[The Trend in Places of Death Over Two Decades in the City of Muenster - an Observational Study Based on evaluated Death Certificates]

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)]

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.

Die ärztliche Leichenschau – Welcher Arzt führt die Untersuchung wann und wo durch?

Hintergrund

Bislang existieren nur wenige Untersuchungen zu strukturellen Rahmenbedingungen der ärztlichen Leichenschau.

Material und Methode

Es wurden alle archivierten Todesbescheinigungen der Stadt Münster des Jahres 2017 hinsichtlich des Leichenschauarztes sowie Tag, Uhrzeit und Ort der durchgeführten Leichenschau einer deskriptiven Analyse unterzogen.

Ergebnisse

Insgesamt wurden 3844 Todesbescheinigungen analysiert. Die Rangfolge der Leichenschauenden setzte sich wie folgt zusammen (ambulant/stationär/gesamt; %): Krankenhausärzte (K) 0,0/100/58,6; niedergelassene Ärzte (N) 42,8/0,0/17,7; Palliativmediziner der spezialisierten ambulanten Palliativversorgung (P) 40,7/0,0/16,8; Notärzte (NÄ) 11,3/0,0/4,7; Rechtsmediziner (R) 5,2/0,0/2,2. An Werktagen (W) bzw. Wochenenden/Feiertagen (WF) war die Leichenschau im ambulanten Bereich (1589) von folgenden Ärzten durchgeführt worden (W/WF, %): N (46,5/34,7), P (35,1/54,6), NÄ (11,1/10,5), R (7,4/0,2). Krankenhausärzte führten relativ unabhängig von der Tages- und Nachtzeit die Untersuchung durch, niedergelassene Ärzte präferierten an Werktagen die Zeit von 12:00 bis 15:59 Uhr. Unterteilt nach dem Sterbeort attestierten vorrangig folgende Ärzte die Todesbescheinigung: häusliches Umfeld (578) > N (31,5 %), P (32,4 %), stationäre Pflegeeinrichtungen (726) > N (65,0 %); Hospiz > P (90,4 %); öffentliche Orte > R (52,9 %), NÄ (44,1 %).

Schlussfolgerung

Die ärztliche Leichenschau wurde 2017 in der Stadt Münster am häufigsten von Krankenhausärzten durchgeführt. Im ambulanten Bereich wurde diese Aufgabe zu etwa gleichen Anteilen von niedergelassenen Ärzten und Palliativmedizinern übernommen. Niedergelassene Ärzte präferierten die Mittagszeit zwischen den klassischen Praxisöffnungszeiten zur Durchführung der Leichenschau.

[Place of death of older people with dementia : Epidemiological data from an observational study of places of death in Germany (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.

[The Place of Death of Neurological Patients with Selected Disease Entities: Data from an Observational Study on Places of Death from Germany]

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 Trends and Utilization of Outpatient Palliative Care at the End of Life

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.

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.

[Epidemiological study on place of death for cancer patients Autoren]

Background | In Germany, place of death is recorded on death certificates, but is not analyzed further. In consequence, only little is known about the place of death among cancer patients at the population level. The aim of the study was to describe the changes of places of death in cancer patients over a time period of 10 years. Material and methods | This study examined death certificates from 2001 and 2011 of selected regions of Westphalia-Lippe (Germany). Cancer patients were identified on the basis of cause of death. Description of frequencies of place of death and subgroup analyses by tumor entity (ICD-10, C00-C96) were performed. Results | A total of 24 009 death certificates were analyzed (2001: 11,585; 2011: 12,424). Cancer was the underlying or contributory cause of death in 34.0%. For the years 2001 and 2011, respectively, the following distributions of place of death were observed: home, 24.1% vs. 24.7% (p=0.553); hospital, 62.8% vs. 51.4% (p=0.001); palliative care unit, 0.0% vs. 2.2%; hospice, 5.5% vs. 12.5% (p=0.001); nursing home, 7.4% vs. 10.9% (p=0.001); other, 0.1% vs. 0.3% (p=0.063); no data, 0.1% vs. 0.3% (p=0.015). Patients with brain tumours had a higher probability of dying in a hospice (2011: female 23.5%; male 27.7%). A higher risk of death in hospital was observed among cancer patients with an underlying hematological malignancy (2011: female 63.7%; male 68.4%). Conclusion | Cancer patients mainly die in institutions, with hospitals being the most frequent location. Only one in four deaths occurs in the home setting. The trend over time shows a shift in place of death away from hospitals towards hospices, palliative care units, and nursing homes.

