Characteristics and Management of Patients with Alopecia Areata and Selected Comorbid Conditions: Results from a Survey in Five European Countries

INTRODUCTION

Alopecia areata (AA) is an autoimmune condition that causes non-scarring hair loss and can impose a high psychosocial burden on patients. The presence of comorbid conditions may impact the management of AA in clinical practice. This analysis aims to describe disease characteristics and management of AA in patients with concomitant atopic, autoimmune, and psychiatric comorbid conditions.

METHODS

Data were collected from the Adelphi Disease Specific Programme™, a cross-sectional survey of physicians and their adult patients with AA conducted in France, Germany, Italy, Spain, and the UK between October 2021 and June 2022. Patients' disease severity was based on physician's definition. Physician-reported data on demographics, AA clinical characteristics, comorbid conditions, and information related to AA therapies were analyzed. Analyses were descriptive.

RESULTS

Overall, 239 dermatologists provided data for 2083 patients, of which 558 patients (27%) had at least one atopic, autoimmune, or psychiatric comorbid conditions. The most common comorbid conditions were atopic dermatitis, autoimmune thyroid disease, and anxiety. The mean (standard deviation) patient age for the three comorbidity groups was 37.6 years (12.1) and 56% of the patients were women (n = 313). In the three comorbidity groups, 51%, 50%, and 55% of patients with atopic, autoimmune, and psychiatric comorbidities had severe AA with disease progression reported as worsening in 30%, 28%, and 30%, respectively, whereas in the group with no comorbidities, 37% were described as having severe AA and 21% getting worse. Scalp hair loss was the primary sign reported across the three groups of comorbid conditions (atopic, 91%; autoimmune, 91%; psychiatric, 88%). Patients with preselected comorbidities presented more frequently AA-related signs and symptoms beyond scalp hair loss than patients without comorbid conditions. These patients were also more likely to receive topical calcineurin inhibitors, topical immunotherapy, conventional systemic immunosuppressants, and oral Janus kinase inhibitors for the treatment of their AA.

CONCLUSION

This analysis provided insights into the burden and management of AA in patients presenting with atopic, autoimmune, and psychiatric comorbid conditions in five European countries.

The impact of kidney function on plasma neurofilament light and phospho-tau 181 in a community-based cohort: the Shanghai Aging Study

BACKGROUND

The blood-based biomarkers are approaching the clinical practice of Alzheimer's disease (AD). Chronic kidney disease (CKD) has a potential confounding effect on peripheral protein levels. It is essential to characterize the impact of renal function on AD markers.

METHODS

Plasma phospho-tau181 (P-tau181), and neurofilament light (NfL) were assayed via the Simoa HD-X platform in 1189 dementia-free participants from the Shanghai Aging Study (SAS). The estimated glomerular filter rate (eGFR) was calculated. The association between renal function and blood NfL, P-tau181 was analyzed. An analysis of interactions between various demographic and comorbid factors and eGFR was conducted.

RESULTS

The eGFR levels were negatively associated with plasma concentrations of NfL and P-tau181 (B = - 0.19, 95% CI - 0.224 to - 0.156, P < 0.001; B = - 0.009, 95% CI - 0.013 to -0.005, P < 0.001, respectively). After adjusting for demographic characteristics and comorbid diseases, eGFR remained significantly correlated with plasma NfL (B = - 0.010, 95% CI - 0.133 to - 0.068, P < 0.001), but not with P-tau181 (B = - 0.003, 95% CI - 0.007 to 0.001, P = 0.194). A significant interaction between age and eGFR was found for plasma NfL (Pinteraction < 0.001). In participants ≥ 70 years and with eGFR < 60 ml/min/1.73 m2, the correlation between eGFR and plasma NfL was significantly remarkable (B = - 0.790, 95% CI - 1.026 to - 0,554, P < 0.001).

CONCLUSIONS

Considering renal function and age is crucial when interpreting AD biomarkers in the general aging population.

Diabetes Among Racial and Ethnically Diverse Older Adults in the United States with Cognitive Limitations

Diabetes is one of the most common coexisting conditions among adults with cognitive limitations. Complexities of diabetes care present challenges for older adults and their caregivers. Few studies have evaluated disparities in the prevalence of coexisting diabetes among older adults with cognitive limitations by race/ethnicity and nativity. Our objectives were to (1) estimate the odds of coexisting diabetes among US- and foreign-born racial/ethnic groups compared to US-born non-Hispanic White older adults and (2) compare US- and foreign-born older adults within each racial/ethnic group. We linked and analyzed 2000-2017 National Health Interview Survey and 2001-2018 Medical Expenditure Panel Survey data among older adults with cognitive limitations (ages ≥ 65 years, n = 4688). The overall prevalence of coexisting diabetes among older adults with cognitive limitations was 30.3%. Among older adults with cognitive limitations and after adjusted for age, sex, education, and risk factors for diabetes and cognitive limitations, non-Hispanic Black (US-born OR = 1.56, 95%CI = 1.23-1.98; foreign-born OR = 2.69, 95%CI = 1.20-6.05) and Hispanic (US-born OR = 2.13, 95%CI = 1.34-3.40; foreign-born OR = 2.02, 95%CI = 1.49-2.72) older adults had higher odds of coexisting diabetes compared to US-born non-Hispanic Whites. There were no differences in the odds of coexisting diabetes among foreign-born non-Hispanic Black and Hispanic adults compared to US-born counterparts. Findings suggest a large potential burden of coexisting diabetes among this growing populations of US- and foreign-born racially/ethnically diverse older adults with cognitive limitations. Future studies are needed to examine how diabetes self-efficacy, treatment, and monitoring are impacted by cognitive limitations and determine ways to improve care in collaboration with caregivers and healthcare providers.

