What causes a generator transition

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1 An analysis of post-mortem explanted pacemakers and ICDs from 2000 Junge M, Nägele H, Püschel K, Rödiger W, Weckmüller J Journal of Cardiology - Austrian Journal of Cardiology 2002; 9 (11), Official Organ of the Austrian Heart Fund Homepage: Online database with author and keyword search Member of the ESC Editors Club Member of the Indexed in EMBASE / Excerpta Medica / Scopus P. b. b. 0 2 Z M, V e r l a g s p o s t a m t: P u r k e r s d o r f, E r s h e i n u n g s o r t: G a b l i t z

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3 An analysis of post-mortem explanted cardiac pacemakers and ICDs from the year 2000 M. Junge 1, J. Weckmüller 2, H. Nägele 3, K. Püschel 1, W. Rödiger 3 Abstract: Question: In a cross-sectional analysis for the year 2000, the Functionality of cardiac pacemakers (PM) and implantable cardioverters / defibrillators (ICD) examined in the deceased. Material, method: Of the deceased who were cremated in the Hamburg crematorium in 2000, they had to undergo a second medical examination before cremation. PM / ICD aggregates diagnosed here were explanted; it was 212 PM and 6 ICD. All devices were electrically tested for the quality of the impulses they emitted, and the pacemaker data was queried by telemetry (197 of 218). Results: The statistical results regarding implantation duration (4 ± 3.2 a), age of the patients at implantation or death (80 ± 8.7 a and 84 ± 8.6 a), gender distribution (111 women, 103 men) are presented of 214), functional status (39 ERI, 13 EOL, 4 only functional again after resetting of 214 verifiable PM / ICD), place of residence (102 own apartment, 68 retirement home of 214) etc. and their correlations. A high level of non-compliance with regard to the follow-up appointments was found (a maximum of 2859 days without follow-up), but the pacemaker wearers grew older on average than the normal population. Almost a fifth (39 out of 214) of the explanted pacemakers had met the replacement criterion, and around 8% percent (17 out of 214) were in an extremely critical condition or inoperable. With one exception, the newer devices with short implantation times worked flawlessly. In individual cases, the circumstances of death and the time of death could be reconstructed from the data in the memory in the pacemaker (death from magnetic reversal, death from cardiac decompensation in the case of PM battery depletion). Abstract: An Analysis of 218 Pace-Makers and ICDs Explanted in the Crematorium Hamburg- Oejendorf in the Year Research Purpose: In a cross-section analysis the post-mortem functional state of the pacemaker (PM) or implantable cardioverter / defibrillator (ICD) was examined for the year Material and Methods: Of the 15,308 bodies cremated in the crematorium Hamburg-Oejendorf during the year 2000, 10,859 were in need of a second external examination. All PM / ICD generators found during the examination of the fatalities were explanted: 212 PM as well as 6 ICD. The quality of the electrical impulses generated by the PM / ICD was measured in all cases, the generators were telemetrically interrogated in every case where possible (197 of N = 218). Results: Statistics of the duration of implantation (4 ± 3.2 a, N = 190 cases), the age of the patients at implantation and at death (80 ± 8.7 a vs. 84 ± 8.6 a, N = 190), gender distribution ( 111 female vs. 103 male, N = 214), state of the generator (39 ERI, 13 EOL, 4 in need of a reset to function correctly, N = 214), residence (102 own home, 68 old people home, N = 214) etc. and their correlations are presented. A high degree of non-compliance with regard to the follow-up checks of the PM / ICD was found (max d without follow-up), contrasting with a higher than average age of the PM patients. A fifth of the PM were in the ERI state (39/214), 8% were in a critical state (EOL) or without function (17/214). All modern PM recently implanted worked flawlessly with one exception. The data stored within the PM were used to reconstruct the cause and timing of death in individual cases (death due to magnet reversion of an ICD, death by cardial decompensation due to battery exhaustion). J Kardiol 2002; 9: n Introduction A cross-sectional analysis for the year 2000 was intended to examine the functionality of cardiac pacemakers (PM) and implantable cardioverters / defibrillators (ICD) in deceased persons. For this purpose, the generators including a 10 cm long piece of electrode were explanted in the case of deceased people who were cremated in the Hamburg crematorium in 2000 [1] as part of the second medical examination before the cremation of pacemaker wearers [2]. There were 212 pacemakers and 