Long-term experience on assisted suicide in Switzerland: dementia, mental disorders, age-related polymorbidity and the slippery slope argument.

OBJECTIVES: According to the Swiss medico-ethical guidelines valid between 2004 and 2018, the key criterion for assisted suicide (AS) was that the patients who wished to die suffered with a disease leading to death in the foreseeable future. Critics of AS fears that broadening of the medical indications will lead to an uncontrolled expansion to persons who are not terminally ill (slippery slope argument). We evaluated to what extent this broadening took place in practice over time. STUDY DESIGN: Retrospective national cohort study. METHODS: By using data of the Swiss Federal Statistical Office, we analyzed the long-term development of AS in Switzerland over a 20-year period (1999-2018; n = 8738 cases). We classified the cases into one of three categories regarding the aforementioned key criterion for AS. RESULTS: In 43.6% of AS cases, the criterion 'end of life is near' was met. In 5.3% of cases, this criterion was not met (4.7%: mental disorders; 0.6%: dementia). In 51.1% of cases, the reason underlying AS comprised several, mostly age-related diseases and/or functional impairments; the aforementioned key criterion, however, was probably not met in most of the cases. Over time, the number of cases doubled over each 5-year period; this increase occurred similarly for the three categories. CONCLUSION: The fact that many AS cases took place outside the valid medico-ethical guidelines might be interpreted as a development in the idea of the slippery slope argument. The fact that the percentage distribution of these cases remained unchanged over time argues against it.

Assisted suicide in patients with cancer.

BACKGROUND: There are limited data on the long-term development and trends of assisted suicide (AS) among cancer patients. PATIENTS AND METHODS: Using data of the Swiss Federal Statistical Office, we analyzed AS trends over an 18-year period (1999-2016; total number of cases = 6553). RESULTS: Among patients who underwent AS, cancer was the most common underlying disease (n = 2704, 41.3% of all AS cases). The most common cancer types were lung (14.0% of cancer-related AS cases), breast (11.0%) and prostate (10.1%). There was a slight preponderance of men compared with women (51.5% versus 48.5%). The proportion of AS cases within cancer types did not change over time. The ratio of cancer-related AS cases in relationship with all cancer-related deaths increased from 0.3% at the beginning of the study period (1999-2003) to 2.1% from 2014 to 2016 (change of age-standardized rates for men: +488%; for women: +417%). At the end of the study period (2014-2016), there were only minor differences between cancer-specific ratios, highest and lowest range: 1.1% (liver cancer) and 2.8% (breast, esophageal and lip/oral cavity/oropharynx cancer). Individuals who underwent AS because of cancer were considerably younger than those who choose AS on account of other diseases (73 years versus 80 years). The median age of people with cancer-related AS was similar to that of all cancer-related deaths (74 years): for women, the median age of cancer-related AS was 72, whereas for men it was 75. The median age at which AS took place increased over time. CONCLUSIONS: During the study period, the proportion of people who chose cancer-related AS has approximately sextupled. However, AS among cancer patients remains rare and represents only ∼2% of all cancer-related deaths.

European all-cause excess and influenza-attributable mortality in the 2017/18 season: should the burden of influenza B be reconsidered?