Epidemiology and outcomes of previously healthy critically ill patients with COVID-19: A population-based cohort

Comorbid conditions represent a major risk for severe illness among persons with COVID-19. Previously healthy people with COVID-19 can also develop severe illness, but are expected to have better outcomes than those with comorbid conditions. Nevertheless, recent data suggest that the former may have, counterintuitively, higher risk of death among those with non-COVID sepsis. However, the epidemiology and outcomes of previously healthy people among critically ill patients with COVID-19 are unknown. We used statewide data to identify intensive care unit (ICU) admissions aged ≥18 years in Texas with COVID-19 in 2020. Multilevel logistic regression was used to estimate the association of comorbid state with short-term mortality (defined as in-hospital mortality or discharge to hospice) overall and with higher illness severity among ICU admissions. Among 52,776 ICU admissions with COVID-19, 6373 (12.1%) were previously healthy. Short-term mortality among previously healthy ICU admissions and those with comorbidities was 16.9% versus 34.6%. On adjusted analyses, the odds of short-term mortality were lower among the previously healthy compared to those with comorbidities overall (adjusted odds ratio (aOR) 0.84 (95% CI: 0.73-0.98)), but did not differ among those with ≥3 organ dysfunctions (aOR 1.11 (95% CI: 0.84-1.46)) and the mechanically ventilated (aOR 0.87 (95% CI: 0.68-1.12)), while being higher among those with do-not-resuscitate status (aOR 1.40 (95% CI: 1.04-1.89)). Over one in eight ICU admissions with COVID-19 were previously healthy. Although being previously healthy was associated with lower risk of death compared to those with comorbidities overall, it had no prognostic advantage among the more severely ill.

Comorbidities were associated with cancer clinical trial discussion and participation: findings from the Health Information National Trends Survey-Surveillance, Epidemiology, and End Results Program (2021)

OBJECTIVES

Oncology clinical trials are recommended to better reflect real-world cancer patient populations and to increase patient access to new treatments in trials. The influence of comorbidities on trial participation is unclear. This study examined the association of having comorbidities and patients' experiences with clinical trial discussion or actual participation.

STUDY DESIGN AND SETTING

We included 958 cancer survivors from Health Information National Trends Survey-Surveillance, Epidemiology, and End Results Program. Trial discussion was defined as whether their medical team discussed cancer clinical trials, and trial participation was defined as whether they participated. Comorbidities included diabetes, hypertension, heart condition, chronic lung disease, and depression/anxiety disorder. Design-based logistic regression results were conducted.

RESULTS

Seventy-five percent of patients had one or more comorbidities, commonly having hypertension (56%) and diabetes (26%). Only 15% of participants reported trial discussion and 8% reported trial participation. Having one or more comorbidities was significantly associated with lower rates of trial discussion in univariate analysis (22.9% vs. 12.1%, odds ratio = 0.46, P = 0.001), and such association was pertained in adjusted logistic regression (20.5% vs. 12.8%, adjusted odds ratio = 0.54, P = 0.02).

CONCLUSION

Findings suggest patients with comorbidities were underrepresented in cancer clinical trials, implying a potential lack of representativeness among trial participants.

Immunologic and Autoimmune-Related Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection: Clinical Symptoms and Mechanisms of Disease

The COVID-19 pandemic has resulted in a significant number of people developing long-term health effects of postacute sequelae SARS-CoV-2 infection (PASC). Both acute COVID-19 and PASC are now recognized as multiorgan diseases with multiple symptoms and disease causes. The development of immune dysregulation during acute COVID-19 and PASC is of high epidemiologic concern. Both conditions may also be influenced by comorbid conditions such as pulmonary dysfunction, cardiovascular disease, neuropsychiatric conditions, prior autoimmune conditions and cancer. This review discusses the clinical symptoms, pathophysiology, and risk factors that affect both acute COVID-19 and PASC.

EAST in Children with Allergic rhinitis: Experience from Indian Tertiary Centre

Allergic rhinitis (AR) is recognized as a growing global health disease with considerable importance among children and adolescents. This study aims to study the clinical and sensitization profile of children with allergic rhinitis using EAST. All children presenting to pediatric ENT outpatient with a clinical diagnosis of AR were prospectively recruited. Detailed demographic and clinical history including self-reported allergens, predominant symptoms and associated comorbid conditions were obtained. Severity of symptoms was graded on a visual analogue scale. Specific Ig E antibodies to 20 inhalant allergens was measured using EAST (EUROIMMUN, Germany).The pattern of sensitization was analyzed with respect to age, symptoms, associated comorbid conditions and urbanization. We recruited 328 children with a clinical diagnosis of AR (Mean age 10.3 year, IQR 8-13 years) Nasal block was the predominant symptom across all age groups, sneezing became more troublesome during adolescence. In 191 children sera were tested for allergen specific IgE, 119 (62.3%) showed positive sensitization. The most common sensitization noted was for cockroach, followed by dust mite and pollens. Majority had polysensitization (73%). Those who were predominantly sneezers were more likely to be sensitized with indoor allergens (p < 0.05). Among the comorbid conditions, asthma and atopic dermatitis accounted for maximum non ENT physician visits. The pattern of sensitization did not vary with age, urbanization or comorbid condition. This study highlights the clinical and sensitization profile of children with AR in South East India. Various peculiarities of this community has been presented which needs further attention.

A complex case of delayed diagnosis of ornithine transcarbamylase deficiency in an adult patient with multiple comorbidities

We report the case of a medically complex African American adult female with ornithine transcarbamylase (OTC) deficiency diagnosed after lifelong protein aversion and new onset of chronic vomiting and abdominal pain with intermittent lethargy and confusion. Symptomatology was crucial to diagnosis as genetic testing did not identify any pathogenic variants in OTC; however, the patient's diagnosis was delayed despite her having longstanding symptoms of a urea cycle disorder (UCD). Her symptoms improved after treatment with a modified protein-restricted diet, long-term nitrogen-scavenger therapy, and supplemental L-citrulline. Adherence to her UCD management regimen remained a challenge due to her underlying frailty and other medical conditions, which included primary renal impairment (further exasperated by type 2 diabetes mellitus) and decreased left-ventricular function. She passed away 3 years after her OTC deficiency diagnosis due to complications of congestive heart failure. Her OTC deficiency did not have a major impact on her final illness, and appropriate OTC deficiency management was provided until the decision was made to withdraw medical care.

Improving multimorbidity measurement using individualized disease-specific quality of life impact assessments: predictive validity of a new comorbidity index

Background

Interpretation of health-related quality of life (QOL) outcomes requires improved methods to control for the effects of multiple chronic conditions (MCC). This study systematically compared legacy and improved method effects of aggregating MCC on the accuracy of predictions of QOL outcomes.

