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Rheumatic Patient and His Clinical “Portrait”

Khanov A.G. Treatment of the “modern” rheumatic patient is impossible without taking into account the associated pathology by the specific patient , i.e. his COMORBIDITY. The term “comorbidity” (C) by itself can be literally translated as “associated/related diseases existing in a single patient”. Currently there are a few terms to identify an associated pathology by a particular patient. The following terms are synonymous – “multimorbidity′”, “polymorbidity′”, “polypathia”. In the terms of medical encyclopedic dictionary: comorbidity (LAT. co–  a prefix with meaning “with-, together” , morbus means a disease) is a coexistence  in a single patient of two or more syndromes (trans-syndromal C) or (trans-nosological C), pathogenetically interrelated or synchronous  (chronological C). We have analyzed the associated pathology by rheumatic patients treated at the rheumatology department of a polyclinic,  to make up a overall characteristic of the clinical situation. Associated pathology  was estimated taking into account the sex of the patients, both in aggregate and for individual diseases. The received data was to be used for the further selection of individual treatment within the standards, determining the need for laboratory diagnostic methods of medical examination, attracting doctors-medical consultants, ensuring the patient with medicaments for treatment of the associated pathology and calculation the real costs connected with the maintenance of rheumatology department of a polyclinic. 889 stories were randomly selected (representing 22% of total amount) of 3458 patients treated at the  rheumatology department of RH  (regional hospital) for 3 years. The distribution of patients by years amounted to: 1st year of treatment 251, 2nd year -318; 3rd year-320. The results of analysis of clinical records of the first two years of treatment are presented in the form of tables. The results of the third year of treatment repeat the first two years, for which reason we decided not to publish them. In addition to  nosological forms of various associated diseases, the following syndromes were additionally marked : metabolic, cardiac insufficiency of varying degrees of severity (without specifying the etiologic causes), arrhythmic. We have taken into account the existence of sites of infection. A number of diseases due to the small number of cohort of patients by whom they occurred, were united into one group, numbering several dozens of nosological forms of diseases. Explanation. Analysis of clinical records of rheumatology department of the polyclinic was carried out in conditions of real medical practice, without setting for a special search for related pathology by rheumatic patients, but in view of the progressing clinical situation. It should be noted that, to date the related pathology is not included into the statistics on comorbidity, and  related pathology treatment at a specialized department shall not be subject to payment by insurance companies. The “human factor” is also playing the role, when the doctor decides to include the comorbidity into a clinical diagnosis or only indicate it in the anamnesis of the patient’s life. The structure of associated diseases in general by stationary patients during the first year of treatment is presented in Figure 1. Fig. 1 Structure of associated diseases by rheumatic patients during the first year of treatment Thus, by 251st rheumatological patient of the first-year of treatment   749 comorbidities have been revealed. By the first year patients the  AH (arterial hypertension) heads the list on the frequency of comorbidities. The following 60 nosological forms are grouped into a one, due to a small number of contingents of patients: MVP (mitral valve prolapse), osteochondrosis, colitis, NCA (neurocirculatory asthenia), pancreatitis, anemia, bronchocele, BA (bronchial asthma), the CCC (chron. calculous cholecystitis), cachexia, C (cholecystitis), solitary kidney, lung resection, hepatitis, 12-peptic  ulcer, drug allergy, CHD (congenital heart disease),  gallbladder polyp, paraproctitis, foot apostem,  acute pneumonia, shin phlegmon , toxicodermia, hypothyroidism, pericardial effusion, ischemic heart disease: progressive cardiac angina, lung heart, adhesive pleuritis, aortic aneurysm, obliterating atherosclerosis, CABG (сoronary artery bypass surgery), allergic rhinitis, umbilical hernia, congenital clubfoot, ARVI, APS (antiphospholipid syndrome), neuropathy, prostate adenoma, prostatitis, arachnoiditis, CKF (chron. kidney failure), thrombocytopenia, aseptic necrosis, breast cancer, thyrotoxicosis, deep vein thrombosis, hip osteosynthesis,  ACVI (acute cardiovascular insufficiency), pregnancy, kraniotomia to remove the brain tumor, multiple bronchiectasis, ruptured sinusitis, septic wounds of shin , psoriasis, DGN (diffuse glomerulonephritis), cyst of the liver, pharyngitis, bacteriuria. In a view of sex the total number of associated pathologists by women-514 (69%), men- 235(31%) . The approximate interrelation by this indicator W:M is 2:1. Based on the analysis of related pathology by W with rheumatic diseases  (see fig. 2) a conditional “woman portrait” of the rheumatic patient can be