Comorbidity Classes Research Articles

Reader response: Migraine progression in subgroups of migraine based on comorbidities: Results of the CaMEO Study.

I read the article by Lipton et al.1 The sociodemographic model creating subdivisions of migraine into statistically valid subgroups based on comorbidity classes to predict progression from episodic migraine (EM) to chronic migraine (CM)1 does not have any biologic or pathophysiologic basis. The distinction between EM and CM is based on a unique, purely arbitrary symptom-based nosologic template. After the widely split primary headache classification,2—itself absolutely without any biologic or pathophysiologic substance—this statistical subdivision of migraine through comorbidities1 ensures continuous generation of data sans any overarching matrix, thereby indefinitely adding to the extant confusion.

Editors' note: Migraine progression in subgroups of migraine based on comorbidities: Results of the CaMEO Study

In their longitudinal survey of more than 8,000 patients with episodic migraine and selected comorbidities, Drs. Lipton et al. reported the results of the CaMEO Study. The investigators used 3 unique mathematical models to estimate the effect of various comorbidities on the progression of episodic migraine to chronic migraine. All comorbidity classes independently contributed to disease progression, and the effect was cumulative—with more comorbidities conferring a greater risk than fewer comorbidities. Dr. Gupta expresses concerns regarding the usefulness of classifying migraine subtypes, as there is presently unclear biologic heterogeneity of various migraine phenotypes. In response, the authors emphasize the importance of distinguishing unique migraine syndromes, as they may signify distinct biomarkers of disease or demonstrate a differential responsiveness to certain therapeutics. The authors acknowledge that the results of this study are one of several steps, which may lead to the improved care of patients with migraine. In their longitudinal survey of more than 8,000 patients with episodic migraine and selected comorbidities, Drs. Lipton et al. reported the results of the CaMEO Study. The investigators used 3 unique mathematical models to estimate the effect of various comorbidities on the progression of episodic migraine to chronic migraine. All comorbidity classes independently contributed to disease progression, and the effect was cumulative—with more comorbidities conferring a greater risk than fewer comorbidities. Dr. Gupta expresses concerns regarding the usefulness of classifying migraine subtypes, as there is presently unclear biologic heterogeneity of various migraine phenotypes. In response, the authors emphasize the importance of distinguishing unique migraine syndromes, as they may signify distinct biomarkers of disease or demonstrate a differential responsiveness to certain therapeutics. The authors acknowledge that the results of this study are one of several steps, which may lead to the improved care of patients with migraine.

Surgical Site Infections and Prophylaxis Antibiotic Use in the Surgical Ward of Public Hospital in Western Ethiopia: A Hospital-Based Retrospective Cross-Sectional Study.

ObjectiveSurgical site infection (SSI) is one of the leading causes of hospital-acquired infection among hospitalized patients. It causes significant health problems and results in an extended length of hospital stay, increased cost, and increased patient morbidity and mortality. To prevent the development of SSI, surgical antibiotic prophylaxis (SAP) administration before surgery is an evidence-based practice. Therefore, this study aimed to assess the prevalence of SSIs and surgical antibiotic prophylaxis practice, and identifying the gap in practicing prophylactic surgical antibiotic use.MethodsA retrospective cross-sectional study design was conducted on randomly selected 281 participants who fulfilled the inclusion criteria. Appropriateness of surgical antibiotic prophylaxis was assessed by clinical pharmacists based on the standard treatment guideline. Descriptive and multivariate logistic regression analyses were performed in SPSS version 25. Statistical significance was set at p <0.05.ResultsThe overall prevalence of SSI was 19.6% (95% CI: 19–20.2). Majority of surgical patients (88.6%) got surgical antibiotic prophylaxis. Ceftriaxone and metronidazole (45.4%), and ceftriaxone (33.3%) were the most frequently used prophylactic antibiotics. Presence of comorbidity (AOR=9.18, 95% CI: 5.17–17.9, p<0.001), contaminated (AOR=6.01, 95% CI: 1.77–16.8, p=0.019) and dirty (AOR=7.20, 95% CI: 1.23–12.1, p=0.029) wound classes, devoid of prophylactic antibiotics (AOR=6.63, 95% CI: 0.89–19.3, p=0.006), the timing of prophylactic antibiotic administration between 1 hour and 2 hours before incision (AOR=8.2, 95% CI: 4.34–18.1, p=0.001), and 48 hours duration of surgical antimicrobial prophylaxis (AOR=7.20, 95% CI: 1.23–28.17, p=0.027) were significantly associated with the development of SSIs.ConclusionThe prevalence of SSI was relatively high despite most surgical patients were given prophylactic antibiotics. The presence of comorbidity, contaminated and dirty wound classes, devoid of prophylactic antibiotics, administering prophylactic antibiotics between 1 hour and 2 hours before incision, and 48 hours duration of surgical antibiotic prophylaxis were significantly associated with SSIs.