Methods

Online surveys administered generic physical (PCS) and mental (MCS) QOL outcome measures, the Charlson Comorbidity Index (CCI), an expanded chronic condition checklist (CCC), and individualized QOL Disease-specific Impact Scale (QDIS) ratings in a developmental sample (N = 5490) of US adults. Controlling for sociodemographic variables, regression models compared 12- and 35-condition checklists, mortality vs. population QOL-weighting, and population vs. individualized QOL weighting methods. Analyses were cross-validated in an independent sample (N = 1220) representing the adult general population. Models compared estimates of variance explained (adjusted R²) and model fit (AIC) for generic PCS and MCS across aggregation methods at baseline and nine-month follow-up.

Results

In comparison with sociodemographic-only regression models (MCS R² = 0.08, PCS = 0.09) and Charlson CCI models (MCS R² = 0.12, PCS = 0.16), increased variance was accounted for using the 35-item CCC (MCS R² = 0.22, PCS = 0.31), population MCS/PCS QOL weighting (R² = 0.31–0.38, respectively) and individualized QDIS weighting (R² = 0.33 & 0.42). Model R² and fit were replicated upon cross-validation.

Conclusions

Physical and mental outcomes were more accurately predicted using an expanded MCC checklist, population QOL rather than mortality CCI weighting, and individualized rather than population QOL weighting for each reported condition. The 3-min combination of CCC and QDIS ratings (QDIS-MCC) warrant further testing for purposes of predicting and interpreting QOL outcomes affected by MCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02016-7.

An Update on Eosinophilic Esophagitis: Etiological Factors, Coexisting Diseases, and Complications

BACKGROUND

Eosinophilic esophagitis (EoE) is an immune-mediated clinicopathological condition characterized by esophageal infiltration with eosinophils resulting in chronic inflammation and stricture.

SUMMARY

The recent increase in the incidence of EoE and the characteristic presentation of symptoms with difficulty swallowing and food bolus impaction has raised key concerns of clinicians as well as researchers. EoE often presents with dysphagia, food impaction, nausea, regurgitation or vomiting, and decreased appetite. It is more common in males, affecting both adults and children. The causative manner of this condition is complex and multifactorial. Throughout recent years, researchers have made a significant contribution to understanding the pathogenesis of EoE, genetic background, natural history, work on allergy, and standardization in the evaluation of disease activity. There is relatively high prevalence of EoE among the population, emphasizing the importance of this disease. Key messages: Esophageal involvement with eosinophils may be manifested as isolated or with coexisting conditions and should be taken into consideration in the differential diagnosis. This study aimed to provide gastroenterologists with novel insights into the evaluation of esophageal involvement with eosinophils and to pay special attention to the etiological factors, coexisting clinical diseases, and complications.

Comorbidities and complications in Japanese patients with type 2 diabetes mellitus: Retrospective analyses of J-DREAMS, an advanced electronic medical records database

AIMS

To investigate the prevalence of comorbid conditions/complications among Japanese patients with type 2 diabetes mellitus (T2DM) in a real-world setting.

METHODS

We performed retrospective analyses of a large-scale database directly linked to electronic medical records, J-DREAMS (Japan Diabetes compREhensive database project based on an Advanced electronic Medical record System), to determine the prevalence of clinically significant comorbid conditions/complications among Japanese patients with T2DM aged ≥ 20 years with ≥ 1 clinical encounter at a referral center between April 1, 2017 and March 31, 2019.

RESULTS

Data were available for 10,151 patients (39.2% female). The mean age and T2DM duration were 66.0 years and 16.1 years, respectively. Only 0.5% had isolated T2DM, 6.6% had one comorbid condition/complication, and the remainder had multiple comorbid conditions/complications. Dyslipidemia (84.7%) and hypertension (75.1%) were the most common, followed by chronic kidney disease (35.4%), retinopathy (23.1%), and cardiovascular diseases (22.1%). Overall, 36.0% of patients were overweight/obese (body mass index ≥ 25 kg/m²) and 18.6% had a history of neoplasms. The prevalence of comorbid conditions/complications tended to increase with advancing age and duration of T2DM.

CONCLUSIONS

We revealed a high prevalence of comorbid conditions/complications, including chronic kidney and cardiovascular diseases, in Japanese patients with T2DM.

Factors associated with viral clearance periods from patients with COVID-19: A retrospective observational cohort study

INTRODUCTION

Knowledge is limited on the virologic course of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, particularly the time taken for viral clearance and the optimal time to discontinue isolation. This study aims to identify the clinical and demographic factors influencing the time taken for viral clearance in patients with COVID-19 to determine the optimal isolation period.

METHODS

This two-center retrospective observational cohort study was conducted between March 1 and June 31, 2020. Patients with COVID-19, which was confirmed by real-time reverse transcription polymerase chain reaction, were included. Data were extracted from medical records. The positive duration, which was defined as the period from the day of symptom onset to the negative conversion day, was assessed using a generalized linear model.

RESULTS

We included 63 patients. The mean positive duration was 20 days. The positive duration was significantly shorter for patients younger than 30 years of age and those between 30 and 60 years of age than for patients older than 60 years of age. We observed a more scattered distribution of the positive duration in older patients than in younger patients.

CONCLUSIONS

Younger patients who recovered from COVID-19 took less time to clear SARS-CoV-2 than older patients; thus, a classification of the isolation periods based on age could be considered. A uniform viral clearance period for older patients may be difficult to determine because of biases such as underlying medical conditions. Further surveillance measures are recommended to determine the viral clearance time and the optimal isolation period.

The Association between Presence of Comorbidities and COVID-19 Severity: A Systematic Review and Meta-Analysis

AIM

Several studies reported the accompaniment of severe COVID-19 with comorbidities. However, there is not a systematic evaluation of all aspects of this association. Therefore, this meta-analysis aimed to assess the association between all underlying comorbidities in COVID-19 infection severity.

METHODS

Electronic literature search was performed via scientific search engines. After the removal of duplicates and selection of articles of interest, 28 studies were included. A fixed-effects model was used; however, if heterogeneity was high (I2 > 50%) a random-effects model was applied to combine the data.