OBJECTIVES: Weekly monitoring of European all-cause excess mortality, the EuroMOMO network, observed high excess mortality during the influenza B/Yamagata dominated 2017/18 winter season, especially among elderly. We describe all-cause excess and influenza-attributable mortality during the season 2017/18 in Europe. METHODS: Based on weekly reporting of mortality from 24 European countries or sub-national regions, representing 60% of the European population excluding the Russian and Turkish parts of Europe, we estimated age stratified all-cause excess morality using the EuroMOMO model. In addition, age stratified all-cause influenza-attributable mortality was estimated using the FluMOMO algorithm, incorporating influenza activity based on clinical and virological surveillance data, and adjusting for extreme temperatures. RESULTS: Excess mortality was mainly attributable to influenza activity from December 2017 to April 2018, but also due to exceptionally low temperatures in February-March 2018. The pattern and extent of mortality excess was similar to the previous A(H3N2) dominated seasons, 2014/15 and 2016/17. The 2017/18 overall all-cause influenza-attributable mortality was estimated to be 25.4 (95%CI 25.0-25.8) per 100,000 population; 118.2 (116.4-119.9) for persons aged 65. Extending to the European population this translates into over-all 152,000 deaths. CONCLUSIONS: The high mortality among elderly was unexpected in an influenza B dominated season, which commonly are considered to cause mild illness, mainly among children. Even though A(H3N2) also circulated in the 2017/18 season and may have contributed to the excess mortality among the elderly, the common perception of influenza B only having a modest impact on excess mortality in the older population may need to be reconsidered.

Trends in hepatitis C-related mortality in Switzerland.

In order to accurately assess the burden of hepatitis C (HCV) and develop effective interventions, we must understand the magnitude and trends of mortality related to the disease. In the United States, HCV-related mortality is continuously increasing. We have no comparable data for Switzerland and other European countries, although a modelling study predicted a similar increase. We analysed time trends (1 January 1995-31 December 2014) in HCV-specific mortality rates in the Swiss general population using the death registry of the Swiss Federal Statistical Office (SFSO). We compared HCV-related mortality to HIV-related and hepatitis B (HBV)-related mortality. To determine potential under-reporting in HCV-related mortality, we probabilistically linked the SFSO data to persons who died in the Swiss Hepatitis C Cohort Study (SCCS). SFSO data showed that HCV-related mortality more than doubled between 1995 and 2003, but has since stabilized at ~2.5/100 000 person-years. Since 2000, HCV-related mortality has been higher than HIV-related mortality and was about fivefold higher in 2014. HBV-related mortality remained low at ~0.5/100 000 person-years. Of 4556 persons in the SCCS, 421 have died and 86.2% could be linked to the death registry. According to the SCCS, 133 deaths were HCV-related. HCV was not mentioned on the SFSO death certificate of 45% of these (n = 60/133). In conclusion, HCV-related mortality remained constant, possibly because quality of care was high, or because of under-reporting or because mortality has not yet increased. However, HCV-related mortality is now much higher than HIV- and HBV-related mortality, and under-reporting was common.

Excess mortality among the elderly in European countries, December 2014 to February 2015.

Since December 2014 and up to February 2015, the weekly number of excess deaths from all-causes among individuals ≥ 65 years of age in 14 European countries have been significantly higher than in the four previous winter seasons. The rise in unspecified excess mortality coincides with increased proportion of influenza detection in the European influenza surveillance schemes with a main predominance of influenza A (H3N2) viruses seen throughout Europe in the current season, though cold snaps and other respiratory infections may also have had an effect.

Pooling European all-cause mortality: methodology and findings for the seasons 2008/2009 to 2010/2011.

Several European countries have timely all-cause mortality monitoring. However, small changes in mortality may not give rise to signals at the national level. Pooling data across countries may overcome this, particularly if changes in mortality occur simultaneously. Additionally, pooling may increase the power of monitoring populations with small numbers of expected deaths, e.g. younger age groups or fertile women. Finally, pooled analyses may reveal patterns of diseases across Europe. We describe a pooled analysis of all-cause mortality across 16 European countries. Two approaches were explored. In the 'summarized' approach, data across countries were summarized and analysed as one overall country. In the 'stratified' approach, heterogeneities between countries were taken into account. Pooling using the 'stratified' approach was the most appropriate as it reflects variations in mortality. Excess mortality was observed in all winter seasons albeit slightly higher in 2008/09 than 2009/10 and 2010/11. In the 2008/09 season, excess mortality was mainly in elderly adults. In 2009/10, when pandemic influenza A(H1N1) dominated, excess mortality was mainly in children. The 2010/11 season reflected a similar pattern, although increased mortality in children came later. These patterns were less clear in analyses based on data from individual countries. We have demonstrated that with stratified pooling we can combine local mortality monitoring systems and enhance monitoring of mortality across Europe.

