on MLTCs across the spectrum of cause, effectiveness, and implementation studies to guide prevention and treatment priorities.

Lost in turbulence? Healthcare workers' conceptualisations and experiences with navigating time in personalised care

PURPOSE

The study aims to explore how healthcare workers (HCWs) navigate and experience time when caring for older cancer patients living with other illnesses.

DESIGN/METHODOLOGY/APPROACH

This paper presents findings from a qualitative study of how HCWs conceptualise and navigate the temporal aspects of delivering personalised care to older people living with multimorbidity. Building on research from organisation studies and the sociology of time, we interviewed 19 UK HCWs about their experiences of delivering care to this patient group.

FINDINGS

Our findings illustrate how the delivery of personalised care contradicts contemporary models for healthcare delivery defined by efficiency and standardisation. We found that HCWs engage with time as both a valuable commodity to be rationed and prioritised within a constrained context and as a malleable resource for managing workload and overcoming "turbulence" in the system. However, participants in this study also shared how the simultaneous multiplicity and lack of time had a profoundly personal impact on them through the emotional toll associated with "time debt" and "lost" time.

ORIGINALITY/VALUE

This research presents a unique analysis of how time is conceptualised and navigated in contemporary healthcare, offering valuable insights for policy improvement. We conclude that personalised models of healthcare are incompatible with many current temporal structures of treatment trajectories and work-practices, by nature of being centred around the person and not the system of delivery.

Major psychiatric comorbidity among the critically ill: a multi-centred cohort study in Queensland

BACKGROUND

Although comorbid medical diseases are important determinants of outcome among the critically ill, the role of psychiatric comorbidity is not well defined. The objective of this study was to determine the occurrence of psychiatric comorbidity and its effect on the outcome of patients admitted to adult intensive care units (ICU) in Queensland.

METHODS

Admissions among adults to 12 ICUs in Queensland during 2015-2021 were included and clinical and outcome information was obtained through linkages between the ANZICS Adult Patient Database, the state-wide Queensland Hospital Admitted Patient Data Collection, and death registry.

RESULTS

A total of 89,123 admissions were included among 74,513 individuals. Overall, 7,178 (8.1%) admissions had psychiatric co-morbidity with 6,270 (7.0%) having one major psychiatric diagnosis and 908 (1%) having two or more. Individual diagnoses of mood, psychotic, anxiety, or affective disorders were present in 1,801 (2.0%), 874 (1.0%), 3,241 (3.6%) and 354 (0.4%) admissions respectively. Significant differences were observed among the main groups (mood, affective, anxiety, psychotic, or multiple disorders) and those without psychiatric comorbidity with respect to main diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) score, sex, age, and medical comorbidity. Crude 30-day case-fatality rates were significantly lower (5.1%) compared to the general ICU population (10.1%) (p < 0.001). After controlling for confounding variables in the logistic regression model, patients with psychiatric comorbidity were at lower odds of death.

CONCLUSIONS

Psychiatric comorbidity is common among ICU presentations and is associated with a lower risk of death. This association is likely to be more complex than being a simple protective factor, and future research needs to further delineate how psychiatric comorbidity informs outcomes of specific ICU presentations.

Efficacy of a Blended Low-Intensity Internet-Delivered Psychological Program in Patients With Multimorbidity in Primary Care: Randomized Controlled Trial

BACKGROUND

Multimorbidity is a highly prevalent phenomenon whose presence causes a profound physical, psychological, and economic impact. It hinders help seeking, diagnosis, quality of care, and adherence to treatment, and it poses a significant dilemma for present-day health care systems.

OBJECTIVE

This study aimed to assess the effectiveness of improved treatment as usual (iTAU) combined with a blended low-intensity psychological intervention delivered using information and communication technologies for the treatment of multimorbidity (depression and type 2 diabetes or low back pain) in primary care settings.

METHODS

A 2-armed, parallel-group, superiority randomized controlled trial was designed for this study. Participants diagnosed with depression and either type 2 diabetes or low back pain (n=183) were randomized to "intervention + iTAU" (combining a face-to-face intervention with a supporting web-based program) or "iTAU" alone. The main outcome consisted of a standardized composite score to consider (1) severity of depressive symptoms and (2a) diabetes control or (2b) pain intensity and physical disability 3 months after the end of treatment as the primary end point. Differences between the groups were estimated using mixed effects linear regression models, and mediation evaluations were conducted using path analyses to evaluate the potential mechanistic role of positive and negative affectivity and openness to the future.

