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We present a challenging case of a loss of domain (LOD) inguinoscrotal hernia in a 77-year-old high-risk patient, successfully managed with the complementary preoperative use of progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA) without complications. Giant inguinoscrotal and LOD hernias, particularly in multimorbid patients, are highly complex and require meticulous preoperative preparation. In this case, PPP was performed with ambient air and a gradual increase in insufflation volume, while BTA was injected at three points on each side, with a total dose of 300 IU. This approach facilitated a complication-free increase in abdominal cavity volume and the repositioning of chronically eventrated abdominal contents. The technique proved safe, feasible, and effective, contributing to atraumatic adhesiolysis, reduced operative time, and avoidance of more invasive surgical methods. A Shouldice pure tissue repair was performed, successfully avoiding the need for prosthetic materials.

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Background: Patients with multiple comorbidities can present as a diagnostic challenge as overlapping symptomatology complicates the discovery of emergent pathology. Symptoms of alcohol misuse or orthostatic hypotension may especially cloud the diagnosis of insidious neurological disease, such as posterior circulation infarct. With a growing elderly population, it is expected that the complex multimorbid patient will represent a growing challenge to prompt stroke detection and treatment. Case Description: Herein, we present a 69-year-old male with a history of alcohol abuse, chronic obstructive pulmonary disease, type 2 diabetes mellitus, paroxysmal atrial fibrillation, and congestive heart disease. The patient arrived at our emergency department with dizziness, ataxia, and diplopia. His symptoms had a sudden onset and gradual exacerbation over a span of 2 days, notably aggravated by standing and walking, but relieved when seated or supine. Notably, a month before admission, the patient had been treated with anti-congestive medications for severe congestive heart failure leading to a weight loss of 55 lbs over period of 2 weeks. The initial differential diagnoses were orthostatism, Wernicke's encephalopathy (WE), and ischemic stroke. Magnetic resonance imaging (MRI) revealed a subacute infarct in the medial longitudinal fasciculus (MLF). Conclusions: The case underscores the challenge in diagnosing neurological conditions in multimorbid individuals. The combination of various underlying conditions may drastically complicate the diagnosis. Successful diagnosis and treatment necessitates meticulous evaluation of clinical observations, medical history, current medications, and pertinent diagnostic evaluations to effectively narrow down the potential differential diagnoses.

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The ever-increasing prevalence of chronic conditions over the last half century has gradually altered the demographic of patients admitted to acute care settings; environments traditionally associated with episodic care rather than chronic and complex healthcare. In consequence, the lifeworld of the hospital medical doctor often entails healthcare for a complex, multi-morbid, patient cohort. This paper examines the experience of providing complex healthcare in the pressurised and fast-paced acute care setting. Four medical doctors from two metropolitan health services were interviewed and their data were analysed using a combinatorial framework of phenomenology and complexity theory. The horizon of complex care revealed itself as dynamic, expansive, immersive, and relational, entailing a specialised kind of practice that is now common in acute care settings. Yet this practice has made inroads largely without heralding the unique nature and potential of its ground. Herein lies opportunity for complex care clinicians to expand notions of health and illness, and to shape research, practice, and system design, for a future in which care for health complexity is optimised, irrespective of care settings.

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AIM: Identifying multimorbid psychopathology is necessary to offer more adequate treatment and ultimately reduce the prevalence of persistent mental illnesses. Psychotic symptoms are increasingly seen as a transdiagnostic indicator of multimorbidity, severity and complexity of non-psychotic psychopathology. This study aims to investigate whether psychotic-like experiences and subclinical psychotic symptoms as measured by the 16-item Prodromal Questionnaire are also associated with multimorbid psychopathology. METHODS: Participants were help-seeking individuals from outpatient mental healthcare settings and intensive home-treatment teams, aged 17-35. Assessment included the 16-item Prodromal Questionnaire to measure psychotic-like experiences, the Structured Clinical Interview for DSM-IV Axis I, and three sections of the Structured Clinical Interview for DSM-IV Axis II Disorders to determine DSM-IV-TR classifications. The final sample comprised of 160 participants who scored above a cutoff of 6 items on the 16-item Prodromal Questionnaire (HIGH-score) and 60 participants who scored below cutoff (LOW-score). A Poisson Regression was executed to determine the association between the PQ-16 and DSM-IV-TR classifications. RESULTS: The HIGH-score group had a mean of 2.76 multimorbid disorders (range 0-7), while the LOW-score group had a mean of 1.45 disorders (range 0-3). Participants with four to seven disorders scored high on the 16-item Prodromal Questionnaire. CONCLUSIONS: Our results suggest that psychotic-like experiences are associated with multimorbidity and severity of psychopathology. Screening for psychotic-like experiences via the PQ-16 in a help-seeking population may help prevent under-diagnosis and under-treatment of comorbid psychopathology.

