Multimorbidity: What do we know? What should we do?

Multimorbidity, which is defined as the co-occurrence of two or more chronic conditions, has moved onto the priority agenda for many health policymakers and healthcare providers. Patients with multimorbidity are high utilizers of healthcare resources and are some of the most costly and difficult-to-treat patients in Europe. Preventing and improving the way multimorbidity is managed is now a key priority for many countries, and work is at last underway to develop more sustainable models of care. Unfortunately, this effort is being hampered by a lack of basic knowledge about the aetiology, epidemiology, and risk factors for multimorbidity, and the efficacy and cost-effectiveness of different interventions. The European Commission recognizes the need for reform in this area and has committed to raising awareness of multimorbidity, encouraging innovation, optimizing the use of existing resources, and coordinating the efforts of different stakeholders across the European Union. Many countries have now incorporated multimorbidity into their own healthcare strategies and are working to strengthen their prevention efforts and develop more integrated models of care. Although there is some evidence that integrated care for people with multimorbidity can create efficiency gains and improve health outcomes, the evidence is limited, and may only be applicable to high-income countries with relatively strong and well-resourced health systems. In low- to middle-income countries, which are facing the double burden of infectious and chronic diseases, integration of care will require capacity building, better quality services, and a stronger evidence base. Journal of Comorbidity 2016;6(1):4–1

Implementing the european union global strategy: analysis of change in defence integration

The European Union is facing new geopolitical challenges that are much more complex than it was before. Old methods of tackling crisis and lack of cooperation do not allow to ensure security of European countries. Hybrid threats, cyber and terrorist attacks require joint action because the state alone cannot solve these security issues. Furthermore, the lack of stability in the world and a rising number of conflicts near the EU’s external borders make a situation even worse. The new EU Global strategy adopted in 2016 shows that there is a willingness to strengthen common security and defence policy. However, member states have to find a consensus and agree on how to implement their strategy. Almost three years have passed after the adoption of the strategy, but there is a lack of deeper analysis in which areas countries have made progress, what projects are falling behind schedule and what possible causes could explain different implementation progress. As a result, it is necessary to fill a research gap and assess what was achieved in defence integration field. As many political initiatives emerge, ongoing changes must be evaluated. It is unclear how has the European Union defence integration changed after the approval of Global strategy. Consequently, the purpose of this study is to scrutinize development taking place in the field of defence integration, to find out the implementation format of initiatives and the causes of smooth or failed realization. Several objectives were set for achieving this goal. First, the concept of neorealism theory was defined. Afterwards, a deductive method was used based on a systematic theory of security environment. The most important sources were reviewed and structured using qualitative content analysis. Lastly, the main initiatives and changes were identified. The research showed that there are three levels of change. Initially, changes in the international structure were observed. It indicates that the modification of great powers and decreased security in the region effect behaviour of member states. This situation encourages countries to seek self-help strategy. The need for Europe to assume greater responsibility, act autonomously, become a global actor is mention in the documents and reports. Changes in the international structure have an impact on the second factor – state-to-state interactions. Increasing threats increase the likelihood of potential agreements leading to the development of military technology (third factor). Approved common defence projects allow to develop balancing strategy and gain relative power at the global level. Member states are less inclined to apply relative benefit calculations, politicians try to find a compromise because security is one of the top priorities. Although countries are tended to strengthen common security and defence policy, initiatives that more restrict the choice of member states and significantly reduce sovereignty in the defence field do not receive an approval even when the security situation deteriorates. Research implies that international structure has changed the understanding of the EU role in the field of defence and security. Nevertheless, the development of common military capabilities in the EU format remains complicated and limited. The European Union is still seen as a source of soft power, therefore, policies are restricted to specific defence mechanisms. Projects directly increasing military power are more difficult to develop. In general, member states approve initiatives which are more flexible, inclusive and based on voluntary principals. Countries usually support defence policies when there is possibility to choose projects and the level of commitment. The study showed that the EU common security and defence policy remains concentrated on a broader concept of security by implementing research, development, prevention and stabilization measures

Swoiste, związane z wiekiem i płcią, cechy u pacjentów ze stanem majaczeniowym na oddziale intensywnej opieki kardiologicznej