[Estimation of the Palliative Care Needs and the Extent of Coverage by Specialized Outpatient Palliative Care Teams in Selected Regions of Westphalia-Lippe]

BACKGROUND

Data to estimate the palliative care needs and its outpatient coverage are of public health interest.

METHODS

The theoretical palliative care needs were determined on the basis of a population with advanced cancer in selected regions of Westphalia (Germany); information from evaluated death certificates issued in 2011 in the cities of Bochum (BO) and Muenster (MS) and the rural districts of Coesfeld (COE) and Borken (BOR) were used for the analysis. The number of patients thus assessed was linked to anonymized data from the regional palliative home care teams and an estimate was made on the extent of palliative care provision.

RESULTS

A total of 12,424 death certificates from 2011 were evaluated. In 22.1% (n=2,751), palliative care needs before death can be assumed. In the same year, 2,396 patients were cared for by the regional palliative home care teams, with 1,288 patients dying of cancer. The coverage of outpatient palliative care was calculated as follows: BO 54.2% (567/1,046), MS 60.6% (385/635), COE 54.4% (210/386), BOR 18.4% (126/684).

CONCLUSIONS

One in 5 individuals has a need for palliative care before death. In statistical terms, more than 50% of tumor patients were cared for by regional palliative home care teams in the cities of Bochum and Muenster and the rural district of Coesfeld. By contrast, the degree of palliative care was less than 20% in the rural district of Borken.

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.

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.

Variations in five genes and the severity of age-related macular degeneration: results from the Muenster aging and retina study

AIMS

Little is known about the role of genetic variants in the early stages of age-related macular degeneration (AMD). We aimed to investigate how genetic variations within five well-defined genes relate to AMD severity.

METHODS

We analysed SNPs in the genes for complement factor H (CFH), age-related maculopathy susceptibility (ARMS2), HtrA serine peptidase 1 (HtrA1), complement factor B (CFB), and complement component 2 (C2)in 183 controls and 730 patients with increasing severity of AMD from the Muenster aging and retina study (MARS). Severity scoring was based on the Rotterdam classification of fundus photographs.

RESULTS

Compared with controls, patients with very early AMD showed a significantly increased minor allele frequency (MAF) only for CFH-rs1061170. With increasing severity of AMD, SNPs in CFH-rs1061170,as well as ARMS2-rs10490924, became consistently more common (P<0.001). Likewise, HtrA1-rs11200638 was less clearly associated with AMD severity, whereas C2-rs9332739 and CFB-rs641153 showed no relation. Multifactorial models confirmed CFH and ARMS2 as major determinants of AMD severity, whereas addition of HtrA1, C2 and CFB did not improve model prediction. In the models, age did not contribute to very early but to all more severe AMD stages, whereas smoking history had a significant impact only for late AMD.

CONCLUSION

Our findings indicate that the CFH gene is involved in the onset of AMD, whereas both, the CFH and ARMS2 genes, and more weakly, the HtrA1 gene, appear to account for the advancement of AMD. The results for SNPs in the C2 and CFB genes were inconclusive. Genetic factors dominated in their impact over age and smoking history.

[Quality of care after distal radius fracture in Germany. Results of a fracture register of 1,201 elderly patients]

BACKGROUND

This study is the first to document the quality of inpatient care provided to elderly patients with distal radius fracture in Germany.

PATIENTS AND METHODS

Inpatient care provided to 1,201 patients age 65 or older with isolated distal radius fracture was documented in a prospective cohort study conducted at 242 acute care clinics in Germany between January 2002 and September 2003.

RESULTS

The median patient age was 75, and nearly 90% of patients were female. Approximately 71% of patients were classified as ASA I or II, and 28% were ASA III. The most common comorbidity was arterial hypertension (60%). Seventy-five percent of patients were admitted on the day of the accident; of these, 63% had surgery on the same day, and 20% on the following day. The primary form of anaesthesia was general anaesthesia (55%). The predominant fracture management procedure was percutaneous K-wire osteosynthesis (56% of cases), followed by plate osteosynthesis (44%). The length of hospital stay after plate osteosynthesis (median 8.5 days) was more than twice as long as after K-wire osteosynthesis (median 4 days). The rate of postoperative complications typical of each procedure was around 10%. Roughly 90% of patients were discharged to home. Although evidence of osteoporosis was observed in 62% of women and 50% of men, only 7.9% of patients were prescribed osteoporosis-specific medication.