Excess mortality among the elderly in 12 European countries, February and March 2012.

In February and March 2012, excess deaths among the elderly have been observed in 12 European countries that carry out weekly monitoring of all-cause mortality. These preliminary data indicate that the impact of influenza in Europe differs from the recent pandemic and post-pandemic seasons. The current excess mortality among the elderly may be related to the return of influenza A(H3N2) virus, potentially with added effects of a cold snap.

Higher all-cause mortality in children during autumn 2009 compared with the three previous years: pooled results from eight European countries.

The paper describes weekly fluctuations of all-cause mortality observed in eight European countries during the period between week 27 and 51, 2009, in comparison with three previous years. Our preliminary data show that the mortality reported during the 2009 influenza pandemic did not reach levels normally seen during seasonal influenza epidemics. However, there was a cumulative excess mortality of 77 cases (1 per 100,000 population) in 5-14-year-olds, and possibly also among 0-4-year-olds.

The TLR4 +896 polymorphism is not associated with lipopolysaccharide hypo-responsiveness in leukocytes.

Toll-like receptor 4 (TLR-4) is required for detection of Gram negative bacterial infections by binding lipopolysaccharide (LPS) and for the initiation of inflammatory signaling. Recent studies have demonstrated that a nonsynonymous single-nucleotide polymorphism (Asp299Gly, A+896G) is associated with decreased endotoxin responsiveness and poor outcomes from sepsis. We show that human carriers of this polymorphism show no deficit in LPS induced peripheral blood mononuclear cell (PBMC) mitogen-activated protein kinase (MAPK) activity, no reduction in sensitivity to endotoxin, and variable differences in whole-blood inflammatory cytokine production. These results indicate that this mutation is not a primary determinant of human endotoxin sensitivity.

Motivation for smoking cessation: what role do doctors play?

PRINCIPLES: Cigarette smoking causes an estimated 13% of all deaths in Switzerland. Though most smokers will eventually become ex-smokers of their own volition, physicians play an important role in accelerating the process of quitting among smoking patients. Even brief advice from physicians is effective in doing so. The purpose of this study was to investigate which smokers were asked about their smoking habits, and how often, whether they received advice to quit, and how this correlates with the patient's desire to quit. METHODS: Telephone interviews were carried out with a random sample of smokers and ex-smokers from the German-speaking Swiss population (n = 993). We collected information on personal characteristics, smoking habits, and recall of physicians' advice. Data was analysed descriptively and by logistic regression. RESULTS: 88% recalled being asked by a doctor about their smoking habits. In contrast, only 34% of smoking patients recalled being advised to stop. Women, older people and those in poor subjective health were asked more frequently. Heavier smokers and those in poor subjective health were advised more frequently. Current smokers more frequently express the desire to quit if they are heavier smokers and have been advised to quit by their physician, compared with those who have not received such advice. CONCLUSIONS: Similarly to the international findings, smoking patients in Switzerland receive brief advice with insufficient frequency. Action should therefore be taken to encourage health professionals not only to question all smoking patients but to advise and motivate them to quit smoking.

[Does the structure of medical services affect the proportion of death in hospitals? An ecological analysis in the mobility regions of Switzerland?]. / Beeinflusst die medizinische Versorgungsstruktur den Anteil Todesfälle im Spital? Eine ökologische Analyse in den MS-Regionen der Schweiz.