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BACKGROUND: Caring for an increasing number of multimorbid people is a challenge for general practices in Germany. A possible approach to ensure future care could be the cooperation between general practices and community care points, which have so far been a little-known option among general practitioners. The aim of this study was to investigate the benefits or additional burdens that, from the perspective of general practices, a cooperation between general practices and community care points would bring for both the general practitioners themselves and their patients. METHODS: In the mixed-methods study COMPASS II, general practices were able to refer multimorbid patients with social counselling needs to a community care point. Semi-structured guideline-based telephone interviews were conducted with nine general practitioners and nine medical practice assistants regarding the feasibility of cooperation with the community care points. The interviews were analysed using framework analysis. RESULTS: In the qualitative interviews, the general practitioners and medical practice assistants reported that the community care points helped them save time by relieving them of social counselling tasks. The interviewees felt relieved by knowing that the community care points expertly take care of their patients' social concerns. From the perspective of the interviewees, multimorbid patients experienced changes in their care through the counselling in community care points, such as adjusting the level of care they require. Social counsellors provided patients and their relatives with an overview of the support options available. The majority of the interviewees did not feel that cooperating with the community care point put an additional burden on their patients or on themselves. DISCUSSION AND CONCLUSION: Cooperation between general practices and community care points has the potential to improve care for multimorbid patients and reduce the workload burden on general practices. Community care points are legally anchored counselling services which general practitioners could increasingly involve in the care of patients with multimorbidity.

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BACKGROUND: Inequality of opportunity (IOp) stemming from social circumstances exists in outpatient service utilization for the multimorbid elderly in China. However, little is known regarding the magnitude of the IOp and its composition. Therefore, this study aims to measure the IOp in outpatient expenditure and provide potential pathways for policy reform by assessing the contribution of each circumstance. METHODS: This study included 3527 elderly aged ≥ 65 years with multimorbidity from the Chinese Longitudinal Healthy Longevity Study conducted in 2017-2018. An ordinary least squares regression model was used to analyze the circumstance-influencing factors of outpatient expenditure. The parametric approach was performed to quantify the IOp in outpatient expenditure and the Shapley value decomposition method was employed to determine the contribution of each circumstance. By extracting heterogeneity in the residual of the circumstance-dependent equation of outpatient expenditure across circumstance groups divided based on cluster analysis, we captured the effect of unobserved circumstances. RESULTS: Except for pension and distance to health facilities, all the associations between circumstance and outpatient expenditure were statistically significant. The inequality caused by circumstances accounted for 25.18% of the total inequality. The decomposition results revealed that the reimbursement rate contributed 82.92% of the IOp, followed by education duration (4.55%), household registration (3.21%), household income (3.18%), pension (1.49%), medical insurance (1.26%), physical labor (0.99%), unobserved circumstances (0.86%), distance to health facilities (0.83%) and region (0.71%). CONCLUSIONS: The priority of policy enhancement is to effectively improve the outpatient reimbursement benefit for treating chronic diseases. Additional crucial actions include enhancing the health literacy of the multimorbid elderly to promote the shift from medical needs to demands and accelerating the construction of rural capacity for providing high-quality healthcare to the elderly with multimorbidity.

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INTRODUCTION: Primary care for multimorbid patients does not only include medical but also social counseling. In Germany, community care points represent an institutionalised support offer for counseling for social and care-related issues at district level. METHODS: Within the framework of an intervention study on the cooperation between general practices and community care points in Berlin, 14 telephone interviews were conducted with multimorbid patients with social counseling needs who received advice by a community care point. The aim was to investigate satisfaction with the cooperation process as a whole and with the counseling provided by the community care points. The transcribed interviews were analysed using the framework analysis. RESULTS: Overall, the patients were satisfied with the counseling they received from the community care points. In many cases, even after counseling, patients were not aware of the range of services offered by the community care points, and there was confusion about community care points and locally known mobile care services. Patients felt that it was particularly important to have a friendly, reliable contact person, to be close to their own place of residence and to have a long-term connection to the service. From the point of view of those affected, the general practitioner remains an important contact person who initiates the counseling, if necessary, and coordinates the interventions to be derived from the counseling result. DISCUSSION: The confusion about community care points and mobile care services due to a lack of knowledge about the range of services offered by community care points are central topics in the interviews. This could be due to the heterogeneous supply of the community care points as well as the lack of networking with GP practices. A standardisation of the offer and increased information and networking activities of the community care points at district level could contribute to an increased level of awareness and improve transparency of their services. CONCLUSION: In the long term, cooperation between community care points and general practitioners could help relieve the burden on general practitioners and improve social care for multimorbid patients at district level.

