Extent Of Comorbidity Research Articles

Routine deprescribing of chronic medications to combat polypharmacy.

The positive benefit-risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our 'war against IMUP' in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the 'single disease model' research and clinical rules we were raised upon and somehow 'fanatically' adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular.

The relative importance of perceived doctor's attitude on the decision to consult for symptomatic osteoarthritis: a choice-based conjoint analysis study.

ObjectivesSome patients spend years with painful osteoarthritis without consulting for it, including times when they are experiencing persistent severe pain and disability. Beliefs about osteoarthritis and what primary care has to offer may influence the decision to consult but their relative importance has seldom been quantified. We sought to investigate the relative importance of perceived service-related and clinical need attributes in the decision to consult a primary care physician for painful osteoarthritis.DesignPartial-profile choice-based conjoint analysis study, using a self-complete questionnaire containing 10 choice tasks, each presenting two scenarios based on a combination of three out of six selected attributes.SettingGeneral population.ParticipantsAdults aged 50 years and over with hip, knee or hand pain registered with four UK general practices.Outcome measuresRelative importance of pain characteristics, level of disruption to everyday life, extent of comorbidity, assessment, management, perceived general practitioner (GP) attitude.Results863 (74%) people responded (55% female; mean age 70 years, range: 58–93). The most important determinants of the patient's decision to consult the GP for joint pain were the extent to which pain disrupted everyday life (‘most’ vs ‘none’: relative importance 31%) and perceived GP attitude (‘legitimate problem, requires treatment’ vs ‘part of the normal ageing process that one just has to accept’: 24%). Thoroughness of assessment (14%), management options offered (13%), comorbidity (13%) and pain characteristics (5%) were less strongly associated with the decision to consult.ConclusionsAnticipating that the GP will regard joint pain as ‘part of the normal ageing process that one just has to accept’ is a strong disincentive to seeking help, potentially outweighing other aspects of quality of care. Alongside the recognition and management of disrupted function, an important goal of each primary care consultation for osteoarthritis should be to avoid imparting or reinforcing this perception.

Delayed Fracture Healing in Diabetics with Distal Radius Fractures.

PURPOSE OF THE STUDY Diabetics may have an increased fracture risk, depending on disease duration, quality of metabolic adjustment and extent of comorbidities, and on an increased tendency to fall. The aim of this retrospective one-centre study consisted in detecting differences in fracture healing between patients with and without diabetes mellitus. Data of patients with the most common fracture among older patients were analyzed. MATERIAL AND METHODS Classification of distal radius fractures was established according to the AO classification. Inital assessment and followup were made by conventional x-rays with radiological default settings. To evaluate fracture healing, formation of callus and sclerotic border, assessment of the fracture gap, and evidence of consolidation signs were used. RESULTS The authors demonstrated that fracture morphology does not influence fracture healing regarding time span, neither concerning consolidation signs nor in fracture gap behavior. However, tendency for bone remodeling is around 70% lower in investigated diabetics than in non-diabetics, while probability for a successful fracture consolidation is 60% lower. CONCLUSIONS To corroborate the authors hypothesis of delayed fracture healing in patients with diabetes mellitus, prospective studies incorporating influencing factors like duration of metabolic disease, quality of diabetes control, medical diabetes treatment, comorbidities and secondary diseaseas, like chronic nephropathy and osteoporosis, have to be carried out. Key words: diabetes, delayed fracture healing, distal radius fractures, callus formation, blood glucose level, osteoblasts.