Background: The overall evidence base regarding delirium has been growing steadily over the past few decades. There has been considerable analysis of delirium concerning, for example, mechanically ventilated patients, patients in the general intensive care unit (ICU) setting, and patients with exclusively postoperative delirium. Nevertheless, there are few studies regarding delirium in a cardiovascular ICU (ICCU) setting and especially scarce literature about the particular features of delirium relating to patient age and gender. Aim: We aimed to determine particular features of delirium not induced by alcohol or other psychoactive substances, relating to patient age and gender in an ICCU setting. Methods: An observational cross-sectional study was conducted to evaluate patients with delirium in a Lithuanian ICCU. From a sample of 19,007 ICCU admissions, 337 (1.8%) had documented delirium diagnosed through liaison and consultation with a psychiatrist and were included in the final analysis. The obtained data was then evaluated and analysed according to patients’ gender and four categorised age groups: < 65 years, 65–74 years, 75–84 years, and ≥ 85 years. Results: Female patients who experienced delirium demonstrated a higher prevalence of hypertension, hyponatraemia, heart failure, cardiac rhythm and conduction disorders, myocardial infarction (MI), and dementia. The men, who were on average seven years younger than the women, significantly more often had hypokalaemia, double- or triple-vessel coronary artery disease, and sepsis. Furthermore, MI, ST-segment elevated MI, and Killip class 4 were most frequent amongst patients less than 65 years of age. Moreover, the youngest patient group demonstrated the highest mortality. Conclusions: Our investigation presented a number of associated peculiarities related to gender and age. It was shown that delirium is a severe complication that more often affects men amongst patients < 65 years old and more frequently affects women in the age group of ≥ 85 years. Male patients < 65 years old, who develop delirium should be treated with more caution because they tend to have more serious forms of disorder and a poorer prognosis.Wstęp: W ostatnich latach wzrosła liczba danych naukowych odnoszących się do stanu majaczeniowego (delirium). Przeprowadzono znaczące analizy delirium obejmujące na przykład pacjentów poddawanych mechanicznej wentylacji, przebywających na ogólnym oddziale intensywnej opieki medycznej (OIOM) i chorych, u których stan majaczeniowy występował wyłącznie w okresie pooperacyjnym. Niemniej niewiele jest badań dotyczących stanu majaczeniowego u pacjentów oddziału intensywnej opieki kardiologicznej (OIOK), a zwłaszcza brakuje prac na temat szczególnych cech stanu majaczeniowego w odniesieniu do wieku i płci chorych. Cel: Badanie przeprowadzono w celu ustalenia szczególnych właściwości substancji niealkoholowych i innych substancji o działaniu psychoaktywnym wywołujących delirium w odniesieniu do wieku i płci pacjentów przebywających na OIOK. Metody: Obserwacyjne badanie przekrojowe przeprowadzono w celu oceny pacjentów w stanie majaczeniowym hospitalizowanych na OIOK na Litwie. W próbie liczącej 19 007 przyjęć na OIOK było 337 (1,8%) chorych z udokumentowanym rozpoznaniem stanu majaczeniowego (poprzez współpracę i konsultacje z psychiatrami), których włączono do końcowej analizy. Uzyskane dane oceniano i analizowano w odniesieniu do płci chorych oraz czterech grup wiekowych: < 65 lat, 65–74 lat, 75–84 lat i ≥ 85 lat. Wyniki: U kobiet, u których występował stan majaczeniowy, częściej stwierdzano nadciśnienie tętnicze, hiponatremię, niewydolność serca, zaburzenia rytmu serca i przewodzenia, zawał serca (MI) oraz demencję. Natomiast u mężczyzn, których średnia wieku była o 7 lat wyższa niż u kobiet, istotnie częściej występowały hipokaliemia, dwu- lub trójnaczyniowa choroba wieńcowa oraz posocznica. Dodatkowo MI, MI z uniesieniem odcinka ST oraz IV klasa wg klasyfikacji Killipa występowały dużo częściej u chorych w wieku poniżej 65 lat. Ponadto w najmłodszej grupie pacjentów śmiertelność była najwyższa. Wnioski: W niniejszym badaniu zaobserwowano wiele szczególnych cech związanych z płcią i wiekiem. Wykazano, że stan majaczeniowy jest ciężkim powikłaniem, które dotyczy częściej mężczyzn niż kobiet w grupie chorych w wieku poniżej 65 lat, natomiast w grupie osób w wieku 85 lat i starszych częściej występuje u kobiet. Mężczyzn poniżej 65 lat, u których rozwinął się stan majaczeniowy, należy traktować ze szczególną uwagą, ponieważ ta grupa charakteryzuje się większym ryzykiem ciężkiego przebiegu choroby i gorszym rokowaniem

