Management Of Comorbidities In Patients Research Articles

The Interplay of Comorbidities in Chronic Heart Failure: Challenges and Solutions.

Chronic heart failure (HF) is frequently associated with various comorbidities. These comorbid conditions, such as anemia, diabetes mellitus, renal insufficiency, and sleep apnea, can significantly impact the prognosis of patients with HF. This review aims to synthesize current evidence on the prevalence, impact, and management of comorbidities in patients with chronic HF. A comprehensive review was conducted, with a rigorous selection process. Out of an initial pool of 59,030 articles identified across various research modalities, 134 articles were chosen for inclusion. The selection spanned various research methods, from randomized controlled trials to observational studies. Comorbidities are highly prevalent in patients with HF and contribute to increased hospitalization rates and mortality. Despite advances in therapies for HF with reduced ejection fraction, options for treating HF with preserved ejection fraction remain sparse. Existing treatment protocols often lack standardization, reflecting a limited understanding of the intricate relationships between HF and associated comorbidities. There is a pressing need for a multidisciplinary, tailored approach to manage HF and its intricate comorbidities. This review underscores the importance of ongoing research efforts to devise targeted treatment strategies for HF patients with various comorbid conditions.

Expert recommendations for the use of apremilast in psoriatic arthritis

Introduction and objectivesDespite the evidence, there are doubts about the positioning of apremilast in the psoriatic arthritis (PsA) treatment algorithm. The objective of this project was to collect the scientific evidence and the experience of a group of rheumatologists who are experts in the management of PsA with apremilast in clinical practice in Spain. Material and methodsA scientific committee made up of 6 experts proposed 5 clinical scenarios where the evidence on the use of apremilast in PsA was controversial: (i) Efficacy in peripheral PsA; (ii) Efficacy in enthesitis and dactylitis; (iii) Efficacy in PsA with skin involvement; (iv) Comorbidities; and (v) Apremilast safety. After this, a panel of 17 rheumatologists with expertise in PsA management discussed these scenarios and generated a questionnaire with 50 questions and 156 items following the Delphi methodology. This questionnaire was anonymously answered by the panel. ResultsAfter 2 voting rounds, the panel of experts reached consensus in 93 of the 156 items raised (59.6%) (67 in agreement and 26 in disagreement). The degree of consensus was 53.3% in the area of “Efficacy in peripheral PsA”; 60.0% in “Efficacy in enthesitis and dactylitis”; 50.0% in “Efficacy in PsA with skin involvement”; 57.1% in “Management of comorbidities in patients with PsA”; and 67.3% in “Implications of safety in the use of apremilast”. ConclusionsThe structured opinion of the experts complements the available evidence and contributes to the establishment of consensual guidelines for the use of apremilast in PsA.

Barriers to monitoring and management of cardiovascular and metabolic health of patients prescribed antipsychotic drugs: a systematic review

BackgroundThe use of atypical antipsychotics which currently form the primary choice pharmacotherapy for several mental health conditions have been linked to cardiovascular and metabolic side effects. This systematic review aimed to investigate the barriers to monitoring and management of cardiovascular co-morbidities in patients prescribed antipsychotic medicines.MethodsA protocol-led (CRD-42018106002) systematic literature review was conducted by searching Medline, Embase, and PsycINFO databases 2003 until October 2019. Cochrane, Centre for Review and Dissemination (CRD) and PRISMA guidelines were followed. Studies investigating barriers to monitoring and management of cardiovascular co-morbidities in patients prescribed antipsychotic medicines were included.ResultsA total of 23 records were included. Key barriers included a) health-care system-related factors such as lack of knowledge and expertise amongst care providers, available resources, confusion around remit and roles, fragmentation of care such as across general practitioners and psychiatrists, and time constraints and b) patient-related factors such as disability resulting from mental health conditions, knowledge and skills of the patients.ConclusionBarriers to monitoring and management of cardiovascular and metabolic health of patients taking antipsychotic medicines are multidimensional. Apart from educational interventions directed to both patients and health-care professionals, the results suggest a need for the improvement of wider system-related factors to improve physical health of patients prescribed antipsychotic medicines.Clearer guidelines, clarity of remit and roles amongst service providers are necessary in addition to educational interventions directed at patients and health-care professionals in improving physical health monitoring, counselling and management of patients prescribed antipsychotic medicines.Trial registrationA protocol was developed and registered with PROSPERO as per PRISMA-P guidelines (CRD 42018106002).

