Heterogeneity of CFTR modulator-induced sweat chloride concentrations in people with cystic fibrosis

BACKGROUND

Sweat chloride (SC) concentrations in people with cystic fibrosis (PwCF) reflect relative CF transmembrane conductance regulator (CFTR) protein function, the primary CF defect. Populations with greater SC concentrations tend to have lesser CFTR function and more severe disease courses. CFTR modulator treatment can improve CFTR function within specific CF genotypes and is commonly associated with reduced SC concentration. However, SC concentrations do not necessarily fall to concentrations seen in the unaffected population, suggesting potential for better CFTR treatment outcomes. We characterized post-modulator SC concentration variability among CHEC-SC study participants by genotype and modulator.

METHODS

PwCF receiving commercially approved modulators for ≥90 days were enrolled for a single SC measurement. Clinical data were obtained from chart review and the CF Foundation Patient Registry (CFFPR). Variability of post-modulator SC concentrations was assessed by cumulative SC concentration frequencies.

RESULTS

Post-modulator SC concentrations (n = 3787) were collected from 3131 PwCF; most (n = 1769, 47 %) were collected after elexacaftor/tezacaftor/ivacaftor (ETI) treatment. Modulator use was associated with lower SC distributions, with post-ETI concentrations the lowest on average. Most post-ETI SC concentrations were <60 mmol/L (79 %); 26 % were <30 mmol/L. Post-ETI distributions varied by genotype. All genotypes containing at least one F508del allele had individuals with post-ETI SC ≥60 mmol/L, with the largest proportion being F508del/minimal function (31 %).

CONCLUSIONS

Post-modulator SC concentration heterogeneity was observed among all genotypes and modulators, including ETI. The presence of PwCF with post-modulator SC concentrations within the CF diagnostic range suggests room for additional treatment-associated CFTR restoration in this population.

Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness

Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.

Implementing wastewater surveillance for SARS-CoV-2 on a university campus: Lessons learned

Wastewater surveillance, also known as wastewater-based epidemiology (WBE), has been successfully used to detect SARS-CoV-2 and other viruses in sewage in many locations in the United States and globally. This includes implementation of the surveillance on college and university campuses. A two-phase study was conducted during the 2020-2021 academic year to test the feasibility of a WBE system on campus and to supplement the clinical COVID-19 testing performed for the student, staff, and faculty body. The primary objective during the Fall 2020 semester was to monitor a large portion of the on-campus population and to obtain an understanding of the spreading of the SARS-CoV-2 virus. The Spring 2021 objective was focused on selected residence halls and groups of residents on campus, as this was more efficient and relevant for an effective follow-up response. Logistical problems and planning oversights initially occurred but were corrected with improved communication and experience. Many lessons were learned, including effective mapping, site planning, communication, personnel organization, and equipment management, and obtained along the way, thereby paving an opportune guide for future planning efforts. PRACTITIONER POINTS: WBE was successful in the detection of many SARS-CoV-2 variants incl. Alpha, Beta, Gamma, Delta, Lambda, Mu, and Omicron. Careful planning and contingencies were essential for a successful implementation of a SARS-CoV-2 monitoring program. A surveillance program may be important for detection and monitoring of other public health relevant targets in wastewater incl. bacteria, viruses, fungi and viruses. Diverse lessons were learned incl. effective mapping, site planning, communication, personnel organization, and equipment management, thereby providing a guide for future planning efforts.

Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness

OBJECTIVE

The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics.

METHODS

Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed.

RESULTS

In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, β=13.54, p=0.003, and naltrexone long-acting injection, β=15.83, p<0.001).

CONCLUSIONS

These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.

