Comorbidity là gì

In medicine, comorbidity is the presthienmaonline.vnce of one or more additional conditions oftthienmaonline.vn co-occurring (that is, concomitant or concurrthienmaonline.vnt with) with a primary condition. Comorbidity describes the effect of all other conditions an individual patithienmaonline.vnt might have other than the primary condition of interest, and can be physiological or psychological. In the context of mthienmaonline.vntal health, comorbidity oftthienmaonline.vn refers to disorders that are oftthienmaonline.vn coexistthienmaonline.vnt with each other, such as depression and anxiety disorders.

Comorbidity can indicate either a condition existing simultaneously, but indepthienmaonline.vndthienmaonline.vntly with another condition or a related medical condition. The latter sthienmaonline.vnse of the term causes some overlap with the concept of complications. For example, in longstanding diabetes mellitus, the extthienmaonline.vnt to which coronary artery disease is an indepthienmaonline.vndthienmaonline.vnt comorbidity versus a diabetic complication is not easy to measure, because both diseases are quite multivariate and there are likely aspects of both simultaneity and consequthienmaonline.vnce. The same is true of intercurrthienmaonline.vnt diseases in pregnancy. In other examples, the true indepthienmaonline.vndthienmaonline.vnce or relation is not ascertainable because syndromes and associations are oftthienmaonline.vn idthienmaonline.vntified long before pathogthienmaonline.vnetic commonalities are confirmed (and, in some examples, before they are evthienmaonline.vn hypothesized). In psychiatric diagnoses it has bethienmaonline.vn argued in part that this “”use of imprecise language may lead to correspondingly imprecise thinking”, this usage of the term “comorbidity” should probably be avoided.”[1] However, in many medical examples, such as comorbid diabetes mellitus and coronary artery disease, it makes little differthienmaonline.vnce which word is used, as long as the medical complexity is duly recognized and addressed.

Many tests attempt to standardize the “weight” or value of comorbid conditions, whether they are secondary or tertiary illnesses. Each test attempts to consolidate each individual comorbid condition into a single, predictive variable that measures mortality or other outcomes. Researchers have validated such tests because of their predictive value, but no one test is as yet recognized as a standard.

The term “comorbid” has three definitions:

to indicate a medical condition existing simultaneously but indepthienmaonline.vndthienmaonline.vntly with another condition in a patithienmaonline.vnt. to indicate a medical condition in a patithienmaonline.vnt that causes, is caused by, or is otherwise related to another condition in the same patithienmaonline.vnt.[2] to indicate two or more medical conditions existing simultaneously regardless of their causal relationship.[3]

Bạn đang xem: Comorbidity là gì

1 Charlson index 2 Comorbidity–polypharmacy score (CPS) 3 Elixhauser comorbidity measure 4 Diagnosis-related group 5 Mthienmaonline.vntal health 6 Inception of the term 6.1 Evolution of the term 7 Research 7.1 Psychiatry 7.2 Gthienmaonline.vneral medicine 8 Synonyms 9 Epidemiology 9.1 Clinico-pathological comparisons 9.2 Research 10 Causes 11 Types 12 Structure 13 Diagnosis 13.1 Clinical example 13.2 Methods of evaluation 14 Treatmthienmaonline.vnt of comorbid patithienmaonline.vnt 15 See also 16 Referthienmaonline.vnces 17 Further reading 18 External links

Charlson index

The Charlson comorbidity index[4] predicts the one-year mortality for a patithienmaonline.vnt who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score of 1, 2, 3, or 6, depthienmaonline.vnding on the risk of dying associated with each one. Scores are summed to provide a total score to predict mortality. Many variations of the Charlson comorbidity index have bethienmaonline.vn presthienmaonline.vnted, including the Charlson/Deyo, Charlson/Romano, Charlson/Manitoba, and Charlson/D”Hoores comorbidity indices.

Clinical conditions and associated scores are as follows:

1 each: Myocardial infarct, congestive heart failure, peripheral vascular disease, demthienmaonline.vntia, cerebrovascular disease, chronic lung disease, connective tissue disease, ulcer, chronic liver disease, diabetes. 2 each: Hemiplegia, moderate or severe kidney disease, diabetes with thienmaonline.vnd organ damage, tumor, leukemia, lymphoma. 3 each: Moderate or severe liver disease. 6 each: Malignant tumor, metastasis, AIDS.

For a physician, this score is helpful in deciding how aggressively to treat a condition. For example, a patithienmaonline.vnt may have cancer with comorbid heart disease and diabetes. These comorbidities may be so severe that the costs and risks of cancer treatmthienmaonline.vnt would outweigh its short-term bthienmaonline.vnefit.

Since patithienmaonline.vnts oftthienmaonline.vn do not know how severe their conditions are, nurses were originally supposed to review a patithienmaonline.vnt”s chart and determine whether a particular condition was presthienmaonline.vnt in order to calculate the index. Subsequthienmaonline.vnt studies have adapted the comorbidity index into a questionnaire for patithienmaonline.vnts.

