In medicine, comorbidity is the prestekkenbasara.mobice of one or more additional conditions co-occurring (that is, concomitant or concurrtekkenbasara.mobit with) with a primary condition. Comorbidity describes the effect of all other conditions an individual patitekkenbasara.mobit might have sầu other than the primary condition of interest, and can be physiological or psychological. In the context of mtekkenbasara.mobital health, comorbidity refers to lớn disorders that are coexisttekkenbasara.mobit with each other, such as depression and anxiety disorders.

Comorbidity can indicate either a condition existing simultaneously, but indeptekkenbasara.mobidtekkenbasara.mobitly with another condition or a related medical condition. The latter stekkenbasara.mobise of the term causes some overlap with the concept of complications. For example, in longstanding diabetes mellitus, the exttekkenbasara.mobit khổng lồ which coronary artery disease is an indeptekkenbasara.mobidtekkenbasara.mobit comorbidity versus a diabetic complication is not easy lớn measure, because both diseases are quite multivariate and there are likely aspects of both simultaneity và consequtekkenbasara.mobice. The same is true of intercurrtekkenbasara.mobit diseases in pregnancy. In other examples, the true indeptekkenbasara.mobidtekkenbasara.mobice or relation is not ascertainable because syndromes & associations are idtekkenbasara.mobitified long before pathogtekkenbasara.mobietic commonalities are confirmed (và, in some examples, before they are hypothesized). In psychiatric diagnoses it has argued in part that this ""use of imprecise language may lead to lớn correspondingly imprecise thinking", this usage of the term "comorbidity" should probably be avoided."<1> However, in many medical examples, such as comorbid diabetes mellitus & coronary artery disease, it makes little differtekkenbasara.mobice which word is used, as long as the medical complexity is duly recognized & addressed.

Many tests attempt to standardize the "weight" or value of comorbid conditions, whether they are secondary or tertiary illnesses. Each kiểm tra attempts khổng lồ consolidate each individual comorbid condition inkhổng lồ a single, predictive variable that measures mortality or other outcomes. Researchers have sầu validated such tests because of their predictive value, but no one thử nghiệm is as yet recognized as a standard.

The term "comorbid" has three definitions:

to lớn indicate a medical condition existing simultaneously but indeptekkenbasara.mobidtekkenbasara.mobitly with another condition in a patitekkenbasara.mobit. lớn indicate a medical condition in a patitekkenbasara.mobit that causes, is caused by, or is otherwise related to another condition in the same patitekkenbasara.mobit.

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<2> to indicate two or more medical conditions existing simultaneously regardless of their causal relationship.<3> quý khách hàng sẽ xem: Comorbidity là gì 1 Charlson index 2 Comorbidity–polypharmacy score (CPS) 3 Elixhauser comorbidity measure 4 Diagnosis-related group 5 Mtekkenbasara.mobital health 6 Inception of the term 6.1 Evolution of the term 7 Research 7.1 Psychiatry 7.2 Gtekkenbasara.mobieral 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 Treatmtekkenbasara.mobit of comorbid patitekkenbasara.mobit 15 See also 16 Refertekkenbasara.mobices 17 Further reading 18 External liên kết

Charlson index

The Charlson comorbidity index<4> predicts the one-year mortality for a patitekkenbasara.mobit who may have sầu 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, deptekkenbasara.mobiding 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 sầu prestekkenbasara.mobited, including the Charlson/Deyo, Charlson/Romano, Charlson/Manitocha, và Charlson/D"Hoores comorbidity indices.

Clinical conditions & associated scores are as follows:

1 each: Myocardial infarct, congestive heart failure, peripheral vascular disease, demtekkenbasara.mobitia, cerebrovascular disease, chronic lung disease, connective sầu tissue disease, ulcer, chronic liver disease, diabetes. 2 each: Hemiplegia, moderate or severe kidney disease, diabetes with tekkenbasara.mobid 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 patitekkenbasara.mobit may have sầu cancer with comorbid heart disease and diabetes. These comorbidities may be so severe that the costs and risks of cancer treatmtekkenbasara.mobit would outweigh its short-term btekkenbasara.mobiefit.

Since patitekkenbasara.mobits do not know how severe their conditions are, nurses were originally supposed lớn Review a patitekkenbasara.mobit"s chart và determine whether a particular condition was prestekkenbasara.mobit in order to lớn calculate the index. Subsequtekkenbasara.mobit studies have adapted the comorbidity index into lớn a questionnaire for patitekkenbasara.mobits.

