RESUMEN
BACKGROUND: This study evaluated the effectiveness of a screening and stepped care program (the TES program) in reducing psychological distress compared with care as usual (CAU) in patients with metastatic colorectal cancer starting with first-line systemic palliative treatment. PATIENTS AND METHODS: In this cluster randomized trial, 16 hospitals were assigned to the TES program or CAU. Patients in the TES arm were screened for psychological distress with the Hospital Anxiety and Depression Scale and the Distress Thermometer/Problem List (at baseline and 10 and 18 weeks). Stepped care was offered to patients with distress or expressed needs, and it consisted of watchful waiting, guided self-help, face-to-face problem-solving therapy, or referral to specialized mental healthcare. The primary outcome was change in psychological distress over time, and secondary outcomes were quality of life, satisfaction with care, and recognition and referral of distressed patients by clinicians. Linear mixed models and effect sizes were used to evaluate differences. RESULTS: A total of 349 patients were randomized; 184 received the TES program and 165 received CAU. In the TES arm, 60.3% of the patients screened positive for psychological distress, 26.1% of which entered the stepped care program (14.7% used only watchful waiting and 11.4% used at least one of the other treatment steps). The observed low use of the TES program led us to pursue a futility analysis, which showed a small conditional power and therefore resulted in halted recruitment for this study. No difference was seen in change in psychological distress over time between the 2 groups (effect size, -0.16; 95% CI, -0.35 to 0.03; P>.05). The TES group reported higher satisfaction with the received treatment and better cognitive quality of life (all P<.05). CONCLUSIONS: As a result of the low use of stepped care, a combined screening and treatment program targeting psychological distress in patients with metastatic colorectal cancer did not improve psychological distress. Our results suggest that enhanced evaluation of psychosocial concerns may improve aspects of patient well-being.
Asunto(s)
Neoplasias Colorrectales/complicaciones , Distrés Psicológico , Estrés Psicológico , Trastornos Relacionados con Traumatismos y Factores de Estrés/etiología , Trastornos Relacionados con Traumatismos y Factores de Estrés/terapia , Anciano , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/terapia , Manejo de la Enfermedad , Femenino , Humanos , Masculino , Inutilidad Médica , Persona de Mediana Edad , Metástasis de la Neoplasia , Estadificación de Neoplasias , Países Bajos/epidemiología , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Trastornos Relacionados con Traumatismos y Factores de Estrés/diagnóstico , Trastornos Relacionados con Traumatismos y Factores de Estrés/epidemiologíaRESUMEN
OBJECTIVE: Our purpose was to resolve the apparent contradiction between the endothelium-dependent and endothelium-independent vasodilator effects of 17 beta-estradiol reported in different studies. STUDY DESIGN: The inner diameters of isolated pressurized spontaneously constricted muscle arterioles (diameter = 63 microm) from Wistar rats (n = 21) were measured during exposure to 17 beta-estradiol, and the role of the endothelium and the influence of sex were assessed. RESULTS: A dose-dependent dilatation was observed during exposure to 17 beta-estradiol concentrations from 10(-10) to 10(-4) mol/L. Arterioles of female rats displayed significantly more dilatation than vessels from male rats. The dilatation was significantly less in endothelium-denuded arterioles or after pretreatment with and in the presence of a nitric oxide synthase inhibitor. CONCLUSIONS: These results provide strong evidence that, in addition to an endothelium-independent effect, 17 beta-estradiol has a dose-dependent, endothelium-mediated, rapid vasodilatory effect on muscle arterioles from the rat, which is stronger in female rats than in male rats.