Role and relevance of dentists in a multiprofessional palliative care team: results of a cross-sectional survey study.

PURPOSE: Despite the multiprofessional concept surrounding palliative care patients (PCPs) and their high prevalence of oral issues, licensed dentists (LDs) are often not included in their treatment team. This study aimed to examine the current state of cooperation and to determine whether and how LDs should be included in the care for PCPs. METHODS: This single-centre cross-sectional study was conducted at the University Hospital Muenster, Germany. We surveyed three participant groups: PCPs, LDs, and healthcare professionals (HCPs). Questionnaires were tailored for each group, with some questions common for comparison. RESULTS: The study encompassed the results of 48 questionnaires from LDs, 50 from PCPs along with 50 from HCPs. Consensus was reached among all parties (LDs: 73% (n = 35/48); HCPs: 94%, n = 47/50; PCPs: 60%, n = 30/50) that involving LDs in the treatment concept is favourable. On the other hand, a significant discrepancy emerged in the perception of the dental treatment effort required by PCPs. While LDs (81%; n = 39/48) and HCPs (64%; n = 32/50) were convinced of increased effort, PCPs (34%; n = 17/50) largely did not share this perspective. To enhance patient care and formulate appropriate treatment plans, LDs consider both training (58%; n = 28/48) and guidebooks (71%; n = 34/48) to be valuable and would attend or use such resources. CONCLUSION: This study sheds light on the current gaps in including LDs in palliative care teams and emphasizes the importance of multidisciplinary collaboration to address oral health needs effectively. Development of continuing education options and collaborative models between LDs and HCPs needs to be further expanded in future.

Telemedicine Plus Standard Care Versus Standard Care Only in Specialized Outpatient Palliative Care: A Randomized Controlled Noninferiority Trial.

Background: Patients suffering from incurable diseases are more likely to die in the hospital than at home. Specialized outpatient palliative care (PC) may be able to counteract this tendency. Similarly, potential benefits of telemedicine in health care were scientifically reported. The aim of this research was to compare patients receiving specialized outpatient PC plus telemedicine with those receiving standard specialized outpatient PC only. In this study, telemedicine is assumed to decrease the number of home visits and therefore should not be considered a mere add-on. Methods: This is a randomized controlled noninferiority trial. Recruitment lasted between January 2020 and October 2021. Quality of care was evaluated using the Integrated Palliative Care Outcome Scale (IPOS) at day 0, 7, and 14 after randomization. Change from day 0 to 7 was defined as the primary outcome (noninferiority margin = 4 points). This study was conducted in an urban setting in collaboration with a university hospital and a local specialized outpatient PC service. Results: A total of 196 patients were screened with 34 patients included (18 telemedicine/16 standard care). The mean change in the total score of the IPOS from day 0 to 7 amounted to -1.8 ± 3.9 (telemedicine) versus 1.2 ± 5.7 (standard care). The telemedicine group was statistically not relevantly inferior to the standard care group (t-test for noninferiority, p = 0.005). Conclusions: Although, due to COVID-19, the sample size remained rather small, our findings indicate that telemedical approaches offer a promising and equally effective option to provide specialized outpatient PC. Clinical Trial Registration Number: NCT06054048.

Palliative care on the radiation oncology ward-improvements in clinical care through interdisciplinary ward rounds.

INTRODUCTION: Palliative care is essential for patients with terminal diseases and aims at effective symptom control. This may stand in opposition to radiation treatment as an oncological treatment modality. The hereby presented work demonstrates the successful integration of a palliative care service in the radiation oncology ward. METHODS: Since 2015, 1018 patients were seen by the palliative care service on the radiation oncology ward and have been analyzed in this single center study. To assess teaching efficacy of the consultation service, a survey was conducted among 15 radiation oncology residents. RESULTS: Cooperation between the two departments proved to be efficient with rising patient numbers. Palliative care was able to guide appropriate postdischarge care with the number of patients dying on the radiation oncology ward decreasing significantly (p = 0.009). The main topics for consultation were pain medication (92.3%), organization of postdischarge care (92.3%), and psycho-oncological support (84.6%). Most residents had a positive image of the palliative care service and consented on adjectives like "enriching", "empathic", "collegial", "professionally founded", and a "low threshold for consultation". All participants agreed that cooperation deepened their knowledge on palliative care. CONCLUSION: A synergistic cooperation between a palliative care consultation service and a radiation oncology department addresses patient symptoms on an individual level. It confers advanced knowledge on palliative care which is essential for resident education and patient treatment.

