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

Stories that matter: a qualitative study of general practitioners' reflections and experiences of exploring patients' impactful life stories

PURPOSE

There is solid evidence of the impact of life experiences on health. Yet, knowledge of how general practitioners (GPs) relate to patients' stories of such experiences is sparse. This study explored GPs' reflections and experiences concerning managing potentially impactful patient stories.

METHODS

We conducted four focus group interviews among Norwegian and Danish GPs and analysed them using Reflexive thematic analysis.

RESULTS

Three main themes were developed. First, GPs apply various strategies to recognize and unfold impactful stories. Second, they attribute diverse purposes to engaging with these stories, from viewing them as instrumentally useful to recognizing their intrinsic value. These views influence GPs' objectives and strategies when managing impactful stories. The instrumental utility approach can lead to an unfair dismissal of impactful stories. Finally, the commitment of some of the GPs to patients' impactful stories is considered fulfilling and highly satisfactory but also associated with external resistance.

CONCLUSIONS

Patients and GPs encounter difficulties in addressing impactful stories, which resonate with the theory of epistemic injustice. Nevertheless, engaging with these stories is vital for providing ethically grounded and meaningful primary care. The paper proposes strategies and a conceptual framework to support work with impactful stories in clinical practice.

Adverse childhood experiences with physical, depressive, and cognitive multimorbidity among Chinese adults and the mediating role of loneliness

Little is known about the associations between adverse childhood experiences (ACES) and physical, depressive, and cognitive (PDC) disorders and their multimorbidity. Moreover, no study has assessed whether loneliness mediates any such associations. Using a nationally population-based study in China, we aimed to investigate the associations between ACES and PDC disorders and their multimorbidity among 11,124 middle-aged and older adults. Eight categories of outcomes including no disorders, physical disorder, depressive symptoms, cognitive disorder, and their four combinations were assessed. Twelve ACES indicators were measured using a validated questionnaire. Multivariate logistic regression and stratification analyses were performed to explore the association between ACES and PDC disorders and their multimorbidity, as well as potential modifiers. Mediate analyses were applied to examine the potential pathways via loneliness. Of the 11,124 individuals (45.8 % women, mean [SD] age: 60.1 [8.9] years), 79.3 % had at least one ACE. Compared with individuals without ACES, those who had four or more ACES had elevated risks of PDC disorders and their multimorbidity. The estimated odds ratios (OR) were 2.95 (95 % CI: 2.46-3.54) for physical-depressive multimorbidity, 1.59 (1.28-1.98) for physical-cognitive multimorbidity, 2.58 (2.01-3.31) for depressive-cognitive multimorbidity, and 2.91 (2.15-3.96) for PDC multimorbidity, respectively. There is an exposure-response relationship between cumulative ACES with different outcomes. These associations were mediated by loneliness, with a mediation proportion varying from 8.7 % to 32.5 %. However, no significant modification was observed by sex, age, educational level, and childhood economic status. Our findings provided important insights for reducing childhood adversity to prevent chronic multimorbidity.

The association between multimorbidity and out-of-pocket expenditure for prescription medicines among adults in Denmark: A population-based register study

BACKGROUND

Multimorbidity, defined as two or more chronic conditions in an individual, is increasing in prevalence and is associated with polypharmacy. Polypharmacy can lead to increased out-of-pocket payments for prescription medicines. This, in turn, can be associated with cost-related non-adherence and impoverishment. Healthcare in Denmark is mostly free at the point-of-use; prescription medicines are one of the only exceptions.

OBJECTIVE

To examine the association between multimorbidity and annual out-of-pocket prescription medicine expenditure for adults in Denmark.

METHODS

A population-based register study was conducted. The study population included all adults residing in Denmark in 2020. Frequencies and descriptive statistics were used and regression analyses were conducted to assess the association between multimorbidity and annual out-of-pocket prescription medicine expenditure, while controlling for demographic and socioeconomic covariates.

RESULTS

Overall, 1,212,033 (24.2 %) individuals had multimorbidity. Individuals with five or more conditions spent, on average, €320 in out-of-pocket prescription medicines expenditure compared to €187 for those with two conditions and €44 for those with no conditions. Amongst those with any out-of-pocket prescription medicine expenditure, having multimorbidity was associated with 2-4 times greater out-of-pocket prescription medicine expenditure than those with zero conditions. Amongst those in the quantile with the highest expenditure, those with five or more conditions spent €408 more than those with no conditions, and those with two conditions spent €185 more than those with no conditions.

CONCLUSIONS

For adults in Denmark, multimorbidity was associated with significantly higher out-of-pocket prescription medicine expenditure, even after controlling for demographic and socioeconomic covariates. This is similar to patterns in other countries and likely affects those with lowest income the most, given the known socioeconomic patterning of multimorbidity, and raises concerns about cost related non-adherence. Potential protective mechanisms could include subsidies for certain vulnerable patient groups (e.g. those with severe mental illness) and low-income groups.

Global, regional, and national burdens of hip fractures in elderly individuals from 1990 to 2021 and predictions up to 2050: A systematic analysis of the Global Burden of Disease Study 2021

PURPOSE

We aimed to analyse the global, regional, and national burdens of hip fractures in older adults from 1990 to 2021, with projections to 2050, on the basis of data from the GBD 2021 study.

METHODS

We employed a joinpoint model to analyse trends in the burden of hip fractures from 1990‒2021. The estimated annual percentage change (EAPC) was used to quantify temporal trends over this period. We evaluated the relationship between the social development index and the burden of hip fracture in elderly people and conducted a health inequality analysis. Additionally, we applied Long-short Term Memory (LSTM) networks to forecast burden trends of hip fractures up to 2050.

RESULTS

The global age-standardized incidence rate (ASIR) for hip fractures in older adults rose from 781.56 per 100,000 in 1990 to 948.81 in 2021. The 2021 age-standardized prevalence rate (ASPR) was 1,894.07, and the age-standardized YLD rate (ASDR) was 173.52. From 1990 to 2021, the incidence and prevalence increased by 168.71 % and 173.07 %, respectively, while the burden of DALYs decreased. Future trends were projected via the LSTM. The burden and risk factors for hip fractures varied significantly by sex, country, and region. Population and aging are primary contributors to the rising incidence of elderly hip fractures, with falls being the leading direct cause.

CONCLUSION

From 1990 to 2021, the global burden of hip fractures in the elderly population, especially among older women, steadily increased. Population ageing highlights the urgent need for targeted public health interventions and resource allocation, including early diagnosis, effective prevention strategies, and region-specific management approaches.

Mitochondrial dysfunction as a biomarker of frailty: The FRAMITO study protocol

Frailty syndrome often coexists with multimorbidity, sharing several risk factors and outcomes. Therefore, considering multimorbidity when exploring frailty biomarkers may deepen our understanding of these conditions' pathophysiology. In this regard, most studies focused on inflammation, but markers of mitochondrial dysfunction, such as mitochondrial DNA damage, cell respiratory impairment, and oxidative stress, are less explored. The FRAMITO project aims to evaluate mitochondrial dysfunction in frailty, with and without multimorbidity. This cross-sectional study will enroll 75 individuals aged ≥65 years from inpatient and outpatient clinics at the Geriatrics Units of the University Hospital of Ferrara (Ferrara, Italy) and Fondazione IRCCS San Gerardo dei Tintori (Monza, Italy). Participants will be categorized into three groups: 25 without frailty and multimorbidity, 25 with frailty but not multimorbidity, and 25 with frailty and multimorbidity. Blood samples will be collected to isolate Peripheral Blood Mononuclear Cells. Frailty biomarkers will be identified using untargeted metabolomics and functional studies on mitochondrial dysfunctions in PBMCs and their subpopulations, evaluating mitochondrial DNA damage, mitochondrial and glycolytic cellular bioenergetics, and intracellular reactive oxygen species. This project will advance our understanding of mitochondrial dysfunctions in frailty, particularly when combined with multimorbidity, revealing potential synergistic effects. CLINICALTRIAL.GOV REGISTRATION NUMBER: NCT06433427.

Multimorbidity and analgesic-related harms: a systematic review

BACKGROUND

Multimorbidity is the presence of two or more long-term medical conditions. Chronic pain affects more than half of people with multimorbidity, and optimal treatment strategies are unknown. We aimed to quantify the risk of adverse outcomes from the following analgesics: opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids in adults with multimorbidity.

METHOD

The review was registered on PROSPERO (CRD42023462592). We searched Medline, CINAHL, Web of Science, Embase, and CENTRAL for studies reporting analgesic-related harms in people with multimorbidity or the impact of multimorbidity on harms in adults exposed to analgesics. Two researchers independently screened titles/abstracts, completed full-text reviews, extracted data, and assessed risk of bias using the Newcastle-Ottawa scale. Studies were synthesised narratively, grouping by analgesic class and direction of effect.

RESULTS

We screened 6690 records and 344 full texts, with 27 studies included (n=2 671 958 patients). Studies were heterogenous, with variable quality (high risk of bias, n=11). Most studies on opioids reported adverse outcomes (12/16). Opioid use compared with non-use was associated with increased mortality in adults with multimorbidity. Multimorbidity was associated with opioid overdose and death among adults prescribed opioids for pain. Half of studies of NSAIDs reported adverse outcomes (6/11) including gastrointestinal bleeding. Only one study assessed gabapentinoids which found an association with delirium and pneumonia, but not mortality in people with multimorbidity.

CONCLUSIONS

There is evidence of harms associated with opioids in adults with multimorbidity, including overdose and increased mortality. There is a lack of evidence on gabapentinoids. Further research is required to understand optimal analgesic management in people with multimorbidity.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42023462592).

Cluster and survival analysis of UK biobank data reveals associations between physical multimorbidity clusters and subsequent depression

BACKGROUND

Multimorbidity, the co-occurrence of two or more conditions within an individual, is a growing challenge for health and care delivery as well as for research. Combinations of physical and mental health conditions are highlighted as particularly important. Here, we investigated associations between physical multimorbidity and subsequent depression.