RESULTS

At 3-month follow-up, the intervention + iTAU group (vs iTAU) exhibited greater reductions in composite multimorbidity score (B=-0.34, 95% CI -0.64 to -0.04; Hedges g=0.39) as well as in depression and negative affect and improvements in perceived health, positive affect, and openness to the future. Similar positive effects were observed after the intervention, including improvements in physical disability. No significant differences were found in glycosylated hemoglobin, pain intensity, or disability at 3-month follow-up (P=.60; P=.79; and P=.43, respectively). Path analyses revealed that the intervention had a significant impact on the primary outcome, mediated by both positive and negative affect (positive affect: indirect effect=-0.15, bootstrapped 95% CI -0.28 to -0.03; negative affect: indirect effect=-0.14, bootstrapped 95% CI -0.28 to -0.02).

CONCLUSIONS

This study supports the efficacy of a low-intensity psychological intervention applied in a blended format on multimorbidity in primary care. It justifies the exploration of the conceptualization of depression in type 2 diabetes as well as the analysis of the implementation of such interventions in routine clinical practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/S12888-019-2037-3.

N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP)-A Prognostic Biomarker in Older and/or Frail Adults with Advanced Gastroesophageal Cancer: A Post Hoc Analysis of the GO2 Clinical Trial

Background: Better prognostic biomarkers are needed in older adults with cancer. There are established links between N-terminal pro-B-type Natriuretic Peptide (NT-proBNP) and sarcopenia, and sarcopenia is associated with poorer cancer survival. However, there are limited data regarding baseline NT-proBNP as a biomarker of cancer outcome. The GO2 trial recruited older and/or frail United Kingdom (UK) patients with advanced gastroesophageal cancer and investigated the role of chemotherapy dose de-escalation. Using the GO2 database, we sought to investigate the prognostic role of NT-proBNP as well as the interaction between NT-proBNP and frailty. Methods: This was a post-hoc analysis of a completed clinical trial. Frailty measures included ECOG performance status (PS) and GO2 frailty grouping (based on an assessment of nine geriatric domains). A corrected NT-proBNP (cBNP) was calculated for each patient, adjusting for the upper limit of normal (ULN) reference from each centre. Results: A total of 241 patients were eligible to be included in the analysis. The median age was 76 (range 52-89), 187 (77.6%) were male and 211 (87.6%) had adenocarcinoma. Eighty (33.2%) patients had a baseline NT-proBNP above the local ULN. There was no association between cBNP and ECOG PS (p = 0.36) or the GO2 frailty group (p = 0.58). Those with the highest cBNP (n = 59) had significantly inferior median overall survival: 5.3 months (mos.) vs. 6.8 mos. (medium, n = 120) vs. 8.2 mos. (low, n = 61); HR 1.57 (95% CI; 1.04-2.37), p = 0.031. This was maintained on a Cox regression analysis (HR 1.69, p = 0.01) accounting for the GO2 trial stratification factors. There was no clear association between frailty and NT-proBNP. Conclusions: In this study, NT-proBNP appeared to be prognostic-independent of other factors. Further investigation and validation are needed to confirm our findings and to determine the potential beneficial role of cardioprotective therapy in at-risk patients with cancer identified in this manner.

Association of inflammatory markers and multimorbidity in young adults: cross-sectional findings from the Pelotas (Brazil) birth cohort, 1993

Early diagnosis can be a beneficial factor for minimizing health risks related to multimorbidity. This study aims to assess the association of multimorbidity with interleukin 6 (IL-6), C-reactive protein (CRP), and adiponectin in 22-year-old participants of the Pelotas (Brazil) birth cohort. A total of 3,578 subjects had serum measurements of IL-6, CRP, and adiponectin at the 22-year-old visit. For multimorbidity evaluation, a list of 15 morbidities was used and divided into subgroups (cardiometabolic, pulmonary, allergic diseases, and mental disorders). The occurrence of ≥ 2 morbidities was higher in females (55.1%) than in males (45.2%). A negative association between multimorbidity and adiponectin was found in females, whereas positive associations between the number of diseases and IL-6 and CRP were observed in males. For both sexes, cardiometabolic problem was the morbidity most associated with the markers. The analysis for isolated diseases identified dyslipidemia was the only cardiometabolic condition associated with physiological markers. Our findings suggest an inverse association between multimorbidity and adiponectin in females, as well as a direct cumulative association between the number of diseases and IL-6 and CRP in males at a young age.

