Journal of Comorbidity

Number 1, 2011

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Research on patients with multiple health conditions: different constructs, different views, one voice

Authors: Jose M. Valderas, Stewart W. Mercer, Martin Fortin

Abstract

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Number of views: 334

Technological advances, improvements in medical care and public health policies have resulted in a growing proportion of patients with multiple health conditions. The prevalence of multiple health conditions among individuals increases with age, is substantial among older adults, and will increase dramatically in coming years [1–4]. This phenomenon has received growing interest in the most recent literature and has led to several – and often differing – conceptualizations. The term “comorbidity” was originally defined by Feinstein as “any distinct additional clinical entity that has existed or may occur during the clinical course of a patient who has the index disease under study” [5]. This definition places one disease in a central position and all other condition(s) as secondary, in that they may or may not affect the course and treatment of the index disease [6]. Feinstein’s principle has been applied all too readily as if the effect of comorbidity was secondary or indeed negligible. In clinical research, individuals with a narrowly defined index condition and no major comorbidities are usually enrolled, leaving the majority of the patients seen in a typical family practice [7,8] out in the cold. In clinical practice, management of the index condition invariably takes priority, with disjointed – if any – treatment plans developed for each of the comorbidities [6]. This model of care is typical of delivery systems constructed around specialized care, where areas of expertise are defined around specific conditions and bodily systems [11]. Not surprisingly, clinical practice guidelines arising from that model of care lack pertinence for patients with multiple health conditions [9,10]. Journal of Comorbidity 2011;1(1):1–3

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Multimorbidity research challenges: where to go from here?

Authors: Gillian E. Caughey, Elizabeth E. Roughead

Abstract

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Number of views: 348

The last decade has seen an increase in research focusing on patients with multiple chronic conditions. A recent review reported only two published studies on multimorbidity between 1990 and 2000, increasing to 39 between 2001 and 2010 [1]. This research has been largely driven by two factors: the increasing demographics of the older population worldwide [2], coupled with a growing awareness of the high prevalence of patients with multiple chronic conditions [1,3]. Through this research, there has been an increasing appreciation and understanding of the complexities associated with the management and care of these patients both from a health practitioner and a patient perspective [4,5]. However, there is still much work to be done if we are to improve health outcomes, quality of care, and develop the necessary healthcare systems required to provide integrated and coordinated care for this growing population. In order to move this research agenda forward, it is important to reflect on what we currently know, to facilitate the identification of potential gaps in our knowledge base. Journal of Comorbidity 2011;1(1):8–10

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Improving the health of people with multimorbidity: the need for prospective cohort studies

Authors: Stewart W. Mercer, Jane Gunn, Sally Wyke

Abstract

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Number of views: 360

The many challenges of multimorbidity The dramatic rise in long-term conditions (LTCs) represents a major challenge for individuals, families, and health care systems worldwide [1]. Due to the scale of this rise, the management of patients with LTCs largely falls within the domain of primary rather than secondary care, at least in countries with well-developed primary care systems. For example, in the UK, which has a comprehensive primary care system based around general practice (trained family physicians working in multidisciplinary teams) and funded by the National Health Service (NHS), primary care contacts account for around 90% of the total activity of the NHS, and patients with LTCs account for 80% of general practice consultations [2]. Effective primary care and community-based management of people with LTCs is thus a top priority [2–6]. Journal of Comorbidity 2011;1(1):4–7

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Chronic obstructive pulmonary disease: a complex comorbidity of lung cancer

Authors: Derek Grose, Robert Milroy

Abstract

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Number of views: 398

Chronic obstructive pulmonary disease (COPD) is a major burden throughout the world. It is associated with a significantly increased incidence of lung cancer and may influence treatment options and outcome. Impaired lung function confirming COPD is an independent risk factor for lung cancer. Oxidative stress and inflammation may be a key link between COPD and lung cancer, with numerous molecular markers being analysed to attempt to understand the pathway of lung cancer development. COPD negatively influences the ability to deliver radical treatment options, so attempts must be made to look for alternative methods of treating lung cancer, while aiming to manage the underlying COPD. Detailed assessment and management plans utilizing the multidisciplinary team must be made for all lung cancer patients with COPD to provide the best care possible. Journal of Comorbidity 2011;1(1):45–50

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Prevalence of disability according to multimorbidity and disease clustering: a population-based study