Management of patients with comorbidity during novel coronavirus (COVID-19) pandemic. National Consensus Statement 2020

The pandemic of the novel coronavirus infection (COVID-19), caused by SARS‑CoV‑2, has become a challenge to healthcare systems in all countries of the world. Patients with comorbidity are the most vulnerable group with the high risk of adverse outcomes. The problem of managing these patients in context of a pandemic requires a comprehensive approach aimed both at the optimal management in self-isolated patients not visiting medical facilities, and management of comorbidities in patients with COVID-19. The presented consensus covers these two aspects of managing patients with cardiovascular disease, diabetes, chronic obstructive pulmonary disease, gastrointestinal disease, and also pay attention to the multiple organ complications of COVID-19.

Improving management of comorbidity in patients with colorectal cancer using comprehensive medical assessment: a pilot study

BackgroundScreening for and active management of comorbidity soon after cancer diagnosis shows promise in altering cancer treatment and outcomes for comorbid patients. Prior to a large multi-centre study, piloting of the intervention (comprehensive medical assessment) was undertaken to investigate the feasibility of the comorbidity screening tools and proposed outcome measures, and the feasibility, acceptability and potential effect of the intervention.MethodsIn this pilot intervention study, 72 patients of all ages (36 observation/36 intervention) with newly diagnosed or recently relapsed colorectal adenocarcinoma were enrolled and underwent comorbidity screening and risk stratification. Intervention patients meeting pre-specified comorbidity criteria were referred for intervention, a comprehensive medical assessment carried out by geriatricians. Each intervention was individually tailored but included assessment and management of comorbidity, polypharmacy, mental health particularly depression, functional status and psychosocial issues. Recruitment and referral to intervention were tracked, verbal and written feedback were gathered from staff, and semi-structured telephone interviews were conducted with 13 patients to assess screening tool and intervention feasibility and acceptability. Interviews were transcribed and analysed thematically. Patients were followed for 6–12 months after recruitment to assess feasibility of proposed outcome measures (chemotherapy uptake and completion rates, grade 3–5 treatment toxicity, attendance at hospital emergency clinic, and unplanned hospitalisations) and descriptive data on outcomes collated.ResultsOf the 29 intervention patients eligible for the intervention, 21 received it with feedback indicating that the intervention was acceptable. Those in the intervention group were less likely to be on 3+ medications, to have been admitted to hospital in previous 12 months, or to have limitations in daily activities. Collection of data to measure proposed outcomes was feasible with 55% (6/11) of intervention patients completing chemotherapy as planned compared to none (of 14) of the control group. No differences were seen in other outcome measures. Overall the study was feasible with modification, but the intervention was difficult to integrate into clinical pathways.ConclusionsThis study generated valuable results that will be used to guide modification of the study and its approaches prior to progressing to a larger-scale study.Trial registrationRetrospective, 26 August 2019, ACTRN12619001192178.

The Prevalence and Risks of Major Co-Morbidities Among Patients with Pulmonary Tuberculosis in China from a Gender and Age Perspective: A Large-Scale Multi-Center Observational Study