METHODS

We performed a clustering analysis upon physical morbidity data for UK Biobank participants aged 37-73. Of 502,353 participants, 142,005 had linked general practice data with at least one baseline physical condition. Following stratification by sex (77,785 women; 64,220 men), we used four clustering methods and selected the best-performing based on clustering metrics. We used Fisher's Exact test to determine significant over-/under-representation of conditions within each cluster. Amongst people with no prior depression, we used survival analysis to estimate associations between cluster-membership and time to subsequent depression diagnosis.

RESULTS

Our results show that the k-modes models perform best, and the over-/under-represented conditions in the resultant clusters reflect known associations. For example, clusters containing an overrepresentation of cardiometabolic conditions are amongst the largest (15.5% of whole cohort, 19.7% of women, 24.2% of men). Cluster associations with depression vary from hazard ratio 1.29 (95% confidence interval 0.85-1.98) to 2.67 (2.24-3.17), but almost all clusters show a higher association with depression than those without physical conditions.

CONCLUSIONS

We show that certain groups of physical multimorbidity may be associated with a higher risk of subsequent depression. However, our findings invite further investigation into other factors, such as social considerations, which may link physical multimorbidity with depression.

Vitamin D status, vitamin D receptor polymorphisms, and risk of cardiometabolic multimorbidity

BACKGROUND

The prevalence of cardiometabolic multimorbidity (CMM) has increased substantially in recent years. Previous studies have established the associations between vitamin D, vitamin D receptor (VDR) polymorphisms, and the risk of individual cardiometabolic disease (CMD). However, the role of these factors in the progression of CMD to CMM or mortality remains unclear. This study aimed to investigate the associations between vitamin D, VDR polymorphisms, and the dynamic progression of CMM, as well as to explore the potential modification effect of VDR polymorphisms.

METHODS

Data for this cohort study were extracted from the UK Biobank. CMM was defined as the coexistence of at least two CMDs, including type 2 diabetes (T2D), coronary heart disease (CHD), and stroke. A multi-state model was used to analyze associations between serum 25(OH)D, VDR polymorphisms and the dynamic progression of CMM.

RESULTS

The sample included 396,192 participants. Over a median follow-up of 13.8 years, 55,772 individuals experienced at least one CMD and 28,624 died. Compared to participants with 25(OH)D < 25 nmol/L, those with 25(OH)D ≥ 75 nmol/L had HRs of 0.70 (95% CI, 0.67, 0.72) for baseline to first CMD (FCMD), 0.74 (95% CI, 0.67, 0.82) for FCMD to CMM, 0.66 (95% CI, 0.62, 0.70) for baseline to death, 0.84 (95% CI, 0.77, 0.92) for FCMD to death, and 0.85 (95% CI, 0.70, 1.03) for CMM to death. L-shaped relationships of these associations were noted, with a threshold around 45 nmol/L. The rs1544410 (BsmI) T alleles may have a detrimental effect, while the rs11568820 (Cdx2) T alleles may exert a protective effect in the early stages of CMM progression. Additionally, VDR polymorphisms significantly modified the association between serum 25(OH)D and certain stages of CMM progression.

CONCLUSIONS

Maintaining adequate vitamin D levels, as a readily implementable intervention strategy, not only reduces the risk of initial CMD but also delays the progression to CMM or death. Risk stratification based on VDR polymorphisms provides further insights for developing personalized prevention strategies.

Anxiety, depression, and poor sleep quality in two-year survivors of mild to severe SARS-CoV-2 infection and matched comparison groups

OBJECTIVE

This study explores differences in the co-distribution of anxiety and depression symptoms and sleep quality scores between survivors of COVID-19 and comparison groups, nearly two years after COVID-19 diagnosis.

METHODS

Individuals enrolled at primary healthcare centers of Matosinhos were selected and grouped according to hospitalization and SARS-CoV-2 infection between March 2020 and February 2021: group#1, hospitalized due to COVID-19 (n = 96); group#2, hospitalized, uninfected (n = 81); group#3, infected, non-hospitalized (n = 205); group#4, uninfected, non-hospitalized (n = 236). Groups #2 and #4 were matched to groups #1 and #3, respectively, in a ratio of 1:1, by age, sex and level of care. They were evaluated between July 2022 and October 2023 with the Hospital Anxiety and Depression Scale (subscales HADS-A, anxiety, and HADS-D, depression) and the Pittsburgh Sleep Quality Index (PSQI). Partition clustering centered on the median of HADS-A, HADS-D, and PSQI scores was used to identify two clusters. Logistic regression was used to compute adjusted Odds Ratios (aOR) and 95 % confidence intervals (CI) of the associations between the study group and the two clusters.

RESULTS

The cluster of worse mental health (n = 338) presented scores mostly above five, while the best mental health cluster (n = 280) presented scores up to five. Participants infected with SARS-CoV-2 during the first year of the pandemic were more likely to have worse mental health (aOR, 95%CI: 1.46, 1.03-2.05).

CONCLUSIONS

Survivors of COVID-19 of the first year of the pandemic may require a special clinical attention to ensure that care is provided to improve mental health and prevent a worsening of anxiety and depression symptoms, and sleep problems.

Early adversity and the comorbidity between metabolic disease and psychopathology

Although the co-existence of metabolic and psychiatric disorders in the same individual (comorbidity) is very prevalent, the mechanisms by which these disorders co-occur are poorly understood, but a history of early-life adversity is a common developmental risk factor. Exposure to adverse environments during critical periods of development (e.g. fetal life and infancy) modifies the metabolism and the function of the brain persistently, influencing behaviours that contribute to both metabolic and mental health disarrangements over the life course. We will review molecular and clinical evidence supporting the notion that early adversity is an important risk factor for the comorbidity between metabolic and psychiatric conditions. We will also discuss the possible mechanisms involved: neurometabolic programming, epigenetic alterations and the cumulative effects of altered inflammatory and oxidative pathways linked to early adversity.

Exploring perspectives on the management of patients with complex care needs in stroke rehabilitation: An interpretive description study

BACKGROUND

Exploring the "wicked" problem of improving care for patients with complex care needs could benefit a large swath of health system stakeholders given the breadth and depth of this issue. Patients with complex health and social needs often require customized care that deviates from expected care trajectories. At Canadian Stroke Distinction sites, clinicians provide care for a high proportion of patients with complex needs while adhering to best practice recommendations.

METHODS

We conducted an interpretive description study, which explored the perspectives of 16 stroke rehabilitation clinicians, four organizational key informants, and two health system key informants. We collected data via 45- to 60-minute virtual interviews and engaged in a hybrid inductive-deductive approach to analysis.

RESULTS

We constructed three main themes: (a) recognizing complexity is routine work for clinicians, (b) clinicians use workarounds to manage complexity, and (c) clinicians perceived and worked to bridge a difference between organizational processes and the realities of patient care. When comparing clinician and key informant perspectives, we noted differences regarding their perceptions of the prevalence and nature of patient complexity. We developed the concept of "work-as-expected" as an intermediary to bridge the gap between the "work-as-imagined" and "work-as-done" framework.

CONCLUSION

We describe the strategies used by expert clinicians to continually manage care for a high proportion of patients with complex care needs. Although expert clinicians have developed effective workarounds, they experience significant moral distress when these strategies are unable to compensate for health system limitations.

PRACTICE IMPLICATIONS

A better understanding of how clinicians manage the needs of patients with complex care needs could support policymakers and organizational leaders to consider macro- and meso-level strategies to support the adaptive practices of clinicians.

Associations between comorbidities and patient-reported outcomes in axial spondyloarthritis: data from a single-center real-world cohort

INTRODUCTION

Comorbidities are frequently present in patients with axial spondyloarthritis (axSpA) and may contribute to poorer health-related outcomes. Patient-reported outcomes (PROs) serve as tools to assess the patient's perspective on the burden of the disease. The study aimed to evaluating the impact of comorbidities on selected PROs in axSpA.

METHOD

Adult patients diagnosed with axSpA based on ASAS classification criteria were included in this cross-sectional study. Data collected included comorbidities and PROs [Health Assessment Questionnaire (HAQ), Multi-Dimensional Health Assessment Questionnaire (MDHAQ), 36-Item Short Form Health Survey (SF-36), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and Bath Ankylosing Spondylitis Functional Index (BASFI)].

RESULTS

In total, 323 participants were included in the study (44.0% female). Multimorbidity and extended multimorbidity were observed in 63.8% and 38.7% of patients, respectively. Extended multimorbidity was associated with higher HAQ (0.5 [0.1-1.0] vs. 0.3 [0.0-0.8], p < 0.01) and MDHAQ scores (0.3 [0.0-0.6] vs. 0.1 [0.0-0.5], p = 0.03). The BASDAI score was higher in patients with three or more comorbidities than in patients with no comorbidities (2.8 [1.7-4.3] vs. 1.9 [0.9-3.6], p < 0.01). The number of comorbidities was associated with higher scores in the mental health (β = 0.20, p < 0.01) and vitality (β = 0.16, p = 0.02) domains of the SF-36 questionnaire.

CONCLUSIONS

Multimorbidity was present in almost two-thirds of cases. Extended multimorbidity was associated with poorer physical functioning, HAQ, MDHAQ, and BASDAI scores, whereas multimorbidity was related to better scores in the mental health and vitality domains. The impact of comorbidities on PROs in axSpA should not be overlooked. Key Points • Multimorbidity is frequent among axial spondyloarthritis' patients. • Only extended multimorbidity (presence of two or more additional diseases, excluding axial spondyloarthritis) was found to be associated with poorer results of patient-reported outcomes, in particular these regarding physical functioning. • Multimorbidity might influence positively some domains of quality of life such as mental health or vitality. • The findings included in the study support the belief that in patients with spondyloarthritis comorbidities might impact patient-reported outcomes which are important when assessing disease activity and response to treatment and should not be disregarded.

Social determinants of distress in South Asian men with long-term conditions: a qualitative study in primary care

BACKGROUND

People with long-term physical conditions are more likely to experience distress, depression, or anxiety. Physical-mental comorbidity is associated with lower quality of life, poorer clinical outcomes, and increased mortality than physical conditions alone. People of South Asian origin are the largest minority group in the UK, and more likely to have long-term conditions (LTCs) such as diabetes and heart disease.