Organizational Capacity and Readiness to Provide Medication for Individuals with Co-Occurring Alcohol Use Disorders in Public Mental Health Settings

Alcohol use disorders (AUD) in individuals with mental illness are largely untreated. The purpose of this study was to identify gaps in organizational capacity and readiness to provide medications for AUD in outpatient public mental health clinics. We selected a purposive sample of eight publicly funded outpatient mental health clinics operated by the Los Angeles County Department of Mental Health; clinics were chosen to maximize heterogeneity. Guided by theories of organizational capacity and readiness and research on the adoption of pharmacotherapy for AUD in primary and specialty care treatment settings, we conducted semi-structured interviews and focus groups with administrators, providers and staff, and a qualitative analysis of the results. Respondents described significant organizational capacity and behavioral readiness constraints to providing medication treatment for AUD. Both groups articulated a perception that mental health clinics were not designed to provide co-occurring AUD treatment because of large caseloads, staffing configurations, and time constraints that did not support the delivery of appropriate treatment, and a lack of protocols and workflow procedures. We documented organizational capacity and readiness constraints which impede the delivery of medication treatment for AUD in a large mental helth system. While some constraints have straightforward solutions, others require structural changes to the way care is delivered, and state-level funding and policy changes.

Attitudes about medications for alcohol use disorder among individuals with serious mental illness: A health belief model analysis

BACKGROUND

Medications for alcohol use disorder (MAUD) are underutilized in mental health settings. Increasing use of MAUD requires increasing both the availability of these medications and the demand by individuals who could benefit. Few studies have explored the views of individuals with severe mental illness and alcohol use disorder about MAUD. We sought to examine, among individuals treated in publicly funded community mental health clinics, perceived need for and attitudes toward MAUD.

METHODS

We conducted 8 focus groups with 87 participants treated in public mental health clinics in Los Angeles County. We aimed to include individuals with a current or past AUD diagnosis and individuals helping others (e.g., a family member) who drink. We examined responses using domains associated with the Health Belief Model to identify factors that shape acceptance of MAUD.

RESULTS

Participants were 53% female; most were minorities. Average age was 47 years (SD = 11). Twenty-four reported never drinking, 13 of whom had a current or past diagnosis of AUD. Twenty-two reported drinking 4 or more times per week. Three-quarters had not heard of naltrexone. Participants understood that alcohol use has severe adverse consequences and perceived themselves to be highly susceptible to these consequences. Regarding attitudes toward MAUD, participants described an internal locus of control (e.g., their own desires, actions, and effort) as central to addressing problem drinking; this shaped their views that MAUD would have only modest benefits and potentially high burden. Those individuals who had tried MAUD expressed the most optimism about its effectiveness.

CONCLUSIONS

Participants worried MAUD would impede the development of self-control over drinking by fostering dependence on medication and undermining self-discipline. Client education and counseling that emphasizes MAUD as a tool to build clients' self-control may increase demand for these medications in mental health settings.

The Impact of Attachment-Disrupting Adverse Childhood Experiences on Child Behavioral Health

OBJECTIVES

To describe patterns of overall, within-household, and community adverse childhood experiences (ACEs) among children in vulnerable neighborhoods and to identify which individual ACEs, over and above overall ACE level, predict need for behavioral health services.

STUDY DESIGN

This was a cross-sectional study that used a sample of 257 children ages 3-16 years who were seeking primary care services with co-located mental healthcare services at 1 of 2 clinics in Chicago, Illinois. The outcome variable was need for behavioral health services (Pediatric Symptom Checklist score ≥28). The independent variables were ACEs, measured with an adapted, 28-item version of the Traumatic Events Screening Inventory.

RESULTS

Six ACE items were individually predictive of a clinical-range Pediatric Symptom Checklist score after adjusting for sociodemographic covariates: emotional abuse or neglect (OR 2.93, 95% CI 1.32-6.52, P < .01), natural disaster (OR 3.89, 95% CI 1.18-12.76, P = .02), forced separation from a parent or caregiver (OR 2.95, 95% CI 1.50-5.83, P < .01), incarceration of a family member (OR 2.43, 95% CI 1.20-4.93, P = .01), physical attack (OR 2.84, 95% CI 1.32-6.11, P < .01), and community violence (OR 2.35, 95% CI 1.18-4.65, P = .01). After adjusting for overall ACE level, only 1 item remained statistically significant: forced separation from a parent or caregiver (OR 2.44, 95% CI 1.19-5.01, P = .02).

