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PubMed2005

Prevalence of co-morbidity in different European RRT populations and its effect on access to renal transplantation.

BACKGROUND: This study compared the prevalence of co-morbidity in patients starting renal replacement therapy (RRT) between European countries and further examined how co-morbidity affects access to transplantation. METHODS: In this ERA-EDTA registry special study, 17907 patients from Austria, Catalonia (Spain), Lombardy (Italy), Norway, and the UK (England/Wales) were included (1994-2001). Co-morbidity was recorded at the start of RRT. RESULTS: The prevalence of co-morbidity was: diabetes mellitus (DM) (primary renal disease and co-morbidity) 28%, ischaemic heart disease (IHD) 23%, peripheral vascular disease (PVD) 24%, cerebrovascular disease (CVD) 14% and malignancy 11%. With exception of malignancy, the prevalence of co-morbidity was highest in Austria, but differences were small among other countries. With exception of DM, males suffered more often from co-morbidity than females. In general, the percentage of haemodialysis was higher in patients with co-morbidity, but treatment modality differed substantially between countries. Using a Cox regression with adjustment for demographics, country, year of start and other co-morbidities, the presence of each of the co-morbid conditions made it less likely [RR; 95%CI] to receive a transplant within 4 years: DM [0.79; 0.70-0.88], IHD [0.59; 0.50-0.70], PVD [0.57; 0.49-0.67], CVD [0.49; 0.39-0.61], and malignancy [0.32; 0.24-0.42]. The age, gender and year of start adjusted relative risk [95%CI] to receive a renal transplant within 4 years ranged from 0.23 [0.19-0.27] for Lombardy (Italy) to 3.86 [3.36-4.45] for Norway (Austria = reference). These international differences existed for patients with and without co-morbidity. CONCLUSIONS: The prevalence of co-morbidity was highest in Austria but differences were small among other countries. The access to a renal graft was most affected by the presence of malignancy and least affected by the presence of DM. International differences in access to transplantation were only partly due to co-morbid variability.

Aged↗
PubMed2005

Impact of morbid obesity on medical expenditures in adults.

CONTEXT: Morbid obesity (body mass index (BMI) > or =40 kg/m2) is associated with substantially increased morbidity and mortality from chronic health conditions and with poorer health-related quality of life; however, less is known about the impact of morbid obesity on healthcare expenditures. OBJECTIVE: To examine the impact of morbid obesity on healthcare expenditures using a nationally representative sample of US adults. DESIGN, SETTING, AND PARTICIPANTS: We performed a cross-sectional analysis of 16 262 adults from the 2000 Medical Expenditure Panel Survey, a nationally representative survey of the noninstitutionalized civilian population of the United States. Per capita healthcare expenditures were calculated for National Institutes of Health BMI categories, based on self-reported height and weight, using a two-part, multivariable model adjusted for age, gender, race, income, education level, type of health insurance, marital status, and smoking status. MAIN OUTCOME MEASURES: Odds of incurring any healthcare expenditure and per capita healthcare expenditures associated with morbid obesity in 2000. RESULTS: When compared with normal-weight adults, the odds of incurring any healthcare expenditure in 2000 were two-fold greater among adults with morbid obesity. Per capita healthcare expenditures for morbidly obese adults were 81% (95% confidence interval (CI): 48-121%) greater than normal-weight adults, 65% (95% CI: 37-110%) greater than overweight adults, and 47% (95% CI: 11-96%) greater than adults with class I obesity. Excess costs among morbidly obese adults resulted from greater expenditures for office-based visits, outpatient hospital care, in-patient care, and prescription drugs. Aggregate US healthcare expenditures associated with excess body weight among morbidly obese US adults exceeded $11 billion in 2000. CONCLUSIONS: The economic burden of morbid obesity among US adults is substantial. Further research is needed to identify interventions to reduce the incidence and prevalence of morbid obesity and improve the health and economic outcomes of morbidly obese adults.

Adult↗
PubMed1998

[An analysis of the relationship between morbidity and the level of demand for pediatric primary care. A study on 1359 children].

