Comorbidity Classes Research Articles

Single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite: a prospective series of 100 cases.

Chronic osteomyelitis may recur if dead space management, after excision of infected bone, is inadequate. This study describes the results of a strategy for the management of deep bone infection and evaluates a new antibiotic-loaded biocomposite in the eradication of infection from bone defects. We report a prospective study of 100 patients with chronic osteomyelitis, in 105 bones. Osteomyelitis followed injury or surgery in 81 patients. Nine had concomitant septic arthritis. 80 patients had comorbidities (Cierny-Mader (C-M) Class B hosts). Ten had infected nonunions. All patients were treated by a multidisciplinary team with a single-stage protocol including debridement, multiple sampling, culture-specific systemic antibiotics, stabilisation, dead space filling with the biocomposite and primary skin closure. Patients were followed up for a mean of 19.5 months (12 to 34). Infection was eradicated in 96 patients with a single procedure and all four recurrences were successfully managed with repeat surgery. Adverse events were uncommon, with three fractures, six wound leaks and three unrelated deaths. Outcome was not dependant on C-M host class, microbial culture, wound leakage or presence of nonunion. This single-stage protocol, facilitated by the absorbable local antibiotic, is effective in the treatment of chronic osteomyelitis. It offers a more patient-friendly treatment compared with other published treatment options. Cite this article: Bone Joint J 2016;98-B:1289-96.

Prediction of Postoperative Complications in Acute Peritonitis

The ability to predict the possibility of postoperative complications is an important component of treatment of acute peritonitis. None of the known methods is fully accepted worldwide.The objective of the research was to develop an informative method for predicting postoperative complications.Materials and methods. A retrospective analysis of the results of treating 169 patients with peritonitis was made. 79 patients developed postoperative complications. 39 patients died. 123 patients were diagnosed with comorbidities. Clinical and laboratory data, parameters of the Mannheim peritonitis index, comorbidity class, and the patients’ age were analyzed using the variance analysis.Results and discussion. The prediction of postoperative complications may be carried out in two stages. Prior to surgery, preceding risk is estimated considering the nature of the underlying disease, clinical signs of acute peritonitis and comorbidity class. During surgery the final risk estimation is made taking into consideration the nature of the underlying disease, the Mannheim peritonitis index, comorbidity class, the number of band forms, use of the programmed peritoneal sanation. For each aforementioned indicator different number of points was determined. Patients were divided into several groups by the sum of these points: normal (2-4 points), increased (5.7 points), medium (8-9 points) and high (more than 10 points) risk of postoperative complications.Conclusions.The proposed prognostic scale allows us to identify groups of normal, increased, medium and high risk of postoperative complications in acute peritonitis.A two-phase prediction - before and during surgery – allow us to differentially apply preventive measures in the preoperative preparation, during surgery and in the postoperative period of treatment.

A5168 - A Single Center Results Examining Diet Compliance and Eating Behaviors from the Essential Trial: A Blinded, Randomized Control Trial Evaluating Safety & Effectiveness of an Endoscopic Weight Loss Procedure (pose procedure™)

The intensity of lifestyle intervention and patient compliance are significant factors in achieving optimal and sustainable weight-loss following any bariatric procedure. The Essential Trial evaluated the safety and effectiveness of the USGI Medical g-CathTM EZ Suture Anchor Delivery Catheter as an endoscopic weight loss procedure (pose procedureTM) for patients with Class I obesity with at least 1 non-severe obesity related co-morbid condition and Class II obesity with or without a non-severe obesity related co-morbid condition. Low intensity lifestyle counseling was provided during the follow-up visits of this study. A total of 332 patients were randomized across 11 U.S. centers. Presented are the weight loss results from one of those centers.

