[Cross-sectoral patient care in the district of Hamburg Harburg: an example of urological cooperation]. / Sektorenübergreifende Versorgung im Landkreis Hamburg-Harburg: Beispiel einer urologischen Kooperation.

BACKGROUND: Ensuring future urological care at the interface between out- and inpatient care is challenging due to demographic developments with an increasing proportion of urological diseases, the simultaneous threat of a shortage of physicians, and the increasing outpatient treatment of complex urological diseases. OBJECTIVES: The cross-sectoral cooperation model between a university maximum care provider and the urologic joint practice with a hospital affiliation (BAG) presented below can serve as an ideal model for outpatient-inpatient care. MATERIALS AND METHODS: Since 2016, there has been close cooperation between the BAG in Winsen/Buchholz and the University Medical Center Hamburg-Eppendorf (UKE). In addition to direct patient transfer and the continuous pre- and posttreatment of patients, two residents from the UKE rotate to the BAG every year. RESULTS: The BAG benefits from this cooperation through planning security and support in everyday patient care, while the UKE benefits from patient transfer as well as surgical and "basic urological" training of residents. By avoiding duplicate examinations and earlier discharge of patients into outpatient follow-up care, resources are spared. Meaningful patient preselection enables minor interventions to be performed close to home via the BAG, whereas complex cases are carried out at a center of excellence. CONCLUSIONS: The cooperation is seen positively by all parties without exception and, above all, as a benefit for the patient's wellbeing. The optimal training and further education of young urologists in this expanding field can thus be supported and should be integrated into urological resident training.

Comment on Chiu et al. Health Promotion and Disease Prevention Interventions for the Elderly: A Scoping Review from 2015-2019. Int. J. Environ. Res. Public Health 2020, 17, 5335.

Chiu et al. report in their paper "Health Promotion and Disease Prevention Interventions for the Elderly: A Scoping Review from 2015-2019" [...].

A comparison of first-attempt cannulation success of peripheral venous catheter systems with and without wings and injection ports in surgical patients-a randomized trial.

BACKGROUND: A peripheral venous catheter (PVC) is the most widely used device for obtaining vascular access, allowing the administration of fluids and medication. Up to 25% of adult patients, and 50% of pediatric patients experience a first-attempt cannulation failure. In addition to patient and clinician characteristics, device features might affect the handling and success rates. The objective of the study was to compare the first-attempt cannulation success rate between PVCs with wings and a port access (Vasofix® Safety, B. Braun, abbreviated hereon in as VS) with those without (Introcan® Safety, B. Braun, abbreviated hereon in as IS) in an anesthesiological cohort. METHODS: An open label, multi-center, randomized trial was performed. First-attempt cannulation success rates were examined, along with relevant patient, clinician, and device characteristics with univariate and multivariate analyses. Information on handling and adherence to use instructions was gathered, and available catheters were assessed for damage. RESULTS: Two thousand three hundred four patients were included in the intention to treat analysis. First-attempt success rate was significantly higher with winged and ported catheters (VS) than with the non-winged, non-ported design (IS) (87.5% with VS vs. 78.2% with IS; PChi < .001). Operators rated the handling of VS as superior (rating of "good" or "very good: 86.1% VS vs. 20.8% IS, PChi < .001). Reinsertion of the needle into the catheter after partial withdrawal-prior or during the catheterization attempt-was associated with an increased risk of cannulation failure (7.909, CI 5.989-10.443, P < .001 and 23.023, CI 10.372-51.105, P < .001, respectively) and a twofold risk of catheter damage (OR 1.999, CI 1.347-2.967, P = .001). CONCLUSIONS: First-attempt cannulation success of peripheral, ported, winged catheters was higher compared to non-ported, non-winged devices. The handling of the winged and ported design was better rated by the clinicians. Needle reinsertions are related to an increase in rates of catheter damage and cannulation failure. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT02213965 , Date: 12/08/2014.

Prognostic impact of somatostatin receptor expression in advanced bladder cancer.