AIM

To explore how men of South Asian origin with LTCs understand and experience emotional distress as well as the experiences of GPs supporting them.

DESIGN AND SETTING

A UK qualitative study interviewing South Asian men with diabetes or coronary heart disease, and GPs working at practices with higher proportions than average in the UK of people of South Asian origin.

METHOD

Online semi-structured interviews with South Asian men and GPs were undertaken. Data were analysed via reflexive thematic analysis. Topic guides were modified iteratively as data collection and analysis progressed. An ethnically appropriate patient advisory group of South Asian men was involved in all stages of the research.

RESULTS

Seventeen South Asian men with LTCs and 18 GPs were interviewed. Participants described contextualising distress, including LTCs influencing distress and the intersections of social determinants of distress including ethnicity, poverty, and perceptions of prejudice. Participants understood distress as different from depression with the need to negotiate multiple identities as well as integrative paradigms of health.

CONCLUSION

This study highlights the influence of social determinants of distress in South Asian men with LTCs. It provides an insight into how primary care has the potential to address health inequalities by considering the intersection of these factors.

In Pursuit of a Person-Centered Approach to Care Delivery: A Qualitative Descriptive Study of the Patient Experience of a Long-Term Conditions Clinic in General Practice

Innovative ways of working are emerging in health care to meet the complex needs of people living with multiple long-term conditions. While these initiatives are often measured for their health and economic outcomes, few studies prioritize the patient experience. This qualitative descriptive study is one of a few studies exploring the patient experience of attending a dedicated long-term conditions annual review clinic in a primary care setting in England. The service model aims to provide a person-centered, holistic approach to the management and support of people living with multiple long-term conditions. The study presents findings from in-depth interviews with 12 participants. Data analyzed through framework analysis revealed four themes relating to the patient experience: the clinic as a place, continuity, staying healthy, and partnership opportunities. Results highlight the challenges to providing personalized care. We found that attendance at the clinic prompted self-care behaviors, however, patients wanted a more holistic, integrated, and consistent service that provided continuity of therapeutic relationships that involved them in decision-making and care planning. We conclude that the experience of patients in this study suggests this service model can enable patients to manage their health and improve well-being, however, while a person-centered philosophy may underpin service models, our research shows that ensuring this philosophy is born out in service delivery and recognized by patients is problematic. Therefore, service providers need to recognize the values and perspectives of patients, aligning these with the design and delivery of services.

Clinical pharmacist assessment of older adults' functional abilities to take their medication: a cross-sectional descriptive study in a geriatric acute care ward

OBJECTIVES

Aging is associated with a decline in functional capacities, which can lead to challenges in medication preparation. Identifying these issues appears essential. The objectives of this study were to describe the proportion of pharmaceutical interventions carried out following the identification of patient difficulties in preparing and administering medications, and to characterize the difficulties identified.

STUDY DESIGN

Descriptive cross-sectional study with data collected during 42 pharmaceutical interviews with patients hospitalized on an acute geriatric ward. The interview consisted of two parts: i) a questionnaire assessing potential difficulties, and ii) direct observation of medication preparation using pharmaceutical forms similar to those usually prescribed to the patient.

MAIN OUTCOME MEASURES

The main outcome was the occurrence of at least one pharmaceutical intervention following the identification of difficulties.

RESULTS

Pharmaceutical intervention was suggested to 95.0 % of patients where a difficulty was identified, representing 45.2 % of patients included. Interventions included education on correct use (16.0 %), substitution of pharmaceutical forms (16.0 %), implementation of tools for patients (36.0 %) and home assistance (32.0 %). These interventions were accepted by the geriatrician in all cases and by the patient in 80.0 %. At least one difficulty was identified for 47.7 % of the patients.

CONCLUSIONS

This study shows that identifying functional difficulties in medication preparation enables tailored interventions to address these issues. Observing older adults' abilities to manage their medication could reduce the risk of medication errors and probably enhance their daily quality of life.

The Multimorbidity Questionnaire (MMQ1): English translation and validation of a Danish patient reported outcome measure for quality of life in people with multiple long-term conditions in a cross-sectional survey

PURPOSE

MMQ1 is a Danish-language patient-reported outcome measure (PROM) for quality of life (QOL) in people with multiple long-term conditions (MLTC). It measures needs-based QOL across six scales: Physical ability, Concerns and worries, Limitations in daily life, Social life, Personal finances and Self-image. There is currently no such measure available in English. This study aimed to translate and validate MMQ1 for use in the United Kingdom.

METHODS

Translation used a two-panel method (expert panel: n = 5; and lay panel: n = 6). Content validity was assessed via cognitive interviews (n = 6). A postal survey of 2,753 patients with MLTC recruited through eight GP practices in Scotland included EQ-5D-5L and ICE-CAP as comparator measures alongside MMQ1. Classical test theory psychometric analysis of survey responses followed the International Society for Quality of Life Research minimum reporting standards.

RESULTS

Translation resulted in an English-language MMQ1 with good face validity. Cognitive interviews established good content validity. 597 survey responses were received (response rate 22%). Good internal consistency reliability and concurrent validity were demonstrated. Confirmatory factor analysis showed acceptable fit to the six-scales of MMQ1. Five of the six scales also demonstrated good discriminative ability for detecting clinically meaningful differences in QOL. However, inter-item and inter-scale correlations suggested item redundancy and scale overlap.

CONCLUSION

The English-language MMQ1 demonstrated adequate psychometric properties using classical test theory. Further validation using Rasch analysis is planned, and may help optimise and abbreviate the measure. This PROM has the potential to improve the measurement of QOL in MLTC research, including trials.

Comparison of retroperitoneal laparoscopic radical nephroureterectomy outcomes in elderly patients based on the Geriatric 8 (G8) screening tool

AIM

The Geriatric 8 (G8) screening tool consists of eight questions and is widely used to assess geriatric frailty. This study aimed to compare laparoscopic radical nephroureterectomy outcomes in patients aged >70 years with high and low G8 scores.

MATERIALS AND METHODS

Patients who underwent laparoscopic radical nephroureterectomy at a single center between 2017 and 2022 were included in this study. Patient background and perioperative outcomes were evaluated in two groups: low G8 (<14) and high G8 (≥14). The effects of age and body mass index (BMI) were assessed using logistic regression models adjusted for inverse-probability treatment weighting in the low G8 and high G8, respectively.

RESULTS

In total, 37 cases were categorized as low G8 and 30 cases as high G8. Significant differences in patient background were found in terms of age, BMI, American Society of Anesthesiologists physical status, presence of dementia, and estimated glomerular filtration rate (eGFR). Significant differences in perioperative outcomes were observed in the operative time and number of lymph node dissections. Postoperative delirium and eGFR were significantly higher in the low G8 group. The high G8 group showed significantly higher recurrence-free survival and overall survival rates than the low G8 group. After adjustment using the inverse-probability treatment weighting method, postoperative delirium and eGFR were significantly higher in the low G8 group but there were no significant differences in recurrence-free survival rates, cancer-specific survival, or overall survival.

CONCLUSION

After adjusting for age and BMI, preoperative G8 had a different frequency of postoperative delirium but had no effect on prognosis. Geriatr Gerontol Int 2025; 25: 694-700.

Multimorbidity in acute ischemic stroke and its impact on short-term mortality: A Chilean nationwide database analysis

BACKGROUND

Multimorbidity predicts a worse prognosis for various diseases but its impact in people after an acute ischemic stroke (AIS) in developing societies is not well established. We aimed to characterize the pattern of multimorbidity and determine its association with in-hospital mortality after AIS in the nationwide Chilean database.

METHODS

A retrospective analysis of the Diagnosis-Related Groups database for hospitalized adult patients in Chile in 2019 was conducted. Association of multimorbidity, defined as the presence of ≥2 health conditions, in patients with AIS (ICD-10 code I63) on in-hospital mortality was determined in logistic regression models adjusted for confounding variables.

RESULTS

Of 1,048,575 recorded ICD-10 codes, there were 10,440 AIS episodes in whom 7,696 (73.7 %) patients had multimorbidity. Age, female sex, and low socioeconomic status were associated with a higher multimorbidity, and the combination of comorbidities differed across age groups. Cardiometabolic multimorbidity was associated with higher in-hospital mortality (odds ratio [OR] 1.39, 95 % confidence interval [CI] 1.16-1.66; p<0.001). Stage 5 chronic kidney disease combined with ischemic heart disease was the comorbidity with the highest risk of death (OR 4.20, 95 %CI 1.58-11.16; p = 0.004). Obesity, which exhibited a predominance in early to mid-life, had the highest association with mortality when combined with other conditions.

CONCLUSIONS

Multimorbidity is common in patients with AIS and its components vary by age and sex. Cardiometabolic multimorbidity increases the likelihood of in-hospital mortality. Adopting a multimorbidity-focused approach to stroke care could improve outcomes.

Frailty, multimorbidity, and polypharmacy: Proposal of the new concept of the geriatric triangle

As people age, the prevalence of frailty, multimorbidity, and polypharmacy increases, presenting significant challenges in geriatric medicine. These three elements are interrelated in a bidirectional manner, forming what can be termed the "geriatric triangle." The complexity of their interconnections means that addressing each issue in isolation is insufficient for achieving an effective resolution. Thus, a comprehensive understanding of this geriatric triangle is essential for appropriate geriatric management. This review aims to illuminate the relationships within the geriatric triangle and to offer insights into potential strategies for managing these interconnected challenges. Geriatr Gerontol Int 2025; 25: 657-662.

The GP's a stranger: an interpretive phenomenological analysis exploring patient experiences of changed access to primary care in the management of long-term conditions

Introduction

Self-management is promoted as a mechanism for those with long-term health conditions to manage their condition day-to-day. Changes in access to primary care in the UK have led to an increased patient burden and reduced access to care.

Methods

This exploratory study considered the impact of such changes for those managing long term physical and mental health conditions. An interpretative phenomenological analysis approach was adopted. Interviews were conducted with eight individuals affected by long-term physical and/or mental health conditions.