A SCALE FOR PREDICTING POSTOPERATIVE SEPTIC COMPLICATIONS AT ACUTE PERITONITIS

The results of retrospective analysis of treatment outcome of 169 patients with acute surgical pathology of abdominal organs complicated by various forms of peritonitis, 79 of whom developed postoperative complications, 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,Mannheimperitonitis index parameters, comorbidity class, age were studied, using the analysis of variance. As a result, 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, Mannheimperitonitis 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), medium (26-34) and high (more than 35) the risk of complications. This distinction makes it possible to apply the necessary preventive measures at all stages of treatment, since preoperative preparation.

Clustering of adversity in young adults on disability pension due to mental disorders: a latent class analysis.

Mental disorders are the leading cause of work disability among young adults. This study examined whether distinct classes could be identified among young adults on the basis of medical history before receiving a disability pension due to a mental disorder. Medical history was obtained from pension applications and attached medical certificates for 1163 individuals aged 18-34 years who, in 2008, received a disability pension due to a mental disorder. Using latent class analysis, 10 clinical and individual adversities and their associations with sex, age and diagnostic category were examined. Three classes were identified: childhood adversity (prevalence, 33%), comorbidity (23%), and undefined (44%). The childhood adversity class was characterized by adverse events and symptoms reported during childhood and it associated with depressive disorders. The comorbidity class was characterized by comorbid mental disorders, suicide attempts and substance abuse and associated with younger age and bipolar disorder. The undefined class formed no distinct profile; individuals in this class had the lowest number of adversities and it associated with psychotic disorders. The identification of subgroups characterized by childhood circumstances and comorbidity may help planning of prevention and support practices for young adults with mental disorders and risk of work disability.

Correlation of Incident Potentially Inappropriate Medication Prescriptions and Hospitalization: An Analysis Based on the PRISCUS List.

BackgroundMultimorbidity and polypharmacy represent a major problem for elderly patients. Potentially inappropriate medication (PIM) use is highly prevalent among the elderly. PIMs are considered high-risk drugs and are suspected to be responsible for adverse drug events (ADEs) leading to hospitalization.ObjectiveThe objective of this study was to determine hospitalization rates related to selected ADEs in elderly patients with an incident prescription of a PIM as defined by the PRISCUS list. A second objective was to identify other factors independently associated with hospitalization.MethodsWe retrospectively analysed a full census of pharmaceutical claims, from one of the largest public sickness funds in Germany, for 647,073 patients aged ≥65 years in 2010, the year of publication of the PRISCUS list. Patients who received an incident PIM in 2010 were assigned to the intervention group. Propensity score matching was used to build a control group of patients at a comparable risk level who received an incident equivalent non-PIM. The risk of hospitalization due to PIM prescription was estimated via the odds ratio (OR). Risk factors were analysed via logistic regression models.ResultsThe results showed significantly more ADEs in the PIM group. The OR for hospitalization was 1.54 [95 % confidence interval (CI) 1.23–1.93] for patients receiving any PIM compared with those who received a non-PIM. This trend remained stable [OR 1.46 (95 % CI 1.16–1.84)] after adjustment for relevant covariates in the logistic regression models showing ORs for each risk factor. Besides PIMs, common risk factors such as greater age, comorbidity and specific drug classes were significantly responsible for hospitalization.ConclusionPIMs (as defined by the PRISCUS list) are associated with high rates of ADEs associated with hospitalization. Our study suggests that PIM reduction may result in a lower risk of hospitalization in the elderly.