drawn up . This is a woman patient with metabolic syndrome, excess weight, arterial hypertension, associated atherosclerotic cardiosclerosis, resulting in the development of  various stages of CHF, atherosclerotic lesion of large vessels and arrhythmia. Blood supply to the joints of the lower limbs is  compounded by varicose disease with CVI and the risk of tromboembolie. At the same time there is a systemic osteoporosis with risk of fatal fractures. The situation is aggravated by the presence of site of infection in the kidneys. A group of 45 united nosological forms by W includes: DEP, mitral valve prolapse, osteochondrosis, pancreatitis, anemia, bronchocele, BA, COPD (chronic obstructive pulmonary disease.), colitis, NCA, USD (urinary stone disease), CCC (chron. calculous cholecystitis), cachexia, C (cholecystitis), lung resection, hepatitis, 12-peptic  ulcer, drug allergy,   gallbladder polyp, toxicodermia, hypothyroidism, aortic aneurysm,  allergic rhinitis, umbilical hernia,  ARVI, arachnoiditis,  thrombocytopenia, aseptic necrosis, breast cancer, thyrotoxicosis, deep vein thrombosis, hip osteosynthesis,  ACVI (acute cardiovascular insufficiency), pregnancy, kraniotomia to remove the brain tumor, multiple bronchiectasis, ruptured sinusitis, septic wounds of shin , psoriasis, DGN, CAD: cardiac angina, cyst of the liver, pharyngitis, bacteriuria. Fig. 2 Structure of associated diseases by  rheumatic diseases of women during the first year of treatment Structure of related pathology by M with rheumatic diseases  (rheumatism) is presented in Figure 3. Figure. 3 Structure of associated diseases by  rheumatic diseases of men during the first year of treatment Sufficient treatment cohort also allows to create a conditional “man portrait” of Russian rheumatic patient. This is a man with expanded cardio continuum, arterial hypertension, atherosclerotic lesions of the heart with symptoms of heart failure, excess weight and metabolic syndrome, atherosclerotic lesion of large vessels. Heart failure is compounded by respiratory failure in connection with COPD. A group of 36 united nosological forms by M includes: DEP, varicosity with CVI, kidney cysts, diabetes mellitus, MVP, myocardium sclerosis, isolated cases of OP, PIX, anemia, CGD, IBC, cachexia, solitary kidney, hepatitis, 12-peptic  ulcer, CHD, paraproctitis, foot apostem,  acute pneumonia, shin phlegmon, pericardial effusion, pulmonary heart disease, lung heart, adhesive pleuritis, aortic aneurysm, obliterating atherosclerosis, CABG, congenital clubfoot, APS, neuropathy, prostate adenoma, prostatitis, CKF (chron. kidney failure). For the purpose of calculation of the comorbidity index (CI) in general for 1 patient and for 1 patient  taking into account the gender and rheumatological diagnosis, we have carried out the analysis of associated pathology by the stationary rheumatic patients during the second year of treatment (fig. 4). Fig. 4 Structure of associated diseases by  rheumatic patients of both genders during the second year of treatment The ratio of the number of related diseases by W:M – 2:1 is remarkable.   543 related diseases (67%) are recorded by W, and 263 (33%) – by M. In general, the “set” of major comorbidity diagnoses repeats the data of the first year of treatment. The group of united nosologies has a large number of diseases: 76 vs 60. It includes 241 patients with the following diseases: Diabetes mellitus, MVP, osteochondrosis, myocardium sclerosis, OP, colitis, NCA, PIX, pancreatitis, cholecystectomy, Raynaud’s syndrome, anaemia, scoliosis, bronchocele,  post-injection abscess, CGD, BA, renal anomalies, USD, nephroptosis, CCC, cachexia, C (cholecystitis), esophageal hernia, solitary kidney, lung resection, hepatitis, 12-peptic  ulcer, lipoma, drug allergy,  CHD,intestinal polyp, episyndrome, Pelger-Huet anomaly, cystitis,   replacement arthroplasty, trophic ulcer, atheroma ,  ganglion, purulent bursitis, residual effects of tuberculosis, leukemoid response, policitemia, Seborrhea, toxicodermia, hypothyroidism, EN (Erythema Nodosum),   agammaglobulinemia, acute bronchitis, thyroiditis, pericardial effusion, chondromatosis, Prurigo, aortic aneurysm, obliterating atherosclerosis, hygroma, allergic rhinitis, inguinal hernia, fractured ribs, ARVI, foreign body in a lung, onychodystrophy, urine acid diathesis, infected tophi wounds, Dupuytren’s contracture, localized skleroderma, prostatitis, myasthenia, osteomyelitis, kidney cancer, skin angiomatosis, hemorrhoid, arachnoiditis, atrophy of the optic nerves, CKD. Structure of related diseases by M and F with rheumatic diseases during second year of treatment are presented in Figure 5 and Figure 6. Figure. 5 Structure of associated diseases by  rheumatic diseases of women (second year of treatment) Figure. 6 Structure of associated diseases by  rheumatic diseases of men (second year of treatment) Statistics on comorbidity in many respects “echoes” with data of the first year of treatment, but additionally discloses suggestions in improvement medical care at the pre-hospital stage. So, associated pathology can be detected for the first time during the patient’s hospitalization.   