Understanding patterns and factors associated with place of death in patients with end-stage kidney disease: A retrospective cohort study.

BACKGROUND: Meeting place-of-death preferences is an important measure of the quality of end-of-life care. Systematic review shows that 42% of end-stage kidney disease patients prefer home death. Little research has been undertaken on place of death. AIM: To understand patterns of place of death in patients with end-stage kidney disease known in one UK renal unit. DESIGN: A retrospective cohort study of all patients with chronic kidney disease stage 4-5, age ⩾75 and known to one UK renal unit, who died between 2006 and 2012. Patients were categorised into three management pathways: haemodialysis, conservative and pre-dialysis. RESULTS: A total of 321 patients (mean age, 82.7; standard deviation, 5.21) died (61.7% male). In all, 62.9% died in hospital (95% confidence interval, 57.5%-68.1%), 21.8% died in their usual place of residence (95% confidence interval, 17.5%-26.6%) and 15.3% died in an inpatient palliative care unit (95% confidence interval, 11.6%-19.5%). Management pathway and living circumstances were most strongly associated with place of death. Patients on the conservative pathway had four times the odds of dying out of hospital (odds ratio, 4.0; 95% confidence interval, 2.1-7.5; p < 0.01). Patients living alone were less likely to die out of hospital (odds ratio, 0.3; 95% confidence interval, 0.1-0.6; p < 0.01). There were also changes in place of death over time, with more patients dying out of hospital in 2012 compared to 2006 (odds ratio, 3.1; 95% confidence interval, 1.0-9.7; p < 0.05). CONCLUSION: Most patients with end-stage kidney disease die in hospital, but patients managed without dialysis are significantly more likely to die outside of hospital. Planning ahead is key to be able to meet preference for place of death.

Case report of the duplex vermiform appendix: A rare presentation in an elderly patient.

INTRODUCTION AND IMPORTANCE: Duplex appendix is a rare anatomical entity with incidence rate of 0.004 and 0.009%. Diagnosis is often missed despite growth in radiological investigations. Missed appendiceal anomalies can lead to undesirable medicolegal implications. CASE PRESENTATION: Here we discuss a case of a 76-year-old-male who initially presented to his primary care physician with right-sided abdominal pain for several weeks. A colonoscopy was performed and demonstrated a lesion arising from the appendicular orifice. The patient underwent staging imaging including Computerised Tomography of the abdomen and pelvis which demonstrated a dilated appendix. The patient underwent a laparoscopic right hemicolectomy. He made an uneventful recovery post-operatively and at his follow-up review at 4 weeks and 2 months. DISCUSSION: While duplex appendix has been reported in the literature, to our knowledge this is the first case report to describe duplicated appendix presenting as a colonic mass in an elderly patient. CONCLUSION: Intra-operative examination of the cecum is paramount to rule out appendiceal anomalies and prevent medicolegal complications.