Psychometric properties and normative values of the revised demoralization scale (DS-II) in a representative sample of the German general population.

BACKGROUND: Demoralization is a clinically relevant syndrome in chronic diseases. The demoralization scale (DS-II) was recently developed as an economic screening tool in clinical populations. Main aim of this study was to provide normative data of DS-II scores in the general population. METHODS: We developed a new German version, the DS-II Münster, and tested internal consistency as well as the previously proposed two-factor structure with confirmatory factor analyses. The DS-II was applied in a household survey of the general population. Associations between DS-II scores and age, gender and other sociodemographic variables were explored. RESULTS: The final sample consisted of N = 2471 participants (mean age = 49.8 years, range: 18-96; 50.1% men, 49.8% women). The DS-II Münster showed nearly excellent internal consistency. The model fit indices of the two-factor structure were not superior to those of the one-factor model. Mean scores of the DS-II were as follows. Total score: M = 3.76 (SD = 5.56), Meaning and Purpose subscale: M = 1.65 (SD = 2.77), Distress and Coping Ability subscale: M = 2.11 (SD = 3.02). DS-II scores were increased in women with an effect size of Cohen's d = 0.19. An age-related increase was specifically found for the Meaning and Purpose subscale (d = 0.21). CONCLUSIONS: The study provides normative values of the DS-II with respect to age and gender in the general population to facilitate interpretation of DS-II scores in clinical samples. A DS-II total score > 5 is suggested as a cut-off value. The findings further our understanding of significant symptom burden that was previously suggested in young patients with cancer.

[Places of death of COVID-19 patients: an observational study based on evaluated death certificates from the city of Muenster, Germany (2021)]. / Sterbeorte von COVID-19-Patienten: eine Observationsstudie auf Grundlage ausgewerteter Todesbescheinigungen der Stadt Münster (2021).

INTRODUCTION: The places of death of COVID-19 patients have so far hardly been investigated in Germany. METHODS: In a places of death study in Westphalia (Germany), statistical evaluations were carried out in the city of Muenster on the basis of all death certificates from 2021. Persons who had died with or from a COVID-19 infection were identified by medical information on cause of death and analyzed with descriptive statistical methods using SPSS. RESULTS: A total of 4044 death certificates were evaluated, and 182 deceased COVID-19 patients were identified (4.5%). In 159 infected patients (3.9%), the viral infection was fatal, whereby the distribution of places of death was as follows: 88.1% in hospital (57.2% in the intensive care unit; 0.0% in the palliative care unit), 0.0% in hospice, 10.7% in nursing homes, 1.3% at home, and 0.0% in other places. All infected patients < 60 years and 75.4% of elderly patients ≥ 80 years died in hospital. Only two COVID-19 patients, both over 80 years old, died at home. COVID-19 deaths in nursing homes (17) affected mostly elderly female residents. Ten of these residents had received end-of-life care from a specialized outpatient palliative care team. DISCUSSION: The majority of COVID-19 patients died in hospital. This can be explained by the rapid course of the disease with a high symptom burden and the frequent young age of the patients. Inpatient nursing facilities played a certain role as a place of death in local outbreaks. COVID-19 patients rarely died at home. Infection control measures may be one reason why no patients died in hospices or palliative care units.

Virtual reality reduces pain in palliative care-A feasibility trial.

BACKGROUND: Effective symptom control is a stated goal of palliative care (PC) to improve quality of life for terminally ill patients. Virtual reality (VR) provides temporary escapes from pharmacologically resistant pain and allows for experiences and journeys patients may not access in any other way. Enabling wishes through virtual worlds may also offer additional benefits such as controlling psychological and physical symptoms. AIMS: We investigated the feasibility of a single VR experience as a viable, satisfying, and effective tool for end-of-life pain relief for inpatients presenting palliative needs. DESIGN: This is an observational, single-arm and national single-center feasibility trial. METHODS: A one-time VR experience with a selection of several videos and games was offered to 45 inpatients receiving PC at Muenster University Hospital. Patients with brain tumors, brain metastases, seizures, motion sickness, claustrophobia, vertigo, hearing or visual impairment, or unable to consent were excluded. Primary outcome measured patient reported pain on a visual analogue scale (VAS). We also measured Karnofsky performance status, health-related quality of life (HRQOL) using the EQ-5D-5 L questionnaire, and the Pain Out Questionnaire for postoperative pain. RESULTS: We analyzed data from 21 women (52.5%) and 19 men (47.5%) at an average age of 51.9 (SD: 15.81) years. The mean Karnofsky score among the sample was 45.5 (SD: 14.97) and the HRQOL was 41.9 (SD: 23.08). While no serious side effects were reported during the intervention, three patients experienced nausea (7%), two headaches (5%), and three reported dry eyes (7%) afterwards. Significant pain reduction (baseline VAS 2.25 (SD: 0.4399)) was demonstrated during (VAS 0.7 (SD: 0.2983, p < 0.0001)), immediately after (VAS 0.9 (SD: 0.3354, p = 0.0001)) and one hour after the intervention (VAS 1.15 (SD: 0.4163, p = 0.0004)). More than 80% rated the VR experience as very good or good (85%, n = 34) and intended to make use of the device again (82.5%, n = 33). However, two participants (5%) also expressed sadness by becoming aware of old memories and previous opportunities that are gone. DISCUSSION: The present pilot study suggests that VR seems to be a feasible and effective tool for pain relief in PC. Its use encompasses the approach of a total pain and symptom therapy and enhances patients' dignity and autonomy. Future research ought to include if and to what extent VR could reduce the necessity of pharmacological pain relief.