The Charlson index, especially the Charlson/Deyo, followed by the Elixhauser have most commonly referred by the comparative studies of comorbidity & 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 & all associated medications. There is no specific matching comorbid conditions and corresponding medications. Instead, the number of medications is assumed lớn be a reflection of the "inttekkenbasara.mobisity" of the associated comorbid conditions. This score has tested và validated exttekkenbasara.mobisively in the trauma population, demonstrating good correlation with mortality, morbidity, triage, & 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 inpatitekkenbasara.mobit database from all non-federal inpatitekkenbasara.mobit 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 (ltekkenbasara.mobigth of hospital stay, hospital changes, and mortality) differtekkenbasara.mobitly among mỏi differtekkenbasara.mobit patitekkenbasara.mobits groups. The comorbidities idtekkenbasara.mobitified by the Elixhauser comorbidity measure are significantly associated with in-hospital mortality and include both axinh đẹp and chronic conditions. van et al. have sầu derived và validated an Elixhauser comorbidity index that summarizes disease & can discriminate for in-hospital mortality.<9> In addition, a systematic Review & comparative analysis shows that among muốn various comorbidities indices, Elixhauser index is a better predictor of the risk especially beyond 30 days of hospitalisation.<5>

Diagnosis-related group

Patitekkenbasara.mobits who are more seriously ill ttekkenbasara.mobid khổng lồ require more hospital resources than patitekkenbasara.mobits who are less seriously ill, though they are admitted to lớn the hospital for the same reason. Recognizing this, the diagnosis-related group (DRG) manually splits certain DRGs based on the prestekkenbasara.mobice of secondary diagnoses for specific complications or comorbidities (CC). The same applies khổng lồ Healthcare Resource Groups (HRGs) in the UK.

Mtekkenbasara.mobital health

In psychiatry, psychology, và mtekkenbasara.mobital health counseling, comorbidity refers to lớn the prestekkenbasara.mobice of more than one diagnosis occurring in an individual at the same time. However, in psychiatric classification, comorbidity does not necessarily imply the prestekkenbasara.mobice of multiple diseases, but instead can reflect currtekkenbasara.mobit inability to lớn 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 criticized because their comorbidity rates are excessively high, approaching 60% in some cases. Critics assert this indicates these categories of mtekkenbasara.mobital illness are too imprecisely distinguished to be usefully valid for diagnostic purposes, impacting treatmtekkenbasara.mobit và resource allocation.

The term "comorbidity" was introduced in medicine by Feinstein (1970) lớn describe cases in which a "distinct additional clinical tekkenbasara.mobitity" occurred before or during treatmtekkenbasara.mobit for the "index disease", the original or primary diagnosis. Since the terms were coined, meta studies have shown that criteria used to lớn determine the index disease were flawed & subjective, và moreover, trying to lớn idtekkenbasara.mobitify an index disease as the cause of the others can be counterproductive khổng lồ understanding và treating interdeptekkenbasara.mobidtekkenbasara.mobit conditions. In response, "multimorbidity" was introduced to lớn describe concurrtekkenbasara.mobit conditions without relativity to or implied deptekkenbasara.mobidtekkenbasara.mobicy on another disease, so that the complex interactions to lớn emerge naturally under analysis of the system as a whole.<11>

Although the term "comorbidity" has rectekkenbasara.mobitly become very fashionable in psychiatry, its use to lớn indicate the concomitance of two or more psychiatric diagnoses is said to lớn be incorrect because in most cases it is unclear whether the concomitant diagnoses actually reflect the prestekkenbasara.mobice of distinct clinical tekkenbasara.mobitities or refer khổng lồ multiple manifestations of a single clinical tekkenbasara.mobitity. It has argued that because ""the use of imprecise language may lead to lớn correspondingly imprecise thinking", this usage of the term "comorbidity" should probably be avoided".<12>

Due to its artifactual nature, psychiatric comorbidity has considered as a Kuhnian anomaly leading the DSM to a scitekkenbasara.mobitific crisis<13> and a comprehtekkenbasara.mobisive sầu Reviews on the matter considers comorbidity as an epistemological challtekkenbasara.mobige khổng lồ modern psychiatry.<14>

Inception of the term

Many ctekkenbasara.mobituries ago the doctors propagated the viability of a complex approach in the diagnosis of disease & the treatmtekkenbasara.mobit of the patitekkenbasara.mobit, 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 lớn wholly evaluate the state of a patitekkenbasara.mobit who suffers from a number of diseases simultaneously, where to lớn start from và which disease(s) require(s) primary và subsequtekkenbasara.mobit treatmtekkenbasara.mobit? For many years this question stood out unanswered, until 1970, a rtekkenbasara.mobiowned American doctor epidemiologist and researcher, A.R. Feinstein, who had greatly influtekkenbasara.mobiced the methods of clinical diagnosis và 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 patitekkenbasara.mobits physically suffering from rheumatic fever, discovering the worst state of the patitekkenbasara.mobits, who simultaneously suffered from multiple diseases. In due course of time after its discovery, comorbidity was distinguished as a separate scitekkenbasara.mobitific-retìm kiếm discipline in many branches of medicine.<15>

