Linear probe endobronchial ultrasound bronchoscopy with guided transbronchial needle aspiration (EBUS-TBNA) in the evaluation of mediastinal and hilar pathology: introducing the procedure to a teaching institution.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an important tool in the diagnosis of mediastinal and hilar pathology. We describe our experience with EBUS-TBNA performed in a teaching institution primarily under conscious sedation. METHODS: Patients who underwent EBUS-TBNA were included in this retrospective review. We focused on the diagnostic yield of EBUS-TBNA in relationship to the nature of the mediastinal or hilar lesions (suspected malignancy vs. benign disease), incremental 25 procedures aliquots, lymph node (LN) station, LN size, and the number of needle aspirations per LN station. RESULTS: Of the 212 patients who underwent EBUS-TBNA, 200 patients had adequate follow-up information and were included in this analysis. The procedure was performed under conscious sedation in 97 % of patients and 133 patients (67 %) were suspected to have malignancy before the procedure. A total of 690 TBNAs were performed from 294 LN stations. The mean number of LN stations sampled per procedure was 1.47 ± 0.6. The mean number of TBNAs per LN station was 2.35 ± 0.91. The mean number of TBNAs per procedure was 3.45 ± 1.2. The overall sensitivity, specificity, negative predictive value (NPV), and diagnostic accuracy for all procedures were 87.41 % (CI 80.76-91.99), 100 % (CI 93.12-100), 75.36 % (CI 64.04-84.01), and 90.91 % (CI 85.92-94.25), respectively. The NPV increased significantly after the initial 25 procedures and remained high thereafter. EBUS-TBNA was more accurate (96.12 % (CI 91.25-98.33)) with higher NPV (90.74 % (CI 80.09-95.98)) in patients with suspected malignancy compared with patients with suspected benign disease (79.31 % (CI 67.23-87.75), 20 % (7.05-45.19)). Samples from relatively smaller LN (>5 to ≤20 mm) and from all analyzed LN stations were similarly accurate with high sensitivity and NPV. CONCLUSIONS: EBUS-TBNA allows safe real-time sampling of mediastinal and hilar lesions under conscious sedation with high diagnostic accuracy. The NPV is high and increased significantly after the initial 25-50 procedures. This is comparable to available surgical techniques, including mediastinoscopy, when malignancy is suspected. The NPV for specific benign disease remains low in our experience. The diagnostic yield is not affected by the LN station, size, or the number of passes per LN station.

Client Perceptions of the Most and Least Helpful Aspects of Couple Therapy.

Couples have a unique perspective to share about the therapy they receive. The current study uses a mixed-methods design to examine what couples report about most and least helpful elements of two behaviorally-based treatments tested in a large clinical trial of couple therapy. Results indicate that responses are highly variable and fall into five main themes, which are then compared between treatment conditions, genders, and outcome groups. One interesting finding is that all groups reported wanting more discussion of sexual issues. Findings are discussed in the context of common factors research, recent developments toward unified principles of change in couple therapy, and model-specific differences.

Observed communication and associations with satisfaction during traditional and integrative behavioral couple therapy.

To investigate changes in couple communication and potential mechanisms of change during treatment, 134 distressed couples, who were randomly assigned to either traditional or integrative behavioral couple therapy (TBCT; IBCT), were observed in relationship and personal problem discussions prior to and near the end of treatment. Analyses were conducted using the Hierarchical Linear Modeling program. Over the time in therapy, during relationship problem discussions, positivity and problem solving increased while negativity decreased. Compared to IBCT, TBCT couples had the largest gains in positivity and reductions in negativity. During personal problem discussions, negativity decreased, while withdrawal increased and positivity decreased. TBCT couples had larger declines in negativity. In both discussion types, increases in marital satisfaction were associated with increases in positivity and problem solving. Declines in marital satisfaction were associated with increased negativity during relationship problem interactions and increased withdrawal during personal problem interactions. However, no treatment differences in these associations were found. Differences in rule-governed and contingency-shaped behavior change strategies between the two therapies and implications of findings are discussed.

Demand-withdraw communication in severely distressed, moderately distressed, and nondistressed couples: rigidity and polarity during relationship and personal problem discussions.