RESULTS

A total of 6,270 individuals were assessed (1,615 severe and 4,655 non-severe patients). The median age was 63 (95% confidence interval [CI]: 49-74) and 47 (95% CI: 19-63) years in the severe and non-severe groups, respectively. Moreover, about 41% of patients had comorbidities. Severity was higher in patients with a history of cerebrovascular disease: OR 4.85 (95% CI: 3.11-7.57). The odds of being in a severe group increase by 4.81 (95% CI: 3.43-6.74) for a history of cardiovascular disease (CVD). This was 4.19 (95% CI: 2.84-6.19) for chronic lung disease and 3.18, 95% CI: 2.09-4.82 for cancer. The odds ratios of diabetes and hypertension were 2.61 (95% CI: 2.02-3.3) and 2.37 (95% CI: 1.80-3.13), respectively.

CONCLUSIONS

The presence of comorbidities is associated with severity of COVID-19 infection. The strongest association was observed for cerebrovascular disease, followed by CVD, chronic lung disease, cancer, diabetes, and hypertension.

Coronavirus Disease 2019 in Pregnancy: The Experience at an Urban Safety Net Hospital

Shortly after the identification of a novel coronavirus, the coronavirus disease 2019, or COVID-19, a global pandemic was declared. There have been conflicting data about the severity of COVID-19 disease course in pregnant women, with most US data suggesting an increase in severity and increased need for hospitalization and intubation in obstetric patients. In the general population, the disease is more common among racial and ethnic minority populations, and severity is increased with comorbid conditions and obesity. The purpose of this study is to characterize COVID-19 infection in pregnancy in a population of women getting prenatal care at an urban safety-net hospital. Beginning in April, 2020, all women were tested at admission for delivery, and additionally as an outpatient if presenting with COVID-19 symptoms. In three months, there were 208 discrete women tested and 23 (11.1%) who were positive for COVID-19. The incidence of COVID-19 was 5.1% in asymptomatic women being screened upon admission to the hospital. There was a high prevalence of obesity (68.2%) and other comorbid conditions (43.5%) in this population, and all patients were racial/ethnic minorities. Despite these risk factors, the patients uniformly had either mild or asymptomatic disease. No symptomatic patients required hospitalization for their infection. In this population of pregnant women at high risk for severe COVID-19 infection, only mild disease was observed.

Effects of Medical Comorbidities on the Surgical Outcomes of Deep Brain Stimulation for Parkinson Disease: A Retrospective, Single-Institution Study

OBJECTIVE

Advancing age and greater number of medical comorbidities are well-known risk factors for higher rates of surgical complications and undesirable outcomes. We sought to determine the risk of increasing medical comorbidities on surgical outcomes for patients with Parkinson disease undergoing deep brain stimulation (DBS) surgery.

METHODS

We retrospectively reviewed 107 consecutive patients who underwent DBS for Parkinson disease at Ochsner Medical Center in 2008-2018. Patients were stratified into 3 groups based on Elixhauser comorbidity index (ECI) at the time of surgery: 0, 1, or ≥2. Outcome measures were changes in Unified Parkinson's Disease Rating Scale III scores, changes in medications, and surgical complications. Analysis of variance, paired t test, and nonparametric equivalents were used for statistical analysis.

RESULTS

Of patients, 31 (29.0%) had ECI score 0, 44 (41.1%) had ECI score 1, and 32 (29.9%) had ECI score ≥2. For all groups, Unified Parkinson's Disease Rating Scale III scores decreased significantly postoperatively (P = 0.0014, P < 0.0001, P < 0.0001). All groups had a reduction in mean levodopa equivalent daily dose after surgery; however, only the group with ≥2 comorbidities achieved statistical significance (P = 0.0026). The rate of postoperative complications was significantly correlated with comorbidity score on univariate logistic regression analysis (P = 0.0425).

CONCLUSIONS

Our findings indicate that DBS is efficacious in patients with multiple medical comorbidities. However, patients with ≥1 medical comorbidities may be more likely to have complications. The most common observed complication was wound infection. Patients with medical comorbidities may still benefit significantly from DBS when performed at experienced centers.

Smoking and cessation-related attitudes among men who have sex with men in the country of Georgia

Among men who have sex with men (MSM) in low- or middle-income countries, smoking and related factors have been understudied. We examined correlates of smoking status, level, and importance and confidence regarding quitting among 608 MSM in the country of Georgia recruited in June-September, 2016 (493 without HIV via peer referral in 3 Georgian cities; 115 with HIV via the National AIDS Center). Median age was 26 years, 78.6% reported current (past 30-day) alcohol use, and 22.4% reported past-year illicit drug use. Overall, 73.8% reported current smoking; of these, 87.1% smoked daily, mean cigarettes per day (cpd) was 19.8, 64.6% smoked ≤30 min of waking, and mean quitting importance and confidence were 6.8 and 6.4 (0 = not at all to 10 = extremely), respectively. Multivariable analyses indicated that current smoking correlated with past-month alcohol and past-year illicit drug use (p's < .001). Among smokers, cpd correlated with being older and smoking within 30 min of waking; greater quitting importance (≥7) correlated with higher education and no illicit substance use; and greater quitting confidence (≥7) was associated with fewer cpd, smoking ≤30 min of waking, and regional versus capital city residence. Given these findings, addressing tobacco and other substance use among MSM in Georgia is critical.

Racial differences in trends of serious hypoglycemia among higher risk older adults in US Veterans Health Administration, 2004-2015: Relationship to comorbid conditions, insulin use, and hemoglobin A1c level

AIMS

To evaluate temporal trends in racial/ethnic groups in rates of serious hypoglycemia among higher risk patients dually enrolled in Veterans Health Administration and Medicare fee-for-service and assess the relationship(s) between hypoglycemia rates, insulin/secretagogues and comorbid conditions.

METHODS

Retrospective observational serial cross-sectional design. Patients were ≥65 years receiving insulin and/or secretagogues. The primary outcome was the annual (period prevalence) rates (2004-2015), per 1000 patient years, of serious hypoglycemic events, defined as hypoglycemic-related emergency department visits or hospitalizations.