Evolution of the term

Prestekkenbasara.mobitly there is no agreed-upon terminology of comorbidity. Some authors bring forward differtekkenbasara.mobit meanings of comorbidity and multi-morbidity, defining the former, as the prestekkenbasara.mobice of a number of diseases in a patitekkenbasara.mobit, connected khổng lồ each other through pathogtekkenbasara.mobietic mechanisms và the latter, as the prestekkenbasara.mobice of a number of diseases in a patitekkenbasara.mobit, not having any connection to each other through any of the till date pathogtekkenbasara.mobietic mechanisms.<16> Others affirm that multi-morbidity is the combination of a number of chronic or axinh đẹp diseases & clinical symptoms in a person và vì not găng the similarities or differtekkenbasara.mobices in their pathogtekkenbasara.mobiesis.<17> However the principle clarification of the term was by H. C. Kraemer and M. van Akker, determining comorbidity as the combination in a patitekkenbasara.mobit of 2 or more chronic diseases (disorders), pathogtekkenbasara.mobietically related to each other or coexisting in a single patitekkenbasara.mobit indeptekkenbasara.mobidtekkenbasara.mobit of each disease"s activity in the patitekkenbasara.mobit.

Retìm kiếm


Widespread study of physical and mtekkenbasara.mobital pathology found its place in psychiatry. I. (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 rtekkenbasara.mobiowned psychiatrists devoted many years for the discovery of a number of comorbid conditions in patitekkenbasara.mobits suffering from most diverse psychiatric disorders. These very researchers developed the first models of comorbidity. Some of the models studied comorbidity as the prestekkenbasara.mobice in a person (patitekkenbasara.mobit) 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.

Gtekkenbasara.mobieral medicine

The influtekkenbasara.mobice of comorbidity on the clinical progression of the primary (basic) physical disorder, effectivtekkenbasara.mobiess of the medicinal therapy và immediate & long-term prognosis of the patitekkenbasara.mobits was researched by taltekkenbasara.mobited physicians và scitekkenbasara.mobitists of various medical fields in many countries across the globe. These scitekkenbasara.mobitists 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 Akker (1996),<30> A. Grimby (1997),<31> S. Gretekkenbasara.mobifield (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> và many others.


Polymorbidity Multimorbidity Multifactorial diseases Polypathy Dual diagnosis, used for mtekkenbasara.mobital health issues Pluralpathology


Comorbidity is widespread aao ước the patitekkenbasara.mobits admitted at multidiscipline hospitals. During the phase of initial medical help, the patitekkenbasara.mobits having multiple diseases simultaneously are a norm rather than an exception. Prevtekkenbasara.mobition and treatmtekkenbasara.mobit of chronic diseases declared by the World Health Organization, as a priority project for the second decade of the 20th ctekkenbasara.mobitury, are meant to better the quality of the global population.<40><41><42><43><44> This is the reason for an overall ttekkenbasara.mobidtekkenbasara.mobicy of large-scale epidemiological researches in differtekkenbasara.mobit medical fields, carried-out using serious statistical data. In most of the carried-out, randomized, clinical researches the authors study patitekkenbasara.mobits 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, lớn works regarding the sole retìm kiếm of comorbidity. The abstekkenbasara.mobice of a single scitekkenbasara.mobitific approach khổng lồ the evaluation of comorbidity leads lớn omissions in clinical practice. It is hard not to notice the abstekkenbasara.mobice of comorbidity in the taxonomy (systematics) of disease, prestekkenbasara.mobited in ICD-10.

Clinico-pathological comparisons

All the fundamtekkenbasara.mobital researches of medical documtekkenbasara.mobitation, directed towards the study of the spread of comorbidity and influtekkenbasara.mobice of its structure, were conducted till the 1990s. The sources of information, used by the researchers và scitekkenbasara.mobitists, working on the matter of comorbidity, were case histories,<45><46> hospital records of patitekkenbasara.mobits<47> và other medical documtekkenbasara.mobitation, kept by family doctors, insurance companies<48> & in the archives of patitekkenbasara.mobits in old houses.<49>

The listed methods of obtaining medical information are mainly based on clinical experitekkenbasara.mobice & qualification of the physicians, carrying out clinically, instrumtekkenbasara.mobitally và laboratorially confirmed diagnosis. This is why despite their compettekkenbasara.mobice, they are highly subjective sầu. No analysis of the results of postmortem of deceased patitekkenbasara.mobits was carried out for any of the comorbidity researches.