OBJECTIVE: To analyse the relationship morbidity and utilization in the context of paediatric primary health care. To verify if the morbidity of children who most use primary care qualitatively different from the rest of the population. PATIENTS AND METHODS: Prospective study of the utilization and morbidity over one year in two offices paediatric in a Health Center. Reasons for consulting were grouped into generic types of morbidity, analysing the different types of morbidity of each patient in relation to their level of use. RESULTS: Acute problems were the main reason behind demand. 85% of high users as opposed to 12% of low users showed recurrent morbidity and 23% as opposed to 7% showed chronic medical morbidity. 1.5% of high users as opposed to 47% of low users presented acute morbidity. Recurrent morbidity was associated with greater use due to acute morbidity and non-specific signs or symptoms. The child who only presented with acute type problems in the first half-year was less likely (relative risk: 0.57, IC 95%, 0.43-0.67) to be a high user in the second half. CONCLUSIONS: Children with high level of use group together and chronic medical morbidity whereas those with low level of demand more often present exclusively acute problems. The most part of visitor is caused by acute problems which patients who most consult present to a greater extent than the rest. Recurrent morbidity conditions greater demand due to acute and non-specific problems which are not necessarily associated from the biological point of view with the underlying illness.

Acute Disease↗
PubMed1999

Prevalence of co-morbidity and its relationship to treatment among unselected patients with Hodgkin's disease and non-Hodgkin's lymphoma, 1993-1996.

A population-based series of patients with cancer is likely to comprise more patients with serious co-morbidity than clinical trials because of restrictive eligibility criteria for the latter. Since co-morbidity may influence decision-making, we studied the age-specific prevalence of co-morbidity and its relationship to applied treatment. Data on all 194 patients with Hodgkin's disease (HD) and on 904 patients with non-Hodgkin's lymphoma (NHL) diagnosed between 1993 and 1996 were derived from the Eindhoven Cancer Registry. In the age-group below 60 years, 87% of patients with HD and 80% with NHL did not have a co-morbid condition. The prevalence of serious co-morbidity was 56% for patients with Hodgkin's disease who were 60 years and over and 43% and 61% for non Hodgkin patients who were 60-69 years and 70 years and over, respectively. The most common co-morbid conditions were cardiovascular disease (18%), hypertension (13%), chronic obstructive pulmonary disease (COPD; 13%), and diabetes mellitus (10%) for elderly Hodgkin's patients. For non-Hodgkin's patients of 60-69 years and 70 years and over, cardiovascular disease (15 and 22%, respectively), hypertension (14 and 14%, respectively), COPD (6 and 10% respectively), and diabetes mellitus (8 and 10%, respectively) were the most prevalent co-morbid conditions. The presence of co-morbidity was not related to stage or grade of disease at diagnosis. In the presence of co-morbidity, 50% less chemotherapy was administered to elderly patients with Hodgkin's disease and 10-15% less to elderly patients with non-Hodgkin's lymphoma. The presence of co-morbidity was associated with a decreased overall survival within the first 4 months after diagnosis in both Hodgkin's disease and non-Hodgkin's lymphoma for all age-groups. In conclusion, serious co-morbidity was found for more than half of all lymphoma patients who were 60 years and older. Elderly patients with serious co-morbidity received chemotherapy less often, which is likely to affect survival adversely, as was indicated by a decreased survival within the first 4 months after diagnosis.

Adolescent↗
PubMed1994

Technical factors affecting morbidity in definitive irradiation for localized carcinoma of the prostate.

PURPOSE: The impact of some technical factors on morbidity was analyzed in 738 patients with histologically confirmed carcinoma of the prostate treated with definitive irradiation. METHODS AND MATERIALS: The records of all patients were reviewed, and morbidity of irradiation was evaluated according to severity. All patients were followed up for a minimum of 3 years (median observation, 6.5 years). RESULTS: The most frequent Grade 2 (moderate) intestinal complication was proctitis, which was observed in 5% of the patients, followed by enteritis (1%) and anal-rectal fibrosis or stricture (about 1%). Incidence of Grade 3 (severe) proctitis was less than 1% and small bowel obstruction, 0.2%. One patient developed radiation-induced ileitis complicated with peritonitis, which was fatal. The most frequent Grade 2 urinary complication was urethral stricture (5%) and cystitis with significant symptoms or hematuria (2%). A vesicosigmoid and a rectovesical fistula (.4%) were noted, which required colostomy. One patient with hemorrhagic cystitis (.2%) required an ileal bladder, and two cases of ureteral stricture (.3%) required surgical correction. Most cases of Grade 2-3 intestinal or urinary morbidity appeared within 2-5 years after therapy (8% moderate and 3% severe cumulative intestinal morbidity at 10 years, and 9% and 3%, urinary). The actuarial incidence of rectosigmoid Grade 2 and 3 morbidity was 10% for patients treated to the pelvic lymph nodes and the prostate and 3% for those treated to the prostate only (p = 0.04). The difference in urinary morbidity in these two groups of patients was not statistically significant. There was also no significant correlation of morbidity with boost portal size for prostate irradiation. Patients treated with a stationary portal technique that delivered higher doses to the urinary bladder had a significantly greater incidence of urinary morbidity (18% cumulative) compared with patients treated with rotational techniques (5%) (p < 0.1). However, patients treated with pelvic fields and rotational techniques had a higher intestinal and rectosigmoid morbidity (11%) than patients treated to the prostate only (< or = 5%) (p = 0.05). No statistically significant difference in intestinal or urinary morbidity was related to doses of irradiation (60-70 Gy). CONCLUSION: Volume treated and, to a lesser extent, dose of irradiation at tolerance levels are important factors influencing significant morbidity in patients with carcinoma of the prostate treated with definitive irradiation. With recent advances in three-dimensional (3-D) treatment planning and conformal radiation therapy techniques, it is imperative to precisely determine optimal volumes and doses of irradiation required to achieve the highest local-pelvic tumor control while minimizing morbidity to enhance the role of irradiation in the management of localized carcinoma of the prostate.

