Prevalence of multimorbidity in a geographically defined American population: patterns by age, sex, and race/ethnicity

Mild cognitive impairment and early Alzheimer's disease eligibility for disease modification therapies in a tertiary centre for cognitive disorders: A simultaneous real-word study on aducanumab and lecanemab

BACKGROUND AND PURPOSE

The Food and Drug Administration approved two disease-modifying treatments (DMTs) for Alzheimer's disease (AD), aducanumab and lecanemab, with limited clinical impact but significant biomarker changes. Identifying suitable candidates for these DMTs outside randomized clinical trials (RCTs) remains uncertain.

METHODS

This cross-sectional study, conducted in an Italian tertiary centre for cognitive disorders, aimed to evaluate how the RCT eligibility criteria for DMT treatments applies to participants with early AD. The broader Cummings et al. (Journal of Prevention of Alzheimer's Disease, 2021, 2023) criteria and the clinical differences between DMT candidates were also assessed.

RESULTS

The study involved 408 participants (mean age 71.1 ± 8.5 years, 48% male) with a clinical diagnosis of mild cognitive impairment (161/408, 39.5%) or mild dementia (247/408, 60.5%). Amongst them, 169 individuals (41%) showed positive AD pathology biomarkers. Eligibility RCT assessment revealed 14 patients eligible for aducanumab (3.43% of 408) and 28 for lecanemab (6.86% of 408). Following Cummings' real-world criteria, aducanumab eligibility increased to 9.56%, whereas lecanemab eligibility rose to 8.33%. Applying selection criteria to only the amyloid positive (169 out of 408), the selection for DMTs was 8.3% for aducanumab and 16.5% for lecanemab.

CONCLUSION

Amongst subjects diagnosed with mild AD and mild cognitive impairment in a tertiary centre for cognitive disorders, only a small percentage of patients using RCT diagnostic criteria are eligible for DMT. The application of Cummings criteria strongly increased the DMT candidates. Nevertheless, the majority of patients with cognitive disorders have been excluded from DMTs approved so far.

Upregulation of GRP78 is accompanied by decreased antioxidant response and mitophagy promotion in streptozotocin-induced type 1 diabetes in rats

Endoplasmic reticulum stress, oxidative stress, and mitochondrial dysfunction are interconnected processes involved in the pathogenesis of diabetes mellitus (DM). In the present study, we demonstrate a distinct unfolded protein response (UPR) signaling pathways in two mammalian models of DM: β-TC-6 cell line and streptozotocin-induced type 1 diabetes model in rats. However, a feature common to both systems was the upregulation of the GRP78 protein. Moreover, in vivo studies showed the disruption of the antioxidant system and an escalation of mitophagy against the background of a depletion of the level of ATP in pancreatic cells. In conclusion, we suggest that glucotoxic conditions induced GRP78 upregulation, and next cause depletion of the antioxidant pool and disruption of the functioning of antioxidant defense enzymes and in consequence promote mitophagy in pancreatic cells. Therefore, GRP78 may be considered as a potential therapeutic factor in patients with diabetes.

Impact of intensive hypertension criteria on multimorbidity prevalence and patterns in a multi-ethnic Chinese population

Background

The impact of intensive hypertension criteria on multimorbidity prevalence and patterns remains understudied. We investigated the prevalence and patterns of multimorbidity using both the current (140/90 mmHg) and intensive (130/80 mmHg) hypertension criteria within a multi-ethnic Chinese population.

Methods

Data were obtained from the baseline survey of the Regional Ethnic Cohort Study in Northwest China, conducted from June 2018 to May 2019, which enrolled adults aged 35-74 years from five provinces. A total of 114,299 participants were included in this study. Multimorbidity was defined as the presence of at least two chronic diseases or conditions from a list of 26, ascertained through self-report and physical examination. Agglomerative hierarchical cluster analysis was employed to identify multimorbidity patterns. A hypertension-related multimorbidity pattern was identified and further analyzed. The prevalence of multimorbidity and hypertension-related pattern were analyzed in different subgroups, and subgroup cluster analyses were conducted stratified by sex, age, and ethnicity.

Results

Applying the intensive 130/80 mmHg hypertension criteria resulted in an increase in multimorbidity prevalence from 17.6% (20,128 participants) to 21.7% (24,805 participants) compared to the 140/90 mmHg criteria. Four distinct multimorbidity patterns were consistently identified: cardiometabolic, digestive-bone-kidney, respiratory, and mental-cancer. Hypertension consistently clustered within the cardiometabolic pattern alongside diabetes, acute myocardial infarction, angina, and stroke/TIA, with relatively stable proportions observed even under the 130/80 mmHg threshold.

Conclusion

The revision of hypertension criteria significantly expands the population identified as having multimorbidity, without altering the identified multimorbidity patterns. Hypertension commonly co-occurs within the cardiometabolic cluster. These findings highlight the need for improved treatment and management strategies specifically targeting cardiometabolic multimorbidity.

Impact of alcohol use disorder on cognition in correlation with aging: a community-based retrospective cohort study

AIMS

Excessive alcohol use is associated with an increased risk of cognitive impairment. Since increased amyloid plaque burden exacerbates cognitive decline, we sought to assess the potential impact of alcohol use disorder (AUD) on cognition, memory, and amyloid burden corresponding with age.

METHODS

We conducted the retrospective analysis with 6036 subjects, including 269 AUD+ subjects. A four-item CAGE (C-Cutting Down, A-Annoyance by Criticism, G-Guilty Feeling, E-Eye-openers) alcohol questionnaire was given during the recruitment to determine AUD in each participant. We assessed cognitive function, focusing on memory using neuropsychological testing. For 1038 participants, including 57 AUD+ subjects, we measured amyloid burden using the 11C Pittsburgh Compound B tracer-based positron emission tomography imaging.

RESULTS

AUD+ was significantly associated with lower scores of cognition and memory function relative to AUD- individuals. No significant association was found with AUD and elevated brain amyloid under the age of 65. However, further analysis showed that those aged ≥65 showed greater odds for abnormal amyloid in AUD+ compared to AUD- participants.

CONCLUSIONS

Our results underscore AUD as a risk factor for cognitive decline and diminished memory, particularly in aging populations. The role of AUD in brain amyloid accumulation requires further study.

Clinician's Guide to Geriatric Assessment

The population of older adults is rapidly growing worldwide. Because of the substantial shortage of geriatricians, all clinicians need basic fluency in older adult care. In our approach to evaluating an older adult in the clinic or at the bedside, we apply the "Geriatric 5Ms" framework to manage the patient's care. The Geriatric 5Ms consist of the following key steps. First, consider the mind: the cognitive and psychological domains of a patient's health. Second, evaluate mobility and fall risk. Third, review and reconcile medications, particularly high-risk medications. Fourth, ask what matters most to the patient. Fifth, assess multicomplexity: how the intersection of multiple chronic conditions and social determinants of health influence the patient's health care management. Herein, we provide clinicians with practical suggestions and resources for quickly and effectively applying the Geriatric 5Ms to the care of older adults.

The Experiences and Perceptions of Older Adults with Multimorbidity Toward E-Health Care: A Qualitative Evidence Synthesis

Background: Given the growing population of older adults globally, e-Health plays an indispensable role in the chronic disease management of multimorbidity. However, qualitative evidence that synthesizes the experiences of older adults with multimorbidity using e-Health service is currently lacking. The objective was to explore the experiences and perceptions of e-Health care in community-based settings among the older adults with multimorbidity. Methods: Seven electronic databases including PubMed, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Embase, Web of Science, China National Knowledge Infrastructure, and Chinese BioMedical Literature were searched, and the search was limited to studies from inception to September 1, 2023. Screening, data extraction, and quality appraisal were conducted independently by two reviewers. Thomas and Harden's thematic synthesis methodology was applied to synthesize the original themes. The methodological quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research, and the confidence of synthesized themes was evaluated by the Confidence in the Evidence from Reviews of Qualitative Research approaches. Results: Ten studies with moderate methodological quality met eligibility criteria and were included finally. Studies were conducted in four countries with 235 participants who were living with multiple chronic conditions. Among the 10 included studies, 37 credible findings were extracted and interpreted into 3 synthesized themes and 12 subthemes: (1) advantages and benefits perceived during e-Health service, (2) multidimensional challenges and negative experience posed by e-Health service, and (3) preferences, suggestions, and expectations for future e-Health improvement. The confidence in the majority of the three final synthesized themes was rated between "low" and "moderate" scales. Conclusions: The findings of this study provide new insights into implementing tailored e-Health care for older adults with multimorbidity. Further research should emphasize on realizing the potential value of e-Health service based on users' needs and perspectives to promote age-friendliness in geriatric practice.

Racial and Ethnic Disparities and the National Burden of COVID-19 on Inpatient Hospitalizations: A Retrospective Study in the United States in the Year 2020

BACKGROUND

Since January 2020, COVID-19 has affected more than 100 million people in the U.S. Previous studies on racial and ethnic disparities related to characteristics and outcomes of COVID-19 patients have been insightful. However, appropriate epidemiologic age-standardization of the disease burden and disparities for hospitalization data are lacking.

OBJECTIVE

To identify and describe racial and ethnic disparities for primary COVID-19 hospitalizations in the U.S. in 2020.

METHODS

In this nationally representative observational study, we use the National Inpatient Sample to quantify racial and ethnic disparities in COVID-19 hospitalizations. Descriptive statistics for patient characteristics, common comorbidities, age-standardized hospitalization rates, inpatient complications, and mortality among COVID-19 hospitalizations were contrasted by race and ethnicity.

RESULTS

There were 1,058,815 primary COVID-19 hospitalizations in 2020. Of those, 47.2% were female, with median age of 66 (IQR, 54, 77). Overall inpatient mortality rate was 11.1%. When compared to White patients, Black, Hispanic, and Native American patients had higher age-standardized hospitalization rate ratios of 2.42 (95% CI 2.40-2.43), 2.26 (2.25-2.28), and 2.51 (2.46-2.56), respectively. Non-White patients had increased age-adjusted rates for procedures and complications. Factors associated with inpatient mortality include age, male sex, Hispanic or Native American race or ethnicity, lower income, Medicaid, heart failure, arrhythmias, coagulopathy, and chronic liver disease.