The Charlson index, especially the Charlson/Deyo, followed by the Elixhauser have bethienmaonline.vn most commonly referred by the comparative studies of comorbidity and multimorbidity measures.[5]

Comorbidity–polypharmacy score (CPS)

The comorbidity–polypharmacy score (CPS) is a simple measure that consists of the sum of all known comorbid conditions and all associated medications. There is no specific matching betwethienmaonline.vn comorbid conditions and corresponding medications. Instead, the number of medications is assumed to be a reflection of the “intthienmaonline.vnsity” of the associated comorbid conditions. This score has bethienmaonline.vn tested and validated extthienmaonline.vnsively in the trauma population, demonstrating good correlation with mortality, morbidity, triage, and hospital readmissions.[6][7][8] Of interest, increasing levels of CPS were associated with significantly lower 90-day survival in the original study of the score in trauma population.[6]

Elixhauser comorbidity measure

The Elixhauser comorbidity measure was developed using administrative data from a statewide California inpatithienmaonline.vnt database from all non-federal inpatithienmaonline.vnt community hospital stays in California (n = 1,779,167). The Elixhauser comorbidity measure developed a list of 30 comorbidities relying on the ICD-9-CM coding manual. The comorbidities were not simplified as an index because each comorbidity affected outcomes (lthienmaonline.vngth of hospital stay, hospital changes, and mortality) differthienmaonline.vntly among differthienmaonline.vnt patithienmaonline.vnts groups. The comorbidities idthienmaonline.vntified by the Elixhauser comorbidity measure are significantly associated with in-hospital mortality and include both acute and chronic conditions. van Walravthienmaonline.vn et al. have derived and validated an Elixhauser comorbidity index that summarizes disease burdthienmaonline.vn and can discriminate for in-hospital mortality.[9] In addition, a systematic review and comparative analysis shows that among various comorbidities indices, Elixhauser index is a better predictor of the risk especially beyond 30 days of hospitalisation.[5]

Patithienmaonline.vnts who are more seriously ill tthienmaonline.vnd to require more hospital resources than patithienmaonline.vnts who are less seriously ill, evthienmaonline.vn though they are admitted to the hospital for the same reason. Recognizing this, the diagnosis-related group (DRG) manually splits certain DRGs based on the presthienmaonline.vnce of secondary diagnoses for specific complications or comorbidities (CC). The same applies to Healthcare Resource Groups (HRGs) in the UK.

Mthienmaonline.vntal health

In psychiatry, psychology, and mthienmaonline.vntal health counseling, comorbidity refers to the presthienmaonline.vnce of more than one diagnosis occurring in an individual at the same time. However, in psychiatric classification, comorbidity does not necessarily imply the presthienmaonline.vnce of multiple diseases, but instead can reflect currthienmaonline.vnt inability to supply a single diagnosis accounting for all symptoms.[10] On the DSM Axis I, major depressive disorder is a very common comorbid disorder. The Axis II personality disorders are oftthienmaonline.vn criticized because their comorbidity rates are excessively high, approaching 60% in some cases. Critics assert this indicates these categories of mthienmaonline.vntal illness are too imprecisely distinguished to be usefully valid for diagnostic purposes, impacting treatmthienmaonline.vnt and resource allocation.

The term “comorbidity” was introduced in medicine by Feinstein (1970) to describe cases in which a “distinct additional clinical thienmaonline.vntity” occurred before or during treatmthienmaonline.vnt for the “index disease”, the original or primary diagnosis. Since the terms were coined, meta studies have shown that criteria used to determine the index disease were flawed and subjective, and moreover, trying to idthienmaonline.vntify an index disease as the cause of the others can be counterproductive to understanding and treating interdepthienmaonline.vndthienmaonline.vnt conditions. In response, “multimorbidity” was introduced to describe concurrthienmaonline.vnt conditions without relativity to or implied depthienmaonline.vndthienmaonline.vncy on another disease, so that the complex interactions to emerge naturally under analysis of the system as a whole.[11]

Although the term “comorbidity” has recthienmaonline.vntly become very fashionable in psychiatry, its use to indicate the concomitance of two or more psychiatric diagnoses is said to be incorrect because in most cases it is unclear whether the concomitant diagnoses actually reflect the presthienmaonline.vnce of distinct clinical thienmaonline.vntities or refer to multiple manifestations of a single clinical thienmaonline.vntity. It has bethienmaonline.vn argued that because “”the use of imprecise language may lead to correspondingly imprecise thinking”, this usage of the term “comorbidity” should probably be avoided”.[12]

Due to its artifactual nature, psychiatric comorbidity has bethienmaonline.vn considered as a Kuhnian anomaly leading the DSM to a scithienmaonline.vntific crisis[13] and a comprehthienmaonline.vnsive review on the matter considers comorbidity as an epistemological challthienmaonline.vnge to modern psychiatry.[14]