RESULTS

Subjects were 77-83% White, 7-10% Black, 4-5% Hispanic, <2% women; 38-58% were ≥75 years old; 72-75% had ≥1 comorbidity. In 2004-2015, rates declined from 63.2 to 33.6(-46.9%) in Blacks; 29.7 to 20.3 (-31.6%) in Whites; and 41.8 to 29.6 (-29.3%) in Hispanics. The Black-White rate differences narrowed regardless of insulin use, hemoglobin A1c level, and frequency and various combinations of comorbid conditions. Among insulin users, the Black-White contrast decreased from 34.7 (98.5 vs. 63.8) in 2004 to 13.2 (43.6 vs. 30.4) in 2015; in non-insulin users, the contrast was 25.7 (44.1 vs. 18.4) in 2004 and 10.1 (18.9 vs. 8.8) in 2015.

CONCLUSION

Marked declines in serious hypoglycemia events occurred across race, medications, and comorbidities, suggesting significant changes in clinical practice.

HIV-associated comorbidities as mediators of the association between people living with HIV and hospital-acquired infections

BACKGROUND

Hospital-acquired infections (HAIs) lead to poor health outcomes in hospitalized patients and may be disproportionately affecting the aging population of people living with HIV (PLWH). This study determined the association between HIV and HAIs, and analyzed the potential mediating effects of comorbidities.

METHODS

The Louisiana Hospital Inpatient Discharge Database for the years 2011-2015 was used. All patients with at least 1 HAI diagnosis within this source population were included as cases in the case-control study, and a 1:1 ratio of controls was randomly selected from the same hospitals.

RESULTS

Of the 1,852,769 eligible hospital discharges that occurred from 2011 through 2015, there were 7,422 patients with at least 1 HAI. Marginal logistic regressions of the case-control sample showed a strong association between HIV and central line-associated bloodstream infections (CLABSIs), but an inverse association between HIV and any HAI. However, the mediation analyses revealed that having at least 1 comorbidity mediates the association between HIV and CLABSIs.

DISCUSSION

The unexpected inverse association between HIV and HAI could be attributed to the sample size of the exposed group of patients, or it could be explained by the mechanisms of treatment for HIV patients.

CONCLUSIONS

This study found that people living with HIV are at an increased risk of developing a CLABSI, which is consistent with the published literature. The mediation analyses indicated that having at least 1 comorbidity mediated the association between HIV and CLABSI diagnosis.

Prevalence of Co-occurring Medical and Behavioral Conditions/Symptoms Among 4- and 8-Year-Old Children with Autism Spectrum Disorder in Selected Areas of the United States in 2010

We compared the prevalence of various medical and behavioral co-occurring conditions/symptoms between 4- and 8-year-olds with autism spectrum disorder (ASD) from five sites in the Autism and Developmental Disabilities Monitoring Network during the 2010 survey year, accounting for sociodemographic differences. Over 95% of children had at least one co-occurring condition/symptom. Overall, the prevalence was higher in 8- than 4-year-olds for 67% of co-occurring conditions/symptoms examined. Further, our data suggested that co-occurring conditions/symptoms increased or decreased the age at which children were first evaluated for ASD. Similarly, among the 8-year-olds, the prevalence of most co-occurring conditions/symptoms was higher in children with a previous ASD diagnosis documented in their records. These findings are informative for understanding and screening co-occurring conditions/symptoms in ASD.

Alcohol Use and Multimorbidity Among Individuals Living with HIV

Alcohol is prevalent among people living with HIV and can lead to multiple comorbid conditions (multimorbidity). The purpose of this study was to examine the relationship between alcohol use history and multimorbidity among people living with HIV. A retrospective cohort study design was conducted at an urban, academic infectious disease clinic in Kentucky. Individuals seeking care between 2010 and 2014 were included. Modified Poisson regression was used to examine the relationship between alcohol use history (never, current, and former use) and multimorbidity (≥ 2 conditions). A total of 949 individuals were included in the study, with 5.1 and 17.6% reporting former and current alcohol use, respectively. Sixty-five percent had ≥ 1 condition and 82.6% of those had ≥ 2 conditions diagnosed. The risk of multimorbidity was 1.70 (95% CI 1.35-2.14) times higher for a current user compared to a never user. Reductions in alcohol use may lead to lower rates of multimorbidity.

Cognitive and Perceptual Factors, Not Disease Severity, Are Linked with Anxiety in COPD: Results from a Cross-Sectional Study

PURPOSE

Guided by the Transactional Model of Stress and Coping, the purpose of this cross-sectional study was to examine clinical factors-demographics, chronic obstructive pulmonary disease (COPD) severity, cognitive/perceptual variables (appraisal and coping)-and their relationship to clinically elevated symptoms of anxiety in a sample of veterans with COPD.

METHOD

Participants included a sample of veterans with COPD, with or without comorbid congestive heart failure, and clinically significant symptoms of anxiety (n = 172, mean age = 65.3, SD = 8.1), who previously presented to an outpatient VA setting. Participants completed questionnaires examining COPD severity (respiratory impairment and dyspnea- and fatigue-related quality of life); perceptions of a stressor (COPD illness intrusiveness); perceptions of control (locus of health control, mastery over COPD, self-efficacy); coping strategies (adaptive and maladaptive); and anxiety and depressive symptoms.

RESULTS

Multivariable linear regressions revealed that anxiety was positively associated with more maladaptive coping and locus of control (attributed to other people), above and beyond disease severity, demographics, and depressive symptoms.

CONCLUSION

These findings suggest that cognitive and perceptual factors are concurrent with anxiety; however, longitudinal investigations are needed to fully understand this relationship. Future research should also focus on identifying optimal assessment and treatment procedures when evaluating and treating patients with COPD and symptoms of anxiety.

TRIAL REGISTRATION

NCT01149772.

Professional fee payments by specialty for inpatient open ventral hernia repair: who gets paid for treating comorbidities and complications?

BACKGROUND

The purpose of this study was to determine perioperative professional fee payments to providers from different specialties for the care of patients undergoing inpatient open ventral hernia repair (VHR).

METHODS

Perioperative data of patients undergoing VHR at a single center over 3 years were selected from our NSQIP database. 180-day follow-up data were obtained via retrospective review of records and phone calls to patients. Professional fee payments (PFPs) to all providers were obtained from our physician billing system for the VHR hospitalization, the 180 days prior to operation (180Prior) and the 180 days post-discharge (180Post).