Results

One overarching superordinate theme was identified as significant to all participants: The GP's a stranger. This superordinate theme was fundamental to five lower order themes: Role of GP; Fighting to gain access; Dismissed, depersonalised and devalued; Resourcefulness borne of desperation, and "There was something wrong", which offered insights into the experiences of participants.

Discussion

Those living with long-term conditions often know when they need to seek additional healthcare support however they shared multiple barriers to accessing this support when needed and reported that the lack of relationship with any health care professional in primary care affected their ability to trust any care advice they were given. Considerations of a new way of operating within a changed paradigm of primary care are explored.

Scope of practice, competencies and impact of advanced practice nurses within APN-led models of care for young and middle-aged adult patients with multimorbidity and/or complex chronic conditions in hospital settings: a scoping review

INTRODUCTION

The number of young and middle-aged adult patients with multimorbid and/or complex chronic conditions is rising, presenting challenges for healthcare systems. Advanced practice nurses (APNs) are crucial in treating these patients due to their expertise and advanced nursing skills. The article outlines the scope of practice (SOP), competencies and impact of APNs in APN-led models of care for this patient group in hospital settings.

OBJECTIVES

Description of the SOP, competencies and impact of APNs within APN-led care models for young and middle-aged adult patients in hospital settings.

DESIGN

Scoping review based on the methodological framework by Arksey and O'Malley, incorporating the methodological enhancement of Levac and collegues, complying with the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines of Tricco and collegues. DATA SOURCES: Systematic research was conducted in the databases MEDLINE (PubMed), CINAHL (EBSCO), EMBASE (Ovid), CENTRAL and PsycINFO (Ovid) using all recognised keywords, item terms and search strings, and OpenGrey was scanned until December 2023. Studies published in English, German or translatable to English using translation tools were included.

ELIGIBILITY CRITERIA

Studies of APN-led models of care in hospitals were included if they involved adult participants aged 18-64 years with multimorbidity (two or more chronic conditions) and/or complex chronic conditions and provided information on SOP, competencies or impact.

DATA EXTRACTIONS AND SYNTHESIS

Data from full-text articles meeting the inclusion criteria were extracted independently by two reviewers, and a narrative summary was developed to present the results related to the objectives and questions of the study.

RESULTS

A total of 2119 records were retrieved, with five studies ultimately included. The results included predischarge, postdischarge and bridging transition SOP. The competencies of APNs varied in both form and intensity, due to the heterogeneity of the APN-led models. Direct clinical practice competencies were most frequently described, especially regarding nursing or medical tasks, and shaped and influenced competencies in leadership, collaboration, guidance and coaching, and evidence-based practice. Indirect care activities were often mentioned. These studies indicated that APNs in APN-led care models positively impact clinical and patient outcomes, although high-intensity integrated care did not lead to cost reductions.

CONCLUSION

The review aims to highlight the heterogeneity and current state of knowledge about the potential role of APNs in the integrated care of this increasing patient group in hospitals. The findings emphasise the significance of focusing on the unique needs of this patient population and may serve as a foundation for developing an APN-led model of care for this group in the clinical setting. However, further research is necessary to better elucidate the role of APNs within APN-led care models in relation to the care needs of this patient group.

TRIAL REGISTRATION NUMBER

OSF 4PM38.

Persistent pain is associated with poorer balance and gait performance for people with Chronic Obstructive Pulmonary Disease

BACKGROUND

People with COPD fall due to balance and gait impairments, and frequently report pain. The influence of pain on balance and gait in people with COPD is unknown. We aimed to compare balance and gait in people with COPD with and without persistent pain and explore factors associated with poor balance and gait.

METHODS

43 participants' characteristics and pulmonary rehabilitation outcomes were recorded. Participants were assigned to two groups, those with persistent pain (pain lasting ≥3months) (n = 25) and those without (n = 18) for analysis. Between-group differences were calculated for pain (BPI-SF), balance (BESTest, BBS), gait (GAITrite), isokinetic hip, knee and ankle strength (MVC), lower limb muscle endurance (30 s STS), physical activity (PASE) and Maximal Inspiratory Pressure (Pimax). Associations between neuromuscular factors and balance/gait outcomes were investigated.

RESULTS

BESTest and BBS scores were 14.0 % (95 % CI: 7.4-20.6) and 3.0 (95 % CI: 0.7-5.3) lower, for the persistent pain group. Mean gait speed was slower for the pain group (0.99 m/s vs 1.18 m/s, 95 %CI for difference: 0.03-0.35 m/s, group main effect: p = 0.02). The mean reduction in dual-task vs single-task gait speed was greater in the pain group (0.12 m/s vs 0.05 m/s, interaction effect: p = 0.045). Lower BESTest scores were associated with poorer muscle endurance (r = 0.650), pain severity (r = -0.584), and weaker hip abductors (r = 0.370) and ankle plantar-flexors (r = 0.438). No associations were apparent for gait speed.

CONCLUSION

People with COPD plus pain have worse balance and slower gait speed, especially under dual-task conditions. Pain severity, muscle endurance and hip and ankle strength are associated with balance performance.

Prevalence of multimorbidity and its relationship with socioeconomic status among Chinese older adults over time

Previous studies linking socioeconomic status (SES) to chronic diseases tended to focus on a single disease. As people age, they are more likely to suffer from multiple coexisting chronic conditions, known as multimorbidity. The study of multimorbidity is one of the key links to understanding the impact of population ageing from a comprehensive perspective. This study used four waves of cross-sectional data from the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2018 to explore the prevalence of multimorbidity and its relationship with socioeconomic status among older adults in China over time. Participants aged 60 and older were selected for analysis. Both the Logistic Regression Model and the Negative Binomial Regression Model were adopted to examine the relationship between socioeconomic status and multimorbidity. The results showed that the prevalence of multimorbidity among older adults in China demonstrated an increasing trend over the years, from 46.16% in 2011 to 57.50% in 2018. A significant association was detected between socioeconomic status and multimorbidity among older adults, which was manifested as the higher the socioeconomic status, the greater the likelihood of being multimorbid. However, the relationship between the two has been changing over time, with the influence of SES on multimorbidity gradually disappearing and then reappearing in the opposite direction. Multimorbidity has become a critical health issue that should not be ignored for older adults in China, and the relationship between socioeconomic status and multimorbidity may be changing over time, which needs to be further explored with data over a longer period of time.

Physical health trajectories of young people with neurodevelopmental conditions: a protocol for a systematic review of longitudinal studies

INTRODUCTION

There is now emerging evidence to suggest a longitudinal association between specific neurodevelopmental conditions (NDCs) in childhood or adolescence (ie, autism, attention deficit hyperactivity disorder (ADHD) and tic disorders) and certain physical long-term conditions (LTCs) in adulthood. However, to date, this literature has never been comprehensively collated and appraised. As a result, our understanding of all the future health risks that young people with NDCs may collectively be at risk of is limited, and the factors which drive these adult health outcomes also remain obscure.

METHODS AND ANALYSIS

A search strategy has been developed in collaboration with two medical librarians and will be used to conduct systematic searches of MEDLINE, EMBASE, APA PsycINFO, CINAHL and Web of Science. Prospective longitudinal studies exploring the association between three common NDCs in childhood or adolescence (ie, ADHD, autism and tic disorders <18 years of age) and any physical LTC in adulthood (ie, >18 years of age) will be selected through title and abstract review, followed by a full-text review. Data extracted will include the definition of exposure and outcome, mediators or moderators investigated, confounders adjusted for, and crude and adjusted effect estimates. Risk of bias assessment will be conducted. Results will be synthesised narratively and, if the data allow, a meta-analysis will also be conducted.

ETHICS AND DISSEMINATION

Ethics approval is not applicable for this study since no original data will be collected. The results of the review will be widely disseminated locally, nationally and internationally through peer-reviewed publications, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42024516684.

Ageing, multimorbidity, and quality of life: a mediation analysis using longitudinal ageing study in India

Background

The ageing population in India is growing rapidly, but the decline in healthy life expectancy is more pronounced. This trend has been compounded and constituted by poor quality of life (QoL), with the salient underlying role of multimorbidity as the leading risk factor. This study primarily aimed to assess the intermediating role of multimorbidity as the risk factor for exogenous socioeconomic and demographic factors on QoL.

Methods

This study used data from 73,396 individuals aged 45 years and above from the Longitudinal Ageing Study in India (LASI), Wave - 1, 2017-18. Multimorbidity was defined as the simultaneous existence of two or more chronic conditions in an individual. The QoL score was constructed using Principal Component Analysis (PCA) by utilizing 21 factors under six domains (physical health, psychological health, social relationship, environmental satisfaction, life satisfaction and general health), with the composite QoL score ranging from 0 to 100. Further, the Structural equation model (SEM) was used to assess the role of multimorbidity as the intermediating risk factor for exogenous factors on QoL.

Results

Distributions of morbidities burden were skewed toward non-communicable diseases (NCDs) and sequentially escalated multimorbidity burden was observed among the oldest of old age groups. After the age of 75, there was a steep decline in the gradient of QoL score. The SEM results showed a substantial rise in multimorbidity burden leading to poor QoL with a magnitude of β = -2.39, p < 0.001. Age and sex of the respondents exhibited a significant negative impact on QoL, impacting it directly (β = -1.25; β = -1.19) as well as indirectly through multimorbidity (β = -0.11). In contrast, childhood health demonstrated a solely direct impact on QoL, with no significant indirect pathway through multimorbidity. This study further revealed that urban residence had a pronounced positive direct effect on QoL (β = 0.9, p < 0.001).

Conclusion

This study underscores the role of multimorbidity as a key mediator between socioeconomic and demographic factors on QoL among older adults in India. With the increasing prevalence of multimorbidity, policies should prioritize integrated geriatric healthcare services. Strengthening healthcare for early screening and affordable chronic disease management is essential.

