The review characterizes the features of modern human pathology and is dedicated to the phenomenon of comorbidity, or syntropy - multiplicity, or coexistence of two or more diseases in one patient. The review summarizes and systematizes modern ideas about the comorbidity, introduces the most important aspects of this problem underlying - epidemiological, clinical, medical and economic, genetic, and acquainted with the concept of distrek, or back comorbidity. Among the numerous aspects of comorbidity, its clinical and utility value is paid to the greatest attention, in particular the markerity of this phenomenon, as well as the most important pathogenetic mechanisms that can determine the development of both syntropy and distrect. Among the pathogenetic comorbidity mechanisms, systemic inflammation, oxidative stress, mesenchymal dysplasia, molecular genetic mechanisms with the involvement of common signal pathways of the cell, as well as the value of the comorbidity in individual types of pathology, in particular cardiovascular and oncopathology are considered.

comorbid

mechanisms of pathogenesis

clinical and commonplace

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The most important features of modern human pathology include the predominance of chronic diseases, the genesis of which has a predominantly multifactorial nature, the predominance of diseases that differ in the systemicity of the lesion (atherosclerosis, diabetes mellitus, diseases of the connecting tissue system, etc.), as well as a comorbidity, or coexistence of several people. Two or more diseases. All this causes the complexity of diagnosis, treatment, rehabilitation, prevention (there is no one causal factor or risk factor) and the forecast of the main types of pathology.

At the same time, an individual approach to the patient (personalization of treatment) dictates the need for a deep understanding of the genesis of the main and related diseases, their causal and pathogenetic communications, their integrated diagnosis and rational treatment.

The term "comorbid" (from Lat. sO - together morbus. - The disease) was proposed in 1970 by the American researcher of the epidemiology of noncommunicable diseases A. Finestein, who understood the additional clinical conditions, already existing or arising against the background of the current disease and always differ from it. As the synonyms of "comorbidity" also use "polypatology" and "multi" - or "polymorbidity", although the discussion on various interpretations of these terms continues.

Epidemiological data on the prevalence of comorbidity vary significantly and significantly depend on the parameters of the sample (patients of a general practice doctor or a specialized clinic, sex of patients, age, commitment to various disease classifiers), but overall an increase in the frequency of comorbidity with age, especially in women. Thus, the number of coexisting diseases in young on average is 2.8, in older people - 6.8. The frequency of occurrence of the phenomenon of comorbidity is 69% in patients aged 18-44 years, reaches 93% in patients of 45-64 years and 98% of persons over 65 years. The most significant (92%) share of patients with comorbidity is detected among patients with chronic heart failure (CHF), and the most common combinations of disease include a combination of diabetes (SD), osteoarthritis (-Arthritis) and coronary heart disease (IBS), and Also arterial hypertension (AG), obesity and hyperlipidemia (ch). At the same time, comorbidity cannot be described using several simple combinations of diseases, which also do not reflect differences in the severity of the state, influence on the level of physiological and mental functions, disability. We cannot answer, for example, to the question - as in the coexistence, each of the patients of three diseases of the patient IBS, AG and SD 2 type differ from the patient with chronic diseases of the lungs, arthritis and depression.

The phenomenon of comorbidity is like multipleness, or coexistence of two or more diseases in one patient, is widely investigated at present from various positions - epidemiological, clinical, medical and economic, genetic, various indices are proposed for its assessment. Charlson Index (CHARLSON INDEX) is used to predict mortality, cumulative disease rating scale (Cumulative Illness Rating Scale) evaluates all organism systems without specific diagnoses, the index of the combined disease (Index of Coexisting Disease) takes into account the severity of the disease and disability. At the same time, the main purpose of these indices is an assessment of the ratio of the number of coexisting diseases with economic costs of health.

The presence of several chronic diseases in one patient is associated with a decrease in the quality of life, psychological distress, long-term hospitalication, an increase in the frequency of postoperative complications and high mortality, as well as a high cost of medical care. Comorbidity should be taken into account when organizing the system itself medical care, and above all, in order to avoid fragmentation of this assistance both in clinical practice and in the health policy.

The most important direction, including allowing to understand the aspects of the comorbidity listed above, is, in our opinion, the study of its biological essence and utility values. The comorbidity cannot be understood as the sum, or the result of the addition of a particular number of diseases and automatic weighting of the patient's condition, probably the laws of the formation of human pathology and the essence of the disease that remains to be studied and understand.

Since we are interested in the unfortunate aspect of comorbidity, then in many respects of the arbitrary interpretation of this phenomenon, when individual nosological forms with systemic manifestations of (one) disease or complications are also included in a number of publications; SD (systemic manifestations and complications of which are interpreted as comorbidity), atherosclerosis, diseases of the connective tissue, more precisely, in our opinion, the essence of the disease reflects the term "syntropy", although in many works a sign of equality between "syntropy" and "comorbidity" is set. This is also important because, in addition to the utility of the comorbidity, its clinical value as a whole, there is another important aspect of this phenomenon - its marker, or the badness of individual combinations of diseases, which we will further talk about, but it is in this context that the concept of syntropy turns out to be more accurate.

So, there are three forms of disease coexistence: comorbidity, or syntropy; "Reverse comorbidity", or distropy; The comorbidity of Mendelian and multi-factor diseases.

The concept of syntropy ("mutual tendency," attraction "of two and more diseases in one person) is proposed by the German pathologists by M. Pfaunder and L. Zhtto before the emergence of the term" comorbidity ". The authors immediately indicated not only on the connection of syntropy with the common factors acting, but also the peculiarities of the response of the body, which were associated with the concept of diathesis (the special conditions of the body, characterized by the propensity of certain groups of diseases), later integrated into the doctrine of human constitution and teaching On mesenchymal dysplasia, or systemic connective tissue dysplasia (DST).