Background: Tuberculosis remains a serious and substantial global public health problem today. Pulmonary tuberculosis (PTB) is the most common clinical presentation of TB. In clinical practice, PTB patients have concurrent many types of co-morbidities such as pneumonia, liver disorder, diabetes mellitus, hematological disorder, malnutrition, hemoptysis, etc. This causes the condition of PTB patients complicated. Detecting and treating specific co-morbidities and preventing their development are important for PTB patients. However, the prevalence of most co-morbid conditions in patients with PTB is not well described. Methods: We conducted a large-scale, multi-center, observational study using admission data at 21 hospitals in China from Jan 1, 2011 to Dec 31, 2017, to elucidate and illustrate the prevalence rates of major co-morbidities in inpatients admitted to hospital for pulmonary TB. The 20 specific co-morbidities were selected for analysis in this patient cohort, and stratified the patient cohort according to age and gender. Findings: A total of 355,929 PTB inpatients were included, with a male:female ratio of 1.97 and the median age 47 (IQR:28~62) years old. The prevalence of 20 specific co-morbidities in patients with PTB was analyzed, with pneumonia being the most common co-morbidity. The prevalence of most co-morbidities were higher in males with PTB except thyroid disorders, mental health disorders, etc. The prevalence of defined most co-morbidities in patients with PTB tended to increase with increasing age, although some specific co-morbidities tended to increase initially then decrease with increasing age. Interpretation: Early identification and management of co-morbidities in patients with PTB may positively influence treatment outcomes for PTB patients. Our study, together with future research into co-morbidity trends in non-hospitalized PTB patients, may be useful in determining community based prevalence rates for PTB co-morbidities, thus enhancing diagnostic and therapeutic decision-making, and clinical outcomes in all PTB patients. Funding Statement: Key Project of Chinese National Programs (Grant No. 2015ZX10003001), ‘Beijing Municipal Administration of Hospitals’ Ascent Plan (No. DFL20181601) and Tongzhou District Science and Technology Committee [No.KJ2017CX054]. Declaration of Interests: All the authors declare no conflicts of interest. Ethics Approval Statement: The Ethics Committee of Beijing Chest Hospital, Capital Medical University approved this study with a waiver of informed consent from the patients involved.

Clinical Profile of Patients with Heart Failure in Eastern Part of Nepal: a Hospital based study

Background: There is limited information on the clinical profile of patients with heart failure from the Nepalese population.
 Materials and Methods: This is a descriptive cross-sectional study on 120 consecutive patients with New York Heart Association class II or IV symptoms of heart failure admitted from June 2018 to January 2019 at Nobel Medical College Teaching hospital, Biratnagar, Nepal.
 Results: Mean age was 52.2 ± 20.6 years. The male and female ratio was 0.71. Ischemic cardiomyopathy, rheumatic heart disease, dilated cardiomyopathy, acute coronary syndrome, hypertensive heart disease, and peripartum cardiomyopathy were common etiologies constituting 22.5%, 19.1%,13.3%, 9.1%, 8.3 %, 5% of cases respectively. Among co-morbid conditions, anemia (91.6%),hypertension (31.6%), coronary artery disease (29.1%), diabetes (20.8%) and chronic kidney disease (11.6%) were common. Among various drugs used, 66.6% patients were prescribed diuretics, 60% mineral corticoid receptor blockers, 33.3% angiotensin-converting enzymeinhibitors, 33.3% beta-blockers, 29.1% digoxin and 8.3% angiotensin receptor blockers. Echocardiography revealed LV systolic and diastolic dysfunction in 75% and 25% respectively, mitral regurgitation in 52.5%, right ventricular dysfunction in 10.8 % and pulmonary artery hypertension in 66.6%.
 Conclusion: Appropriate use of evidence-based therapies, careful attention to the diagnosis and management of specific co-morbidities in patients with HF may help to improve outcomes.

E059 Development of a nurse-led integrated care review based in primary care to identify and improve the management of co-morbidities in patients with inflammatory rheumatological conditions: the INCLUDE study

E059 Development of a nurse-led integrated care review based in primary care to identify and improve the management of co-morbidities in patients with inflammatory rheumatological conditions: the INCLUDE study

Evaluation of relationships between onychomycosis and vascular diseases using sequential pattern mining

