Mean Number Of Treatment Sessions Research Articles

The reliability of self-image change scores in psychotherapy research: An application of generalizability theory.

The aim of this study was to estimate the reliability of the pre- to posttreatment change scores for 3 different self-image aspects, Attack, Love, and Control. To measure self-image, we used the Norwegian version of the introject surface of Benjamin's (1974) structural analysis of social behavior. The article introduces Generalizability (G-) theory, combined with the recent concept of tolerance for error, as a framework for estimating the reliability and precision of change scores in 1- and 2-facet designs. Data were obtained from the Norwegian Multi-Site Study of Process and Outcome in Psychotherapy, including 291 outpatients. The mean number of treatment sessions was 47. The results show that change scores may be highly reliable. Generalizability coefficients resting on the relative and absolute score interpretations, respectively, for both the Love and Attack change scores reached acceptable levels. The reliability of the Control change score was, however, poor. G-theory combined with the error-tolerance concept proved to be a helpful framework for assessing the dependability of change scores in a psychotherapy research setting. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Review of first year result of photodynamic therapy on age-related macular degeneration in chinese population

To evaluate the effect of verteporfin therapy (Visudyne) on age-related macular degeneration (AMD) in Chinese patients. The baseline characteristic and the visual outcome will be compared with the treatment of AMD with photodynamic therapy study (TAP) and verteporfin in photodynamic therapy study (VIP). Retrospective comparative case series. We recruited patients >50 years old, with best-corrected visual acuity >20/200 and fluorescein angiography documenting subfoveal either predominantly classic with greatest linear dimension <5400 mum or pure occult choroidal neovascularization (CNV) secondary to AMD. We applied non-thermal laser to the lesion 15 min after visudyne infusion as described in TAP study. Patients were followed up with fluorescein angiography every 3 months. Additional treatment would be offered if there was evidence of recurrence of CNV. Baseline characteristic and visual outcome. In all, 46 eyes of 42 patients were enrolled at our centre from July 2002 to June 2003. They comprised 11 eyes with predominantly classic lesions and 35 eyes with pure occult lesion. The mean number of treatment sessions given was 2.9 in the first year. At the 12-month examination, there were 63 and 29% of patients showing visual improvement in predominantly classic and occult groups, respectively, while there were only 16% of patients in the TAP study and 12% of patients in the VIP study showing visual improvement in the same period. Verteporfin therapy for subfoveal CNV is beneficial to Chinese patients with AMD at first year. The visual result seems to be better than that observed in Caucasian patients.

Treatment of Cervicofacial Lymphatic Malformations with OK-432 Sclerotherapy

Lymphatic malformations (LMs) are low-flow congenital lesions that consist of cysts of varying size. Sclerotherapy with intralesional bleomycin and OK-432 has been reported to yield dramatically beneficial results for this disorder. However, inflammation-related symptoms are often seen after treatment with these sclerosing agents. On the other hand, polidocanol (POL) is reportedly associated with fewer allergic and inflammatory reactions. Up to now, however, very few reports have documented the use of POL microfoam for treatment of LMs. This study was performed to assess the efficacy and safety of POL microfoam sclerotherapy for LMs.Between 2003 and 2016, cases were identified from a prospectively compiled database on low-flow congenital vascular malformations before undertaking a retrospective electronic chart review. Patients were included if they had LMs that had been treated by POL microfoam sclerotherapy. The location, size, and type of LMs were assessed using ultrasound and magnetic resonance imaging. Twenty-gauge venous catheters were inserted into the lymphatic space under ultrasound visualization. The LMs were then fully aspirated if they were macrocystic in form. Microfoam composed of 3% POL was then injected under ultrasound guidance. Microcystic LMs were treated by direct injection with POL microfoam under ultrasound guidance. The outcome was assessed by clinical examination combined with findings of postsclerotherapy imaging using ultrasound and magnetic resonance imaging.During a 13-year period, 32 patients met the inclusion criteria. These were 11 (34%) male patients and 21 (66%) female patients with a mean age of 18 years. The LMs were localized to the head and neck (47%), the trunk (38%), and the extremities (15%). The lesions were subdivided into macrocystic (56%), mixed macrocystic and microcystic (31%), and microcystic (13%) LMs. The average lesion size was 6.6 × 4.6 × 3.0 cm. The mean number of treatment sessions was 2.8 (range, 1-15), with a mean foam volume of 4.6 (range, 1-10) mL. Excellent (47%) and moderate (41%) responses were seen in 88% of the patients. Notably, half of the patients achieved excellent or moderate resolution with a single treatment session. Intralesional hemorrhage occurred in four patients (13%) but resolved spontaneously. Only one patient with mixed macrocystic and microcystic LMs developed post-therapy infection. However, the other patients did not develop any post-therapy inflammation-related symptoms, including fever, pain, and marked swelling.Percutaneous sclerotherapy using POL microfoam appears to be safe and effective for treatment of LMs. Ultrasound-guided POL microfoam sclerotherapy should be considered for such lesions, particularly those that are exclusively macrocystic.