Mental health Profiles of Sexually Abused Youth: Comorbidity, Resilience and Complex Trauma

Objectives: The current study’s objectives were to 1) determine if sexually abused youth in child protective agencies (CPA) were given more psychiatric diagnoses and exhibited more comorbidity than youth from the general population, 2) examine the comorbidity profiles of sexually abused youth over 10 years of medical consultations and hospitalizations. Method: Diagnoses of 882 youth with a substantiated sexual abuse report between 2001 and 2010 at a participating CPA were compared to those of 882 matched controls (n = 1764). Results: Results of generalized linear mixed models showed that sexually abused youth presented higher rates of all diagnostic categories and were up to four times more likely to present comorbid diagnoses. Latent class analyses among abused youth revealed four different comorbidity profiles; two more severe groups named complex trauma (11%) and dissociation (14%); and two less severe groups named depression (10%) and low or no comorbidity/resilience (65%). Youth with more cumulative maltreatment and greater number of years of data following CSA report were more at risk of presenting a comorbidity profile, while females were more likely to present a depression profile. Profiles of youth in the highest comorbidity class were similar to what is defined as complex trauma or complex post-traumatic stress disorder. Implications: Sexually abused youth's varied profiles warrant varied interventions. Integrated trauma informed interventions are needed to address the cumulative maltreatment experienced and the psychiatric comorbidity some youth exhibit.

Healthcare services use and costs for a cohort of high needs elderly diabetic patients

Abstract Background The worldwide prevalence of diabetes mellitus is increasing, which especially involves people aged &amp;gt;65 years. A recent study also found that almost 75% of adults with diabetes have two or more comorbid conditions. The aim of the study was to investigate the impact of comorbidities on health care service use and health care costs of an elderly diabetes cohort with high health care needs (HHCN), based on real-world data. Methods For the purposes of the present study, people with a diagnosis of diabetes, residing in the area served by the ex-ULSS4-Veneto LHU, and characterized as having HHCN, corresponding to ACG-RUBs 4 and 5 were considered. The comorbidities was assessed using clinical diagnoses that the ACG System assigns to single patients by combining different information flows. The presence of correlation between comorbidity classes and total annual health care costs and use was tested with Spearman Test. Moreover, the association between above mentioned variables was tested with a appropriate regression, adjusting for age and sex. Results Mean overall cost and drug cost ranged respectively from 6284 euro, 525 euro in a patient with only 1 comorbidity to 10752 euro and 1764 euro for a patient with more than 8 comorbidities. The study shows that all measures of health care services use (as emergency care accesses; number of outpatients visits; number of inpatients admissions) have a statistically significant correlation with comorbidities class. However, multivariate analyses revealed that no different use in hospitalization was associated with comorbidity class. A significant correlation was also detected among costs variables (total annual costs and pharmacy costs) and comorbidity classes. Conclusions The increase in total healthcare services use and costs due to the increased number of comorbidities was seen mainly for primary care services, highlighting the need of primary care to be strengthen in an ageing and multi-morbid population. Key messages Overall cost and drug cost for patients with more than 8 comorbidities are respectively almost doubled and more than threefold greater than those with only one comorbidities. The study revealed an increase in primary care services, suggesting an implementation of these services giving the aging population and the increase prevalence of comorbid diabetic patients worldwide.

Abstract 4631: Pre-diagnosis comorbidity class, health-related quality of life, and treatment selection among older women with breast cancer