Association Between Volume, Intensity and Rhythm of Physical Activity Measured by Accelerometer and Risk of All-Cause and Cause-Specific Mortality in Individuals With MASLD

BACKGROUND

Individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) have a higher mortality risk, and physical activity is important to MASLD management. However, a comprehensive exploration of associations of volume and intensity of physical activity and rest-activity rhythm (RAR) based on an accelerometer with all-cause and cause-specific mortality in MASLD individuals was scarce.

METHODS

We included 10,143 individuals with MASLD from the UK Biobank. Volume and intensity of physical activity [low-intensity physical activity (LPA), moderate-to-vigorous-intensity physical activity (MVPA) and sedentary time] and RAR (amplitude, mesor, pseudo-F statistics and acrophase) were computed from accelerometer data. The Cox proportional hazards model was used to estimate the relationships of volume and intensity of physical activity and RAR with all-cause, cardiovascular disease (CVD) and cancer mortality risk in individuals with MASLD and further in common subtypes of cardiometabolic abnormalities. The population attributable risk and relative importance of physical activity were estimated.

RESULTS

Higher LPA, MVPA and normal RAR (amplitude and mesor) were associated with decreased risk of all-cause and CVD mortality among individuals with MASLD (HRs: 0.712-0.805), especially of all-cause mortality in those with common subtypes of more than two metabolic abnormalities (overweight/obesity-elevated blood pressure-hyperlipidemia and all the four abnormalities). Furthermore, we found MVPA and amplitude represented relatively important contributors to all-cause and CVD mortality risk in individuals with MASLD.

CONCLUSIONS

In individuals with MASLD, a higher volume and intensity of physical activity, as well as normal RAR supported lower all-cause and CVD mortality risk, which provided insights for management guidelines.

Depression care trajectories and associations with subsequent depressive episode: a registry-based cohort study (The Norwegian GP-DEP study)

BACKGROUND

Depression often has a recurrent course, but knowledge about the impact of treatment trajectories is scarce. We aimed to estimate treatment trajectories for patients with recurrent depression, and to explore associations between the trajectories and subsequent depressive episodes.

METHODS

Cohort study based on linked registry data, comprising all Norwegian residents ≥ 18 years with an (index) depressive episode in 2012 following previous episode(s) in 2008-2011. We generated multi-trajectories based on treatment during index episode including GP follow-up consultation(s), long consultation(s) and/or talking therapy (with GP), antidepressants, and contact(s) with specialist care. Generalized linear models were used to analyse associations between different treatment trajectories and subsequent depression within one year.

RESULTS

The study population consisted of 9 027 patients, mean age 44.6 years, 63.9% women. Five treatment trajectory groups were identified: "GP 1 month" (45.2% of the patients), "GP 6 months" (31.9%), "GP 12 months" (9.3%), "Antidepressants 12 months" (9.0%), and"Specialist 12 months" (4.6%). In group"GP 1 month" (reference), 25.1% had subsequent depression. While trajectory group "Antidepressants 12 months", had similar likelihood of subsequent depression as the reference (Relative risk (RR) = 1.04, 95% confidence interval (CI) 0.91-1.18), the groups "GP 12 months" (RR = 1.43, CI 1.28-1.59), "Specialist 12 months" (RR = 1.26, CI 1.08-1.47) and "GP 6 months" (RR = 1.17, CI 1.07-1.26) had increased risk of subsequent depression.

CONCLUSIONS

Our findings suggest that long-term antidepressant treatment of patients with recurrent depressive episodes may prevent subsequent depression episodes. However, this finding needs to be confirmed through studies that take into account the severity of depression.

Multimorbidity patterns of mental disorders and physical diseases of adults in northeast China: a cross-sectional network analysis

AIMS

Multimorbidity, especially physical-mental multimorbidity, is an emerging global health challenge. However, the characteristics and patterns of physical-mental multimorbidity based on the diagnosis of mental disorders in Chinese adults remain unclear.

METHODS

A cross-sectional study was conducted from November 2004 to April 2005 among 13,358 adults (ages 18-65years) residing in Liaoning Province, China, to evaluate the occurrence of physical-mental multimorbidity. Mental disorders were assessed using the Composite International Diagnostic Interview (version 1.0) with reference to the Diagnostic and Statistical Manual of Mental Disorders (3rd Edition Revised), while physical diseases were self-reported. Physical-mental multimorbidity was assessed based on a list of 16 physical and mental morbidities with prevalence ≥1% and was defined as the presence of one mental disorder and one physical disease. The chi-square test was used to calculate differences in the prevalence and comorbidity of different diseases between the sexes. A matrix heat map was generated of the absolute number of comorbidities for each disease. To identify complex associations and potential disease clustering patterns, a network analysis was performed, constructing a network to explore the relationships within and between various mental disorders and physical diseases.

RESULTS

Physical-mental multimorbidity was confirmed in 3.7% (498) of the participants, with a higher prevalence among women (4.2%, 282) than men (3.3%, 216). The top three diseases with the highest comorbidity rate and average number of comorbidities were dysphoric mood (86.3%; 2.86), social anxiety disorder (77.8%; 2.78) and major depressive disorder (77.1%; 2.53). A physical-mental multimorbidity network was visually divided into mental and physical domains. Additionally, four distinct multimorbidity patterns were identified: 'Affective-addiction', 'Anxiety', 'Cardiometabolic' and 'Gastro-musculoskeletal-respiratory', with the digestive-respiratory-musculoskeletal pattern being the most common among the total sample. The affective-addiction pattern was more prevalent in men and rural populations. The cardiometabolic pattern was more common in urban populations.

CONCLUSIONS

The physical-mental multimorbidity network structure and the four patterns identified in this study align with previous research, though we observed notable differences in the proportion of these patterns. These variations highlight the importance of tailored interventions that address specific multimorbidity patterns while maintaining broader applicability to diverse populations.

Relationship between dietary inflammatory index and chronic diseases in older U.S. Adults: NHANES 1999-2018

BACKGROUND

Chronic diseases pose a significant public health challenge, especially among the aging population. Understanding the potential impact of an inflammatory diet on the prevalence of chronic diseases is crucial for effective health interventions.

OBJECTIVE

This study assesses the relationship between the Dietary Inflammatory Index (DII) and chronic diseases in older adults.

METHODS

Data from the National Health and Nutrition Examination Surveys (NHANES) were utilized, with the DII calculated from 28 food parameters obtained through 24-hour dietary recalls and food records. Five major chronic diseases, including cardiovascular disease, hypertension, diabetes, COPD, and cancer, were used in the analysis. Logistic multivariable regression was used to determine odds ratios for chronic diseases across DII quartiles and with one unit increment in DII.

RESULTS

16,512 adults aged over 60 years were included in the study, with DII scores ranging from - 5.28 to 5.48. In the fourth DII quartile, individuals with one or more chronic diseases were more prevalent than those without. Compared to the first quartile, individuals in the fourth quartile had 28% higher odds of having CVD, 17% higher odds of having diabetes, and 19% higher odds of having hypertension, after adjusting for age, sex, smoking status, drinking status, BMI, ethnicity, poverty, marital status, education, annual family income, and citizenship. Similarly, one unit increase in DII was significantly associated with higher odds of CVD (OR [95%CI] = 1.05[1.02,1.09]) and hypertension (OR [95%CI] = 1.03 [1.00,1.06]). In Model 2, one unit increase in DII was positively associated with the number of chronic diseases (β[95%CI], 0.02[0.01, 0.03], p = 0.003).

CONCLUSION

Higher DII scores were associated with increased odds of cardiovascular disease, diabetes, and hypertension in older adults. Following an anti-inflammatory diet may be beneficial for preventing and treating chronic diseases in an older population.

The association between multimorbidity and food insecurity among US parents, guardians, and caregivers

BACKGROUND

Multimorbidity among parents, guardians, and caregivers may increase the risk of household food insecurity, which would negatively impact both parents and children. However, limited research has been done to evaluate this relationship among this population. To fill this gap, we examined the association between multimorbidity and food insecurity among U.S. parents.

METHODS

Cross-sectional data from 2019 to 2022 of the National Health Interview Survey were analyzed. Parents, guardians, and caregivers with complete data (N = 26,579) were included. Multimorbidity is defined as having 2 or more conditions. In this study, multimorbidity was categorized as 2 or 3 + conditions from a sum of 11 chronic conditions: hypertension, hyperlipidemia, diabetes, arthritis, stroke, cancer, asthma, depression, anxiety, chronic obstructive pulmonary disease, and heart disease. The presence of food insecurity was defined in four nominal categories (secure, marginal food security, low food security, very low food security). Survey-weighted multinomial regression was used to assess the association of multimorbidity with food insecurity categories, controlling for sociodemographic characteristics. The association between physical versus physical-mental comorbidities and food insecurity was also analyzed.

RESULTS

The mean study sample age was 38.8 years, 51% were women and 53% were non-Hispanic White race/ethnicity. Nearly half (49%) had ≥ 1 chronic condition; 23% had 1, 14% had 2, and 13% had 3+. The most common pair of chronic conditions among parents was depression and anxiety, and most common triad was depression, anxiety, and hypertension. After controlling for potential confounders, we found that parents with 3 + conditions had a higher risk of marginal (OR 1.75, 95% CI 1.47-2.10), low (OR 2.20, 95% CI 1.75-2.75), and very low food security (OR 4.1, 95% CI 3.2-5.2) compared to parents with no conditions. Differences were seen in the odds of food insecurity among parents with mental and physical conditions, as opposed to physical comorbidities alone.

CONCLUSIONS

Our findings suggest a higher risk of food insecurity in parents with multimorbidity. Parents with multimorbidity (especially those with comorbid depression and anxiety disorders) may be a key population to identify and intervene on food insecurity to improve health and well-being among US families.

Trends in obesity-related ischemic heart disease mortality among adults in the United States from 1999 to 2020

BACKGROUND

Obesity is a critical risk factor for ischemic heart disease (IHD), affecting 42% of the U.S. population. This study examines trends in obesity-related IHD mortality among U.S. adults aged 25 and older from 1999 to 2020, using the CDC WONDER database.