6 implantable cardioverters / defibrillators. From a forensic point of view, the following questions should be investigated: The condition of the pacemaker: Was the pacemaker in perfect mechanical and electrical condition until the patient died? The cause of death of the implant: Did the pacemaker or the implantable defibrillator cause death by malfunction? Received on February 13, 2002, revision received on May 12, 2002, accepted on August 26 From the 1 Institute for Forensic Medicine, University of Hamburg, the 2 Center for Internal Medicine B, Ernst-Moritz-Arndt-University Greifswald, and the 3 Cardiovascular Surgery, University of Hamburg, Germany. Correspondence address: Dr. med. Mirko Junge, Institute for Forensic Medicine, University of Hamburg, Butenfeld 34, D Hamburg; Determining the duration of the implantation: Did the patient live longer because of the implant, i.e. gained years? Socio-economic influences in aftercare: Are patients in old people's homes better cared for than those living alone? n Reasons for explantation Disposal regulations The manufacturers recommend that all implanted PM / ICDs are removed before the corpse is cremated. The Battery Ordinance (BattV) [3] has been in force in Germany since 1998. The aim of the BattV is to reduce the entry of pollutants into waste by batteries by z. B. used batteries are taken back and recycled properly and without damage in accordance with the provisions of the Recycling and Waste Management Act or non-recyclable batteries are disposed of in a manner compatible with the common good. According to the exemption in Appendix 2, Paragraph 2 BattV i.v. In accordance with 13 para. 2 sentence 3 BattV, it is explicitly not forbidden to put pacemakers with permanently installed and encapsulated batteries into circulation. According to 2 para. 1 no. 4 BattV does not contain pollutants, but the manufacturers and distributors of pacemakers are subject to the battery ordinance (2 Para. 4 BattV) due to the built-in batteries. In accordance with 14 BattV, there is an obligation to take back the entire device for the manufacturer or the distributor, as well as an obligation to give the end user the 490 J KARDIOL 2002; 9 (11) For personal use only. Not to be reproduced without permission from Krause & Pachernegg GmbH.

4 the obligation to properly return the device. According to 2 para. 2 no. 4 BattV, the person who uses the devices with built-in batteries, or whoever the batteries incur as waste for the first time, is obliged according to 7 BattV to return the batteries and devices that are waste to a distributor [.. .] return. Special feature of PM Due to the hermetic seal of the PM / ICD generators and the batteries they contain, considerable pressure can build up when the devices heat up at the high cremation temperatures. This takes place through thermal decomposition of the constituents of the actual pacemaker battery as well as the electrolyte, the high-capacity electrolytic capacitors used as intermediate storage for electrical energy and the substrate on which the generator electronics are built [4, 5]. The temperatures that usually arise during cremation are so extreme that a pressure builds up that is high enough to cause both the battery or the batteries and the actual pacemaker housing to explode. This releases the ingredients of the components used in the PM / ICD generators. Special feature of the ICD For comprehensive information, cardiac pacemakers (PM) and especially the ICD should be read out and deactivated on site. In the case of deceased persons with an implantable cardioverter / defibrillator (ICD), special care is required [6]: on the one hand, to preserve important information stored in the ICD, on the other hand, for self-protection. The electrodes should be secured against accidental contact with appropriate clamps. Even when storing the explanted ICD, greater care must be taken than normal due to the inherent risk of a fatal electric shock. A handing over of an explanted ICD to the relatives is generally not responsible for reasons of electrical safety. In any case, the ICD should be explanted in order to rule out malfunction of the ICD and an electrical hazard on the last route to the corpse. n Material and methods Explant and evaluation In the present study, only the generators and the generator-electrode junction were examined. For this purpose, the electrode was cut with a wire cutter approx. 