INTRODUCTION AND OBJECTIVES: Somatostatin receptors (SSTR) recently have been identified as potential targets for treatment of solid tumors. Furthermore, they have been shown to be of high relevance for tumor biology and prognosis in various types of cancer. However, there is a lack of clinical data for SSTR in bladder cancer (BC). Aim of this study was to determine the expression of all relevant somatostatin receptor subtypes in benign urothelium and tumor tissue of patients with muscle invasive BC. Furthermore, their potential role as prognostic factor for cancer-specific survival (CSS) and overall survival (OS) was evaluated. METHODS: The collective included BC and benign urothelium tissue of 103 patients (Median age 69; range 32-84, 79 male, 24 female) who underwent a radical cystectomy. A tissue microarray with subsequent immunohistochemical staining was used to assess membranous expression of SSTR1-5. Results were correlated to clinical and histopathological data as well as CSS and OS. RESULTS: Expressions of SSTR1-4 were significantly decreased in BC compared to benign urothelium (P < 0.002 each), whereas SSTR5 expression was increased (P = 0.0017). Expression of SSTR1 was associated with organ-confined disease (≤pT2) (P = 0.0477). No correlation between SSTR1-5 expression and N- and M-stage was observed. Univariate analyses showed a significantly longer CSS and OS in patients with high expression of SSTR3 (P = 0.0316 and 0.0044). Multivariate analyses confirmed SSTR3 expression as independent marker of improved CSS and OS (P = 0.0324 and 0.0076). CONCLUSIONS: The majority of somatostatin receptor subtypes exhibit decreased expression in BC compared to benign bladder tissue. Expression of SSTR3 is an indicator for favorable prognosis in patients with muscle-invasive BC. These results support preclinical investigations using somatostatin receptor analogues such as octreotide to influence BC growth.

Perioperative Management of Alcohol Withdrawal Syndrome.

BACKGROUND: In the perioperative course, alcohol withdrawal syndrome (AWS) can occur in any setting, especially in aero-digestive and acute trauma surgery. Challenging issues are the overlap of other forms of delirium in perioperative and intensive care settings as well as general anesthesia masking the onset of withdrawal symptoms. In contrast to other etiologies of delirium, the pathophysiology and thus treatment strategy of AWS is different: the key point is the tolerance to GABAergic molecules of alcohol-dependent subjects resulting in central nervous hyperactivity once the effect of alcohol or other GABA-stimulating agents is decreased. SUMMARY: Despite limitations due to insufficient accuracy of self-reporting questionnaires and limited feasibility in emergency settings, the AUDIT and the shortened AUDIT-C are the standard tools for detection of alcohol use disorders (AUD), as well as predicting AWS risk and severity in approximately half of these AUD patients. The most important risk factors for AWS are a high blood alcohol concentration at hospital admission, AWS episodes in medical history, and lack of control of alcohol use. Patients considered at risk for severe AWS must be treated with prophylactic medication before the onset of symptoms. Thiamine supplementation is required for all malnourished alcohol-dependent patients. Writing down alcohol-related diagnoses in the medical records requires the patient's presumed consent after shared decision-making. These reports should remain strictly confidential if the patient desires. Psychological support for the perioperative period as well as the following course should be offered to all AUD patients including support in short- and long-term detoxification. Alternative diagnoses must be ruled out with no timely delay, especially if fever and coma are the leading symptoms. The backbone of AWS therapy is the symptom-triggered administration of intravenous benzodiazepines (BZO) in escalating doses until the aimed revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) or Richmond Agitation-Sedation Scale (RASS) score is achieved. Clonidine, dexmedetomidine, baclofen, ketamine, and neuroleptics may be used as symptom-orientated adjuncts. The therapeutic administration of ethanol or clomethiazole is considered to be harmful in critically ill patients after the onset of AWS. General supportive and intensive care including high-dose thiamine supplementation are mandatory in severe AWS cases. The timely differential diagnosis of delirium is important - and AWS is a diagnosis of exclusion - because BZO are strongly recommended for AWS patients but may not be the treatment of choice in other etiologies of delirium. KEY MESSAGES: Screening for AWS risk factors should be integrated in the preoperative and emergency assessment. Other severe diagnoses must be ruled out before the diagnosis of AWS can be established. Preventive treatment should be given to high-risk patients scoring positive for AUD and for patients with a lack of alcohol use control. The principles of AWS therapy are symptom-orientated doses of BZO and as adjuncts α2-agonists, neuroleptics, and others guided by repeated reassessment with validated tools and thiamine administration. Length of stay and morbidity are reduced if AWS therapy is symptom-orientated and protocol-based.

Impact of Histopathological Prostate Inflammation on Urine-Based Prostate Cancer Prediction Using the Prostate Cancer Gene 3 Score.

