[The Trend in Places of Death Over Two Decades in the City of Muenster - an Observational Study Based on evaluated Death Certificates]. / Sterbeortentwicklung über zwei Jahrzehnte in der Stadt Münster ­ eine Observationsstudie auf Basis ausgewerteter Todesbescheinigungen.

Aim of the study The study examined the distribution of places of death in the Westphalian city of Muenster over an observation period of 20 years.Methods All death certificates issued in the city of Muenster from 2001, 2011, 2017, 2021 were evaluated by places of death (home (HO), hospital (HT), hospice (HP), nursing home (NH), other place (OP)). For hospital patients, deaths on intensive care units (ICU) and palliative care units (PAL) were also considered separately. Any medical information on cause of death was used to identify decedents with malignant tumor or dementia disease.Results A total of 14,240 death certificates were evaluated. A malignant tumor disease was documented in 34.0%, dementia in 11.1%. For the general population, the distribution of places of death was as follows (2001/2021; %): HO (24.0/14.6); HT (63.2/60.2) [ICU (13.3/24.6), PAL (0.0/10.9)], HP (3.8/4.9), NH (7.8/19.5), OP (1.1/0.7). Most tumor patients died in hospital (2021: 60.6%), fewer patients at home (2021: 15.4%). From 2001 to 2021, the proportion of cancer patients who died in a PAL increased significantly (+24.4%); hospices showed a moderate increase (+5.0%). A majority of dementia patients died in nursing homes (2021: 66.6%) and fewer patients at home (2021: 12.2%).Conclusion For the general population and for tumor patients, the hospital is the most common place of death and the nursing home for patients with dementia. Overall, deaths at home decreased continuously over time. For tumor patients, palliative care units and hospices are becoming increasingly important as places of death, and for dementia patients, nursing homes in particular.

[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.

Frequency of discharge of hospitalized patients with stroke to free-standing hospice facilities-a register study from Germany.

BACKGROUND: Due to a lack of data, it is unknown if and how frequently in-patients with severe stroke are discharged to free-standing hospice facilities in Germany. METHODS: Patients aged 18 or over who had been hospitalized for ischemic stroke (IS) (International Statistical Classification of Diseases, ICD-10: I63), intracerebral bleeding (ICB) (ICD-10: I61), or subarachnoid bleeding (SAB) (ICD-10: I60) were investigated. The analysis was based on data from the Northwest-German Stroke Registry from 2017 to 2020. The aim was to determine the frequency (crude/age-standardized) of hospital discharges to hospices. In addition, factors influencing the primary outcome, hospital discharge to a free-standing hospice, were assessed using multivariate logistic regression. RESULTS: A total of 339,513 cases of hospitalized patients diagnosed with stroke were recorded, comprising 308,067 (90.7%) with IS, 26,957 (7.9%) with ICB, and 4,489 (1.3%) with SAB. Their mean age was 73.1±13.1 years, and 52.6% were men. During hospitalization, 26,037 patients died (7.7%), including 18,623 with IS, 6,818 with ICB, and 596 with SAB. A total of 497 patients were transferred to a hospice (IS: 414, ICB: 76, SAB: 7). The corresponding (age-standardized) frequencies were as follows [95% confidence interval (CI)]: all patients, 0.05% (0.04-0.06%); IS, 0.05% (0.04-0.06%); ICB, 0.07% (0.05-0.09%); SAB, 0.01% (0.00-0.02%). Independent influencing factors that were identified included nursing-home care prior to hospitalization [odds ratio (OR) 0.34, 95% CI: 0.25-0.44], impaired vigilance on admission (OR 1.71, 95% CI: 1.39-2.10), severe functional impairment at hospital discharge (modified Rankin scale 5 vs. 0-2: OR 34.78, 95% CI: 22.94-52.75), and determination of a palliative care treatment goal during hospitalization (OR 14.22, 95% CI: 11.32-17.87). CONCLUSIONS: In-patients with severe stroke are hardly ever discharged to free-standing hospice facilities in Germany. The reasons for this may be complex, including an acute course in severe stroke, inadequate perception by physicians of these patients' need for palliative care, and structural conditions in long-term care for patients outside the hospital.

