Presence Of Comorbidities Research Articles

The impact of comorbidities on therapy-optimization and their prognostics role among hospitalized patients with heart failure with reduced ejection fraction

Abstract Background The early, accurate diagnosis and proper treatment of comorbidities (CMs) are of strategic importance in heart failure (HF), as stated in the current ESC HF Guidelines. Unquestionably, the presence of CMs is associated with worse prognosis. Moreover, CMs can unfavourably affect the implementation of the guideline-directed medical therapy (GDMT) in heart failure with reduced ejection fraction (HFrEF). Aim To assess the prevalence of the relevant prognosis-modifying CMs among patients requiring hospitalization due to HFrEF, investigate their effect on the implementation and optimization of GDMT, and examine the impact of the presence of CMs on the prognosis in HFrEF. Patients and methods The data of 313 patients requiring hospitalization at our Institution due to HFrEF between 2021-2023 (male: 77%, age: 60[50-70]years, coronary artery disease: 46%, diabetes: 36%, hypertension: 65%, atrial fibrillation: 42%, LVEF: 24[20-30]%, eGFR at admission: 57[46-74]mL/min/1.73m², NT-proBNP at admission: 5035[2376-9369]pg/mL, SBP: 121[110-140]mmHg; GDMT at admission - RASi[ACEi/ARB/ARNI]: 60%, βB: 59%, MRA: 44%, SGLT2i: 14%) were analyzed retrospectively. Based on the number of diagnosed CMs, patients were divided into 3 categories: 0-1 vs. 2-3 vs. ≥4 CMs. The implemented GDMT at discharge was compared among CM categories with Chi-square test, while all-cause mortality (ACM) rates were investigated with Kaplan-Meier method and multivariate Cox-regression analysis. Results During the hospitalization in the total cohort the proportion of patients on GDMT increased significantly (RASi: 91%, βB: 85%, MRA: 96%, SGLT2i: 57%; patients on triple [TT] therapy [RASi+βB+MRA]: 83%, patients on quadruple therapy [TT+SGLT2i]: 52%; p＜0.05). However, among patients with higher rates of CMs, the application of GDMT was less favourable (RASi: 97% vs. 94% vs. 82%; βB: 93% vs. 89% vs. 75%; p＜0.05; 0-1 vs. 2-3 vs. ≥4 CMs), the proportion of patients on TT and QT remained remarkably high even among those with ≥4 CMs (TT: 93% vs. 87% vs. 71%; QT: 65% vs. 52% vs. 45%; p＜0.05). During the median follow-up period of 1.3 year, the ACM of patients with increased burden of CMs was higher (12% vs. 18% vs. 37%, p＜0.001). According to the results of the multivariate Cox-regression analysis, more advanced left ventricular systolic dysfunction (/1%), previously confirmed diagnosis of HFrEF, the growing number of CMs proved to be negative independent predictors of ACM, while the application of TT or QT reduced the risk of ACM significantly (HR: 0.471, 95% CI: 0.271-0.819, p=0.008). Conclusions According to our real-world analysis, although among HFrEF patients with an increased burden of CMs, less favourable prognosis can be expected, the application of modern GDMT is even possible among them, resulting in a significantly improved prognosis. Thus, clinicians should insist on the early, conscious implementation of GDMT among these patients as well.

High comorbidity rates in congenital lobar emphysema and the effect on clinical presentation.