This study investigated demand-withdraw communication among 68 severely distressed couples seeking therapy, 66 moderately distressed couples seeking therapy, and 48 nondistressed couples. Self-report and videotaped discussions replicated previous research, demonstrating that greater demand-withdraw during relationship problem discussions was associated with greater distress and that overall, wife-demand/husband-withdraw was greater than husband-demand/wife-withdraw. Results extended the conflict structure view of demand-withdraw by indicating that this gender polarity in demand-withdraw roles varied in strength and direction depending on who chose the topic for discussion, distress level, and marriage length. Further, in videotaped personal problem discussions, typical gender patterns of demand-withdraw were reversed. Across the relationship and personal problem discussions, a pattern of gender polarity emerged when husbands held the burden of changing.

Relative contributions of relationship distress and depression to communication patterns in couples.

Researchers have long been interested in the relationship between marital distress and depression. Empirical findings from investigations into the relative contributions of marital distress and depression to marital communication have been inconsistent, and some communication behaviors, such as the demand/withdraw interaction pattern, have yet to be examined. The ability of depression to predict major types of communication (positive communication, negative communication, problem-solving, and demand/withdraw) was analyzed after controlling for the shared variance between marital distress and depression. Across two studies of couples beginning therapy and one study of couples beginning an enhancement program, results failed to provide support for a unique contribution of depression to couples' communication behaviors.

Infidelity and behavioral couple therapy: optimism in the face of betrayal.

Infidelity is a common issue with which distressed couples and their therapists grapple. However, there are no data on the efficacy of commonly used therapies to treat couples in which there has been an affair. In the present exploratory study, the authors examined the therapy outcomes of a sample of infidelity couples (n=19) who had participated in a randomized clinical trial of marital therapy (N=134). Results show that infidelity couples began treatment more distressed than noninfidelity couples; however, evidence suggests that couples who had an affair and who revealed this affair prior to or during therapy showed greater improvement in satisfaction than noninfidelity couples. Implications for therapy with infidelity couples are discussed.

Observed communication in couples two years after integrative and traditional behavioral couple therapy: outcome and link with five-year follow-up.

OBJECTIVE: To examine changes in observed communication after therapy termination in distressed couples from a randomized clinical trial. METHOD: A total of 134 distressed couples were randomly assigned to either traditional behavioral couple therapy (TBCT; Jacobson & Margolin, 1979) or integrative behavioral couple therapy (IBCT; Jacobson & Christensen, 1998). Videotaped samples of each couple's interactions were coded from pre-therapy, post-therapy, and 2-year follow-up assessments. At these 3 time points, each partner chose 1 current relationship problem to discuss. Relationship satisfaction was assessed at 2-year follow-up, and clinically significant treatment response and marital status were assessed 5 years after treatment. RESULTS: Observed negativity and withdrawal decreased from therapy termination through the 2-year follow-up as expected, but problem solving did not change, and observed positivity decreased. IBCT produced superior changes from post-therapy to the 2-year follow-up assessment compared with TBCT. Post-therapy levels and changes in communication over follow-up were associated with wife satisfaction at 2-year follow-up; only post-therapy to 2-year follow-up changes in communication were associated with husband satisfaction at 2-year follow-up. Post-therapy levels of problem solving and changes in wives' positivity from pre-therapy to post-therapy were associated with 5-year relationship outcomes. We found some counterintuitive results with positivity, but they were no longer significant after controlling for withdrawal. CONCLUSIONS: We found support for improvements in observed communication following treatment termination, with IBCT demonstrating greater maintenance of communication improvement over follow-up. We found limited evidence of associations between communication and relationship outcomes at 5-year follow-up.

The language of demand/withdraw: verbal and vocal expression in dyadic interactions.

Associations between vocally expressed emotional arousal, influence tactics, and demand/withdraw behavior were examined in a treatment-seeking sample of 130 seriously and stably distressed, married, heterosexual couples and in a community sample (N = 38) of 18 married heterosexual and 20 dating heterosexual couples. Fundamental frequency was used to measure emotional arousal, and computational linguistics were used to measure influence tactics. Higher levels of demand/withdraw behavior were associated with greater use of manipulative and controlling influence tactics, higher levels of emotional arousal, and less frequent use of cooperative and compromising influence tactics. Overall, demanders tended to express more arousal and to use more influence tactics than withdrawers. Both influence tactics and emotional arousal were uniquely associated with demand/withdraw behavior. Implications of results are discussed for refining theories of demand/withdraw interaction.