RESULTS

PFPs for 283 cases were analyzed. Average total 360-day PFPs per patient were $3409 ± SD 3294, with 14.5% ($493 ± 1546) for services in the 180Preop period, 72.5% ($2473 ± 1881) for the VHR hospitalization, and 13.0% ($443 ± 1097) in the 180Postop period. The surgical service received 62% of PFPs followed by anesthesia (18%), medical specialties (9%), radiology (6%), and all other provider services (5%). Medical specialties received increased PFPs for care of patients with COPD and HCT < 38% ($90 and $521, respectively) and for the pulmonary complications ($2471) and sepsis ($2714) that correlated with those patient comorbidities; surgeons did not. Operative duration, mesh size, and separation of components were associated with increased surgeon PFPs (p < .05). At 6 months, wound complications were associated with increased surgeon and radiology payments (p < .01).

CONCLUSIONS

Management of acute comorbid conditions and the associated higher postoperative morbidity is not reimbursed to the surgeon under the 90-day global fee. These represent opportunity costs of care that pressure busy surgeons to select against these patients or to delegate more management to their medical specialty colleagues, thereby increasing total system costs. A comorbid risk adjustment of procedural reimbursement is warranted. In negotiating bundled payments, surgeon groups should keep in mind that surgeon reimbursement, unlike medical specialty and hospital reimbursement, have been bundled since the 1990s.

Chromosomal microarray analysis in developmental delay and intellectual disability with comorbid conditions

BACKGROUND

Developmental delay (DD) and intellectual disability (ID) are frequently associated with a broad spectrum of additional phenotypes. Chromosomal microarray analysis (CMA) has been recommended as a first-tier test for DD/ID in general, whereas the diagnostic yield differs significantly among DD/ID patients with different comorbid conditions.

METHODS

To investigate the genotype-phenotype correlation, we examined the characteristics of identified pathogenic copy number variations (pCNVs) and compared the diagnostic yields among patient subgroups with different co-occurring conditions.

RESULTS

This study is a retrospective review of CMA results generated from a mixed cohort of 710 Chinese patients with DD/ID. A total of 247 pCNVs were identified in 201 patients (28%). A large portion of these pCNVs were copy number losses, and the size of copy number losses was generally smaller than gains. The diagnostic yields were significantly higher in subgroups with co-occurring congenital heart defects (55%), facial dysmorphism (39%), microcephaly (34%) or hypotonia (35%), whereas co-occurring conditions of skeletal malformation (26%), brain malformation (24%) or epilepsy (24%) did not alter the yield. In addition, the diagnostic yield nominally correlated with ID severity.

CONCLUSION

Varied yields exist in DD/ID patients with different phenotypic presentation. The presence of comorbid conditions can be among factors to consider when planning CMA.

Improving Quality of Care in Patients with Liver Cirrhosis

Liver cirrhosis is a major chronic disease in the field of digestive diseases. It causes more than one million deaths per year. Despite established evidence based guidelines, the adherence to standard of care or quality indicators are variable. Complete adherence to the recommendations of guidelines is less than 50%. To improve the quality of care in patients with cirrhosis, we need a more holistic view. Because of high rate of death due to cardiovascular disease and neoplasms, the care of comorbid conditions and risk factors such as smoking, hypertension, high blood sugar or cholesterol, would be important in addition to the management of primary liver disease. Despite a holistic multidisciplinary approach for this goal, the management of such patients should be patient centered and individualized. The diagnosis of underlying etiology and its appropriate treatment is the most important step. Definition and customizing the quality indicators for quality measure in patients are needed. Because most suggested quality indicators are designed for measuring the quality of care in decompensated liver cirrhosis, we need special quality indicators for compensated and milder forms of chronic liver disease as well. Training the patients for participation in their own management, design of special clinics with dedicated health professionals in a form of chronic disease model, is suggested for improvement of quality of care in this group of patients. Special day care centers by a dedicated gastroenterologist and a trained nurse may be a practical model for better management of such patients.

Evaluating the potential for primary care to serve as a mental health home for people with schizophrenia

OBJECTIVE

Primary care-based medical homes could improve the coordination of mental health care for individuals with schizophrenia and comorbid chronic conditions. The objective of this paper is to examine whether persons with schizophrenia and comorbid chronic conditions engage in primary care regularly, such that primary care settings have the potential to serve as a mental health home.

METHOD

We examined the annual primary care and specialty mental health service utilization of adult North Carolina Medicaid enrollees with schizophrenia and at least one comorbid chronic condition who were in a medical home during 2007-2010. Using a fixed-effects regression approach, we also assessed the effect of medical home enrollment on utilization of primary care and specialty mental health care and medication adherence.

RESULTS

A substantial majority (78.5%) of person-years had at least one primary care visit, and 17.9% had at least one primary care visit but no specialty mental health services use. Medical home enrollment was associated with increased use of primary care and specialty mental health care, as well as increased medication adherence.

CONCLUSIONS

Medical home enrollees with schizophrenia and comorbid chronic conditions exhibited significant engagement in primary care, suggesting that primary-care-based medical homes could serve a care coordination function for persons with schizophrenia.

Patient prioritization of comorbid chronic conditions in the Veteran population: Implications for patient-centered care

Objective:

Patients with comorbid chronic conditions may prioritize some conditions over others; however, our understanding of factors influencing those prioritizations is limited. In this study, we sought to identify and elaborate a range of factors that influence how and why patients with comorbid chronic conditions prioritize their conditions.

Methods:

We conducted semi-structured, one-on-one interviews with 33 patients with comorbidities recruited from a single Veterans Health Administration Medical Center.

Findings:

The diverse factors influencing condition prioritization reflected three overarching themes: (1) the perceived role of a condition in the body, (2) self-management tasks, and (3) pain. In addition to these themes, participants described the rankings that they believed their healthcare providers would assign to their conditions as an influencing factor, although few reported having shared their priorities or explicitly talking with providers about the importance of their conditions.

Conclusion:

Studies that advance understanding of how and why patients prioritize their various conditions are essential to providing care that is patient-centered, reflecting what matters most to the individual while improving their health. This analysis informs guideline development efforts for the care of patients with comorbid chronic conditions as well as the creation of tools to promote patient–provider communication regarding the importance placed on different conditions.