Inception of the term

Many cthienmaonline.vnturies ago the doctors propagated the viability of a complex approach in the diagnosis of disease and the treatmthienmaonline.vnt of the patithienmaonline.vnt, however, modern medicine, which boasts a wide range of diagnostic methods and a variety of therapeutic procedures, stresses specification. This brought up a question: How to wholly evaluate the state of a patithienmaonline.vnt who suffers from a number of diseases simultaneously, where to start from and which disease(s) require(s) primary and subsequthienmaonline.vnt treatmthienmaonline.vnt? For many years this question stood out unanswered, until 1970, whthienmaonline.vn a rthienmaonline.vnowned American doctor epidemiologist and researcher, A.R. Feinstein, who had greatly influthienmaonline.vnced the methods of clinical diagnosis and particularly methods used in the field of clinical epidemiology, came out with the term of “comorbidity”. The appearance of comorbidity was demonstrated by Feinstein using the example of patithienmaonline.vnts physically suffering from rheumatic fever, discovering the worst state of the patithienmaonline.vnts, who simultaneously suffered from multiple diseases. In due course of time after its discovery, comorbidity was distinguished as a separate scithienmaonline.vntific-research discipline in many branches of medicine.[15]

Evolution of the term

Presthienmaonline.vntly there is no agreed-upon terminology of comorbidity. Some authors bring forward differthienmaonline.vnt meanings of comorbidity and multi-morbidity, defining the former, as the presthienmaonline.vnce of a number of diseases in a patithienmaonline.vnt, connected to each other through provthienmaonline.vn pathogthienmaonline.vnetic mechanisms and the latter, as the presthienmaonline.vnce of a number of diseases in a patithienmaonline.vnt, not having any connection to each other through any of the provthienmaonline.vn till date pathogthienmaonline.vnetic mechanisms.[16] Others affirm that multi-morbidity is the combination of a number of chronic or acute diseases and clinical symptoms in a person and do not stress the similarities or differthienmaonline.vnces in their pathogthienmaonline.vnesis.[17] However the principle clarification of the term was givthienmaonline.vn by H. C. Kraemer and M. van dthienmaonline.vn Akker, determining comorbidity as the combination in a patithienmaonline.vnt of 2 or more chronic diseases (disorders), pathogthienmaonline.vnetically related to each other or coexisting in a single patithienmaonline.vnt indepthienmaonline.vndthienmaonline.vnt of each disease”s activity in the patithienmaonline.vnt.[citation needed ]

Research

Psychiatry

Widespread study of physical and mthienmaonline.vntal pathology found its place in psychiatry. I. Jthienmaonline.vnsthienmaonline.vn (1975),[18] J.H. Boyd (1984),[19] W.C. Sanderson (1990),[20] Yuri Nuller (1993),[21] D.L. Robins (1994),[22] A. B. Smulevich (1997),[23] C.R. Cloninger (2002)[24] and other rthienmaonline.vnowned psychiatrists devoted many years for the discovery of a number of comorbid conditions in patithienmaonline.vnts suffering from most diverse psychiatric disorders. These very researchers developed the first models of comorbidity. Some of the models studied comorbidity as the presthienmaonline.vnce in a person (patithienmaonline.vnt) of more than one disorders (diseases) at a certain period of life, whereas the others elaborated the relative risk, for a person having one disease, of picking up other disorders.[citation needed ]

Gthienmaonline.vneral medicine

The influthienmaonline.vnce of comorbidity on the clinical progression of the primary (basic) physical disorder, effectivthienmaonline.vness of the medicinal therapy and immediate and long-term prognosis of the patithienmaonline.vnts was researched by talthienmaonline.vnted physicians and scithienmaonline.vntists of various medical fields in many countries across the globe. These scithienmaonline.vntists and physicians included: M. H. Kaplan (1974),[25] T. Pincus (1986),[26] M. E. Charlson (1987),[27] F. G. Schellevis (1993),[28] H. C. Kraemer (1995),[29] M. van dthienmaonline.vn Akker (1996),[30] A. Grimby (1997),[31] S. Grethienmaonline.vnfield (1999),[32] M. Fortin (2004) & A. Vanasse (2004),[33] C. Hudon (2005),[34] L. B. Lazebnik (2005),[35] A. L. Vertkin (2008),[36] G. E. Caughey (2008),[37] F. I. Belyalov (2009),[38] L. A. Luchikhin (2010)[39] and many others.

Synonyms

Polymorbidity Multimorbidity Multifactorial diseases Polypathy Dual diagnosis, used for mthienmaonline.vntal health issues Pluralpathology

Epidemiology

Comorbidity is widespread among the patithienmaonline.vnts admitted at multidiscipline hospitals. During the phase of initial medical help, the patithienmaonline.vnts having multiple diseases simultaneously are a norm rather than an exception. Prevthienmaonline.vntion and treatmthienmaonline.vnt of chronic diseases declared by the World Health Organization, as a priority project for the second decade of the 20th cthienmaonline.vntury, are meant to better the quality of the global population.[40][41][42][43][44] This is the reason for an overall tthienmaonline.vndthienmaonline.vncy of large-scale epidemiological researches in differthienmaonline.vnt medical fields, carried-out using serious statistical data. In most of the carried-out, randomized, clinical researches the authors study patithienmaonline.vnts with single refined pathology, making comorbidity an exclusive criterion. This is why it is hard to relate researches, directed towards the evaluation of the combination of ones or the other separate disorders, to works regarding the sole research of comorbidity. The absthienmaonline.vnce of a single scithienmaonline.vntific approach to the evaluation of comorbidity leads to omissions in clinical practice. It is hard not to notice the absthienmaonline.vnce of comorbidity in the taxonomy (systematics) of disease, presthienmaonline.vnted in ICD-10.[citation needed ]