Syntropy is the type of polypatology, in which the diseases are "stretching" to each other, seek to connect or prepare the conditions one for another. At the heart of syntropios, or naturally frequent combinations of certain diseases, it is possible to identify the community of etiological factors or pathogenetic mechanisms. Distropy, on the contrary, understand a rare or even impossible combination of certain diseases. Thus, such syntropias such as hypertensive disease (GB) and atherosclerosis, SD and atherosclerosis, in which the relationship between diseases is well understood is widely known. There is, for example, a rare combination of pulmonary tuberculosis with mitral stenosis, which is explained by the adverse effects of chronic hypoxia on the tuberculosis mycobacteria, which are aerobs. Rarely combined lung cancer and bronchial asthma.

The mechanisms for the formation of nosological syntropions are diverse and among them the special place is occupied by hereditary anomalies or diseases with hereditary predisposition, often this, as already noted, numerous variants of mesenchymal dysplasia, or DST. Universal pathophysiological mechanisms and developing utility processes (chronic inflammation, dystrophy, impaired blood and lymphorty, etc. are played in the most important role in the formation of comorbidity. On the one hand, the study of most syntropy is limited to a phenotypic level and is characterized by a disadvantage of the knowledge of their structural-genetic bases, on the other - the phenotypic level of research is of great practical importance, as it is fundamentally important in detecting certain diseases to diagnose characteristic syntropy (syntropy marking).

One of the well-known syntropy includes metabolic syndrome - interrelated hypertension, hypercholesterolemia, insulin resistance and obesity, which is often joined by choletiasis, gout and urine-free diathesis. In the origin of the metabolic syndrome, the value of deviations from the normal level of metabolic and enzymological (enzymological) status of the body, the constitutional-acrcentage factor (the constitution is just associated with the features of enzymatic metabolic status), lifestyle factors. In numerous works, the connection of abdominal obesity with insulin resistance and a number of hormoneal and metabolic disorders, which turn out to be, in turn, the risk factors for the development of atherosclerosis, cardiovascular diseases (CVD) and type 2 types 2 are proved. The phenotype of manifestations of metabolic syndrome depends on the ratio of genetic factors and factors of the external environment, but its obligatory component is insulin resistance.

One of the current health problems is a combination of chronic obstructive lung diseases (COPD) and CVD due to a high level of disability, mortality and budgetary load. In some works, it is shown that chronic inflammation in respiratory tract It is the predictor of the risk of IBS, regardless of other cardiovascular risk factors. Thus, a decrease of 10% of the forced exhalation in 1 second increases the risk of cardiovascular mortality by 28%, and non-infamous coronary events - by 20%, while the problem of adequate use of β-blockers in patients with IBS, since their long-term reception It may worsen the indicators of the function of external respiration, which means to increase the cardiovascular risk.

Currently confirmed the relationship between the effects of aircrafttutants, chronic inflammation in the respiratory tract, chronomic and progression of atherosclerosis through the development of systemic inflammatory reaction - Increased in the systemic blood flow of pro-inflammatory cytokines (CC) - factor of necrosis of the alpha tumor (TNF ɑ), interleukin (IL) 6, IL 8, IL 1β. Understanding the pathogenetic bases of atherogenesis during COPD (admission to the systemic blood flow of pro-inflammatory CC, the strengthening of systemic oxidative stress, the development of endothelial dysfunction, activation of matrix metalloproteinases) led to a decrease in cardiovascular mortality in this category of patients through the use of statins and anti-inflammatory drugs.

The inverse dependence is also noted - the effect of CVD on the development of the exacerbations of COPD, especially in the presence of heart rate disorders (high risk and non-hydrogen-induced arrhythmias when using high doses of armored aircraft, β2 agonists). All of the above creates a picture of a peculiar vicious circle of mutual influence of these diseases in their coexistence, or comorbidity.

A certain conjugacy was noted between HSN and oncological diseases, it was established that the risk of developing cancer in patients with HSN is 68% higher than those without insufficiency of blood circulation. The causes of such a conjugacy may be associated, on the one hand, with a more thorough examination of this category of patients, on the other, with the carcinogenic effect of cardiotropic drugs (inhibitors of angiotensin-sparing enzyme, angiotensin receptor blockers, calcium channel blockers), risk factors (chronic tissue hypoxia, systemic Inflammatory response as the most important link of Pathogenesis of HSN). Such coexistence is also relevant due to the similarities of many clinical manifestations CHF and oncological diseases (the appearance of edema, shortness of swelling, pleural effusion, cyanosis, anemia). The comorbidity in this case determines not only differential diagnostic difficulties, but also a question about the possibility of the existence of the causal relationship of these diseases. It is known that HSN is characterized by hyperactivation immune system, manifested in increased expression of the pro-inflammatory CC not only in the myocardium of the left ventricle, but also by systemic blood flow, as well as the high level of formation of free radicals of oxygen and nitrogen capable of providing a genotoxic effect.

The final stages of chronic diseases of the kidneys are also associated with an increased frequency of cancer development of various localizations, which can be explained by the weakening of the immune system in chronic infection and disruption of DNA repair.

The comorbidity in oncology has a great clinical significance. Studying the causes of death According to the results of pathologists, it shows that only in one case of five it is limited to one reason, the number of reasons can reach 16 and averages 2.68. Even if presence malignant neoplasms The coexistence of another chronic noncommunicable pathology does not exclude its influence on the deterioration of the patient's condition. The comorbidity imposes a kind of imprint to the entire "trajectory" of the tumor process: from the formation of a preposition to it before establishing the diagnosis, treatment and rehabilitation.

Thus, concomitant diseases for cancer of various localization can affect the choice of treatment, determining the low tolerance for adjuvant chemotherapy, influence the delay in the diagnosis of the underlying disease. At the same time, in particular, on the example of a lung cancer (RL), it was shown that, despite the prevalence (30-50%) among patients with PL people under the age of 70 years and a high frequency of accompanying diseases (mostly cardiovascular system and COPD), the prognostic effect and age, and the accompanying diseases themselves remain controversial. The nature of the concomitant pathology and biological, and not the passport age of the patient may have a predictory value.