Adenocarcinoma↗
PubMed1996

Lateral rectal shielding reduces late rectal morbidity following high dose three-dimensional conformal radiation therapy for clinically localized prostate cancer: further evidence for a significant dose effect.

PURPOSE: Using conventional treatment methods for the treatment of clinically localized prostate cancer central axis doses must be limited to 65-70 Gray (Gy) to prevent significant damage to nearby normal tissues. A fundamental hypothesis of three-dimensional conformal radiation therapy (3DCRT) is that, by defining the target organ(s) accurately in three dimensions, it is possible to deliver higher doses to the target without a significant increase in normal tissue complications. This study examines whether this hypothesis holds true and whether a simple modification of treatment technique can reduce the incidence of late rectal morbidity in patients with prostate cancer treated with 3DCRT to minimum planning target volume (PTV) doses of 71-75 Gy. METHODS AND MATERIALS: The 257 patients with clinically localized prostate cancer who completed 3DCRT by December 31, 1993 and received a minimum PTV dose of 71-75 Gy are included in this report. The median follow-up time was 22 months (range: 4-67 months); 98% of patients had follow-up of longer than 12 months. The calculated dose at the center of the prostate was < 74 Gy in 19 patients, 74-76 Gy in 206 patients, and > 76 Gy in 32 patients. Late rectal morbidity was graded according to the Late Effects Normal Tissue (LENT) scoring system. Eighty-eight consecutive patients were treated with a rectal block added to the lateral fields. In these patients the posterior margin from the prostate to the block edge was reduced from the standard 15 to 5 mm for the final 10 Gy, which reduced the dose to portions of the anterior rectal wall by approximately 4-5 Gy. Estimates of rates for rectal morbidity were determined by Kaplan-Meier actuarial analysis. Differences in morbidity percentages were evaluated by the Pearson chi-square test. RESULTS: Grade 2-3 rectal morbidity developed in 46 out of 257 patients (18%) and in the majority of cases consisted of rectal bleeding. No patient has developed Grade 4 or 5 rectal morbidity. The actuarial rate of Grade 2-3 morbidity is 23% at 24 months and the median time to the development of Grade 2-3 complications is 15 months. A statistically significant dose effect is evident. The incidence of Grade 2-3 rectal morbidity increased as the dose at the center of the prostate increased (p = 0.05). In patients receiving minimum PTV doses of < or = 76 Gy the use of a rectal block significantly reduced the incidence of Grade 2-3 toxicity; 6 out of 88 (7%) with a block vs. 30 out of 137 (22%) without a block, (p = 0.003). CONCLUSION: The incidence of late rectal morbidity with 3DCRT to minimum PTV doses of 71-75 Gy is acceptable and to date no Grade 4-5 rectal morbidities have been observed. In our experience, higher doses to the center of the prostate are associated with an increased likelihood of developing Grade 2-3 rectal morbidity but treatment techniques that reduce the total dose to the anterior rectal wall have reduced the incidence of late rectal morbidity. If clinical studies indicate improved tumor control with minimum PTV doses above 71 Gy, then dose escalation above 76 Gy to the center of the prostate should be pursued cautiously with treatment techniques that limit the total dose to the anterior rectal wall.

Adult↗
PubMed2006

The prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma.