CONCLUSIONS

Marginalized populations in the U.S. had over twice the COVID-19 hospitalization rate relative to White patients. Age-adjusted mortality rates were highest for Black, Hispanic, and Native American patients. Careful consideration for vulnerable populations is encouraged during highly communicable respiratory pandemics.

Complex relationships of socioeconomic status with vascular and Alzheimer's pathways on cognition

INTRODUCTION

AD and CVD, which frequently co-occur, are leading causes of age-related cognitive decline. We assessed how demographic factors, socioeconomic status (SES) as indicated by education and occupation, vascular risk factors, and a range of biomarkers associated with both CVD (including white matter hyperintensities [WMH], diffusion MRI abnormalities, infarctions, and microbleeds) and AD (comprising amyloid-PET and tau-PET) collectively influence cognitive function.

METHODS

In this cross-sectional population study, structural equation models were utilized to understand these associations in 449 participants (mean age (SD) = 74.5 (8.4) years; 56% male; 7.5% cognitively impaired).

RESULTS

(1) Higher SES had a protective effect on cognition with mediation through the vascular pathway. (2) The effect of amyloid directly on cognition and through tau was 11-fold larger than the indirect effect of amyloid on cognition through WMH. (3) There is a significant effect of vascular risk on tau deposition.

DISCUSSION

The utilized biomarkers captured the impact of CVD and AD on cognition. The overall effect of vascular risk and SES on these biomarkers are complex and need further investigation.

Ethnic inequalities in age-related patterns of multiple long-term conditions in England: Analysis of primary care and nationally representative survey data

Little is known about the patterning of multiple long-term conditions (MLTCs) by age, ethnicity and across conceptualisations of MLTCs (e.g. MLTCs with/without mental health conditions [MHCs]). We examined ethnic inequalities in age-related patterns of MLTCs, and combinations of physical and MHCs using the English GP Patient Survey and Clinical Practice Research Datalink. We described the association between MLTCs and age using multilevel regression models adjusting for sex and area-level deprivation with patients nested within GP practices. Similar analyses were repeated for MLTCs that include MHCs. We observed ethnic inequalities from middle-age onwards such as older Pakistani, Indian, Black Caribbean and Other ethnic people had increased risk of MLTCs compared to white British people, even after adjusting for area-level deprivation. Compared to white British people, Gypsy and Irish Travellers had higher levels of MLTCs across the age groups, and Chinese people had lower levels. Pakistani and Bangladeshi people aged 50-74 years were more likely than white people to report MLTCs that included MHCs. We find clear evidence of ethnic inequalities in MLTCs. The lower prevalence of MLTCs that include MHCs among some minoritised ethnic groups may be an underestimation due to underdiagnosis and/or inadequate primary care and requires further scrutiny.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Associations between vascular health, brain stiffness and global cognitive function

Vascular brain injury results in loss of structural and functional connectivity and leads to cognitive impairment. Its various manifestations, including microinfarcts, microhaemorrhages and white matter hyperintensities, result in microstructural tissue integrity loss and secondary neurodegeneration. Among these, tissue microstructural alteration is a relatively early event compared with atrophy along the aging and neurodegeneration continuum. Understanding its association with cognition may provide the opportunity to further elucidate the relationship between vascular health and clinical outcomes. Magnetic resonance elastography offers a non-invasive approach to evaluate tissue mechanical properties, providing a window into the microstructural integrity of the brain. This retrospective study evaluated brain stiffness as a potential biomarker for vascular brain injury and its role in mediating the impact of vascular dysfunction on cognitive impairment. Seventy-five participants from the Mayo Clinic Study of Aging underwent brain imaging using a 3T MR imager with a spin-echo echo-planar imaging sequence for magnetic resonance elastography and T1- and T2-weighted pulse sequences. This study evaluated the effects of vascular biomarkers (white matter hyperintensities and cardiometabolic condition score) on brain stiffness using voxelwise analysis. Partial correlation analysis explored associations between brain stiffness, white matter hyperintensities, cardiometabolic condition and global cognition. Mediation analysis determined the role of stiffness in mediating the relationship between vascular biomarkers and cognitive performance. Statistical significance was set at P-values < 0.05. Diagnostic accuracy of magnetic resonance elastography stiffness for white matter hyperintensities and cardiometabolic condition was evaluated using receiver operator characteristic curves. Voxelwise linear regression analysis indicated white matter hyperintensities negatively correlate with brain stiffness, specifically in periventricular regions with high white matter hyperintensity levels. A negative association between cardiovascular risk factors and stiffness was also observed across the brain. No significant patterns of stiffness changes were associated with amyloid load. Global stiffness (µ) negatively correlated with both white matter hyperintensities and cardiometabolic condition when all other covariables including amyloid load were controlled. The positive correlation between white matter hyperintensities and cardiometabolic condition weakened and became statistically insignificant when controlling for other covariables. Brain stiffness and global cognition were positively correlated, maintaining statistical significance after adjusting for all covariables. These findings suggest mechanical alterations are associated with cognitive dysfunction and vascular brain injury. Brain stiffness significantly mediated the indirect effects of white matter hyperintensities and cardiometabolic condition on global cognition. Local cerebrovascular diseases (assessed by white matter hyperintensities) and systemic vascular risk factors (assessed by cardiometabolic condition) impact brain stiffness with spatially and statistically distinct effects. Global brain stiffness is a significant mediator between vascular disease measures and cognitive function, highlighting the value of magnetic resonance elastography-based mechanical assessments in understanding this relationship.

Lack of leisure time physical activity and variations in cardiovascular mortality across US communities: a comprehensive county-level analysis (2011-2019)

OBJECTIVES

To investigate the associations between county-level proportions of adults not engaging in leisure-time physical activity (no LTPA) and age-adjusted cardiovascular mortality (AACVM) rates in the overall US population and across demographics.

METHODS

Analysing 2900 US counties from 2011 to 2019, we used the Centers for Disease Control and Prevention (CDC) databases to obtain annual AACVM rates. No LTPA data were sourced from the CDC's Behavioural Risk Factor Surveillance System survey and county-specific rates were calculated using a validated multilevel regression and poststratification modelling approach. Multiple regression models assessed associations with county characteristics such as socioeconomic, environmental, clinical and healthcare access factors. Poisson generalised linear mixed models were employed to calculate incidence rate ratios (IRR) and additional yearly deaths (AYD) per 100 000 persons.

RESULTS

Of 309.9 million residents in 2900 counties in 2011, 7.38 million (2.4%) cardiovascular deaths occurred by 2019. County attributes such as socioeconomic, environmental and clinical factors accounted for up to 65% (adjusted R2=0.65) of variance in no LTPA rates. No LTPA rates associated with higher AACVM across demographics, notably among middle-aged adults (standardised IRR: 1.06; 95% CI (1.04 to 1.07)), particularly women (1.09; 95% CI (1.07 to 1.12)). The highest AYDs were among elderly non-Hispanic black individuals (AYD=68/100 000).

CONCLUSIONS

Our study reveals a robust association between the high prevalence of no LTPA and elevated AACVM rates beyond other social determinants. The most at-risk groups were middle-aged women and elderly non-Hispanic black individuals. Further, county-level characteristics accounted for substantial variance in community LTPA rates. These results emphasise the need for targeted public health measures to boost physical activity, especially in high-risk communities, to reduce AACVM.

Urban-rural differences in associations among perceived stress, resilience and self-care in Chinese older adults with multiple chronic conditions

BACKGROUND

Social determinants of health (SDH) are mainly comprised of structural and intermediary domains. Emerging evidence suggests that the burden of multiple chronic conditions (MCCs) in older adults is exacerbated by structural determinants (e.g. low income and low education). However, less attention was paid to the intermediary determinants (i.e. material circumstances, psychosocial factors and behavioural factors) of MCCs.

OBJECTIVES

To investigate the associations among perceived stress, resilience and self-care in Chinese older adults with MCCs by comparing urban and rural groups.

METHODS

A convenience sample (125 and 115 participants from urban and rural settings, respectively) of Chinese older adults with MCCs was enrolled between January and April 2022. Hierarchical multiple regression analyses and propensity score weights were used to determine the associations among perceived stress, resilience and self-care.

RESULTS

Hypothesis 1 regarding the negative associations between perceived stress and self-care was fully supported in the rural group. However, for the urban group, the negative association was only supported for the relationship between MCCs-related perceived stress and self-care maintenance. Hypothesis 2 was fully supported regarding the positive associations between resilience and the three components of self-care in both groups, although the relationship between resilience and self-care monitoring was marginally significant in the urban group. Hypothesis 3 regarding the moderating effect of resilience was only supported in the relationship between general perceived stress and self-care monitoring in the rural group. After adding the propensity score weights, the moderating effect was no longer statistically significant in the rural group.

CONCLUSIONS

The urban-rural disparities in the Chinese context might largely be attributed to the complex interactions of the structural determinants and intermediary determinants. Findings can inform the development of culturally tailored interventions to promote self-care and reduce urban-rural disparities for Chinese older adults with MCCs.

IMPLICATIONS FOR PRACTICE

With the increasing number of older adults in China who are living with multiple chronic conditions and the call for effective interventions to improve their health outcomes, current findings can inform the development and implementation of nurse-led culturally tailored interventions to promote self-care and reduce urban-rural disparities for Chinese older adults with MCCs.

Multimorbidity in patients with atrial fibrillation and community controls: A population-based study

Background

Multimorbidity is common in patients with atrial fibrillation (AF), yet comorbidity patterns are not well documented.

Methods

The prevalence of 18 chronic conditions (6 cardiometabolic, 7 other somatic, 5 mental health) was obtained in patients with new-onset AF from 2013-2017 from a 27-county region and controls matched 1:1 on age, sex, and county of residence. For AF patients and controls separately, clustering of conditions and co-occurrence beyond chance was estimated (using the asymmetric Somers' D statistic), overall and for ages <65, 65-74, 75-84, and ≥85 years.

Results

Among 16,509 patients with AF (median age 76 years, 57% men), few (4%) did not have any of the 18 chronic conditions, whereas nearly one-quarter of controls (23%) did not have any chronic conditions. Clustering of cardiometabolic conditions was common in both AF patients and controls, but clustering of other somatic conditions was more common in AF. Although the prevalence of most condition pairs was higher in AF patients, controls had a larger number of condition pairs occurring together beyond chance. In persons aged <65 years, AF patients more frequently exhibited concordance of condition pairs that included either pairs of somatic conditions or a combination of conditions from different condition groups. In persons aged 65-74 years, AF patients more frequently had pairs of other somatic conditions.