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Coordinating follow-up care after discharge from hospital is critical to ensuring good outcomes for patients, but is difficult when multiple care providers are involved. In 2018, Sweden adopted the Care Coordination Act, which modified economic incentives to reduce discharge delays and mandated a discharge planning process for patients requiring post-discharge social- or primary care services. This study evaluates the impact of this reform on hospital length-of-stay and unplanned readmissions among multi-morbid elderly patients. Interrupted time series analysis of all in-patient care episodes involving multi-morbid elderly patients in Sweden from 2015 - 2019 (n = 2 386 039) was performed. Secondary analyses using case-mix adjustment and controlled interrupted time series analysis were employed to assess for bias. Average length of stay decreased during the post-reform period, corresponding to 248 521 saved care days. Unplanned readmissions meanwhile increased, corresponding to 7 572 excess unplanned readmissions. While reductions in length-of-stay were concentrated among patients targeted by the reform, increases in readmission rates were similar in patients not targeted by the reform, indicating potential confounding. The reform thus appears to have achieved its goal of decreasing in-patient length of stay, but a robust effect on readmissions, outpatient visits, or mortality was not found. This may be due to lackluster implementation or an ineffective mandated intervention.

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BACKGROUND: Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden. METHODS: We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases. RESULTS: Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (<0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers. CONCLUSIONS: Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.

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BACKGROUND: Although mobile health (mHealth) apps are increasingly being used to support patients with multiple chronic conditions (multimorbidity), most mHealth apps experience low interaction and eventual abandonment. To tackle this engagement issue, when developing an mHealth program, it is important to understand the social-behavioral factors that affect patients' use behavior. OBJECTIVE: The aim of this study was to explore the social and behavioral factors contributing to patients' use behavior of an mHealth app called the electronic Patient-Reported Outcome (ePRO). The ePRO app supports goal-oriented care delivery in interdisciplinary primary care models. METHODS: A descriptive qualitative study was used to analyze interview data collected for a larger mixed methods pragmatic trial. The original 15-month trial was conducted in 6 primary care teams across Ontario, Canada, between 2018 and 2019. The eligibility criteria for patients were being aged ≥60 years with ≥10 visits within the previous 12 months of study enrollment. For this analysis, patients were classified as long-term or short-term users based on their length of use of the ePRO app during the trial. The Social Cognitive Theory by Bandura was used to categorize social-behavioral factors that contributed to patients' decision to continue or discontinue using the app. RESULTS: The patient-provider relationship emerged as a key factor that shaped patients' experiences with the app and subsequent decision to continue using the app. Other factors that contributed to patients' decision to continue using the app were personal and social circumstances, perceived usefulness, patients' previous experience with goal-related behaviors, and confidence in one's capability. There was an overlap of experience between long- and short-term app users but, in general, long-term users perceived the app to be more useful and their goals to be more meaningful than short-term app users. This observation was complicated by the fact that patient health-related goals were dynamic and changed over time. CONCLUSIONS: Complex patients' use behavior of a goal-supporting mHealth app is shaped by an array of sociobehavioral factors that can evolve. To tackle this dynamism, there should be an emphasis on creating adaptable health technologies that are easily customizable by patients and able to respond to their changing contexts and needs. TRIAL REGISTRATION: ClinicalTrials.gov NCT02917954; https://clinicaltrials.gov/ct2/show/NCT02917954.