CONCLUSIONS

Unexpected findings were the predominance of general anaesthesia and percutaneous K-wire osteosynthesis. Osteoporosis, affecting a majority of elderly women, is neglected in clinical practice. Good quality of care is reflected by the low rate of complications.

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.

Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data

BACKGROUND

Approximately 30-80% of postoperative patients complain about moderate to severe post-surgical pain, indicating that postoperative pain treatment is still a problem.

METHODS

We analysed prospectively collected data on patients in a university hospital receiving systemic and epidural patient-controlled analgesia and continuous peripheral nerve block (CPNB) documented by the acute pain service team in a computer-based system.

RESULTS

Of 18 925 patients visited in the postoperative period between 1998 and 2006, 14 223 patients received patient-controlled epidural analgesia (PCEA), 1591 i.v. patient-controlled analgesia (IV-PCA), 1737 continuous brachial plexus block, and 1374 continuous femoral/sciatic nerve block. Mean dynamic and resting pain scores (VAS 0-100) were significantly lower for peripheral or neuroaxial regional analgesia compared with patient-controlled systemic opioid analgesia (P<0.05). The risk of a symptomatic spinal mass lesion including epidural haematoma (0.02%; 1:4741) or epidural abscess (0.014%; 1:7142) after PCEA was 1:2857 (0.04%). Neurological complications after CPNB occurred in two patients who received interscalene brachial plexus block.

CONCLUSIONS

We demonstrated that PCEA, IV-PCA, and CPNB are safe and efficient. Although all of these treatment strategies provide effective analgesia, PCEA and CPNB provided superior pain relief compared with IV-PCA. We demonstrated that serious complications of analgesic techniques are rare but possibly disastrous necessitating a close supervision by an acute pain service. We found a low rate of adverse effects including hypotension and motor impairment and a low incidence of epidural haematoma for thoracic PCEA compared with lumbar PCEA.

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.

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.

Modeling Smoking History: A Comparison of Different Approaches in the MARS Study on Age-Related Maculopathy

PURPOSE

Smoking is an established risk factor for the development of age-related maculopathy (ARM), and its end stage, age-related macular degeneration (AMD). We evaluated the benefit of various smoking-related variables in modeling the association of smoking with ARM and AMD in a mixed sample of current, former, and never smokers.

METHODS

This was a cross-sectional study in participants of the Muensteraner Altern- und Retina-Studie (MARS). Participants were classified according to the Rotterdam classification system as healthy, or having ARM or AMD. Using multinomial logistic regression techniques, the association with number of cigarettes, years of smoking, pack-years and time since cessation in former smokers were evaluated.

RESULTS

Mean age of the 982 participants (58.6% females) was 70.9 +/- 5.5 years. ARM was present in 483 (49.2%) and AMD in 285 (29.0%) individuals. The adjusted prevalence odds ratio (OR) in current smokers versus never smokers was 2.61 (95% confidence interval [CI] 1.34-5.09) for ARM and 3.94 (95% CI 1.91-8.14) for AMD. This effect decreased in former smokers with an OR = 0.55 (95% CI 0.33-0.99) per log-transformed time since smoking cessation for ARM and an OR = 0.52 (95% CI 0.30-0.90) for AMD.

CONCLUSIONS

By including a variable for time since smoking cessation, we were able to handle current, former, and never smokers in one model that estimates the association of smoking with ARM or AMD. Logarithmical transformation of the time since smoking cessation seemed to increase the model fit and to reflect a non-linear protective effect of smoking cessation on the onset of ARM and AMD in former smokers.

Patients with femoral or distal forearm fracture in Germany: a prospective observational study on health care situation and outcome

Background

Distal radius and proximal femoral fractures are typical injuries in later life, predominantly due to simple falls, but modulated by other relevant factors such as osteoporosis. Fracture incidence rates rise with age. Because of the growing proportion of elderly people in Western industrialized societies, the number of these fractures can be expected to increase further in the coming years, and with it the burden on healthcare resources. Our study therefore assessed the effects of these injuries on the health status of older people over time. The purpose of this paper is to describe the study method, clinical parameters of fracture patients during hospitalization, mortality up to one and a half years after discharge in relation to various factors such as type of fracture, and to describe changes in mobility and living situation.