Onychomycosis (OM) is a common nail disease. Although controversial, vascular diseases are considered independent predictors of OM and vice versa. Sequential pattern mining (SPM) has not been previously used for statistical analysis in dermatology, but it is an efficient method for identifying frequent association rules in multiple sequential data sets. The aim of our study was to identify the relationship between OM and vascular diseases in the real world through a population-based study using SPM. We obtained population-based data recorded from 2002 to 2013 by the Health Insurance Research and Assessment Agency. Cases of vascular-related disease and OM were identified using the diagnostic codes of the International Classification of Diseases 10th Revision, version 2010. SPM measures were based on comorbidity and duration values. We estimated 3-year risk for progression from OM to vascular disease and vice versa using logistic regression. Patients with varicose veins and peripheral vascular disease had higher OM comorbidity (comorbidity: 1.26% and 0.69%, respectively) than did those with other vascular diseases. Patients diagnosed with varicose veins and peripheral vascular disease were diagnosed with OM after 25.50 and 55.10 days, respectively, which was a shorter duration than that observed for other diseases. Patients with OM were at higher risk for peripheral vascular disease (adjusted odds ratio (aOR) 1.199 [95% confidence interval (CI) 1.151–1.249]) and varicose veins (aOR 1.150 [95% CI 1.063–1.245]). Patients with peripheral vascular disease (aOR 1.128 [95% CI 1.081–1.177]) were at higher risk for OM, while patients with varicose veins had no significant risk for OM. Careful consideration of varicose veins or peripheral vascular disease is required for proper management of comorbidities in patients with OM.

Recommendations for the Management of Comorbidity in Patients With Axial Spondyloarthritis in Clinical Practice

ObjectivesTo identify priorities among comorbidities in axial spondyloarthritis (AxSpA) and recommend how to follow them from an eminently practical perspective. MethodsA multidisciplinary group was selected (10 rheumatologists—6 of them experts in AxSpA—, 2 general practitioners, an internist, a cardiologist, a gastroenterologist and a psychologist). In a first discussion meeting, the scope and users were established and a list of comorbidities was voted based on frequency and impact. The panellists had to defend the inclusion of each comorbidity/item in the document with consistent arguments. Four panellists and two methodologists developed systematic reviews on controversial topics. In a second meeting, the results of the reviews and the arguments concerning the items to be included were presented. After the meeting, the final document was drafted. ResultsThe final document includes two checklists, one for health professionals and another for patients; they incorporate cardiovascular risk, renal comorbidities, gastrointestinal risk, lifestyle, risk of infections and vaccinations, pulmonary involvement, concomitant medication, psycho-affective disorders, osteoporosis, and risk of fracture. In addition, the document reflects the arguments favouring the inclusion of each item and how to record the items for subsequent collection. The panel considered it also appropriate to likewise establish «practices to avoid» applicable to comorbidity in AxSpA. ConclusionsTwo checklists and a list of situations to avoid were generated to facilitate the management of comorbidities in AxSpA. In a future step, their utility and acceptance will be tested by a broad group of users that includes doctors, patients and nurses.

The Management of Co-Morbidities in Patients with Heart Failure – Obstructive Sleep Apnoea

Heart failure (HF) patients are older and frequently present with multiple co-morbidities. Co- morbidities worsen patient symptoms and may contribute to the progression of heart failure, increase mortality or limit the therapeutic response to treatment. Obstructive sleep apnoea (OSA) affects 2–4% of the adult population world-wide and is associated with similar risk factors to HF, meaning it is a frequent finding in HF patients, including HFrEF, HFmrEF and HFpEF. OSA has consistently been shown to be associated with hypertension, coronary artery disease, arrhythmias, heart failure, and stroke. A thorough understanding of the diagnosis and treatment options of OSA is of paramount importance to the practising HF clinician. Patients may present to the HF specialist having been diagnosed by a formal sleep study or may be suspected of OSA because of symptoms of snoring, reports of obstructed breathing by the sleep partner or day-time sleepiness. The mainstay of treatment for OSA is a positive airway pressure mask which can be used in mild moderate and severe OSA. The need for therapy should be discussed with the patient and if the AHI is above 15/hr then treatment is indicated to reduce this to below 15. This is a consensus recommendation and no adequately powered clinical trials have shown this improves either mortality or the risk of disease progression. Other options are discussed

The Management of Co-Morbidities in Patients with Heart Failure – Angina and Coronary Disease

Co-morbidities are particularly relevant in the management of HF as they may confound HF diagnosis, worsen symptomatology, impact quality of life and aggravate the prognosis. According to the most recent European Society of Cardiology (ESC) guidelines, treatment of co- morbidities is an essential element of the comprehensive care of HF. Angina and coronary artery disease (CAD), in particular are common disorders associated with HF. The pharmacological and surgical management of angina according to the ESC guidelines is reviewed in this article.