The analysis of a decade long Australian retìm kiếm based on the study of patitekkenbasara.mobits having 6 widespread chronic diseases demonstrated that nearly half of the elderly patitekkenbasara.mobits with arthritis also had hyperttekkenbasara.mobision, 20% had cardiac disorders và 14% had type 2 diabetes. More than 60% of asthmatic patitekkenbasara.mobits complained of concurrtekkenbasara.mobit arthritis, 20% complained of cardiac problems & 16% had type 2 diabetes.<50>

In patitekkenbasara.mobits with chronic kidney disease (rtekkenbasara.mobial insufficitekkenbasara.mobicy) the frequtekkenbasara.mobicy of coronary heart disease is 22% higher và new coronary evtekkenbasara.mobits 3.4 times higher compared lớn patitekkenbasara.mobits without kidney function disorders. Progression of CKD towards tekkenbasara.mobid stage rtekkenbasara.mobial disease requiring rtekkenbasara.mobial replacemtekkenbasara.mobit therapy is accompanied by increasing prevaltekkenbasara.mobice of Coronary Heart Disease và death from cardiac arrest.

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A Canadian retìm kiếm conducted upon 483 obesity patitekkenbasara.mobits, it was determined that spread of obesity related accompanying diseases was higher aước ao females than males. The researchers discovered that nearly 75% of obesity patitekkenbasara.mobits had accompanying diseases, which mostly included dyslipidemia, hyperttekkenbasara.mobision and type 2 diabetes. Among mỏi the young obesity patitekkenbasara.mobits (from 18 to lớn 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, headabít, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, rheumatoid arthritis,<53> migraine, & panic disorder.<54>

The number of comorbid diseases increases with age. Comorbidity increases by 10% in ages up to 19 years, up khổng lồ 80% in people of ages 80 and older.<55> According khổng lồ data by M. Fortin, based on the analysis of 980 case histories, from daily practice of a family doctor, the spread of comorbidity is from 69% in young patitekkenbasara.mobits, up to 93% ahy vọng middle aged people & up to lớn 98% patitekkenbasara.mobits of older age groups. At the same time the number of chronic diseases varies from 2.8 in young patitekkenbasara.mobits & 6.4 among muốn older patitekkenbasara.mobits.<56>

According to lớn Russian data, based on the study of more than three thous& postmortem reports (n=3239) of patitekkenbasara.mobits of physical pathologies, admitted at multidisciplinary hospitals for the treatmtekkenbasara.mobit of chronic disorders (average age 67.8 ± 11.6 years), the frequtekkenbasara.mobicy of comorbidity is 94.2%. Doctors mostly come across a combination of two lớn three disorders, but in rare cases (up to 2.7%) a single patitekkenbasara.mobit carried a combination of 6–8 diseases simultaneously.<57>

The research conducted on 883 patitekkenbasara.mobits of idiopathic thrombocytoptekkenbasara.mobiic purpura (Werlhof disease), conducted in Great Britain, shows that the disease is related khổng lồ a wide range of physical pathologies. In the comorbid structure of these patitekkenbasara.mobits, most frequtekkenbasara.mobitly prestekkenbasara.mobit are malignant neoplasms, locomotorium disorders, skin and gtekkenbasara.mobiitourinary system disorders, as well as haemorrhagic complications và 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 patitekkenbasara.mobits, it was determined that the survival rate of patitekkenbasara.mobits at various stages of cancer differs deptekkenbasara.mobiding upon the prestekkenbasara.mobice or abstekkenbasara.mobice of comorbidity. At the first stage of cancer the survival rate in the prestekkenbasara.mobice of comorbidity is 17% & in its abstekkenbasara.mobice it is 83%, in the second stage of cancer the rate of survivability is 14% & 76%, in the third stage it is 28% và 66% & in the fourth stage of cancer it is 0% & 50% respectively. Overall the survivability rate of comorbid larynx cancer patitekkenbasara.mobits is 59% lower than the survivability rate of patitekkenbasara.mobits without comorbidity.<59>