Own studies of comorbidity during stomach cancer (RS) in patients with the presence and absence of visceral signs of systemic undifferentiated DST, as a whole, showed a high frequency of association of RS with gastrithe and ulcerative history in patients (68.2%), chronic pathology of the hepato pancreato-duodenal zone ( 67.3%), in particular, gall-eyed disease (20.0%), chronic diseases of the cardiovascular system (52.7%), polynecoplasia (15.4%), in women with diseases (65.0%), Related to clinical markers of hyperstrogenemia (proliferative processes in endo- and miometry, ovarian dysfunction, mastopathy). Among the characteristics of the comorbidity in patients with RJ and systemic undifferentiated DST were allocated: high frequency of stigmatization of the gastrointestinal tract (47.6%) and gOOD SYSTEM (42.9%), high frequency of phenomenon of cystovation in various organs (65.1%), but more often in the kidneys (38.1%). The identified features, on the one hand, may have marker importance for the formation of risk groups for the development of RS (in particular, patients with DST), on the other, they make a question about the mechanisms for the formation of various types of comorbidity during RJ. In our opinion, the relationship between cystoration, gastric carcinogenesis and systemic undifferentiated DST (the latter is determined by various defects of the synthesis of the synthesis and decay of the extracellular matrix, the morphogenetic proteins of the connective tissue, numerous growth factors, their receptors and antagonists presented mainly by the adhesive complex molecules) can be explained Through the overall nature of violations in various signaling paths, the cells, in particular the Wnt signal path, TGF pathways, disorders of the expression of a number of common genes, for example, a bone morphogenetic protein gene, whose expression changes are associated with various kidney anomalies and other mesenchymal dysmortifications, as well as gastric carcinogenesis .

In general, the pathogenetic relationship of many coexistent diseases still needs a deep study. Thus, among the syntropios, a combination of ulcerative and hypertension deserves attention (the combination frequency reaches 12.9%), ulcerative disease and chronic lung diseases (10.6%). The risk of mortality in ulcerative disease, complicated by bleeding, above in the presence of 3 and more concomitant diseases than in the presence of one and two, it is also higher in concomitant diseases of the liver, kidneys, malignant neoplasms than with accompanying diseases of cardiovascular and respiratory systems.

Relevance is also feedback - a high frequency of gastroduodenal pathology of a inflammatory-degenerative or erosive-ulcer nature in patients with chronic lung diseases. The frequency of identification of such syntropy, according to various authors, ranges from 2.7 to 98%. More often (from 30 to 100%), gastritis is detected, while the frequency of atrophic gastritis reaches 30% or more. Those or other morphological changes in the gastric mucosa are detected even in every second child with chronic diseases of the bronchopulmonary system. At increasing the degree of severity of chronic respiratory failure, a change in a gastritic nature is detected essentially for each patient. In the pathogenesis of such a combined damage, the importance of chronic tissue hypoxia may have the formation of chronic tissue hypoxia, due to the violation of the microcirculation and the rheological properties of the blood, the decrease in the regenerator potential of the gastric mucosa (coolant), in particular due to the disruption of the non-spiratory metabolic function of the lungs and accumulation in the blood of aghydonic acid metabolism (leukotrienes, Prostaglandins, thromboxanes) and other Central Commissars Conditioning the development of a systemic inflammatory response. With a combination of BA and the pathology of the gastrointestinal tract, it is very similar to a single mechanism of immune disorders, in particular at the level of mucosoascular lymphoid tissue.

According to our data, the frequency of the combined atrophic lesion of the mucous membrane of the bronchi and the stomach is significantly higher, and the fact that it depends on the nature of the process in the respiratory system depends on the nature of the process in the respiratory system. In the pathological row from the primary atrophic bronchopathy (ABP), ABP against the background of chronic obstructive pathology and professional dusty pathology of the lungs to the radiation frequency of coolant coolant and epithelial liner of the bronchi is at the first three options pathological process Accordingly, 51.9, 25.6 and 43% of cases and reaches a maximum with a peripheral ral - 77% of cases, which is likely to be considered as a clinical marker of systemic disorders of epithelio-stromal relations, reducing the morphogenetic and protective function of the junction tissue system.

In recent years, not only an increase in the frequency of incidence of bronchial asthma (BA), but also the frequency of its combination with obesity of various degrees of severity reaching 28-44% is noted. The formation of a "vicious circle" with a combination of ba and obesity is determined by numerous common pathogenetic mechanisms. This is an increase in blood levels of pro-inflammatory CC (TNFα, IL-4, IL-5, IL-6, IL-13, the vascular endothelial growth factor) produced by adipocytes and determine both the development of systemic inflammation and the formation of bronchial hemosinophile in the mucous membrane , and a neutrophilic inflammatory response. In patients with obesity, the enhancement of immune reactions mediated by T-lymphocytes (TH) of the 2nd type under the influence of permanent excess synthesis IL-6 and probably leptin, the expression level of which increases with increasing body weight. At the heart of the pathogenesis of the BA also lies an imbalance of TH with the activation of TH-2 type, the consequence of which the development becomes chronic inflammation in respiratory tract. An important link of pathogenesis and BA, and obesity is oxidative stress, activation of lipid peroxidation peroxidation processes (floor) and a number of proteolytic enzymes (matrix metalloproteinases, Catencin G, etc.), damaging endothelium of the vessels of a small circle and pulmonary interstics, and stimulating the formation of angiotensin II and increase sensitivity to vessels. For the formation of endothelial dysfunction having a significant pathogenetic value in the damage to the vessels of a small circle and formation light Heart, responsible for obesity also low level Adiponectin, which, in turn, stimulates the synthesis of nitrogen oxide in the endothelium of vessels and inhibits the products of TNFɑ.

Similar pathogenetic mechanisms (chronic systemic inflammation, oxidative stress, free radical damage to DNA, etc.) underlie the coexistence of obesity and a variety of malignant diseases. Excessive weight among Europeans caused 3.2% of cancer in men and 8.6% - in women. In the study of comorbidity in patients with RS, the excess body of the body (the equity and obesity of the I - III degree) was noted in 61.5% of patients.