Healthcare Services Needs and Co-Morbidity Assessment Among Adolescents and Young Adults with Cancer: the AYA Hope Study

Cancer is the leading cause of disease-related death in the Adolescent and young adult (AYA) population; and though strides have been made in survival of children with cancer, cancer patients diagnosed between 15 and 39 years have not had survival improvement in more than 20 years. Individuals within this population may possess a greater need of particular health services in order to cope with disease. AYA cancer patients may present with co-morbidities that pre-date their cancer treatment and could create challenges for appropriate treatment. Previous studies have demonstrated that co-morbidities can result in increased hospitalizations, difficulties with treatment, high health care costs, reduced quality of life and higher mortality. Although the extent of co-morbidities and their association with poor outcomes have been examined extensively in the adult cancer population, there is little data on children, and even less in the AYA cancer population.Methods:In order to determine what co-morbidities exist in the AYA cancer population, we examined the prevalence of co-morbidities in the National Cancer Institute’s Adolescent and Young Adult Health Outcomes and Patient Experience (AYA HOPE) Study, a population-based cohort of AYAs recently diagnosed with cancer. All co-morbidities were abstracted from the medical record at the time of initial diagnosis and during the first course of treatment. We compared the fitness of current co-morbidity indices for chronic conditions (Charlson and National Cancer Institute Index (NCI)) and created an AYA HOPE index that covers more clinically relevant chronic co-morbid conditions in AYA cancer survivors. We examined self-reported services needed or received, and self-reported health status with the count of co-morbidities in the AYA HOPE cohort using the AYA HOPE Index.Results:Four hundred and eighty-five patients were eligible for this study; the mean age of diagnoses was 28 years. The prevalence of co-morbidities in the AYA HOPE participants was examined using the Charlson index, the NCI index and the AYA Hope index. For diabetes, HIV/AIDS, hypertension, liver, asthma/respiratory, and rheumatologic/autoimmune, the co-morbidity counts were the same for the three co-morbidity indices. Mental health and obesity/overweight were not included in the Charlson or the NCI indices but included in the AYA HOPE Index. When compared to Charlson and NCI indices, the prevalence of co-morbidities was higher for cardiovascular, endocrine, gastrointestinal and neurologic conditions with the AYA HOPE index. The prevalence of mental health co-morbid conditions was 8.2% within the population, with 17 of the 40 individuals affected (42.5%) reporting a depressive disorder. Also, the prevalence of obesity/overweight conditions was 5.8%. Of the 485 patients examined, 70 (14.4%) had 2 or more co-morbid conditions using the AYA HOPE index, which was much higher than the number of patients determined to have multiple co-morbidities based on the Charlson and NCI indices (4.9% and 2.7%, respectively). Overall, 39.6% of AYA patients responding to the survey 6-14 months after diagnosis reported needing some type of health service with the most common service needed being mental health (25.2%), followed by support group (17.7%). After controlling for significant clinical factors (e.g., cancer site, health status and treatment received) and socio-demographic predictors (e.g., age, sex, race), AYA patients with 2 or more co-morbidities based on the AYA HOPE index had twice the odds of needing mental health services as those with no co-morbidity (OR: 2.00; 95% CI 1.05-3.81). AYA patients with 2 or more co-morbidities were also three times more likely to report their health status as fair/poor (OR: 3.15; 95% CI 1.56-6.37).Conclusion:The AYA HOPE index is the first co-morbidity index to be developed specifically for the AYA cancer population. The inclusion of mental health and obesity, and the expansion of neurologic and gastrointestinal categories enhances the predictive ability of the AYA HOPE index and allows for a more accurate picture of the conditions prevalent in this unique population; in doing so, it aids in prediction of common healthcare services that should be directed to this population. DisclosuresNo relevant conflicts of interest to declare.