The Management of Co-Morbidities in Patients with Heart Failure - Iron Deficiency

Co-morbidities have been recognised as playing a crucial role in the progress of the older patient with HF in particular. The 2016 ESC/HFA HF guidelines stress the significance of co-morbidities more than any previous guidelines have. Iron deficiency is a co-morbidity, that has received very little attention until the last decade, as evidence has accumulated both for the significance of this co-morbidity and the emergence of safe effective therapies that appear to offer significant benefits to the HF population who suffer this co-morbidity.

The Management of Co-Morbidities in Patients with Heart Failure – Potassium Balance

Both hypokalaemia and hyperkalaemia are common in HF patients. They are each associated both with HF and with the many drugs used for HF. They are important as they both can aggravate ventricular arrhythmias, both can cause symptoms in HF patients and in the case of hyperkalaemia in particular, are a common reason not to prescribe or reduce the dose of or even cease use of effective medication with life- prolonging benefits in HFrEF, including ACEI’s and MRA’s. Treatment optiosn for bioth hypokalaemia and hyperkalaemia are discussed including the emerging evidence that agents such as patiromer may be safe and effective agents to be used long-term in high-risk patients with HF to allow them to take doses of RAAS inhibitors in particular which they otherwise may not be able to take. This might allow them to continue to receive the mortality morbidity benefits these treatments confer.

The Management of Co-Morbidities in Patients with Heart Failure – Central Sleep Apnoea

Despite many therapeutic advances, heart failure (HF) remains challenging to treat and continues to be associated with high rates of morbidity and mortality. There is an ongoing need to identify co-morbidities that either contribute to the progression of heart failure or limit the therapeutic response to treatment. One area under active investigation is the treatment of central sleep apnoea (CSA). CSA has consistently been shown to be associated with a worse prognosis in HF patients. Thus, understanding how to diagnose and treat CSA is of paramount importance to the HF clinician. Without treatment, HF patients continue to be at risk for the devastating consequences of CSA. Prognosis is very poor with studies consistently demonstrating poor outcomes among HF patients with CSA. Over the course of the night, each discrete event contributes to increased nor- epinephrine levels and hypoxia which are associated with progressive heart failure and arrhythmias. Initial therapeutic options utilized therapies which were developed for obstructive sleep apnoea with limited success or even harm. ASV is now contraindicated in HF patients with an EF < 45% leaving only 2 potential treatment options: CPAP and transvenous phrenic nerve stimulation. Data from the recently presented (post ESC guidelines) trial on transvenous phrenic nerve stimulation demonstrated efficacy without the need for patient compliance or any safety concerns. It is expected that additional studies in CSA will continue to demonstrate the full impact of treating this important co-morbidity on patients with HF.

The Management of Co-Morbidities in Patients with Heart Failure – Lung Disorders

The 2016 ESC/HFA HF guidelines carry an important section on the treatments of co- morbidities in HF. One of the most common and most confusing, in terms of overlapping symptoms and interfering treatments is the presence of significant lung disorders. In this article is reviewed what the recent guidelines say about the management of lung disorders in the setting of HF, both HFrEF and HFpEF and expand on some of the practical advice.

The Management of Co-Morbidities in Patients with Heart Failure – Hypertension

The 2016 ESC/HFA HF guidelines carry an important section on the treatments of co- morbidities in HF. Foremost of these in terms of frequency and its relevance to the aetiology of HF, especially HFpEF is hypertension. In this artcile we will review what the recent guidelines say about the management of hypertension in the setting of HF, both HFrEF and HFpEF and expand on some of the practical advice.

Identification and management of comorbidity in psoriatic arthritis: evidence- and expert-based recommendations from a multidisciplinary panel from Spain.