Methods

Data were collected from all consecutive patients (no age limit) admitted to 423 hospitals throughout Germany with distal radius or femoral fractures (57% acute-care, femoral and forearm fractures; 43% rehabilitation, femoral fractures only) between January 2002 and September 2003. Polytrauma and coma patients were excluded. Demographic characteristics, exact fracture location, mobility and living situation, clinical and laboratory parameters were examined. Current health status was assessed in telephone interviews conducted on average 6–7 months after discharge. Where telephone contact could not be established, at least survival status (living/deceased/date of death) was determined.

Results

The study population consisted of 12,520 femoral fracture patients (86.8% hip fractures), average age 77.5 years, 76.5% female, and 2,031 forearm fracture patients, average age 67.6 years, 81.6% female. Women's average age was 6.6 (femoral fracture) to 10 years (forearm fracture) older than men's (p < 0.0001). Only 4.6% of femoral fracture patients experienced changes in their living situation post-discharge (53% because of the fracture event), although less than half of subjects who were able to walk without assistive devices prior to the fracture event (76.7%) could still do so at time of interview (34.9%). At time of interview, 1.5% of subjects were bed-ridden (0.2% before fracture). Forearm fracture patients reported no change in living situation at all. Of the femoral fracture patients 119 (0.95%), and of the forearm fracture patients 3 (0.15%) died during hospital stay. Post-discharge (follow-up one and a half years) 1,463 femoral fracture patients died (19.2% acute-care patients, 8.5% rehabilitation patients), but only 60 forearm fracture patients (3.0%). Ninety percent of femoral fracture deaths happened within the first year, approximately 66% within the first 6 months. More acute-care patients with a pertrochanteric fracture died within one year post-discharge (20.6%) than patients with a cervical fracture (16.1%).

Conclusion

Mortality after proximal femoral fracture is still alarmingly high and highest after pertrochanteric fracture. Although at time of interview more than half of femoral fracture patients reported reduced mobility, most patients (96%) attempt to live at home. Since forearm fracture patients were on average 10 years younger than femoral fracture patients, forearm fractures may be a means of diagnosing an increased risk of later hip fractures.

Association of low ankle brachial index with high mortality in primary care

AIMS

We aimed to assess the increased risk of death and severe vascular events in elderly individuals with subclinical or manifest peripheral arterial disease (PAD), evidenced by low ankle brachial index (ABI < 0.9) in primary care.

METHODS AND RESULTS

In this monitored prospective observational study, 6880 representative unselected patients aged >or=65 years were followed up over 3 years by 344 primary care physicians. Main outcome measures were mortality or a combined endpoint of mortality and severe vascular events. In total, 20 127 patient-years were observed. In the group of PAD patients (n=1230), 134 patients died; in the group without PAD (n=5591), 237 patients died [multivariate hazard ratio (HR) 2.0; 95% confidence interval 1.6-2.5, P<0.001]. Compared with an ABI>or=1.1, the risk of death increased linearly in the lower ABI categories: ABI 0.7-0.89, HR 1.7 (1.2-2.4, P<0.001); ABI<0.5, HR 3.6 (2.4-5.4, P<0.001).

CONCLUSION

Patients with a low ABI (PAD), who can be readily identified in a primary care setting, have a substantially increased risk of death and severe vascular events. Patients with an ABI between 1.1 and 0.9 should be considered and followed up as borderline PAD cases. Particular attention should be paid to patients with PAD and previous vascular events, as their risk is markedly increased.

[Association between classic cardiovascular risk factors and age-related maculopathy (ARM). Results of the baseline examination of the Münster Aging and Retina Study (MARS)]

BACKGROUND

Epidemiological studies have reported inconsistent associations between cardiovascular risk factors and the occurrence of age-related maculopathy (ARM).

METHODS

In the baseline examination of the Muenster Aging and Retina Study (MARS), we assessed this potential relationship in 1060 subjects who underwent clinical and ophthalmologic examinations. The ARM status was graded according to international standardized classifications.

RESULTS

There were 974 eye pairs available for analysis. Smoking, hypertension, hypercholesterolemia, and a history of myocardial infarction or stroke were found significantly more often in patients with ARM. There were no statistically significant multivariate associations between overweight, diabetes, or a history of myocardial infarction or stroke.