The Clustering of Psychopathology Among Adults Seeking Treatment for Alcohol and Drug Addiction

Beyond the high prevalence of co-occurring mental and substance use disorders, little is known about more complex patterns of psychopathology and multimorbidity, particularly in treatment populations. We sought to identify a parsimonious set of latent classes to describe the structure of mental disorder comorbidity among adults entering outpatient addiction treatment, and explore differences in the structure and prevalence of classes across sociodemographic characteristics. Participants (N=544) completed the Psychiatric Diagnostic Screening Questionnaire at treatment admission. We used latent class analysis to identify classes of clients with specific patterns of co-occurring mental disorders. The best-fitting solution identified 3 classes, characterized by no comorbidity (i.e., substance use disorders only), co-occurring major depression, and multimorbidity or a high degree of psychopathology. Older age was associated with lower probability of being in the class with co-occurring major depression, women were more likely than men to be in the multimorbid class, and being married or partnered was associated with a lower probability of being in either of the comorbid classes. These results are consistent with general population research on the patterning of psychiatric disorders, implying that while clients in addiction treatment may have extraordinarily high levels of psychopathology, the patterns of symptoms and the groups most affected are not markedly different than in other settings. By capturing the complexity of interrelationships among the many factors that are known to influence prognosis and outcomes, latent class analysis offers a useful way to examine and represent case-mix in clinical populations.

Psychiatric comorbidity and perceived alcohol stigma in a nationally representative sample of individuals with DSM-5 alcohol use disorder.

Alcohol use disorder (AUD) is among the most stigmatized health conditions and is frequently comorbid with mood, anxiety, and drug use disorders. Theoretical frameworks have conceptualized stigma-related stress as a predictor of psychiatric disorders. We described profiles of psychiatric comorbidity among people with AUD and compared levels of perceived alcohol stigma across profiles. Cross-sectional data were analyzed from a general population sample of U.S. adults with past-year DSM-5 AUD (n=3,368) from the National Epidemiologic Survey on Alcohol and Related Conditions, which was collected from 2001 to 2005. Empirically derived psychiatric comorbidity profiles were established with latent class analysis, and mean levels of perceived alcohol stigma were compared across the latent classes while adjusting for sociodemographic characteristics and AUD severity. Four classes of psychiatric comorbidity emerged within this AUD sample, including those with: (i) high comorbidity, reflecting internalizing (i.e., mood and anxiety disorders) and externalizing (i.e., antisocial personality and drug use disorders) disorders; (ii) externalizing comorbidity; (iii) internalizing comorbidity; and (iv) no comorbidity. Perceived alcohol stigma was significantly higher in those with internalizing comorbidity (but not those with high comorbidity) as compared to those with no comorbidity or externalizing comorbidity. Perceived stigma, as manifested by anticipations of social rejection and discrimination, may increase risk of internalizing psychiatric comorbidity. Alternatively, internalizing psychiatric comorbidity could sensitize affected individuals to perceive more negative attitudes toward them. Future research is needed to understand causal and bidirectional associations between alcohol stigma and psychiatric comorbidity.

Traumatic brain injury and PTSD screening efforts evaluated using latent class analysis.

To empirically identify latent classes of service members according to persistent postconcussive symptom patterns and to characterize the identified classes relative to other postdeployment variables including posttraumatic stress disorder (PTSD) and mild traumatic brain injury (TBI) screening results. Such comparisons may directly inform policy regarding these routine assessments and translate to improved treatment decisions. Self-report data were obtained for 12,581 combat-exposed male U.S. Navy and Marine Corps personnel who returned from deployment in 2008-2009 and completed a Post-Deployment Health Assessment (PDHA) and an associated Post-Deployment Health Reassessment (PDHRA). Persistent postconcussive symptoms indicated on the PDHRA were used as manifest variables in a latent class analysis yielding 4 distinct classes: systemic, cognitive/behavioral, comorbid, and nonpresenting. Although the nonpresenting class endorsed few or no postconcussive symptoms, the systemic and cognitive/behavioral classes displayed elevated likelihoods of neurological and mental health symptoms, respectively. Members of the comorbid class had an increased probability of reporting a wide range of symptoms across both domains. Characterization of identified classes suggested that class membership may indicate the presence or absence of persistent conditions resulting from head injury and/or mental health issues. Under this assumption, estimated class membership probabilities implied a rate of probable neurological injury among this sample to be 17.9%, whereas the standard assessments aimed at identifying repercussions of mild TBI reported a positive screening rate of only 13.1%. Findings suggest that the routinely administered PDHA and PDHRA appear to underestimate the true prevalence of service members experiencing postdeployment health problems. Supplemental items or an alternative screening algorithm incorporating persistent postconcussive symptoms may enable identification of additional cases requiring treatment following return from deployment.