Variation in general practitioners' follow-up of depressed patients starting antidepressant medication: a register-based cohort study

BACKGROUND

Guidelines recommend follow-up within 2 weeks for patients starting medication for depression. Knowledge is lacking about how general practitioners' (GPs) follow-up varies with patients' sociodemographic characteristics.

OBJECTIVE

To describe follow-up by GP and specialist in mental healthcare provided to men and women with depression within 3 months of starting drug therapy. Furthermore, to examine whether follow-up varied according to patients' age and education.

METHODS

Registry-based cohort study comprising all patients aged ≥18 years in Norway with a new depression episode in 2014 who started on antidepressants within 12 months from diagnosis. Patients' age and educational level were the exposures. Outcomes were follow-up by GP and/or mental healthcare specialist, and talking therapy with GP, within 90 days of first prescription. Cox proportional hazard models were used to estimate the likelihood of having follow-up contacts. Log binomial regression analysis was performed to explore the likelihood of having talking therapy with a GP. Time to first contact was illustrated by Kaplan-Meier survival curves.

RESULTS

The study population comprised 17 000 patients, mean age 45.7 years, 60.6% women. Only 27.8% of the patients were followed up by GP and/or specialist within 2 weeks of the first drug dispensing, 67.1% within 90 days. Older or less educated men and women received less and later contacts than the younger or more highly educated.

CONCLUSIONS

Differences in age and educational level were associated with follow-up of depressed patients who started medication. This may indicate unwarranted variation in depression care that GPs should consider when prescribing antidepressants.

Reduced functional independence and multimorbidity increases the risk of severe infection among older patients with Omicron: a multicenter retrospective cohort study

BACKGROUND

Multimorbidity and physical function in older adults have been identified as associated with coronavirus disease 2019 (COVID-19) outcomes. This study aimed to investigate whether multimorbidity affects the association of impaired functional independence (FI) with critical COVID-19 among older inpatients during the peak of Omicron infection in China.

METHODS

This is a multicentre, retrospective cohort study in northeastern China. Patients aged ≥ 60 years, who were diagnosed with COVID-19 at the time of admission or during hospitalisation. The Barthel index was used to assess FI. Patients were classified into independent, mildly dependent, moderately dependent, and severely dependent groups. Disease severity was classified as critical, severe, and non-severe and combined into severe or critical and non-severe. Binary logistic regression analysis was used to investigate any correlation between FI and disease severity. Patients were further stratified by presence or absence of multimorbidity.

FINDINGS

In this study, of 1598 patients, 530 (33.17%) developed severe or critical infections during the entire hospital stay. Patients with severe dependency had 7.39 times (95% CI: [4.60, 12.15]) higher risk of serious or critical infections than those without dependency. An interaction was noted between reduced FI and multimorbidity (p for interaction < 0.001). Compared to non-multimorbid patients (OR = 3.71, 95% CI: [1.58, 9.16]), multimorbid patients (OR = 10.04, 95% CI: [5.63, 18.57]) had a more pronounced risk of severe or critical infection.

CONCLUSIONS

Our results provide further scientific evidence on the association between FI, multimorbidity, and disease severity in older COVID-19 patients, contributing to future health decision-making for COVID-19 and other infectious diseases.

Nursing Students' Perspectives Toward Providing Oral Health Care for Older People

Introduction: Oral care for older adults in residential homes and long-term hospital care has been largely ignored by health care professionals. The purpose of this study was to understand the perspectives of nursing students' on incorporating oral health care topics in the nursing curricula. Methods: As a part of a broader cross-sectional quantitative study, we asked nursing students their opinions on incorporating an oral health care curriculum in their nursing programme. This resulted in a total of 148 responses, representing ~15% of New Zealand's nursing graduates and exceeding the anticipated survey response rate of 10%. The respondents were from 61% of nursing schools across the country. Thematic coding was used to analyze and report on the participants' responses. Results: The nursing students thought oral health care education is overlooked in the nursing curriculum. Nursing students believed health professionals should be accountable for their patients' oral health. Conclusion: Nursing students do not feel confident providing oral care for their patients. However, they recognize their responsibility and understand the need to provide oral health care as part of long-term care for older adults.