OBJECTIVE: to investigate the prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma. DESIGN: a retrospective cross-sectional community survey of postnatal women. PARTICIPANTS AND SETTING: a total population sample of 2100 women were surveyed from two maternity units within Birmingham. Women were identified from the Trust's computerised Maternity Information System (MIS). METHODS: Women were surveyed using a self-administered postal questionnaire 12 months after birth. The questionnaire included self-assessment of perineal pain, perineal healing, urinary incontinence, flatus incontinence, faecal incontinence, sexual morbidity and dyspareunia. FINDINGS: a response rate of 23.3% was achieved (n=482). A high level of perineal morbidity was reported (53.8% stress urinary incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence, 54.5% with at least one index of sexual morbidity). Women with perineal trauma reported significantly more morbidity (sexual morbidity, dyspareunia, stress and urge urinary incontinence) than women with an intact perineum. Women with perineal trauma also resumed sexual intercourse later than women with an intact perineum. Women with a first- or second-degree tear reported significantly more perineal morbidity (stress incontinence, sexual morbidity) than women with an intact perineum, and resumed sexual intercourse later. However, a high percentage of women with an intact perineum also reported new-onset perineal morbidity: stress urinary incontinence (34.8%); urge urinary incontinence (19.5%); flatus incontinence (13.8%); and dyspareunia (25.3%), highlighting that enduring perineal morbidity can occur irrespective of perineal trauma. CONCLUSION: enduring postnatal perineal morbidity is common in women with all types and grades of perineal trauma and intact perineum after childbirth. This highlights the need for further debate and research into the prevalence and experience of postnatal morbidity.

Adult↗
PubMed2000

Risk factors for high herd level calf morbidity risk from birth to weaning in beef herds in the USA.

We analyzed data from a national survey of beef cow-calf producers in the USA to quantify the effects of hypothesized risk factors on herd-level calf morbidity risk from birth to weaning. The analysis included 2490 herds from 23 states. Two stepwise logistic regressions were fit to identify factors associated with &ge;10% morbidity. The first model included all herds dichotomized into high-morbidity herds with &ge;10% morbidity and low-morbidity herds with <10% morbidity. The second model excluded herds with between 5 and 10% morbidity, and compared >/=10% morbidity with </=5% morbidity. The risk of dystocia was categorized into five levels for analysis; all non-zero categories were associated with increased odds of being a high-morbidity herd compared to herds with no dystocia (OR=2.7-5.5). Having >70% of cows and heifers calves in confinement also increased the odds of being a high-morbidity herd (OR=1.8). The population attributable fractions for dystocia and confined calving for the model including all herds dichotomized at 10% morbidity were 0.41 and 0.11, respectively. The summary population attributable fraction for both factors was 0.46.

Animal Husbandry↗
PubMed2003

Probability of late rectal morbidity in 125I prostate brachytherapy.

PURPOSE: Rectal toxicity is a concern in prostate brachytherapy because it is difficult to avoid delivering a dose equal to, or greater than, the prescription dose to the anterior surface of the rectum. The purpose of this study was to define the probability that a patient will experience Grade 2 (bleeding/ulceration) late rectal morbidity after 125I prostate brachytherapy according to the rectal dosimetry. METHODS AND MATERIALS: Ninety-eight consecutive patients who received monotherapy 125I prostate implants for treatment of Stage T1-T2, favorable-risk adenocarcinoma of the prostate were evaluated for Radiation Therapy Oncology Group Grade 2 late rectal morbidity. All reported incidences of late morbidity were retrospectively confirmed by colonoscopy. All patients had at least 15 months follow-up after implantation. The median follow-up was 32 months (range 15-54). The rectal dosimetry was based on a CT scan obtained at 3-9 weeks after implantation. The rectum was contoured on each CT image between the base and apex of the prostate. A dose-surface histogram was compiled for each implant, and the relative surface area that received a dose > or =100, > or =150, > or =200, > or =300, > or =400, and > or =500 Gy was recorded. The probability of developing late rectal toxicity was calculated by logistic regression analysis as a function of dose and the percentage of the rectal surface that received that dose. RESULTS: Of the 98 patients, 10 developed Grade 2 late rectal morbidity. The percentage of the rectal surface that received 100, 150, 200, and 300 Gy was significantly greater (p < or =0.02) for patients who experienced late rectal morbidity. The probability of late rectal morbidity increased with both the dose and the percentage of the rectal surface that received that dose. The probability was < or =1% when 20%, 7%, and 0% of the rectal surface received 100, 150, and 200 Gy, respectively. The probability increased to < or =5% when 31%, 19%, and 9% of the rectal surface received these doses. The probability of late rectal morbidity can also be expressed in terms of the maximal rectal dose. The probability of late morbidity was 0.4%, 1.2%, and 4.7% when the maximal rectal dose was 150, 200, and 300 Gy, respectively. CONCLUSION: The percentage of the rectal surface that receives a dose > or =100 Gy is predictive of Grade 2 (bleeding/ulceration) late rectal morbidity after 125I prostate brachytherapy. The probability of late morbidity depends on both the dose and the percentage of the rectal surface that received that dose. Our results indicate that the rectum can tolerate doses of 100, 150, and 200 Gy to approximately 30%, 20%, and 10% of the rectal surface with a < or =5% risk of late morbidity. Our results also indicate that the practical guideline for limiting the incidence of late morbidity to 1%, 3%, or 5% is to keep the maximal rectal dose to <200, 250, and 300 Gy, respectively.