Factors associated with comorbidity patterns in full and partial PTSD: Findings from the PsyCoLaus study

Subtypes of comorbid conditions and their associated trauma and clinical characteristics in full and partial PTSD were examined. Data from 289 subjects from the general population that met criteria for full or partial PTSD were analyzed. Latent class analyses (LCA) were performed to derive homogeneous patterns of DSM-IV Axis-I disorders and anti-social personality comorbid to PTSD. Logistic regression models were conducted to characterize these classes by trauma-related and clinical features. The LCA revealed three classes: (1) low comorbidity; (2) high comorbidity with primarily substance-related disorders and a higher proportion of males; and (3) more severe PTSD-symptomatology and higher comorbid anxiety disorders and depression, almost entirely represented by females. Exposure to sexual abuse was more likely in the substance-dependent class and contributed strongly to the distinction between classes. Affective disorders tended to precede the onset of PTSD in the substance-dependent class, whereas phobias were more likely to follow PTSD in the depressed–anxious class. Posttrauma onset of alcohol use disorders in the substance dependent class confirmed the self-medication hypothesis. The three classes of comorbidity and their sequence of onset with PTSD suggest different mechanisms involved in their development. Our findings suggest that PTSD-related comorbidity subtypes also apply to individuals with partial PTSD.

Predominant typologies of psychopathology in the United States: A latent class analysis

BackgroundLatent class analysis (LCA) offers a parsimonious way of classifying common typologies of psychiatric comorbidity. We used LCA to identify the nature and correlates of predominant typologies of Axis I and II disorders in a large and comprehensive population-based sample of U.S. adults. MethodsWe analyzed data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (2004–2005; n = 34,653), a population-based sample of U.S. adults. We derived latent classes based on all assessed Axis I and II disorders and examined the relationship between the identified Axis I classes and lifetime psychiatric disorders and suicide attempts, and physical and mental health-related quality of life. ResultsA four-class solution was optimal in characterizing predominant typologies of both Axis I and II disorders. For Axis I disorders, these included low psychopathology (n = 28,935, 84.0%), internalizing (n = 3693, 9.9%), externalizing (n = 1426, 4.5%), and high psychopathology (n = 599, 1.6%) classes. For Axis II disorders, these included no/low personality disorders (n = 31,265, 90.9%), obsessive/paranoid (n = 1635, 4.6%), borderline/dysregulated (n = 1319, 3.4%), and highly comorbid (n = 434, 1.1%) classes. Compared to the low psychopathology class, all other Axis I classes had significantly increased odds of mental disorders, elevated Axis II classes, suicide attempts and poorer quality of life, with the high psychopathology class having the overall highest rates of these correlates, with the exception of substance use disorders. Compared to the low psychopathology class, the internalizing and externalizing classes had increased rates of mood and anxiety disorders, and substance use disorders, respectively. ConclusionAxis I and II psychopathology among U.S. adults may be best represented by four predominant typologies. Characterizing co-occurring patterns of psychopathology using person-based typologies represents a higher-order classification system that may be useful in clinical and research settings.