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BACKGROUND: Research involving multimorbid older patients is gaining momentum. However, little is known about how to plan a randomised controlled trial (RCT) involving this group of patients. An evidence-based approach to the challenges of a recruitment process could guide researchers and help prevent underpowered trials. AIM: To define the number of multimorbid older patients that need to be identified and the number of eligible patients that need to be invited to achieve the desired recruitment number to a RCT. METHOD: We used recruitment data from the GerMoT trial, a RCT comparing proactive outpatient care based on Comprehensive Geriatric Assessment with usual care. Multimorbid older patients with high healthcare utilisation were recruited to the trial. RESULTS: Of the 1212 patients identified in a database as meeting the inclusion criteria 838 (70%) could be invited to participate in the trial. The rest could not be invited for a variety of reasons; 162 had moved out of area or into nursing homes and 86 had died before they could be contacted. 113 could not be reached. 450 (54%) of the invited patients agreed to participate. CONCLUSIONS: In our study, we have shown that it is possible to achieve a good consent rate despite older participants with multimorbidity. This can be used when planning an RCT for this patient group, who are often excluded from clinical trials. Our results are specific to a context that provides similar abilities to identify and recruit patients as can be seen in Sweden.

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Patients with chronic wounds (leg ulcers, decubitus, and diabetic foot ulcers) suffer from marked restrictions in their quality of life and can often no longer adequately carry out their everyday tasks. The need for nursing and medical care increases when other illnesses and complaints are present at the same time. Qualified wound care and the treatment of comorbidities are therefore of particular importance. The treatment of this disease, which is increasing in number, requires a holistic, multimodal treatment approach which, in addition to professional wound care, also includes comorbidities in the treatment. This case study describes an old treatment method for refractory wounds, the so-called "maggot therapy", and shows how this is integrated into a holistic, multimodal therapeutic approach.

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Heart failure (HF) can be considered a disease of older people. It is a leading cause of hospitalisation and is associated with high rates of morbidity and mortality in the over-65s. In 2012, an editorial in this journal detailed the latest HF research and guidelines, calling for greater integration of geriatricians in HF care. This current article reflects upon what has been achieved in this field in recent years, highlighting some future challenges and promising areas. It is written from the perspective of one such integrated team and explores the new role of cardiogeriatrician, working in a multidisciplinary team to deliver and improve care to increasingly complex, older, frail patients with multiple comorbidities who present with primary cardiology problems, especially decompensated HF. Geriatric liaison has improved the care of frail patients in orthopaedics, cancer services, stroke, acute medicine and numerous community settings. We propose that this vital role should now be extended to cardiology teams in general and to HF in particular.

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Merkel cell carcinoma (MCC) is a rare and aggressive form of skin cancer. Many people suffer early local recurrences and distant metastases. The anti-PDL1 (PDL1: programmed death ligand 1) antibody avelumab has been approved as first-line treatment for advanced MCC in Europe. It is also an alternative treatment for old and multimorbid patients.

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BACKGROUND: The number of multiple chronically ill older people is increasing and multimorbidity is associated with high utilization of health services. Integrated care management is increasingly used to address this problem; however, there is a substantial lack of reliable data on its effectiveness in this target group. OBJECTIVE: To assess the effectiveness of components of integrated care management in adults of all ages and to estimate the transferability to older, multimorbid people in Germany. METHODS: A systematic search was carried out in the Cochrane Library for Cochrane reviews (CR) on (a) the 13 most frequent health problems in old age, which (b) evaluated components of integrated care management in (c) adults of all ages. Experts assessed the transferability of the included CR to multiple chronically ill older people in Germany. RESULTS: Out of 1412 hits 126 CR were included. Regarding independence and functional health outcomes, 25 CR showed clinically relevant results with at least a moderate level of evidence. The following intervention components were estimated to be transferable and could be adapted to be part of an effective integrated care management for multimorbid chronically ill older people, specified by indications and taking identified barriers into account: (1) physical activation, (2) multidisciplinary interventions (3) interventions that enhance self-management, (4) cognitive therapy modalities, (5) telemedical interventions and (6) disease management programs. CONCLUSION: The effectiveness of the identified components in frail older patients should be assessed in care-related and patient-related randomized controlled studies.

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BACKGROUND: General practitioners (GPs) are the first point of contact and they coordinate the care for multimorbid patients. This article discusses possible solutions for GPs' needs and wishes regarding the support for non-medical issues, in particular social and legal tasks as well as the cooperation with already existing institutions. METHODS: In the third study phase of a mixed-methods approach, two focus groups with eleven GPs from Berlin were carried out. The project is part of the NAVICARE project, funded by the federal Ministry of Education and Research. The focus groups were analyzed using the framework analysis. RESULTS: GPs caring for multimorbid patients are often faced with non-medical patient needs and social consultation issues. They would like to receive support in these areas and want more cooperative care structures. They are largely unaware of existing offers by social institutions in their city districts. The designation of a fixed contact person in social institutions could improve communication and thus enable low-threshold access. DISCUSSION AND CONCLUSION: The GPs agree that there is a need for support with social and legal matters in general practice. The focus groups discussed already existing offers that GPs could use more frequently and how a cooperation with providers of social care could succeed. GPs in Berlin think that support and relief measures, in particular in the form of cooperation with institutions in the district that provide social and legal support, are both desirable and conceivable.