On the other hand, in presence of a medical history, rheumatic patients already being treated in the hospital, insist on consultations of specialized professionals. Comorbidity analysis enabled to calculate the CI on gender in all nosological forms of rheumatic disease by inpatients. The highest rate of CI by men with rheumatic diseases is 4.6 diseases per 1 patient; the smallest rate with rheumatic diseases- -2.0. There is no point in viewing the CI rates in periodic disease, Reiter’s disease, secondary arthropathy and paraneoplastic disease statistically due to  the small number of  treatment groups and the severity of the prognosis of the main disease. Women have  the highest CI by aortic stenosis (5.0), low CI by G (gout) (0.7). Total CI rates by stationary rheumatic patients on particular nosology, in view of gender, according to the data of first year treatment are presented in Figure 7, the second year data – Fig. 8. In general a rheumatic patient being hospitalized  has 2.6 related diseases. Fig. 7 Comorbidity index by rheumatic patients with various nosological forms of patients in a view of gender (data of first year of treatment) Fig. 8 Total comorbidity index by rheumatic patients with various nosological forms (second year of treatment) Conclusions/proposals. To provide medical assistance at the hospital stage it is necessary to estimate the comorbidity among the most commonly hospitalized forms of  rheumatic diseases (in our observations it is rheumatoid arthritis, arthropathy deformans, aortic stenosis, gout, and various seronegative spondyloarthropathies). According to our data, the greatest number of associated diseases occurred by patients with arthropathy deformans (4.2). Then go rheumatoid arthritis and aortic stenosis -3.6 diseases per 1 patient. Among the other nosologies of rheumatic diseases both among frequent illnesses, and in small treatment groups the rate has changed from 3 to 2. Record of clinical situation, in general, allows the doctor to choose the main directions and stages of  treatment of the rheumatic patient and to some extent avoid polypragmasy. It is preferably at the pre-hospital stage to offer consultations the rheumatic patients of certain age your by cardiologist, endocrinologist, neurologist, urologist, even when there are no complaints at the time of examination. Particular attention should be paid to estimation of the risk of death from cardiovascular diseases, taking into account the existing tables, such as, for example, the SCORE. This is necessary in case of  critical general condition of the patient to determine the profile of the hospital, in a stable condition – to prevent complications of cardiac diseases. Nowadays the medicine is widely invaded by processes of IT management in the frame of which the national registers of rheumatic patients are being organized. At the same time, there are no individual programs for a particular patient except for a standard medical documentation. To improve the efficiency and reliability of individual medical information we propose a medical passport for rheumatic patients. It can be executed in hard copy, in electronic version, or recorded on a plastic card. A medical passport of rheumatic patient can contain the passport section, warning notes, dispensary observation data and information on related diseases with dates on which they were identified. As a basis of medical passport were taken the records of USSR health care on maintaining the medical documentation in conditions of work with millions of people, including significant territorial distances, a great amount of hospitals from medical ambulant clinics and rural district hospitals to polyclinics for more than 1000 beds. Sections of the passport and their content may be modified, depending on local conditions. But we consider it necessary to introduce into the passport the “just” rheumatic data on treatment, namely GIBP (genetically engineered biological preparations), basic and disease-modifying drugs (a list of which can be negotiated), as well as programmed treatment of osteoporosis. A new account form, unequivocally, will at first cause the negativity among the health workers who in conditions of Russian health care are overwhelmed by the maintenance of paper medical records with its excessive information, which transforms the treatment process into “paper medicine” which is far from real medical practice, and most important is that it wastes the “precious” time of the doctor, to the detriment of the communication with the patient and his examination. A medical passport of rheumatic patient answers the expectations of the  patients, some of which  long before by themselves, in any form, have described what happens with them, records on treatment at medical institutions, the results of the basic examinations, printed such records, and given to their doctor. The initial time expenditures for filling the medical passport “will pay for itself” by increase of the reliability of health information, simplification of the anamnesis, when it is possible to insert a copy of anamnesis into a medical card, strengthening the relations between the doctor and the patient, the increase of patient’s adherence to treatment  improving of continuity of work of various medical preventive institutions. Passport of rheumatic patient definitely does not replace the traditional communication of the patient and the doctor in real time.