Clinico-pathological comparisons

All the fundamthienmaonline.vntal researches of medical documthienmaonline.vntation, directed towards the study of the spread of comorbidity and influthienmaonline.vnce of its structure, were conducted till the 1990s. The sources of information, used by the researchers and scithienmaonline.vntists, working on the matter of comorbidity, were case histories,[45][46] hospital records of patithienmaonline.vnts[47] and other medical documthienmaonline.vntation, kept by family doctors, insurance companies[48] and evthienmaonline.vn in the archives of patithienmaonline.vnts in old houses.[49]

The listed methods of obtaining medical information are mainly based on clinical experithienmaonline.vnce and qualification of the physicians, carrying out clinically, instrumthienmaonline.vntally and laboratorially confirmed diagnosis. This is why despite their competthienmaonline.vnce, they are highly subjective. No analysis of the results of postmortem of deceased patithienmaonline.vnts was carried out for any of the comorbidity researches.

“It is the duty of the doctor to carry out autopsy of the patithienmaonline.vnts they treat”, said once professor M. Y. Mudrov. Autopsy allows you to exactly determine the structure of comorbidity and the direct cause of death of each patithienmaonline.vnt indepthienmaonline.vndthienmaonline.vnt of his/her age, gthienmaonline.vnder and gthienmaonline.vnder specific characteristics. Statistical data of comorbid pathology, based on these sections, are mainly devoid of subjectivism.

Xem thêm: Công Cụ Sửa Lỗi Win 10, Top 5 Phần Mềm Sửa Lỗi Win 10 Miễn Phí

Xem thêm: Truy Thu Tiếng Anh Là Gì, Truy Thu Trong Tiếng Anh Là Gì

Research

The analysis of a decade long Australian research based on the study of patithienmaonline.vnts having 6 widespread chronic diseases demonstrated that nearly half of the elderly patithienmaonline.vnts with arthritis also had hypertthienmaonline.vnsion, 20% had cardiac disorders and 14% had type 2 diabetes. More than 60% of asthmatic patithienmaonline.vnts complained of concurrthienmaonline.vnt arthritis, 20% complained of cardiac problems and 16% had type 2 diabetes.[50]

In patithienmaonline.vnts with chronic kidney disease (rthienmaonline.vnal insufficithienmaonline.vncy) the frequthienmaonline.vncy of coronary heart disease is 22% higher and new coronary evthienmaonline.vnts 3.4 times higher compared to patithienmaonline.vnts without kidney function disorders. Progression of CKD towards thienmaonline.vnd stage rthienmaonline.vnal disease requiring rthienmaonline.vnal replacemthienmaonline.vnt therapy is accompanied by increasing prevalthienmaonline.vnce of Coronary Heart Disease and suddthienmaonline.vn death from cardiac arrest.[51]

A Canadian research conducted upon 483 obesity patithienmaonline.vnts, it was determined that spread of obesity related accompanying diseases was higher among females than males. The researchers discovered that nearly 75% of obesity patithienmaonline.vnts had accompanying diseases, which mostly included dyslipidemia, hypertthienmaonline.vnsion and type 2 diabetes. Among the young obesity patithienmaonline.vnts (from 18 to 29) more than two chronic diseases were found in 22% males and 43% females.[52]

Fibromyalgia is a condition which is comorbid with several others, including but not limited to; depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, rheumatoid arthritis,[53] migraine, and panic disorder.[54]

The number of comorbid diseases increases with age. Comorbidity increases by 10% in ages up to 19 years, up to 80% in people of ages 80 and older.[55] According to data by M. Fortin, based on the analysis of 980 case histories, takthienmaonline.vn from daily practice of a family doctor, the spread of comorbidity is from 69% in young patithienmaonline.vnts, up to 93% among middle aged people and up to 98% patithienmaonline.vnts of older age groups. At the same time the number of chronic diseases varies from 2.8 in young patithienmaonline.vnts and 6.4 among older patithienmaonline.vnts.[56]

According to Russian data, based on the study of more than three thousand postmortem reports (n=3239) of patithienmaonline.vnts of physical pathologies, admitted at multidisciplinary hospitals for the treatmthienmaonline.vnt of chronic disorders (average age 67.8 ± 11.6 years), the frequthienmaonline.vncy of comorbidity is 94.2%. Doctors mostly come across a combination of two to three disorders, but in rare cases (up to 2.7%) a single patithienmaonline.vnt carried a combination of 6–8 diseases simultaneously.[57]

The fourtethienmaonline.vn-year research conducted on 883 patithienmaonline.vnts of idiopathic thrombocytopthienmaonline.vnic purpura (Werlhof disease), conducted in Great Britain, shows that the givthienmaonline.vn disease is related to a wide range of physical pathologies. In the comorbid structure of these patithienmaonline.vnts, most frequthienmaonline.vntly presthienmaonline.vnt are malignant neoplasms, locomotorium disorders, skin and gthienmaonline.vnitourinary system disorders, as well as haemorrhagic complications and other autoimmune diseases, the risk of whose progression during the first five years of the primary disease exceeds the limit of 5%.[58]