CONCLUSIONS

ACEs that disrupt attachment relationships between children and their caregivers are a significant predictor of risk for child emotional or behavioral problems.

A Clinical Care Monitoring and Data Collection Tool (H3 Tracker) to Assess Uptake and Engagement in Mental Health Care Services in a Community-Based Pediatric Integrated Care Model: Longitudinal Cohort Study

BACKGROUND

National recommendations for pediatric integrated care models include improved capacity for care coordination and communication across primary care and specialty mental health providers using technology, yet few practical, short-term solutions are available for low-resource, community-based pediatric integrated care clinics.

OBJECTIVE

The goal of the paper is to describe the development and features of a Web-based tool designed for program evaluation and clinician monitoring of embedded pediatric mental health care using a community-partnered approach. In addition, a longitudinal study design was used to assess the implementation of the tool in program evaluation, including clinical monitoring and data collection.

METHODS

Biweekly meetings of the partnered evaluation team (clinic, academic, and funding partners) were convened over the course of 12 months to specify tool features using a participatory framework, followed by usability testing and further refinement during implementation.

RESULTS

A data collection tool was developed to collect clinic population characteristics as well as collect and display patient mental health outcomes and clinical care services from 277 eligible caregiver/child participants. Despite outreach, there was little uptake of the tool by either the behavioral health team or primary care provider.

CONCLUSIONS

Development of the H3 Tracker (Healthy Minds, Healthy Children, Healthy Chicago Tracker) in two community-based pediatric clinics with embedded mental health teams serving predominantly minority children is feasible and promising for on-site program evaluation data collection. Future research is needed to understand ways to improve clinic integration and examine whether promotion of primary care/mental health communication drives sustained use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02699814; https://clinicaltrials.gov/ct2/show/NCT02699814 (Archived by WebCite at http://www.webcitation.org/772pV5rWW).

Validation of the Traumatic Events Screening Inventory for ACEs

OBJECTIVES

Our purpose in this study was to adapt and validate the Traumatic Events Screening Inventory (TESI) as a primary-care childhood adversity screening tool for children living in vulnerable neighborhoods using a community-partnered approach.

METHODS

In this cross-sectional, descriptive study, we used a sample of 261 children (3-16 years old) who were seeking services at a Federally Qualified Health Center with colocated behavioral health services in Chicago and had a positive Pediatric Symptom Checklist screen result or received a referral for behavioral health evaluation. The TESI was adapted as a screening tool to be sensitive to adverse childhood experiences (ACEs) unique to the clinic communities. ACEs were mapped by zip code with objective neighborhood crime data, and latent class analysis was performed to identify ACE subgroups.

RESULTS

The mapping validation suggested face validity for geographic overlap between participant ACEs and objective violent-crime occurrence. With latent class analysis, we identified 3 ACE subgroups: (1) high ACE (18.0% of the sample; polyvictimization and/or maltreatment), (2) moderate ACE (52.1%; violent environments), and (3) low ACE (29.9%; few adverse experiences). Membership in the high-ACE subgroup was associated with higher odds of a clinically significant Pediatric Symptom Checklist score (odds ratio = 3.83) and clinical-level attention problems (odds ratio = 3.58) even after accounting for child resilience and parent depression.

CONCLUSIONS

ACEs play a significant role in predicting a need for behavioral health services among children seeking primary-care services. The community-adapted TESI is a valid ACE screening tool.

Updated diagnostic criteria for neuromyelitis optica spectrum disorder: Similar outcomes of previously separate cohorts

Background

The specificity of the aquaporin-4 antibody to predict recurrent inflammatory central nervous system disease has led to the design of the 2015 neuromyelitis optica spectrum disorder criteria which capture all aquaporin-4 antibody seropositive patients.

Objective

The purpose of this study was to compare treatment outcomes in aquaporin-4 antibody seropositive patients who met the previous 2006 clinical criteria for neuromyelitis optica with patients who meet the 2015 neuromyelitis optica spectrum disorder criteria.