OBJECTIVES: With the discussion about measures to reduce over-capacities in the health services in mind, we examined the influence of medical supply structures and services on hospital utilisation directly before death. METHODS: Based on the specification of the place of dying from the death certificates, we determined the proportions of deaths in hospitals in an ecological study. We analysed deaths of persons above age 65 in each of the 106 mobility regions of Switzerland in the years 1979 to 1980. RESULTS: The proportion of deaths occurring in hospitals varied between 27% and 81%. Despite missing data regarding stationary and ambulatory care services, more than half of the variance could be explained by means of a multivariate regression analysis. Our results imply an inverse relation between the proportion of deaths in the hospital and the number of consultations provided by primary care physicians, as well as the number of nursing home beds. Further, we observe a direct relation to the number of hospital beds in a region. All indicators are calculated per inhabitant. CONCLUSIONS: In health care supply planning, such systematic associations should be taken into account. We recommend to analyse regularly interregional differences in supply and outcome of medical performances with the best available data.

Occupational class and ischemic heart disease mortality in the United States and 11 European countries.

OBJECTIVES: Twelve countries were compared with respect to occupational class differences in ischemic heart disease mortality in order to identify factors that are associated with smaller or larger mortality differences. METHODS: Data on mortality by occupational class among men aged 30 to 64 years were obtained from national longitudinal or cross-sectional studies for the 1980s. A common occupational class scheme was applied to most countries. Potential effects of the main data problems were evaluated quantitatively. RESULTS: A north-south contrast existed within Europe. In England and Wales, Ireland, and Nordic countries, manual classes had higher mortality rates than nonmanual classes. In France, Switzerland, and Mediterranean countries, manual classes had mortality rates as low as, or lower than, those among nonmanual classes. Compared with Northern Europe, mortality differences in the United States were smaller (among men aged 30-44 years) or about as large (among men aged 45-64 years). CONCLUSIONS: The results underline the highly variable nature of socioeconomic inequalities in ischemic heart disease mortality. These inequalities appear to be highly sensitive to social gradients in behavioral risk factors. These risk factor gradients are determined by cultural as well as socioeconomic developments.

Adherence to published standards of reporting: a comparison of placebo-controlled trials published in English or German.

CONTEXT: Although standards of reporting randomized controlled trials are well established internationally, essential study elements continue to be omitted, which hampers interpretation and systematic review of randomized controlled trials. OBJECTIVE: To identify deficiencies in the quality of reporting of placebo-controlled randomized trials published in German or English. DESIGN: Observational study comparing 32 German- and 89 English-language reports of placebo-controlled trials with parallel design, published by the same group of authors between 1985 and 1994. MAIN OUTCOME MEASURE: High reporting quality, defined as adherence to published standards and measured by an 18-item scale based on 2 standard guidelines. RESULTS: The mean quality score was 8.4 (SD, 3.0; range, 1-16) of 18. The difference of the mean quality scores between English-language reports compared with German-language reports was small (0.27; 95% confidence interval, -0.97 to 1.52). More articles reported clinical aspects than trial methods or statistics. CONCLUSION: There is room for improvement in the reporting of placebo-controlled randomized trials for both English and German reports.

Neurological intensive care admissions: identifying candidates for intermediate care and the services they receive.

OBJECTIVE: The high cost and scarcity of intensive care unit (ICU) beds has resulted in a need for improved utilization. This study describes the characteristics of patients who are admitted to the ICU for neurosurgical and neurological care, identifies patients who might receive all or most of their care in an intermediate care unit, and describes the services the patients would receive in an intermediate care unit. METHODS: We describe patients who received neurological care and who were part of a prospective study of 17,440 patients admitted to 42 ICUs at 40 United States hospitals. We identified patients who received only monitoring during ICU Day 1 and then used a previously validated equation to distinguish which patients were at low risk (< 10%) for subsequent active life-supporting therapy. We also describe the services these patients received during their ICU stay. RESULTS: Among 3000 patients admitted to the ICU for neurological care, 1350 received active therapy and 1650 (55%) underwent monitoring and received concentrated nursing care on ICU Day 1. After excluding those patients who received active therapy at admission, 1288 (78%) of the 1650 patients who underwent monitoring at admission were at low risk (< 10%) for subsequent active therapy; 95.8% received no active therapy. These patients who were at low risk for subsequent active therapy were significantly (P < 0.001) more often admitted postoperatively, were younger and less severely ill, and had lower ICU and hospital mortality rates (0.9 and 3.9%, respectively) than patients who received active treatment at admission. CONCLUSIONS: Patients receiving neurological care at an ICU who receive only monitoring during their 1st ICU day and have a less than 10% predicted risk of active treatment can be safely transferred to an intermediate care unit. Some of these patients may not require ICU admission. We suggest guidelines for equipping and staffing neurological intermediate care units based on the type and amount of therapy received by these patients.