RESEARCH DESIGN AND METHODS

We analyzed IHD as the primary cause and obesity as a contributing factor, calculating age-adjusted (AAMRs) and crude mortality rates (CMRs) per 100,000 individuals. Joinpoint regression assessed annual percent changes (APC), stratifying by race, sex, age, and region.

RESULTS

From 1999 to 2020, 139,644 obesity-related IHD deaths were recorded. AAMR rose from 1.92 to 4.69 per 100,000. Rates were higher in men (3.79) than women (2.10), with Black Americans showing the highest AAMR (4.07). Older adults (65+) had the highest CMR (5.73). Nonmetropolitan areas exhibited higher AAMRs (3.47) than metropolitan regions (2.78). States with the highest mortality included Vermont, Oklahoma, Wyoming, Wisconsin and Iowa while Alabama, Virginia, Massachusetts, Connecticut and Georgia had the lowest.

CONCLUSION

The findings indicate a 2.5-fold increase in obesity-related IHD mortality, highlighting the need for targeted public health interventions and further research to address this growing public health concern.

Perceived treatment burden and health-related quality of life in association with healthcare utilisation among patients attending multiple outpatient clinics

INTRODUCTION

Patients with multimorbidity who frequently require healthcare may experience a higher treatment burden. In this study, we investigated whether high perceived treatment burden and low perceived health-related quality of life (HRQoL) were associated with healthcare utilisation among patients who attended at least two medical outpatient hospital clinics.

METHODS

Patients who underwent medical treatment in two or more outpatient medical clinics at Silkeborg Regional Hospital in Denmark in August 2018 were included. The patients received a questionnaire containing the Multimorbidity Treatment Burden Questionnaire and the Short Form-12 questionnaire measuring HRQoL in terms of physical and mental health. Information on healthcare utilisation was collected from electronic registers one year prior to receiving the questionnaire. Logistic regression was applied to estimate the odds of 'no/low' and 'high' perceptions of treatment burden and 'low' self-rated HRQoL in relation to healthcare utilisation.

RESULTS

In total, 930 patients (59.8%) answered the questionnaire. The degree of patient-assessed treatment burden was not associated with the number of outpatient contacts, hospital admissions or admission days. A high perceived treatment burden was associated with a high number of general practice contacts, whereas a low treatment burden was associated with fewer contacts in general practice, indicating a dose‒response pattern. The same pattern of associations was observed for perceived physical and mental health.

CONCLUSION

Patients with high perceived treatment burden and low HRQoL seemed to consult their general practitioner primarily despite hospital involvement. These patients may require frequent primary care attention due to other factors than those being treated at the hospital. However, further research is warranted to explore the mechanisms underlying these associations and strategies for reducing treatment burden and enhancing HRQoL in patients with multiple medical conditions.

Triage decisions and health outcomes among oncology patients: a comparative study of medical and surgical cancer cases in emergency departments

BACKGROUND

Cancer-related emergencies are a significant challenge for healthcare systems globally, including Jordan. Effective triage is critical in ensuring timely and accurate prioritization of care, especially for surgical cancer patients requiring urgent intervention. However, under-triage-misclassification of high-acuity patients into lower urgency categories-can lead to significant delays and worsened outcomes. Despite the recognized importance of accurate triage, limited research has evaluated its impact on cancer patients in Jordan, particularly those requiring surgical care.

OBJECTIVES

This study aimed to evaluate the timeliness and prioritization of care for cancer patients admitted through the emergency department (ED) in Jordan. The specific objectives were to examine the association between under-triage and treatment delays and assess its impact on key outcomes, including time to physician assessment, time to treatment, and hospital length of stay.

METHODS

A retrospective cohort design was used to analyze data from 481 cancer patients admitted through the ED in four governmental hospitals across Jordan. Two cohorts were established: surgical cancer patients requiring emergency interventions and non-surgical cancer patients presenting with other oncological emergencies. Triage accuracy was assessed using the Canadian Triage and Acuity Scale (CTAS), and under-triage was identified when patients requiring high urgency care (CTAS I-III) were misclassified into lower urgency categories (CTAS IV-V). Data were collected from electronic health records and analyzed using multiple linear regression to evaluate the association between under-triage and treatment outcomes.

RESULTS

The majority of patients were elderly, with a mean age of 62.6 years (± 10.7), and a significant proportion presented with advanced-stage cancer (83.4% in stages III and IV). Surgical patients frequently exhibited severe symptoms such as acute pain (51.6%) and respiratory discomfort (41.1%). Under-triage rates were 44.1% for surgical patients and 39.4% for non-surgical patients. Among surgical patients, under-triage significantly delayed time to physician assessment (β = 34.9 min, p < 0.001) and time to treatment (β = 68.0 min, p < 0.001). For non-surgical patients, under-triage delays were even greater, with prolonged physician assessment times (β = 48.6 min, p < 0.001) and ED length of stay (β = 7.3 h, p < 0.001). Both cohorts experienced significant increases in hospital length of stay (surgical: β = 3.2 days, p = 0.008; non-surgical: β = 3.2 days, p < 0.001).

CONCLUSION

Under-triage in Jordanian EDs is strongly associated with significant delays in care for both surgical and non-surgical cancer patients, highlighting systemic gaps in acuity recognition and triage processes. These findings underscore the need for targeted interventions to improve triage accuracy, particularly through oncology-specific training and the integration of evidence-based tools like SIRS criteria. Enhancing ED processes for cancer patients is crucial to reducing delays, optimizing resource allocation, and improving clinical outcomes in this vulnerable population.

CLINICAL TRIAL NUMBER

Not applicable.

The story of pain in people with dementia: a rationale for digital measures

BACKGROUND

The increasingly older world population presents new aging-related challenges, especially for persons with dementia unable to express their suffering. Pain intensity and the effect of pain treatment are difficult to assess via proxy rating and both under- and overtreatment lead to neuropsychiatric symptoms, inactivity, care-dependency and reduced quality of life. In this debate piece, we provide a rationale on why valid digitalization, sensing technology, and artificial intelligence should be explored to improve the assessment of pain in people with dementia.

MAIN TEXT

In dementia care, traditional pain assessment relies on observing the manifestations of typical pain behavior. At the same time, pain treatment is complicated by polypharmacy, potential side effects, and a lack of around-the-clock, timely measures. But proper pain treatment requires objective and accurate measures that capture both the levels of pain and the treatment effects. Sensing systems research for personalized pain assessment is underway, with some promising results regarding associations between physiological signals and pain. Digital phenotyping, making use of everyday sensor data for monitoring health behaviors such as patterns of sleep or movement, has shown potential in clinical trials and for future continuous observation. This emerging approach requires transdisciplinary collaboration between medical and engineering sciences, with user involvement and adherence to ethical practices.

CONCLUSION

Digital phenotyping based on physiological parameters and sensing technology may increase pain assessment objectivity in older adults with dementia. This technology must be designed with user involvement and validated; however, it opens possibilities to improve pain relief and care.

Relationship between multimorbidity, SARS-COV-2 infection and long COVID: a cross-sectional population-based French survey

BACKGROUND

Understanding the risks of COVID-19-related consequences for vulnerable groups such as people with multimorbidity is crucial to better tailor health care and public health measures. The main objective of this study was to explore the association between multimorbidity and WHO-defined post-COVID condition (PCC), while also considering the association with SARS-COV-2 infection given that the infection is a prerequisite of PCC.

METHODS

This population-representative cross-sectional study was conducted in the general adult population in mainland France between 29 August and 31 December 2022 (N = 1813). The analyses of the association between multimorbidity (defined as disease count and most prevalent dyads/triads) and PCC or SAR-COV-2 infection were adjusted for age, sex, socioeconomic variables and number of infections (for PCC only) using adjusted Poisson regression with robust variance.

RESULTS

The study population had a mean age (SD) of 53 (± 18.5) years, while 53.6% were women. The likelihood of SARS-COV-2 infection increased with disease count but was only significant for ≥ 4 diseases. Five dyads and one triad presented a higher risk; almost all included anxiety. The likelihood of PCC increased with disease count, prevalence ratios (PRs) (95% CI) for 1, 2-3 and ≥ 4 diseases versus 0 were 1.90 (1.16-3.13), 3.32 (2.07-5.35) and 5.65 (3.41-9.38), respectively, and for 19 of 26 most prevalent dyads and the triad. The association was strongest for cardiac rhythm disorder and either low back pain (PR (95%CI) 4.17 (2.03-8.53)) or anxiety (PR (95%CI) 3.73 (1.98-7.01)).

CONCLUSIONS

Multimorbidity, most frequently in combination with anxiety or low back pain, presented a significant association with PCC beyond that of SARS-CoV-2 infection underscoring the importance of implementing strategies to prevent and manage persistent symptoms in vulnerable groups.

Association between time to geriatric ward admission and change in functional status in older adults after an emergency department visit: a prospective cohort study

The impact of total time from emergency department (ED) admission to geriatric ward admission in older patients remains unknown. The objective of the study was to assess the association between time to geriatric ward admission on 6-month mortality and functional decline in older adults. A prospective, single-center cohort study was conducted including patients 75 years or older admitted to an acute-care geriatric unit following an ED visit in 2023 with a 6-month follow-up. Functional decline was defined as a decrease of at least 1 point in the Activities of Daily Living (ADL) scale between admission and 6 months. The primary end point was a composite of 6-month mortality and functional decline. Association between quartiles of time to geriatric ward admission and the primary end point was analyzed using multivariable logistic regression. Among the 360 included patients (median age 86, median time to geriatric ward admission 32.2 h), 198 (55%) experienced the composite outcome (31% death and 24% functional decline): 42%, 47%, 60%, and 71% in the first to last quartile, respectively. Compared to the first quartile, there was an independent association between time to geriatric ward admission and the primary outcome with an adjusted odds ratios of 1.4 (95% CI 0.8-2.7), 2.3 (95% CI 1.2-4.3), and 3.4 (95% CI 1.8-6.6) for the second, third, and fourth quartiles, respectively. Prolonged time to geriatric ward admission following ED consultation is associated with a higher risk of 6-month mortality and functional decline in older adults.Trial registration 2023-A02753-42 (CPP Sud-Est V approval).