Conclusion

Patterns of co-existing conditions differed between patients with AF and controls, particularly in younger ages. A better understanding of the clinical consequences of multimorbidity in AF patients, including those diagnosed at younger ages, is needed.

Biomarkers of cellular senescence and risk of death in humans

A robust and heterogenous secretory phenotype is a core feature of most senescent cells. In addition to mediators of age-related pathology, components of the senescence associated secretory phenotype (SASP) have been studied as biomarkers of senescent cell burden and, in turn, biological age. Therefore, we hypothesized that circulating concentrations of candidate senescence biomarkers, including chemokines, cytokines, matrix remodeling proteins, and growth factors, could predict mortality in older adults. We assessed associations between plasma levels of 28 SASP proteins and risk of mortality over a median follow-up of 6.3 years in 1923 patients 65 years of age or older with zero or one chronic condition at baseline. Overall, the five senescence biomarkers most strongly associated with an increased risk of death were GDF15, RAGE, VEGFA, PARC, and MMP2, after adjusting for age, sex, race, and the presence of one chronic condition. The combination of biomarkers and clinical and demographic covariates exhibited a significantly higher c-statistic for risk of death (0.79, 95% confidence interval (CI): 0.76-0.82) than the covariates alone (0.70, CI: 0.67-0.74) (p < 0.001). Collectively, these findings lend further support to biomarkers of cellular senescence as informative predictors of clinically important health outcomes in older adults, including death.

The Impact of Preoperative Antithrombotic Therapy on the Risks for Thrombo-ischemic Events and Bleeding among Patients Undergoing Elective Spine Surgery

STUDY DESIGN

Retrospective matched analysis.

PURPOSE

To evaluate the effect of antithrombotic drug therapy on the rates of thrombo-ischemic or bleeding events 90 days following elective spine surgery.

OVERVIEW OF LITERATURE

Thrombo-ischemic and bleeding complications in patients undergoing spine surgery are major causes of morbidity. Many patients who pursue elective spine surgery are concurrently receiving antithrombotic therapy for unrelated conditions; however, at this time, the effects of preoperative antithrombotic use on postoperative bleeding and thrombosis are unclear.

METHODS

Using an all-payer claims database, patients who underwent elective cervical and lumbar spine interventions between January 1, 2010, and June 30, 2018, were identified. Individuals were categorized into groups taking and not taking antithrombotics. A 1:1 analysis was constructed based on comorbidities found to be independently associated with bleeding or ischemic complications using logistic regression models. The primary outcomes were the rates of thrombo-ischemic events and bleeding complications.

RESULTS

A total of 660,866 patients were eligible for inclusion. Following the matching procedure, 56,476 patient records were analyzed, with 28,238 in each group. The antithrombotic agent group had significantly greater odds of developing any 90-day thromboischemic event after surgery: deep vein thrombosis (odds ratio [OR], 3.61; 95% confidence interval [CI], 3.06-4.25), pulmonary embolism (OR, 3.93; 95% CI, 3.34-4.62), myocardial infarction (OR, 6.20; 95% CI, 5.69-6.76), and ischemic stroke (OR, 3.76; 95% CI, 3.31-4.27). In addition, the antithrombotic agent group had an increased likelihood of experiencing hematoma (OR, 1.54; 95% CI, 1.35-1.76) and need for transfusion (OR, 2.61; 95% CI, 2.29-2.96).

CONCLUSIONS

Patients taking antithrombotic medications before elective surgery of the cervical and lumbar spine had increased risks of both ischemic and bleeding events. Spine surgeons should carefully consider these implications when appraising patients for surgery, given the lack of guidelines on perioperative management of antithrombotic agents.

Are we enrolling the right patients? A scoping review of external validity and generalizability of clinical trials in bloodstream infections

BACKGROUND

Having a representative population in randomized clinical trials (RCTs) improves external validity and generalizability of trial results. There are limited data examining differences between RCT-enrolled and real-world populations in bloodstream infections (BSI).

OBJECTIVES

We conducted a scoping review aiming to review studies assessing generalizability of BSI RCT populations, to identify sub-groups that have been systematically under-represented and to explore approaches to improve external validity of future RCTs.

SOURCES

MEDLINE, Embase, and Cochrane Library databases were searched for terms related to external validity or generalizability, BSI, and clinical trials in papers published up to 1 August 2023. Studies comparing enrolled versus nonenrolled patients, or papers discussing external validity or generalizability in the context of BSI RCTs were included.

CONTENT

Sixteen papers were included in the final review. Five compared RCT-enrolled and nonenrolled participants from the same source population. There were significant differences between the two groups in all studies, with nonenrolled patients having a greater comorbidity burden and consistently worse outcomes including mortality. We identified several barriers to improving generalizability of RCT populations and outlined potential approaches to reduce these barriers, such as alternative/simplified consent processes, streamlining eligibility criteria and follow-up procedures, quota-based sampling techniques, and ensuring diversity in site and study team selection.

IMPLICATIONS

Study cohorts in BSI RCTs are not representative of the general BSI patient population. As we increasingly adopt large pragmatic trials in infectious diseases, it is important to recognize the importance of maximizing generalizability to ensure that our research findings are of direct relevance to our patients.

Racial differences in healthcare expenditures for prevalent multimorbidity combinations in the USA: a cross-sectional study

BACKGROUND

We aimed to model total charges for the most prevalent multimorbidity combinations in the USA and assess model accuracy across Asian/Pacific Islander, African American, Biracial, Caucasian, Hispanic, and Native American populations.

METHODS

We used Cerner HealthFacts data from 2016 to 2017 to model the cost of previously identified prevalent multimorbidity combinations among 38 major diagnostic categories for cohorts stratified by age (45-64 and 65 +). Examples of prevalent multimorbidity combinations include lipedema with hypertension or hypertension with diabetes. We applied generalized linear models (GLM) with gamma distribution and log link function to total charges for all cohorts and assessed model accuracy using residual analysis. In addition to 38 major diagnostic categories, our adjusted model incorporated demographic, BMI, hospital, and census division information.

RESULTS

The mean ages were 55 (45-64 cohort, N = 333,094) and 75 (65 + cohort, N = 327,260), respectively. We found actual total charges to be highest for African Americans (means $78,544 [45-64], $176,274 [65 +]) and lowest for Hispanics (means $29,597 [45-64], $66,911 [65 +]). African American race was strongly predictive of higher costs (p < 0.05 [45-64]; p < 0.05 [65 +]). Each total charge model had a good fit. With African American as the index race, only Asian/Pacific Islander and Biracial were non-significant in the 45-64 cohort and Biracial in the 65 + cohort. Mean residuals were lowest for Hispanics in both cohorts, highest in African Americans for the 45-64 cohort, and highest in Caucasians for the 65 + cohort. Model accuracy varied substantially by race when multimorbidity grouping was considered. For example, costs were markedly overestimated for 65 + Caucasians with multimorbidity combinations that included heart disease (e.g., hypertension + heart disease and lipidemia + hypertension + heart disease). Additionally, model residuals varied by age/obesity status. For instance, model estimates for Hispanic patients were highly underestimated for most multimorbidity combinations in the 65 + with obesity cohort compared with other age/obesity status groupings.

CONCLUSIONS

Our finding demonstrates the need for more robust models to ensure the healthcare system can better serve all populations. Future cost modeling efforts will likely benefit from factoring in multimorbidity type stratified by race/ethnicity and age/obesity status.

Could an optimally fitted categorization of difference between multi-disease score and multi-symptom score be a practical indicator aiding in improving the cost-effectiveness of healthcare delivery for older adults in developing countries?

BACKGROUND

Physio-psycho-socioeconomical health comprehensively declines during aging, the complexity of which is challenging to measure. Among the complexity, multiple chronic disorders continuously cumulated during aging, further aggravating the challenge.

METHODS

A population-based survey on Comprehensive Ageing Health Assessment was conducted in older adults (age >  = 60) enrolled from hospital settings and community settings in 13 working centers in six subnational regions in China. Cross-sectional datasets of 8,093 older participants with approximately complete assessment results were collected for the present analysis. Individual's multi-disease or multi-symptom was respectively scored by summing coexistent multiple diseases or multiple symptoms by respective weighting efficient for Self-Rated Health (SRH). Individual's age-dependent health decline was further summed of four SRH-weighted scores for daily function (activity of daily life, ADL), physical mobility (an average of three metrics), cognitive function (mini mental state examination, MMSE) and mental being (geriatric depression scale, GDS) plus multi-disease score (MDS) and multi-symptom score (MSS).Multi-disease patten among 18 diseases or multi-symptom pattern among 15 symptoms was latent-clustered in the older adults, the optimal outcome of which was categorized into high, moderate or low aging-associated clusters, respectively. Percentage distribution was compared between overall health decline score and multi-disease pattern cluster or multi-symptom patten cluster. A new variable of difference between MDS and MSS (hereinafter terming DMM) that displayed linear variation with socioeconomic factors was further fitted using multilevel regression analyses by substantial adjustments on individual confounders (level-1) and subnational region variation (level-2).

RESULTS

Consistent gradient distribution was shown between health decline and multimorbidity pattern cluster in the older adults. DMM was found linearly varied with personal education attainment and regional socioeconomic status. Using optimally fitted stratification of DMM (DMM interval = 0.02), an independent U-shaped interrelated tendency was shown between health decline, multi-disease and multi-symptom, which could be well explained by regional disparities in socioeconomic status.

CONCLUSION

Newly developed metrics for age-dependent health decline and aging-associated multimorbidity patten were preliminarily validated from within. The new variable of optimally fitted categorization of DMM might function as a practical indicator aiding in improving the cost-effectiveness and reduce inequity of healthcare delivery for older adults in developing countries.

Ethnic differences in physical and mental multimorbidity in working age adults with a history of depression and/or anxiety

BACKGROUND

The current study used data from an ethnically diverse population from South London to examine ethnic differences in physical and mental multimorbidity among working age (18-64 years) adults in the context of depression and anxiety.