Syntropy, as a natural-specious combination of two or more pathological conditions In the individual and its closest relatives are not random and have an evolutionary-genetic basis. The genes caused by the development of syntropy and called syntropic are sets of functionally interacting adjustable genes, localized in the entire space of the human genome and are involved in common biochemical and physiological paths for this syntropy.

Phenotypic information on the combination of human diseases as genotyping technologies improve is complemented by the construction of gene networks, followed by the analysis of the "gene hairdryer" of associations. If previously network tools were used to analyze gene interaction in a separate disease, then a conceptual basis for studying the relationship of all human diseases ("hairdryer" of diseases) is developed with a full list of genes controlling the disease ("genome" of diseases), which creates a global picture "Disise", including all known associations "gene - illness". Distera is a set of all known Associations "Gene - Disease", organized into a human disease network (HDN), consisting of nodes (hubs), in which there are diseases and connecting edges, which are represented by common cause-dependent genes. Thus, the study of the genetic profile (used 1400 genetic markers) in three different samples of the cardiovascular continuum: patients with only IBS, patients with a combination of IBS, type 2, ag and hypercholesterolemi (GC) and patients with a combination of two diseases - IBS and AG showed that between a combination of several and two diseases (IBS and AG) had two common genetic markers ( Sez6lrS663048 and RS6501455); Between the combination of IBS with AG and only IBS - one common marker ( SCARB1rS4765623). There were no general genes from among the studied combination between the combination of four diseases and IHS. Analysis of the belonging of associated genes to a particular metabolic pathway showed that the lipid metabolic genes are involved in the formation of all three options for the combination of heart-vascular disease diseases, and the genes of the immune response are specific to IHD and are not involved in the formation of syntropy.

Currently, it has been established that the associations of diseases at the level of clinical phenotypes have a molecular genetic basis - common genes and overlapping metabolic pathways.

Paradoxicals were discovered in the genetic analysis of inverse comorbidity, or distrets - Distropic genes were the same for diseases with contrasting relations. Thus, with the help of transcriptomic meta-analysis of molecular evidence of reverse comorbidity for three diseases of the central nervous system: Alzheimer's diseases, Parkinson's disease and schizophrenia, and three types of cancer: lung cancer, prostate and rectum. It was revealed that 74 genes are simultaneously suppressed at three indicated CNS diseases and enhance activity at these three types of cancer. On the contrary, expression of 19 genes is simultaneously enhanced with three studied CNS diseases and is suppressed at three types of cancer. It is impossible to exclude that some of the drugs used to treat CNS disorders could cause a reverse of the expression of a number of genes controlling the development of cancer. The feedback mechanisms may be of great importance for refining pathogenesis and the treatment of many widespread and socially significant diseases, in particular - oncopathology.

One of the actual aspects of the problem of comorbidity is the issues of treatment. Being a common phenomenon in the practice of a modern doctor, a comorbidity is often accompanied by polypragmazia - the patient's appointment of a large number medicinal preparations In the desire to treat all diseases that make up a specific syntropy, which not only does not lead to the achievement of the goal, but often becomes dangerous, causing iatrogenia.

One of the approaches to the treatment of multiple combined diseases is the "node therapy of syntropic diseases", aimed at modulation or even "decay" of nodular networks involved simultaneously in the regulation of several signaling paths common for the corresponding syntropy. So, it was shown that in patients with early forms of coronary atherosclerosis in combination with autoimmune diseases (rheumatoid arthritis, psoriasis) statins are a common, efficient and safe drug.

The coexistence and mutual influence of disease complicates the formation of the diagnosis, in the logical structure of which the specific syntropy of this patient should be reflected. For this purpose, the diagnostic headings are used: the main, background, concomitant diseases.

The main one of the patients in the patient is legitimately considered the nosological form, which in itself or as a result of its complications, currently determines the greatest threat to the disability and life of the patient and requires urgent treatment.

The formalization of the diagnosis in accordance with the accepted headings is often accompanied by a violation of the logic of the development of the pathological process. Here there is an element of convention characteristic of any classification, or an element of agreement reached, in particular, this concerns such a pathological process as atherosclerosis. But, even retreating from the logic of the development of the pathological process in favor of the classification adopted, the doctor must understand the true essence of things.

Bibliographic reference

We bring to your attention the magazines publishing in the publishing house "Academy of Natural Science"

Comorbidity - Simultaneous occurrence in a patient as if of various diseases or pathological conditions.
This is the only common place for all the diversity of the interpretation of K., if you try to summarize them.

Synonym (more precisely, in Russian): capacularity.

1. "TO. - coexistence of two and / or more syndromes (transomundromal K.) or diseases (transnoological) in one patient, pathogenetically interrelated or coinciding (chronological) ".
   • (If they did not coincide in time, the word "coexistence" would be inappropriate. It's great that the author specifies: "one patient" (!). It is strange that he did not decorate his definition by the term "pathogenetic K." ... Prefix "Trans" suggests something more than a joint occurrence).
2. . "TO. - a combination of two or several independent diseases or syndromes, none of which is a complication of another if the frequency of this combination exceeds the probability of random coincidence. "
   • (A.Finestein and complications, and pregnancy are suitable).
3. "TO. may be associated with a single cause or single pathogenesis mechanisms these states but sometimes due to similarity their clinical manifestations that does not allow you to clearly retperiate them from each other. An example is atherosclerosis and hypertensive disease. "
   • (I simply read this way: "may be connected, and maybe not related - it is not known to science"!).

Phrase ending this confusion: "So, the comorbidity is not an artifact, atypical phenomenon or a certain myth and fashion.<…> K. is a clinical reality ... ", you need to read exactly the opposite, because there is no greater artifact than the so-called. "Clinical reality." And the fact that K. became fashionable to doubt not accounted for - 500,000 finds on the Internet in Russian; More than 3.5 million in English.

When you read that "K. heterogeneous (random, causal, complicated, unspecified) "; "Transundromal, transnostic, chronological; It has "three different subtypes: pathogenetic, diagnostic and prognostic ...", etc. etc., you understand that the Medical Institute is not the best forge of scientific personnel ... All the same "Clinical Bardak" is visible in the heads (see Medical Classifications), which supports Wikipedia, completing the collection as if "synonyms K." ™:

• polymorbidity;
• multimorbide;
• multifactorial diseases;
• polypathy;
• condolence;
• dual diagnosis (why not triple? Not a quadruple?);
• pluripatology.