Latent class analysis of comorbidity patterns among women with generalized and localized vulvodynia: preliminary findings

BackgroundThe pattern and extent of clustering of comorbid pain conditions with vulvodynia is largely unknown. However, elucidating such patterns may improve our understanding of the underlying mechanisms involved in these common causes of chronic pain. We sought to describe the pattern of comorbid pain clustering in a population-based sample of women with diagnosed vulvodynia.MethodsA total of 1457 women with diagnosed vulvodynia self-reported their type of vulvar pain as localized, generalized, or both. Respondents were also surveyed about the presence of comorbid pain conditions, including temporomandibular joint and muscle disorders, interstitial cystitis, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, endometriosis, and chronic headache. Age-adjusted latent class analysis modeled extant patterns of comorbidity by vulvar pain type, and a multigroup model was used to test for the equality of comorbidity patterns using a comparison of prevalence. A two-class model (no/single comorbidity versus multiple comorbidities) had the best fit in individual and multigroup models.ResultsFor the no/single comorbidity class, the posterior probability prevalence of item endorsement ranged from 0.9% to 24.4%, indicating a low probability of presence. Conversely, the multiple comorbidity class showed that at least two comorbid conditions were likely to be endorsed by at least 50% of women in that class, and irritable bowel syndrome and fibromyalgia were the most common comorbidities regardless of type of vulvar pain. Prevalence of the multiple comorbidity class differed by type of vulvar pain: both (37.6% prevalence, referent), generalized (21.6% prevalence, adjusted odds ratio 0.41, 95% confidence interval 0.27–0.61), or localized (12.5% prevalence, adjusted odds ratio 0.31, 95% confidence interval 0.21–0.47).ConclusionThis novel work provides insight into potential shared mechanisms of vulvodynia by describing that a prominent comorbidity pattern involves having both irritable bowel syndrome and fibromyalgia. In addition, the prevalence of a multiple comorbidity class pattern increases with increasing severity of vulvar pain.

Rates, variability, and associated factors of polypharmacy in nursing home patients

ObjectivesTo determine the rate and variability of polypharmacy in nursing home (NH) residents and investigate its relationship to age, sex, functional status, length of stay, and comorbidities.MethodsWe conducted a cross sectional, multicenter study that included six nursing homes. Demographic, clinical characteristics, Charlson comorbidity index (CCI), the number and classes of chronic medications, rate of polypharmacy >5 drugs (per day) and polypharmacy >7 drugs (per day) were recorded.ResultsNine hundred and ninety-three residents were included; 750 (75.5%) fully dependent residents and 243 (24.5%) mobile demented residents requiring institutional care. The mean age was 85.04±7.55 (65–108) years. The mean rates of polypharmacy >5 drugs and polypharmacy >7 drugs were 42.6% and 18.6%, respectively. Differences in polypharmacy >5 drugs and polypharmacy >7 drugs were observed in NHs 24.7%–56% and 4.9%–30.4%, respectively (P<0.001). Mean number of chronic drugs per resident was 5.14±2.60 from 3.81±2.24 to 5.95±2.73 (P<0.001). No differences in polypharmacy were found between sex and fully dependent versus mobile demented residents. The most common medications taken were for gastrointestinal, neurological, and cardiovascular disorders. Regression analysis revealed four independent variables for polypharmacy >5 drugs: groups aged 75–84 and >85 relative to 65–74, odds ratio (OR) 0.46 (95% confidence interval [CI] 0.27–0.78) P=0.004, OR 0.35 (95% confidence interval 0.19–0.53), respectively, P<0.001; length of stay >2 years, OR 0.51 (95% CI 0.36–0.73) P<0.001; CCI, OR 1.58 (95% CI 1.42–1.75) P<0.001; and feeding tube versus normal feeding, OR 0.27 (95% CI 0.12–0.60) P=0.001.ConclusionRates of polypharmacy in NHs are high with significant variability. Variability rates of polypharmacy, distinct residents’ characteristics, and excessive use of certain drug groups may indicate that a decrease in medication is potentially feasible.