[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.

Place of Death Trends and Utilization of Outpatient Palliative Care at the End of Life­Analysis of Death Certificates (2001, 2011, 2017) and Pseudonymized Data From Selected Palliative Medicine Consultation Services (2017) in Westphalia, Germany.

BACKGROUND: The largest German study on place of death was performed for deaths in selected regions of Westphalia in the years 2001 and 2011. In the period thereafter, provision of palliative care was regionally expanded. This upgrade included the establishment of palliative medicine consultation services (PMCS), combining general and specialized palliative care on an outpatient basis. A follow-up place of death survey took place in 2017. The aim was to depict the trends in place of death between 2001 and 2017. A second goal was to determine how often outpatient PMCS were used by persons who died in 2017. METHODS: Descriptive analysis of place of death as specified in all death certificates (2001, 2011, 2017) issued in the cities of Bochum and Münster and the districts of Borken and Coesfeld. Comparison of pseudonymized data on deceased patients (2017) treated by the PMCS of Münster and Coesfeld with the place of death database to ascertain the rate of PMCS care at the end of life. RESULTS: A total of 38 954 death certificates were analyzed, and 5887 deaths were compared with PCMS data. The distribution of place of death was as follows: (2001, 2011, 2017; age standardized; %): own residence 27.8; 23.3; 21.3; hospital: 55.8; 51.8; 51.8; palliative care unit: 0.0; 1.0; 6.2; hospice: 1.9; 4.5; 4.8; nursing home: 13.1; 18.6; 20.4; other: 1.2; 1.2; 1.5. The rate of PMCS use was 28.8% (1694/5887). CONCLUSION: Over the period 2001-2017, the proportion of people who died at home or in the hospital went down, while the number who died in a palliative care unit, hospice, or nursing home increased. In the city of Münster and the district of Coesfeld, one fourth of the people who died in 2017 received PMCS care at the end of life.

Prevalence of therapeutic and diagnostic procedures in the last 14 days of life in hospital patients: a single-center observational study from Germany.

BACKGROUND: The opportunities available for maintaining and prolonging life in modern medicine give rise to medical-ethical dilemmas in patients at the end of life, raising the question of whether intensified treatment and diagnosis is appropriate in these patients. This affects hospital patients in particular. METHODS: This single-center cross-sectional study from Germany analyzed hospital records of all deceased patients of a university hospital who died between October 2016 and September 2017. The prevalence of therapeutic and diagnostic procedures during the last 14 days before death was determined. In-hospital transfer practices shortly before patients' deaths were also examined. RESULTS: A total of 468 hospital patients died. The mean age at death was 76.3±13.7 years; 47.0% [220] were female; 12.0% [56] died on the day of hospital admission, 41.9% [196] 1 to 6 days and 46.1% [216] more than 6 days later; the case mix index (CMI) was 4.6. The majority of patients {57.1% [267]} died on intensive care unit (ICU). Therapeutic and diagnostic procedures within the last 14 days before death: 30.3% [142] resuscitation, 28.6% [134] surgery, 10.9% [51] extracorporeal membrane oxygenation (ECMO), 23.7% [111] renal replacement therapy, 4.3% [20] tracheostomy, 2.8% [13] PTCA/cardiac stenting, 1.9% [9] chemotherapy, 29.3% [137] transfusion of packed red blood cells, 13.7% [64] transfusion of prothrombin complex concentrate, 5.3% [25] cardiac catheter examination, 7.5% [35] upper gastrointestinal endoscopy, 79.1% [370] chest X-ray, 41.9% [196] computed tomography. In-hospital transfer from ICU to PCU before patients' death: 1.5% (4/274 ICU patients). CONCLUSIONS: Intensified therapeutic and diagnostic procedures are often performed at the end of life in hospital patients. Closer interdisciplinary cooperation between intensive care and palliative care would be beneficial to improve in-patient care for these patients.