Effectiveness of CBT Versus Standard Treatment for Childhood Anxiety Disorders in a Community Clinic Setting

AbstractThe efficacy of cognitive—behavioural therapy (CBT) for the treatment of childhood anxiety has mainly been demonstrated in university-clinic settings. This study aimed to evaluate the effectiveness of CBT for the treatment of childhood anxiety in a community mental health service, compared with standard treatments (‘Treatment as Usual’ [TAU]) 'child psychotherapy, family therapy and eclectic treatments. Fifty-four children with anxiety disorders, aged from 7 to 14 years, were randomly assigned to either a CBT or TAU group. CBT and the standard treatments were provided by 18 experienced therapists, and the mean number of treatment sessions was 12. Baseline and follow-up measures at 3, 6 and 12 months included an interview based on criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) that was conducted by a clinical psychologist who was blind to the treatment conditions, and standardised anxiety measures (parent, child and teacher reports). Significant improvements were found on all anxiety measures over time, but no significant differences were found between CBT and TAU. The challenge of conducting such research in community settings is discussed.

Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett's esophagus

Endoscopic ablation of Barrett's esophagus has been described in which various thermocoagulation modalities are used in combination with a high dose of a proton pump inhibitor. No randomized comparison of ablation strategies has been published. Referred patients were screened to identify those with Barrett's esophagus 2 to 7 cm in length, without high-grade dysplasia or cancer. Included patients received pantoprazole (40 mg twice a day), followed by randomization to treatment with argon plasma coagulation (APC) or multipolar electrocoagulation (MPEC). The primary outcome measure was the number of treatment sessions required for endoscopic ablation. Of 235 patients screened, 52 were randomized. The mean length of Barrett's esophagus was 3.1 cm in the MPEC group vs. 4.0 cm in the APC group (p = 0.03). Otherwise, the treatment groups were similar with regard to baseline characteristics. The mean number of treatment sessions required for endoscopic ablation was 2.9 for MPEC vs. 3.8 for APC (p = 0.04) in an intention-to-treat analysis (p = 0.249, after adjustment for the difference in length of Barrett's esophagus). The proportion of patients in which ablation was endoscopically achieved proximal to the gastroesophageal junction was 88% for the MPEC group vs. 81% for the APC group (p = 0.68) and histologically achieved in 81% for MPEC vs. 65% for APC (p = 0.21). The mean time required for the first treatment session was 6 minutes with MPEC vs. 10 minutes with APC (p = 0.01) in per protocol analysis. There was no serious adverse event, but transient moderate to severe upper-GI symptoms occurred after MPEC in 8% vs. 13% after APC (p = 0.64). Conclusions Although there were no statistically significant differences, ablation of Barrett's esophagus with pantoprazole and MPEC required numerically fewer treatment sessions, and endoscopic and histologic ablation was achieved in a greater proportion of patients compared with treatment with pantoprazole and APC.