Methods

The study involved a three-center retrospective chart review of clinical outcomes among aquaporin-4 patients diagnosed with neuromyelitis optica and neuromyelitis optica spectrum disorder.

Results

Hazard ratios of relapse during immunosuppressive therapy, relative to pre-therapy, were not significantly different for patients who met the 2006 criteria of neuromyelitis optica versus the 2015 neuromyelitis optica spectrum disorder criteria among those treated with azathioprine ( p = 0.24), mycophenolate mofetil ( p = 0.63), or rituximab ( p = 0.97).

Conclusion

Reductions in the hazard of relapse during treatment with immunosuppressive therapies, relative to average pre-treatment, were not different for aquaporin-4 antibody seropositive patients categorized using the 2006 criteria of neuromyelitis optica and the 2015 neuromyelitis optica spectrum disorder criteria. These therapeutic findings support the design of the 2015 neuromyelitis optica spectrum disorder criteria which capture all aquaporin-4 antibody seropositive patients.

12-Month Cost Outcomes of Community Engagement Versus Technical Assistance for Depression Quality Improvement: A Partnered, Cluster Randomized, Comparative-Effectiveness Trial

Objective

To compare community engagement and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period.

Design

Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS.

Setting

Two Los Angeles communities.

Participants

Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino.

Interventions

CEP and RS to support programs in depression QI.

Main Outcome Measures

Intervention training and service-use costs over 12 months.

Results

CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training participation vs RS, with no significant differences in 12-month service-use costs.

Conclusions

Compared with RS, CEP had higher planning and training costs with similar service-use costs.

Development and Evaluation of Two Integrated Care Models for Children Using a Partnered Formative Evaluation Approach

Objective

To describe the development and evaluation of two integrated care models using a partnered formative evaluation approach across a private foundation, clinic leaders, providers and staff, and a university-based research center.

Design

Retrospective cohort study using multiple data sources.

Setting

Two federal qualified health care centers serving low-income children and families in Chicago.

Participants

Private foundation, clinic and academic partners.

Interventions

Development of two integrated care models and partnered evaluation design.

Main Outcome Measures

Accomplishments and early lessons learned.

Results

Together, the foundation-clinic-academic partners worked to include best practices in two integrated care models for children while developing the evaluation design. A shared data collection approach, which empowered the clinic partners to collect data using a web-based tool for a prospective longitudinal cohort study, was also created.

Conclusion

Across three formative evaluation stages, the foundation, clinic, and academic partners continued to reach beyond their respective traditional roles of project oversight, clinical service, and research as adjustments were collectively made to accommodate barriers and unanticipated events. Together, an innovative shared data collection approach was developed that extends partnered research to include data collection being led by the clinic partners and supported by the technical resources of a university-based research center.

Community Resilience Learning Collaborative and Research Network (C-LEARN): Study Protocol with Participatory Planning for a Randomized, Comparative Effectiveness Trial

This manuscript presents the protocol and participatory planning process for implementing the Community Resilience Learning Collaborative and Research Network (C-LEARN) study. C-LEARN is designed to determine how to build a service program and individual client capacity to improve mental health-related quality of life among individuals at risk for depression, with exposure to social risk factors or concerns about environmental hazards in areas of Southern Louisiana at risk for events such as hurricanes and storms. The study uses a Community Partnered Participatory Research (CPPR) framework to incorporate community priorities into study design and implementation. The first phase of C-LEARN is assessment of community priorities, assets, and opportunities for building resilience through key informant interviews and community agency outreach. Findings from this phase will inform the implementation of a two-level (program-level and individual client level) randomized study in up to four South Louisiana communities. Within communities, health and social-community service programs will be randomized to Community Engagement and Planning (CEP) for multi-sector coalition support or Technical Assistance (TA) for individual program support to implement evidence-based and community-prioritized intervention toolkits, including an expanded version of depression collaborative care and resources (referrals, manuals) to address social risk factors such as financial or housing instability and for a community resilience approach to disaster preparedness and response. Within each arm, the study will randomize individual adult clients to one of two mobile applications that provide informational resources on services for depression, social risk factors, and disaster response or also provide psychoeducation on Cognitive Behavioral Therapy to enhance coping with stress and mood. Planned data collection includes baseline, six-month and brief monthly surveys for clients, and baseline and 12-month surveys for administrators and staff.