Obesity associated risk using Edmonton staging in bariatric surgery

With a prevalence of Morbid Obesity of 1,2% of the Spanish population, the current criteria for Bariatric Surgery do not classify patients taking into consideration co-morbidities or functional status. We need new staging systems useful in predicting mortality and able to support prioritizing treatments. Applying Edmonton staging system to patients awaiting Bariatric Surgery. Data collected from 81 patients from 2011- 2013 after pre-surgery protocol. Weight, height, waist, BMI, biochemical parameters and blood pressure are registered. Also taken down are hepatic, renal, osteoarticular diseases, sleep-apnea syndrome and/or gastro-oesophageal reflux, if present. Edmonton staging of ten variables is applied to each patient. 81 patients: 67% women, average age 47y, 18% below 30y. Average BMI of 47, 90% of patients have a BMI >40. 34% of patients show sleep-apnea syndrome and 25% gastro-oesophageal reflux. 9% of the patients have a BMI >45, diabetes mellitus and sleep-apnea syndrome. Applying the Edmonton Staging, nine patients (11%) are in the highest risk range (stage 3), 70% are in the high-risk range (stage 2) and 15 patients (18%) are included in the low-risk range. No patient was found to be in stage 0 without obesity risk factors. The Edmonton staging system provides us with information on presence or extent of co-morbidities that guide decision making in individuals. The mortality- predictive ability of Edmonton proposal could help to assist in determining the urgency of Bariatric Surgery and establish better criteria to prioritize these group of patients.

Independent influence of negative blood cultures and bloodstream infections on in-hospital mortality

BackgroundThe independent influence of blood culture testing and bloodstream infection (BSI) on hospital mortality is unclear.MethodsWe included all adults treated in non-psychiatric services at our hospital between 2004 and 2011. We identified all blood cultures and their results to determine the independent association of blood culture testing and BSI on death in hospital using proportional hazards modeling that adjusted for important covariates.ResultsOf 297 070 hospitalizations, 48 423 had negative blood cultures and 5274 had BSI. 12 529 (4.2%) died in hospital. Compared to those without blood cultures, culture-negative patients and those with BSI were sicker. Culture-negative patients had a significantly increased risk of death in hospital (adjusted hazard ratio [HR] ranging between 3.1 and 4.4 depending on admission urgency, extent of comorbidities, and whether the blood culture was taken in the intensive care unit). Patients with BSI had a significantly increased risk of death (adj-HR ranging between 3.8 and 24.3] that was significantly higher when BSI was: diagnosed within the first hospital day; polymicrobial; in patients who were exposed to immunosuppressants or were neutropenic; or due to Clostridial and Candidal organisms. Death risk in culture negative and bloodstream infection patients decreased significantly with time.ConclusionsRisk of death in hospital is independently increased both in patients with negative blood cultures and further in those with bloodstream infection. Death risk associated with bloodstream infections varied by the patient’s immune status and the causative microorganism.

PP228-SUN GLUTAMINE AND INSULIN RESISTANCE FOR CARDIAC PATIENTS WITH DIABETES MELLITUS

Rationale: The Edmonton Obesity Staging System (EOSS) [1] is a novel risk-classification system for obese patients in addition to BMI based on the presence or extent of comorbidities or functional limitations. The aim of this study was to apply EOSS to morbidly obese patients scheduled for bariatric surgery (BS). Methods: In 205 consecutive outpatients with indication for BS EOSS was assessed retrospectively using data from the patients’ medical files. Obesity-related metabolic, functional and psychological comorbidities were ranked on a 5-point ordinal scale, ranging from Stage 0 (no apparent obesityrelated risk factors/limitations) to Stage 4 (severe disabilities/limitations). Results: EOSS could be completed in 83.4% (171/205) of patients (59m, 112 f; median BMI 51.9 [35.1 89.9] kg/m2, median age 47 [19 67] yrs). The distribution of EOSS stages was 0% in Stage 0, 5.8% in Stage 1, 55.0% in Stage 2, 35.7% in Stage 3, and 3.5% in Stage 4. In 80.7% of patients metabolic disorders in combination with both functional and psychological problems were present. Significant and severe (Stage 3+4) metabolic disorders were more frequent (24.6%) than Stage 3+4 psychological (16.4%) or functional (10.5%) limitations. Conclusion: The EOSS is easily applicable and feasible in patients scheduled for bariatric surgery. Although these patients are highly selected we found a great variety in the type and severity of comorbidities and functional limitations. These results have to be accounted for when comparing studies in bariatric patients. The association of EOSS to outcome after BS warrants further investigation.