The presence of comorbidities (CM) in congenital lobar emphysema (CLE) has been previously described with varying rates. However, the clinical implication of CM on the clinical presentation and patient outcome in CLE is unclear. This was a retrospective cohort study between 2000 and 2022 in a single institution. The study included pediatric patients diagnosed with CLE. During the study period, 36 patients were identified with CLE. The presence of respiratory symptoms at diagnosis was documented in 69% (24/35) of the patients with 48% admitted to intensive care units. The presence of CM was documented in 14/36 (39%) of the patients, with cardiovascular anomalies as the most common (22%), followed by genitourinary anomalies (11%) and large airway anomalies (8%). When comparing the CM group (n = 14) vs the non-CM group (N = 22), there was no significant difference regarding gender, term birth, age of diagnosis, and the location of the lesion. The CM group had significantly higher rates of intensive care unit (ICU) admissions (75% vs 33%, p = 0.02), longer duration of admission (median 46days vs 9, p = 0.02), and need for pre-operative non-invasive respiratory support (50% vs 5%, p = 0.002).Conclusion: The presence of CM in CLE was associated with a more severe presentation as reflected with significantly higher rates of ICU admissions, prolonged admissions, and higher need for non-invasive respiratory support. Screening for CM, mostly for cardiac anomalies, is recommended at time of CLE diagnosis. What is Known: • Congenital lobar emphysema (CLE) is a developmental lung anomaly generally associated with other comorbidities; however, their clinical implication on presentation is unclear • The prevalence of comorbidities in CLE was previously reported around 15-20%, with cardiovascular anomalies as the most common What is New: • Comorbidities are very common (39%) in CLE, and their presence is related to a more severe clinical presentation and need for respiratory support • Screening for comorbidities is recommended in CLE, specifically for cardiovascular and genitourinary anomalies.

AGGRAVATION OF COVID 19 INFECTION SECONDARY TO SURGERY

Patients with COVID-19 who have underwentsurgery have high rates of mortality and complications includingincreasedrespiratorydistress, bacterialinfections, pneumothorax and multi-visceralfailure. Pneumomedistinis a rare complication. Surgical indications in COVID-19 patients shouldbediscussed in a multidisciplinary consultation meeting, considering the presenceof comorbidities and the availability of therapeutic alternatives. We report the case ofa 43-year-old womanpresentingwith COVID-19 infection, whounderwent a cholecystectomywith post-operative complications.

Outcome of negative pressure wound therapy with different devices

Negative pressure wound therapy (NPWT) is an evidence-based therapy for the treatment of chronic and acute wounds. The application of specific dressing kits with the NPWT unit enables physiological processes in the wound that support healing especially by promoting wound bed preparation and managing high levels of exudate. The aim of NPWT is to close the wound faster by reducing complications like sepsis, wound recurrence, which reduce wound healing and may lead to amputation. The duration of the therapy depends on the therapeutic aims, wound pathology and the presence of co-morbidities. The aim of this study was to evaluate the efficiency and effectiveness of two different topical negative pressure devices. We analysed results of 70 patients suffering from wound healing disorders treated with KCI (VAC®) as well as by Hartmann (Vivano®) negative pressure wound therapy devices between 2008 and 2012.

Review of Medical Treatment of Stable Ischemic Heart Disease

Medical treatment is the initial treatmentstrategy and is the cornerstone of management in patients with stable ischemicheart disease (IHD). Many patients are not suitable for percutaneous orsurgical revascularization because of unfavourable anatomy, or the presence ofco-morbidities. In addition, many patients have recurrence of anginafollowing revascularization due to restenosis or incomplete revascularization.Furthermore, randomized clinical trials comparing optimal medical treatment torevascularization have not clearly shown that myocardial revascularization issuperior to optimal medical treatment. Traditional drugs for angina treatmentinclude b-blockers, calcium channel blockers and nitrates. Newer drugs areavailable with different mechanisms of action and with equal efficacy that donot cause significant hemodynamic deterioration. The availability of thesenewer drugs expands the therapeutic potential of medical treatment to even awider population with stable IHD. Revascularization in patients with stableischemic heart disease has never been shown to reduce hard endpoints (death ormyocardial infarction) in randomized clinical trials.