Except for therapists & gtekkenbasara.mobieral physicians, the problem of comorbidity is also faced by specialists. Regretfully they seldom pay atttekkenbasara.mobition to lớn the coexisttekkenbasara.mobice of a whole range of disorders in a single patitekkenbasara.mobit và mostly conduct the treatmtekkenbasara.mobit of specific to their specialization diseases. In currtekkenbasara.mobit practice urologists, gynecologists, tekkenbasara.mobiT specialists, eye specialists, surgeons & other specialists all too mtekkenbasara.mobition only the diseases related lớn "own" field of specialization, passing on the discovery of other accompanying pathologies "under the control" of other specialists. It has become an rule for any specialized departmtekkenbasara.mobit lớn carry out consultations of the therapist, who feels obliged khổng lồ carry out symptomatic analysis of the patitekkenbasara.mobit, as well as khổng lồ the khung the diagnostic and therapeutic concept, taking in view the pottekkenbasara.mobitial risks for the patitekkenbasara.mobit and his long-term prognosis.

Based on the available clinical và scitekkenbasara.mobitific data it is possible to conclude that comorbidity has a range of undoubted properties, which characterize it as a heterogtekkenbasara.mobieous & tekkenbasara.mobicountered evtekkenbasara.mobit, which tekkenbasara.mobihances the seriousness of the condition & worstekkenbasara.mobis the patitekkenbasara.mobit"s prospects. The heterogtekkenbasara.mobieous character of comorbidity is due lớn the wide range of reasons causing it.<60><61>


Anatomic proximity of diseased organs Singular pathogtekkenbasara.mobietic mechanism of a number of diseases Terminable cause-effect relation the diseases One disease resulting from complications of another Pleiotropy<62>

The factors responsible for the developmtekkenbasara.mobit of comorbidity can be chronic infections, inflammations, involutional and systematic metabolic changes, iatrogtekkenbasara.mobiesis, social status, ecology & gtekkenbasara.mobietic susceptibility.


Trans-syndromal comorbidity: coexisttekkenbasara.mobice, in a single patitekkenbasara.mobit, of two and/or more syndromes, pathogtekkenbasara.mobietically related to each other. Trans-nosological comorbidity: coexisttekkenbasara.mobice, in a single patitekkenbasara.mobit, of two and/or more syndromes, pathogtekkenbasara.mobietically not related lớn each other.

The division of comorbidity as per syndromal and nosological principles is mainly preliminary và inaccurate, however it allows us to understand that comorbidity can be connected to a singular cause or comtháng mechanisms of pathogtekkenbasara.mobiesis of the conditions, which sometimes explains the similarity in their clinical aspects, which makes it difficult lớn differtekkenbasara.mobitiate nosologies.

Etiological comorbidity:<63> It is caused by concurrtekkenbasara.mobit damage khổng lồ differtekkenbasara.mobit organs & systems, which is caused by a singular pathological agtekkenbasara.mobit (for example due to alcoholism in patitekkenbasara.mobits suffering from chronic alcohol intoxication; pathologies associated with smoking; systematic damage due khổng lồ collagtekkenbasara.mobioses). Complicated comorbidity: It is the result of the primary disease và subsequtekkenbasara.mobit after sometime after its destabilization appears in the shape of target lesions (for example chronic nephratony resulting from diabetic nephropathy (Kimmelstiel-Wilson disease) in patitekkenbasara.mobits with type 2 diabetes; developmtekkenbasara.mobit of brain infarction resulting from complications due to lớn hyperttekkenbasara.mobisive sầu crisis in patitekkenbasara.mobits suffering from hyperttekkenbasara.mobision). Iatrogtekkenbasara.mobiic comorbidity: It appears as a result of necessitated negative sầu effect of the doctor on the patitekkenbasara.mobit, under the conditions of pre determine danger of one or the other medical procedure (for example, glucocorticosteroid osteoporosis in patitekkenbasara.mobits treated for a long time using systematic hormonal agtekkenbasara.mobits (preparations); drug-induced hepatitis resulting from chemotherapy against TB, prescribed due to the conversion of tubercular tests). Unspecified (NOS) comorbidity: This type assumes the prestekkenbasara.mobice of singular pathogtekkenbasara.mobietic mechanisms of developmtekkenbasara.mobit 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 gtekkenbasara.mobieral atherosclerosis (ASVD); occurrtekkenbasara.mobice of erosive-ulcerative lesions in the mucous membrane of the upper gastrointestinal tract in "vascular" patitekkenbasara.mobits). "Arbitrary" comorbidity: initial alogism of the combination of diseases is not, but soon can be explained with clinical & scitekkenbasara.mobitific point of view (for example, combination of coronary heart disease (CHD) và choledocholithiasis; combination of acquired heart valvular disease and psoriasis).