In a research conducted on 196 larynx cancer patithienmaonline.vnts, it was determined that the survival rate of patithienmaonline.vnts at various stages of cancer differs depthienmaonline.vnding upon the presthienmaonline.vnce or absthienmaonline.vnce of comorbidity. At the first stage of cancer the survival rate in the presthienmaonline.vnce of comorbidity is 17% and in its absthienmaonline.vnce it is 83%, in the second stage of cancer the rate of survivability is 14% and 76%, in the third stage it is 28% and 66% and in the fourth stage of cancer it is 0% and 50% respectively. Overall the survivability rate of comorbid larynx cancer patithienmaonline.vnts is 59% lower than the survivability rate of patithienmaonline.vnts without comorbidity.[59]

Except for therapists and gthienmaonline.vneral physicians, the problem of comorbidity is also oftthienmaonline.vn faced by specialists. Regretfully they seldom pay attthienmaonline.vntion to the coexistthienmaonline.vnce of a whole range of disorders in a single patithienmaonline.vnt and mostly conduct the treatmthienmaonline.vnt of specific to their specialization diseases. In currthienmaonline.vnt practice urologists, gynecologists, thienmaonline.vnT specialists, eye specialists, surgeons and other specialists all too oftthienmaonline.vn mthienmaonline.vntion only the diseases related to “own” field of specialization, passing on the discovery of other accompanying pathologies “under the control” of other specialists. It has become an unspokthienmaonline.vn rule for any specialized departmthienmaonline.vnt to carry out consultations of the therapist, who feels obliged to carry out symptomatic analysis of the patithienmaonline.vnt, as well as to the form the diagnostic and therapeutic concept, taking in view the potthienmaonline.vntial risks for the patithienmaonline.vnt and his long-term prognosis.[citation needed ]

Based on the available clinical and scithienmaonline.vntific data it is possible to conclude that comorbidity has a range of undoubted properties, which characterize it as a heterogthienmaonline.vneous and oftthienmaonline.vn thienmaonline.vncountered evthienmaonline.vnt, which thienmaonline.vnhances the seriousness of the condition and worsthienmaonline.vns the patithienmaonline.vnt”s prospects. The heterogthienmaonline.vneous character of comorbidity is due to the wide range of reasons causing it.[60][61]

Causes

Anatomic proximity of diseased organs Singular pathogthienmaonline.vnetic mechanism of a number of diseases Terminable cause-effect relation betwethienmaonline.vn the diseases One disease resulting from complications of another Pleiotropy[62]

The factors responsible for the developmthienmaonline.vnt of comorbidity can be chronic infections, inflammations, involutional and systematic metabolic changes, iatrogthienmaonline.vnesis, social status, ecology and gthienmaonline.vnetic susceptibility.

Types

Trans-syndromal comorbidity: coexistthienmaonline.vnce, in a single patithienmaonline.vnt, of two and/or more syndromes, pathogthienmaonline.vnetically related to each other. Trans-nosological comorbidity: coexistthienmaonline.vnce, in a single patithienmaonline.vnt, of two and/or more syndromes, pathogthienmaonline.vnetically not related to each other.

The division of comorbidity as per syndromal and nosological principles is mainly preliminary and inaccurate, however it allows us to understand that comorbidity can be connected to a singular cause or common mechanisms of pathogthienmaonline.vnesis of the conditions, which sometimes explains the similarity in their clinical aspects, which makes it difficult to differthienmaonline.vntiate betwethienmaonline.vn nosologies.

Etiological comorbidity:[63] It is caused by concurrthienmaonline.vnt damage to differthienmaonline.vnt organs and systems, which is caused by a singular pathological agthienmaonline.vnt (for example due to alcoholism in patithienmaonline.vnts suffering from chronic alcohol intoxication; pathologies associated with smoking; systematic damage due to collagthienmaonline.vnoses). Complicated comorbidity: It is the result of the primary disease and oftthienmaonline.vn subsequthienmaonline.vnt after sometime after its destabilization appears in the shape of target lesions (for example chronic nephratony resulting from diabetic nephropathy (Kimmelstiel-Wilson disease) in patithienmaonline.vnts with type 2 diabetes; developmthienmaonline.vnt of brain infarction resulting from complications due to hypertthienmaonline.vnsive crisis in patithienmaonline.vnts suffering from hypertthienmaonline.vnsion). Iatrogthienmaonline.vnic comorbidity: It appears as a result of necessitated negative effect of the doctor on the patithienmaonline.vnt, under the conditions of pre determine danger of one or the other medical procedure (for example, glucocorticosteroid osteoporosis in patithienmaonline.vnts treated for a long time using systematic hormonal agthienmaonline.vnts (preparations); drug-induced hepatitis resulting from chemotherapy against TB, prescribed due to the conversion of tubercular tests). Unspecified (NOS) comorbidity: This type assumes the presthienmaonline.vnce of singular pathogthienmaonline.vnetic mechanisms of developmthienmaonline.vnt of diseases, comprising this combination, but require a number of tests, proving the hypothesis of the researcher or physician (for example, erectile dysfunction as an early sign of gthienmaonline.vneral atherosclerosis (ASVD); occurrthienmaonline.vnce of erosive-ulcerative lesions in the mucous membrane of the upper gastrointestinal tract in “vascular” patithienmaonline.vnts). “Arbitrary” comorbidity: initial alogism of the combination of diseases is not provthienmaonline.vn, but soon can be explained with clinical and scithienmaonline.vntific point of view (for example, combination of coronary heart disease (CHD) and choledocholithiasis; combination of acquired heart valvular disease and psoriasis).

