Effects of stepped psychooncological care on referral to psychosocial services and emotional well-being in cancer patients: A cluster-randomized phase III trial.

OBJECTIVE: Emotional distress in cancer patients often goes unnoticed in daily routine; therefore, distress screening is now recommended in many national guidelines. However, screening alone does not necessarily translate into better well-being. We examined whether stepped psychooncological care improves referral to consultation-liaison (CL) services and improves well-being. METHODS: In a cluster-randomized trial, wards were randomly allocated to stepped versus standard care. Stepped care comprised screening for distress, consultation between doctor and patient about the patient's need for CL services, and provision of CL service. Primary outcomes were referral to psychosocial services and emotional well-being half a year after baseline, measured with the Hospital Anxiety and Depression Scale. A secondary endpoint was uptake of outpatient health care. Analysis employed mixed-effects multivariate regression modeling. RESULTS: Thirteen wards were randomized; 1012 patients participated. With stepped care (N = 570; 7 wards), 22% of the patients were referred to CL services and 3% with standard care (N = 442; 6 wards; odds ratio [OR] 10.0; P < .001). Well-being 6 months after baseline was 9.5 after stepped care (N = 341) and 9.4 after standard care (N = 234, ß -0.3; P = .71). After stepped care, patients with psychiatric comorbidity went more often to psychotherapists (OR 4.0, P = .05) and to psychiatrists (OR 2.3, P = .12), whereas patients without comorbidity used psychiatrists less often (OR 0.4, P = .04) than in standard care. CONCLUSIONS: Stepped care resulted in better referral to CL services. The patients' emotional well-being was not improved, but uptake of outpatient psychiatric help was increased in patients with psychiatric comorbidity and decreased in patients without.

Successful liver transplantation with continued dual antiplatelet therapy.

BACKGROUND: Liver transplantation in patients with dual antiplatelet therapy is considered high-risk procedure due to possible bleeding complications. However, withdrawal of antiplatelet therapy can lead to major adverse cardiac events such as stent thrombosis and even fatal myocardial infarction. CASE REPORT: We report on a 61-year-old male patient with nutritive toxic liver cirrhosis who underwent liver transplantation at our hospital in March 2010. Following two strokes he received secondary prophylaxis with aspirin and clopidogrel, which was continued at time of liver transplantation. The transplantation was performed successfully without withdrawal of the antiplatelet therapy. No cardiac event and no major bleeding complication occurred. CONCLUSIONS: This is, to our knowledge, the first report of a liver transplantation under dual antiplatelet therapy with aspirin and clopidogrel. It shows that even major procedures such as liver transplantation, with its associated high risk of surgical bleeding, can be safely performed with an appropriate risk.

Failure of screening or failure to screen? The screening behavior of patients with colorectal cancer in the Leipzig area.

BACKGROUND: Colorectal cancer (CRC) is the second most common cancer-related cause of death in Germany. Screening for colorectal cancer is effective and is covered by statutory health insurance in Germany. METHODS: The authors studied the screening behavior of patients with CRC in the Leipzig area in the 10 years before their diagnosis. The patients were asked to fill out a standardized questionnaire, and their primary care physicians were questioned, in order to determine what screening measures had been performed and why none had been performed in some cases. RESULTS: 212 patients with CRC were studied. In 175 (83%), cancer had been diagnosed after the appearance of symptoms ("symptomatic group"); in 37 (17%), it had been detected by screening ("screening group"). 51% of the overall patient group had undergone CRC screening in the 10 years before their diagnosis. A test of the stool for occult blood was the most common screening method but was generally not performed in conformity with guidelines. 25 patients (12%) had undergone a screening colonoscopy in the 10 years before their diagnosis; of these 25, 20 had undergone a screening colonoscopy in the 5 years before their diagnosis. The main reason why screening was not performed was ignorance of its availability. CONCLUSIONS: This retrospective study revealed that, of 212 patients with CRC, most had not previously undergone CRC screening in conformity with guidelines. Better patient education by physicians may improve the effectiveness of screening. Appropriate screening measures include fecal occult blood testing and colonoscopy in conformity with guidelines.