Multiple states clustering analysis (MSCA), an unsupervised approach to multiple time-to-event electronic health records applied to multimorbidity associated with myocardial infarction

Multimorbidity is characterized by the accrual of two or more long-term conditions (LTCs) in an individual. This state of health is increasingly prevalent and poses public health challenges. Adapting approaches to effectively analyse electronic health records is needed to better understand multimorbidity. We propose a novel unsupervised clustering approach to multiple time-to-event health records denoted as multiple state clustering analysis (MSCA). In MSCA, patients' pairwise dissimilarities are computed using patients' state matrices which are composed of multiple censored time-to-event indicators reflecting patients' health history. The use of state matrices enables the analysis of an arbitrary number of LTCs without reducing patients' health trajectories to a particular sequence of events. MSCA was applied to analyse multimorbidity associated with myocardial infarction using electronic health records of 26 LTCs, including conventional cardiovascular risk factors (CVRFs) such as diabetes and hypertension, collected from south London general practices between 2005 and 2021 in 5087 patients using the MSCA R library. We identified a typology of 11 clusters, characterised by age at onset of myocardial infarction, sequences of conventional CVRFs and non-conventional risk factors including physical and mental health conditions. Interestingly, multivariate analysis revealed that clusters were also associated with various combinations of socio-demographic characteristics including gender and ethnicity. By identifying meaningful sequences of LTCs associated with myocardial infarction and distinct socio-demographic characteristics, MSCA proves to be an effective approach to the analysis of electronic health records, with the potential to enhance our understanding of multimorbidity for improved prevention and management.

Senescence-associated T cells in immunosenescence and diseases

Age-related changes in the immune system, referred to as immunosenescence, appear to evolve with rather paradoxical manifestations, a diminished adaptive immune capacity, and an increased propensity for chronic inflammation often with autoimmunity, which may underlie the development of diverse disorders with age. Immunosenescent phenotypes are associated with the emergence of unique lymphocyte subpopulations of both T and B lineages. We report that a CD153+ programmed cell death protein 1 (PD-1)+ CD4+ T-cell subpopulation with severely attenuated T-cell receptor (TCR)-responsiveness, termed senescence-associated T (SAT) cells, co-evolve with potentially autoreactive CD30+ B cells, such as spontaneous germinal center B cells and age-associated B cells, in aging mice. SAT cells and CD30+ B cells are reciprocally activated with the aid of the interaction of CD153 with CD30 in trans and with the TCR complex in cis, resulting in the restoration of TCR-mediated proliferation and secretion of abundant pro-inflammatory cytokines in SAT cells and the activation and production of autoantibodies by CD30+ B cells. Besides normal aging, the development of SAT cells coupled with counterpart B cells may be robustly accelerated and accumulated in the relevant tissues of lymphoid or extra-lymphoid organs under chronic inflammatory conditions, including autoimmunity, and may contribute to the pathogenesis and aggravation of the disorders. This review summarizes and discusses recent advances in the understanding of SAT cells in the contexts of immunosenescent phenotypes, as well as autoimmune and chronic inflammatory diseases, and it provides a novel therapeutic clue.

Exploring biomarkers and molecular mechanisms of Type 2 diabetes mellitus promotes colorectal cancer progression based on transcriptomics

Type 2 diabetes mellitus (T2DM) has been confirmed as an independent risk factor for colorectal cancer (CRC) in many studies. However, the mechanisms behind T2DM's role in the progression of CRC remain unclear. This study aims to explore the potential biomarkers and molecular mechanisms involved in T2DM-promoted CRC progression. The limma package was used to identify differentially expressed genes in tumor tissue from CRC patients with or without T2DM. The key biological processes were screened by gene ontology and gene set enrichment analysis. A diagnostic model for co-morbidities was constructed by logistic regression model with least absolute shrinkage and selection operator (Lasso) regularization method. The diagnostic performance was assessed by supplementing external datasets to draw ROC curves on the diagnostic model. The diagnostic model was further screened for key genes by prognostic analysis. The relationship of key genes with immune cells and other cells was evaluated by immune infiltration algorithm and single-cell transcription analysis. Drug prediction was performed by cMAP and the obtained drugs were molecularly docked with the key genes. The differentially expressed genes of T2DM-promoted CRC progression were mainly enriched to O-linked glycosylation-related processes. The diagnostic model constructed based on Lasso logistic regression had good diagnostic performance (AUC > 0.8). COX11 was the key gene for co-morbidities: in tumor tissues, COX11 expression was significantly higher than that in normal colon tissues. However, COX11 gene expression was significantly lower in patients with comorbidities than in patients without T2DM in tumor tissue. External datasets confirmed from both mRNA and protein expression levels that low COX11 expression was significantly associated with poor CRC prognosis. Immune infiltration analysis suggested that its expression related to the proportion of M2 macrophages. Single-cell transcriptome analysis revealed a close association of COX11 expression with endothelial cells and macrophages. The top4 drugs predicted bound well to COX11. Our study revealed that the pathogenesis of T2DM-promoted CRC progression related to O-linked glycosylation. We constructed a diagnostic model for T2DM-CRC co-morbidity. Meanwhile, we identified COX11 as a potential immune-related molecular marker closely associated with T2DM-promoted CRC progression. These mechanisms and molecular markers may provide new ideas for further studies of T2DM-promoted CRC progression and contribute to drug discovery for the treatment of co-morbidities.