10 cm after leaving the generator block during explantation. After a first optical inspection, the electrode ends were secured with connecting clamps, the explant was mechanically cleaned and given a number, placed in the plastic bags provided for this purpose. After entering the institute, the electrode-generator interface was checked mechanically and electrically. The mechanical test consisted of a loosening test of the locked plug-in connection, the electrical test of a comparison of the signal form at the electrode end with that on the generator block by displaying it on an oscilloscope. To measure the impulses emitted by the pacemaker more precisely, they were checked with a pulse width / pulse duration meter. Finally, the pacemakers were telemetrically queried and checked using the appropriate programming devices. The function of an explanted ICD cannot be checked without precise knowledge of the internal structure. With the help of the respective programming devices, a long-term ECG and some functional parameters can be loaded from the ICD, but functional diagnostics cannot be carried out with the devices. The respective manufacturers offer a free inspection as well as professional disposal for the devices they manufacture. For the evaluation, the dates of birth and death were taken from the death certificates, insofar as these were clearly recognizable. Due to the unique serial numbers of most pacemakers, the implantation date could be precisely determined via the implantation feedback from hospitals and cardiology practices to the manufacturers. To check the completeness of the explant, in 2000 all metal residues were handpicked after cremation and searched for pacemaker residues. The data were recorded and evaluated with SPSS. Life expectancy The term life expectancy should be understood here as the distant life expectancy of a person at the age of a years, that is, the average number of years that an a-year-old still has to live in the reference year. Years gained is the number of years a patient lives longer than their life expectancy. One of the premises of the official mortality tables for the Federal Republic of Germany is a temporary decline in mortality up to the year 2000, after which it remains constant [7, p. 83]. No rational justification can be found for this assumption. Buslei [8] has dropped this premise in his calculations and comes to longer distant life expectancies than the Federal Statistical Office, which are more in line with reality. The values ​​used in the following for the distant life expectancy are based on the corrected model by Bomsdorf [9, 10] for the year. The model does not differentiate between risk factors, except for the breakdown by gender. Due to the high age compared to the normal population and the associated low life expectancy of the patients who are to be treated with a PM / ICD, it is not sufficient for the calculation of the life expectancy to group the patients in annual classes, as is done in the life tables for the old age is carried out by default. The values ​​between the values ​​given in the life table were approximated to the exact day using Lagrange interpolation. To calculate the interpolation, the SPSS column with the age values ​​was exported to Mathematica 4.0. There the interpolation was calculated for each data value and the result was imported back into the SPSS table. J KARDIOL 2002; 9 (11) 491

5 n Results Manufacturer-related data In total, cardiac pacemakers and implantable cardioverters / defibrillators from 12 different manufacturers were explanted (see Fig. 1). The dominant position of the companies Biotronik, Germany, and Medtronic, USA, in the greater Hamburg area is evident in the graph. 40.8% of all pacemakers were from Biotronik, 31.2% from Medtronic. Despite the dominant position of two companies in the market, there are a large number of different generators in the material under investigation (see Fig. 2). The reason for the variety of models is the approval regulations, particularly of the US Food and Drug Administration (FDA), which has very high requirements for new approvals, and the testing of which can take years. However, follow-up approvals are carried out in 2 to 3 months to enable technical progress to quickly find its way into marketable devices. Patient-related data The most important thing in evaluating implants is the benefit that patients can derive from them. In addition to the therapy of the acute illness, the survival time is the outstanding characteristic of a successful therapy. Age of implantation Of central importance for the efficiency of a PM / ICD implantation is the determination of the age of the patient at the time of implantation. Only with the help of the so-called implantation age can it be determined whether the PM / ICD implantation represented a life-prolonging measure. The lifetime extension is generally used as a proxy variable for the gained quality of life. As Figure 3 shows, the age of implantation is not normally distributed. This is also not to