PATTERNS OF LIFETIME PTSD COMORBIDITY: A LATENT CLASS ANALYSIS

Posttraumatic stress disorder (PTSD) is associated with high rates of psychiatric comorbidity, most notably substance use disorders, major depression, and other anxiety disorders. However, little is known about how these disorders cluster together among people with PTSD, if disorder clusters have distinct etiologies in terms of trauma type, and if they confer greater burden over and above PTSD alone. Utilizing Latent Class Analysis, we tested for discrete patterns of lifetime comorbidity with PTSD following trauma exposure (n = 409). Diagnoses were based on the Structured Clinical Interview for DSM-IV (SCID). Next, we examined if gender, trauma type, symptom frequency, severity, and interference with everyday life were associated with the latent classes. Three patterns of lifetime comorbidity with PTSD emerged: a class characterized by predominantly comorbid mood and anxiety disorders; a class characterized by predominantly comorbid mood, anxiety, and substance dependence; and a relatively pure low-comorbidity PTSD class. Individuals in both high comorbid classes had nearly two and a half times the rates of suicidal ideation, endorsed more PTSD symptom severity, and demonstrated a greater likelihood of intimate partner abuse compared to the low comorbidity class. Men were most likely to fall into the substance dependent class. PTSD comorbidity clusters into a small number of common patterns. These patterns may represent an important area of study, as they confer distinct differences in risk and possibly etiology. Implications for research and treatment are discussed.

Personality and changes in comorbidity patterns among anxiety and depressive disorders.

This prospective study examined the prognostic value of the Big Five personality model for changes in comorbidity patterns of emotional disorders both from a person- and trait-centered perspective. Moreover, it is investigated whether the predictive effect of personality can be attributed to symptom severity at baseline. We followed a cohort of 2566 persons (18-65 years) recruited in primary and specialized mental health care during two years. Personality dimensions at baseline were assessed with the NEO-FFI. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.)-based diagnostic interviews with the CIDI allowed assessment of changes in comorbidity patterns of anxiety and depressive disorders over two years. Data were analyzed with latent class analysis (LCA) and latent transition analysis (LTA). LCA identified a four-class latent comorbidity class solution (Few Disorders, Fear Disorders, Distress Disorders, and Comorbid Fear and Distress Disorders) and a five-class latent personality class solution (High Resilients, Medium Resilients, Low Overcontrollers, Medium Overcontrollers, and High Overcontrollers). LTA showed that the likelihood of remaining in the same latent class was larger than that of transitioning to a less severe comorbidity class. Also, after correcting for symptom severity, medium and high Overcontrollers as well as participants with lower levels of conscientiousness were less likely to transition to a less severe comorbidity class. In particular, the individual trait of conscientiousness may be less dependent on current levels of anxiety and depressive symptoms and be a key pathoplastic or even predisposing variable in anxiety and depression and needs more theoretical and empirical study.

Are Autism Spectrum Disorder and Attention-Deficit/Hyperactivity Disorder Different Manifestations of One Overarching Disorder? Cognitive and Symptom Evidence From a Clinical and Population-Based Sample

Autism spectrum disorders (ASD) and attention-deficit/hyperactivity disorder (ADHD) frequently co-occur. Given the heterogeneity of both disorders, several more homogeneous ASD-ADHD comorbidity subgroups may exist. The current study examined whether such subgroups exist, and whether their overlap or distinctiveness in associated comorbid symptoms and cognitive profiles gives support for a gradient overarching disorder hypothesis or a separate disorders hypothesis. Latent class analysis was performed on Social Communication Questionnaire (SCQ) and Conners' Parent Rating Scale (CPRS-R:L) data for 644 children and adolescents (5 through 17 years of age). Classes were compared for comorbid symptoms and cognitive profiles of motor speed and variability, executive functioning, attention, emotion recognition, and detail-focused processing style. Latent class analysis revealed five classes: two without behavioral problems, one with only ADHD behavior, and two with both clinical symptom levels of ASD and ADHD but with one domain more prominent than the other (ADHD[+ASD] and ASD[+ADHD]). In accordance with the gradient overarching disorder hypothesis were the presence of an ADHD class without ASD symptoms and the absence of an ASD class without ADHD symptoms, as well as cognitive functioning of the simple ADHD class being less impaired than that of both comorbid classes. In conflict with this hypothesis was that there was some specificity of cognitive deficits across classes. The overlapping cognitive deficits may be used to further unravel the shared etiological underpinnings of ASD and ADHD, and the nonoverlapping deficits may indicate why some children develop ADHD despite their enhanced risk for ASD. The two subtypes of children with both ASD and ADHD behavior will most likely benefit from different clinical approaches.