Identifying differential miR and gene consensus patterns in peripheral blood of patients with cardiovascular diseases from literature data

Abstract Background Numerous recent studies suggest the potential of circulating MicroRNAs (miRs) in peripheral blood samples as diagnostic or prognostic markers for coronary artery disease (CAD), acute coronary syndrome (ACS) and heart failure (HF). However, literature often remains inconclusive regarding as to which markers are most indicative for which of the above diseases. This shortcoming is mainly due to the lack of a systematic analyses and absence of information on the functional pathophysiological role of these miRs and their target genes. Methods We here provide an-easy-to-use scoring approach to investigate the likelihood of regulation of several miRs and their target genes from literature by identifying consensus patterns of regulation. We therefore have screened over 1000 articles that study mRNA markers in cardiovascular and metabolic diseases, and devised a scoring algorithm to identify consensus means for miRs and genes regulation across several studies. We then aimed to identify differential markers between CAD, ACS and HF. Results We first identified miRs (miR-122, −126, −223, −138 and −370) as commonly regulated within a group of metabolic disease, while investigating cardiac-related pathologies (CAD, ACS, HF) revealed a decisive role of miR-1, −499, −208b, and -133a. Looking at differential markers between cardiovascular disease revealed miR-1, miR-208a and miR-133a to distinguish ACS and CAD to HF. Relating differentially expressed miRs to their putative gene targets using MirTarBase, we further identified HCN2/4 and LASP1 as potential markers of CAD and ACS, but not in HF. Likewise, BLC-2 was found oppositely regulated between CAD and HF. Interestingly, while studying overlap in target genes between CAD, ACS and HF only revealed little similarities, mapping these genes to gene ontology terms revealed a surprising similarity between CAD and ACS compared to HF. Conclusion We conclude that our analysis using gene and miR scores allows the extraction of meaningful markers and the elucidation of differential pathological functions between cardiac diseases and provides a novel approach for literature screening for miR and gene consensus patterns. The analysis is easy to use and extendable upon further emergent literature as we provide an Excel sheet for this analysis to the community

Daily heart rate variability indices in subjects with and without metabolic syndrome before and after the elimination of the influence of day‐time physical activity

Background and Objectives: The available research shows conflicting data on the heart rate variability (HRV) in metabolic syndrome (MetS) subjects. The discrepancy suggests a methodical shortcoming: due to the influence of physical activity, the standard measuring of HRV at rest is not comparable with HRV assessment based on 24h Holter monitoring, which is preferred because of its comprehensiveness. To obtain a more reliable measure and to clarify to what extent HRV is altered in MetS, we assessed a 24h HRV before and after the elimination of the influence of physical activity. Materials and Methods: We investigated 69 metabolic syndrome (MetS) and 37 control subjects, aged 50–55. In all subjects, 24h monitoring of electrocardiogram, blood pressure, and actigraphy profiles were conducted. To eliminate the influence of day-time physical activity on RR intervals (RRI), a linear polynomial autoregressive model with exogenous terms (ARX) was used. Standard spectral RRI analysis was performed. Results: Subjects with MetS had blunted HRV; the diurnal SDNN index was reliably lower in the MetS group than in control subjects. The elimination of the influence of physical activity did not reveal a significant HRV change in long-term indices (SDNN, SDANN, and SD2), whilst adjacent RRI values (RMSSD, pNN50, and SD1) and SDNN index significantly increased (p < 0.001). An increase in the latter indices highlighted the HRV difference between the MetS and control groups; a significant (p < 0.001) decrease of all short-term HRV variables was found in the MetS group (p < 0.01), and low-frequency spectral components were less pronounced in the MetS group. Conclusion: The application of a polynomial autoregressive model in 24h HRV assessment allowed for the exclusion of the influence of physical activity and revealed that MetS is associated with blunted HRV, which reflects mitigated parasympathetic tone