It came to full clinical wrapal. Caused by the doctor in the patient complication, the main disease, began to be called a "yathedral comorbidity" (exactly as theft - "Inadequate use of funds"...). And finally, K. itself announced "New pathology". "New" - that is, until 2013, patients had "accompanying diseases", and now (thanks to A. Faynstein or A.L. Velkin?) - New pathology!

Oh, something one, gentlemen-comrades! Or "comorbidity" is a term for a combination of pathologies, or pathology itself. Reading this, you start thinking that she is "new pathology" exclusively thinking of the authors.

Interestingly, many Russian articles on the topic begins with the proclamation of some unity of the body (here and Plato, and Hippocratic, and S. P. Botkin, and G. A. Zaharin, and who will not yet remember!), But ending with definition this unity separating. Coexistence of something implies the presence of two or more units (pieces) of this "something" ... that is, essentially K. not much different from banal nosological views:
1st nosology + 2nd nosology \u003d comorbidity!
This is its methodological primitivismSo attracting "scientists" -klitsyists who exercise in the assignment of new Greek, Latin and English consoles and the roots of the "new clinical entity"!

What is it

Determining the comorbidity as coexistence of several diseases Sends us to ideas about them, as about the Kantian "things-in-in-ourselves" (existing outside of our consciousness), that is, "Valid", which "settle" in our body separately... And the term K., as if a flirting smile to times when the body was considered as a kind of integrity, instead of which will now be a "piece of the body", populated, for example, two - three diseases.

Because every year (in difficult times we live!), As well as with the age of the patient, K. is growing, it remains to wait, when the whole body "becomes shaken". Obviously, it will be guaranteed to happen before death, and finally (!), It will be hurting the whole holistic organism, and you can begin to treat the patient, and not a disease (as the great classics bequeathed) ...

It is also not clear why the authors of the article about K. in Wikipedia consider that "... a fundamental refinement The term Dali H.C. Kraemer and M. Van Den Akker, defining a comorbidity, as a combination of one patient two and / or more chronic diseases pathogenetically interrelated or coinciding in time One patient, regardless of the activity of each of them. "

Termwhich theoretically must designate something one, denotes two Concepts separated by the Union "or"… ("Are you married or a maiden?" - "Not that and not else! Hee Hee-Hee ... ").

So what is a common pathogenesis or a simple coincidence in time? If both, and the other why this is called "clarification" and still "principled", for what, besides the word "chronic" differs from the definition of A. Faynstein itself? Finally, all chronic diseases were once sharp / subacted. So at this stage about K. Can not speak? And generally speaking, why it is important?

And if they have a common pathogenesis (that is, it would seem presupposing a single pathogenetic treatment), it is not clear how the ideologists of the topic everywhere talk about necessity with C. combined, polylertoral therapy. That is, the head and ass worm from the epigraph to this article receive different treatment! Or vice versa: if it one Worm, then why the head and ass are different names? And, finally, if there are diseases (worm), consider as a continuum of states, how can you use many drugs at the same time, and not consistently - as you move along the continuum? Listed - Evidence of View on K. as a simple totality of disease.

Since doctors who think the body as some kind of integrity, with a rare exception, is not found in the afternoon with fire, then everyone likes comorbide diseases in post-Finstein reading. We still have 2-3-4, etc. sOexisting diseases. This allows you to smallerly think and treat according to the tables of pharmaceuticals, according to the principle of "every disease - its medicine." Such a "understanding" of the integrity of the body is ashamed to pharmaceuticals to expand its sales (we say K., I mean - polypragmasia). So you hear: "When buying this drug usually takes these medicines" ...

All because this raban "index illness" in Russian is not normal anywhere and, more importantly, nowhere not clarified And it hypnotize the public. Maybe it is necessary to translate it as a "pointing disease"? Pointing the path of therapy or knowledge? Timberity! Or is it a primary detected disease? In all the definitions of K. "from A.Finestein" and their interpretations or meant, or referred to this main (main, stem leading, etc.) of the disease. At the same time, the presence, sorry for the expression, the "index illness" is stated, as something of granted, and how it was formed, as if uncomfortable in a decent society ...

Who and how does it determine what disease will be the main one? Is this a convention or not? Such a disease, what began before or was the first detected? But when is the role of chance in the formulation of the "main" diagnosis? Patient got to a specialist in the "Main Disease"? Or complained about something in the first place? Is this a disease that researcher studies? And maybe the ICD or DSM "Tell" to us to allocate the main disease, and then the accompanying? And otherwise, what is the case of taste?

The "primacy" of diagnosis may depend on the time of its holding: the disease took illness at the late stage - one main disease, at an earlier stage, "Other".

What is the integration of the main and minor diseases? What, actually meaning This main disease? Can K. flow into multimorbidity (see below)? All these issues are practically not discussed and, certainly, they are not solved, neither the Finestein itself nor his followers.

"The main disease", for some reason, which became the inviolable sacred cow theory of K. Apparently predened not only me. From her tried to get rid of.

The appearance of multimorbidity. What kind of beast?

The comorbidity was invented to distinguish from multimimorbidity (mm), which we also offered to us and as Synonym K.!

Do not try to understand why comorbid decided to separate OT. multimorbide. Here as in the anecdote, but already about the lesson of the Russian language in the Georgian school: "Deti, in Russian Willka and a plate are written a soft sign BEZ, and Sol and Beans - on the contrary. Remember it Dati, because it is possible to understand it - it's possible!».