Prevalence of resuscitation in cancer patients at the end of life-a population-based observational study from Germany.

BACKGROUND: Cardiopulmonary resuscitation (CPR) is a medical emergency intervention aimed at ending a life-threatening cardiovascular arrest as quickly as possible. However, the medical ethics of starting CPR in patients who have incurable and terminal disease is a matter of controversy. This ethical dilemma affects cancer patients in particular, as they are often suffering from advanced disease in a palliative situation. Few data are as yet available concerning the prevalence of CPR in patients with terminal cancer. METHODS: A population-based cross-sectional study was carried out on the basis of death certificates of two large cities in Germany evaluated for 2017. Medical data on resuscitation and cause of death were analyzed. Cancer patients with or without a palliative situation were identified, and the prevalence of resuscitation in these patients was determined. In addition, factors influencing resuscitation were calculated using binary multivariate regression. RESULTS: A total of 8,496 persons died, 32.1% of whom [2,723] were cancer patients. A palliative situation was present in 80.9% of the cancer patients [2,202]. A total of 163 cancer patients and 1,006 individuals without cancer were resuscitated at the end of life, representing prevalences of 6.0% (95% CI, 5.1-6.9%) and 17.4% (95% CI, 16.4-18.4%), respectively. Cancer patients with a palliative disease status received CPR in 3.4% of cases (95% CI, 2.6-4.2%). More than half of the resuscitations were performed in hospital (57.7% of resuscitated persons and 68.7% of cancer patients). Sex, age, presence of a palliative situation, and care provided by a specialized outpatient palliative service were found to be independent influencing factors. CONCLUSIONS: Six in 100 cancer patients, and slightly more than three in 100 cancer patients with a palliative disease status, undergo CPR at the end of their lives. Thus, the indication for resuscitation in advanced cancer patients is handled with care and responsibility in Germany.

The prevalence of bereavement rooms at German hospitals: a cross-sectional observational study from 2016.

BACKGROUND: Hospitals represent the most frequent place of death in Germany. Therefore, these health institutions should be adequately prepared for post-death caring for deceased patients and their bereaved relatives. To enable the next of kin a dignified farewell to the deceased in a private atmosphere, some hospitals have established a bereavement room. To date, no data exist on the prevalence of bereavement rooms at German hospitals. METHODS: We conducted a cross-sectional observational study at all German hospitals with 100 or more beds for the year 2016. A questionnaire was used to collect data on the existence, structure and organization of bereavement rooms. The data were presented descriptively by analyzing absolute and relative frequencies. The prevalence of bereavement rooms was derived from these calculated numbers. RESULTS: Of the 1,281 eligible hospitals, a total of 301 hospitals participated (23.5%). A bereavement room existed at 230 hospitals, corresponding to a prevalence of 76.4% (230/301) for the participating hospitals. Concerning all German hospitals ≥100 beds, a prevalence of at least 17.9% (230/1,281) was determined. These special rooms existed most commonly for a duration of 10 to 25 years (39.1%); were mainly located near an autopsy room (46.5%) and in the basement (31.3%); were used very frequently (30.9%), moderately (37.4%) or rarely (24.8%); were mostly designed with esthetic features like flowers and candles (80.4%) and often equipped with religious symbols (79.1%), and had air conditioning in only 37.4% of respondent answers. The responsibility for the bereavement room had mainly been transferred to the hospital pastoral care and the nursing staff. CONCLUSIONS: In 2016, less than one in five German hospitals ≥100 beds provided a bereavement room. This may indicate that more attention should be paid to the post-death care of deceased patients and bereaved relatives in hospitals.

Place of death in patients with dementia and the association with comorbidities: a retrospective population-based observational study in Germany.