Complex Chronic Conditions Among Children Undergoing Cardiac Surgery

Children with complex chronic conditions (CCCs) require a disproportionate amount of inpatient resources and are at increased risk of mortality during hospital admissions. This study examines the impact of non-cardiac, comorbid complex chronic conditions on outcomes in children undergoing congenital heart surgery. All admissions associated with a congenital cardiac surgical procedure in the Kids' Inpatient Database from 1997 to 2012 were examined. Children were classified by the number as well as type (genetic vs. non-genetic) of CCC. Baseline demographics as well as proportion of total inpatient days and total hospitalization charges was assessed. Multivariate regression models examining occurrence of a complication, mortality, prolonged length of stay and high hospitalization charges were constructed. In multivariate models, an increasing number of CCC was associated with increased risk of mortality and complications (mortality: 1 CCC: odds ratio (OR) = 1.17, 95 % CI = 1.03-1.33); ≥2 CCC: OR = 1.54, 95 % CI = 1.26-1.87). Additionally, the presence of a genetic CCC was protective against mortality (OR = 0.71, 95 % CI = 0.56-0.89) while non-genetic CCCs were associated with mortality (OR = 1.62, 95 % CI = 1.41-1.88) and high resource utilization. Over time, the proportion of genetic CCC remained stable while non-genetic CCC increased in prevalence. Complex chronic conditions have a varying association with mortality, morbidity and resource utilization in children undergoing congenital heart surgery. While genetic CCCs were not associated with poor outcomes, non-genetic CCCs were risk factors for morbidity and mortality. These findings suggest that pre-surgical counseling and surgical planning should account for the type of non-cardiac comorbid conditions.

Impact of a behavioral weight loss intervention on comorbidities in overweight and obese breast cancer survivors

PURPOSE

Comorbid medical conditions are common among breast cancer survivors, contribute to poorer long-term survival and increased overall mortality, and may be ameliorated by weight loss. This secondary analysis evaluated the impact of a weight loss intervention on comorbid medical conditions immediately following an intervention (12 months) and 1-year postintervention (24 months) using data from the Exercise and Nutrition to Enhance Recovery and Good health for You (ENERGY) trial-a phase III trial which was aimed at and successfully promoted weight loss.

METHODS

ENERGY randomized 692 overweight/obese women who had completed treatment for early stage breast cancer to either a 1-year group-based behavioral intervention designed to achieve and maintain weight loss or to a less intensive control intervention. Minimal support was provided postintervention. New medical conditions, medical conditions in which non-cancer medications were prescribed, hospitalizations, and emergency room visits, were compared at baseline, year 1, and year 2. Changes over time were analyzed using chi-squared tests, Kaplan-Meier, and logistic regression analyses.

RESULTS

At 12 months, women randomized to the intervention had fewer new medical conditions compared to the control group (19.6 vs. 32.2 %, p < 0.001); however, by 24 months, there was no longer a significant difference. No difference was observed in each of the four conditions for which non-cancer medications were prescribed, hospital visits, or emergency visits at either 12 or 24 months.

CONCLUSIONS

These results support a short-term benefit of modest weight loss on the likelihood of comorbid conditions; however, recidivism and weight regain likely explain no benefit at 1-year postintervention follow-up.

Indicators of resilience and healthcare outcomes: findings from the 2010 health and retirement survey

OBJECTIVE

To test the hypothesis that higher levels of resilience indicators are associated with lower overall healthcare utilization (HCU) as well as improvements in self-rated health (SRH), we analyzed a representative sample of 4562 adults 50-70 years old enrolled in the US 2010 health and retirement survey.

METHODS

Multivariable logistic regression models estimated odds ratios (ORs) and 95 % confidence intervals (CIs) for high versus low resilience in relation to HCU and SRH improvements over 2 years. Resilience indicators included: cumulative lifetime adversity, social support, global mastery and domain-specific mastery. Cumulative lifetime adversity was defined as 0, 1-2, 3-4 or 5+ events. HCU included hospitalization (any vs. none) and physician visits (< 20 vs. ≥ 20) over 2 years.

FINDINGS

Hospitalization odds declined by 25 % (OR 0.75, 95 %CI 0.64-0.86), odds of ≥ 20 physician visits declined by 47 % (OR 0.53, 95 % CI 0.45-0.63) and the odds of SRH improvement increased by 49 % (OR 1.49, 95 % CI 1.17-1.88) for respondents with high versus low health mastery. Cumulative lifetime adversity manifested a dose-dependent positive relationship with HCU. Specifically, hospitalization odds was, respectively, 25, 80 and 142 % elevated for participants that reported 1-2, 3-4 and 5+ versus 0 lifetime adversities. High versus low global, financial and health mastery, respectively, predicted improved SRH, lower physician's visits and hospitalizations.

CONCLUSION

In this sample of adults near or in retirement, resilience predicted lower HCU and improved SRH. Resilience is a dynamic state that can be enhanced in adults with positive impacts on subjective well-being and HCU.

The Comorbid and Individual Impacts of Maternal Depression and Substance Dependence on Parenting and Child Behavior Problems

Maternal depression, substance dependence, and the comorbidity of these conditions are highly prevalent risk factors among families involved with Child Protective Services (CPS). Data from the National Survey of Child and Adolescent Well-Being I (NSCAW I) were analyzed to examine the influence of maternal substance dependence, depression, and comorbidity on parenting and child behavior over 36-months among children reported to CPS who remained in the home at all waves. Although neglect and child behavior problems were highest for mothers with comorbidity at baseline, mothers with substance dependence had the poorest self-reported parenting and child behavior problems over time. Results indicate a need for intensive targeted services to address the complex needs of CPS-involved mothers with substance dependence and their in-home children.

The use of a frailty index to predict adverse health outcomes (falls, fractures, hospitalization, medication use, comorbid conditions) in people with intellectual disabilities

Frailty in older people can be seen as the increased likelihood of future negative health outcomes. Lifelong disabilities in people with intellectual disabilities (ID) may not only influence their frailty status but also the consequences. Here, we report the relation between frailty and adverse health outcomes in older people with ID (50 years and over). In a prospective population based study, frailty was measured at baseline with a frailty index in 982 older adults with ID (≥50 yr). Information on negative health outcomes (falls, fractures, hospitalization, increased medication use, and comorbid conditions) was collected at baseline and after a three-year follow-up period. Odds ratios or regression coefficients for negative health outcomes were estimated with the frailty index, adjusted for gender, age, level of ID, Down syndrome and baseline adverse health condition. The frailty index was related to an increased risk of higher medication use and several comorbid conditions, but not to falls, fractures and hospitalization. Frailty at baseline was related to negative health outcomes three years later in older people with ID, but to a lesser extent than found in the general population.