Abstract WP281: Multicenter Analysis of Stroke Risk Factor Treatment

The majority of the 800,000 strokes occurring in the US each year are first-time strokes. To understand how these can be prevented, our study assessed primary care (PC) treatment of common stroke risk factors (RF) in the year prior to a first-time stroke. We compared hospitals in three major health systems – a California County (OVMC), VA (WLAVA), and Kaiser HMO (KSD), both before and after the Affordable Health Care Act (ACA).

Methods: We identified patients who suffered a first-time stroke in 2013 and 2015 at all three sites. We then assessed the three most recent PC visits for these patients in the year before their stroke for “missed opportunities” (MO) in stroke preventative care. MOs included: Systolic blood pressure (SBP) >140 not addressed, elevated A1C not addressed, LDL never checked or >100 but not addressed, antiplatelet medication not refilled, and no RF counseling (smoking, alcohol, obesity, or physical activity). MOs were compared between sites, before (2013) and after the ACA (2015).

Results: 85 patients from OMVC, 88 patients from KSD and 64 patients from WLAVA met entry criteria. All sites had an increase in the number of patients who had PC visits prior to first-time stroke between 2013 and 2015 (OVMC 2013: 1/26, 2015 15/59 (25.4%). KSD 2013: 50/67 (74.6%), 2015 16/21 (76.2%). VA 2013: 24/33 (72.7%) 2015 28/31 (90.3%). In 2013, only one OVMC patient had primary care. In 2013, the WLAVA had significantly less MO than Kaiser (23.6% vs 59.0%, p<0.001). In 2015, there was no significant difference in MO between the three sites (p=0.21). The most common MOs were in addressing hypertension, elevated LDL, and lack of RF counseling.

Conclusions: Stroke RFs were often not addressed during PC visits at all 3 sites. All sites had an increase in PC visits among first-time stroke patients after the ACA, particularly within the LA County system. It is unclear if this resulted in increased stroke RF counseling and intervention. Efforts to promote primary stroke prevention are still needed.

How Do Communities Use a Participatory Public Health Approach to Build Resilience? The Los Angeles County Community Disaster Resilience Project

Community resilience is a key concept in the National Health Security Strategy that emphasizes development of multi-sector partnerships and equity through community engagement. Here, we describe the advancement of CR principles through community participatory methods in the Los Angeles County Community Disaster Resilience (LACCDR) initiative. LACCDR, an initiative led by the Los Angeles County Department of Public Health with academic partners, randomized 16 community coalitions to implement either an Enhanced Standard Preparedness or Community Resilience approach over 24 months. Facilitated by a public health nurse or community educator, coalitions comprised government agencies, community-focused organizations and community members. We used thematic analysis of data from focus groups (n = 5) and interviews (n = 6 coalition members; n = 16 facilitators) to compare coalitions’ strategies for operationalizing community resilience levers of change (engagement, partnership, self-sufficiency, education). We find that strategies that included bidirectional learning helped coalitions understand and adopt resilience principles. Strategies that operationalized community resilience levers in mutually reinforcing ways (e.g., disseminating information while strengthening partnerships) also secured commitment to resilience principles. We review additional challenges and successes in achieving cross-sector collaboration and engaging at-risk groups in the resilience versus preparedness coalitions. The LACCDR example can inform strategies for uptake and implementation of community resilience and uptake of the resilience concept and methods.

12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial

BACKGROUND

Depression collaborative care implementation using community engagement and planning (CEP) across programs improves 6-month client outcomes in minority communities, compared with technical assistance to individual programs (resources for services [RS]). However, 12-month outcomes are unknown.