BACKGROUND: Due to increasing life expectancy, more and more older people are suffering from dementia and comorbidities. To date, little information is available on place of death for dementia patients in Germany. In addition, the association of place of death and comorbidities is unknown. METHODS: A population-based cross-sectional survey was conducted in Westphalia-Lippe (Germany), based on the analysis of death certificates from 2011. Individuals with dementia ≥ 65 years were identified using the documented cause of death. In this context, all mentioned causes of death were included. In addition, ten selected comorbidities were also analyzed. The results were presented descriptively. Using multivariate logistic regression, place of death was analyzed for any association with comorbidities. RESULTS: A total of 10,364 death certificates were analyzed. Dementia was recorded in 1646 cases (15.9%; mean age 86.3 ± 6.9 years; 67.3% women). On average, 1.5 ± 1.0 selected comorbidities were present. Places of death were distributed as follows: home (19.9%), hospital (28.7%), palliative care unit (0.4%), nursing home (49.5%), hospice (0.9%), no details (0.7%). The death certificates documented cardiac failure in 43.6% of cases, pneumonia in 25.2%, and malignant tumour in 13.4%. An increased likelihood of dying in hospital compared to home or nursing home, respectively, was found for the following comorbidities (OR [95%-CI]): pneumonia (2.96 [2.01-4.35], p = 0.001); (2.38 [1.75-3.25], p = 0.001); renal failure (1.93 [1.26-2.97], p = 0.003); (1.65 [1.18-2.32], p = 0.003); and sepsis (13.73 [4.88-38.63], p = 0.001); (7.34 [4.21-12.78], p = 0.001). CONCLUSION: The most common place of death in patients with dementia is the retirement or nursing home, followed by hospital and home. Specific comorbidities, such as pneumonia or sepsis, correlated with an increased probability of dying in hospital.

Care of cancer patients at the end of life in a German university hospital: A retrospective observational study from 2014.

BACKGROUND: Cancer care including aggressive treatment procedures during the last phase of life in patients with incurable cancer has increasingly come under scrutiny, while integrating specialist palliative care at an early stage is regarded as indication for high quality end-of-life patient care. AIM: To describe the demographic and clinical characteristics and the medical care provided at the end of life of cancer patients who died in a German university hospital. METHODS: Retrospective cross-sectional study on the basis of anonymized hospital data for cancer patients who died in the Munich University Hospital in 2014. Descriptive analysis and multivariate logistic regression analyses for factors influencing the administration of aggressive treatment procedures at the end of life. RESULTS: Overall, 532 cancer patients died. Mean age was 66.8 years, 58.5% were men. 110/532 (20.7%) decedents had hematologic malignancies and 422/532 (79.3%) a solid tumor. Patients underwent the following medical interventions in the last 7/30 days: chemotherapy (7.7%/38.3%), radiotherapy (2.6%/6.4%), resuscitation (8.5%/10.5%), surgery (15.2%/31.0%), renal replacement therapy (12.0%/16.9%), blood transfusions (21.2%/39.5%), CT scan (33.8%/60.9%). In comparison to patients with solid tumors, patients with hematologic malignancies were more likely to die in intensive care (25.4% vs. 49.1%; p = 0.001), and were also more likely to receive blood transfusions (OR 2.21; 95% CI, 1.36 to 3.58; p = 0.001) and renal replacement therapy (OR 2.65; 95% CI, 1.49 to 4.70; p = 0.001) in the last 7 days of life. Contact with the hospital palliative care team had been initiated in 161/532 patients (30.3%). In 87/161 cases (54.0%), the contact was initiated within the last week of the patient's life. CONCLUSIONS: Overambitious treatments are still reality at the end of life in cancer patients in hospital but patients with solid tumors and hematologic malignancies have to be differentiated. More efforts are necessary for the timely inclusion of specialist palliative care.

Survival after long-term isoflurane sedation as opposed to intravenous sedation in critically ill surgical patients: Retrospective analysis.