be expected, since the likelihood of needing a pacemaker for causal therapy increases with age. A mean implantation age of 80 years is calculated with a standard deviation of 8.66 years. The decrease in the number of cases in the 85 ± 2.5-year bar is due to a corresponding sink in the population. The sharp decline in the number of cases beyond the 90-year-old group results from the low number of people of this age who are still alive. Figure: 1: Distribution of the cardiac pacemakers and ICDs explanted in 2000 among the various manufacturers: Some have meanwhile disappeared from the market or have merged into other companies (Intermedics, Siemens, Teletronic, Vitatron). Figure 3: Age histogram for PM / ICD implantation. It should be noted that the distribution is not normally distributed, since it shows a pronounced tailing towards old age.This is based on the one hand on the fact that some younger people are already suffering from the disease, and on the other hand on the smaller number of older people. Duration of implantation The duration of implantation gives the time period for the data set. Figure 2: Frequency distribution of the individual types for the cardiac pacemakers and ICDs explanted in 2000. Due to the large number of devices on the market, the individual groups are relatively small or comprise only a single device. 492 J CARDIOL 2002; 9 (11)

6 from the generator implantation to the death of the patient. Due to the poor data situation, a distinction between first implantation and reimplantation could not be made. Figure 4 shows the duration of the implantation in years for the 190 of the 218 cases in which an implantation date could be determined. A mean duration of implantation of 4 years (45 months) is calculated with a standard deviation of 3.2 years (38.5 months). In the diagram, a decrease in the number of cases can be observed with increasing implantation time. Figure 5 shows a section of the implantation duration of up to 3 years, quantified in months. Figure 4: PM / ICD implantation time in years. Of the 218 implants examined, the implantation data could only be obtained from 190 and the implantation duration calculated. Overall, there is a decrease in the number per group with a longer implantation duration. Figure 5: Implantation time of the PM / ICD in months for the first years, with a grouping of one month. What is striking is the relatively large number of devices with an implantation time of up to 6 months. Life expectancy vs. duration of implantation The life expectancy of patients with pacemakers or ICDs can be compared with the normal population. In a two-dimensional representation, the observed age is plotted against the age expected at the time of implantation. Even if the comparison of the total population consisting of healthy and sick, smokers and non-smokers, etc. with cardiac PM / ICD patients is initially not valid, the diagrams obtained in this way do not show any significant differences between the two groups. The cluster display using sun flower plots was selected as the display type, with individual data points being represented by circles. If there are several data points in an area, a so-called stick is added to the circle for each data point. The resulting sunflower is placed in the center of the summarized data. In addition, the line was drawn in each of the diagrams where the life expectancy at implantation is the same as the number of years still lived. For all data points below the line, the duration of the implantation was longer than the life expectancy at the time of implantation; That is, despite their illness, the patients lived longer than would be probable for a statistical normal person. All points above the diagonal indicate cases in which the patients have not reached this age. Figure 6 shows all the data collected. The data are summarized in both axes in groups of one year each. The sunflower, which represents the first year in each case, deserves special consideration: this is where the short implantation time and short life expectancy come together. Figure 7 shows this section with a grouping of a quarter for the first 5 years of implantation; the raw data for the first 3 years are visualized in the scatter plot in Figure 8. Gender distribution The gender of the people examined is almost equally distributed with 111 women and 103 men. A projection of the gender distribution in the scatter plot of the duration of implantation / life expectancy does not lead to a measurable cluster formation either, as Figure 9 illustrates. Life expectancy at implantation / years Life expectancy at implantation / years Figure 6: Sun Flower-Plot of the life expectancy of a statistical normal person in the year of