Abstract Purpose of the study: The NCCN guidelines state that adjuvant radiotherapy (RT) can be omitted in older women with estrogen receptor (ER)-positive, node-negative early-stage (i.e., Tis and T1) breast cancer (ESBC). However, there is no specific algorithm to select a subgroup of women who can safely forgo RT. Older women commonly present with multiple comorbid conditions with different levels of functional limitations and health-related quality of life (HRQOL), which challenge the RT-decision process. This study aimed to understand pre-diagnosis comorbidity burdens in this patient group and to examine its relationship with HRQOL and treatment selection in a retrospective cohort study design. Methods: From the SEER-MHOS database, we included 985 older women who were diagnosed at age ≥ 70 years, with ER-positive, node-negative ESBC between 1998 and 2013. SEER provides primary treatments (surgery and radiation), and MHOS provides self-reported comorbidity, functionality, and HRQOL. We used latent class analysis (LCA) to identify clinically distinct comorbidity burden classes. The associations between the comorbidity burdens with HRQOL and treatment selection (lumpectomy only, lumpectomy + RT, mastectomy, mastectomy + RT) were examined using generalized linear models. Results: A mean age at diagnosis was 77 years, 81 % of patients were whites, and 43 % were married. A majority had stage I disease (80 %) with 20 % stage 0. About one fourth (26 %) had ≤ 1 comorbid condition, whereas 28 % had ≥ 4 comorbidities. LCA identified four distinct comorbidity burden classes; healthy (n=577, 58 %), low comorbidity with limited functionality (n=64, 7 %), moderate comorbidity with symptoms (n=247, n=25 %), and high comorbidity with highly limited functionality and symptoms (n=97, 10 %). Classes were distinguished by the presence or absence of comorbid conditions and functional limitations as well as symptoms. Comorbidity burdens were independently associated with HRQOL mental component summary (MCS-12) score (p &amp;lt; .0001) and physical component summary (PCS-12) score (p &amp;lt; .0001) but not with treatment selection (p = 0.096). In stage 0, age (p=0.025) and education level (p=0.024) were the independent predictors of treatment selection while age (p&amp;lt;.0001), education level (p=0.0013), income (p=0.044), and obesity (p=0.026) determined the treatment selection in stage I. Conclusions: Older women with ESBC can be described by four distinct comorbidity burdens that are independent predictors of HRQOL. However, it seems that the comorbidity burdens were not considered in the treatment selection process. Future studies need to address treatment outcomes (such as changes in HRQOL and survival) by comorbidity burdens to better guide treatment decisions. Citation Format: Eunkyung Lee, Jianbin Zhu, Robert Hines, Eunji Nam, Cassie Odahowski. Pre-diagnosis comorbidity class, health-related quality of life, and treatment selection among older women with breast cancer [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4631.

Feasibility and clinical impact of out-of-ICU noninvasive respiratory support in patients with COVID-19-related pneumonia.

IntroductionThe severe acute respiratory syndrome-coronavirus 2 outbreak spread rapidly in Italy and the lack of intensive care unit (ICU) beds soon became evident, forcing the application of noninvasive respiratory support (NRS) outside the ICU, raising concerns over staff contamination. We aimed to analyse the safety of the hospital staff and the feasibility and outcomes of NRS applied to patients outside the ICU.MethodsIn this observational study, data from 670 consecutive patients with confirmed coronavirus disease 2019 referred to pulmonology units in nine hospitals between March 1 and May 10, 2020 were analysed. Data collected included medication, mode and usage of NRS (i.e. high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), noninvasive ventilation (NIV)), length of stay in hospital, endotracheal intubation (ETI) and deaths.Results42 (11.1%) healthcare workers tested positive for infection, but only three of them required hospitalisation. Data are reported for all patients (69.3% male), whose mean±sd age was 68±13 years. The arterial oxygen tension/inspiratory oxygen fraction ratio at baseline was 152±79, and the majority (49.3%) of patients were treated with CPAP. The overall unadjusted 30-day mortality rate was 26.9%, with 16%, 30% and 30% for HFNC, CPAP and NIV, respectively, while the total ETI rate was 27%, with 29%, 25% and 28%, respectively; the relative probability of death was not related to the NRS used after adjustment for confounders. ETI and length of stay were not different among the groups. Mortality rate increased with age and comorbidity class progression.ConclusionsThe application of NRS outside the ICU is feasible and associated with favourable outcomes. Nonetheless, it was associated with a risk of staff contamination.