Patient-centered evaluation of integrated care and health equity: evidence from county medical alliances in Henan province

BACKGROUND

Integrated care services have been initiated in China for several years, yet there remains a dearth of substantial evidence and research elucidating the service's efficacy, particularly in underdeveloped areas. This study aims to address this gap by evaluating the effectiveness of integrated care from the patients' perspective, thereby offering practical strategies to improve service effectiveness and promote health equity within county medical alliances.

METHODS

The Patient Perceptions of Integrated Care (PPIC) and European Quality of Life-5 Dimensions-5 Levels (EQ-5D-5 L) scales were employed to gather information on patients' perceptions of integrated care and their self-rated health status. A total of 1093 respondents from two pilot areas were selected for data collection. T-tests and one-way analysis of variance (ANOVA) were recruited, additionally, the study utilized multiple linear regression models to examine the specific impact of various factors on the effectiveness of integrated care services.

RESULTS

The average score for the effectiveness of integrated healthcare services from the patients' perspective was 67.72 (SD = 14.443, n = 1093). Statistical analysis revealed that as the respondents' age increased and their self-rated health declined, the PPIC scores showed an upward trend. Regression analysis found that factors such as age, education level, income, health status, and level of healthcare intervention significantly influenced PPIC scores. Overall, there is a trend where respondents with higher health needs tend to have higher perceptions of the service, while those with relatively higher socioeconomic status are more likely to provide lower ratings. Additionally, increasing the frequency and duration of healthcare interventions can improve respondents' evaluations of the services.

CONCLUSIONS

This study analyzes the effectiveness of integrated services in China's county-level medical alliance from the patients' perspective. It finds progress in resource integration and efficiency but identifies limitations in implementation, particularly in balancing equity. Socio-economic factors continue to affect the fairness of service utilization and patient satisfaction. Constraints in finance, human capital, and technology hinder the provision of more targeted services for vulnerable groups. To promote health equity, future services need to focus more on key populations and provide more targeted services, accelerate the integration of information technology, and expand service coverage to address the diverse needs of marginalized communities.

Attenuation of Cellular Senescence and Improvement of Osteogenic Differentiation Capacity of Human Liver Stem Cells Using Specific Senomorphic and Senolytic Agents

Expansion of adult stem cells in culture increases the percent of senescent cells, reduces their differentiation capacity and limits their clinical use. Here, we investigated whether treatment with certain senotherapeutic drugs would reduce the accumulation of senescent cells during expansion of human liver stem cells (HLSCs) while maintaining their differentiation capacity. Our results demonstrate that chronic treatment with the senomorphic XJB-5-131 or the senolytics cocktail D + Q reduced the number of senescent cells and significantly reduced the expression of senescence-associated genes and several inflammatory SASP factors in later passage HLSCs. Additionally, treatment with XJB-5-131 and D + Q improved the capacity of HLSCs to undergo osteogenic differentiation following extensive in vitro expansion. Overall, our data demonstrate that treatment with XJB-5-13 or D + Q results in a reduction in the percentage of replication-induced senescent HLSCs and likely other types of adult stem cells and improve the potential therapeutic use of later passage human stem cells.

Cost-Effectiveness Analysis of a Machine Learning-Based eHealth System to Predict and Reduce Emergency Department Visits and Unscheduled Hospitalizations of Older People Living at Home: Retrospective Study

BACKGROUND

Dependent older people or those losing their autonomy are at risk of emergency hospitalization. Digital systems that monitor health remotely could be useful in reducing these visits by detecting worsening health conditions earlier. However, few studies have assessed the medico-economic impact of these systems, particularly for older people.

OBJECTIVE

The objective of this study was to compare the clinical and economic impacts of an eHealth device in real life compared with the usual monitoring of older people living at home.

METHODS

This study was a comparative, retrospective, and controlled trial on data collected between May 31, 2021, and May 31, 2022, in one health care and home nursing center located in Brittany, France. Participants had to be aged >75 years, living at home, and receiving assistance from the home care service for at least 1 month. We implemented among the intervention group an eHealth system that produces an alert for a high risk of emergency department visits or hospitalizations. After each home visit, the home care aides completed a questionnaire on participants' functional status using a smartphone app, and the information was processed in real time by a previously developed machine learning algorithm that identifies patients at risk of an emergency visit within 7 to 14 days. In the case of predicted risk, the eHealth system alerted a coordinating nurse who could then inform the family carer and the patient's nurses or general practitioner.

RESULTS

A total of 120 patients were included in the study, with 60 in the control group and 60 in the intervention group. Among the 726 visits from the intervention group that were not followed by an alert, only 4 (0.6%) resulted in hospitalizations (P<.001), confirming the relevance of the system's alerts. Over the course of the study, 37 hospitalizations were recorded for 25 (20.8%) of the 120 patients. Additionally, of the 120 patients, 9 (7.5%) were admitted to a nursing home, and 7 (5.8%) died. Patients in the intervention group (56/60, 93%) remained at home significantly more often than those in the control group (48/60, 80%; P=.03). The total cost of primary care and hospitalization during the study was €167,000 (€1=US $1.09), with €108,000 (64.81%) attributed to the intervention group (P=.20).

CONCLUSIONS

This study presents encouraging results on the impact of a remote medical monitoring system for older adults, demonstrating a reduction in both emergency department visits and hospitalization costs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05221697; https://clinicaltrials.gov/study/NCT05221697.

Unplanned hospital readmission of older adults having undergone digestive surgery

Decreasing the risk of unplanned hospital readmission in older adults is of major concern in public health. If this risk is heightened in comparison with the general population in those having undergone digestive surgery, it is due not only to more frequent occurrence of postoperative complications, but also to overall frailty, which combines comorbidities, functional disorders and dependency. Moreover, given that any unplanned readmission is a major event in the life of an elderly patient, counteraction to its consequences (immobilization syndrome, malnutrition, cognitive disorders, loss of autonomy…) must be considered by the entire surgical team, in coordination with geriatric specialists, as the priority. Readmission prevention is based on a dedicated, comprehensive geriatric assessment accompanied by an individualized, multidisciplinary prehabilitation program. The intervention of geriatricians before and after surgery is likely to improve perioperative management of the elderly patient, thereby reducing the frequency and impact of hospital readmission.

Guidelines for Familial Adenomatous Polyposis (FAP): challenges in defining clinical management for a rare disease

Recent updated management guidelines for Familial Adenomatous Polyposis (FAP) have been published by professional bodies internationally. These recommendations reflect the diverse needs and capabilities of varying health systems worldwide, including thresholds for intervention and population health priorities. Whilst guidelines are closely aligned in many regards, there are areas of disparity. However, alongside discrepancies in guideline recommendations, common challenges also face professional bodies across the globe. Generation of a robust evidence-base in the environment of limited data is difficult in rare diseases such as FAP, underscored by the fact that expert consensus opinion underpins virtually all guidelines. The presence of a wide phenotypic spectrum in FAP and the other hereditary gastrointestinal polyposis syndromes, whilst now well recognised, further complicates the creation of universal recommendations. In this review we draw comparison between the various international guidelines for the management of FAP, using examples to focus on thematic areas of agreement and divergence. However, beyond this, we also wish to highlight the persisting evidence gaps in clinical management, and any areas of ongoing debate among clinicians, where we are yet to establish the optimal approach.

Circadian rest-activity rhythms and multimorbidity and mortality risks among menopausal women: a trajectory analysis of a UK Biobank cohort

BACKGROUND

Menopausal women undergo substantial physiological changes that can impact their overall health.

OBJECTIVES

We examined relationships between circadian rest-activity rhythms (CRARs) and multimorbidity progression in this population.

METHODS

We used UK Biobank data, involving 10,138 participants, who were initially free of chronic conditions. We primarily focused on the relative amplitude (RA) of CRARs, tracking incident first chronic conditions (FCC), multimorbidity, and all-cause mortality. Multimorbidity was indicated by the presence of any 2/35 chronic conditions during the follow-up period. We used a multi-state model to assess the RA impact on the multimorbidity progression trajectory, encompassing transition from health to an FCC, to consequent multimorbidity, and ultimately to mortality, in parallel with sensitivity analyses to ensure results stability and reliability.

RESULTS

During a mean 8.13-year follow-up period, we identified 855 incident multimorbidity cases and recorded 88 deaths. In a multi-state model, a lower RA was associated with an increased risk of transition from health to FCC onset [hazard ratio (HR): 1.18, 95% confidence interval (CI): 1.07-1.31] and also from an FCC to multimorbidity development (HR: 1.34, 95% CI: 1.12-1.61), even after adjusting for several confounding factors.

CONCLUSIONS

Among menopausal women, circadian rhythm disturbance increased the risk of transitioning from health to a single chronic condition, as well as transitioning from a single chronic condition to multimorbidity.

Vitexin alleviates lipid metabolism disorders and hepatic injury in obese mice through the PI3K/AKT/mTOR/SREBP-1c pathway

Obesity is recognized as a metabolic disorder, and its treatment and management pose ongoing challenges worldwide. Hawthorn, a traditional Chinese herb used to alleviate digestive issues and reduce blood lipid levels, has unclear mechanisms of action regarding its active components in the treatment of obesity. This study investigated the anti-obesity effects of vitexin, a major flavonoid compound found in hawthorn, in high-fat diet (HFD)-induced C57BL/6 mice. The results demonstrated that vitexin significantly reduced body weight, liver weight, blood lipid levels, and inflammatory markers in obese mice, while also inhibiting hepatic lipid accumulation. Mechanistic studies revealed that vitexin likely suppresses adipogenesis by modulating the PI3K-AKT signaling pathway, as evidenced by reduced expression of PI3K, phosphorylated AKT, phosphorylated mTOR, and SREBP-1c in the livers of vitexin-treated obese mice. Additionally, vitexin inhibited NFκB expression by regulating IκBα phosphorylation, thereby alleviating obesity-induced liver injury. These findings suggest that vitexin may be the primary active component in hawthorn responsible for reducing blood lipid levels, highlighting its potential in the treatment of obesity and its associated metabolic disorders.