METHOD

The study included 44 506 patients who had previously attended Improving Access to Psychological Therapies services in the London Borough of Lambeth. Multinomial logistic regression examined cross-sectional associations between ethnicity with physical and mental multimorbidity. Patterns of multimorbidity were identified using hierarchical cluster analysis.

RESULTS

Within 44 056 working age adults with a history of depression or anxiety from South London there were notable ethnic differences in physical multimorbidity. Adults of Black Caribbean ethnicity were more likely to have physical multimorbidity [adjusted relative risk ratio (aRRR) = 1.25, 95% confidence interval (CI) 1.15-1.36] compared to adults of White ethnicity. Relative to adults of White ethnicity, adults of Asian ethnicity were more likely to have physical multimorbidity at higher thresholds only (e.g. 4 + conditions; aRRR = 1.53, 95% CI 1.17-2.00). Three physical (atopic, cardiometabolic, mixed) and three mental (alcohol/substance use, common/severe mental illnesses, personality disorder) multimorbidity clusters emerged. Ethnic minority groups with multimorbidity had a higher probability of belonging to the cardiometabolic cluster.

CONCLUSION

In an ethnically diverse population with a history of common mental health disorders, we found substantial between- and within-ethnicity variation in rates of physical, but not mental, multimorbidity. The findings emphasised the value of more granular definitions of ethnicity when examining the burden of physical and mental multimorbidity.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

Disparities in Clinical Ethics Consultation among Hospitalized Children: A Case-Control Study

OBJECTIVE

To identify sociodemographic factors associated with pediatric clinical ethics consultation (CEC).

STUDY DESIGN

Matched, case-control study at a single center, tertiary pediatric hospital in the Pacific Northwest. Cases (patients hospitalized January 2008-December 2019 with CEC) were compared with controls (those without CEC). We determined the association of the outcome (CEC receipt) with exposures (race/ethnicity, insurance status, and language for care) using univariate and multivariable conditional logistic regression.

RESULTS

Of 209 cases and 836 matched controls, most cases identified as white (42%), had public/no insurance (66%), and were English-speaking (81%); most controls identified as white (53%), had private insurance (54%), and were English-speaking (90%). In univariate analysis, patients identifying as Black (OR: 2.79, 95% CI: 1.57, 4.95; P < .001), Hispanic (OR: 1.92, 95% CI: 1.24, 2.97; P = .003), with public/no insurance (OR: 2.21, 95% CI: 1.58, 3.10; P < .001), and using Spanish language for care (OR: 2.52, 95% CI: 1.47, 4.32; P < .001) had significantly increased odds of CEC, compared with patients identifying as white, using private insurance, and using English for care, respectively. In multivariable regression, Black race (adjusted OR: 2.12, 95% CI: 1.16, 3.87; P = .014) and public/no insurance (adjusted OR: 1.81, 95% CI: 1.22, 2.68; P = .003) remained significantly associated with receipt of CEC.

CONCLUSIONS

We found disparities in receipt of CEC by race and insurance status. Further study is needed to determine the causes of these disparities.

Prevalence of multimorbidity and its associations with hospitalisation or death in Japan 2014-2019: a retrospective cohort study using nationwide medical claims data in the middle-aged generation

OBJECTIVE

To describe the prevalence of multimorbidity and its associations with clinical outcomes across age groups.

DESIGN

Retrospective cohort study using nationwide medical claims data.

SETTING

Carried out in Japan between April 2014 and March 2019.

PARTICIPANTS

N=246 671 Japanese individuals aged 20-74 enrolled in the health insurance were included into the baseline data set for fiscal year (FY) 2014. Of those, N=181 959 individuals were included into the cohort data set spanning FY2014-FY2018.

EXPOSURES

Multimorbidity was defined as having ≥2 of 15 chronic conditions according to the International Classification of Diseases 10th Revision codes of the Charlson Comorbidity Index.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome: the standardised prevalence of multimorbidity across age groups was evaluated using data from FY2014 and extrapolated to the Japanese total population.

SECONDARY OUTCOME

hospitalisation or death events were traced by month using medical claims data and insurer enrolment data. Associations between multimorbidity and 5-year hospitalisation and/or death events across age groups were analysed using a Cox regression model.

RESULTS

The standardised prevalence rate of multimorbidity in the nationwide Japanese total population was estimated to 26.1%. The prevalence rate with age was increased, approximately 5% (ages 20-29), 10% (30-39), 20% (40-49), 30% (50-59), 50% (60-69) and 60% (70-74). Compared with individuals aged 20-39 without multimorbidity, those with multimorbidity had a higher incidence of clinical events in any age group (HR=2.43 (95% CI 2.30 to 2.56) in ages 20-39, HR=2.55 (95% CI 2.47 to 2.63) in ages 40-59 and HR=3.41 (95% CI 3.23 to 3.53) in ages ≥60). The difference in the incidence of clinical events between multimorbidity and no multimorbidity was larger than that between age groups.

CONCLUSIONS

Multimorbidity is already prevalent in the middle-aged generation and is associated with poor clinical outcomes. These findings underscore the significance of multimorbidity and highlight the urgent need for preventive intervention at the public healthcare level.

Association between maternal multimorbidity and preterm birth, low birth weight and small for gestational age: a prospective birth cohort study from the Japan Environment and Children's Study

OBJECTIVES

Multimorbidity is defined as the coexistence of two or more chronic physical or psychological conditions within an individual. The association between maternal multimorbidity and adverse perinatal outcomes such as preterm delivery and low birth weight has not been well studied. Therefore, this study aimed to investigate this association.

METHODS

We conducted a prospective cohort study using data from the Japan Environment and Children's Study of pregnant women between 2011 and 2014. Those with data on chronic maternal conditions were included in the study and categorised as having no chronic condition, one chronic condition or multimorbidities. The primary outcomes were the incidence of preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). Adjusted logistic regression was performed to estimate ORs (aORs) and 95% CIs.

RESULTS

Of the 104 062 fetal records, 86 885 singleton pregnant women were analysed. The median maternal age and body mass index were 31 years and 20.5 kg/m², respectively. The prevalence of pregnant women with one or more chronic conditions was 40.2%. The prevalence of maternal multimorbidity was 6.3%, and that of PTB, LBW, and SGA were 4.6%, 8.1%, and 7.5%, respectively. Pre-pregnancy underweight women were the most common, observed in 15.6% of multimorbidity cases, followed by domestic violence from intimate partner in 13.0%. Maternal multimorbidity was significantly associated with PTB (aOR 1.50; 95% CI 1.33-1.69), LBW (aOR 1.49; 95% CI 1.35-1.63) and SGA (aOR 1.33; 95% CI 1.20-1.46).

CONCLUSION

Maternal multimorbidity was associated with adverse perinatal outcomes, including PTB, LBW and SGA. The risk of adverse perinatal outcomes tends to increase with a rise in the number of chronic maternal conditions. Multimorbidity becomes more prevalent among pregnant women, making our findings important for preconception counselling.

Long-Term Maintenance of Cardiorespiratory Fitness Gains After Cardiac Rehabilitation Reduces Mortality Risk in Patients With Multimorbidity

PURPOSE

The objective of this study was to characterize the impact of multimorbidity and cardiorespiratory fitness (CRF) on mortality in patients completing cardiac rehabilitation (CR).

METHODS

This cohort study included data from patients with a history of cardiovascular disease (CVD) completing a 12-wk CR program between January 1996 and March 2016, with follow-up through March 2017. Patients were stratified by the presence of multimorbidity, which was defined as having a diagnosis of ≥2 noncommunicable diseases (NCDs). Cox regression analyses were used to evaluate the effects of multimorbidity and CRF on mortality in patients completing CR. Symptom-limited exercise tests were completed at baseline, immediately following CR (12 wk), with a subgroup completing another test at 1-yr follow-up. Peak metabolic equivalents (METs) were determined from treadmill speed and grade.

RESULTS

Of the 8320 patients (61 ± 10 yr, 82% male) included in the analyses, 5713 (69%) patients only had CVD diagnosis, 2232 (27%) had CVD+1 NCD, and 375 (4%) had CVD+≥2 NCDs. Peak METs at baseline (7.8 ± 2.0, 6.9 ± 2.0, 6.1 ± 1.9 METs), change in peak METs immediately following CR (0.98 ± 0.98, 0.83 ± 0.95, 0.76 ± 0.95 METs), and change in peak METs 1 yr after CR (0.98 ± 1.27, 0.75 ± 1.17, 0.36 ± 1.24 METs) were different ( P < .001) among the subgroups. Peak METs at 12 wk and the presence of coexisting conditions were each predictors ( P < .001) of mortality. Improvements in CRF by ≥0.5 METS from baseline to 1-yr follow-up among patients with or without multimorbidity were associated with lower mortality rates.

CONCLUSION

Increasing CRF by ≥0.5 METs improves survival regardless of multimorbidity status.

Comorbid status of patients with hypertension

Aim. To establish age and gender characteristics, nosological structure of comorbidity among persons 2099 years with hypertension. Materials and methods. The study is based on data from 21 514 electronic health records of the population (2099 years old) with hypertension, mean age 63.0 years, 68.2% women. Diseases associated with hypertension with a frequency above 10% were analyzed. Results. In the sample of people with hypertension, concomitant diseases were detected in 82.7% of cases, 1 disease accompanies 21.0% of the sample with hypertension, 2 diseases 17.9%, 3 diseases 14.0%, 4+ diseases 29.8%. The frequency of association of hypertension with 1 concomitant disease at the 2029 years is 60.8% of cases, at 3039 years 65.1%, at 4049 years 73.9%, at 5059 years 81.1%, 6069 years 85.8%, 7079 years 87.3%, 80+ years 86.2% of cases. Among women with hypertension, the average number of concomitant diseases is higher compared to men (3.47 vs 2.4 cases; p0.001). Among young and middle-aged people, hypertension in most cases is associated with osteochondrosis, osteoarthritis, chronic pancreatitis, gastritis and duodenitis, retinal diseases, thyroid diseases, the female with hypertension accompanied by benign breast disease and menopausal disorders. Hypertension in the elderly is most often associated with cerebrovascular disease, coronary heart disease, diabetes mellitus, senile cataract, but osteochondrosis and osteoarthritis also do not lose their relevance. Conclusion. The existing system of organization of medical care cannot meet the needs of patients with comorbidity, which indicates the need to reorient medical care towards patient-centered care.