[The Place of Death of Neurological Patients with Selected Disease Entities: Data from an Observational Study on Places of Death from Germany]. / Der Sterbeort neurologischer Patienten mit ausgewählten Erkrankungsentitäten: Daten einer Beobachtungsstudie zu Sterbeorten aus Deutschland.

BACKGROUND: So far, there are only few data on places where neurological patients die in Germany. METHODS: In the context of the most comprehensive study on the place of death in Germany to date, the present investigation examined the place of death of neurological patients with selected disease entities (ALS (ALS), malignant neoplasm of the brain (BNG), brain metastasis(es) (HM), hypoxic brain damage after resuscitation (HHS), non-traumatic SAB (SAB), dementia (≥65 years) (DEM)). All death certificates issued in the city of Münster of 2017 were evaluated. Patients were identified on the basis of the medical information on the cause of death. RESULTS: A total of 3,844 people died, including neurological patients with the following disease entities: ALS (6), BNG (29), HM (102), HHS (54), SAB (20), DEM (485). The distribution of places of death was as follows: (AS, BNG, HM, HHS, SAB, DEM;%): home 50.0/10.3/13.7/1.9/0.0/12.0; hospital 33.3/48.3/38.2/90.7/100/23.1; intensive care unit 0.0/6.9/5.9/61.1/65.0/2.7; palliative care unit 33.3/0.0/6.9/0.0/0.0/1.4; hospice 16.7/27.6/43.1/0.0/0.0/1.2; nursing home 0.0/13.8/4.9/7.4/0.0/63.7; other places 0.0/0.0/0.0/0.0/0.0/0.0. CONCLUSION: The most common place of death of neurological patients with selected disease entities is as follows: ALS>home, malignant brain tumour>hospital, brain metastasis(es)>hospice, hypoxic brain injury after resuscitation>hospital, non-traumatic SAB>hospital, dementia patients (≥65 years)>nursing home.

[Place of death of older people with dementia : Epidemiological data from an observational study of places of death in Germany (2001, 2011, 2017)]. / Der Sterbeort älterer Menschen mit einer Demenz : Epidemiologische Daten einer Beobachtungsstudie zu Sterbeorten in Deutschland (2001, 2011, 2017).

BACKGROUND: Dementia is increasingly perceived as a terminal illness due to disease progression with a shortened life expectancy and often a lack of therapeutic options. In the context of palliative care, the preferred place of death is considered a quality indicator for needs-based patient care. The aim of this study was to describe the distribution of places of death of older patients with dementia. MATERIAL AND METHODS: Death certificates from the years 2001, 2011 and 2017 were evaluated from the most comprehensive study on places of death in Germany to date, conducted in selected regions of Westphalia. Medical information on the cause of death was also analyzed. In this way, deceased patients with dementia ≥ 65 years (ICD-10: F01, F02, F03, G30) were identified and the distribution of their places of death statistically determined. RESULTS: Dementia was present in 4720 out of 31,631 (14.9%; 95% CI: 14.5-15.3%) deceased patients ≥ 65 years. The distribution of places of death was as follows (%; age-standardized; 2001/2011/2017): home environment 24.0/19.7/15.8, hospital 40.4/29.0/24.3, palliative care unit 0.0/0.3/1.8, hospice 0.4/0.9/0.9, nursing home 35.2/49.5/57.1 and other places 0.0/0.0/0.0. CONCLUSION: The majority of older patients (≥ 65 years) with dementia die in nursing homes, followed by hospitals and the home environment. Palliative care units and hospices play a subordinate role as places of death for patients with dementia.