Comorbidity patterns and socioeconomic inequalities in children under 15 with medical complexity: a population-based study

BackgroundChildren with medical complexity (CMC) denotes the profile of a child with diverse acute and chronic conditions, making intensive use of the healthcare services and with special health and social needs. Previous studies show that CMC are also affected by the socioeconomic position (SEP) of their family. The aim of this study is to describe the pathologic patterns of CMC and their socioeconomic inequalities in order to better manage their needs, plan healthcare services accordingly, and improve the care models in place.MethodsCross-sectional study with latent class analysis (LCA) of the CMC population under the age of 15 in Catalonia in 2016, using administrative data. LCA was used to define multimorbidity classes based on the presence/absence of 57 conditions. All individuals were assigned to a best-fit class. Each comorbidity class was described and its association with SEP tested. The Adjusted Morbidity Groups classification system (Catalan acronym GMA) was used to identify the CMC. The main outcome measures were SEP, GMA score, sex, and age distribution, in both populations (CMC and non-CMC) and in each of the classes identified.Results71% of the CMC population had at least one parent with no employment or an annual income of less than €18,000. Four comorbidity classes were identified in the CMC: oncology (36.0%), neurodevelopment (13.7%), congenital and perinatal (19.8%), and respiratory (30.5%). SEP associations were: oncology OR 1.9 in boys and 2.0 in girls; neurodevelopment OR 2.3 in boys and 1.8 in girls; congenital and perinatal OR 1.7 in boys and 2.1 in girls; and respiratory OR 2.0 in boys and 2.0 in girls.ConclusionsOur findings show the existence of four different patterns of comorbidities in CMC and a significantly high proportion of lower SEP children in all classes. These results could benefit CMC management by creating more efficient multidisciplinary medical teams according to each comorbidity class and a holistic perspective taking into account its socioeconomic vulnerability.

Long‐term prognosis of adolescent and middle‐aged Chinese patients with low‐medium risk community‐acquired pneumonia: A cohort study

The long-term mortality rate in adolescent and middle-aged patients with low-medium risk community-acquired pneumonia (CAP) remains unelucidated. Understanding the long-term mortality rate in adolescent and middle-aged patients with low-medium risk CAP in Beijing, China, to provide a basis for the long-term management of CAP patient. A follow-up survey was conducted telephonically from December 2017 to January 2018 to assess the survival status among 808 patients from a CAP-China cohort enrolled from 10 general hospitals in Beijing between November 2010 and April 2012. The all-cause mortality rate was determined and Cox's proportional hazard model was performed to identify potential factors predicting mortality. Among the 808 patients, the mean age (SD) was 45.4 (19.6) year-old and the median (IQR) pneumonia severity index (PSI) score was 42.0 (35.8). Survival status for a total of 426 (52.7%) were determined during the follow-up and the non-follow-up patients were with slightly larger PSI score. The mean age (SD) for the follow-up patients were 44.6 (18.7) year-old and the median (IQR) PSI score was 42.0 (33.3). Over a median of 7 years, 32 participants died and the cumulative 1-, 3-, 5- and 7-year all-cause mortality rates were 1.6%, 4.2%, 5.9% and 7.5%, respectively. The average annual standardized mortality rate among the study participants was 9.79‰, which was significantly higher than the mortality rate of 5.20‰ among Beijing residents in 2016. Multivariable Cox proportional hazards analyses revealed that age, comorbidity and PSI were independent prognostic factors associated with long-term mortality, with hazard ratios of 4.953 (95% confidence interval [CI]3.270-7.502), 2.393 (95% CI 1.148-4.985) and 3.553 (95% CI 2.607-4.843), respectively. [Correction added on 20 August 2020, after first online publication: "9.79%" has been corrected to "9.79‰".] CONCLUSION: The long-term mortality rate is higher among patients with CAP compared with the age-adjusted general population in the same city. Age, comorbidity and initial PSI class are independently prognostic factors for the long-term mortality rate.

Patterns of comorbidity associated with ICD-11 PTSD among older adults in the United States

Little research has been conducted on posttraumatic stress disorder (PTSD) comorbidity among older adults regarding the description of PTSD in the 11th version of the International Classification of Diseases (ICD-11). This study sought to provide evidence of a dimensional model of psychopathology using the ‘Hierarchical Taxonomy of Psychopathology’ (HiTOP) model as a theoretical framework to explain patterns of ICD-11 PTSD comorbidity. Distinct patterns of ICD-11 PTSD comorbidity among a nationally representative sample (n = 530) of adults aged 60 years and older from the United States were examined using latent class analysis (LCA). Covariates associated with comorbidity classes were assessed through multinomial logistic regression. ICD-11 PTSD was highly comorbid with other psychopathologies. LCA results favoured a two-class solution. Class 1 (71.7%) was characterised by moderate probabilities for major depressive disorder and alcohol use disorder; Class 2 (28.3%) was characterised by a moderate-high probability of general psychopathology and was associated with lower social support, spousal/partner physical abuse, and history of attempted suicide. PTSD was highly comorbid with other disorders among older adults. Distinct patterns of PTSD comorbidity exist among this cohort and these findings can aid clinicians and researchers in understanding and predicting maladaptive responses to trauma and associated psychopathology.