Medical complications and outcomes at an onsite rehabilitation unit for older people

The rehabilitation of older patients in Ireland after an acute medical event occurs at dedicated onsite hospital units or at offsite centres. Information on medical complications and outcomes is inadequate. Enumeration of medical complications of patients admitted to a dedicated onsite rehabilitation unit for older people, and the extent of co-morbidity in the population with the effects that this had on the evolution of medical complications. A retrospective analysis of patients admitted to a 58-bed onsite unit over a 1-year period was performed. Information collating co-morbidities, medical complications and functional outcomes was recorded. Medical complications occurred in almost 95% of patients, where full data were available. Over one-third required intravenous therapy. Twenty-four hour medical cover is required for older patients managed at onsite rehabilitation units. Further studies on offsite medical rehabilitation facilities for older patients are required.

Contributions of Environment, Comorbidity, and Stage of Dementia to the Onset of Walking and Eating Disability in Long‐Term Care Residents

To estimate the relative effects of environment, comorbidities, stage of dementia and other variables on disability onset. A 1-year prospective cohort study was conducted in which the walking and eating abilities of long-term care residents were observed fortnightly. Structural equation modeling was used to assess the contributions of individual and environmental factors to the onset of disability. Fifteen nursing homes in western Canada. One hundred twenty residents with middle-stage Alzheimer disease or related dementia. Environmental quality was assessed using the Professional Environmental Assessment Protocol, comorbidity using the Charlson Comorbidity Index, and stage of dementia using the Global Deterioration Scale. More-advanced baseline dementia had a direct effect on onset of walking and eating disability (standardized maximum likelihood estimate (SMLE) = 0.24, P = .006). Resident environment (SMLE = -0.25, P = .007) and comorbidities (SMLE = 0.32, P < .001) influenced disability onset approximately as strongly as stage of dementia. Smaller and publicly owned facilities provided superior environmental quality, which indirectly contributed to a delay in onset of walking and eating disability. Environmental quality and extent of comorbidity are at least as important as progression of dementia in initiating or delaying the onset of disability.

Comorbidity in patients with asymptomatic AS

In response to our Perspectives article (Vaishnava, P., Fuster, V., Goldman, M. & Bonow, R. O. Surgery for asymptomatic degenerative aortic and mitral valve disease. Nat. Rev. Cardiol. 8, 173–177 [2011])1 on asymptomatic valve disease, Gilmanov et al. (Gilmanov, D., Mazzone, A., Berti, S. & Glauber, M. Is comorbidity equivalent to symptoms in asymptomatic AS? Nat. Rev. Cardiol. doi:10.1038/nrcardio.2011.203-c1)2 correctly note the often insidious and not easily recognized onset of symptoms in aortic stenosis (AS). We agree that subtle and nonspecific symptoms might not be fully acknowledged by patients, or become falsely attributed to the effects of aging, deconditioning, or comorbidities. Gilmanov et al. also suggest that the “extent of comorbidity” could be considered a “symptom equivalent for prognostic stratification.” Although we agree that comorbidities are common in patients with severe AS, we would caution against this approach of ascribing symptom equivalency to a heterogeneous group of coexisting illnesses. Rather, we would advocate exercise testing with or without echocardiography to risk-stratify asymptomatic patients with AS, by unmasking symptoms and abnormal hemodynamic responses.3, 4, 5