Adenocarcinoma↗
PubMed2004

Morbid obesity is not a contraindication to kidney transplantation.

BACKGROUND: Concern that morbidly obese (body mass index [BMI] 35) kidney transplant recipients have worse outcomes than non-morbidly obese recipients leads many transplant centers to deny them the benefit of kidney transplantation. These concerns are supported by guidelines recently published by the American Society of Transplantation. However, successfully transplanted morbidly obese persons have a survival advantage over those that remain on dialysis. It is our practice to evaluate morbidly obese transplant candidates for transplantation under the same criteria used for nonobese candidates. This report reviews our experience with morbidly obese kidney transplant recipients having a three year follow-up. METHODS: Outcomes for 23 morbidly obese (BMI 35, range 37 to 56) kidney transplant recipients transplanted between January 1995 and February 2000 were compared with 224 nonobese (BMI 25) kidney recipients transplanted during the same period. RESULTS: Patient and graft survivals were similar between both groups. Although 3-year graft survival for morbidly obese recipients of cadaver organs was 75% compared with 90% for the nonobese group, this finding was not statistically significant, and 3-year graft survival was 100% for morbidly obese recipients of living donor organs compared with 91% for nonobese recipients. Morbidly obese recipients had significantly longer hospital stays, higher readmission rates, and a higher wound infection rate than nonobese recipients. CONCLUSIONS: We found that morbidly obese persons have 3-year graft and patient survivals similar to nonobese persons. Although they also have greater complications and greater numbers of days in the hospital, we believe these reasons are not sufficient to deny morbidly obese persons the survival and quality-of-life advantages of kidney transplantation.

Actuarial Analysis↗
PubMed2005

Reduced incidence of neonatal morbidities: effect of home-based neonatal care in rural Gadchiroli, India.

OBJECTIVE: We found a high burden of morbidities in a cohort of neonates observed in rural Gadchiroli, India. We hypothesised that interventions would reduce the incidence of neonatal morbidities, including the seasonal increase observed in many of them. This article reports the effect of home-based neonatal care on neonatal morbidities in the intervention arm of the field trial by comparing the early vs late periods, and the possible explanation for this effect. METHODS: During 3 years (1995 to 1998), trained village-health-workers (VHWs) in 39 villages prospectively collected data by making home visits during pregnancy, home-delivery and during neonatal period. We estimated the incidence and burden of neonatal morbidities over the 3 years from these data. In the first year, the VHWs made home visits only to observe. From the second year, they assisted mothers in neonatal care and managed the sick neonates at home. Health education of mothers and family members, individually and in group, was added in the third year. We measured the coverage of interventions over the 3 years and evaluated maternal knowledge and practices on 21 indicators in the third year. The effect on 17 morbidities was estimated by comparing the incidence in the first year with the third year. RESULTS: The VHWs observed 763 neonates in the first year, 685 in the second and 913 in the third year. The change in the percent incidence of morbidities was (i) infections, from 61.6 to 27.5 (-55%; p<0.001), (ii) care-related morbidities (asphyxia, hypothermia, feeding problems) from 48.2 to 26.3 (-45%; p<0.001); (iii) low birth weight from 41.9 to 35.2 (-16%; p<0.05); (iv) preterm birth and congenital anomalies remained unchanged. The mean number of morbidities/100 neonates in the 3 years was 228, 170 and 115 (a reduction of 49.6%; p<0.001). These reductions accompanied an increasing percent score of interventions during 3 years: 37.9, 58.4 and 81.3, thus showing a dose-response relationship. In the third year, the proportion of correct maternal knowledge was 78.7% and behaviours was 69.7%. The significant seasonal increase earlier observed in the incidence of five morbidities reduced in the third year. CONCLUSION: The home-based care and health education reduced the incidence and burden of neonatal morbidities by nearly half. The effect was broad, but was especially pronounced on infections, care-related morbidities and on the seasonal increase in morbidities.