Monitoring of osteoporosis among geriatric population in the primary care service

Introduction. Osteoporosis is a chronic, progressive bone disease which leads to a reduction in bone mineral density and disruption of bone micro-architecture. Patients with osteoporosis have an increased risk of fractures caused by ?small trauma? - stresses which would not normally cause fracture in a non-osteoporotic individual. This study was aimed at determining the incidence of osteoporosis in geriatric population, crucial demographic parameters (gender and age structure) in patients, presence of comorbidities, and the most common drug choice in treatment of osteoporosis. Material and Methods. A retrospective study was conducted in the period from August 1st, 2012 to May 12th, 2014 and it included 526 patients over 65 years of age who were diagnosed to have osteoporosis based on clinical findings (presence/absence of pathological fractures), laboratory tests and osteodensitometry. Data were analyzed by using standard statistical methods and statistical significance was assessed by x2 and t - test. Results. The most affected patients were women (91%). The incidence of pathological fractures was 31.80%. The presence of two or more fractures caused by a ?small trauma? was determined in 13.6%. Cardiovascular comorbidities dominated in 72.70% of cases. The most common therapeutic choice was the bisphosphonates, being administered in 77% along with the simultaneous use of vitamin D analogs - alfacalciferol (13.6%), cholecalciferol (40.9%), calcium carbonate + cholecalciferol (22.7%). Conclusion. Osteoporosis shows predominance in females aged 65-70 years. Comorbidities do not increase the risk of disease but significantly reduce the quality of life in patients. Bisphosphonates are the most common drug choice with the simultaneous use of calcium and vitamin D analogs.

Autologous stem cell transplant in older patients with multiple myeloma (MM): Analysis of the nationwide inpatient sample (NIS).

e18551 Background: Autologous stem cell transplant (ASCT) improves survival in MM patients <65 years and is applied to select patients ≥ age 65. We hypothesized that comorbidities (CM) are associated with increased length of stay (LOS), hospital charges, toxicity, and in-hospital mortality in older patients with MM undergoing ASCT. Methods: This is a retrospective cohort study of patients over the age of 65 with MM admitted to U.S. hospitals for ASCT in the 2008 NIS. CM were coded using the Comorbidity Software; toxicities were determined by ICD-9-CM codes. Relationships between CM and toxicities, LOS, hospital charges, and in-hospital mortality were analyzed. Results: 206 patients MM ≥ 65 years who underwent ASCT were identified. Median age was 68 years (range 65-82). As defined by Elixhauser (Medical Care 1998), 83.5% of patients had ≥ 1 CM. Median LOS was 17 days (range 1-152). Median total charges were $162,998 (range $4289-$953,789). The most common complications coded were: neutropenic fever (29.6%), diarrhea (28.6%), bacteremia (13.6%), mucositis (8.7%) and pneumonia (6.8%). In-hospital mortality was <5% (precise percentage cannot be reported due to cell size <10). Elixhauser CM did not predict LOS, total charges, in-hospital mortality, or toxicities. When CM were restricted to those in the Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI, Sorror et al 2005), only 35.4% of patients had CM. The presence of CM using a modified HCT-CI was associated with longer LOS (23.5 vs 17.6 days, p=0.0047) higher mean total charges [$189,896 (95% CI $154,333-225,459) vs $148,234 (95%CI $121,887-174,581), p=0.02] and increased risk of “complications of transplant” or “delirium” codes (p=0.035; precise percentage cannot be reported due to cell size <10). Conclusions: ASCT was well-tolerated with low in-hospital mortality in a population-based cohort of older patients with MM.The Elixhauser CM method did not predict outcomes. Using a modified HCT-CI CM index predicted longer LOS, greater hospital charges, and some toxicities, highlighting differences in the utility of different CM indices. Further investigation must define the optimal CM index for studying hematopoietic cell transplantation using administrative data.