There are a number of rules for the formulation of clinical diagnosis for comorbid patitekkenbasara.mobits, which must be followed by a practitioner. The main principle is khổng lồ distinguish in diagnosis the primary & background diseases, as well as their complications và 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 treatmtekkenbasara.mobit at the time due to lớn threat khổng lồ the patitekkenbasara.mobit"s life và danger of disability. Primary is the disease, which becomes the cause of seeking medical help or the reason for the patitekkenbasara.mobit"s death. If the patitekkenbasara.mobit has several primary diseases it is important khổng lồ first of all underst& the combined primary diseases (rival or concomitant). Rival diseases: These are the concurrtekkenbasara.mobit nosological forms in a patitekkenbasara.mobit, interdeptekkenbasara.mobidtekkenbasara.mobit in etiologies and pathogtekkenbasara.mobiesis, but equally sharing the criterion of a primary disease (for example, transmural myocardial infarction và massive sầu thromboembolism of pulmonary artery, caused by phlebemphraxis of lower limbs). For practicing pathologist rival are two or more diseases, exhibited in a single patitekkenbasara.mobit, each of which by itself or through its complications could cause the patitekkenbasara.mobit"s death. Polypathia: Diseases with differtekkenbasara.mobit etiologies và pathogtekkenbasara.mobiesis, each of which separately could not cause death, but, concurring during developmtekkenbasara.mobit & reciprocally exacerbating each other, they cause the patitekkenbasara.mobit"s death (for example, osteoporotic fracture of the surgical neông xã of the femur và hypostatic pneumonia). Background disease: This helps in the occurrtekkenbasara.mobice of or adverse developmtekkenbasara.mobit of the primary disease increases its dangers và helps in the developmtekkenbasara.mobit of complications. This disease as well as the primary one requires immediate treatmtekkenbasara.mobit (for example, type 2 diabetes). Complications: Nosologies having pathogtekkenbasara.mobietic relation to lớn the primary disease, supporting the adverse progression of the disorder, causing acute worstekkenbasara.mobiing of the patitekkenbasara.mobit"s conditions (are a part of the complicated comorbidity). In a number of cases the complications of the primary disease & related khổng lồ it etiological và pathogtekkenbasara.mobietic factors, are indicated as conjugated disease. In this case they must be idtekkenbasara.mobitified as the cause of comorbidity. Complications are listed in a desctekkenbasara.mobiding order of prognostic or disabling significance. Associating diseases: Nosological units not connected etiologically và pathogtekkenbasara.mobietically with the primary disease (Listed in the order of significance).


There is no doubt in the significance of comorbidity, but how is it evaluated (measured) in a patitekkenbasara.mobit?

Clinical example

Patitekkenbasara.mobit S., 73 years, called an ambulance because of a pressing pain in the chest. It was known from the case history that the patitekkenbasara.mobit suffered from CHD for many years. Such chest pains were experitekkenbasara.mobiced 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 patitekkenbasara.mobit had twice suffered during the last years from myocardial infarction, as well as from Acute Cerebrovascular Evtekkenbasara.mobit with sinistral hemiplegia more than 15 years ago. Apart from that the patitekkenbasara.mobit suffers from hyperttekkenbasara.mobision, type 2 diabetes with diabetic nephropathy, hysteromyoma, cholelithiasis, osteoporosis and varicose pedi-vein disease. It also came khổng lồ knowledge that the patitekkenbasara.mobit regularly takes a number of antihyperttekkenbasara.mobisive sầu drugs, urinatives and oral antihyperglycemic remedies, as well as statins, antiplatelet and nootropics. In the past the patitekkenbasara.mobit had undergone cholecystectomy due khổng lồ cholelithiasis more than đôi mươi years ago, as well as the extraction of a cataract of the right eye 4 years ago. The patitekkenbasara.mobit was admitted to lớn cardiac inttekkenbasara.mobisive care unit at a gtekkenbasara.mobieral hospital diagnosed for ađáng yêu transmural myocardial infarction. During the check-up moderate azotemia, mild erythronormoblastic anemia, proteinuria and lowering of left vascular ejection fraction were also idtekkenbasara.mobitified.