Acute Type B Dissection: Intervention for Rupture or Impending Rupture

Objective: Operative procedures for acute type B aortic dissection (ABAD) are usually performed in the setting of complications. This study focuses on outcomes for repair of ABAD for indications of rupture or impending rupture. Methods: Of the 383 patients admitted with ABAD (1995-2010), 41 (10.7%) underwent open (DTAR, 18) or endovascular aortic repair (TEVAR, 23) for rupture or impending rupture at a median of 3.5 days following presentation. Indications for intervention included rupture (17) or factors portending rupture including rapid expansion (11), uncontrolled pain (13), aortic size >5.0 cm (13) or refractory hypertension (2). 11 patients had multiple indications. Isolated intramural hematoma was present in 10. Extent of repair included arch (32, 78%) or total descending aorta (16, 39%). Selection of therapy was based upon age and extent of comorbidities. TEVAR, though available since 1993, was preferentially used since 2007. Patients undergoing TEVAR were older and more frequently had prior MI, renal failure, tobacco use history, or Debakey IIIA ABAD (all P < .05). Results: 30-day mortality was 17% (n = 7). Morbidity included stroke (3), renal failure needing dialysis (3), or permanent paraplegia (3). Independent correlates of a composite outcome of mortality and these morbidities included presentation with rupture (P = .02, OR 7.6) or active tobacco use (P = .02, OR 9.8), but not treatment strategy (P = .18). 8 yr Kaplan-Meier survival was 49.4%. Independent predictors of late mortality included occurrence of perioperative stroke or presentation with aortic rupture during late follow-up (both P < .002). 8 yr freedom from aortic rupture or reintervention was 76.6%. When compared to open repair, TEVAR had a similar late survival (3 yr 67.1% vs. DTAR 72.2%, log rank P = .8), and rate of false lumen thrombosis (P = .56). 3 yr freedom from aortic reintervention or rupture was higher after open repair (DTAR 94% vs. TEVAR 61%, log rank P = .16). Conclusion: Intervention for acute type B dissection complicated by rupture or impending rupture remains associated with significant rates of early and late morbidity and reintervention. Understanding the baseline differences in the treatment groups presented in this study, these data support the use of an endovascular approach for this indication in acute dissection.

Comorbidity and Labor Force Activity Among People With Psychiatric Disorders

Comorbidity among people with psychiatric disorders with respect to other health conditions is extensive yet is rarely explored in-depth in occupational studies. We investigated how other ICD-10 comorbidity impacted on the labor force activity of people with psychiatric disorders. A secondary analysis of data files was conducted provided by the Australian Bureau of Statistics (ABS) from a 2003 population survey (N = 36,088). The reference group was working age community residents without long-term health conditions. Comorbidity with a broad range of ICD-10 health conditions can be characterized by both type and extent of comorbidity. Both dimensions are needed to explain impacts on labor force activity. Health professionals, policymakers, and administrators can utilize these results to identify people with psychiatric disorders and comorbidity profiles most likely to need more intensive vocational services.

Cardiovascular and musculskeletal co-morbidities in patients with alpha 1 antitrypsin deficiency

BackgroundDetermining the presence and extent of co-morbidities is fundamental in assessing patients with chronic respiratory disease, where increased cardiovascular risk, presence of osteoporosis and low muscle mass have been recognised in several disease states. We hypothesised that the systemic consequences are evident in a further group of subjects with COPD due to Alpha-1 Antitrypsin Deficiency (A1ATD), yet are currently under-recognised.MethodsWe studied 19 patients with PiZZ A1ATD COPD and 20 age, sex and smoking matched controls, all subjects free from known cardiovascular disease. They underwent spirometry, haemodynamic measurements including aortic pulse wave velocity (aPWV), an independent predictor or cardiovascular risk, dual energy X-ray absorptiometry to determine body composition and bone mineral density.ResultsThe aPWV was greater in patients: 9.9(2.1) m/s than controls: 8.5(1.6) m/s, p = 0.03, despite similar mean arterial pressure (MAP). The strongest predictors of aPWV were age, FEV1% predicted and MAP (all p < 0.01). Osteoporosis was present in 8/19 patients (2/20 controls) and was previously unsuspected in 7 patients. The fat free mass and bone mineral density were lower in patients than controls (p < 0.001).ConclusionsPatients with A1ATD related COPD have increased aortic stiffness suggesting increased risk of cardiovascular disease and evidence of occult musculoskeletal changes, all likely to contribute hugely to overall morbidity and mortality.