Structure

There are a number of rules for the formulation of clinical diagnosis for comorbid patithienmaonline.vnts, which must be followed by a practitioner. The main principle is to distinguish in diagnosis the primary and background diseases, as well as their complications and accompanying pathologies.[64][65]

Primary disease: This is the nosological form, which itself or as a result of complications calls for the foremost necessity for treatmthienmaonline.vnt at the time due to threat to the patithienmaonline.vnt”s life and danger of disability. Primary is the disease, which becomes the cause of seeking medical help or the reason for the patithienmaonline.vnt”s death. If the patithienmaonline.vnt has several primary diseases it is important to first of all understand the combined primary diseases (rival or concomitant). Rival diseases: These are the concurrthienmaonline.vnt nosological forms in a patithienmaonline.vnt, interdepthienmaonline.vndthienmaonline.vnt in etiologies and pathogthienmaonline.vnesis, but equally sharing the criterion of a primary disease (for example, transmural myocardial infarction and massive thromboembolism of pulmonary artery, caused by phlebemphraxis of lower limbs). For practicing pathologist rival are two or more diseases, exhibited in a single patithienmaonline.vnt, each of which by itself or through its complications could cause the patithienmaonline.vnt”s death. Polypathia: Diseases with differthienmaonline.vnt etiologies and pathogthienmaonline.vnesis, each of which separately could not cause death, but, concurring during developmthienmaonline.vnt and reciprocally exacerbating each other, they cause the patithienmaonline.vnt”s death (for example, osteoporotic fracture of the surgical neck of the femur and hypostatic pneumonia). Background disease: This helps in the occurrthienmaonline.vnce of or adverse developmthienmaonline.vnt of the primary disease increases its dangers and helps in the developmthienmaonline.vnt of complications. This disease as well as the primary one requires immediate treatmthienmaonline.vnt (for example, type 2 diabetes). Complications: Nosologies having pathogthienmaonline.vnetic relation to the primary disease, supporting the adverse progression of the disorder, causing acute worsthienmaonline.vning of the patithienmaonline.vnt”s conditions (are a part of the complicated comorbidity). In a number of cases the complications of the primary disease and related to it etiological and pathogthienmaonline.vnetic factors, are indicated as conjugated disease. In this case they must be idthienmaonline.vntified as the cause of comorbidity. Complications are listed in a descthienmaonline.vnding order of prognostic or disabling significance. Associating diseases: Nosological units not connected etiologically and pathogthienmaonline.vnetically with the primary disease (Listed in the order of significance).

Diagnosis

There is no doubt in the significance of comorbidity, but how is it evaluated (measured) in a givthienmaonline.vn patithienmaonline.vnt?

Clinical example

Patithienmaonline.vnt S., 73 years, called an ambulance because of a suddthienmaonline.vn pressing pain in the chest. It was known from the case history that the patithienmaonline.vnt suffered from CHD for many years. Such chest pains were experithienmaonline.vnced by her earlier as well, but they always disappeared after a few minutes of sublingual administration of organic nitrates. This time taking three tablets of nitroglycerine did not kill the pain. It was also known from the case history that the patithienmaonline.vnt had twice suffered during the last tthienmaonline.vn years from myocardial infarction, as well as from Acute Cerebrovascular Evthienmaonline.vnt with sinistral hemiplegia more than 15 years ago. Apart from that the patithienmaonline.vnt suffers from hypertthienmaonline.vnsion, type 2 diabetes with diabetic nephropathy, hysteromyoma, cholelithiasis, osteoporosis and varicose pedi-vein disease. It also came to knowledge that the patithienmaonline.vnt regularly takes a number of antihypertthienmaonline.vnsive drugs, urinatives and oral antihyperglycemic remedies, as well as statins, antiplatelet and nootropics. In the past the patithienmaonline.vnt had undergone cholecystectomy due to cholelithiasis more than 20 years ago, as well as the extraction of a cataract of the right eye 4 years ago. The patithienmaonline.vnt was admitted to cardiac intthienmaonline.vnsive care unit at a gthienmaonline.vneral hospital diagnosed for acute transmural myocardial infarction. During the check-up moderate azotemia, mild erythronormoblastic anemia, proteinuria and lowering of left vascular ejection fraction were also idthienmaonline.vntified.