The Impact of Mental Health Comorbidities on Unplanned Admissions for Physical Conditions: A Retrospective Observational Analysis

Background: This study aimed to evaluate the impact of mental health comorbidities on unplanned hospital admissions (UHAs) in the Province of Pescara, Southern Italy, during 2015-2022. Mental health comorbidities are underreported in administrative data, yet their association with UHAs has significant public health implications. Methods: A retrospective observational design was used to analyze 59,374 hospital admissions extracted from hospital discharge records (HDRs). Admissions of patients under 18 years of age, deliveries, day admissions, and readmissions were excluded. Socio-economic deprivation was assessed using a standardized deprivation index. Multivariate logistic regression analyzed the association between UHAs and mental health comorbidities, adjusting for socio-demographic and clinical factors. Results: Of the 59,374 admissions, 43,293 (72.9%) were unplanned. Mental health comorbidities had a low prevalence (1552 cases, 2.6%) but were significantly more common in UHAs (3.4%) compared to planned admissions (0.4%, p < 0.001). UHAs were also associated with the female gender (OR = 1.10; 95% CI: 1.06-1.14), younger age categories, living in less deprived areas, two or more physical comorbidities (OR = 1.66; 95% CI: 1.56-1.75), and mental health comorbidities (aOR = 9.85; 95% CI: 7.74-12.55, p < 0.001). Conclusions: Mental health comorbidities significantly increase the risk of UHAs independent of socio-economic deprivation or physical comorbidities. These findings underscore the need for enhanced mental health management to reduce UHAs, improve patient outcomes, and address healthcare inequities.

Presumed periodontitis and multimorbidity patterns: a prospective cohort study in the UK Biobank

OBJECTIVES

To examine the pattern of multimorbidity among people with high risk of periodontitis.

MATERIALS AND METHODS

Over 358,000 UK Biobank participants aged 40-69 years at baseline who took part in the baseline assessment and answered mouth/teeth dental problems were included (2006-2010). Cox proportional hazard models and logistic regression models were used to estimate the association of the risk factors of periodontitis with chronic diseases and multimorbidity, stratified by follow-up time.

RESULTS

A total of 154,985 participants developed multimorbidity during follow-up. We observed increased risk of multimorbidity among participants with presumed periodontitis (adjusted HR = 1.06, 95% confidence interval [CI] = 1.05-1.08), especially in those participants with age < 50 years old (adjusted HR = 1.11, 95% CI = 1.08-1.14). Among the different multimorbidity patterns, presumed periodontitis was mainly associated with the mental disorder pattern and metabolic and vascular disease pattern.

CONCLUSIONS

Presumed periodontitis was positively associated with multimorbidity, even more so in younger age. We need to pay more attention to the prevention of periodontitis in the early stage to reduce the burden of multimorbidity in the future.

CLINICAL RELEVANCE

Early life interventions to prevent periodontitis are crucial to reduce the incidence of multimorbidity and enhance the quality of life in older adults. Additionally, greater attention should be given to the mental and cardiovascular metabolic health of patients with periodontitis.

Multimorbidity patterns and premature mortality in a prospective cohort: effect modifications by socioeconomic status and healthy lifestyles

BACKGROUND

Few studies have explored the impact of multimorbidity patterns on premature mortality. This study aimed to assess the associations between multimorbidity patterns and long-term mortality and whether the associations were modified by socioeconomic status (SES) and healthy lifestyles.

METHODS

Data were from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 in the US. The latent class analysis was used to establish multimorbidity patterns based on 11 chronic conditions. Mortality outcomes were ascertained by linking with the public-use mortality data from the National Death Index through December 31, 2019. Accelerated failure time models were used to estimate time ratios (TRs) and corresponding 95% confidence intervals (CIs) for the associations between multimorbidity patterns and all-cause and CVD mortality and to exmine the extent to which SES and healthy lifestyles modified those associations.

RESULTS

In our study, six multimorbidity patterns were identified, including "relatively healthy", "hypercholesterolemia", "metabolic", "arthritis-respiratory", "CKD-vascular-cancer", and "severely impaired" classes. Compared with the "relatively healthy" class, TRs for all-cause and CVD mortality progressively decreased across the multimorbidity classes, with the "severely impaired" class showing the shortest survival time (TR, 0.53; 95% CI: 0.48, 0.58 for all-cause mortality; 0.42; 0.35, 0.50 for CVD mortality). A significant interaction was noted between SES and multimorbidity patterns for survival time, with a stronger positive association in individuals with low SES. Adherence to healthy lifestyles was related to longer survival time across all multimorbidity patterns, especially in those with relatively less severe multimorbidity.

CONCLUSIONS

Multiple multimorbidity patterns were identified and associated with mortality. Lower SES was associated with higherexcess multimorbidity-associated mortality, while adopting healthy lifestyles contributed to longer survival regardless of multimorbidity patterns. Efforts should be mobilized to reduce SES gaps and promote healthy lifestyles to alleviate the health burden of multimorbidity.

Comorbidities and health-related quality of life among rural older community-dwellers in Vietnam

This study explored the patterns of comorbidities and their impact on health-related quality of life (HRQoL) among elderly individuals living in rural communities in Vietnam. A cross-sectional study was conducted across four communes in Thai Binh province. The demographic characteristics and comorbidities of the participants were evaluated, along with their Euroqol-5 dimensions-5 levels (EQ-5D-5L), using a structured questionnaire supplemented by clinical examinations. A multivariate Tobit regression model was applied to assess the relationship between comorbidities and HRQoL. Results showed that a minority of participants (9.5%) were free of comorbidities. Cataracts were the most common condition (61.0%), followed by osteoarthritis (55.4%), rheumatoid arthritis (46.1%), and dementia (39.0%). The average EQ-5D index was 0.806 (SD =  0.184). Pain/discomfort, difficulties with usual activities, and anxiety/depression contributed most to the reduction in the EQ-5D-5L index. Participants with rheumatoid arthritis (β =  - 0.10; 95% CI =  - 0.13, - 0.07) and postural hypotension (β =  - 0.08; 95% CI =  - 0.14, - 0.02) experienced the greatest decrease in EQ-5D index, followed by those with urinary diseases (β =  - 0.05; 95% CI =  - 0.09, - 0.02) and stroke (β =  - 0.05; 95% CI =  - 0.09, - 0.01). This study highlights the high prevalence of comorbidities among the elderly in rural Vietnam, with arthritis, postural hypotension, urinary diseases, and stroke being most strongly associated with reduced HRQoL. Regular screening and monitoring of comorbidities are vital to identify individuals who would benefit most from healthcare interventions to enhance HRQoL.

Cognitive Authority Theory: Reframing health inequity, disadvantage and privilege in palliative and end-of-life care

BACKGROUND

There persist disparities in access to quality palliative and end-of-life care, often based on avoidable injustice. Research and theory to explain this health inequity focuses on structural or individual-based factors, overlooking important relational factors between health professionals, patients and families.

AIM

To apply Cognitive Authority Theory in palliative and end-of-life care to explain neglected relational drivers of inequity in access and experience.

METHODS

Cognitive Authority Theory, a middle-range theory of power relations between individuals and authority over knowledge, was developed from empirical and review data. This paper demonstrates its utility in explaining an overlooked component of inequity in palliative care: interactions between health professionals and patients/caregivers.

RESULTS

Using examples from the palliative care literature, we characterise how people who are socially disadvantaged have fewer resources to exploit during consultations with health professionals which makes it difficult for them to have their voices heard, their choices prioritised by others, and to express their expertise. We examine the implications of health professionals' judgements of expertise for care access, experience, involvement and appropriateness. We offer a fresh perspective on the mechanisms by which stereotypes, bias and power imbalances between health professionals and patients reinforce existing health inequities, drawing on the role of social privilege in shaping inequity in palliative care.

CONCLUSION

This paper provides a new language to articulate relational drivers of inequity in palliative care. It explains how to use Cognitive Authority Theory to design and interpret research to determine how healthcare interactions reinforce both social privilege and social disadvantage at end-of-life.

[Multimorbidity and the Kidney]

Multimorbidity, i.e. the simultaneous presence of 2 or more diseases, is common in patients with chronic kidney disease (CKD). Cardiovascular diseases such as coronary heart disease, heart failure, stroke or vascular dementia are of particular importance. CKD and comorbidities influence each other, which is why the current KDIGO guidelines emphasize the need for personalized treatment approaches. This applies in particular to older patients, who are especially frequently affected by CKD. The diagnosis of CKD patients should not only include typical comorbidities, but also a comprehensive risk assessment and an evaluation to avoid polypharmacy.Recognising CKD is of particular importance for patients with chronic diseases in old age, as kidney disease can have a profound effect on or worsen the course of other diseases and the limitation of kidney function has a significant influence on the treatment approach. Particular attention must be paid to the correct assessment of kidney function in older people in terms of determining the estimated glomerular filtration rate (eGFR). Here, a measurement of serum creatinine is not always sufficient due to lower muscle mass and may need to be supplemented by additional parameters to estimate the glomerular filtration rate, such as cystatin C.Depending on the eGFR, kidney disease is categorized into the stages CKD G1-G5. In addition, if kidney disease is suspected, a test for proteinuria should also be performed, preferably as a measurement of albumin excretion in spontaneous urine (albumin-to-creatinine ratio, ACR). Geriatric screening and assessment are also crucial to recognize the multimorbidity, frailty and psychosocial aspects of older patients.The treatment of multimorbidity in CKD patients focusses on progression reduction and secondary and tertiary prevention, whereby a healthy lifestyle, regular exercise and a balanced diet are also important. The prevention of cardiovascular disease, particularly in the case of high blood pressure and diabetes mellitus, requires individualized therapy, in which the choice and dosage of medication must also be taken into account, particularly in the case of advanced renal impairment. If heart failure and/or atrial fibrillation are also present, close interdisciplinary collaboration between nephrologists, cardiologists and GPs is helpful in order to optimize treatment. In addition, CKD patients with dementia face particular challenges in terms of medication and the avoidance of delirium and mental symptoms.