CONCLUSIONS

Our results confirm previous epidemiological studies pointing to a potential role of atherosclerotic processes in the development of ARM.

Inflammatory markers in age-related maculopathy: cross-sectional analysis from the Muenster Aging and Retina Study

OBJECTIVE

To evaluate recent reports indicating that plasma levels of fibrinogen and high-sensitivity C-reactive protein (CRP) are associated with age-related maculopathy (ARM).

METHODS

From the baseline examinations of the Muenster Aging and Retina Study, a cohort of 1060 subjects aged 59 to 82 years was assembled. Of these, 873 persons (82%) with bilateral gradable fundus photographs and complete data on fibrinogen, CRP, and potential confounders were included in a cross-sectional analysis. The main outcome measure was the association among fibrinogen, CRP, and ARM as assessed by multivariate logistic regression analysis.

RESULTS

Fibrinogen and CRP levels were higher among participants with early and late ARM than among those without ARM. The crude odds ratios for ARM between the highest vs the lowest quartile were 1.90 (95% confidence interval [CI], 1.29-2.80) for fibrinogen and 1.43 (95% CI, 0.97-2.10) for CRP. After adjustment for cardiovascular risk factors, these odds ratios were 1.37 for fibrinogen (95% CI, 0.91-2.06) and 1.12 (95% CI, 0.73-1.73) for CRP.

CONCLUSIONS

After adjustment for cardiovascular risk factors, we found no statistically significant association between fibrogen, CRP, and ARM. Therefore, our results do not indicate a role of systemic inflammation in ARM beyond what is already present owing to concurrent cardiovascular disease.

Visuelle Funktion und Lebensqualität bei Patienten mit altersabhängiger Makulopathie: Ergebnisse der Münsteraner Altern- und Retina-Studie (MARS)

BACKGROUND

The aim of this study was to examine the association between increasing severity of age-related maculopathy (ARM) stages, visual function and quality of life.

METHODS

Using the 25-item version of the National Eye Institute Visual Function Questionnaire (NEI VFQ) in the Münster age and retina study (MARS), 974 patients (normal fundus: n = 208; early ARM: n = 466; late ARM: n = 300) with bilateral gradable fundus photographs were asked about their visual function and quality of life. The NEI VFQ scales with regard to general health, general vision, near vision, distance vision and peripheral vision were assessed. According to the ARM stages, age- and gender-adjusted mean scores were calculated and tested for statistically significant differences.

RESULTS

The perception of general health, general vision, near vision, distance vision and peripheral vision was getting worse with increasing severity of ARM stages. Comparing the maculopathy groups, significant differences in age- and gender-adjusted mean scores were found between patients with late ARM and healthy subjects and patients with late and early ARM. Furthermore, we observed for the dimension general vision a significant difference of the mean score between early ARM and healthy control group [mean score; early ARM: 68.7 (0.7) vs. control group: 72.2 (1.1); p = 0.005].

CONCLUSIONS

The results of the NEI VFQ reflect the clinical expectation of an inverse relation between increasing severity of ARM stages and visual function and quality of life.

Serum levels of macular carotenoids in relation to age-related maculopathy

BACKGROUND

It has been hypothesized that the macular carotenoids, lutein and zeaxanthin, may protect against age-related maculopathy. We evaluated the association between blood concentrations of lutein (L) and zeaxanthin (Z) and age-related maculopathy (ARM) in a case-control analysis of the baseline examination of the Muenster Ageing and Retina Study (MARS).

METHODS

Of the 1060 participants aged 59-82 years at baseline, 910 (85.9%) with bilateral gradable fundus photographs and complete data for the carotenoids and potential confounders were included. The Rotterdam classification system was used for definition of ARM stages. Multivariate linear regression methods were applied to model the relationship between macular carotenoids and the presence of ARM.

RESULTS

The participants' mean age was 70.9+5.5 years, 59.9% were female, 20.8% had a normal bilateral fundus, and 48.5% showed signs of early ARM (uni- or bilateral) and 30.7% of late ARM (in at least one eye). In study participants with L and/or Z supplementation (15.6%), the median serum levels for L (Z) were approximately 2 times (1.5 times) higher than in subjects with no supplementation. After exclusion of subjects with L and/or Z supplementation, no statistically significant bivariate relationship was observed between the serum levels of L or Z and the presence of ARM. Multivariate regression models, adjusting for age, gender, smoking, body-mass index, and HDL-cholesterol blood levels, produced adjusted mean serum levels of 0.124, 0.112, and 0.131 microg/ml for L and 0.019, 0.020, and 0.022 microg/ml for Z in subjects with normal fundus, early ARM, and late ARM, respectively.