Breast Feeding↗
PubMed2005

Intra-abdominal pressure in the morbidly obese.

BACKGROUND: Recent data suggests that increased intra-abdominal pressure (IAP) is one factor associated with the morbidity of morbidly obese patients, who have a BMI>35 kg/m2. IAP has been proposed to be an abdominal compartment syndrome (ACS). This study investigated the characteristics of IAP in morbidly obese patients. METHODS: 45 morbidly obese patients (mean BMI55+/-2 kg/m2) had IAP measured using urinary bladder pressure. RESULTS: The mean IAP for the morbidly obese group was 12+/-0.8 cmH2O, increased when compared to controls (IAP=0+/-2 cmH2O). The IAP correlated to the sagittal abdominal diameter, an index of the degree of central obesity (r=+0.83, P<0.02); however, it did not correlate to basal insulin, body weight, or BMI. The end-expiratory IAP did not change when measured after the laparotomy incision was made, but IAP measured in the last 15 patients increased during the first 2 postoperative days. The IAP for patients with pressure-related morbidity (gastroesophageal reflux disease, hernia, stress incontinence, diabetes, hypertension, and venous insufficiency) was 12+/-1 cmH2O, while those without these morbidities had an IAP of 9+/-0.8 cmH2O. CONCLUSION: We conclude that IAP is increased in morbid obesity. This increased IAP is a function of central obesity and is associated with increased morbidity. The degree of IAP elevation correlates with increased co-morbidities. We also conclude that elevation in IAP in morbid obesity is not a true ACS but represents a direct mass effect of the visceral obesity.

Abdomen↗
PubMed1992

Smokers with IDDM experience excess morbidity. The Colorado IDDM Registry.

OBJECTIVE--To determine whether there is an association between smoking and the self-reported morbidity of people with IDDM and to evaluate the nature of a possible interaction between smoking and IDDM in increasing the risk of morbidity among smokers with IDDM. RESEARCH DESIGN AND METHODS--Subjects were non-Hispanic whites aged 18-28 yr who participated in the Colorado IDDM Registry Follow-up Survey (case subjects, n = 24) or the 1985 NHIS (control subjects, n = 5876). Assessments of self-reported morbidity included any hospitalization in the past year; bed days, sick days, and limited-activity days in the past 2 wk; and ratings of poor health. The criteria outlined by Saracci were used to determine whether smoking was associated with greater morbidity among IDDM case compared to control subjects (smoking by IDDM interaction). RESULTS--Age- and sex-adjusted ORs, estimated from logistic regression, showed that people with IDDM reported excess morbidity compared with control subjects, regardless of smoking status. Smokers with IDDM reported morbidity 3-10 times as often as nonsmoking control subjects and were 2-3 times more likely to report morbidity than nonsmokers with IDDM. The smoking by IDDM interaction was more than multiplicative for all morbidity measures. Fifty to 75% of excess morbidity in young smokers with IDDM over simple additive effects was related to the interaction between smoking and IDDM. CONCLUSIONS--There was excess reported morbidity among people with IDDM who smoked, greater than that expected from the combined effects of smoking and IDDM. Smoking cessation in young people with IDDM may alleviate some of this excess, but more study is needed to determine whether smoking serves as an indicator of poor IDDM care practices or has a physiological impact that compounds the morbidity experienced by people with IDDM.

Adult↗
PubMed2006

A Q methodology study of women's experience of enduring postnatal perineal and pelvic floor morbidity.