Efficacy and safety of argon plasma coagulation for the treatment of hemorrhagic radiation proctitis

To evaluate the efficacy, safety and medium-/long-term clinical course of patients undergoing endoscopic treatment with argon plasma coagulation for hemorrhagic radiation proctopathy. Descriptive, retrospective study with medium- and long-term follow-up. Ten patients were treated with argon plasma coagulation for hemorrhagic radiation proctopathy between July 1998 and February 2003. Inclusion criteria were: evidence of chronic rectal bleeding, consistent endoscopic findings, and absence of any other cause of hematochezia after a comprehensive ano-rectal examination and complete colonoscopy. The equipment used was a standard colonoscope, an argon delivery unit, an argon plasma coagulation probe 1.5 mm in internal diameter, and a high-frequency electrosurgical generator. Consecutive treatment sessions were programmed whenever it was considered necessary until all mucosal lesions had been treated. Clinical and evolutive follow-up was performed with a focus on tolerance, efficacy, and potential argon plasma coagulation-related complications. Data were updated by personal or telephonic interview. In all patients, chronic rectal bleeding stopped after the last treatment session. The mean number of treatment sessions to stop symptoms was 1.7. Mean follow-up was 31.1 months. All sessions were well tolerated, similarly to standard rectoscopy. In one case a recurrence of rectal bleeding was observed four months later, which required two repeat sessions. Four patients were anemic at inclusion. Three of them reported a resolved anemia at the end of the study. No delayed argon plasma coagulation-related complications such us ulcers or strictures were seen. Argon plasma coagulation appears to be a useful, effective and safe treatment for rectal bleeding resulting from chronic radiation proctitis when compared to standard medical and endoscopic treatments. These successful outcomes seem to persist even after long-term follow-up.

Transpupillary thermotherapy as initial treatment for small intraocular retinoblastoma: Technique and predictors of success

Objective To determine which small retinoblastoma tumors can be treated with transpupillary thermotherapy (TTT) alone and to clarify the minimum amount of treatment required to prevent recurrence. Design Noncomparative interventional case series. Participants Ninety-one tumors in 22 eyes of 24 patients were treated with TTT as the primary treatment modality at a single institution from 1995 until 2002. Methods Transpupillary thermotherapy was applied only when a tumor first appeared or if growth subsequently occurred. Treatment was performed while patients were under general anesthesia with the Iris diode laser (810 nm) on continuous mode with a 1.2-mm spot size. Main outcome measures Local tumor recurrence, failure of TTT requiring the use of salvage therapies. Results Mean age at diagnosis was 3 months (range, 0–19 months), and mean initial tumor base was 0.67 disc diameters (DD) (range, 0.1–1.5). Eighty-four tumors (92%) were cured with TTT alone. Seven tumors (8%) required between 1 and 5 salvage treatments: 4 tumors received cryotherapy, 3 tumors received systemic chemotherapy, 2 tumors received external beam radiation, and 1 tumor received periocular chemotherapy. All 7 tumors requiring salvage treatment were cured without enucleation. Twenty-one eyes were preserved (95%), with 1 eye enucleated secondary to growth of other tumors. The mean number of treatment sessions required for cure was 1.7 (median, 1 session, range 1–6), with 64% of the tumors requiring only 1 session. The mean power was 420 mW, the mean total duration for all sessions was 320 seconds, and the mean total energy for all treatments was 139.6 J. Univariate analysis revealed that predictors of tumor recurrence were male gender, increasing age at diagnosis, posterior and inferior tumor location, increasing initial tumor base diameter, and increasing total energy. Multivariate analysis indicated that the predictive combination of variables included male gender, increasing age at diagnosis, and increasing total energy. The predictors of need for salvage treatment on univariate analysis were male gender, inferior tumor location, increasing initial tumor base diameter, and increasing total energy. Multivariate analysis demonstrated that the most important combination of variables was male gender and increasing total energy. Conclusions Retinoblastoma tumors <1.5 DD in base diameter can be successfully treated with TTT alone. Treatment can be implemented only when recurrences occur and can be used at low power settings for a short duration.

Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids

Background This study assessed the efficacy of endoscopic hemorrhoidal ligation for treatment of patients with symptoms caused by internal hemorrhoids. Methods A total of 576 consecutive patients with symptoms caused by internal hemorrhoids were enrolled in the study. Symptoms were rectal bleeding (239 patients) and prolapse (337 patients). The severity of the hemorrhoids was classified by using the grading system of Goligher. Results All patients were treated by the same operator. Mean follow-up was 17.5 months (range 8 to 24 months). The mean number of band ligations per session was 2.86. The mean number of treatment sessions was 1.24. At least one grade reduction in the severity of the hemorrhoids was achieved in most patients (93.58%). Moreover, rectal bleeding was controlled in 228 patients (95.4%), and rectal prolapse was reduced in 310 patients (91.99%). After treatment, 85 patients experienced anal pain, 37 had mild bleeding, 4 developed external hemorrhoidal thrombosis, and one had a peri-anal abscess. The latter 5 patients were treated surgically and recovered uneventfully. Conclusions Endoscopic hemorrhoidal ligation is a simple, safe, and effective treatment for patients with symptoms caused by internal hemorrhoids.

Long-term results of noncontact neodymium:yttrium–aluminum–garnet cyclophotocoagulation in neovascular glaucoma

Purpose To determine the long-term efficacy and safety of noncontact transscleral neodymium:yttrium–aluminum–garnet (Nd:YAG) cyclophotocoagulation (CP) for the treatment of neovascular glaucoma (NVG). Design Retrospective, noncomparative, interventional case series. Participants One hundred fifteen eyes of 111 subjects treated from December 1987 to January 2001. Methods Eyes with uncontrolled NVG underwent noncontact Nd:YAG CP. Treatment parameters and pretreatment and posttreatment intraocular pressures (IOP) were reviewed. Preoperative and postoperative IOP were compared using a paired Student’s t test. Success was defined as an IOP ≤22 mmHg, with or without medications, in the absence of phthisis bulbi, and without having undergone further surgical procedures. Results were subjected to a Kaplan–Meier life-table analysis. Results Mean follow-up was 27.0 ± 34.3 months (range, 1–148 months). Mean preoperative IOP was 47.4 ± 11.1 mmHg (range, 26–70 mmHg). Mean postoperative IOP was 18.3 ± 12.2 mmHg (range, 0–44 mmHg). The mean number of treatment sessions was 1.4 ± 0.7 (range, 1–6), with 82 eyes (71.3%) having only one treatment. Kaplan–Meier survival analysis showed a probability of continued success at 1 year of 65.0%, at 3 years of 49.8%, and at 6 years of 34.8%. Phthisis developed in 8.6% of the eyes. Conclusions Noncontact Nd:YAG CP provides long-term IOP reduction in eyes with medically uncontrolled NVG. This can be associated with complications that include inflammation, visual loss, and hypotony. Repeat treatment may be necessary.

What is an appropriate indication for endoscopic papillary balloon dilation?