Psychiatric comorbidity in patients with epilepsy: a population-based study

Patients with epilepsy often suffer from concomitant psychiatric disorders. Treatment patterns and the extent of comorbidity are insufficiently investigated and appropriate methods are scarce. The purpose of the study was to estimate the prevalence of psychiatric comorbidity in patients with epilepsy and to investigate prescription patterns of drugs prescribed for psychiatric disorders in epilepsy. Prescription data from the Norwegian Prescription Database (NorPD) regarding the use of CNS-active drugs included anonymous data from almost 190,000 patients and 1.1-1.3 million prescriptions per year (2004-2007). Searches were based upon use of specific drugs, defined daily doses, number of patients, prescriptions, gender, and age. Reimbursement codes related to psychiatric diagnosis were used as indicators for clinical use. The prevalence of psychiatric comorbidity in patients with epilepsy was estimated to be 32%. There were 56% women and 44% men participating in the study. Among patients using antidepressants two thirds were women, but no gender differences were seen with antipsychotic medication. Antidepressants and antipsychotics were used 3.4 (20.9%) and 5.8 (13.4%) times more frequently than in the general population, accounting for 7.88 and 1.99 defined daily doses (DDDs)/1,000 inhabitants/day/year respectively. Lamotrigine was the most commonly used antiepileptic drug (AED) in epilepsy, accounting for 33% of the use of AEDs (in total 5.65 DDDs/1,000 inhabitants/day/year). The use of benzodiazepines was 9.55 DDDs/1,000 inhabitants/day/year. The patients had complex pharmacotherapy with two to eight concomitant drugs. The present study gives an estimate of psychiatric comorbidity of 32% in patients with epilepsy in a nation-wide population. The pharmacotherapy in this patient population is complex. The results provide valuable data on prescription patterns that contribute to pharmacovigilance on a national scale.

A proposed clinical staging system for obesity

Current classifications of obesity based on body mass index, waist circumference and other anthropometric measures, although useful for population studies, have important limitations when applied to individuals in clinical practice. Thus, these measures do not provide information on presence or extent of comorbidities or functional limitations that would guide decision making in individuals. In this paper we review historical and current classification systems for obesity and propose a new simple clinical and functional staging system that allows clinicians to describe the morbidity and functional limitations associated with excess weight. It is anticipated that this system, when used together with the present anthropometric classification, will provide a simple framework to aid decision making in clinical practice.

Elders Are Fit for Lung Cancer Therapy

Elders Are Fit for Lung Cancer Therapy

Impact of Comorbidities on Ischemic Stroke Outcomes in Women

We assessed the association of prestroke comorbidities with long-term stroke outcomes among women with ischemic stroke. Prestroke comorbid conditions in 133 women admitted with acute ischemic stroke were scored with the Charlson Index (CI). We assessed whether the CI and other specific conditions were associated with modified Rankin Score (mRS) at 90 days or more poststroke. After adjustment for initial NIHSS and age, higher CI was the sole factor independently associated with poorer 90 day mRS scores. When CI was excluded, coronary disease and diabetes were independently associated with poorer outcome. The extent of comorbidities as assessed by the CI is independently associated with 90-day mRS among women with ischemic stroke, but the individual comorbidities of CHD and DM were each associated with functional outcome.