INTRODUCTION: The Prostate Cancer gene 3 (PCA3) urine test has gained importance in the diagnostic workup of prostate cancer (PC). Limited evidence suggests that PCA3 is not altered in the presence of inflammation. OBJECTIVE: To assess the impact of histological inflammation on PCA3. METHODS: PCA3 was evaluated in patients prior to prostate biopsy (n = 193) and to radical prostatectomy (n = 197). In patients without PC, inflammation was assessed and quantified by individual scores integrating grade and extent. Uni- and multivariate analyses were performed to assess the impact of inflammation grade on PCA3. RESULTS: The PCA3 scores prior to prostatectomy were lower (median 45) than those before positive biopsy (57; p = 0.008). Of 101 negative biopsies, 78% showed inflammation. The median PCA3 scores in the groups with no inflammation and with maximum grade 1 (n = 22), 2 (n = 38), and 3 (n = 19) inflammation were 45, 38, 27, and 25 (p = 0.016). The multivariate models revealed a decrease in PCA3 proportional to the grade and extent of inflammation (p < 0.04 each). CONCLUSIONS: The present data imply that the PCA3 score decreases in the presence of inflammation, which is relevant, for instance, to testing after a recently performed biopsy. In general, inflammation should be regarded as a factor putatively influencing PCA3 and other available and upcoming PC tests.

Validation of the updated eighth edition of AJCC for prostate cancer: Removal of pT2 substages - Does extent of tumor involvement matter?

BACKGROUND: Updates in the eighth edition of the AJCC prostate cancer staging manual include removal of the organ-confined (pT2) substages. METHODS: Retrospective analyses of 12,028 pT2 patients that underwent radical prostatectomy between 2003 and 2016 and did not receive neo- or adjuvant treatments. Kaplan-Meier curves as well as multivariable Cox-regression analyses compared biochemical recurrence (BCR), metastatic progression (MP) and overall mortality (OM) between the 3 subcategories (pT2a, pT2b and pT2c). RESULTS: After surgery, 1,441 patients were classified as pT2a, 126 as pT2b and 10.495 as pT2c. Five-year BFS rates for pT2a, pT2b and pT2c were 92.0% vs. 97.4% vs. 88.0%. For the same groups, 5-year MP-FS rates were 99.5% vs. 100% vs. 99.0% and 5-year OS rates were 98.0% vs. 98.2% vs. 97.7%. In multivariable analyses pT2 substratification did not reach independent predictor status for biochemical recurrence, MP or overall mortality. CONCLUSIONS: Substratification of pT2 prostate cancer was not predictive for further disease progression. Therefore, removing the substages simplifies the staging system without loss of important information.

Age-Adapted Prostate Cancer Gene 3 Score Interpretation - Suggestions for Clinical Use.

BACKGROUND: The prostate cancer antigen 3 (PCA3) gene urine assay is established for biopsy decision in case of prostate cancer (PC) suspicion. Recent findings pointed to an age dependence of PCA3, with putative impact on test interpretation. However, to date no experience has been reported with regard to the extent age might modify the score in certain age ranges. Therefore, the aim of the present study was to re-evaluate the age dependency and, moreover, give suggestions for interpretation of the PCA3 score in dependence of patient's age in daily routine. METHODS: The study comprised 684 patients before prostate biopsy or prostatectomy. Post-massage voided urine samples were assessed by PCA3 measurement. PCA3 scores were correlated to patient's age. The collective was divided into four subcollectives by quartiles of age distribution. For every subcollective the cutoff value at specificity of ≥ 60 was determined. Results were classified by age-class specific cutoff values and test qualities were compared at different cutoffs. RESULTS: In the collective, 59.1% of patients had a positive biopsy. PCA3 correlated to patient's age in univariate and multivariate analysis (p < 0.001 each). The division into age subcollectives revealed groups < 60, 60 - 65, 66 - 69 and > 69 years. Median PCA3 values of patients without/with PC were 17/32, 27/42, 34/55 and 52/68 in the four age classes. Cutoff values for which specificity was determined with ≥ 60 were 23, 39, 42, and 65. Constant cutoff values showed lower sensitivities in younger and lower specificities in older patients. Only the age adjusted values revealed an improved performance with PPV 68.7, accuracy 59.5 and sensitivity 57.7 at specificity of 62.1% in the whole cohort. CONCLUSIONS: The study confirms that the PCA3 score increases with age. The recommended cutoff score of 35 is suitable especially for patients aged in their sixties. Lower reference values between 20 and 30 have to be taken into account in patients aged < 60 years and higher values around 40 to 50 may point to suspicion for PC in patients > 69 years. These results may further improve the diagnostic performance of the PCA3 test and keep the PCA3 test as a significant test in PC diagnostics along with new upcoming urine markers.