implantation, plotted against the years actually lived through by the observed person. The diagonal describes the points at which the life expectancy at implantation is equal to the real life expectancy. For all data points below the line, the duration of the implantation was longer than the life expectancy at the time of implantation; That is, the patients lived longer than statistically probable despite their illness. All points above the diagonal indicate cases in which the patients have not reached their statistical age. Mortality in the first few months deserves special consideration, see Figure 8. Figure 7: Sun flower plot of the life expectancy of a statistical normal person in the year of implantation, plotted against the years actually lived by the observed person for the first 5 years. J KARDIOL 2002; 9 (11) 493

7 Functional condition of the generators All generators were checked for their functionality. A distinction was made between the functionality of the generator and the condition of the battery. In all cases, the function of the generators could be restored by replacing the battery. 158 of the 218 generators examined (72.5%) showed no complaints during the electrical and telemetric check. In 41 cases, battery depletion was found such that the generator should have been replaced; in FIG. 14 the battery was so discharged that the generator was no longer giving adequate signals. In 4 cases the generator was in an operating state in which no more electrical signals were emitted and telemetric interrogation was only possible after the generator was reset. After the reset, the generators worked perfectly. In one case, it was not possible to classify the operating status. In Figure 10, the generators with battery exhaustion are distinguished from those that are still fully functional. For a better overview, Figure 11 shows the generators that were to be classified as EOL or that were no longer electrically functional. The data points in the first year of implantation deserve special attention. The patient with an implantation period of 0 months died periprocedurally. In the other case, the pacemaker was no longer programmed after implantation: the energy output was set to maximum, as is usual for better healing of the electrode tip. Usually, however, this value is reduced again in the first few weeks; this non-programming explains the rapid battery depletion. In Figure 12, the state of the generators is embedded in the scatter plot of the overall data. Number of cases Figure 10: Functional status of the 218 PM / ICD generators examined. 158 generators were working properly, 41 were diagnosed with ERI, i.e. the immediate replacement recommendation, and 14 were diagnosed with EOL, End of Life. 4 units could only be put into a functional state by means of a telemetric reset; for one device, telemetric and electrical checks did not provide a clear result. All generators worked perfectly with a new energy source. Life expectancy at implantation / years Life expectancy at implantation / years Figure 8: Scatter plot of life expectancy in the first 36 months after implantation, plotted against the months actually lived by the observed person. Life expectancy at implantation / years Figure 11: Sun flower plot of all generators that have reached the end of life criterion or are no longer electrically functional. Life expectancy at implantation / years Figure 9: Scatter plot of the life expectancy of a statistical normal person in the year of implantation, plotted against the years actually survived by the observed person, taking gender into account. Figure 12: Distribution of the functional status of the generators after explantation. 494 J CARDIOL 2002; 9 (11)

8 Influence of the place of residence on the pacemaker state In order to determine whether the supply state of the residents of residential complexes for the elderly is identical to those who still live in their own apartment, the places of residence specified in the death certificate were examined. In 214 of the 218 cases examined, there was information on the place of residence, of which 102 (47%) could be identified as private and 68 (31%) as retirement homes. In 44 (20%) a clear explanation was not possible. At a 5% level, the hypothesis The functional states of the pacemakers of patients in old people's homes and those who live alone is different, neither for achieving the replacement criterion nor for the pacemaker defect (c 2 tests, p = 0.116 or p = 0.067). The data of the analysis are given in Table 1 and visualized in Figure 13. Time since the last cardiological examination From the total of 218 generators examined, the time of the last telemetric query could be determined in 83 cases (38%). Of the 83 patients, 23 (28%) had not had pacemaker control in the last year. 12 of the PM functioned perfectly, 9 had met the replacement criterion (ERI) and 2 were inoperable (EOL) (Tab. 2, Fig. 14). In no case could the attending physician be identified from the data stored in the pacemaker. Table 1: Cross table of pacemaker function and place of residence. 