OBJECTIVE: to explore women's experiences of enduring postnatal perineal and pelvic floor morbidity. DESIGN: a retrospective Q methodology study of postnatal women between 12 and 18 months postpartum. SETTING: maternity services at the Heart of England NHS Foundation Trust, Birmingham. PARTICIPANTS: women were self-identified by expression of interest as part of their earlier involvement in a retrospective cross-sectional community survey of enduring postnatal perineal and pelvic floor morbidity. Twenty women responded to the invitation posted on the back of the initial survey questionnaire. All 20 women took part in stage one (interview) of the study (100% response rate). Fourteen women returned the completed response grids in stage four after 1 month of dissemination (response rate 70%). METHODS: the project included five stages: (1) data were gathered using an individual face-to-face, semi-structured, community-based interview method (developing the concourse); (2) the concourse was analysed using MAXqda (2004) to produce 'themes'; (3) the themes were reduced to 'statements' that reflected the overall content of the concourse using an unstructured evolving approach to Q set design (giving the Q set); (4) participants were asked to sort the statements (Q sorting) according to a pre-designed distribution grid (providing individual participant response grids); and (5) the response grids were factor analysed using PQMethod (V2.0), which generates clusters of participants rather than clusters of variables. Factor loadings were calculated using factor analysis by principal components with varimax rotation. This produced a list of factors, each of which represents a 'story' of women's experience of enduring postnatal perineal and pelvic floor morbidity. FINDINGS: five factors were identified: perineal morbidity of minor inconvenience, insufficient support and services, the 'taboo' subject of enduring perineal and pelvic floor morbidity, normalising morbidity and the isolation of perineal morbidity. Women varied in their experiences of enduring postnatal perineal and pelvic floor morbidity, with some having minor problems, with little affect on daily living, whereas others were significantly affected. The affect of the morbidity varied. Women highlighted the lack of service provision for these problems and stated that health-care practitioners, and society at large, were often dismissive of, or trivialised, their experiences of enduring postnatal perineal and pelvic floor morbidity. CONCLUSION: the findings from this study highlight that the postnatal recovery period is longer than the presumed 6 weeks. The effect of postnatal perineal and pelvic floor morbidity on women's lives varies, and more long-term postnatal health support and research using women-centred outcomes is needed.

Adult↗
PubMed2004

The prevalence and co-morbidity of subthreshold psychiatric conditions.

BACKGROUND: In previous studies of subthreshold conditions, co-morbidity has been largely ignored. The purpose was to examine rates of co-morbidity among subthreshold disorders and between subthreshold and full-syndrome disorders for the major non-psychotic classes of disorders from DSM-IV. METHOD: Participants came from the Oregon Adolescent Depression Project (mean age=16.6 years; females=52.1%). On the basis of a diagnostic interview (K-SADS), participants were assigned to eight subthreshold disorders (MDD, bipolar, eating, anxiety, alcohol use, substance use, conduct, ADHD). RESULTS: Of the 1704 adolescents in the analyses, 52.5% had at least one subthreshood disorder. Of those, 40.0% had also experienced a co-morbid subthreshold condition, and 29.9% of those had a second co-morbid subthreshold condition. Of those with a subthreshold, 36.4% also had a full syndrome. The subthreshold forms of externalizing disorders were co-morbid with each other. As expected, subthreshold anxiety was co-morbid with subthreshold MDD but subthreshold anxiety was also co-morbid with subthreshold alcohol, conduct, and ADHD. The pattern of co-morbidities was nearly identical for males and females. CONCLUSIONS: The hypotheses that externalizing disorders would be co-morbid with other externalizing disorders and that internalizing disorders would be co-morbid with other internalizing disorders was partially supported. Co-morbidities between subthreshold disorders and between subthreshold disorders and full syndrome should impact future research and clinical practice. The assessment of subthreshold disorders needs to include the assessment of other subthreshold and full-syndrome conditions.

Adolescent↗
PubMed2005

Accuracy of diagnosing depression in primary care: the impact of chronic somatic and psychiatric co-morbidity.

BACKGROUND: Depression is highly co-morbid with both psychiatric and chronic somatic disease. These types of co-morbidity have been shown to exert opposite effects on underdiagnosis of depression by general practitioners (GPs). However, past research has not addressed their combined effect on underdiagnosis of depression. METHOD: Co-morbidity data on 191 depressed primary-care patients selected by a two-stage sampling procedure were analysed. Diagnoses of major depression and/or dysthymia in the last 12 months were assessed using a standardized psychiatric interview (CIDI) and compared with depression diagnoses registered by GPs in patient contacts during the same period. Presence of psychiatric and chronic somatic co-morbidity was determined using the CIDI and contact registration, respectively. RESULTS: Regression analysis showed a significant interaction effect between psychiatric and chronic somatic co-morbidity on GPs' diagnosis of depression, while taking into account the effects of sociodemographic variables, depression severity and number of GP contacts. Subsequent stratified analysis revealed that in patients without chronic somatic co-morbidity, a lower educational level, a less severe depression, and fewer GP contacts all significantly increased the likelihood of not being diagnosed as depressed. In contrast, in patients with chronic somatic co-morbidity, only having no psychiatric co-morbidity significantly decreased the likelihood of receiving a depression diagnosis. CONCLUSIONS: Our results indicate that the effects of psychiatric co-morbidity and other factors on underdiagnosis of depression by GPs differ between depressed patients with and without chronic somatic co-morbidity. Efforts to improve depression diagnosis by GPs seem to require different strategies for depressed patients with and without chronic somatic co-morbidity.