There are a number of views on the indication for endoscopic papillary balloon dilation (EPBD) in the management of bile duct stones. In this study, we have evaluated the efficacy and safety of EPBD compared with endoscopic sphincterotomy (EST). Prospective randomized trial. One university hospital and one general hospital. One hundred and forty patients were randomly allocated to EPBD or EST. Outcomes and complications were observed for a median period of 30 months. Both treatment approaches finally achieved similar success rates and needed similar numbers of treatment sessions for patients with stones less than 10 mm in diameter. However, for patients with stones of 10 mm or more, EPBD required a significantly greater mean number of treatment sessions than EST (2.4 vs 1.6, P < 0.01). Early complications occurred in seven EPBD (four pancreatitis, two cholangitis and one basket impaction) and eight EST (three pancreatitis, two bleeding and three cholangitis) patients. Late complications occurred in four EPBD (three recurrent bile duct stones and one cholecystitis) and six EST (three recurrent stones and three cholecystitis) patients. EPBD has little risk of bleeding. The technique removed small bile duct stones just as easily as did EST. These two procedures had approximately the same risk of pancreatitis and incidence of recurrent bile duct stones. Therefore, both procedures appear to be appropriate treatments for small bile duct stones. Whether or not EPBD becomes an established treatment will depend on further long-term studies.

Efficacy and complications of argon plasma coagulation for hematochezia related to radiation proctopathy

Background: Endoscopic treatments effectively control bleeding caused by radiation proctopathy. The aims of this study were to determine the efficacy and side effects of argon plasma coagulation in the treatment of this type of bleeding. Methods: Records of 21 consecutive patients in whom argon plasma coagulation was used to treat hemorrhagic radiation proctopathy were reviewed. Results: Pharmacologic measures had been unsuccessful in 12 patients. Endoscopic treatment had been unsuccessful in 5 patients. All patients were anemic and 4 had received blood transfusions. The mean number of treatment sessions was 1.7, and 10 patients were successfully treated in single session. Rectal bleeding resolved within 1 month of the last treatment in 19 patients, usually on the day of the last procedure. Bleeding resolved 2 months after cessation of therapy in another patient. Short-term side effects occurred in 3 (14%) patients (rectal pain, tenesmus, and/or abdominal distention); long-term complications (rectal pain, tenesmus, diarrhea) developed in 4 patients (19%). Conclusions: Hematochezia caused by radiation proctopathy is effectively controlled by argon plasma coagulation, in some cases after a single treatment session. Treatment may result in protracted bowel symptoms. (Gastrointest Endosc 2002;55:70-4.)

A retrospective study on the efficacy and complications of Q-switched alexandrite laser in the treatment of acquired bilateral nevus of Ota-like macules.

Acquired bilateral nevus of Ota-like macules (ABNOM), or Hori's macules, is a common Asian condition that is characterized by bluish hyperpigmentation in the bilateral malar regions. Unlike nevus of Ota, ABNOM is an acquired condition that often develops after 20 years of age and involves both sides of the face, but there is no mucosal involvement. Recently Q-switched (QS) 1064 nm Nd:YAG lasers have been effective in clearing this condition. The effectiveness of QS alexandrite lasers has not yet been studied. To retrospectively assess the efficacy and complications of QS alexandrite lasers in the treatment of ABNOM. Thirty-two Chinese women with ABNOM ranging in age from 28 to 66 years were involved in the study. All underwent QS alexandrite laser treatment (755 nm, spot size 3 mm, 8 J/cm(2)). Topical hydroquinone and tretinoin cream were given to those with hyperpigmentation after the laser surgery. Clinical photographs were taken before and after laser surgery and assessed by two independent observers. The degree of clearing was scored and complications, including hypopigmentation, hyperpigmentation, scarring, and erythema, were assessed. The mean number of treatment sessions was 7 (range 2-11) and the mean treatment interval was 33 days. Both observers identified more than 80% of the patients as having more than a 50% degree of clearing, and complete clearance was seen in more than 28% of patients. Although most patients had postlaser hyperpigmentation and were on depigmentary regimes, the hyperpigmentation was seen in only 12.5% of the patients during photographic evaluation. Hypopigmentation was seen in 50% of patients and erythema in 41%. QS alexandrite appears to be effective in the treatment of ABNOM. Postoperative pigmentary changes were frequent and the use of topical depigmentary agents was necessary to achieve a satisfactory result. Transient hypopigmentation risk was high, affecting up to 50% of the patients. Further study is warranted to compare the efficacy and complications of different laser systems in the treatment of this condition.