Oxy-Borylenes as Photoreductants: Synthesis and Application in Dehalogenation and Detosylation Reactions.

While the range of accessible borylenes has significantly broadened over the last decade, applications remain limited. Herein, we present tricoordinate oxy-borylenes as potent photoreductants that can be readily activated by visible light. Facile oxidation of CAAC stabilized oxy-borylenes (CAAC)(IPr2 Me2 )BOR (R=TMS, CH2 CH2 C6 H5 , CH2 CH2 (4-F)C6 H4 ) to their corresponding radical cations is achieved with mildly oxidizing ferrocenium ion. Cyclovoltammetric studies reveal ground-state redox potentials of up to -1.90 V vs. Fc+/0 for such oxy-borylenes placing them among the strongest organic super electron donors. Their ability as photoreductants is further supported by theoretical studies and showcased by the application as stoichiometric reagents for the photochemical hydrodehalogenation of aryl chlorides, aryl bromides and unactivated alkyl bromides as well as the detosylation of anilines.

Bowel Preparation With Polyethylene Glycol 3350 or Fasting Only Before Peroral Single-balloon Enteroscopy: A Randomized European Multicenter Trial.

BACKGROUND: Although bowel preparation before colonoscopy and capsule endoscopy is widely evaluated and usually follows established guidelines, a standard preparation regime for peroral small bowel enteroscopy is yet to be defined.The aim of the present study was to compare small bowel preparation with polyethylene glycol (PEG) and "fasting only" (FO) before peroral single-balloon enteroscopy (SBE). STUDY: We compared small bowel preparation with PEG versus "FO" for peroral SBE in a randomized European multicenter trial. Patients' and procedural characteristics were documented and carefully analyzed. Primary endpoint was the oral intubation depth of the small bowel. A modified Boston preparation scale was used to assess bowel cleansing as a secondary endpoint. RESULTS: In total, 43 patients were enrolled in this study (FO group: n=25; PEG group: n=18). In both groups, patients' characteristics were comparable. The indications for oral enteroscopy were equally distributed in both groups (P=0.894). The oral intubation depth was significantly higher in the PEG versus the FO group (261±87 vs. 203±66 cm; P=0.019; mean±SD), while the quality of bowel preparation was equally sufficient in both groups [complete visualization of the mucosa (Boston preparation scale) 83% versus 76% (P=1.000)]. CONCLUSIONS: Small bowel preparation with PEG for SBE yields significantly deeper intubation as compared with "FO" preparation. As patient comfort and safety was similar in both groups, PEG preparation might be favored, especially if deep intubation of the small bowel is desired. For patients requiring visualization of the proximal jejunum, a FO preparation seems to be sufficient.

Endocuff-assisted colonoscopy: a new accessory to improve adenoma detection rate? Technical aspects and first clinical experiences.

BACKGROUND AND STUDY AIMS: The Endocuff is a new colonoscopy accessory that has been designed to improve both the adenoma detection rate and endoscope tip control. PATIENTS AND METHODS: A total of 50 Endocuff-assisted colonoscopies were analyzed retrospectively with regard to safety, procedural success, and complications. RESULTS: The cecal intubation rate was 98 %, and the mean intubation time was 6.0 minutes (95 % confidence interval 5.3 - 6.6 minutes). The ileal intubation rate was 76 %. In 30 % of patients, the Endocuff caused small, superficial, "scratch-like" mucosal lesions. In all other patients, no Endocuff-associated complications were observed. A total of 36 adenomas were detected in 50 patients. The adenoma detection rate was 34 %. CONCLUSIONS: Endocuff-assisted colonoscopy showed good procedural success rates in terms of cecal intubation rate and time, and a promising adenoma detection rate. Endocuff seems to improve endoscope tip control, especially during polypectomy. Endocuff may be a useful device for colorectal adenoma screening, and should be investigated in larger trials.

CO2 insufflation during single-balloon enteroscopy: a multicenter randomized controlled trial.