Socioeconomic and Ethnic Inequalities in the Progress of Multimorbidity and the Role of Health Behaviors

OBJECTIVES

To assess socioeconomic and ethnic inequalities in the progress of multimorbidity and whether behavioral factors explain these inequalities among older Americans.

DESIGN

Health and Retirement Study, a longitudinal survey of older American adults.

SETTING AND PARTICIPANTS

Data pooled from 2006 to 2018 (waves 8-14), which include 38,061 participants.

METHODS

We used 7 waves of the survey from 2006 to 2018. Socioeconomic factors were indicated by education, total wealth, poverty-income ratio (income), and race/ethnicity. Multimorbidity was indicated by self-reported diagnoses of 5 chronic conditions: diabetes, heart conditions, lung diseases, cancer, and stroke. Behavioral factors were smoking, excessive alcohol consumption, physical activity, and body mass index (BMI). Multilevel mixed effects generalized linear models were constructed to assess socioeconomic and ethnic inequalities in the progress of multimorbidity and the role of behavior. All variables included in the analysis were time-varying except gender, race/ethnicity, and education.

RESULTS

African American individuals had higher rates of multimorbidity than White individuals; however, after adjusting for income and education, the association was reversed. There were clear income, wealth, and education gradients in the progress of multimorbidity. After adjusting for behavioral factors, the relationships were attenuated. The rate ratio (RR) of multimorbidity attenuated by 9% among participants with the lowest level of education after accounting for behavior (RR 1.21; 95% CI 1.18-1.23 and 1.11; 95% CI 1.17-1.14) in the models unadjusted and adjusted for behaviors, respectively. Similarly, RR for multimorbidity among those in the lowest wealth quartile attenuated from 1.47 (95% CI 1.44-1.51) and 1.31 (95% CI 1.26-1.36) after accounting for behaviors.

CONCLUSION AND IMPLICATIONS

Ethnic inequalities in the progress of multimorbidity were explained by wealth, income, and education. Behavioral factors partially attenuated socioeconomic inequalities in multimorbidity. The findings are useful in identifying the behaviors that should be included in health promotion programs aiming at tackling inequalities in multimorbidity.

Convergence of four measures of multi-morbidity

Objectives

To compare the agreement between percentile ranks from 4 multi-morbidity scores.

Design

Population-based descriptive study.

Setting

Olmsted County, Minnesota (USA).

Participants

We used the medical records-linkage system of the Rochester Epidemiology Project (REP; http://www.rochesterproject.org) to identify all residents of Olmsted County, Minnesota who reached one or more birthdays between 1 January 2005 and 31 December 2014 (10 years).

Methods

For each person, we calculated 4 multi-morbidity scores using readily available diagnostic code lists from the US Department of Health and Human Services, the Clinical Classifications Software, and the Elixhauser Comorbidity Index. We calculated scores using diagnostic codes received in the 5 years before the index birthday and fit quantile regression models across age and separately by sex to transform unweighted, simple counts of conditions into percentile ranks as compared to peers of same age and of same sex. We compared the percentile ranks of the 4 multi-morbidity scores using intra-class correlation coefficients (ICCs).

Results

We assessed agreement in 181,553 persons who reached a total of 1,075,433 birthdays at ages 18 years through 85 years during the study period. In general, the percentile ranks of the 4 multi-morbidity scores exhibited high levels of agreement in 6 score-to-score pairwise comparisons. The agreement increased with older age for all pairwise comparisons, and ICCs were consistently greater than 0.65 at ages 50 years and older.

Conclusions

The assignment of percentile ranks may be a simple and intuitive way to assess the underlying trait of multi-morbidity across studies that use different measures.

Synergistic interactions of obesity with sex, education, and smoking and accumulation of multi-morbidity (MM) across the lifespan

Objectives

Obesity is a potentially modifiable risk factor that has been consistently associated with the development and progression of multi-morbidity (MM). However, obesity may be more problematic for some persons compared to others because of interactions with other risk factors. Therefore, we studied the effect of interactions between patient characteristics and overweight and obesity on the rate of accumulation of MM.

Methods

We studied 4 cohorts of persons ages 20-, 40-, 60-, and 80-years residing in Olmsted County, Minnesota between 2005 and 2014 using the Rochester Epidemiology Project (REP) medical records-linkage system. Body mass index, sex, race, ethnicity, education, and smoking status were extracted from REP indices. The rate of accumulation of MM was calculated as the number of new chronic conditions accumulated per 10 person years through 2017. Poisson rate regression models were used to identify associations between characteristics and rate of MM accumulation. Additive interactions were summarized using relative excess risk due to interaction, attributable proportion of disease, and the synergy index.

Results

Greater than additive synergistic associations were observed between female sex and obesity in the 20- and 40-year cohorts, between low education and obesity in the 20-year cohort (both sexes), and between smoking and obesity in the 40-year cohort (both sexes).

Conclusions

Interventions targeted at women, persons with lower education, and smokers who also have obesity may result in the greatest reduction in the rate of MM accumulation. However, interventions may need to focus on persons prior to mid-life to have the greatest effect.

Association rules analysis on patterns of multimorbidity in adults: based on the National Health and Nutrition Examination Surveys database

OBJECTIVE

To explore the prevalence and patterns of multimorbidity in population with different genders and age ranges.

DESIGN

A cross-sectional study.

SETTING

National Health and Nutrition Examination Surveys database.

PARTICIPANTS

12 576 patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The prevalence and patterns of multimorbidity.

RESULTS

High cholesterol had the highest prevalence in all population (33.4 (95% CI: 32.0 to 34.9)) and males. In females <65 years, the most prevalent disease was sleep disorder (32.1 (95% CI: 29.6 to 34.5)) while in females ≥65 years, hypertension was the most prevalent disease (63.9 (95% CI: 59.9 to 67.9)). Hypertension and high cholesterol were associated with the highest support (occur together most frequently) in all population regardless of genders. Hypertension displayed the highest betweenness centrality (mediating role in the network) followed by high cholesterol and arthritis in all population. For males aged <65 years, hypertension and high cholesterol presented the highest betweenness centrality. In males ≥65 years, hypertension, high cholesterol and arthritis were the top three diseases of degree centrality (direct association with other conditions). As for females ≥65 years, hypertension showed the highest betweenness centrality followed by high cholesterol and arthritis. The associations of hypertension, arthritis and one other item with high cholesterol presented the highest support in all population. In males, the associations of depression, hypertension with sleep disorders had the highest lift (the chance of co-occurrence of the conditions and significant association). Among females, the associations of depression, arthritis with sleep disorders had the highest lift.

CONCLUSION

Hypertension and high cholesterol were prevalent in all population, regardless of females and males. Hypertension and high cholesterol, arthritis and hypertension, and diabetes and hypertension were more likely to coexist. The findings of this study might help make plans for the management and primary care of people with one or more diseases.

The Contribution of Chronic Conditions to Hospitalization, Skilled Nursing Facility Admission, and Death: Variation by Race

Multimorbidity (≥2 chronic conditions) is a common and important marker of aging. To better understand racial differences in multimorbidity burden and associations with important health-related outcomes, we assessed differences in the contribution of chronic conditions to hospitalization, skilled nursing facility admission, and mortality among non-Hispanic Black and non-Hispanic White older adults in the United States. We used data from a nationally representative study, the National Health and Aging Trends Study, linked to Medicare claims from 2011-2015 (n = 4,871 respondents). This analysis improved upon prior research by identifying the absolute contributions of chronic conditions using a longitudinal extension of the average attributable fraction for Black and White Medicare beneficiaries. We found that cardiovascular conditions were the greatest contributors to outcomes among White respondents, while the greatest contributor to outcomes for Black respondents was renal morbidity. This study provides important insights into racial differences in the contributions of chronic conditions to costly health-care utilization and mortality, and it prompts policy-makers to champion delivery reforms that will expand access to preventive and ongoing care for diverse Medicare beneficiaries.

Prevalence of multimorbidity combinations and their association with medical costs and poor health: A population-based study of U.S. adults

Background

Multimorbidity is common, but the prevalence and burden of the specific combinations of coexisting disease has not been systematically examined in the general U.S. adult population.

Objective

To identify and estimate the burden of highly prevalent combinations of chronic conditions that are treated among one million or more adults in the United States.

Methods

Cross-sectional analysis of U.S. households in the Medical Expenditure Panel Survey (MEPS), 2016-2019, a large nationally-representative sample of the community-dwelling population. Association rule mining was used to identify the most common combinations of 20 chronic conditions that have high relevance, impact, and prevalence in primary care. The main measures and outcomes were annual treated prevalence, total medical expenditures, and perceived poor health. Logistic regression models with poor health as the outcome and each multimorbidity combination as the exposure were used to calculate adjusted odds ratios and 95% confidence intervals.

Results

Frequent pattern mining yielded 223 unique combinations of chronic disease, including 74 two-way (dyad), 115 three-way (triad), and 34 four-way combinations that are treated in one million or more U.S. adults. Hypertension-hyperlipidemia was the most common two-way combination occurring in 30.8 million adults. The combination of diabetes-arthritis-cardiovascular disease was associated with the highest median annual medical expenditures ($23,850, interquartile range: $11,593-$44,616), and the combination of diabetes-arthritis-asthma/COPD had the highest age-race-sex adjusted odds ratio of poor self-rated health (adjusted odd ratio: 6.9, 95%CI: 5.4-8.8).

Conclusion

This study demonstrates that many multimorbidity combinations are highly prevalent among U.S. adults, yet most research and practice-guidelines remain single disease focused. Highly prevalent and burdensome multimorbidity combinations could be prioritized for evidence-based research on optimal prevention and treatment strategies.

Employment Characteristics and Risk of Hospitalization Among Older Adults Participating in the Mayo Clinic Biobank

Objective

To determine the relationship between characteristics of employment and future hospitalization in older adults.

Patients and Methods

We conducted a survey of adults aged 65 years or older participating in the Mayo Clinic Biobank. Using a frequency-matched, case-control design, we compared patients who were hospitalized within 5 years of biobank enrollment (cases) with those who were not hospitalized (controls). We assessed the duration of work, age at first job, number of jobs, disability, retirement, and reasons for leaving work. We performed logistic regression analysis to assess the association of these factors with hospitalization, accounting for age, sex, comorbid conditions, and education level.