BACKGROUND: Isoflurane has shown better control of intensive care sedation than propofol or midazolam and seems to be a useful alternative. However, its effect on survival remains unclear. OBJECTIVE: The objective of this study is to compare mortality after sedation with either isoflurane or propofol/midazolam. DESIGN: A retrospective analysis of data in a hospital database for a cohort of consecutive patients. SETTING: Sixteen-bed interdisciplinary surgical ICU of a German university hospital. PATIENTS: Consecutive cohort of 369 critically ill surgical patients defined within the database of the hospital information system. All patients were continuously ventilated and sedated for more than 96 h between 1 January 2005 and 31 December 2010. After excluding 169 patients (93 >79 years old, 10 <40 years old, 46 mixed sedation, 20 lost to follow-up), 200 patients were studied, 72 after isoflurane and 128 after propofol/midazolam. INTERVENTIONS: Sedation with isoflurane using the AnaConDa system compared with intravenous sedation with propofol or midazolam. MAIN OUTCOME MEASURES: Hospital mortality (primary) and 365-day mortality (secondary) were compared with the Kaplan-Meier analysis and a log-rank test. Adjusted odds ratios (ORs) [with 95% confidence interval (95% CI)] were calculated by logistic regression analyses to determine the risk of death after isoflurane sedation. RESULTS: After sedation with isoflurane, the in-hospital mortality and 365-day mortality were significantly lower than after propofol/midazolam sedation: 40 versus 63% (P = 0.005) and 50 versus 70% (P = 0.013), respectively. After adjustment for potential confounders (coronary heart disease, chronic obstructive pulmonary disease, acute renal failure, creatinine, age and Simplified Acute Physiology Score II), patients after isoflurane were at a lower risk of death during their hospital stay (OR 0.35; 95% CI 0.18 to 0.68, P = 0.002) and within the first 365 days (OR 0.41; 95% CI 0.21 to 0.81, P = 0.010). CONCLUSION: Compared with propofol/midazolam sedation, long-term sedation with isoflurane seems to be well tolerated in this group of critically ill patients after surgery.

Place of Death: Trends Over the Course of a Decade: A Population-Based Study of Death Certificates From the Years 2001 and 2011.

BACKGROUND: In Germany, data on place of death is recorded from death certificates, but not further analyzed. Consequently, hardly any information is available at the population level regarding the distribution of place of death (e.g. home, hospital, palliative care unit, nursing home, hospice). METHODS: We carried out a descriptive statistical analysis of the registered places of death in evaluated death certificates from selected areas of Westphalia-Lippe for the years 2001 and 2011. Factors affecting the place of death were determined with binary multivariate regression. RESULTS: We analyzed 24 009 death certificates (11 585 for 2001 and 12 424 for 2011). The distribution of places of death for the overall population was as follows (2001 vs. 2011): at home, 27.5% vs. 23.0% (p<0.001); in the hospital, 57.6% vs. 51.2% (p<0.001); on a palliative care unit, 0.0% vs. 1.0%, in a care or nursing home, 12.2% vs. 19.0% (p<0.001); in a hospice, 2.0% vs. 4.6% (p<0.001); elsewhere, 0.6% vs. 0.6% (p = 0.985); not indicated, 0.1% vs. 0.6% (p<0.001). Independent factors affecting the place of death were age, sex, place of residence, and the presence of cancer or of dementia. CONCLUSION: Most people in Germany die in institutions; the most common place of death is still the hospital, where more than half of all deaths take place. Only one death in four occurs at home. There is a marked secular trend away from dying at home or in the hospital, in favor of dying in a care or nursing home; death in palliative care units and hospices is also becoming more common.

Effects of liberal vs. conventional volume regimen on pulmonary function in posterior scoliosis surgery.