There is even the International Scientific Society of Multimorbide ("IRCM" - International Research Community On Multimorbidy). Do not hope (like me) that on the first page of their site you will find a definition of mm.! Not. There is even no clear explanation when this community arose! But there is a list of theoretical works in which the article is chronologically the first place, where it says: "In the view of the ambiguity of the term, we offer to distinguish to K., based on the" classic "definition (the assumption of a certain main," index ", illness) and a multimorbidity, meaning any joint occurrence of medical conditions at the subject".
The site has a note Martina Fortin (Martin Fortin) from which it follows that colleagues in the IRCM community have created, but have not yet decided that they will consider MM., Since the definitions are confused and offered to everyone to help them. , responding to the question: "How to determine mm?". Answers are offered as on EGE:

1. many simultaneously existing chronic or long diseases or states, none of which is considered as a leading disease (index deease);
2. several concomitant diseases or states, none of which is considered as a leading disease (index deease);
3. any of the above definitions;
4. other definition (please give definition or link)

This is surprisingly rich in the diversity of answers, in the second "definition" there is only no word "chronic or long-term". It turns out the whole cheese - boron due to chime or duration?

Confusion with K. and mm. Early banal mistakes are aggravated. In Article 2014, when the authors, as usual, outlined "in their own words" written by Van den Akker and A.Finestein, the last, confusing references, attributed the term "mm" and "clarified" (p. 363), which is based on it in contrast From K., "... is not a disease, but a particular patient ..." (that is, not acidic, but a round ...). Full pis paragraph. In short, the next Eksegez A.Finestein and other turbid texts.

And here is another folding of wisdom, a certain medical reference book Belyalova F.I. :

The comorbidity of the presence simultaneously with the present disease of another disease or medical condition. Multimorbide The combination of many chronic or sharp diseases and medical conditions for one person (National Library of Medicine).

100 1000 rubles to those who will find the difference. Is that in the first definition meant two or three people, and not one?

TOTAL

Summing it is written, it can be seen that the authors of different definitions of K. and KK, in the process of watercropping the water in a stage of clarifying these concepts, make an emphasis on the presence of the "main" disease, then on the process of processing the process, then on the general pathogenesis (risk factors, etc. ) then on the absence / presence of the listed, then include "Nonaboles", then no, etc. etc. Only one obgomovsky question remains open - what for?

This is to blame for sure not K. Faynstein. It is impossible to get rid of the feeling that he just wound their "followers" rewrite in places traditional medicine "into K. language." Fact himself unbearable The term, its use in a Cyrillized version - already a claim for the presence of some other sense in it. Tell me: "Constabilities" and the scourless bubble will immediately burst! Change occurred languagefor the designation former known under others names.

Some examples of language transformation

In the form of Russian terms of Faynstein followers.

We must admit that:

1. The definitions and "k" today, and "mm" designate completely different things. Common for them is only the fact of the joint occasion of the disease.
2. The term "K". In the author, failed from a linguistic point of view, since he patologizes the norm.
3. In any case, the term K, both in its initial, Fienestein sense and in its interpretations does not indicate any qualitatively new integrity.
4. The term "K". I went beyond the limits of Faynsteinovsky, epidemiological sense and stop its confusing use in other contexts will now be very difficult.

Using the example of the history of the term K. It is clear how the human consciousness convulsively tries to escape from the archetypical opposition of health / illness expressed in terms of the "struggle of goodness with evil". Invented MM, where (like public development), all diseases acquire "democratic equality", overthrowing the monarchy in the person of the main disease. But the understanding of them interaction within these views It is impossible, since diseases still exist separately.

It seems that many doctors and researchers reached out to the theory of K. Because with different degrees of awareness, they were interested interaction (if this word is generally appropriate) "different" diseases, and not the very fact of their joint occurrence. However, this immediately destroys the concept of a nosological form and returns us to "to the origins" - to the patient.

Sometimes the diva is given, as in general, the ideas of the existence of individual diseases are so Luggage, when all-resting systems have long been opened: blood circulation, lymphorage, hormonal, immune, connective tissue, finally, etc.?

46 years have passed since the term of the term K. Internet appeared, a desktop computer; The ebonite disk telephone and a TV with a kinescope changed the aid-pads and ay-backgrounds, but the doctors like "Ai-hurts", and remained with a comorbidity from A. Finestein ... take a look at what they write about K. today.

Qualitatively made epidemiological works of the XXI century, E.G., 2012, this, as Finestein thought - Another study of the joint occasion of the disease in one or another population, which has already made tens of thousands. Learn their clinical epidemiologists. Their recommendations suitable to a greater degree for the organization of health, Just geographically localize all new and new data on co-morbidity, and their conclusions are not God's god as complex.

Numerous attempts to directly adapt such data to the therapeutic process of specific patients usually end with a complete failure. In Articles 2000-Kh. Recommendations (or rather - slogans), as common and banal, as nonspecific.

As for the practical doctors of the professor, whose life (like the life of V.S. Chernomyrdin) "... passed in an atmosphere of comorbidity"? Here are some of the profound recommendations - the slogans, apparently selected for the long years of "scientific work" (A.L. Wörkkin, N.O. Khovasov). After the establishment of the growth of the age K. and the percentages of their joint occurring, we already read the conclusions and recommendations:

The article also highlighted as NB! following: "Risk factors in Russia must be considered as diseases that need to be treated!".<…> "Risk factors, polymorphism of a clinical picture, lesion polyorganism, drug polyprodia - these are key links that need to be considered when assisting a patient with comorbide pathology."

Reading it, immediately understand that now it will go with us!

Afterword

Completing the consideration of the "Epoch" to "A. Faynstein", we note that the author of the term K. did not claim to study the mutual influence of diseases (mechanisms of pathogenesis, etc.) and did not do thisHe just stated such an opportunity. Thank you for instructing the importance of the joint occasion of the disease (which was known to him) and now turn to consideration interaction that today we still call individual diseases.

C point of view medical workas well as for scientific design of general human pathology, Talk about the joint occurrence of diseases, etc., it makes sense only if they are united by something else, except for the very fact of meeting in the human body (for where else to meet them?). Actually, it is the meeting of them in one body and marks their community (etiological, pathogenetic, or any other).

Run ahead will say that if there is no communitythen such diseases in one body are not found! This phenomenon, thanks to the dominant and fetishization of the term A. Faynstein, was extremely unfortunately called "Reverse K." or more adequately - distropy . Why unsuccessful? Well, it's like in opposition love / hatred, name the last "return love" ...