Intratumoral Heterogeneity Determines the Expression of mTOR-pathway Proteins in Prostate Cancer.

The aim of this study was to evaluate the expression of mammalian target of rapamycin (mTOR), phosphorylated-mTOR (p-mTOR), and eukaryotic translation initiation factor 4E-binding protein 1 (4E-BP1) in prostate cancer (PCa) in order to assess intratumoral heterogeneity and correlation with clinicopathological parameters. Tissue samples from 115 patients undergoing radical prostatectomy were included in a tissue microarray comprising (A) tissue from the tumor center, (B) malignant border of the tumor, (C) tumor-adjacent benign tissue, and (D) tumor-distant benign prostatic tissue. Immune reactive scores 0-12 were correlated with clinical data in reference to localization. A meta-analysis of studies investigating the association between biochemical recurrence (BCR) and parameters of the mTOR pathway was conducted. Regardless of the location within the tumor, cancer tissue showed higher expression of mTOR, p-mTOR, and 4EB-P1 compared to benign tissue (p < 0.01). Significant differences in expression between tissue samples from groups C and D were observed for mTOR and p-mTOR. When considering expression according to the pathological stage, we observed lower p-mTOR expression in pT3 vs. pT2 (7.9 and 6.3; p = 0.01). After a median follow-up of 74.5 months (IQR 65.0-84.0), 27 patients (23.47%) developed BCR. Weak staining of mTOR was associated with shorter time to BCR (HR: 2.0; p = 0.049) after correcting for PSA and T stage. However, a significant association of mTOR expression with BCR was found for specimens from the malignant border of the tumor (B) but not the tumor center (A) (p = 0.0034 log rank). In a meta-analysis, we found that the expressions of mTOR ((RR) = 0.70; 95% CI 0.43-1.12; p = 0.13) and 4E-BP1 ((RR) = 0.86; p = 0.53) were not statistically associated with BCR, while strong staining of p-mTOR was associated with a lower risk of BCR ((RR) = 0.57; p = 0.002). All 3 markers showed stronger expression in PCa and exhibited local gradients in relation to the border of tumor and healthy tissue. Our results suggest an important role of intratumor heterogeneity for the use of mTOR parameters as biomarkers in PCa.

The predictive value of a modified Carpentier classification in patients with coincidental mitral regurgitation undergoing TAVI for severe aortic valve stenosis1.

INTRODUCTION: Concomitant mitral-regurgitation (MR) is frequently observed in patients undergoing trans-catheter aortic valve implantation (TAVI). The predictive value of MR etiology remains to be elucidated. METHODS: 600 patients with coincidental MR (≥moderate) undergoing TAVI were categorized according to a modified Carpentier classification [Groups: no/mild MR, n = 477; left atrial (LA) functional MR, n = 18; MR due to left ventricular dilatation, n = 29; degenerative MR, n = 50; MR with restricted leaflet motion n = 26]. MR improvement and patient outcome was compared among the groups in a retrospective analysis. RESULTS: MR regression was most pronounced in patients with restricted leaflet motion after 6 months, although a significant improvement was observed in all subgroups. MR relief was predominantly observed within the first 30 days after TAVI. Only patients with restricted leaflet motion experienced further improvement thereafter.In the entire cohort a total of 15 strokes (2.5%) during the first 30 days after TAVI were observed, with the highest incidence in the LA functional cohort (3 events, 17%; p = 0.008). In multivariate analysis, organic etiology was associated with an increased 1-year mortality.In conclusion, despite significant MR regression in all MR groups, some individuals may require additional mitralvalve repair after TAVI. According to our data the timing of these procedures should be based on the underlying MR etiology. The Carpentier classification in patients with coincidental MR undergoing TAVI for severe AS may also have prognostic implications as we found an increased incidence of strokes in our LA functional cohort and a worse mortality rates in organic MR.

Repeated MitraClip procedure in patients with recurrent MR after a successful first procedure: Limitations and outcome.