Temporal Trends in Comorbidity Burden and Impact on Prognosis in Patients With Acute Coronary Syndrome Using the Elixhauser Comorbidity Index Score

Despite current evidence, little is known about the impact of comorbidity burden on invasive management strategies and clinical outcomes in the context of acute coronary syndrome (ACS). All ACS hospitalizations between 2004 and 2014 from the National Inpatient Sample were included, stratified by Elixhauser Comorbidity Score (ECS) and number of Elixhauser Comorbidities (NEC) to compare the receipt of invasive management and clinical outcomes between different ECS and NEC classes to the lowest class of either measure. A total of 6,613,623 records with ACS were included in the analysis. Overall comorbidity burden increased over the 11-year period, with higher comorbidity classes (ECS ≥ 14 and NEC ≥ 5) increasing from 2.1% to 4.6% and 4% to 16%, respectively. Higher ECS and NEC classes negatively correlated with the rates of utilization of coronary angiography (CA) and percutaneous coronary intervention (PCI) (ECS ≥14 vs <0: CA: 38.2% vs 69.3%, PCI: 18.6% vs 45.3%; NEC ≥5 vs 0: CA: 49.3% vs 73.4%, PCI: 24.4% vs 57.4%). Overall, higher ECS and NEC classes were independently associated with significantly increased odds of all complications, including major acute cardiovascular and cerebrovascular events, mortality, stroke and bleeding. In conclusion, among patients hospitalized for ACS, a higher comorbidity number or severity is associated with lower rates of receipt of CA and PCI, but not coronary artery bypass grafting, and worse clinical outcomes. Comorbidity burden assessment using ECS can help stratify patient groups at greatest risk of adverse outcomes in which invasive management is currently underutilized.

Management of postoperative complications in patients with acute peritonitis

Acute peritonitis remains one of the most severe and threatening abdominal cavity disease. An important component of the treatment of acute peritonitis is the ability to prognosis adequately the possibility of postoperative complications, which allows using appropriate preventive measures. For the case, numerous methods, based on the account of various parameters, are developed. Nevertheless, none of them is fully accepted, and useful. The purpose was to develop an informative scale for postoperative complications predicting. The retrospective analysis of the outcome of treatment of 169 patients with acute surgical pathology of abdominal organs complicated by various forms of peritonitis, 79 of whom developed postoperative complications results are presented. The dependence of occurrence and severity of complications on the nature of the underlying disease, clinical manifestations of peritonitis before surgery, anthropometric data research, laboratory methods, Mannheim peritonitis index parameters, comorbidity class, and age were studied, using the analysis of variance. A scale, according to which the prediction of complications is conducted in two stages, was developed. Before the surgery, we estimate the previous risk according to the nature of the underlying disease, clinical manifestations of peritonitis, comorbidity class. According to identified changes, the final estimation due to the nature of the underlying disease, Mannheim peritonitis index parameters, comorbidity class, stab neutrophil leukocytes number, use of programmed peritoneal cavity sanations is being made during the operation. These indicators provided a certain number of points. Due to these points, patients were referred to several groups: normal group (less than 18), increased (18-25), and medium (26-34) and high (more than 35) the risk of complications. The developed scale makes it possible to apply the necessary preventive measures at all stages of treatment, since preoperative preparation.

Migraine progression in subgroups of migraine based on comorbidities: Results of the CaMEO Study.