Results

Among 3536 participants (1600 cases and 1936 controls; median age, 68.5 years; interquartile range, 63.4-73.9 years), cases were older, more likely to be male, and had lower education levels. Comorbid illnesses had the largest association with hospitalization (odds ratio [OR], 4.09; 95% CI, 3.37-4.97 [highest vs lowest quartile]). On adjusted analyses, odds of hospitalization increased with the presence of disability (OR, 1.31; 95% CI, 1.01-1.69) and decreased with having 1 or 2 lifetime jobs vs no employment (OR, 0.77; 95% CI, 0.60-1.00). The length of work, furlough, age of retirement, childcare issues, and reasons for leaving a job were not associated with hospitalization.

Conclusion

This study reports an association between disability during work and hospitalization. On the basis of our findings, it may be important to obtain a more detailed work history from patients because it may provide further insight into their future health.

The Alzheimer's Cell Atlas (TACA): A single-cell molecular map for translational therapeutics accelerator in Alzheimer's disease

Introduction

Recent advances in generating massive single-cell/nucleus transcriptomic data have shown great potential for facilitating the identification of cell type-specific Alzheimer's disease (AD) pathobiology and drug-target discovery for therapeutic development.

Methods

We developed The Alzheimer's Cell Atlas (TACA) by compiling an AD brain cell atlas consisting of over 1.1 million cells/nuclei across 26 data sets, covering major brain regions (hippocampus, cerebellum, prefrontal cortex, and so on) and cell types (astrocyte, microglia, neuron, oligodendrocytes, and so on). We conducted nearly 1400 differential expression comparisons to identify cell type-specific molecular alterations (e.g., case vs healthy control, sex-specific, apolipoprotein E (APOE) ε4/ε4, and TREM2 mutations). Each comparison was followed by protein-protein interaction module detection, functional enrichment analysis, and omics-informed target and drug (over 700,000 perturbation profiles) screening. Over 400 cell-cell interaction analyses using 6000 ligand-receptor interactions were conducted to identify the cell-cell communication networks in AD.

Results

All results are integrated into TACA (https://taca.lerner.ccf.org/), a new web portal with cell type-specific, abundant transcriptomic information, and 12 interactive visualization tools for AD.

Discussion

We envision that TACA will be a highly valuable resource for both basic and translational research in AD, as it provides abundant information for AD pathobiology and actionable systems biology tools for drug discovery.

Highlights

We compiled an Alzheimer's disease (AD) brain cell atlas consisting of more than 1.1 million cells/nuclei transcriptomes from 26 data sets, covering major brain regions (cortex, hippocampus, cerebellum) and cell types (e.g., neuron, oligodendrocyte, astrocyte, and microglia).We conducted over 1400 differential expression (DE) comparisons to identify cell type-specific gene expression alterations. Major comparison types are (1) AD versus healthy control; (2) sex-specific DE, (3) genotype-driven DE (i.e., apolipoprotein E [APOE] ε4/ε4 vs APOE ε3/ε3; TREM2R47H vs common variants) analysis; and (4) others. Each comparison was further followed by (1) human protein-protein interactome network module analysis, (2) pathway enrichment analysis, and (3) gene-set enrichment analysis.For drug screening, we conducted gene set enrichment analysis for all the comparisons with over 700,000 drug perturbation profiles connecting more than 10,000 human genes and 13,000 drugs/compounds.A total of over 400 analyses of cell-cell interactions against 6000 experimentally validated ligand-receptor interactions were conducted to reveal the disease-relevant cell-cell communications in AD.

Predictors of Changes in Peak Oxygen Uptake After Outpatient Cardiac Rehabilitation: Importance of Cardiac Rehabilitation Attendance

Objective

To determine whether the number of cardiac rehabilitation (CR) sessions attended and selected clinical characteristics were predictive of patients who exhibited improvement in peak oxygen uptake (VO₂peak) after CR.

Patients and Methods

Using the Rochester Epidemiology Project records-linkage system, we identified all consecutive patients aged 18 years or older from Olmsted County, Minnesota, who underwent cardiopulmonary exercise testing before and after CR from 1999 to 2017. Regression models were created to assess the clinical predictors of VO₂peak improvement (>0% baseline) after CR.

Results

The analysis included 671 patients, of which 524 (78%) patients exhibited VO₂peak improvement after CR. The significant univariate predictors of VO₂peak improvement included younger age (odds ratio [OR], 0.98; 95% CI, 0.96-0.99), lower pre-CR VO₂peak (OR, 0.96; 95% CI, 0.94-0.99), and no history of peripheral artery disease (OR, 0.50; 95% CI, 0.31-0.81) (all, P<.005). The significant independent predictors of VO₂peak improvement from the multivariable analysis included the number of CR sessions (OR, 1.04; 95% CI, 1.02-1.05), younger age (OR, 0.96; 95% CI, 0.94-0.98), lower pre-CR VO₂peak (OR, 0.92; 95% CI, 0.89-0.95), and no history of peripheral artery disease (OR, 0.47; 95% CI, 0.28-0.78) (all, P<.005).

Conclusion

These findings highlight the importance of patient participation in CR sessions and individual clinical characteristics in influencing VO₂peak improvement after CR in patients with cardiovascular disease.

Prepregnancy Emergency Department Use and Risks of Severe Maternal and Neonatal Morbidity in Canada

IMPORTANCE

Emergency department (ED) use during pregnancy may be associated with worse obstetrical outcomes, possibly because of differences in access to health care. It is not known whether ED use before pregnancy is associated with serious adverse maternal and perinatal outcomes.

OBJECTIVE

To study the association between prepregnancy ED use and adverse maternal and perinatal outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study was conducted in Ontario, Canada, and included all livebirths and stillbirths from April 2003 to January 2020.

EXPOSURES

Main exposure was any ED encounter within 90 days preceding the start of the index pregnancy.

MAIN OUTCOMES AND MEASURES

Primary outcome was a composite of severe maternal morbidity (SMM) from 20 weeks' gestation to 42 days' post partum. Secondary outcomes included severe neonatal morbidity (SNM) from 0 to 27 days, neonatal death, and stillbirth. Relative risks (RRs) were adjusted for maternal age, income, and rurality.

RESULTS

Of 2 130 245 births, there were 2 119 335 livebirths (99.5%) and 10 910 stillbirths (0.5%). The mean (SD) maternal age was 29.6 (5.4) years, 212 478 (9.9%) were rural dwelling, and 498 219 (23%) had 3 or more comorbidities. Among all births, 218 011 (9.7%) had a prepregnancy ED visit. The rate of SMM was higher among women with a prepregnancy ED visit than those without (22.3 vs 16.5 per 1000 births), with an RR of 1.34 (95% CI, 1.30-1.38) and an adjusted RR (aRR) of 1.37 (95% CI, 1.33-1.42). Compared with no prepregnancy ED visit, the aRR was higher in those with 1 (1.29; 95% CI, 1.24-1.34), 2 (1.51; 95% CI, 1.42-1.61), and 3 or more (1.74; 95% CI, 1.61-1.90) ED visits. Prepregnancy ED visits for a hematological (aRR, 13.60; 95% CI, 10.48-17.64), endocrine (aRR, 4.96; 95% CI, 3.72-6.62), and circulatory (aRR, 2.27; 95% CI, 1.68-3.07) conditions were associated with the highest aRRs for SMM. The rate of SNM was higher among newborns whose mother visited the ED within 90 days before pregnancy (68.2 vs 55.4 per 1000 births; aRR, 1.24; 95% CI, 1.22-1.26) as was the risk of neonatal death (aRR, 1.26; 95% CI, 1.16-1.37) and stillbirth (aRR, 1.18; 95% CI, 1.11-1.25).

CONCLUSIONS AND RELEVANCE

In this study, ED use was common before pregnancy. These findings suggest that ED use may not only reflect a woman's access to prepregnancy care but also higher future risk of severe maternal and perinatal morbidity, potentially offering a useful trigger for health system interventions to decrease adverse pregnancy outcomes.

Coexisting Morbidity Burden in Hospitalized Elderly Patients with New-Onset Heart Failure vs Acutely Decompensated Chronic Heart Failure

Coexisting morbidities (CM) are common in patients with heart failure (HF). This study evaluated the CM burden and its clinical significance in elderly hospitalized patients with new-onset (De-novo) HF (n = 84) and acutely decompensated chronic HF (ADCHF) (n = 122). All had HF symptoms associated with: (a) LVEF <50%, or, (b) left ventricular ejection fraction (LVEF) ≥50% and NT-proBNP ≥300 pg/mL. The primary endpoint was the composite of all-cause death/HF rehospitalization at 6 months. Age was similar between patients with new-onset HF and ADCHF [82 (12.5) vs 80 (11) years, respectively; P = .549]. The CM burden was high in both groups. However, the number of CM [3 (2) vs 4 (1.75)] and the prevalence of multimorbidity [CM ≥2; 65 (77.4%) vs 108 (88.5%)] were lower in new-onset HF ( P = .016 and P = .035, respectively). The survival probability without the primary endpoint was higher in new-onset HF than in ADCHF ( P = .001) driven by less rehospitalizations ( P = .001). In the total study population significant primary endpoint predictors were red blood cell distribution width (RDW), urea, and coronary artery disease (CAD) prevalence (AUC of the model =.7685), whereas significant death predictors were RDW, urea, and the number of CM (AUC = .7859), all higher in ADCHF. Thus, the higher CM burden in ADCHF than in new-onset HF most likely contributed to the worse outcome.

Gender differences in the association between multimorbidity and depression in older Korean adults: an analysis of data from the National Survey of Older Koreans (2011-2017)

OBJECTIVES

Previous studies have shown that people with multimorbidity have a higher risk of depression than those without multimorbidity. However, few studies have examined the association between depression and multimorbidity in men and women separately. Since the rates of depression and multimorbidity are different in men and women, it is necessary to examine whether gender differences affect their association.