OBJECTIVES: The present study aimed to evaluate the outcome and potential limitations of a repeated MitraClip procedure (ReClip). BACKGROUND: The MitraClip procedure has emerged as a treatment option in high surgical risk patients suffering from severe mitral regurgitation (MR). However, despite successful initial repair a significant number of patients develops severe recurrent MR. METHODS: Patients undergoing a ReClip procedure in our institution were retrospectively identified. Baseline data and the procedural outcome were assessed to identify potential limitations of such procedures. RESULTS: Fifteen out of 234 patients undergoing a mitral-valve repair with the MitraClip device (Abbott Vascular) underwent a ReClip due to recurrent MR. In 11 patients, a MR reduction of at least one degree without causing mitral valve stenosis (trans-mitral mean gradient ≥5 mmHg) was achieved by performing a ReClip. After 1 year, two patients developed severe recurrent MR again. Pulmonary artery pressures significantly decreased after the procedure in individuals with successful repair (MR reduction of at least one degree and mitral valve mean gradient <5 mmHg). CONCLUSION: A ReClip procedure may be feasible in patients with recurrent MR but the risk benefit ratio should be carefully balanced against other treatment options.

Ex vivo γH2AX radiation sensitivity assay in prostate cancer: Inter-patient and intra-patient heterogeneity.

INTRODUCTION: The aim of the study is to assess inter-patient and intra-patient heterogeneity in tumour cell radiosensitivity using the ex vivo γH2AX assay in prostate cancer specimens. METHODS: Excised specimens from untreated prostate cancer patients were cultivated 24h in media, irradiated ex vivo and fixed after 24h. Residual γH2AX foci were counted and the slope of the dose response was calculated. Intra-patient heterogeneity was studied from three to seven different biopsies. RESULTS: In pathology-confirmed tumour samples from 21 patients the slope of residual γH2AX foci and radiation dose showed a substantial heterogeneity ranging from 0.82 to 3.17 foci/Gy. No correlation was observed between the slope values and the Gleason score (p=0.37), prostate specific antigen (p=0.48) and tumour stage (p=0.89). ANOVA indicated that only in 1 out of 9 patients, biopsies from different tumour locations yielded statistically significant differences. Variance component analysis indicated higher inter-patient than intra-patient variability. Bootstrap simulation study demonstrated that one biopsy is sufficient to estimate the mean value of residual γH2AX per dose level and account for intra-patient heterogeneity. CONCLUSIONS: In prostate cancer inter-patient heterogeneity in tumour cell radiation sensitivity is pronounced and higher than intra-patient heterogeneity supporting the further development of the γH2AX ex vivo assay as a biomarker for individualized treatment.

Effect of radical prostatectomy on levels of cancer related epitopes in circulating macrophages of patients with clinically localized prostate cancer.

OBJECTIVE: Epitopes of the apoptosis related protein DNaseX (Apo10) and the pentose-phosphate-pathway associated protein transketolase-like 1 (TKTL1) have been shown to be increased in circulating macrophages of patients with different cancer types including prostate cancer (PC). So far, the effect of cancer-specific therapies on the levels of these markers in blood samples of patients with PC has not been evaluated yet. The aim of the present study was to prospectively assess the effect of surgical removal of the prostate on levels of Apo10 and TKTL1 in blood macrophages using Epitope Detection In Monocytes (EDIM). METHODS: We prospectively enrolled 174 patients with clinically localized PC undergoing radical prostatectomy. Peripheral blood was collected preoperatively in all patients and postoperatively in a subgroup of 72 patients. We separately assessed the proportion of CD14/CD16-positive monocytes expressing Apo10 and TKTL1 using flow cytometry. The proportion of positive cells was multiplied by ten to generate a score for Apo10 and TKTL1, separately. Pre- and postoperative scores of Apo10 and TKTL1 were compared. Moreover, results were correlated with clinicopathologic parameters. RESULTS: In the total cohort, Median preoperative Apo10 and TKTL1 scores were 136 (Range 101-254) and 139 (102-216). In patients who underwent blood collection and testing either pre- and postoperatively (n = 72), median pre- versus postoperative scores were 132 (101-215) versus 103 (70-156) for Apo10 (P < 0.0001) and 140 (102-212) versus 115 (84-187) (P < 0.0001) for TKTL1. Following radical prostatectomy, 56 (77.7%) and 59 (81.9%) patients in the cohort of patients with blood collection before and after prostatectomy showed a decrease of Apo10 and TKTL1 expressing monocytes. TKTL1 and Apo10 did not show any correlation with known histopathologic and clinical risk parameters. CONCLUSIONS: The present study demonstrates that surgical removal of the primary tumor leads to a significant decrease of Apo10 and TKTL1 expressing macrophages. This observation further encourages studies assessing the optimal clinical utility of EDIM-based detection of Apo10 and TKTL1 in patients with PC.