ObjectiveTo test the hypothesis that statistically defined subgroups of migraine (based on constellations of comorbidities and concomitant conditions; henceforth comorbidities), previously identified using Chronic Migraine Epidemiology and Outcomes (CaMEO) Study data, differ in prognosis, as measured by rates of progression from episodic migraine (EM) to chronic migraine (CM).MethodsThe onset of CM was assessed up to 4 times over 12 months in individuals with EM and ≥1 comorbidity at baseline, based on constellations of comorbidities (comorbidity classes). The “fewest comorbidities” class served as reference. Individuals completing ≥1 follow-up survey from the web-based CaMEO Study were included. Covariates included sociodemographic variables and headache characteristics. Sex, income, cutaneous allodynia, and medication overuse were modeled as binary variables; age, body mass index, headache-related disability (Migraine Disability Assessment [MIDAS]), and Migraine Symptom Severity Scale as continuous variables. CM onset was assessed using discrete time analysis.ResultsIn the final sociodemographic model, all comorbidity classes had significantly elevated hazard ratios (HRs) for risk of progression to CM from EM, relative to fewest comorbidities. HRs for CM onset ranged from 5.34 (95% confidence interval [CI] 3.89–7.33; p ≤ 0.001) for most comorbidities to 1.53 (95% CI 1.17–2.01; p < 0.05) for the respiratory class. After adjusting for headache covariates independently, each comorbidity class significantly predicted CM onset, although HRs were attenuated.ConclusionsSubgroups of migraine identified by comorbidity classes at cross-section predicted progression from EM (with ≥1 comorbidity at baseline) to CM. The relationship of comorbidity group to CM onset remained after adjusting for indicators of migraine severity, such as MIDAS.Clinicaltrials.gov identifierNCT01648530.

Heterogeneous health classes for older adults and their regional disparities in China: based on multidimensional health

ObjectivesChina is currently facing an unprecedented complex health demand from a rapidly aging population. Based on multidimensional health, this study aimed to identify heterogeneous latent health classes for older Chinese people, and assess regional disparities and associated sociodemographic factors. Study designChinese Longitudinal Healthy Longevity Survey in 2014 was adopted. MethodsFor 2886 participants aged 65 years and more without missing health indicators in physical, psychological, and social dimensions, latent class analysis was used to identify heterogeneous health. For 2128 participants with complete information, logistic regressions were used to examine how regional divisions and sociodemographic factors impact each identified class. ResultsFour classes were identified and labeled as ‘Lacking Socialization’ (17.4%), ‘High Comorbidity’ (13.7%), ‘Functional Impairment’ (7.1%), and ‘Relative Health’ (61.8%). When the Relative Health class was the reference, the likelihoods of the High Comorbidity and Functional Impairment classes were higher for older adults in eastern and central regions than in western regions. Those in eastern regions also tended to be in the Lacking Socialization class than in western regions. The effects of regional divisions on the different classes were significantly impacted by sociodemographic characteristics. ConclusionsFour health classes identified by multidimensional health have enhanced our understanding of heterogeneity among older Chinese people. By examining regional disparities in China, our study provided evidence for health policies addressing the issue of aging with respect to regional disparities.

Comorbidity Profiles Identified in Older Primary Care Patients Who Attempt Suicide.

To identify comorbidity profiles of older patients last seen in primary care before a suicide attempt and assess attempt and clinical factors (eg, means and lethality of attempt) associated with these profiles. Cohort study and latent class analysis using Department of Veterans Affairs (VA) national data (2012-2014). All VA medical centers in the United States. A total of 2131 patients 65 years and older who were last seen by a primary care provider before a first documented suicide attempt. Fatal suicide attempt and means were identified using the National Suicide Data Repository. Nonfatal attempt was defined using the National Suicide Prevention Applications Network. Medical and psychiatric diagnoses and other variables were determined from electronic medical records. Patients (mean age = 74.4 y; 98.2% male) were clustered into five classes based on medical and psychiatric diagnoses: Minimal Comorbidity (23.2%); Chronic Pain-Osteoarthritis (30.1%); Depression-Chronic Pain (22.9%); Depression-Medical Comorbidity (16.5%); and High Comorbidity (7.3%). The patients in the Minimal Comorbidity and Chronic Pain-Osteoarthritis classes were most likely to attempt fatally compared with classes with a higher burden of comorbidities. Overall, 61% of the sample attempted fatally, and 82.5% of suicide decedents used firearms. This study provides evidence that most comorbidity profiles (>50%) in primary care patients attempting suicide were characterized by minimal depression diagnoses and fatal attempts, mostly with firearms. These findings suggest that more than a depression diagnosis contributes to risk and that conversations about firearm safety by medical providers may play an important role in suicide intervention and prevention. J Am Geriatr Soc 67:2553-2559, 2019.