Language bias in randomised controlled trials published in English and German.

BACKGROUND: Some randomised controlled trials (RCTs) done in German-speaking Europe are published in international English-language journals and others in national German-language journals. We assessed whether authors are more likely to report trials with statistically significant results in English than in German. METHODS: We studied pairs of RCT reports, matched for first author and time of publication, with one report published in German and the other in English. Pairs were identified from reports round in a manual search of five leading German-language journals and from reports published by the same authors in English found on Medline. Quality of methods and reporting were assessed with two different scales by two investigators who were unaware of authors' identities, affiliations, and other characteristics of trial reports. Main study endpoints were selected by two investigators who were unaware of trial results. Our main outcome was the number of pairs of studies in which the levels of significance (shown by p values) were discordant. FINDINGS: 62 eligible pairs of reports were identified but 19 (31%) were excluded because they were duplicate publications. A further three pairs (5%) were excluded because no p values were given. The remaining 40 pairs were analysed. Design characteristics and quality features were similar for reports in both languages. Only 35% of German-language articles, compared with 62% of English-language articles, reported significant (p < 0.05) differences in the main endpoint between study and control groups (p = 0.002 by McNemar's test). Logistic regression showed that the only characteristic that predicted publication in an English-language journal was a significant result. The odds ratio for publication of trials with significant results in English was 3.75 (95% CI 1.25-11.3). INTERPRETATION: Authors were more likely to publish RCTs in an English-language journal if the results were statistically significant. English language bias may, therefore, be introduced in reviews and meta-analyses if they include only trials reported in English. The effort of the Cochrane Collaboration to identify as many controlled trials as possible, through the manual search of many medical journals published in different languages will help to reduce such bias.

[Determinants in decisions for the utilization of an ambulatory medical service]. / Determinanten der Entscheidung für die Inanspruchnahme einer ambulanten ärztlichen Einrichtung.

The purpose of this research is to know more about the factors determining the decision to see a doctor. Especially the influence of characteristics of the delivery system (e.g. differences between urban and rural regions) and characteristics of users (e.g. social class) are investigated. In this article the conceptual frame of the study is described. The model is based on assumptions of the action-decision-theory. It structures the process of decision and action into four phases: the first two, perception and interpretation, are summarized as "process of attention"; the subsequent ones, coping and evaluation, as "process of acting". The model describes the social system (the total of demographic, socio-structural and socio-economic variables) and the memory system (contained within the individual life history) as mediating factors influencing the decision to act.

[Expectations concerning physician consultation]. / Einige Bedingungen von Erwartungen an die Arztkonsultation.

Immediately prior to their consultation of a physician 259 ambulatory patients were interviewed concerning their expectations of the interaction with the physician, the course and results of the consultation. From the responses received to open and closed questions several quasi-scales were developed. These scales showed correlations to variables such as nature of the medical problem, type of practice and socio-economic indicators.

[Experience with timolol in consulting patients (author's transl)]. / Erfahrungen mit Timolol in der Sprechstunde.

Experience obtained in the treatment of 78 eyes of patients suffering from open-angle glaucoma with the beta-blocker Timolol 0.25% and 0.5%. Timolol was only given to patients whose intraocular pressure could no longer be adequately regulated by the medications previously employed. A synopsis is given of the medications used over many years. The intraocular pressures of the eyes that responded to Timolol remained below 23 mmHg even after prolonged use, so that a fistulizing operation was initially unnecessary.