Chronic Periodontitis Does Not Impact Serum Levels of Prostate-specific Antigen.

BACKGROUND/AIM: Chronic periodontitis (CP) has already been associated with altered PSA values in men undergoing biopsy. This study addressed the impact of CP treatment on PSA screening. PATIENTS AND METHODS: Fifty-two asymptomatic men presenting for CP treatment were prospectively enrolled. Total (t)PSA, free (f)PSA and %PSA were determined (n=47) before and after therapy. Pre- and post-therapy values were correlated pairwise regarding patients and dental characteristics. RESULTS: Median age was 54 years (SD=±7.7 years) and mean tPSA was 1.3 ng/ml (±1.9 ng/ml). tPSA and fPSA correlated linearly and positively with age (p<0.002). After stratification by age, tPSA/fPSA remained significantly lower in smokers (p<0.05). No other patient or dental factor was associated with tPSA, fPSA, %PSA. CP therapy had no effect on PSA reduction and did not affect indication for biopsy. CONCLUSION: The potential influence of CP on PSA testing seems to be excludable in asymptomatic men.

The Value and Evaluability of the PCA3 Urine Assay in Prostate Carcinoma is Independent of the Tumor Localization.

INTRODUCTION: The prostate cancer gene 3 (PCA3) test is based on the analysis of tumor cell mRNA in urine. As an exprimated urinary marker, its retrieval is subject to certain physical aspects like palpation pressure and detachment force during the squeezing of cells. Other potential factor of influence may be the distance the cells have to cover until they reach the urethra. Thus, it was investigated whether the localization of the tumors within the prostate with regard to the urethra and the seminal colliculus influences the PCA3 score. METHODS: Prostatectomy specimens of 55 organ-confined prostate cancer patients were processed according to the Stanford protocol. For each prostatectomy specimen, a three-dimensional reconstruction including the surface of the prostate, the tumor areas and the urethra was created. By model simulating, virtual concentric tubes were placed around the urethra and spherical volumes were virtually positioned around the seminal colliculus at diameters of 8, 16 and 32 mm. Depending on localization, tumor volumes may or may not protrude into the tubes or spherical volumes. For each respective diameter, PCA3 levels were compared between the subgroup with and without protrusion of tumor tissue into the tube or spherical ball. RESULTS: For none of the diameters, whether in tubes or spherical balls, were patients without intersection volumes-hence showing peripherally located tumors-found to have lower PCA3 levels. No clinical or histopathological parameter correlated with the PCA3 score. CONCLUSION: The location of the tumor mass in the prostate with respect to the urethra or the seminal colliculus did not to affect the PCA3 score. Hence, the location of the tumor does not limit the validity of the PCA3 score, and even for exclusively peripherall y located tumors, this possible influencing factor did not lead to an artificial modulation of the PCA3 score.

[The addicted patient in anaesthesia -screening, diagnosis and treatment of alcohol use disorders]. / Der suchtkranke Patient in der Anästhesie - Screening, Diagnose und Behandlung Alkoholkonsum-bezogener Störungen.

Patients consuming > 60g/d of alcohol (e.g. 1.5l of beer), are 2-5 times more likely to suffer post-operative complications such as infectious, bleeding or cardiac complications or an alcohol withdrawal syndrome. By screening and a systematic evaluation risk patients can be identified that may benefit from interventions such as counseling, brief interventions, abstinence, tailored anesthesia, prophylactic treatment of withdrawal symptoms, stress reduction, harm reduction, psychosocial therapy, addiction therapy, multidisciplinary treatment.

Effects of an Innovative Psychotherapy Program for Surgical Patients: Bridging Intervention in Anesthesiology--A Randomized Controlled Trial.