METHODS

This study included 30,138 participants (aged ≥ 65 years) from the National Survey of Older Koreans (2011-2017). Depression was defined using the Korean version of the Geriatric Depression Scale (SGDS-K). Multimorbidity was defined as people who had 2 or more chronic diseases, including arthritis, diabetes, heart disease, hypertension, pulmonary disease, cancer, stroke, or osteoporosis. Multiple logistic regression analysis was performed to determine the association between depression and multimorbidity.

RESULTS

In total, 22.2% and 30.7% of men and women, respectively, had depression. Those with multimorbidity had a higher risk of depression than those without chronic conditions; specifically, the difference in risk among men was greater than that among women. Age was considered a moderator for women. While the effects of pulmonary disease, stroke, and cancer were especially substantial in the integrated analysis, gender differences were observed related to various chronic conditions comorbid with heart disease.

CONCLUSIONS

There are gender differences in the association between multimorbidity and depression among older Korean adults. Therefore, gender-specific care should be provided to reduce depression in older adults with multimorbidity.

Association of Depression and Anxiety With the Accumulation of Chronic Conditions

IMPORTANCE

Longitudinal associations between comorbid depression and anxiety with the accumulation of chronic illnesses are unclear, and questions remain about the contributions associated with each condition in the increasing prevalence of multimorbidity.

OBJECTIVE

To compare the risk and rate of accumulating chronic conditions in people with depression, anxiety, and comorbid depression and anxiety vs individuals with neither depression nor anxiety.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the Rochester Epidemiology Project medical records-linkage system to identify residents of Olmsted County, Minnesota, from January 1, 2005, to December 31, 2014, with follow-up ending December 31, 2017. The sample was divided into cohorts anchored at birthday ages of 20, 40, and 60 years. Individuals were classified at anchoring birthday age as having depression alone, anxiety alone, comorbid depression and anxiety, or neither depression nor anxiety (reference group), using electronically extracted diagnosis codes from the International Classification of Diseases, Ninth Revision (ICD-9) in the 5 years before each anchoring birthday. Data were analyzed from August 2020 through November 2021.

EXPOSURES

Depression alone, anxiety alone, comorbid depression and anxiety, or neither depression nor anxiety (reference group).

MAIN OUTCOMES AND MEASURES

The main outcome was sex-specific risk, calculated as hazard ratios (HRs) and rates of accumulation, calculated as mean annual incidence rates per 100 person-years, of 15 common chronic conditions within each birthday age cohort through the end of study.

RESULTS

Among the 40 360 individuals included across all 3 age cohorts, 21 516 (53.3%) were women. After balancing cohorts on race, Hispanic ethnicity, education level, body mass index, smoking status, and calendar year at index birthday, the risk of accumulating chronic conditions was significantly increased among women with depression alone (cohort aged 20 years: HR, 1.20 [95% CI, 1.02-1.42]; cohort aged 40 years: HR, 1.20 [95% CI, 1.10-1.31]; cohort aged 60 years: HR, 1.09 [95% CI, 1.02-1.16]) and women with comorbid depression and anxiety (cohort aged 20 years: HR, 1.60 [95% CI, 1.28-1.99]; cohort aged 40 years: HR, 1.41 [95% CI, 1.21-1.65]; cohort aged 60 years: HR, 1.29 [95% CI, 1.15-1.44]) compared with referent women in the same birthday cohorts and in men with comorbid depression and anxiety compared with referent men in the cohort aged 20 years (HR, 1.77 [95% CI, 1.08-2.91]). For women, the rates of accumulation of conditions were significantly higher across birthday cohorts in the comorbid depression and anxiety group compared with the depression alone group (eg, cohort aged 20 years: difference, 1.2 [95% CI, 0.2-2.1] per 100 person-years) and reference group (eg, cohort aged 20 years: difference, 1.7 [95% CI, 0.9-2.6] per 100 person-years). For men, compared with the reference group, the rates of accumulation of conditions were significantly higher in men with comorbid depression and anxiety in the cohort aged 20 years (difference, 1.4 [95% CI, 0.1-2.6] per 100 person-years) and in men with depression in the cohort aged 40 years (difference, 2.0 [95% CI, 0.8-3.2] per 100 person-years).

CONCLUSIONS AND RELEVANCE

In this cohort study, the risk of accumulating chronic conditions was increased with depression and comorbid depression and anxiety in women across the age span and in younger men with comorbid depression and anxiety. Compared with women without depression or anxiety, there was a more rapid rate of accumulation of chronic conditions in women with depression and anxiety individually and an even higher rate when depression and anxiety cooccurred.

Cohort profile: the Olmsted County hypertensive disorders of pregnancy (HDP) cohort using the Rochester Epidemiology Project

PURPOSE

The Olmsted County hypertensive disorders of pregnancy (HDP) cohort is a population-based retrospective study designed to compare the incidence of HDP on a per-pregnancy and per-woman basis and to identify associations between HDP with ageing-related diseases, as well as accumulation of multimorbidity.

PARTICIPANTS

Using the Rochester Epidemiology Project (REP) medical records-linkage system, a cohort was collected consisting of women who gave birth in Olmsted County between 1976 and 1982. After exclusions, a per-pregnancy cohort of 7544 women with 9862 pregnancies between 1976 and 1982 was identified, and their delivery information was manually reviewed. A subset of these women comprised the per-woman cohort of 4322 pregnancies from 1839 women with delivery information available throughout the entirety of their childbearing years, along with decades of follow-up data available for research via the REP.

FINDINGS TO DATE

By constructing both per-pregnancy and per-woman cohorts, we reported a doubling of HDP incidence rates when assessed on a per-woman basis compared with rates observed on a per-pregnancy basis. Moreover, in addition to finding that women with a history of HDP developed specific diseases at higher rates and at early ages, we also discovered that a history of HDP is associated with accelerated ageing, through accumulation of multimorbidity.

FUTURE PLANS

In addition to these outcomes described above, many other potential outcomes of interest for studies of HDP can be ascertained from accessing the electronic health records (EHR) and billing systems available through the REP. These data can include all International Classification of Diseases (ICD)-9 and ICD-10 and Current Procedural Terminology coded diagnoses and procedures, healthcare utilisation, including office visits, hospitalisations and emergency room visits, and full text of the EHR that is available for chart abstraction or for natural language processing of the clinical notes.

Low Blood Pressure, Comorbidities, and Ischemic Stroke Mortality in US Veterans

BACKGROUND AND PURPOSE

Low blood pressure (BP) is associated with higher stroke mortality, although the factors underlying this association have not been fully explored. We investigated prestroke BP and long-term mortality after ischemic stroke in a national sample of US veterans.

METHODS

Using a retrospective cohort study design of veterans hospitalized between 2002 and 2007 with a first ischemic stroke and with ≥1 outpatient BP measurements 1 to 18 months before admission, we defined 6 categories each of average prestroke systolic BP (SBP) and diastolic BP, and 7 categories of pulse pressure. Patients were followed-up to 12 years for primary outcomes of all-cause and cardiovascular mortality. We used Cox models to relate prestroke BP indices to mortality and stratified analyses by the presence of preexisting comorbidities (smoking, myocardial infarction, heart failure, atrial fibrillation/flutter, cancer, and dementia), race and ethnicity.

RESULTS

Of 29 690 eligible veterans with stroke (mean±SD age 67±12 years, 98% men, 67% White), 2989 (10%) had average prestroke SBP<120 mm Hg. During a follow-up of 4.1±3.3 years, patients with SBP<120 mm Hg experienced 61% all-cause and 27% cardiovascular mortality. In multivariable analyses, patients with the lowest SBP, lowest diastolic BP, and highest pulse pressure had the highest mortality risk: SBP<120 versus 130 to 139 mm Hg (hazard ratio=1.26 [95% CI, 1.19-1.34]); diastolic BP <60 versus 70 to 79 mm Hg (hazard ratio=1.35 [95% CI, 1.23-1.49]); and pulse pressure ≥90 versus 60 to 69 mm Hg (hazard ratio=1.24 [95% CI, 1.15-1.35]). Patients with average SBP<120 mm Hg and at least one comorbidity (smoking, heart disease, cancer, or dementia) had the highest mortality risk (hazard ratio=1.45 [95% CI, 1.37-1.53]).

CONCLUSIONS

Compared with normotension, low prestroke BP was associated with mortality after stroke, particularly among patients with at least one comorbidity.

Use of hospital care services by chronic patients according to their characteristics and risk levels by adjusted morbidity groups

BACKGROUND

In-hospital care of chronic patients is based on their characteristics and risk levels. Adjusted morbidity groups (AMG) is a population stratification tool which is currently being used in Primary Care but not in Hospitals. The objectives of this study were to describe the use of hospital services by chronic patients according to their risk levels assigned by AMG and to analyze influencing variables.

MATERIAL AND METHODS

In this cross-sectional study, patients aged ≥18 years from a healthcare service area classified as chronically ill by the AMG classification system who used their referral hospital services from June 2015 to June 2016 were included. Predisposing and needs factors were collected. Univariate, bivariate and multiple linear regressions were performed.

RESULTS

Of the 9,443 chronic patients identified (52.1% of the population in the selected area), 4,143 (43.9%) used hospital care services. Their mean age was 62.1 years (standard deviation (SD) = 18.4); 61.8% were female; 9% were high risk; 30% were medium risk, and 61% were low risk. The mean number of hospital service contacts was 5.0 (SD = 6.2), with 3.8 (SD = 4.3) visits to outpatient clinic, 0.7 (SD = 1.2) visits to emergency departments, 0.3 (SD = 2.8) visits to day hospital, and 0.2 (SD = 0.5) hospitalizations. The factors associated with greater service use were predisposing factors such as age (coefficient B (CB) = 0.03; 95% confidence interval (CI) = 0.01-0.05) and Spanish origin (CB = 3.9; 95% CI = 3.2-4.6). Among the needs factors were palliative care (CB = 4.8; 95% CI = 2.8-6.7), primary caregiver status (CB = 2.3; 95% CI = 0.7-3.9), a high risk level (CB = 2.9; 95% CI = 2.1-3.6), multimorbidity (CB = 0.8, 95% CI = 0.4-1.3), chronic obstructive pulmonary disease (COPD) (CB = 1.5, 95% CI = 0.8-2.3), depression (CB = 0.8, 95% CI = 0.3-1.3), active cancer (CB = 4.4, 95% CI = 3.7-5.1), and polymedication (CB = 1.1, 95% CI = 0.5-1.7).