Return on Investment of Enhanced Behavioral Health Services

Importance

Employer-sponsored benefit programs aim to increase access to behavioral health care, which may help contain health care costs. However, research has either focused solely on clinical outcomes or demonstrated reductions in medical claims without accounting for the costs of behavioral health services, leaving the financial return on investment unknown.

Objective

To determine whether a clinically effective employer-sponsored behavioral health benefit is associated with net medical cost savings.

Design, Setting, and Participants

This retrospective cohort study included participants eligible for an employer-sponsored behavioral health benefit between November 1, 2019, and May 31, 2023. Eligibility criteria included having a behavioral health diagnosis and, in the program group, attending at least 1 behavioral health appointment. Program users were matched to nonusers on medical risk scores, behavioral health diagnoses, date of diagnosis, age, sex, and employer. Participants were followed up for 1 year before and after the benefit launch.

Exposure

A digital platform screened individuals for common behavioral health conditions and provided access to video and in-person psychotherapy, medication management, care navigation, and self-guided digital content.

Main Outcomes and Measures

Primary outcomes were per member per month (PMPM) medical spending, inclusive of all medical claims and program costs. A difference-in-differences analysis was used to compare changes in net medical spending between groups from the year before and up to 1 year after an index mental health diagnosis.

Results

This study included 13 990 participants: 4907 of 4949 (99.1%) eligible program group members were matched to 9083 control participants. Their mean (SD) age was 37 (13.2) years, and most participants (65.5%) were female. Costs decreased in the program group relative to the control group, with a net difference-in-differences of -$164 PMPM (95% CI, -$228 to -$100 PMPM), corresponding to savings of $1070 per participant in the first program year and a return on investment of 1.9 times the costs (ie, every $100 invested reduced medical claims costs by $190). Behavioral health costs in the program group increased relative to the control group but were more than offset by decreases in physical health care costs. Savings were larger for participants with higher medical risk.

Conclusions and Relevance

In this cohort study, every $100 invested in an employer-sponsored behavioral health program with fast access to psychotherapy and medication management was associated with a reduction in medical claims costs by $190. These findings suggest that expanding access to behavioral health care may be a financially viable cost-reduction strategy for health care buyers.

Pathophysiological insights into HFpEF from studies of human cardiac tissue

Heart failure with preserved ejection fraction (HFpEF) is a major, worldwide health-care problem. Few therapies for HFpEF exist because the pathophysiology of this condition is poorly defined and, increasingly, postulated to be diverse. Although perturbations in other organs contribute to the clinical profile in HFpEF, altered cardiac structure, function or both are the primary causes of this heart failure syndrome. Therefore, studying myocardial tissue is fundamental to improve pathophysiological insights and therapeutic discovery in HFpEF. Most studies of myocardial changes in HFpEF have relied on cardiac tissue from animal models without (or with limited) confirmatory studies in human cardiac tissue. Animal models of HFpEF have evolved based on theoretical HFpEF aetiologies, but these models might not reflect the complex pathophysiology of human HFpEF. The focus of this Review is the pathophysiological insights gained from studies of human HFpEF myocardium. We outline the rationale for these studies, the challenges and opportunities in obtaining myocardial tissue from patients with HFpEF and relevant comparator groups, the analytical approaches, the pathophysiological insights gained to date and the remaining knowledge gaps. Our objective is to provide a roadmap for future studies of cardiac tissue from diverse cohorts of patients with HFpEF, coupling discovery biology with measures to account for pathophysiological diversity.