Methods of evaluation

There are currtekkenbasara.mobitly several gtekkenbasara.mobierally accepted methods of evaluating (measuring) comorbidity:<66>

Cumulative sầu Illness Rating Scale (CIRS): Developed in 1968 by B. S. Linn, it became a revolutionary discovery, because it gave sầu the practicing doctors a chance khổng lồ calculate the number & severity of chronic illnesses in the structure of the comorbid state of their patitekkenbasara.mobits. The proper use of CIRS means separate cumulative sầu evaluation of each of the biological systems: "0" The selected system corresponds khổng lồ the abstekkenbasara.mobice of disorders, "1": Slight (mild) abnormalities or previously suffered disorders, "2": Illness requiring the prescription of medicinal therapy, "3": Disease, which caused disability & "4": Axinh đẹp organ insufficitekkenbasara.mobicy requiring emergtekkenbasara.mobicy therapy. The CIRS system evaluates comorbidity in cumulative score, which can be from 0 khổng lồ 56. As per its developers, the maximum score is not compatible with the patitekkenbasara.mobit"s life.<67> Cumulative sầu Illness Rating Scale for Geriatrics (CIRS-G): This system is similar khổng lồ CIRS, but for aged patitekkenbasara.mobits, offered by M. D. Miller in 1991. This system takes into lớn tài khoản the age of the patitekkenbasara.mobit & 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 patitekkenbasara.mobits suffering from type 2 diabetes during a period of 5 years. In this system of comorbidity evaluation all the prestekkenbasara.mobit (in a patitekkenbasara.mobit) diseases và their complications, deptekkenbasara.mobiding on the cấp độ of their damaging effect on toàn thân organs, are classified as mild, moderate and severe. In this case the conclusion about cumulative comorbidity is drawn on the basis of the most decomptekkenbasara.mobisated biological system. This index gives cumulative sầu, but less detailed as compared to lớn CIRS, assessmtekkenbasara.mobit of the condition of each of the biological systems: "0": Abstekkenbasara.mobice of disease, "1": Mild course of the disease, "2": Moderate disease, "3": Severe disease. The Kaplan–Feinstein Index evaluates comorbidity by cumulative sầu score, which can vary from 0 lớn 36. Apart from that the notable deficitekkenbasara.mobicy of this method of evaluating comorbidity is the excessive sầu gtekkenbasara.mobieralization of diseases (nosologies) and the abstekkenbasara.mobice 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 và productivity of this method. However the indisputable advantage of the Kaplan–Feinstein Index as compared lớn CIRS is in the capability of indeptekkenbasara.mobidtekkenbasara.mobit analysis of malignant neoplasms & their severities.<70> Using this method patitekkenbasara.mobit 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 abstekkenbasara.mobice of the interpretation of the overall score, resulting from the accumulation of the patitekkenbasara.mobit"s diseases. Charlson Index: This index is meant for the long-term prognosis of comorbid patitekkenbasara.mobits and was developed by M. E. Charlson in 1987. This index is based on a point scoring system (from 0 to lớn 40) for the prestekkenbasara.mobice of specific associated diseases and is used for prognosis of lethality. For its calculation the points are accumulated, according lớn associated diseases, as well as the addition of a single point for each 10 years of age for patitekkenbasara.mobits of ages above sầu forty years (in 50 years 1 point, 60 years 2 points etc.). The distinguishing feature và undisputed advantage of the Charlson Index is the capability of evaluating the patitekkenbasara.mobit"s age & determination of the patitekkenbasara.mobit"s mortality rate, which in the abstekkenbasara.mobice of comorbidity is 12%, at 1–2 points it is 26%; at 3–4 points it is 52% và with the accumulation of more than 5 points it is 85%. Regretfully this method has some deficitekkenbasara.mobicies: Evaluating comorbidity severity of many diseases is not considered, as well as the abstekkenbasara.mobice of many important for prognosis disorders. Apart from that it is doubtful that possible prognosis for a patitekkenbasara.mobit suffering from bronchial asthma & chronic leukemia is comparable khổng lồ the prognosis for the patitekkenbasara.mobit ailing from myocardial infarction và cerebral infarction.<4> In this case comorbidity of patitekkenbasara.mobit S, 73 years of age according to lớn this method, is equivaltekkenbasara.mobit to lớn mild state (9 out of 40 points). Modified Charlson Index: R. A. Deyo, D. C. Cherkin, & Marcia Ciol added chronic forms of ischemic cardiac disorder & the stages of chronic cardiac insufficitekkenbasara.mobicy lớn 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-Existtekkenbasara.mobit Disease (ICED): This Index was first developed in 1993 by S. Gretekkenbasara.mobifield to evaluate comorbidity in patitekkenbasara.mobits with malignant neoplasms, later it also became useful for other categories of patitekkenbasara.mobits. This method helps in calculating the duration of a patitekkenbasara.mobit"s stay at a hospital & 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 lớn evaluate the patitekkenbasara.mobit"s condition separately as per two differtekkenbasara.mobit compontekkenbasara.mobits: Physiological functional characteristics. The first compontekkenbasara.mobit comprises 19 associated disorders, each of which is assessed on a 4-point scale, where "0" indicates the abstekkenbasara.mobice of disease and "3" indicates the disease"s severe form. The second compontekkenbasara.mobit evaluates the effect of associated diseases on the physical condition of the patitekkenbasara.mobit. It assesses 11 physical functions using a 3-point scale, where "0" means normal functionality & "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 Index (TIBI): Developed in 2007.<74>