That is, at first they climbed all the brains confused by all the concept of K., and then, were forced to repel from this name to express something from her, K. Excellent ...
It turns out that the times "before Christmas A. Faynstein" (to the Russian Federation), when the problem of the joint occasion of the disease was considered much more progressively than after the invention, they were so for all the term Film

The comorbidity parallelly studied completely different people who opened the ERU of integral medicine.

Still

Home reading

• The opposite version of this article, published in the "Plastic Surgery and Cosmetology" journal, August 2016.

The human body is a single whole, where each organ, each cell is closely related to each other. Only the well-coordinated and agreed work of all organs and systems makes it possible to maintain homeostasis (constancy) of the inner environment of the human body needed for its normal life activity.

But, as is known, the stability in the body disrupts various pathological agents (bacteria, viruses, etc.), leading to pathological changes and causing the development of diseases. Moreover, with a failure of at least one system, many protective mechanisms are launched, which through a number of chemical and physiological processes are trying to eliminate the disease or to prevent its further development. However, despite this, the "footprint" from the disease still remains. Violation in the work of a single unified chain of the body's life activity ricochet is reflected in the functioning of other systems and organs. So new diseases appear. They can not develop immediately, and years after the suffering of the disease that served as the impetus for their development. In the course of the study of this mechanism, the concept of "comorbidity" appeared.

Definition and history of occurrence

Under the comorbidity, the simultaneous flow of two or more diseases or syndromes, which pathogenetic (according to the mechanism of occurrence) are interconnected by each other. In the literal translation from the Latin language in the word Comorbid 2 Semantic parts: CO - together, and morbus is a disease. The concept of comorbidity was first proposed in 1970 by an outstanding American-epidemiologist Alvan Fenztein. In the open concept of comorbidity, the Fenstein researcher invests an idea of \u200b\u200bthe existence of an additional clinical picture against the background of the current disease. The first example of the comorbidity studied by Professor Fenztein was a somatic (therapeutic) disease - an acute rheumatic fever, which worsened a prognosis in patients suffering from other diseases.

Shortly after the opening of the phenomenon of the comorbidity, it attracted the attention of researchers from around the world. The concept of "comorbidity" over time was modified in "polymorbidity", "Multimorbide", "Polypathy", "double diagnosis", "condolences", "plumepatology", but the essence remained the same.

The Great Hippocrat wrote: "Inspection of the human body is a single and whole process that requires hearing, of sight, tangles, smell, language and reasoning." That is, before you begin to treat the patient, it is necessary to comprehensively study the overall condition of its organism: the clinical picture of the main disease, complications associated pathologies. Only after that the possibility of choosing the most rational strategy of therapy appears.

Types of comorbidity

Comorbidity can be divided into the following groups:
1. The causal comorbidity caused by parallel damage to organs and systems caused by a single pathological factor. An example of such a comorbidity may be the damage to the internal organs during alcoholism.
2. Complicated comorbidity. This type of comorbidity appears as a result of a major disease, which in one degree or another destroys the so-called target bodies. This is, for example, about chronic renal failure, which appeared due to diabetic nephropathy (with type 2 diabetes mellitus). Another example of this type of comorbidity can serve as an infarction (or stroke), which developed against the background of a hypertensive crisis in arterial hypertension.
3. Yatrogenic comorbidity. The cause of its appearance is the forced negative impact of diagnosis or therapy on the patient, provided that the danger of any medical procedure is established and is known in advance. A vivid example of such a type of comorbidity is osteoporosis (bone fragility), which develops due to the use of hormonal drugs (glucocorticosteroids). Such a comorbidity can also develop during chemotherapy, which can cause the development of drug hepatitis in the patient.
4. Uncomfortable comorbidity. This form of comorbidity is spoken in the case when the presence of uniform mechanisms for the development of diseases that make up a common clinical picture, but to confirm this thesis requires certain studies. For example, in a patient suffering from arterial hypertension, erectile dysfunction (impotence) can develop. Another example of unspecified comorbidity may be the presence of erosions and an ulcers on the mucous membrane of the upper digestive tract in patients with vascular diseases.

5. "Random" comorbide. The combination of patient chronic ischemic heart disease and the presence of stones in the bustling bubble (gall-eyed disease) demonstrates an example of a "random" comorbidity.

Some statistics

It has been established that the number of comorbide diseases directly depends on the age of the patient: young people have such a combination of diseases less often, however, the older man, the greater the likelihood of the development of comorbide pathologies. At the age of 19 years, comorbide diseases occur only in 10% of cases, by the 80 years this indicator reaches 80%.

If we consider the data of pathologue studies (autopsy) of those who died from therapeutic pathology in the age category of 67-77 years, then the comorbidity is about 95%. A comorbidity occurs in the form of a combination of two or three diseases, but there are cases when one patient has a combination of up to 6-8 diseases (in 2-3% of cases).

More often than others with comorbidity faces general practitioners and therapists. However, narrow specialists are also not insured against meetings with this phenomenon. But in this case, the doctors often "close their eyes" on the phenomenon of comorbidity, preferring to treat only "their" - profile disease. And other diseases leave their colleagues - therapists.

Diagnosis for comorbidity

If there is a comorbidity for setting the correct diagnosis, the patient must comply with certain rules: the diagnosis is distinguished by the underlying disease, background diseases, complications and related pathologies. That is, among the "bouquet" of diseases, it is primarily necessary to identify that disease that requires priority treatment, as it threatens the patient's life, reduces its ability to work, or can provoke dangerous complications. It happens that the main disease is not one, but several. In this case, they are talking about competing diseases, i.e., diseases occurring in a patient at the same time interconnected by the mechanism of occurrence.

Background pathologies complicate the current disease, exacerbate the situation, make it more dangerous to the patient's health and life, contribute to the development of various complications. The background disease, as well as the main, requires immediate treatment.

Complications of the main disease are associated with it by pathogenesis (mechanism of occurrence) and can lead to an unfavorable outcome, in some cases even to the death of the patient.