Parent, sibling and peer associations with subtypes of psychiatric and substance use disorder comorbidity in offspring

BackgroundParental substance use disorder (SUD) is associated with a range of negative offspring outcomes and psychopathology, but the clustering of these outcomes into subtypes has seldom been examined, nor have the familial and environmental contexts of these subtypes been reported. The present study examines the clustering of offspring lifetime substance use and psychiatric disorders into subtypes and characterizes them in terms of familial and non-familial influences using an offspring-of-twins design. MethodTelephone-administered diagnostic interviews were used to collect data on psychiatric disorders and SUD from 488 twin fathers, 420 biological mothers and 831 offspring. Latent class analysis (LCA) was used to derive subtypes of lifetime comorbidity in offspring. Familial risk and environmental variables associated with each subtype (i.e., parenting, childhood physical or sexual abuse, perceived sibling and peer substance use) were identified using multinomial logistic regression. ResultsFour classes identified by LCA were characterized as (1) unaffected, (2) alcohol abuse/dependence, (3) alcohol abuse/dependence comorbid with anxiety and depression, and (4) alcohol, cannabis abuse/dependence and nicotine dependence comorbid with conduct disorder. Inconsistent parenting, childhood physical/sexual abuse, and perceived sibling and peer substance use were significantly associated with profiles of offspring comorbidity after adjusting for familial vulnerability. Some associations were specific (i.e., perceived peer alcohol use to the AUD class), while others were general (peer smoking to all 3 comorbidity classes). ConclusionsWe observed distinct subtypes of psychiatric and SUD comorbidity in adolescents and young adults. Subtypes of offspring psychopathology have varied associations with parental psychopathology, family environment, and sibling and peer behaviors.

Ninety day mortality and its predictors after primary shoulder arthroplasty: an analysis of 4,019 patients from 1976-2008

BackgroundExamine 90-day postoperative mortality and its predictors following shoulder arthroplastyMethodsWe identified vital status of all adults who underwent primary shoulder arthroplasty (Total shoulder arthroplasty (TSA) or humeral head replacement (HHR)) at the Mayo Clinic from 1976-2008, using the prospectively collected information from Total Joint Registry. We used univariate logistic regression models to assess the association of gender, age, body mass index, American Society of Anesthesiologist (ASA) class, Deyo-Charlson comorbidity index, an underlying diagnosis and implant fixation with odds of 90-day mortality after TSA or HHR. Multivariable models additionally adjusted for the type of surgery (TSA versus HHR). Adjusted Odds ratio (OR) with 95% confidence interval (CI) were calculated.ResultsTwenty-eight of the 3, 480 patient operated died within 90-days of shoulder arthroplasty (0.8%). In multivariable-adjusted analyses, the following factors were associated with significantly higher odds of 90-day mortality: higher Deyo-Charlson index (OR, 1.54; 95% CI:1.39, 1.70; p < 0.001); a diagnosis of tumor (OR, 16.2; 95%CI:7.1, 36.7); and ASA class III (OR, 3.57; 95% CI:1.29, 9.91; p = 0.01) or class IV (OR, 13.4; 95% CI:2.44, 73.86; p = 0.003). BMI ≥ 30 was associated with lower risk of 90-day mortality (OR, 0.25; 95% CI:0.08, 0.78). In univariate analyses, patients undergoing TSA had significantly lower 90-day mortality of 0.4% (8/2, 580) compared to 1% in HHR (20/1, 411) (odds ratio, 0.22 (95% CI: 0.10, 0.50); p = 0.0003).Conclusions90-day mortality following shoulder arthroplasty was low. An underlying diagnosis of tumor, higher comorbidity and higher ASA class were risk factors for higher 90-day mortality, while higher BMI was protective. Pre-operative comorbidity management may impact 90-day mortality following shoulder arthroplasty. A higher unadjusted mortality in patients undergoing TSA versus HHR may indicate the underlying differences in patients undergoing these procedures.