CONCLUSIONS

The use of hospital services by chronic patients was high and increased with the risk level assigned by the AMG. The most frequent type of contact was outpatient consultation. Use was increased with predisposing factors such as age and geographic origin and by needs factors such as multimorbidity, risk level and severe diseases requiring follow-up, home care, and palliative care.

Long-term associations between amyloid positron emission tomography, sex, apolipoprotein E and incident dementia and mortality among individuals without dementia: hazard ratios and absolute risk

Dementia and mortality rates rise inexorably with age and consequently interact. However, because of the major logistical difficulties in accounting for both outcomes in a defined population, very little work has examined how risk factors and biomarkers for incident dementia are influenced by competing mortality. The objective of this study was to examine long-term associations between amyloid PET, APOE ɛ4, sex, education and cardiovascular/metabolic conditions, and hazard and absolute risk of dementia and mortality in individuals without dementia at enrolment. Participants were enrolled in the Mayo Clinic Study of Aging, a population-based study of cognitive ageing in Olmsted County, MN, USA. All were without dementia and were age 55-92 years at enrolment and were followed longitudinally. Predictor variables were amyloid PET, APOE ɛ4 status, sex, education, cardiovascular/metabolic conditions and age. The main outcomes were incident dementia and mortality. Multivariable, multi-state models were used to estimate mortality and incident dementia rates and absolute risk of dementia and mortality by predictor variable group. Of the 4984 participants in the study, 4336 (87%) were cognitively unimpaired and 648 (13%) had mild cognitive impairment at enrolment. The median age at enrolment was 75 years; 2463 (49%) were women. The median follow-up time was 9.4 years (7.5 years after PET). High versus normal amyloid (hazard ratio 2.11, 95% confidence interval 1.43-2.79), APOE ɛ4 (women: hazard ratio 2.24, 95% confidence interval 1.80-2.77; men: hazard ratio 1.37, 95% confidence interval 1.09-1.71), older age and two additional cardiovascular/metabolic conditions (hazard ratio 1.37, 95% confidence interval 1.22-1.53) were associated with the increased hazard of dementia (all P < 0.001). Among APOE ɛ4 carriers with elevated amyloid, remaining lifetime risk of dementia at age 65 years was greater in women [74% (95% confidence interval 65-84%) high and 58% (95% confidence interval 52-65%) moderate amyloid], than men [62% (95% confidence interval 52-73%) high and 44% (95% confidence interval 35-53%) moderate amyloid]. Overall, the hazard and absolute risk of dementia varied considerably by predictor group. The absolute risk of dementia associated with predictors characteristic of Alzheimer's disease was greater in women than men while at the same time the combination of APOE ɛ4 non-carrier with normal amyloid was more protective in women than men. This set of findings may be attributed in part to different biological effects and in part to lower mortality rates in women.

Multimorbidity and mortality: A data science perspective

Background

With multimorbidity becoming the norm rather than the exception, the management of multiple chronic diseases is a major challenge facing healthcare systems worldwide.

Methods

Using a large, nationally representative database of electronic medical records from the United Kingdom spanning the years 2005–2016 and consisting over 4.5 million patients, we apply statistical methods and network analysis to identify comorbid pairs and triads of diseases and identify clusters of chronic conditions across different demographic groups. Unlike many previous studies, which generally adopt cross-sectional designs based on single snapshots of closed cohorts, we adopt a longitudinal approach to examine temporal changes in the patterns of multimorbidity. In addition, we perform survival analysis to examine the impact of multimorbidity on mortality.

Results

The proportion of the population with multimorbidity has increased by approximately 2.5 percentage points over the last decade, with more than 17% having at least two chronic morbidities. We find that the prevalence and the severity of multimorbidity, as quantified by the number of co-occurring chronic conditions, increase progressively with age. Stratifying by socioeconomic status, we find that people living in more deprived areas are more likely to be multimorbid compared to those living in more affluent areas at all ages. The same trend holds consistently for all years in our data. In general, hypertension, diabetes, and respiratory-related diseases demonstrate high in-degree centrality and eigencentrality, while cardiac disorders show high out-degree centrality.

Conclusions

We use data-driven methods to characterize multimorbidity patterns in different demographic groups and their evolution over the past decade. In addition to a number of strongly associated comorbid pairs (e.g., cardiac-vascular and cardiac-metabolic disorders), we identify three principal clusters: a respiratory cluster, a cardiovascular cluster, and a mixed cardiovascular-renal-metabolic cluster. These are supported by established pathophysiological mechanisms and shared risk factors, and largely confirm and expand on the results of existing studies in the medical literature. Our findings contribute to a more quantitative understanding of the epidemiology of multimorbidity, an important pre-requisite for developing more effective medical care and policy for multimorbid patients.

Multi-morbidity and patient-reported functional limitations: a population-based cohort study

Background

Persons who accumulate chronic conditions at a rate faster than their peers may experience accelerated aging and poor health outcomes, including functional limitations.

Methods

Adults aged ≥40 years who resided in Olmsted County, Minnesota on 1 January 2006 were identified. The prevalence of 21 chronic conditions was ascertained, and age-specific quartiles of the number of chronic conditions was estimated within 4 age groups: 40-54, 55-64, 65-74, and ≥75 years. Difficulty with nine patient-reported functional limitations (including basic and instrumental activities of daily living and mobility activities) were ascertained through 31 October 2018. Cox regression was used to model associations of chronic condition quartiles with new-onset functional limitations considered separately. We estimated absolute risk differences and hazard ratios stratified by age group, and adjusted for sex, race, ethnicity, marital status, education, and the residual effect of age.

Results

Among 39,624 persons (44.5% men, 93.2% white), the most common reported new functional limitations were difficulty with climbing stairs, walking, and housekeeping. For all functional limitations, the absolute risk differences were largest among the oldest age group (≥75 years). Approximately twofold increased hazard ratios were observed among those in the highest vs. lowest quartile for the three oldest age groups, and approximately threefold or higher hazard ratios were observed for persons aged 40-54 years.

Conclusion

Persons with increased accumulation of chronic conditions experience increased risks of developing functional limitations compared to their peers. These findings underscore the importance of assessing health status and of employing interventions to prevent and effectively manage multi-morbidity at all ages.

Trends in Cardiometabolic and Cancer Multimorbidity Prevalence and Its Risk With All-Cause and Cause-Specific Mortality in U.S. Adults: Prospective Cohort Study

Several prospective cohort studies have assessed the association between multimorbidity and all-cause mortality, but the findings have been inconsistent. In addition, limited studies have assessed the association between multimorbidity and cause-specific mortality. In this study, we used the population based cohort study of National Health Interview Survey (1997–2014) with linkage to the National Death Index records to 31 December 2015 to examine the trends in prevalence of multimorbidity from 1997 to 2014, and its association with the risk of all-cause and cause-specific mortality in the U.S. population. A total of 372,566 adults aged 30–84 years were included in this study. From 1997 to 2014, the age-standardized prevalence of specific chronic condition and multimorbidity increased significantly (P < 0.0001). During a median follow-up of 9.0 years, 50,309 of 372,566 participants died from all causes, of which 11,132 (22.1%) died from CVD and 13,170 (26.2%) died from cancer. Compared with participants without the above-mentioned chronic conditions, those with 1, 2, 3, and ≥4 of chronic conditions had 1.41 (1.37–1.45), 1.94 (1.88–2.00), 2.64 (2.54–2.75), and 3.68 (3.46–3.91) higher risk of all-cause mortality after adjustment for important covariates. Similarly, a higher risk of CVD-specific and cancer-specific mortality was observed as the number of chronic conditions increased, with the observed risk stronger for CVD-mortality compared with cancer-specific mortality. Given the prevalence of multimorbidity tended to increase from 1997 to 2014, our data suggest effective prevention and intervention programs are necessary to limit the increased mortality risk associated with multimorbidity.

The flavonoid procyanidin C1 has senotherapeutic activity and increases lifespan in mice

Ageing-associated functional decline of organs and increased risk for age-related chronic pathologies is driven in part by the accumulation of senescent cells, which develop the senescence-associated secretory phenotype (SASP). Here we show that procyanidin C1 (PCC1), a polyphenolic component of grape seed extract (GSE), increases the healthspan and lifespan of mice through its action on senescent cells. By screening a library of natural products, we find that GSE, and PCC1 as one of its active components, have specific effects on senescent cells. At low concentrations, PCC1 appears to inhibit SASP formation, whereas it selectively kills senescent cells at higher concentrations, possibly by promoting production of reactive oxygen species and mitochondrial dysfunction. In rodent models, PCC1 depletes senescent cells in a treatment-damaged tumour microenvironment and enhances therapeutic efficacy when co-administered with chemotherapy. Intermittent administration of PCC1 to either irradiated, senescent cell-implanted or naturally aged old mice alleviates physical dysfunction and prolongs survival. We identify PCC1 as a natural senotherapeutic agent with in vivo activity and high potential for further development as a clinical intervention to delay, alleviate or prevent age-related pathologies.

Multimorbidity measures from health administrative data using ICD system codes: A systematic review

BACKGROUND

We aimed to identify and characterize adult population-based multimorbidity measures using health administrative data and the International Classification of Diseases (ICD) codes for disease identification.

METHODS

We performed a narrative systematic review of studies using or describing development or validation of multimorbidity measures. We compared the number of diseases included in the measures, the process of data extraction (case definition) and the validation process. We assessed the methodological robustness using eight criteria, five based on general criteria for indicators (AIRE instrument) and three multimorbidity-specific criteria.

RESULTS

Twenty-two multimorbidity measures were identified. The number of diseases they included ranged from 5 to 84 (median = 20), with 19 measures including both physical and mental conditions. Diseases were identified using ICD codes extracted from inpatient and outpatient data (18/22) and sometimes including drug claims (10/22). The validation process relied mainly on the capacity of the measures to predict health outcome (5/22), or on the validation of each individual disease against a gold standard (8/22). Six multimorbidity measures met at least six of the eight robustness criteria assessed.

CONCLUSION

There is significant heterogeneity among the measures used to assess multimorbidity in administrative databases, and about a third are of low to moderate quality. A more consensual approach to the number of diseases or groups of diseases included in multimorbidity measures may improve comparison between regions, and potentially provide better control for multimorbidity-related confounding in studies.