BACKGROUND AND STUDY AIMS: Carbon dioxide (CO2) insufflation has previously been shown to have advantages over air insufflation in terms of procedure-related pain and oral insertion depth during double-balloon enteroscopy. The aim of this prospective study was to evaluate the performance of CO2 vs. air insufflation during single-balloon enteroscopy. PATIENTS AND METHODS: This study was a randomized European multicenter trial (ClinicalTrials.gov: NCT01524055). Patients and endoscopists were blinded to the type of insufflation gas used. Patient discomfort during and after the procedure was scored using a visual analog scale. RESULTS: A total of 107 patients were enrolled in the study (52 in the CO2 group and 55 in the air group). Patient characteristics were comparable in both groups. The mean (±SD) oral intubation depth was not significantly deeper in the CO2 group vs. the air group (254±80 vs. 238±55 cm; P=0.726). However, in patients with previous abdominal surgery, oral intubation depth was significantly higher in the CO2 group compared with the air group (258±84 vs. 192±42 cm; P<0.05). In patients undergoing SBE via the anal approach, CO2 showed no significant difference in intubation depth compared with air insufflation (86±67 vs. 110±68 cm; P=0.155). The diagnostic yield was comparable (CO2 67%; air 73%). Procedure times, dosage of sedation, and therapeutic interventions did not differ between the two groups. Patients in the CO2 group reported less pain than those in the air group. CONCLUSIONS: This study demonstrated an advantage of using CO2 insufflation during single-balloon enteroscopy in patients with a history of previous abdominal surgery. Overall, single-balloon enteroscopy was a well-tolerated procedure that may benefit from the use of CO2 insufflation to reduce post-procedural pain.

Older adults coping with critical life events - results of the revised demoralization scale in a representative sample of older adulthood.

Background: High suicide rates in older adults are a relevant public health concern. Social isolation or widowhood as well as physical decline play a crucial role for suicidality in older adulthood. Previous evidence suggested that demoralization is an important risk factor for suicide. Whether demoralization is a relevant phenomenon in older adulthood which possibly could account for high suicide rates remains unclear. Methods: Demoralization Scale II (DS-II) scores assessed in a survey of the German general population were investigated with respect to older adults (aged ≥ 65 years). DS-II scores were compared between older (≥ 65 years) and younger (< 65 years) adulthood and between young-old (65-74y), middle-old (75-84y), and old-old (85+y) individuals. We tested the impact of sociodemographic factors on DS-II scores within older adults. Results: The sample comprised N = 545 adults ≥ 65 years and N = 1922 adults < 65 years. DS-II scores increased in older compared to younger adults (F(1,2465) = 6.1; p = 0.013; d = 0.09) and further from young-old to old-old (Mdiff = 2.7; 95% CI 0.45, 5.46; p = 0.034). One-fourth of individuals ≥ 65 years and almost half of old-old individuals reported DS-II scores above the cut-off > 5. Living with a partner protected from demoralization in old-old individuals. Discussion: This study provides first evidence for an increased rate of demoralization in very old adults, in particular women, which is partly related to partnership status. We suggest that demoralization is considered as a crucial entity in older adulthood which can be missed by standard psychological screenings.

Double- vs. single-balloon enteroscopy: single center experience with emphasis on procedural performance.

PURPOSE: This study aims to compare double- (DBE) and single-balloon enteroscopy (SBE) in small bowel disorders with respect to procedural performance and clinical impact. METHODS: This retrospective analysis at a tertial referral center included 1,052 DBEs and 515 SBEs performed in 904 patients over 7 years. Procedural and patients' characteristics were precisely analyzed. RESULTS: Significantly more patients with anemia and gastrointestinal bleeding were investigated by DBE (P < 0.01). Oral insertion depth and length of investigated small bowel in the combined approach were significantly higher in the DBE compared to the SBE group (245 ± 65.3 vs. 218 ± 62.6 and 355 ± 101.9 vs. 319 ± 91.2, respectively; P < 0.001, each). By analyzing only recent years of enteroscopy (2008-2011), no difference in small bowel visualization could be observed. The anal insertion depths and complete enteroscopy rates (CER) were comparable. Procedure times were significantly shorter within the SBE procedure (oral: 50 vs. 40 min; anal: 55 vs. 46 min, P < 0.001) and the usage of sedation was significantly less (propofol: P < 0.001; pethidine: P < 0.05). Diagnostic yield was significantly higher in the SBE, compared to the DBE group (61.7 vs. 48.2 %; P < 0.001). The rate of severe adverse events was close to zero. CONCLUSION: Both enteroscopy techniques are safe diagnostic tools and proved to be indispensable in the daily gastroenterological practice. The lower insertion depths, but higher diagnostic yield, of SBE may reflect the more focused selection of patients scheduled for small bowel diagnostics in recent years.