Modifiable Factors Associated with Quality of Life at 3 Months and the Mediator Effect of Functional Status in Patients with Heart Failure

Objectives To examine modifiable factors associated with quality of life (QOL) at 3 months and the mediator effect of functional status at 3 months on the relationship between baseline heart failure (HF) symptoms and QOL at 3 months in patients with HF. Background Good QOL in patients with HF is as value as or more valuable than longer survival. Thus, it is important to know modifiable factors associated with QOL. HF symptoms have been suggested to impact functional status, and, in turn, QOL, but the mediator effect of functional status on the relationship between HF symptoms and QOL has not been frequently examined. Methods and Materials In a descriptive, correlational study, data on QOL (the EQ-VAS) and functional status (the Korean Activity Scale/Index) were collected at 3 months; and HF symptoms (the Symptom Status Questionnaire-Heart Failure), depressive symptoms (the Patient Health Questinnaire-9), and sample characteristics, such as age, comorbidity, and New York Heart Association (NYHA) class (severity of disease), were collected at baseline from 65 patients with HF (Mean age: 75 years, 60% males, and 31% NYHA III). Multiple regression and Process Macro for SPSS were used to analyze the data. Results In multiple regression analysis, among the modifiable factors of HF symptoms, functional status, depressive symptoms, and severity of disease, only functional status at 3 months (p = .024) was significantly associated with QOL at 3 months, controlling for age and comorbidities (F = 2.557, p = .029, R2 = .209). Better functional status was associated with better QOL. In the Process Macro analysis, baseline HF symptoms (p = .012) and age (p Conclusion Functional status was directly and indirectly associated with QOL, while HF symptoms only indirectly predicted QOL through the effects on functional status. Clinicians and researcher need to assess and manage both HF symptoms and functional status to improve QOL in patients with HF. Further studies are needed to examine whether improvements in HF symptoms lead to improvements in functional status, and in turn, improvements in QOL.

OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis

To update and expand upon prior Osteoarthritis Research Society International (OARSI) guidelines by developing patient-focused treatment recommendations for individuals with Knee, Hip, and Polyarticular osteoarthritis (OA) that are derived from expert consensus and based on objective review of high-quality meta-analytic data. We sought evidence for 60 unique interventions. A systematic search of all relevant databases was conducted from inception through July 2018. After abstract and full-text screening by two independent reviewers, eligible studies were matched to PICO questions. Data were extracted and meta-analyses were conducted using RevMan software. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence Profiles were compiled using the GRADEpro web application. Voting for Core Treatments took place first. Four subsequent voting sessions took place via anonymous online survey, during which Panel members were tasked with voting to produce recommendations for all joint locations and comorbidity classes. We designated non-Core treatments to Level 1A, 1B, 2, 3, 4A, 4B, or 5, based on the percentage of votes in favor, in addition to the strength of the recommendation. Core Treatments for Knee OA included arthritis education and structured land-based exercise programs with or without dietary weight management. Core Treatments for Hip and Polyarticular OA included arthritis education and structured land-based exercise programs. Topical non-steroidal anti-inflammatory drugs (NSAIDs) were strongly recommended for individuals with Knee OA (Level 1A). For individuals with gastrointestinal comorbidities, COX-2 inhibitors were Level 1B and NSAIDs with proton pump inhibitors Level 2. For individuals with cardiovascular comorbidities or frailty, use of any oral NSAID was not recommended. Intra-articular (IA) corticosteroids, IA hyaluronic acid, and aquatic exercise were Level 1B/Level 2 treatments for Knee OA, dependent upon comorbidity status, but were not recommended for individuals with Hip or Polyarticular OA. The use of Acetaminophen/Paracetamol (APAP) was conditionally not recommended (Level 4A and 4B), and the use of oral and transdermal opioids was strongly not recommended (Level 5). A treatment algorithm was constructed in order to guide clinical decision-making for a variety of patient profiles, using recommended treatments as input for each decision node. These guidelines offer comprehensive and patient-centered treatment profiles for individuals with Knee, Hip, and Polyarticular OA. The treatment algorithm will facilitate individualized treatment decisions regarding the management of OA.

The distribution of psychosis, ICD-11 PTSD and complex PTSD symptoms among a trauma-exposed UK general population sample