BACKGROUND: The stepped care program Bridging Intervention in Anesthesiology (BRIA) aims at motivating and supporting surgical patients with comorbid mental disorders to engage in psychosocial mental healthcare options. This study examined the efficacy of BRIA. METHODS: This randomized, parallel-group, open-label, controlled trial was conducted in the preoperative anesthesiological assessment clinics and surgical wards of a large university hospital in Germany. A total of 220 surgical patients with comorbid mental disorders were randomized by using the computer-generated lists to one of two intervention groups: BRIA psychotherapy sessions up to 3 months postoperatively (BRIA) versus no psychotherapy/computerized brief written advice (BWA) only. Primary outcome was participation in psychosocial mental healthcare options at month 6. Secondary outcome was change of self-reported general psychological distress (Global Severity Index of the Brief Symptom Inventory) between baseline and month 6. RESULTS: At 6-month follow-up, the rate of patients who engaged in psychosocial mental healthcare options was 30% (33 of 110) in BRIA compared with 11.8% (13 of 110) in BWA (P = 0.001). Number needed to treat and relative risk reduction were 6 (95% CI, 4 to 13) and 0.21 (0.09 to 0.31), respectively. In BRIA, Global Severity Index decreased between baseline and month 6 (P < 0.001), whereas it did not change significantly in BWA (P = 0.197). CONCLUSIONS: Among surgical patients with comorbid mental disorders, BRIA results in an increased engagement in subsequent therapy options and a decrease of general psychological distress. These data suggest that it is reasonable to integrate innovative psychotherapy programs into the context of interdisciplinary surgical care.

Gold standard program for heavy smokers in a real-life setting.

BACKGROUND: High-intensity smoking cessation programs generally lead to more continuous abstinence, however, lower rates of success have been reported among heavy smokers. The aim was to evaluate continuous abstinence among heavy smokers during the intensive 6-week Gold Standard Program (GSP) and to identify modifiable factors associated with continuous abstinence. METHODS: In this nationwide clinical study based on 36,550 smokers attending an intensive cessation program in Denmark. Heavy smoking was defined as ≥7 points in the Fagerström Nicotine Dependency Test, smoking ≥20 cigarettes daily or ≥20 pack-years. RESULTS: Overall, 28% had a Fagerström score ≥7 points, 58% smoked ≥20 cigarettes daily and 68% smoked ≥20 pack-years. Continuous abstinence was 33% in responders (6-months response rate: 78%); however, abstinence was approximately 1-6% lower in the heavy smokers than the overall population. Attending GSP with an individual format (vs. group/other, OR 1.23-1.44); in a hospital setting (vs. pharmacy/municipality services, OR 1.05-1.11); and being compliant (attending the planned meetings OR 4.36-4.89) were associated with abstinence. Abstinence decreased in a dose-dependent manner with increasing smoking severity. CONCLUSIONS: Abstinence after GSP was 1-6% lower in the heavy smokers than in the overall study population. Modifiable factors may be used for small improvements in continued abstinence. However attempts to improve compliance seemed especially promising.

The Gold Standard Programme: smoking cessation interventions for disadvantaged smokers are effective in a real-life setting.

OBJECTIVES: To evaluate the real-life effect of an evidence-based Gold Standard Programme (GSP) for smoking cessation interventions in disadvantaged patients and to identify modifiable factors that consistently produce the highest abstinence rates. DESIGN: Observational prospective cohort study. SETTING: GSPs in pharmacies, hospitals and communities in Denmark, reporting to the national Smoking Cessation Database. PARTICIPANTS: Disadvantaged patients, defined as patients with a lower level of education and those receiving unemployment benefits. INTERVENTIONS: 6-week manualised GSP smoking cessation interventions performed by certified staff. MAIN OUTCOME MEASURES: 6 months of continuous abstinence, response rate: 80%. RESULTS: Continuous abstinence of the 16 377 responders was 34% (of all 20 588 smokers: 27%). Continuous abstinence was lower in 5738 smokers with a lower educational level (30% of responders and 23% of all) and in 840 unemployed (27% of responders and 19% of all). In respect to modifiable factors, continuous abstinence was found more often after programmes in one-on-one formats (vs group formats) among patients with a lower educational level, 34% (vs 25%, p=0.037), or among unemployed, 35% (vs 24%, p=0.099). The variable 'format' stayed in the final model of multivariable analyses in patients with a lower educational level, OR=1.31 (95% CI 1.05 to 1.63). CONCLUSIONS: Although continuous abstinence was lower among disadvantaged smokers, the absolute difference was small. If the programme had been as effective in disadvantaged as in non-disadvantaged groups, there would have been an extra 46 or 8 quitters annually, respectively. Promoting individual interventions among those with a low education may increase the effectiveness of GSP.