Concomitant diseases are all other pathologies that are not related to the main disease and, as a rule, not affecting its current.

Thus, the comorbidity is a negative factor for the forecast of the disease, which increases the likelihood of death. Comornel pathologies lead to an increase in the treatment of the patient in the hospital, increase the number of complications after operations, the percentage of disability, slow down the patient's rehabilitation.

Therefore, the task of each doctor is to see the clinical picture as a whole, which is called, "to treat is not a disease, but the patient himself." With this approach, in particular, the likelihood of severe side effects is reduced when chosen by the pharmaceuticals: the doctor may and should take into account their combination with simultaneously treatment of several pathologies at once, and it is simply obliged to always remember the saying E.M. Tareeva: "Each disintended medicine is contraindicated."

A lot of interesting and unusual terms know different areas of human livelihoods. Many of them are heard, but about some majority of people did not even hear. For instance,comorbidity. This is a medical term denoting a very interesting scope of professional diagnosis and therapy.

History of the term

If you go along the path of a clear vocational dictionary, then in medicine there is a term denoting the combination of diseases according to certain signs - comorbidity. The definition is traditional for medicine, with its roots goes to Latin. It is from it that two components are taken - coniuunctim and morbus - "together" and "disease", which have become the basis of an unusual for a simple intention of the term, denoting a complex of chronic diseases in one patient, in some particularly interconnected.

Such a definition of the patient's condition was considered since the most long time, at the dawn of the nucleation of diseases of disease. And the ancient Greeks, and the healers of the Ancient East treated not the disease itself, as something separate, but the entire body suffering from the manifestation of a particular illness. The relationship of several problems in the state of human health, which manifests itself with certain symptoms, and, it means, the treatment of a whole complex of diseases, the doctors of different generations said. And by now, the comorbidity is the proven clinically method of formulation of adequate diagnosis and competent treatment that promotes health.

The term "comorbidity" himself was proposed in 1970 by the American epidemiologist and researcher Alvan R. Feinstein (A.R. Fainstein). At first, this concept was used mainly in clinical epidemiology, but over time it became the main research and development methodology for various industries of medicine.

Combination of disease

Turning to the doctor about a specific health problem, a person most often does not suspect that his condition is not caused by one, but a whole complex of problems. And for many specialists, when setting an adequate diagnosis, it becomes clear that in a particular case we can be on comorbidity. But at the same time, multimindication will be a multimindiciency for other physicians to diagnose the disease and treatment of treatment, that is, no combination of diseases on the pathogenetic level, and their presence is separately, which gives the overall picture of the patient's state at the moment.

But meanwhile, for the absolute majority of practitioners around the world, the combined diseases become the most qualitative definition of diagnosis and treatment. For instance,the comorbidity in cardiology takes into account in addition to the two main problems of the cardiovascular system - arterial hypertension and ischemic heart disease - also the problems of respiratory and urinary systems.

What are the reasons?

For medical practice, comorbidity is a combination of several interrelated diseases that the concrete person suffers. Peripant medicine faces a feature that, with the initial treatment of the patient to a specialized medical institution, speech in the absolute majority of registered cases is under one particular disease, which is prescribed treatment. But in multidisciplinary hospitals, the picture changes dramatically, the same patients are diagnosed with a comorbidity that allows you to better prescribe treatment in accordance with the complex vision of the identified pathologies. This is due to the fact that more thorough observation and examination of the patient in different profiles takes into account all parties on the basis of which there is a question of combined diseases:

• anatomical feature - patient organs close to each other;
• a single pathogenetic mechanism for the development of diseases;
• diseases have one causal relationship and combined with a single temporary threshold;
• one disease "follows" from the other, as a complication.

I mean the presence in a patient a comorbidity, a specialist bases the opinion on identified or potentially possible factors:

• inflammatory process;
• genetic predisposition;
• infection;
• metabolic changes in an involutive or systemic nature;
• social status;
• ecology of the Region of Permanent Residence;
• natrogenation is the deterioration of the condition of the patient (physical and / or emotional medical worker's fault).

How is the problem?

At the present stage of the development of medicine, as sciences in different spheres of vital activity of the human body, the concept of "comorbidity" is a combination of diseases related to the pathogenetic mechanism of occurrence, development, manifestations. Observation since a long time per condition of the patient allowed the doctors to conclude that only the manifestation of the disease was qualitatively treated, without eliminating the cause of its occurrence, it is impossible, besides, the disease often occurs not as a separate damage to the organ or system. In fact, there are several diseases, and they are interrelated among themselves. The most accurate and ancient method of studying such a combination is autopsy. It is the posthumous study of the diseases that the person suffered, made it possible to draw conclusions that many of them proceed together, and thus reveal the presence of comorbidity.

How are combined diseases divide?

Combined diseases are present in different fields of medicine. And conventionally can be divided into comorbidity in psychiatry and a combination of clinical internal diseases. Medicine scientists interrelated diseases are studied in two directions:

• transussdromal - syndromes are interconnected by pathogenetic causes;
• transnogenic - diseases available in a patient do not have common pathogenetic causes.

It is this division that makes it possible to differentiate the combination of diseases for the overall reasons for occurrence or similar clinical manifestations.

Also, the comorbidity is divided into the following types:

• causal;
• complicated;
• yatrogenic;
• uncomfortable;
• "Random" comorbide.

Diagnosis and treatment of complex disease

The problems of comorbidity are studied by medicine from different points of view over the past decades. Recently, this question again rises in the highest levels, potential work is carried out to improve diagnostics, treatment methods, prediction. World medicine has already developed several methods for measuring comorbidity, each of which works at a specific direction. And the main problem is that each such technique may have different results for the same patient. In determining the presence of comorbidity, which means the prediction of the mortality or quality of the patient's life, practitioners doctors do not have a single tool that operates specific arguments that allow to obtain the most accurate result. That is why all these techniques are small in practical therapy of various directions.

At the present stage of development of medicine, comorbidity is a scope of study of the existing diseases in one patient, interrelated with the reasons or symptoms, potentially significant, but little applied in practice due to the lack of specific work algorithms.