The quality of life in patients with diabetes mellitus type 2

Through its vrious activities, World Health Organization (WHO) contributed to increasing the understanding of the concept of quality of life. People with diabetes have a lower quality of life than people without chronic illnesses. The aim of this study was to examine the differences in the quality of life, related to health, in patients with diabetes mellitus (DM) type 2 by age, gender and type of therapy. We performed a cross-sectional study at the outpatient department of the Clinical Center in Novi Sad and the Health Center Ruma-General Practice. The group consisted of 90 patients with DM type 2, 41 men and 49 women. The age of respondents was from 40 to 80 years and they were classifed into four groups according to the ten-year age intervals. We applied WHO Quality of life questinnaire--BREF 100 composed of four domains: physical health, psychological health, social relationships and environment. The general questionnaire asks questions about socio-demographic data, duration of diabetes, the last value of blood glucose and glycosylated hemoglobin, training for self-control and its implementation, informing patients about their disease, therapy and its impact on daily activities and the presence of comorbidity. In statistical analysis the following tests were used: Student's t-test, F-test, ANOVA (one way). The average duration of DM type 2 was 11.2 +/- 9.2 years. Most of the patients (76%) were trained to self-control and 91% received enough information about their disease. Oral hypoglycemic preparations were used by 49%, insulin by 21%, and oral drugs and insulin by 29% patients while 1% were on a special regime of a diet therapy. Daily activities were performed without difficulties by over 29%, with some difficulties by 41% and 30% of patients who could not perform daily activities. The patients with DM type 2 had significantly lower scors in all 4 domains of quality of life (physical health, psychological health, social relations, environment). The biggest influence was on physical domains (51.31). Education level had an imact on physical and psychological domains. Comorbidity was found in 83% of the respondents. The most common were: arterial hypertension (63%), chronic cardiovascular disease (46%), neuropathy (23%), impaired vision 24%, elevated blood lipids (39%) and amputation of toes or feet (2.2%). The average value HbA1c in the group with comorbidity was 8.47% and in the group without comorbidity 6.46%. The subjects with comorbidity had low quality of life assessment in relation to the group without comorbidity: the domain of physical health (45.64 vs. 79.66), psychological health (50.3 vs. 76.86), social relations (52.97 vs. 75.46) and environment (52.7 vs. 75.06). Diabetes mellitus type 2 has negative influence on the quality of life. It contributes to the presence of comorbidity. The occurrence of comorbidity was associated with higher glucosylated HbA1c values. There was no difference in the assessment of quality of life regarding gender, age, or the type of therapy used. The quality of life was assessed as low in patients with comorbidity. However, certain personality characteristics play a decisive role in self-evaluation.

Sequential vinorelbine (V) and docetaxel (D) in advanced non-small cell lung cancer (NSCLC) patients age > 70, or with performance status (PS) 2: A SWOG phase II trial (S0027)

7056 Background: The value of V in elderly patients (pts) with advanced NSCLC was demonstrated in the ELVIS and MILES trials. (JNCI 1999,91:66; JNCI 2003,95:362) More limited evidence suggests value for V and D in PS 2 NSCLC pts. Toxicity concerns have hindered enrollment of PS 2 and elderly pts into trials of combination chemotherapy. No prospective trial targeting these pts has compared a single agent to a platinum-based doublet. Given the efficacy and tolerability of sequential chemotherapy in several settings, we conducted a phase II trial of sequential V and D. Methods: Eligibility: stage IIIB (pleural effusion)/stage IV NSCLC, age ≥ 70 and/or a PS of 2. Treatment: V 25 mg/m2 days 1,8 every 21 days for 3 cycles immediately followed by D 35 mg/m2 days 1,8,15 every 28 days for 3 cycles. Strata: age ≥ 70, PS 0,1; PS 2, any age. Comorbidities (CM) were noted at entry. Results: Patients: 125 from 42 institutions; 119 eligible; 118 assessable for toxicity; 99 for response. Stage IV: 83%. Response (RR), progression free survival (PFS), median survival (MST) and toxicity - see table. Treatment was generally well tolerated. There were 2 toxic deaths per stratum. A trend toward worse survival was noted with presence of CM. In ≥ 70, PS 0,1 group, survival by CM count(mo): 0 = 13;1 = 9; ≥ 2 = 6.Conclusions: Sequential V and D is well tolerated. Efficacy data confirm that good PS elderly pts do better than PS 2 pts. Survival of elderly good PS pts compares favorably to phase III trials with younger pts employing platinum regimens. Good PS elderly pts with no CM had encouraging survival (median = 13 mo; 1-yr 56%). Survival in the PS 2 group is comparable, with less toxicity, to the experience of PS 2 pts in ECOG 1594 (Cancer 2001,92:2639) a trial of 4 platinum doublets. Author Disclosure Employment or Leadership Consultant or Advisory Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration GlaxoSmithKline Aventis; GlaxoSmithKline