BACKGROUND: We observed an increased rate of pulmonary complications (hypoxemia, pulmonary edema, re-intubation) in some patients after posterior spinal fusion, though standardized intraoperative volume regimens for major surgery were used. Therefore, we focused on the effects of two different standardized fluid regimens (liberal vs. conventional) as well as on two different types of postoperative pain management (thoracic epidural catheter vs. intravenous analgesia) concerning pulmonary function in patients undergoing posterior spinal fusion. METHODS: 23 patients received a conventional intraoperative fluid management (crystalloids 5.5 ml/kg/h), whereas 22 patients obtained a liberal regimen (crystalloids approximately 11 ml/kg/h) during surgery. After surgery a thoracic epidural catheter was used in 29 patients, whereas 16 patients got a conventional intravenous analgesia. Regarding pulmonary outcome, the re-intubation rate, the postoperative oxygen saturations as well as delivery volumes and retention times of pleural drainages were evaluated. RESULTS: Patients with conventional intraoperative fluid management had a less frequent reintubation rate (p = 0.015), better postoperative oxygen saturations (p = 0.043) and lower delivery volumes of pleural drainages (p = 0.027) compared to those patients with liberal volume regimen. Patients with thoracic epidural catheter had improved oxygen saturations on pulse oximetry at the first day after surgery (p < 0.001) and lower delivery volumes of pleural drainages than patients with intravenous analgesia (p = 0.008). CONCLUSIONS: The combination of a more restrictive fluid management (better pulmonary oxygen uptake and ventilation, less pulmonary edema) and a thoracic epidural catheter (sympatholysis, pain management) in posterior spinal fusion may be advantageous as both factors can improve pulmonary outcome.

The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures.

BACKGROUND: Whether reducing time-to-surgery for elderly patients suffering from hip fracture results in better outcomes remains subject to controversial debates. METHODS: As part of a prospective observational study conducted between January 2002 and September 2003 on hip-fracture patients from 268 acute-care hospitals all over Germany, we investigated the relationship of time-to-surgery with frequency of post-operative complications and one-year mortality in elderly patients (age > or =65) with isolated proximal femoral fracture (femoral neck fracture or pertrochanteric femoral fracture). Patients with short (< or =12 h), medium (> 12 h to < or =36 h) and long (> 36 h) times-to-surgery, counting from the time of the fracture event, were compared for patient characteristics, operative procedures, post-operative complications and one-year mortality. RESULTS: Hospital data were available for 2916 hip-fracture patients (mean age (SD) in years: 82.1 (7.4), median age: 82; 79.7% women). Comparison of groups with short (n = 802), medium (n = 1191) and long (n = 923) time-to-surgery revealed statistically significant differences in a few patient characteristics (age, American Society of Anesthesiologists ratings classification and type of admission) and in operative procedures (total hip endoprosthesis, hemi-endoprosthetic implants, other osteosynthetic procedures). However, comparison of these same groups for frequency of postoperative complications revealed only some non-significant associations with certain complications such as post-operative bleeding requiring treatment (early surgery patients) and urinary tract infections (delayed surgery patients). Both unadjusted rates of one-year all-cause mortality (between 18.1% and 20.5%), and the multivariate-adjusted hazard ratios (HR for time-to-surgery: 1.04; p = 0.55) showed no association between mortality and time-to-surgery. CONCLUSION: Although this study found a trend toward more frequent post-operative complications in the longest time-to-surgery group, there was no effect of time-to-surgery on mortality. Shorter time-to-surgery may be associated with somewhat lower rates of post-operative complications such as decubitus ulcers, urinary tract infections, thromboses, pneumonia and cardiovascular events, and with somewhat higher rates of others such as post-operative bleeding or implant complications.

LOC387715, smoking and their prognostic impact on visual functional status in age-related macular degeneration-The Muenster Aging and Retina Study (MARS) cohort.

PURPOSE: To prospectively evaluate the impact of homozygosity in the A69S-SNP of the LOC387715-gene, smoking history, and their interaction on visual functional status (v-FS) in age-related macular degeneration (AMD). METHODS: The Muenster Aging and Retina Study (MARS) cohort (n = 656; 58.8% women, mean age 70.2 years) was followed over a mean of 2.5 years. AMD-status, genotype and smoking history were assessed at baseline. V-FS [from 0 (low) to 100 (unimpaired) points in general-, near- and far-vision], were AMD-status assessed at baseline and at follow-up. Linear models with stepwise adjustments for covariates were used to analyze decline of v-FS over time. RESULTS: In initial models, homozygosity for the A69S-variant was negatively associated with all three dimensions of the v-FS. After including smoking history, ever smoking was negatively associated with declines in near and far vision (-4.82 and -5.12 points, respectively; each p < 0.05). In smokers homozygous for the A69S-variant the number of cigarettes smoked per day (smoking intensity) was negatively associated with all three dimensions of the v-FS (interaction term each p < 0.05). Time since smoking cessation in former smokers protected against declines in near and far vision. These effects were independent of the AMD-status at baseline. CONCLUSIONS: The interaction of homozygosity for the A69S-variant and smoking intensity had a negative impact on general-, near-, and far visual functional status independent of AMD-status. Quitting smoking seemed to have a time-dependent protective effect on near and far vision.