Uric acid levels and all-cause and cardiovascular mortality in the hemodialysis population.

Hyperuricemia is associated with hypertension, coronary artery disease, and chronic kidney disease. However, there are no specific data on the relationship of uric acid to cardiovascular disease in the chronic hemodialysis setting. Data from 5827 patients on chronic hemodialysis from six countries affiliated with the Dialysis Outcomes and Practice Patterns Study (DOPPS) were analyzed. All laboratory data were based upon the initial cross-section of patients in DOPPS I and II. Cox regression was used to calculate the hazard ratio (HR) of all-cause and cardiovascular (CV) mortality with adjustments for case-mix including 14 classes of comorbidity. There were no clinically significant differences in baseline characteristics between those who had measured uric acid (n = 4637) and those who did not (n = 1190). Uric acid level was associated with lower all-cause mortality (HR: 0.95, 95% confidence interval [CI]: 0.90 to 1.00 per 1 mg/dl higher uric acid level) and CV mortality (HR: 0.92, 95% CI: 0.86 to 0.99). When analyzed as a dichotomous variable, the adjusted HR at uric acid ≤8.2 mg/dl compared with >8.2 mg/dl was 1.24 (95% CI: 1.03 to 1.49) for all-cause mortality and 1.54 (95% CI: 1.15 to 2.07) for CV mortality. Higher uric acid levels were associated with lower risk of all-cause and CV mortality in the hemodialysis population. These results are in contrast to the association of hyperuricemia with higher cardiovascular risk in the general population and should be the subject of further research.

Laparoscopic radical prostatectomy is feasible and effective in ‘fit’ senior men with localized prostate cancer

OBJECTIVE To assess the effect of age and comorbidity on short-term complications, long-term continence and oncological outcome after laparoscopic radical prostatectomy (LRP) for localized prostate cancer. PATIENTS AND METHODS In all, 2048 consecutive men underwent LRP for localized prostate cancer in one institution. Comorbidity was assessed using the Charlson index. Short-term postoperative complications, transfusion rate, duration of hospital stay, long-term continence and oncological outcome were analysed by age and comorbidity classes. RESULTS Of the 2048 men, 297 were aged ≥ 70 years and 281 had a Charlson index of >0 (mainly diabetes 31%, chronic pulmonary disease 26%, prior other nonmetastatic cancer 16%, prior myocardial infarction 12%). Compared with younger men, senior men had significantly higher pathological stages and tumor grades. Of those 297 men aged ≥ 70 years, 90 (30.3%) developed biochemical relapse, none died from prostate cancer and five (1.7%) died from another cause over a median follow-up of 5 years. The occurrence and severity of short-term postoperative complications were more strongly related to comorbidity than chronological age. Multivariate analysis with stepwise regression confirmed that most important predictors of short-term postoperative complications were a Charlson index of ≥ 2, prostate weight of >80 g, obesity and age of ≥ 70 years. Postoperative continence significantly declined with age (ranging from 87% in men aged <60 years to 67.5% in men aged ≥ 70 years). Predictors of long-term incontinence were age of ≥ 70 years, obesity and need for perioperative transfusion. CONCLUSIONS LRP is feasible and effective in fit senior men (aged ≥ 70 years) with localized prostate cancer, including those at high risk of dying from it.