Health‐related Quality of Life in Patients on Peritoneal Dialysis in Serbia: Comparison with Hemodialysis

Patients' health-related quality of life (HRQoL) is an important indicator of the effectiveness of the medical care they receive. Patients who reach end-stage renal disease are older and have a considerable extent of comorbidity. The objectives of this study were (i) to evaluate HRQoL in patients at the initiation of continuous ambulatory peritoneal dialysis (CAPD) treatment (incident cohort) and in patients on long-term CAPD therapy (prevalent cohort), and (ii) to compare influence of comorbidity on HRQoL in CAPD and hemodialysis (HD) patients. In a cross-sectional study we enrolled 99 CAPD and 192 HD patients. HRQoL was assessed with the 36-item Short Form Health Survey Questionnaire (SF-36). HRQoL summary scales in both incident and prevalent groups of CAPD patients were similar for physical component summary score (PCS) and for mental component summary score (MCS). Generally, higher values were found in mental health domains in comparison to PCS. In the incident group of patients, 1 year of peritoneal dialysis treatment was associated with a slight improvement in both PCS and MCS, but statistical significance (P < 0.05) was found in the role-physical limitation (RP), bodily pain (BP), and vitality (VT) scales only. CAPD patients with the highest disease severity (Index of Disease Severity [IDS]-3) and physical impairment (Index of Physical Impairment [IPI]-2) scored significantly higher parameters of HRQoL than HD patients. Comorbidity had negative influence on HRQoL, but statistically significant correlation has been found in HD patients only. In conclusion, comorbid conditions had negative correlation with parameters of HRQoL in both CAPD and HD patients. One year after starting CAPD, patients reported better scores in some domains, especially in RP, BP, and VT scales. Assessment of HRQoL and comorbidity might be useful in clinical practice in the follow-up of patients treated with both CAPD and HD.

Acute upper gastrointestinal haemorrhage

Acute gastrointestinal haemorrhage is a common medical emergency that has a hospital mortality of approximately 10%. Peptic ulcer bleeding, complicating non-steroidal anti-inflammatory drugs, aspirin or Helicobacter pylori infection is the most common cause of major bleeding. Gastro-oesophageal varices are less common but managing the underlying liver disease and the severity of bleeding may be demanding. The prognosis of patients presenting with acute bleeding is dictated by the presence of medical co-morbidities and by the severity of liver disease in patients with varices. Validated prognostic scoring systems, based upon the severity of bleeding, diagnosis, endoscopic findings and extent of co-morbidities, predict mortality and have clinical utility. The treatment of non-variceal bleeding is based upon cardiovascular resuscitation followed by endoscopic therapy in patients with active bleeding or major stigmata of recent haemorrhage. Proton pump inhibitor drugs reduce the risk of re-bleeding but have little effect on mortality. Emergency surgery is undertaken for uncontrolled bleeding or re-bleeding that cannot be controlled by further endoscopic therapy. Oesophageal varices are managed by fluid resuscitation, antibiotics and endoscopic band ligation. Vasoactive drugs may stop active bleeding but have no effect upon mortality. Management of the complications of the underlying liver disease and complete variceal ablation in a banding programme are essential. Gastric varices are treated by injection with tissue adhesives or transjugular intrahepatic porto-systemic shunt (TIPSS) insertion. Surgical intervention has little role in the management of varices and patients who do not respond to endoscopic therapies are best treated by TIPSS.

The Prevalence and Comorbidity Between Delinquency, Drug Abuse, Suicide Attempts, Physical and Sexual Abuse, and Self-Mutilation Among Delinquent Hispanic Females

Representative data show that drug abuse, delinquency, and suicide attempts are major concerns among adolescent Hispanic females. Although comorbidity research indicates that such problems tend to be related to each other, this research largely neglects Hispanic females. Using data from presentence investigations on 141 Hispanic girls sentenced to probation, the present research assesses the prevalence of drug abuse, delinquency, suicide attempts, physical and sexual abuse, and self-mutilation as well as the extent of comorbidity among these problems. Results show very high levels of violent delinquency, marijuana abuse, suicide attempts, and self-mutilation. Comorbidity was also extensive between suicide attempts, self-mutilation, physical and sexual abuse, and between these variables and drug abuse and certain forms of delinquency. This study is among the first to describe the problems of adolescent Hispanic females and highlights the need for additional research to better understand and address the serious issues many of these young women face.