Brief cognitive therapy for social phobia: a case series

Social phobia is a common and disabling anxiety disorder. The most effective psychological treatments for social phobia are cognitive therapy and exposure. However, the degree of improvement across these treatments is variable, and their implementation is costly and time-consuming. This study aimed to conduct a preliminary clinical evaluation of the effectiveness of a brief, new form of cognitive therapy based on a recent cognitive model of social phobia. Six consecutively referred patients with social phobia were treated using established single case series methodology. Brief cognitive therapy was effective with all patients demonstrating clinically significant improvements in all measures. Treatment gains were maintained at follow-up. The mean number of treatment sessions delivered was 5.5 and improvements compare favourably with previous treatment studies. Brief cognitive therapy for social phobia appears promising and it is potentially cost-effective. Future randomised and controlled evaluations of this brief treatment are warranted.

3514 ENDOSCOPIC MUCOSAL RESECTION OF EARLY CANCER AND HIGH GRADE DYSPLASIA IN BARRETT'S ESOPHAGUS.

Introduction: In the view of the mortality and morbidity rate of esophagectomy and the relatively large group of inoperable patients local therapeutic techniques for high grade dysplasias (HGD) and early Barrett's cancer (EC) are required. Patients&Method: From 10/96 to 4/99 in Wiesbaden 96 Pat. with proven HGD and/or EC in Barrett's esophagus were treated by means of a local therapy after carefull staging (Video-endoscopy including chromoendoscopy, if necessary photodynamic diagnostics, biopsies from all visible lesions and quadrant biopsies every 2 cm, conventional endosonography as well as 20MHz-probe, abdominal ultrasound, X-ray of the thorax, CT of the thorax and upper abdomen). In 64/96 patients EMR was performed. These 64 pat. were divided into 2 groups: group A (n=35) fulfilled "low-risk"-criteria: mucosal lesion, diameter up to 20mm; macroscopic type I, IIa, IIb, IIc and histological grading G1-G2 or HGD. The remaining 29 patients were included in group B ("high risk"). Results: Totally, 120 resections were performed without technical problems. The mean number of treatment sessions per patient was 1.3±0.6 in group A and 2.8±2.0 in group B (p<0.0005). Only one major complication in form of a spurting bleeding was seen, which could be managed endoscopically, no perforation occurred. Complete local remission (CLR) was significantly (p=0.008) earlier achieved in group A than group B. Up to now complete remission was achieved in 97% in group A and in 59% in group B, but 1 resp. 9 patients are still under therapy or the first control has to be expected, so the CLR will be probably higher. During the mean follow-up period of 12±8 months recurrent or metachronous carcinomas were seen in 14%. Conclusions: Mucosectomy of Barrett's early carcinomas shows a promising low morbidity and mortality. Mucosectomy might offer a new minimally invasive therapeutic alternative to esophagectomy especially in "low risk" situations. A comparison with surgery remains to be done until long-term results are available.

Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus

Background & Aims: In view of the mortality and morbidity rates of esophagectomy and the relatively large group of inoperable patients, local therapeutic techniques are required for high-grade dysplasia and early Barrett's cancer. Methods: A prospective investigation of endoscopic mucosal resection was conducted in 64 patients (mean age, 65 ± 10 years) who had early carcinoma (61 patients) or high-grade dysplasia (3 patients) in Barrett's esophagus. Thirty-five patients met the criteria for low risk: macroscopic types I, IIa, IIb, and IIc; lesion diameter up to 20 mm; mucosal lesion; and histological grades G1 and G2 and/or high-grade dysplasia (group A). The remaining 29 patients were included in group B (high risk). Results: A total of 120 resections were performed, with no technical problems encountered. The mean number of treatment sessions per patient was 1.3 ± 0.6 in group A and 2.8 ± 2.0 in group B ( P < 0.0005). Only one major complication occurred, a case of spurting bleeding, which was managed endoscopically. Complete local remission was achieved significantly earlier ( P = 0.008) in group A than in group B. In May 1999, complete remission had been achieved in 97% of the patients in group A and in 59% of those in group B; however, 1 patient in group A and 9 in group B are still undergoing treatment or awaiting the first check-up. During a mean follow-up of 12 ± 8 months, recurrent or metachronous carcinomas were found in 14%. Conclusions: Endoscopic mucosal resection of early carcinoma in Barrett's esophagus is associated with promisingly low morbidity and mortality rates. The procedure may offer a new minimally invasive therapeutic alternative to esophagectomy, especially in low-risk situations. Comparisons with surgical results will need to be done when the long-term results of this procedure become available. GASTROENTEROLOGY 2000;118:670-677