214 of the 218 cases examined were taken into account, for which either the place of residence or the pacemaker status are known. Pacemaker status Place of residence O. K. ERI defect reset No EOL data S At home, nursing home No data S n Discussion Problems in the observed sample Incompleteness of the sample During the explantation period, the non-biological cremation residues were examined by another working group. 33 generator remains were found, each of which could be assigned to a corpse [11]. The size of the population is therefore = 251 PM / ICD, of which 218 (87%) were explanted before cremation and could be examined. Distortions due to the location of the sampling. The pacemakers were only explanted and examined in the crematorium. No information is available about the distribution of pacemaker wearers among the various types of burial (cremation, burial in the ground, burial at sea). Surveys by the German Association of Cities in 1999 [12] show that, on a national average, 1% of the deceased allowed themselves to be cremated. A cremation rate of 63.4% was determined for Hamburg: cremations of the dead. It should be noted that the cremations included 4560 (27.9%) deceased from abroad. This distortion is partly offset by the cremation of those who died in Hamburg in the surrounding area, but not corrected. Table 2: Statistical position parameters of the period since the last pacemaker interrogation with a telemetric programming device. The telemetric query is usually carried out by a cardiologist and not by the treating family doctor, so that although the patients were under regular medical control, their pacemaker was still not checked. Pacemaker status parameter defect functional ERI EOL capable N last test> 1a mean value [d] median [d] minimum [d] maximum [d] Figure 13: PM / ICD function broken down by place of residence. In the residential complexes for the elderly, there was no significantly higher number of pacemakers to be replaced or battery-depleted. Figure 14: Box plot representation of the time in days since the last telemetric query. The outliers in the functional box speak for a high quality of the implants: A generator worked for almost 8 years without follow-up care. These individual values ​​should not hide the fact that the overwhelming majority of patients (81%) with a functioning generator had a cardiological follow-up within one year and that this had a positive influence on functionality. J KARDIOL 2002; 9 (11) 495

9 Unfortunately, therefore, no representative statement can be made about the functional status of pacemakers in the general population. It is very likely, however, that this situation does not differ significantly from that of the corpses to be cremated. Small size of the sample Due to the small size of the sample (n = 218 with 190 complete data sets), the group sizes for statistical processing must be larger than would be desirable in the individual case. Looking at the implantable cardioverters / defibrillators, the number of 6 explanted devices in one year seems small. However, in 2 of the 6 cases there were indications that justify a post-mortem diagnosis [13]. Pacemaker (PM) It is true that individual pacemaker model series could not be identified as the cause of fatal complications, but the sample did contain some devices that had been recalled by the manufacturers. The large number of defective generators (see Figure 10) is not due to a malfunction of the generator or one of its components, but in all cases to battery exhaustion. In some of the explanted pacemakers, the housing was opened mechanically with a saw and a corresponding new energy source was connected. In this way, the functionality of the generator could be restored in all cases. Thanks to the telemetry functions built into all PM / ICDs, battery depletion can be diagnosed long before the EOL (End Of Life) of the battery. Some of the PM / ICD programs even offer a temporal projection of the battery depletion state based on the actual energy consumption of the generator. The frequency of the EOL diagnosis thus suggests a lack of follow-up care for pacemaker patients: either due to a lack of patient compliance or an incomplete review of the pacemaker function by the general practitioner or the responsible cardiologist. The control function of the general practitioner is made more difficult by the large number of programming