Hemoglobin A1c, comorbid conditions and all-cause mortality in older patients with diabetes: a retrospective 9-year cohort study

AIMS

To examine whether hemoglobin A1c levels and comorbid conditions are related to all-cause mortality in a cohort of patients with type 1 or 2 diabetes receiving continuous care for 9 years. In patients with comorbid congestive heart failure (CHF), we test for 'reverse epidemiology,' or whether greater HbA1c values are associated with lower risk of mortality.

METHODS

The population for this longitudinal cohort study was 8820 Group Health enrollees in the Seattle area with type 1 or 2 diabetes in 1997 and enrolled continuously from 1997 to 2006. Comorbid conditions were hypertension, coronary artery disease, congestive heart failure, depression, and chronic pulmonary disease. Mistimed HbA1c scores were addressed by multiple imputation, and Cox proportional hazards models estimated associations controlling for other risk factors.

RESULTS

About 30% of the enrollees died in 1998-2006. CHF had the strongest association with all-cause mortality. Compared to enrollees with HbA1c ≥ 7.1% (54 mmol/mol) and < 7.5% (58 mmol/mol; 5th decile), enrollees with HbA1c < 6.4% (46 mmol/mol) had a significantly greater risk of death (HR range: 1.28-2.26). HbA1c > 7.5% had HR < 1.0 but were not significant. For enrollees with diabetes and CHF at baseline, HbA1c scores ≥ 8.7% (72 mmol/mol) had a significantly lower risk of death (HR range: 0.64-0.69).

CONCLUSIONS

In our patient population, HbA1c scores<6.4% have significantly higher all-cause mortality. CHF is a major determinant of all-cause mortality. Adults with comorbid CHF and high HbA1c scores have lower all-cause mortality.

Premature mortality in poor health and low income adults with epilepsy

OBJECTIVE

To examine mortality and causes of death (CODs) in socioeconomically disadvantaged persons with epilepsy (PWEs) in the United States.

METHODS

We performed a retrospective open cohort analysis using Ohio Medicaid claims data between 1992 and 2008 to assess mortality and COD in 68,785 adult Medicaid beneficiaries with epilepsy. Case fatality (CF), mortality rates (MRs), standardized mortality ratios (SMRs), and years of potential life lost (YPLLs) were calculated. The SMRs were estimated to compare risk of death in PWEs with that in the general Medicaid population with and without disabilities. Proportionate mortality ratios (PMRs), YPLLs, and SMRs for specific COD were also obtained.

RESULTS

There were 12,630 deaths in PWEs. CF was 18.4%, the age-race-sex adjusted MR was 18.6/1,000 person-years (95% confidence interval [CI], 18.3-18.9). The SMR was 1.8 (95% CI, 1.8-1.9) when compared to the general Medicaid population, and was 1.4 (95% CI, 1.3-1.6) when compared to those with disabilities. The average YPLL was 16.9 years (range 1-47 years). Both epilepsy and comorbid conditions significantly contributed to premature mortality in PWEs. Cardiovascular diseases, cancer, and unintentional injuries were the most common COD and account for a large proportion of YPLLs. Deaths from epilepsy-related causes occurred in about 10% of the cases.

SIGNIFICANCE

Socioeconomically deprived PWEs, especially young adults, experience high mortality and die 17 years prematurely. The high mortality in Medicaid beneficiaries with epilepsy affirms that comorbid conditions and epilepsy play a crucial role in premature death. Management of comorbid conditions is, at a minimum, as important as epilepsy management, and therefore deserves more attention from physicians, particularly those who care for Medicaid beneficiaries with epilepsy.

Pre-injury polypharmacy as a predictor of outcomes in trauma patients

Background:

One of the hallmarks of modern medicine is the improving management of chronic health conditions. Long-term control of chronic disease entails increasing utilization of multiple medications and resultant polypharmacy. The goal of this study is to improve our understanding of the impact of polypharmacy on outcomes in trauma patients 45 years and older.

Materials and Methods:

Patients of age ≥45 years were identified from a Level I trauma center institutional registry. Detailed review of patient records included the following variables: Home medications, comorbid conditions, injury severity score (ISS), Glasgow coma scale (GCS), morbidity, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, functional outcome measures (FOM), and discharge destination. Polypharmacy was defined by the number of medications: 0–4 (minor), 5–9 (major), or ≥10 (severe). Age- and ISS-adjusted analysis of variance and multivariate analyses were performed for these groups. Comorbidity–polypharmacy score (CPS) was defined as the number of pre-admission medications plus comorbidities. Statistical significance was set at alpha = 0.05.

Results:

A total of 323 patients were examined (mean age 62.3 years, 56.1% males, median ISS 9). Study patients were using an average of 4.74 pre-injury medications, with the number of medications per patient increasing from 3.39 for the 45–54 years age group to 5.68 for the 75+ year age group. Age- and ISS-adjusted mortality was similar in the three polypharmacy groups. In multivariate analysis only age and ISS were independently predictive of mortality. Increasing polypharmacy was associated with more comorbidities, lower arrival GCS, more complications, and lower FOM scores for self-feeding and expression-communication. In addition, hospital and ICU LOS were longer for patients with severe polypharmacy. Multivariate analysis shows age, female gender, total number of injuries, number of complications, and CPS are independently associated with discharge to a facility (all, P < 0.02).

Conclusion:

Over 40% of trauma patients 45 years and older were receiving 5 or more medications at the time of their injury. Although these patients do not appear to have higher mortality, they are at increased risk for complications, lower functional outcomes, and longer hospital and intensive care stays. CPS may be useful when quantifying the severity of associated comorbid conditions in the context of traumatic injury and warrants further investigation.

Comorbidity in inflammatory bowel disease

Patients with inflammatory bowel disease (IBD) can be affected by other unrelated diseases. These are called comorbid conditions, and can include any secondary health problem that affects a person suffering from a primary or main disease, and which is neither linked physiopathologically to the primary condition, nor is it due to the treatments used for the primary condition or to its long-term anatomical or physiological consequences. Different comorbid conditions, as well as their influence on IBD, are discussed.