The objective is to establish recommendations, based on evidence and expert opinion, for the identification and management of comorbidities in patients with psoriatic arthritis (PsA). The following techniques were applied: discussion group, systematic review, and Delphi survey for agreement. A panel of professionals from four specialties defined the users, the sections of the document, possible recommendations, and what systematic reviews should be performed. A second discussion was held with the results of the systematic reviews. Recommendations were formulated in the second meeting and voted online from 1 (total disagreement) to 10 (total agreement). Agreement was considered if at least 70% voted ≥7. The level of evidence and grade of recommendation were assigned using the Oxford Centre for Evidence-Based Medicine guidance. The full document was critically appraised by the experts, and the project was supervised at all times by a methodologist. In a final step, the document was reviewed and commented by a patient and a health management specialist. Fourteen recommendations were produced, together with a checklist to facilitate the implementation. The items with the largest support from evidence were those related to cardiovascular disease and risk factors. The panel recommends paying special attention to obesity, smoking, and alcohol consumption, as they are all modifiable factors with an impact on treatment response or complications of PsA. Psychological and organizational aspects were also deemed important. We herein suggest practical recommendations for the management of comorbidities in PsA based on evidence and expert opinion.

Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association.

The comorbidities of hypertension, diabetes mellitus, obesity, hyperlipidemia, and metabolic syndrome are common in patients with heart failure (HF) and affect clinical outcomes.1–3 Interestingly, although these comorbidities are associated with the development of incident HF in the general population, in patients with established HF, their contributory roles to clinical outcomes are not predictable, and their management is quite challenging. Recent American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines have addressed the role of lifestyle modification,4 treatment of blood cholesterol,5 and management of overweight and obesity6 in the general population and in patients with increased cardiovascular risk, and a recent report from the Eighth Joint National Committee addressed the management of hypertension.7 However, these guidelines did not specifically address the management of such comorbidities in patients with HF. Similarly, the most recent ACCF/AHA HF practice guidelines8 in 2013 addressed the overall management of comorbidities in patients with HF in broad terms, but again, specific and detailed recommendations on how to manage hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome are lacking. The intent of this AHA scientific statement is to summarize data relevant to contributory risk and to provide guidance on the management of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in the development and prognosis of HF to provide recommendations (Table 1) and to foster communication between physicians and other healthcare professionals and patients on the management of these comorbidities. Recommendations in this document are based on published studies and the multidisciplinary expertise of the writing group and harmonized with published practice guidelines from the ACC/AHA4–6,8–12 and other organizations.7,13–15 View this table: Table 1. Applying Classification of Recommendations and Level of Evidence Hypertension is a worldwide epidemic; in many countries, 50% of …

Gout-related inpatient utilization: a study of predictors of outcomes and time trends.

BackgroundTo assess inpatient healthcare burden of gout in the USA after an Emergency Department (ED) visit and the predictors of gout-related hospitalizations.MethodWe used the 2009, 2010 and 2012 US National ED Sample (NEDS) data to examine the time trends in inpatient visits with gout as the primary diagnosis. We used the 2012 NEDS data to assess multivariable-adjusted predictors of length of hospital stay, discharge to home (versus other) and total charges for gout-related inpatient visits.ResultsOf the 205,152 ED visits for gout as the primary diagnosis in 2012, 7.7 % resulted in hospitalization. In 2009, 2010 and 2012, 63 %, 63 % and 64.5 % of hospitalized patients were discharged home; respective durations of hospital stay were 4.15, 4.00 and 3.86 days. Older age 50 to <65 years (ref <50), renal failure, heart failure, osteoarthritis and diabetes were associated with a longer hospital stay and self-pay/uninsured status, hospital location in the Midwest or Western USA with a shorter hospital stay for gout. Similar factors were associated with total charges for gout-related admissions. Older age (65 to <80 and ≥80, relative to <50 years), diabetes, self-pay/no charge insurance status, metropolitan area residence, and a longer length of hospital stay were associated with lower odds of discharge to home; and self-pay/no charge (uninsured) status was associated with higher odds of discharge to home, compared to Medicare coverage.ConclusionsUsing a national sample, we noted declining duration of hospital stay and identified factors associated with the length of hospital stay, discharge to home and charges for gout hospitalization following an ED visit. Future studies should examine whether better management of comorbidities in patients with gout can further reduce utilization and cost of gout-related hospitalizations.