devices. The implantation is not carried out by the general practitioners who later take over the basic care of the patients, but by specialized cardiologists, so that a general practitioner will find as many different pacemakers among his patients as we do with the post-mortem analysis. With a programming device price of over EUR, it is not financially viable for the family doctor to be able to check every type of pacemaker. However, a doctor treating a pacemaker patient must ensure that the patient regularly attends the cardiological follow-up appointments. ICD All ICDs write ECGs of the cardiac excitation states before and after activation, i.e. anti-tachycardem pacing (ATP) or cardioversion, and thus enable post-shock diagnostics. For the documentation of episodic interventions, a more secure and more permanent documentation would be desirable for the future, which can still be read without falsification regardless of the battery status and a possible system crash [14]. n Summary All pacemakers and ICD implants diagnosed in 2000 during the 2nd external investigation before cremation were explanted and subjected to a detailed technical examination. There were no technical defects in any of the generators, but in a third of the cases the battery was exhausted, so that the pacemaker either no longer worked at all (total battery exhaustion) or still functioned outside of the specification. Due to the extremely large variety of models, no statistically significant statements on the reliability of individual units could be made with the sample comprising only 218 generators. Considered across all generators, a high level of reliability can be determined. The problem of the patient's low compliance with regard to the follow-up appointments to check the pacemaker function is not a primary problem for the manufacturers, but they should not only take on this problem more than before out of social responsibility, as the non-function of some aggregates ultimately results in the excellent therapeutic success PM / ICD questions. Intensive cooperation between general practitioners and cardiologists as a quality assurance measure in pacemaker therapy should be encouraged again. Literature 1. Hamburger Friedhöfe AöR (2001). Burial statistics of the Hamburg cemeteries for the year Junge M, Weckmüller J, Tsokos M, Püschel K. Pacemakers (PM) and implantable cardioverter defibrillators (ICD) from a forensic medical point of view. In: Püschel K, Tsokos M (eds). Crematorium inquest. Schmidt-Römhild, Lübeck Research in Legal Medicine 2000; 22: Ordinance on the return and disposal of used batteries and accumulators (Battery Ordinance BattV). Federal Law Gazette G5702, No. 20, published in Printed matter 13/9516 by Sanders RS, Lee MT. Implantable Pacemakers. Proceedings of the IEEE 1996; 84: Warren JA, Dreher RD, Jaworski RV, Putzke JJ, Russie RJ. Implantable cardioverter defibrillators. Proceedings of the IEEE 1996; 84: Junge M, Weckmüller J. Forensic and safety-relevant aspects of the deceased with cardiac pacemaker (PM) and implantable cardioverter defibrillators (ICD). Lecture, 1st International Congress of the Syrian Society of Forensic Medicine, May 2000, Damascus, Syria. 7. Bomsdorf E. Cohort mortality table 2000, modeling approaches, model calculations, sensitivity considerations and economic consequences. In: Dinkel RH, Höhn C, Scholz RD (eds). Mortality trends with special consideration of the cohort approach. Harald Boldt Verlag in the R.Oldenburg Verlag, Munich, (series of publications by the Federal Institute for Population Research, Volume 23, 67 88) 8. Buslei H. Comparison of long-term population projections for Germany. Center for European Economic Research (ZEW) Documentation No., Mannheim, Bomsdorf E. Generation mortality tables for the birth cohorts, model calculations for the Federal Republic of Germany. Josef Eul Verlag, Bergisch-Gladbach, Cologne, Bomsdorf E, Trimborn M. Life table 2000, model calculations for the life table. Journal for the Entire Insurance Science 1992; 81: Trieglaff C. Occurrence of allogeneic materials in cremated corpses in the Hamburg area in 2000 (working title). Med. Dissertation, University of Hamburg, German Association of Cities. Cremations 1999, results of a survey by the German Association of Cities. Umdruck 6713, Deutscher Städtetag, Cologne, Junge M, Weckmüller J, Nägele H, Püschel K. Natural Death of a patient with a deactivated Implantable Cardioverter Defibrillator (ICD)? For Sci Int 2002; 125: Mattke S, Dorwarth U, Müller D, Hoffmann E, Markewitz A, Kaulbach H, Schmöckel M, Steinbeck G. Inappropriate therapies for implantable defibrillators. Z Kardiol 1994; 83: J KARDIOL 2002; 9 (11)

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