CONCLUSION

In this large study, the serum concentrations of L and Z were not related to the prevalence of ARM. However, the large proportion of study participants taking L and/or Z supplementation may have affected these results.

[Münster age- and retina study (MARS). Association between risk factors for arteriosclerosis and age-related macular degeneration]

BACKGROUND

The association between arteriosclerosis and age-related macular degeneration (AMD) has only been examined in a few studies and the data is still very inconsistent.

METHODS

A cross sectional study was initiated with 730 patients from the Münster age and retina study (MARS) which examines patients in the age range 60 to 80 years old who were referred by ophthalmologists from the Muenster area. Patients with narrow angle glaucoma were excluded. All patients underwent a standardized ophthalmoscopic examination und were classified into four groups: group 1 without AMD ( n=190), group 2 with unilateral or bilateral early forms of AMD ( n=340), group 3 with unilateral late forms of AMD ( n=139) and group 4 with bilateral late forms of AMD ( n=50). By means of these groups it was tested if there was a significant difference between the different risk factors for arteriosclerosis.

RESULTS

The mean age was 72 years and 58% were women and the sex distribution within the different groups did not differ significantly (all trend tests with p>0.1). General risk factors for arteriosclerosis such as diabetes, body-mass-index and hypertension did not differ significantly (all trend tests with p>0.1). The number of smokers increased significantly with the severity of AMD ( p=0.02). Furthermore, various lipids were examined, adjusted for age and sex and showed significant decrease of HDL ( p=0.087) and significant increases of the HDL/LDL quotient ( p=0.0007) and the non-sober triglyceride values ( p=0.0058) correlated with the severity of AMD.

CONCLUSIONS

There was a highly significant, direct association of indicators of dyslipidemia such as increasing HDL/LDL quotient and decreasing HDL with the severity of AMD. These results were underlined by increased triglyceride levels even if they were taken non-sober. The results must be interpreted with caution due to the explorative character of the evaluation.

Impact of left ventricular dysfunction on cytokines, hemodynamics, and outcome in bypass grafting

BACKGROUND

Although patients with reduced left ventricular ejection fraction undergoing cardiac operation experience a higher rate of perioperative complications, the contribution of proinflammatory cytokines released during extracorporeal circulation is not well defined.

METHODS

We compared arterial and mixed venous levels of interleukin-6, tumor necrosis factor-alpha, soluble interleukin-2 receptor, and interleukin-2 at 10 points in time (24 hours before until 48 hours after extracorporeal circulation) in 21 patients with an ejection fraction of less than 0.45 (study group) to 15 patients with an ejection fraction of more than 0.55 (control group) undergoing elective coronary artery bypass grafting. The study and control group differed with regard to left ventricular ejection fraction (0.37 +/- 0.05 versus 0.66 +/- 0.11, p < 0.05) and reperfusion time (35 +/- 42 minutes versus 18 +/- 4 minutes, p = 0.07), but not age, sex, vessel involvement, number of grafts performed, cross-clamp time, extracorporeal circulation time, core temperature, and duration of ventilation.

RESULTS

Six patients in the study group required mechanical support and 1 died. There were no complications in the control group. In the study group, there were higher preoperative interleukin-2 and tumor necrosis factor-alpha levels and a higher maximum cytokine response to extracorporeal circulation for interleukin-2, soluble interleukin-2 receptor, interleukin-6, and tumor necrosis factor-alpha (all p < 0.05). Interleukin-6 correlated with duration of extracorporeal circulation, dose of norepinephrine and epinephrine support, pulmonary capillary wedge pressure, mean pulmonary arterial pressure, right atrial pressure, heart rate, cardiac index, and inversely with systemic vascular resistance. Interleukin-6 was highest in patients with complications. Arterial and venous cytokine levels correlated closely.

CONCLUSIONS

Preoperative left ventricular dysfunction is associated with a higher degree of proinflammatory cytokine release during elective coronary artery bypass grafting. This response is associated with impaired hemodynamics and a higher incidence of perioperative complications.