Fracture-related hip pain in elderly patients with proximal femoral fracture after discharge from stationary treatment.

BACKGROUND: Proximal femoral fracture is a common condition in the elderly but very little is known about fracture-related hip pain in these patients after discharge from stationary treatment. AIMS: To identify risk factors associated with persistent hip pain in elderly hip-fracture patients. METHODS: We analysed data from a large observational study, evaluating the health care situation of hip-fracture patients between January 2002 and September 2003 in Germany. For this analysis, we focused on a sub-sample of patients who were 65 years or older, had sustained an isolated proximal femoral fracture and had undergone surgical intervention. A telephone interview was conducted 6-12 months after discharge. Pain intensity, pain-related disability and severity of chronic pain were measured using the Graded Chronic Pain Scale (GCPS). Multivariate linear regression methods were applied to test hospital patient data for their value in predicting post-hospitalisation presence of fracture-related pain. RESULTS: In total, 1541 patients (mean age 78.4, 76.1% female) were enrolled in this analysis. The prevalence of fracture-related hip pain was 13.4% (206/1541). Among these 206 patients, 57.3% had pain intensity scores 50, 65.0% had pain disability scores 50, and the severity of chronic pain (Grades 1-4) was assessed as follows: (1) 34.0%, (2) 19.4%, (3) 31.5%, (4) 15.1%. The clinical variables age, weight and operative procedure were found to be predictive of post-hospitalisation fracture-related pain. CONCLUSIONS: This analysis shows that a substantial percentage of elderly patients with proximal femoral fracture suffer intense fracture-related hip pain after stationary treatment.

Diagnosis and treatment of osteoporosis in postmenopausal women with distal radius fracture in Germany.

OBJECTIVE: The aim of this study was to evaluate osteoporosis diagnosis and treatment on the basis of medical history, at hospital discharge, and 6-12 months after discharge, as well as to assess the frequency of subsequent fractures in postmenopausal women with distal radius fracture. RESEARCH DESIGN AND METHODS: A prospective, observational study of hospitalized women aged 55 years and older with an isolated distal radius fracture from minimal trauma. Subjects were recruited in 242 acute care hospitals in Germany. OUTCOME MEASURES: Potential risk factors for osteoporosis, frequency of osteoporosis assessment, frequency of medication treatment and subsequent fractures 6-12 months after discharge. RESULTS: Among 2031 patients we identified 652 appropriate postmenopausal women. Less than one-third of patient histories contained any bone density parameters, and only a minority of subjects (33%, 217) underwent bone density assessment while in hospital. Of these, 55% (119) were diagnosed with low bone density, yet only 30% of those were prescribed supplements (calcium/vitamin D) and/or specific osteoporosis medication (mostly bisphosphonates) at discharge. Six to twelve months after hospital discharge, the low rate of treatment had not changed substantially. In the interval, 4.3% had sustained a subsequent fracture from minimal trauma: 1.4% a distal radius fracture (0.3% a refracture) and 2.9% a hip joint or other fracture (not specified). A significant age difference between those with and without subsequent distal radius fractures was found (p = 0.01) but not a significant difference between patients with or without osteoporosis medication (p = 0.79), primarily because the case numbers were too small. CONCLUSIONS: A substantial proportion of postmenopausal women hospitalized with distal radius fracture were not sufficiently evaluated or treated for their potential risk of osteoporosis.