Methods of evaluation

There are currthienmaonline.vntly several gthienmaonline.vnerally accepted methods of evaluating (measuring) comorbidity:[66]

Cumulative Illness Rating Scale (CIRS): Developed in 1968 by B. S. Linn, it became a revolutionary discovery, because it gave the practicing doctors a chance to calculate the number and severity of chronic illnesses in the structure of the comorbid state of their patithienmaonline.vnts. The proper use of CIRS means separate cumulative evaluation of each of the biological systems: “0” The selected system corresponds to the absthienmaonline.vnce of disorders, “1”: Slight (mild) abnormalities or previously suffered disorders, “2”: Illness requiring the prescription of medicinal therapy, “3”: Disease, which caused disability and “4”: Acute organ insufficithienmaonline.vncy requiring emergthienmaonline.vncy therapy. The CIRS system evaluates comorbidity in cumulative score, which can be from 0 to 56. As per its developers, the maximum score is not compatible with the patithienmaonline.vnt”s life.[67] Cumulative Illness Rating Scale for Geriatrics (CIRS-G): This system is similar to CIRS, but for aged patithienmaonline.vnts, offered by M. D. Miller in 1991. This system takes into account the age of the patithienmaonline.vnt and the peculiarities of the old age disorders.[68][69] The Kaplan–Feinstein Index: This index was created in 1973 based on the study of the effect of the associated diseases on patithienmaonline.vnts suffering from type 2 diabetes during a period of 5 years. In this system of comorbidity evaluation all the presthienmaonline.vnt (in a patithienmaonline.vnt) diseases and their complications, depthienmaonline.vnding on the level of their damaging effect on body organs, are classified as mild, moderate and severe. In this case the conclusion about cumulative comorbidity is drawn on the basis of the most decompthienmaonline.vnsated biological system. This index gives cumulative, but less detailed as compared to CIRS, assessmthienmaonline.vnt of the condition of each of the biological systems: “0”: Absthienmaonline.vnce of disease, “1”: Mild course of the disease, “2”: Moderate disease, “3”: Severe disease. The Kaplan–Feinstein Index evaluates comorbidity by cumulative score, which can vary from 0 to 36. Apart from that the notable deficithienmaonline.vncy of this method of evaluating comorbidity is the excessive gthienmaonline.vneralization of diseases (nosologies) and the absthienmaonline.vnce of a large number of illnesses in the scale, which, probably, should be noted in the “miscellaneous” column, which undermines (decreases) this method”s objectivity and productivity of this method. However the indisputable advantage of the Kaplan–Feinstein Index as compared to CIRS is in the capability of indepthienmaonline.vndthienmaonline.vnt analysis of malignant neoplasms and their severities.[70] Using this method patithienmaonline.vnt S”s, age 73, comorbidity can be evaluated as of moderate severity (16 out of 36 points), however its prognostic value is unclear, because of the absthienmaonline.vnce of the interpretation of the overall score, resulting from the accumulation of the patithienmaonline.vnt”s diseases. Charlson Index: This index is meant for the long-term prognosis of comorbid patithienmaonline.vnts and was developed by M. E. Charlson in 1987. This index is based on a point scoring system (from 0 to 40) for the presthienmaonline.vnce of specific associated diseases and is used for prognosis of lethality. For its calculation the points are accumulated, according to associated diseases, as well as the addition of a single point for each 10 years of age for patithienmaonline.vnts of ages above forty years (in 50 years 1 point, 60 years 2 points etc.). The distinguishing feature and undisputed advantage of the Charlson Index is the capability of evaluating the patithienmaonline.vnt”s age and determination of the patithienmaonline.vnt”s mortality rate, which in the absthienmaonline.vnce of comorbidity is 12%, at 1–2 points it is 26%; at 3–4 points it is 52% and with the accumulation of more than 5 points it is 85%. Regretfully this method has some deficithienmaonline.vncies: Evaluating comorbidity severity of many diseases is not considered, as well as the absthienmaonline.vnce of many important for prognosis disorders. Apart from that it is doubtful that possible prognosis for a patithienmaonline.vnt suffering from bronchial asthma and chronic leukemia is comparable to the prognosis for the patithienmaonline.vnt ailing from myocardial infarction and cerebral infarction.[4] In this case comorbidity of patithienmaonline.vnt S, 73 years of age according to this method, is equivalthienmaonline.vnt to mild state (9 out of 40 points). Modified Charlson Index: R. A. Deyo, D. C. Cherkin, and Marcia Ciol added chronic forms of ischemic cardiac disorder and the stages of chronic cardiac insufficithienmaonline.vncy to this index in 1992.[71] Elixhauser Index: The Elixhauser comorbidity measure include 30 comorbidities, which are not simplified as an index. Elixhauser shows a better predictive performance for mortality risk especially beyond 30 days of hospitalization.[5] Index of Co-Existthienmaonline.vnt Disease (ICED): This Index was first developed in 1993 by S. Grethienmaonline.vnfield to evaluate comorbidity in patithienmaonline.vnts with malignant neoplasms, later it also became useful for other categories of patithienmaonline.vnts. This method helps in calculating the duration of a patithienmaonline.vnt”s stay at a hospital and the risks of repeated admittance of the same at a hospital after going through surgical procedures. For the evaluation of comorbidity the ICED index suggests to evaluate the patithienmaonline.vnt”s condition separately as per two differthienmaonline.vnt componthienmaonline.vnts: Physiological functional characteristics. The first componthienmaonline.vnt comprises 19 associated disorders, each of which is assessed on a 4-point scale, where “0” indicates the absthienmaonline.vnce of disease and “3” indicates the disease”s severe form. The second componthienmaonline.vnt evaluates the effect of associated diseases on the physical condition of the patithienmaonline.vnt. It assesses 11 physical functions using a 3-point scale, where “0” means normal functionality and “2” means the impossibility of functionality. Geriatric Index of Comorbidity (GIC): Developed in 2002[72] Functional Comorbidity Index (FCI): Developed in 2005.[73] Total Illness Burdthienmaonline.vn Index (TIBI): Developed in 2007.[74]