Adolescent↗
PubMed2006

Deriving utility scores for co-morbid conditions: a test of the multiplicative model for combining individual condition scores.

BACKGROUND: The co-morbidity of health conditions is becoming a significant health issue, particularly as populations age, and presents important methodological challenges for population health research. For example, the calculation of summary measures of population health (SMPH) can be compromised if co-morbidity is not taken into account. One popular co-morbidity adjustment used in SMPH computations relies on a straightforward multiplicative combination of the severity weights for the individual conditions involved. While the convenience and simplicity of the multiplicative model are attractive, its appropriateness has yet to be formally tested. The primary objective of the current study was therefore to examine the empirical evidence in support of this approach. METHODS: The present study drew on information on the prevalence of chronic conditions and a utility-based measure of health-related quality of life (HRQoL), namely the Health Utilities Index Mark 3 (HUI3), available from Cycle 1.1 of the Canadian Community Health Survey (CCHS; 2000-01). Average HUI3 scores were computed for both single and co-morbid conditions, and were also purified by statistically removing the loss of functional health due to health problems other than the chronic conditions reported. The co-morbidity rule was specified as a multiplicative combination of the purified average observed HUI3 utility scores for the individual conditions involved, with the addition of a synergy coefficient s for capturing any interaction between the conditions not explained by the product of their utilities. The fit of the model to the purified average observed utilities for the co-morbid conditions was optimized using ordinary least squares regression to estimate s. Replicability of the results was assessed by applying the method to triple co-morbidities from the CCHS cycle 1.1 database, as well as to double and triple co-morbidities from cycle 2.1 of the CCHS (2003-04). RESULTS: Model fit was optimized at s = .99 (i.e., essentially a straightforward multiplicative model). These results were closely replicated with triple co-morbidities reported on CCHS 2000-01, as well as with double and triple co-morbidities reported on CCHS 2003-04. CONCLUSION: The findings support the simple multiplicative model for computing utilities for co-morbid conditions from the utilities for the individual conditions involved. Future work using a wider variety of conditions and data sources could serve to further evaluate and refine the approach.

Journal Article↗
PubMed2004

Severe acute respiratory syndrome-related psychiatric and posttraumatic morbidities and coping responses in medical staff within a primary health care setting in Singapore.

BACKGROUND: Severe acute respiratory syndrome (SARS) is a major new infectious disease of this century that is unique in its high morbidity and concentration in health care settings. We aimed to determine the level of psychological impact and coping styles among the medical staff in a primary health care setting. METHOD: Using a structured questionnaire, we conducted a cross-sectional survey of the doctors and nurses working within a public, primary health care setting in mid-July 2003. The main outcome measures were rates of psychiatric morbidity, level of posttraumatic stress symptoms, and coping strategies. RESULTS: The response rate was 92.0%. Of the 277 respondents (91 doctors and 186 nurses), psychiatric morbidity and posttraumatic morbidity were found in 20.6% and 9.4%, respectively. Both psychiatric and posttraumatic morbidities were associated with higher scores on coping efforts including self-distraction, behavioral disengagement, social support, venting, planning, and self-blame (all p <.001), but not with direct exposure factors such as contact with suspected SARS patients or working in fever rooms/tentages. Multivariate analysis showed that psychiatric morbidity was associated with post-traumatic morbidity (p =.02) and denial (p =.03), whereas posttraumatic morbidity was associated with younger age (p =.007), being married (p =.02), psychiatric morbidity (p =.02), self-distraction (p =.02), behavioral disengagement (p =.01), religion (p =.003), less venting (p =.04), less humor (p =.04), and less acceptance (p =.02). CONCLUSION: SARS-related psychiatric and posttraumatic morbidities were present in the medical staff within a primary health care setting. Specific coping efforts, age, and marital status, not direct exposure factors, were associated with psychological morbidity. These findings provide possible foci for early identification and psychological support.

Adaptation, Psychological↗