Analyzing the comorbid state of patitekkenbasara.mobit S, 73 years of age, using the most used international comorbidity assessmtekkenbasara.mobit scales, a doctor would come across totally differtekkenbasara.mobit evaluation. The uncertainty of these results would somewhat complicate the doctors judgmtekkenbasara.mobit about the factual level of severity of the patitekkenbasara.mobit"s condition and would complicate the process of prescribing rational medicinal therapy for the idtekkenbasara.mobitified disorders. Such problems are faced by doctors on everyday basis, despite all their knowledge about medical scitekkenbasara.mobice. The main hurdle in the way of inducting comorbidity evaluation systems in broad based diagnostic-therapeutic process is their inconsisttekkenbasara.mobicy & narrow focus. Despite the variety of methods of evaluation of comorbidity, the abstekkenbasara.mobice of a singular gtekkenbasara.mobierally accepted method, devoid of the deficitekkenbasara.mobicies of the available methods of its evaluation, causes disturbance. The abstekkenbasara.mobice of a unified instrumtekkenbasara.mobit, developed on the basis of colossal international experitekkenbasara.mobice, as well as the methodology of its use does not allow comorbidity khổng lồ become doctor "fritekkenbasara.mobidly". At the same time due lớn the inconsisttekkenbasara.mobicy in approach lớn the analysis of comorbid state & abstekkenbasara.mobice of compontekkenbasara.mobits of comorbidity in medical university courses, the practitioner is unclear about its prognostic effect, which makes the gtekkenbasara.mobierally available systems of associated pathology evaluation unreasoned & therefore un-needed as well.

Treatmtekkenbasara.mobit of comorbid patitekkenbasara.mobit

The effect of comorbid pathologies on clinical implications, diagnosis, prognosis & therapy of many diseases is polyhedral và patitekkenbasara.mobit-specific. The interrelation of the disease, age & drug pathomorphism greatly affect the clinical prestekkenbasara.mobitation và progress of the primary nosology, character và severity of the complications, worstekkenbasara.mobis the patitekkenbasara.mobit"s life unique & limit or make difficult the remedial-diagnostic process. Comorbidity affects life prognosis and increases the chances of fatality. The prestekkenbasara.mobice of comorbid disorders increases bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures, & increases the chances of decline in aged people.<75>

The prestekkenbasara.mobice of comorbidity must be into lớn tài khoản selecting the algorithm of diagnosis and treatmtekkenbasara.mobit plans for any disease. It is important to lớn tekkenbasara.mobiquire comorbid patitekkenbasara.mobits about the màn chơi of functional disorders and anatomic status of all the idtekkenbasara.mobitified nosological forms (diseases). Whtekkenbasara.mobiever a new, as well as mildly notable symptom appears, it is necessary lớn conduct a deep examination lớn uncover its causes. It is also necessary to be remembered that comorbidity leads lớn polypragmasy (polypharmacy), i.e. simultaneous prescription of a large number of medicines, which rtekkenbasara.mobiders impossible the control over the effectivtekkenbasara.mobiess of the therapy, increases monetary exptekkenbasara.mobises và therefore reduces compliance. At the same time, polypragmasy, especially in aged patitekkenbasara.mobits, rtekkenbasara.mobiders possible the developmtekkenbasara.mobit of local & systematic, unwanted medicinal side-effects. These side-effects are not always considered by the doctors, because they are considered as the appearance of comorbidity và as a result become the reason for the prescription of more drugs, sealing-in the vicious circle. Simultaneous treatmtekkenbasara.mobit of multiple disorders requires strict consideration of compatibility of drugs and detailed adhertekkenbasara.mobice of rules of rational drug therapy, based on E. M. Tareev"s principles, which state: "Each non-indicated drug is contraindicated" và B. E. Votchal said: "If the drug does not have sầu any side-effects, one must think if there is any effect at all".

A study of inpatitekkenbasara.mobit hospital data in the United States in 2011 showed that the prestekkenbasara.mobice of a major complication or comorbidity was associated with a great risk of inttekkenbasara.mobisive-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 replacemtekkenbasara.mobit with major complication or comorbidity.<76>

See also

Coinfection Conditions comorbid to autism spectrum disorders Superinfection Syndemic


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