Endoscopic treatment of carpet-like adenomas of the rectum.

Transanal microsurgery, endoscopic laser photocoagulation and snare resection have all been used to treat large sessile adenomas of the rectum alternatively to a surgical approach. However, such modalities are often defective due to the carpet-like shape and the frequently large extension of the lesions. Ten patients with carpet-like adenoma were submitted to transanal endoscopic resection by urological resectoscope. Complete eradication was obtained in all lesions. The mean number of treatment sessions was 3 (range, 1-5). The mean time between the first treatment and the complete eradication was 6 months (range, 1-18). The only complications were an intraoperative and an early postoperative bleeding. There was no early or late mortality related to the procedure. Transanal endoscopic resection by urological resectoscope appears to be a suitable therapeutic approach for sessile and carpet-like adenomas of the rectum or for pTI cancer in patients who refuse major surgery.

Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?

The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.

Sclerotherapy with OK-432 for recurrent cystic thyroid nodule.

We have adopted OK-432 as a sclerosing agent in the treatment of cystic predominant thyroid nodules and have analyzed our findings to assess the efficacy of intralesional instillation of OK-432. From 1992 through 1993, 48 patients with recurrent or progressive cystic thyroid nodules after 2 or 3 aspirations alone, and whom were cytologically negative for malignancy, were used for this study. The OK-432 solution was prepared by dissolving 0.1 mg of OK-432 in 2 ml of physiologic saline and it was instilled in the amount of 1/10-to-1/5 of the aspirated cystic fluid. A repeated course of therapy was given up to 3 times when sufficient resolution was not obtained 4-to-6 weeks after treatment. The mean number of treatment sessions per patient was 1.5. Throughout the follow-up period from 30-to-45 months (mean, 38 months), 32 (66.7%) patients experienced an almost complete disappearance (< 0.05 cm in diameter) of the cystic lesion, and 12 (25%) patients responded partially by having it decrease by more than half (> 0.5 cm in diameter) of the initial cyst size, and none of these patients required further treatment. The remaining 4 (8.3%) patients showed insufficient resolution despite 3 courses of therapy and 2 of these patients underwent thyroidectomy, in which the lesion proved benign in both cases. All of the patients tolerated the sclerotherapy well. No significant local complications attributed to this treatment were observed. However, a low-grade fever was observed in 26 (54.2%) patients for 2 to 5 days after instillation, which subsided with symptomatic treatment. On the basis of our experience, OK-432 sclerotherapy appears to be safe, simple and effective, and can be a useful alternative treatment for cystic thyroid nodules.