Authors: Alessandra Marengoni, Sara Angleman, Laura Fratiglioni

Abstract

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Number of views: 333

Background: The prevalence of chronic diseases has increased with population ageing, and research has attempted to elucidate the correlation between chronic diseases and disability. However, most studies in older populations have focused on the effect of single disabling conditions, even though most older adults have more than one chronic disease (multimorbidity). Objective: The aims of this study were to evaluate the association of disability with disease, in terms of multimorbidity and specified pairs of diseases, in a population-based study of older adults. Materials and Methods: Using the Kungsholmen Project, we estimated the prevalence of disability by the number of chronic diseases, disease status by organ systems, and in specific pairs of chronic conditions, in a Swedish population (n=1,099; ≥77 years). Disability was defined as need of assistance in at least one activity of daily living (Katz index). Results: Functional disability was seen in 17.9% of participants. It increased as the number of chronic diseases increased. The prevalence of disability varied greatly amongst specific pairs of diseases: from 6.7% in persons affected by hypertension and atrial fibrillation to 82.4% in persons affected by dementia and hip fracture. In multivariate logistic regression models, the disease pairs that were significantly associated with the highest increased relative odds of disability contained dementia (dementia–hip fracture, dementia–CVD, and dementia–depression). Conclusions: Our findings suggest specific pairs of diseases are much more highly associated with disability than others, particularly diseases coupled with dementia. This knowledge may improve prevention of disablement and planning of resource distribution. Journal of Comorbidity 2011;1(1):11–18

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Diabetes alone should not be a reason for withholding adjuvant chemotherapy for stage III colon cancer

Authors: Maren A. van Waalwijk, Saskia A.M. van de Schans, Harm R. Haak, Martine Extermann, Wouter M.W. Dercksen, Maryska L.G. Janssen-Heijnen

Abstract

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Number of views: 356

Background: With increasing prevalence of diabetes mellitus and colon cancer, the number of patients suffering from both diseases is growing, and physicians are being faced with complicated treatment decisions. Objective: To investigate the association between diabetes and treatment/course of stage III colon cancer and the association between colon cancer and course of diabetes. Materials and Methods: Additional information was collected from the medical records of all patients with both stage III colon cancer and diabetes (n=201) and a random sample of stage III colon cancer patients without diabetes (n=206) in the area of the population-based Eindhoven Cancer Registry (1998–2007). Results: Colon cancer patients without diabetes were more likely to receive adjuvant chemotherapy compared with diabetic colon cancer patients (OR 1.8; 95% CI 1.2–2.7). After adjustment for age, this difference was borderline significant (OR 1.6; 95% CI 1.0–2.6). Diabetic patients did not have: significantly more side-effects from surgery or adjuvant chemotherapy; more recurrence from colon cancer; significantly shorter time interval until recurrence; or a poorer disease-free survival or overall survival. Age and withholding of adjuvant chemotherapy were most predictive of all-cause mortality. After colon cancer diagnosis, the dose of antiglycaemic medications was increased in 22% of diabetic patients, resulting in significantly lower glycaemic indexes than before colon cancer diagnosis. Conclusions: Since diabetic patients did not have more side-effects of adjuvant chemotherapy, and adjuvant chemotherapy had a positive effect on survival for both patients with and without diabetes, diabetes alone should not be a reason for withholding adjuvant chemotherapy. Journal of Comorbidity 2011;1(1):19–27

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Haemophilia and joint disease: pathophysiology, evaluation and management

Authors: Karin Knobe, Erik Berntorp

Abstract

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Number of views: 632

In patients with haemophilia, regular replacement therapy with clotting factor concentrates (prophylaxis) is effective in preventing recurrent bleeding episodes into joints and muscles. However, despite this success, intra-articular and intramuscular bleeding is still a major clinical manifestation of the disease. Bleeding most commonly occurs in the knees, elbows, and ankles, and is often evident from early childhood. The pathogenesis of haemophilic arthropathy is multifactorial, with changes occurring in the synovium, bone, cartilage, and blood vessels. Recurrent joint bleeding causes synovial proliferation and inflammation (haemophilic synovitis) that contribute to end-stage degeneration (haemophilic arthropathy); with pain and limitation of motion severely affecting patients’ quality of life. If joint bleeding is not treated adequately, it tends to recur, resulting in a vicious cycle that must be broken to prevent the development of chronic synovitis and degenerative arthritis. Effective prevention and management of haemophilic arthropathy includes the use of early, aggressive prophylaxis with factor replacement therapies, as well as elective procedures, including restorative physical therapy, analgesia, aspiration, synovectomy, and orthopaedic surgery. Optimal treatment of patients with haemophilia requires a multidisciplinary team comprising a haematologist, physiotherapist, orthopaedic practitioner, rehabilitation physician, occupational therapist, psychologist, social workers, and nurses. Journal of Comorbidity 2011;1(1):51–59

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Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium

Authors: Alessandro Nobili, Silvio Garattini, Pier Mannuccio Mannucci

Abstract

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Number of views: 384

The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20–30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20–30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare. This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy. Journal of Comorbidity 2011;1(1):28–44