OBJECTIVE

To compare effects of CEP and RS on mental health-related quality of life (MHRQL) and use of services among depressed clients at 12 months.

DESIGN

Matched health and community programs (n = 93) in 2 communities randomly assigned to receive CEP or RS. (ClinicalTrials.gov: NCT01699789).

MEASUREMENTS

Self-reported MHRQL and services use at baseline, 6 months, and 12 months.

SETTING

Los Angeles, California.

PATIENTS

1018 adults with depressive symptoms (8-item Patient Health Questionnaire score ≥10), 88% of whom were an ethnic minority.

INTERVENTION

CEP and RS to implement depression collaborative care.

MEASUREMENTS

The primary outcome was poor MHRQL (12-item mental health composite score ≤40) at baseline, 6 months, and 12 months; the secondary outcome was use of services at 12 months.

RESULTS

At 6 months, the finding that CEP outperformed RS to reduce poor MHRQL was significant but sensitive to underlying statistical assumptions. At 12 months, some analyses suggested that CEP was advantageous to MHRQL, whereas others did not confirm a significant difference favoring CEP. The finding that CEP reduced behavioral health hospitalizations at 6 months was less evident at 12 months and was sensitive to underlying statistical assumptions. Other services use did not significantly differ between interventions at 12 months.

LIMITATION

Data are self-reported, and findings are sensitive to modeling assumptions.

CONCLUSION

In contrast to 6-month results, no consistent effects of CEP on reducing the likelihood of poor MHRQL and behavioral health hospitalizations were found at 12 months. Still, given the needs of underresourced communities, the favorable profile of CEP, and the lack of evidence-based alternatives, CEP remains a viable strategy for policymakers and communities to consider.

PRIMARY FUNDING SOURCE

National Institute of Mental Health, Robert Wood Johnson Foundation, California Community Foundation, National Library of Medicine, and National Institutes of Health/National Center for Advancing Translational Science for the UCLA Clinical and Translational Science Institute.

Efficacy of percutaneous treatment of biliary tract calculi using the holmium:YAG laser

BACKGROUND

Few Western studies have focused on percutaneous techniques using percutaneous transhepatic choledochoscopy (PTHC) and holmium:yttrium-aluminum-garnet (YAG) laser to ablate biliary calculi in patients unable or unwilling to undergo endoscopic or surgical removal of the calculi. The authors report the efficacy of the holmium:YAG laser in clearing complex biliary calculi using percutaneous access techniques.

METHODS

This study retrospectively reviewed 13 non-Asian patients with complex secondary biliary calculi treated percutaneously using holmium:YAG laser. Percutaneous access was accomplished via left, right, or bilateral hepatic ducts and upsized for passage of a 7-Fr video choledochoscope. Lithotripsy was performed under choledochoscopic vision using a holmium:YAG laser with 200- or 365-microm fibers generating 0.6 to 1.0 joules at 8 to 15 Hz. Patients underwent treatment until stone clearance was confirmed by PTHC. Downsizing and subsequent removal of percutaneous catheters completed the treatment course.

RESULTS

Seven men and six women with an average age of 69 years underwent treatment. All the patients had their biliary tract stones cleared successfully. Of the 13 patients, 3 were treated solely as outpatients. The average length of percutaneous access was 108 days. At this writing, one patient still has a catheter in place. The average number of holmium:YAG laser treatments required for stone clearance was 1.6, with no patients requiring more than 3 treatments. Of the 13 patients, 8 underwent a single holmium:YAG laser treatment to clear their calculi. Prior unsuccessful attempts at endoscopic removal of the calculi had been experienced by 7 of the 13 patients. Five patients underwent percutaneous access and subsequent stone removal as their sole therapy for biliary stones. Five patients were cleared of their calculi after percutaneous laser ablation of large stones and percutaneous basket retrieval of the remaining stone fragments. There was one complication of pain requiring admission, and no deaths.

CONCLUSIONS

The use of PTHC with holmium:YAG laser ablation is safe and efficacious, but requires prolonged biliary access and often multiple procedures to ensure clearance of all calculi.