COLLAGEN INJECTION THERAPY FOR POST-RADICAL RETROPUBIC PROSTATECTOMY INCONTINENCE: ROLE OF VALSALVA LEAK POINT PRESSURE

Purpose We retrospectively evaluated the role of Valsalva leak point pressure as a predictor of successful management of post-radical retropubic prostatectomy incontinence with collagen injection. Materials and Methods Urodynamic studies and Valsalva leak point pressures of 31 men who received retrograde collagen injection for post-radical retropubic prostatectomy incontinence were reviewed. Patients were interviewed before and after treatment to assess pad use and the American Urological Association quality of life index (scale 0 to 6). Parameters for success were postoperative quality of life score 3 or less or 50% or greater decrease in pad use and that the patient would recommend collagen therapy to someone else. Results Of 31 patients 11 (35%) met the criteria for success, 2 (6%) were completely dry and 9 (29%) were improved. Successfully treated patients had a mean Valsalva leak point pressure of 64.0 cm. water compares to 42.2 cm. water in the failure group (p <0.01). Of patients with Valsalva leak point pressure of 60 cm. water or greater, 70% responded favorably to collagen injection (positive predictive value), while 81% with Valsalva leak point pressure less than 60 cm. water had treatment failure (negative predictive value) (p <0.02). There were no other statistically significant differences between those successfully treated with collagen injection and those in whom treatment failed, including mean age (62.7 to 68.1 years), mean volume of collagen (26.1 to 28.9 ml.), mean number of treatment sessions (2.45 to 2.65), mean followup (14.9 to 15.1 months), preoperative quality of life score (5.1 to 4.9), and preoperative pads per day (4.0 to 3.37). Conclusions Our data suggest that collagen injection improves 35% but cures a minority of patients (less than 10%) with post-radical retropubic prostatectomy incontinence. A pretreatment Valsalva leak point pressure of 60 cm. water or greater has high predictive value for a beneficial outcome after collagen injection. We propose a role for Valsalva leak point pressure to select men cost-effectively with post-radical retropubic prostatectomy incontinence for therapy with collagen injection.

Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences.

In argon plasma coagulation (APC), high-frequency energy is transmitted to tissue by ionized gas, thus reducing contact with the tissue to a minimum. Successful endoscopic APC was initially reported in the palliative treatment of gastrointestinal neoplasms. The main objectives in this pilot study were to evaluate the treatment indications, efficacy and safety of the use of APC. Between September 1994 and January 1996, APC was used to treat 125 patients with various forms of gastrointestinal pathology. For local palliative treatment, APC was successfully used alongside snare loop coagulation, dilation, stenting and/or radiotherapy to treat the following conditions: carcinoma of the esophagus: 15 patients, mean number of treatment sessions (MTS) 3.3; gastric carcinoma: 10 patients, MTS 4.9; rectosigmoid carcinoma: seven patients, MTS 2.7; carcinoma of the papilla of Vater: two patients, MTS 1.5. Repeated treatment was also effective for tubulovillous adenoma of the rectum (20 patients, MTS 2.5), stomach (three patients, MTS 2.0), duodenum (two patients, MTS 1.5) and papilla of Vater (two patients, MTS 3.0). In addition, APC proved helpful in coagulating the remaining tissue and achieving hemostasis after polypectomy in the colon (18 patients, MTS 1.2) and in endoscopic treatment of Zenker's diverticulum, for coagulation of the tissue bridge and hemostasis (31 patients, MTS 2.5). Finally, APC was helpful in coagulation of multiple gastric polyps (one patient, one session), hemostasis in superficial ulceration of the duodenal bulb (one patient, one session), after dilation of benign stenoses of anastomoses in the esophagus (one patient, one session) and colon (one patient, one session) and for vascular malformations in the colon (three patients, MTS 1.3), duodenum (one patient, one session), antrum (one patient, two sessions), and watermelon stomach (six patients, MTS 2.8). We recognized signs of perforation in six patients after treatment of Zenker's diverticulum (n = 3), polypectomy in the colon (n = 2) and coagulation of angiodysplasia in the cecum. Laparotomy was carried out in two patients; in one, a perforation was sutured, and in the other no focus of leakage was seen. All six patients recovered without further complications. No complications were observed in any other patients. These initial experiences indicate that APC seems to be effective in a number of indications, and relatively safe. Objective evaluation, a longer follow-up period, and comparative trials with other treatment modalities should follow.