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BACKGROUND: Soft tissue reconstruction in aged patients is challenging. Free tissue transfer can be carried out in healthy patients with a high success rate despite old age. When free tissue transfer is contraindicated in multimorbid patients, local flaps are often chosen, which are associated with a high complication rate. Such salvage interventions must be selected so that an amputation is not disadvantageously influenced by the selection of the donor site or is even impossible. METHODS: The three distally based local flaps the sural artery flap, peroneus brevis muscle flap and perforator-based propeller flaps are discussed with respect to placement of the donor site as well as wound healing disorders. RESULTS: The sural artery flap is disadvantageous as the donor site because the proximal dorsal calf region is affected, which in the case of a below the knee amputation enables soft tissue covering of the stump. CONCLUSION: If a local flap is to be used as a salvage surgery in an attempt to prevent a below the knee amputation in a patient who is not suitable for free tissue transfer, special emphasis must be placed on the donor site of this flap. The proximal dorsal aspects of the distal calf are required for covering a potential stump and should not be violated by harvesting a local flap.

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BACKGROUND: With demographic change, the number of noncommunicable diseases, chronic diseases and multimorbidity is increasing, and so is the demand for health services. This represents a further challenge for the healthcare system. An adequate and efficient treatment of multimorbid patients requires a well-structured, informed and cross-indicated treatment. Therefore, a new form of coordinated, managed and cross-sectoral care for multimorbid patients - the "MamBo" care model - has been developed. Along with the implementation of MamBo, a process and outcome evaluation will be carried out, which is described in this study protocol. The aim of the study is to evaluate the care model according to its implementation process and effectiveness. METHODS: The MamBo-care model will be evaluated in multi-perspective terms. Thus, a process and outcome evaluation with several data sources will be conducted: (1) Annual focus groups and individual interviews with those involved in the process. (2) Various primary data, including surveys of patients, physicians and practice staff at the time of enrolment and 1 year later to enable pre-post comparison. (3) Claim data from the health insurance of the MamBo population in comparison to a comparative population, formed by the propensity score matching method. (4) Process data of the care management. The analysis of qualitative data will be carried out by content analysis according to Mayring. For the analysis of the quantitative data, multivariate analyses are planned. DISCUSSION: A new form of coordinated care has been introduced to improve intersectoral care of multimorbid patients and reduce the workload on physicians. The effects of the MamBo care model are being investigated for patients, physicians and the cost units. The results will form the basis for the decision whether the care model should be transferred to standard care and what needs to be taken into account for implementation. TRIAL REGISTRATION: The study was retrospectively registered in the German Register for Clinical Studies (DRKS00014047) on June 28, 2019.

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BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a progressive and debilitating condition that affects individuals' quality of life. COPD self-management and supports provided by carers is key to the quality of life people living with COPD. Health literacy (HL) and Patient Activation (PA) are main drivers of self-management practices (SMPs). However, their contribution remains to be fully explored. This study aimed to examine the level of self-management practices, and the relationship with socio-demographic factors, HL and PA among multi-morbid COPD patients from rural Nepal. METHODS: This is a cross-sectional study conducted between July 2018 and January 2019. Patients completed a survey, including Self-management Practices questionnaire (SMPQ), five domains of the Health Literacy Questionnaire (HLQ), and Patient Activation Measure (PAM). The relationship between HL, PAM, and SMPs was examined using univariate statistics. Multivariable analysis was conducted to identify the factors associated with SMPs. RESULTS: A total of 238 patients responded to the study. The mean score of SMPQ was 45.31(SD = 9.00). The HLQ and PAM scores were positively correlated with the total score of SMPQ. Low level of SMPs were found to be positively associated with being uneducated (ß = - 0.43, p = .001), having a low family income (ß = - 5.22, p = .002), and, negatively associated with the presence of more than one co-morbidity (ß = 3.58, p = 0.007) after controlling for other socio-demographic variables in the multivariable analysis. CONCLUSION: The overall SMPs among this sample of Nepalese with COPD were low. Our findings highlight the need to implement a self-management intervention program involving patient activation and health literacy-focused activities for COPD, creating a support system for patients from low-income families and low education.

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