ABSTRACTBackground: Co-occurrence of psychosis and posttraumatic stress disorder (PTSD) symptoms has been demonstrated, but the ICD-11 marks a significant divergence in the formulation of PTSD with a focus on the core symptoms and the addition of complex PTSD (CPTSD).Objective: To evaluate the distribution of psychosis and traumatic stress symptoms using the ICD-11 conceptualisation of PTSD and CPTSD.Method: A latent class analysis was conducted on psychosis symptoms, PTSD and CPTSD among a random adult sample from the UK general population with a history of traumatic events (N = 1,051).Results: Six classes were identified; a low-symptom class, a PTSD-class, a CPTSD-class, a class characterized by disturbances in self-organization alone as well as two classes characterized by CPTSD and various levels of psychosis symptom endorsement. Cumulative childhood adversity predicted membership of the PTSD, CPTSD and comorbid classes in a dose-response manner with the strongest effects observed for classes characterised by comorbid symptoms.Conclusion: The present study confirms the co-occurrence of psychosis symptoms and ICD-11 PTSD and CPTSD. Psychosis symptoms did not emerge in isolation from traumatic stress symptoms, underpinning the need for a greater recognition of psychosis symptoms as part of the broader clinical picture among trauma-exposed populations.

Comorbidity Patterns Among Patients With Opioid Use Disorder and Problem Gambling: ADHD Status Predicts Class Membership

Objective: Psychiatric comorbidities are highly prevalent among individuals affected by substance use disorders and those with non-substance-related addictive disorders such as gambling disorder. More recently, the frequent co-occurrence of substance use disorders and attention-deficit hyperactivity disorder (ADHD) has received particular attention. The aim of our study was to identify patterns of psychiatric comorbidity and to examine associations between patient group and ADHD status with class membership. Methods: Participants were patients with opioid use disorder enrolled in opioid maintenance treatment (OMT), either recruited from the community (n = 142; M age = 35.8 years; 38.7% female) or prison (n = 133; M age = 35.7 years; 21.8% female), and patients undergoing treatment for problem gambling (PrG; n = 80; M age = 43.1 years; 20% female). To enable direct comparisons, the following instruments were applied: Mini International Neuropsychiatric Interview, Adult ADHD self-report scale, Wender Utah Rating Scale, and European Addiction Severity Index. We used a latent class analysis (LCA) to identify psychiatric comorbidity patterns and a multinomial logistic regression to examine associations between patient group, ADHD status, age, and gender with class membership. Results: The LCA resulted in a three-class solution: (1) a class of individuals with a relatively low probability of current psychiatric comorbidities, except for a high probability of substance use disorders; (2) a class with markedly increased probabilities of current and recurrent psychiatric comorbidities, especially for major depression; and (3) a class with very low probabilities of psychiatric comorbidities, except for moderate probabilities of substance use disorders and antisocial personality disorder. Both OMT patients recruited from the community and those in prison were less likely than PrG patients to be assigned to the most burdened class with respect to psychiatric comorbidity (class 2). Further, both individuals with ADHD in childhood and those with adult ADHD were more likely members of class 2. Conclusions: PrG patients seem to be at an even higher risk for psychiatric comorbidities compared to OMT patients. Raising awareness among practitioners for the high prevalence of psychiatric comorbidities among patients with gambling disorder and individuals with ADHD is crucial to initiate adequate treatment and to improve response.

Preferential prescribing of linagliptin in type2 diabetes patients in an expanded post-marketing surveillance study in Japan.

Aims/IntroductionTo evaluate linagliptin prescribing in type 2 diabetes mellitus patients with different comorbidities, an expanded Japanese post‐marketing surveillance also collected baseline data for patients initiating other glucose‐lowering drugs.Materials and MethodsPatients initiating linagliptin monotherapy were enrolled, then the next patient starting monotherapy with another glucose‐lowering drug was enrolled (2012–2014). Baseline data were collected and analyzed by the Medical Dictionary for Regulatory Activities system organ class. Analyses were descriptive, and meaningful differences defined as absolute standardized difference >10%.ResultsOver 4,200 type 2 diabetes mellitus patients were enrolled. Most system‐organ class comorbidities were more common in patients initiating linagliptin versus other glucose‐lowering drugs, with meaningful differences observed for metabolism/nutritional (50.5 vs 45.5%, respectively), cardiac (12.2 vs 8.6%, respectively), vascular (56.4 vs 51.3%, respectively) and renal/urinary disorders (9.9 vs 5.7%, respectively).ConclusionsExpanding the linagliptin Japanese post‐marketing surveillance revealed linagliptin prescribing to a type 2 diabetes mellitus population with more comorbidities versus other glucose‐lowering drugs. Although such preferential prescribing might be expected, as linagliptin requires no dose adjustment or monitoring in renally or hepatically impaired patients, this innovative post‐marketing surveillance approach generated important evidence that could only be shown in such a non‐randomized comparative study. These data generated insights important for the design and interpretation of observational studies and spontaneous reports, which are key for public health.