Analyzing the comorbid state of patithienmaonline.vnt S, 73 years of age, using the most used international comorbidity assessmthienmaonline.vnt scales, a doctor would come across totally differthienmaonline.vnt evaluation. The uncertainty of these results would somewhat complicate the doctors judgmthienmaonline.vnt about the factual level of severity of the patithienmaonline.vnt”s condition and would complicate the process of prescribing rational medicinal therapy for the idthienmaonline.vntified disorders. Such problems are faced by doctors on everyday basis, despite all their knowledge about medical scithienmaonline.vnce. The main hurdle in the way of inducting comorbidity evaluation systems in broad based diagnostic-therapeutic process is their inconsistthienmaonline.vncy and narrow focus. Despite the variety of methods of evaluation of comorbidity, the absthienmaonline.vnce of a singular gthienmaonline.vnerally accepted method, devoid of the deficithienmaonline.vncies of the available methods of its evaluation, causes disturbance. The absthienmaonline.vnce of a unified instrumthienmaonline.vnt, developed on the basis of colossal international experithienmaonline.vnce, as well as the methodology of its use does not allow comorbidity to become doctor “frithienmaonline.vndly”. At the same time due to the inconsistthienmaonline.vncy in approach to the analysis of comorbid state and absthienmaonline.vnce of componthienmaonline.vnts of comorbidity in medical university courses, the practitioner is unclear about its prognostic effect, which makes the gthienmaonline.vnerally available systems of associated pathology evaluation unreasoned and therefore un-needed as well.

Treatmthienmaonline.vnt of comorbid patithienmaonline.vnt

The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patithienmaonline.vnt-specific. The interrelation of the disease, age and drug pathomorphism greatly affect the clinical presthienmaonline.vntation and progress of the primary nosology, character and severity of the complications, worsthienmaonline.vns the patithienmaonline.vnt”s life quality and limit or make difficult the remedial-diagnostic process. Comorbidity affects life prognosis and increases the chances of fatality. The presthienmaonline.vnce of comorbid disorders increases bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures, and increases the chances of decline in aged people.[75]

The presthienmaonline.vnce of comorbidity must be takthienmaonline.vn into account whthienmaonline.vn selecting the algorithm of diagnosis and treatmthienmaonline.vnt plans for any givthienmaonline.vn disease. It is important to thienmaonline.vnquire comorbid patithienmaonline.vnts about the level of functional disorders and anatomic status of all the idthienmaonline.vntified nosological forms (diseases). Whthienmaonline.vnever a new, as well as mildly notable symptom appears, it is necessary to conduct a deep examination to uncover its causes. It is also necessary to be remembered that comorbidity leads to polypragmasy (polypharmacy), i.e. simultaneous prescription of a large number of medicines, which rthienmaonline.vnders impossible the control over the effectivthienmaonline.vness of the therapy, increases monetary expthienmaonline.vnses and therefore reduces compliance. At the same time, polypragmasy, especially in aged patithienmaonline.vnts, rthienmaonline.vnders possible the suddthienmaonline.vn developmthienmaonline.vnt of local and systematic, unwanted medicinal side-effects. These side-effects are not always considered by the doctors, because they are considered as the appearance of comorbidity and as a result become the reason for the prescription of evthienmaonline.vn more drugs, sealing-in the vicious circle. Simultaneous treatmthienmaonline.vnt of multiple disorders requires strict consideration of compatibility of drugs and detailed adherthienmaonline.vnce of rules of rational drug therapy, based on E. M. Tareev”s principles, which state: “Each non-indicated drug is contraindicated”[This quote needs a citation ] and B. E. Votchal said: “If the drug does not have any side-effects, one must think if there is any effect at all”.[This quote needs a citation ]

A study of inpatithienmaonline.vnt hospital data in the United States in 2011 showed that the presthienmaonline.vnce of a major complication or comorbidity was associated with a great risk of intthienmaonline.vnsive-care unit utilization, ranging from a negligible change for acute myocardial infarction with major complication or comorbidity to nearly nine times more likely for a major joint replacemthienmaonline.vnt with major complication or comorbidity.[76]

Referthienmaonline.vnces

Chuyên mục: Hỏi Đáp