Detection of significant liver fibrosis in Chinese psoriasis patients receiving methotrexate: a comparison between transient elastography and liver histology

INTRODUCTION

Methotrexate (MTX) is effective for treating psoriasis and psoriatic arthritis, but its potential hepatoxicity remains a concern. Liver biopsy, the gold standard for detecting MTX-induced liver injury, is invasive and carries considerable risk. Transient elastography (TE) offers a non-invasive alternative for detecting advanced liver fibrosis. This study investigated the performance of TE in detecting MTX-induced liver fibrosis among Chinese psoriasis patients, compared with liver biopsy.

METHODS

This study included adult patients with clinical psoriasis. Liver stiffness measurement using TE was performed in patients receiving MTX. Exclusion criteria were known liver cirrhosis, positive viral hepatitis carrier status, or conditions influencing TE performance. Liver biopsy was performed when liver stiffness was ≥7.1 kilopascals (kPa) or when the total cumulative dose (TCD) of MTX was ≥3.5 g.

RESULTS

A total of 228 patients were screened; among 34 patients who met the inclusion criteria, nine (26.5%) had significant liver fibrosis (Roenigk grade ≥3a). The area under the receiver operating characteristic curve was 0.76 (95% confidence interval=0.59-0.93; P=0.021), indicating that TE had satisfactory performance in detecting liver fibrosis. A cut-off value of 7.1 kPa of liver stiffness yielded 100% sensitivity and 68% specificity. Liver fibrosis was not correlated with the TCD of MTX or the duration of MTX use; it was significantly correlated with obesity and diabetes status (body mass index ≥30 kg/m2, waist circumference ≥138 cm, and glycated haemoglobin level ≥7.8%).

CONCLUSION

Transient elastography is reliable and superior to the TCD for detecting liver fibrosis in Chinese psoriasis patients receiving MTX. Liver biopsy should be reserved for high-risk patients or patients with liver stiffness ≥11.7 kPa on TE.

Cutaneous manifestations, viral load, and prognosis among hospitalised patients with COVID-19: a cohort study

INTRODUCTION

Various cutaneous manifestations have been reported as symptoms of coronavirus disease 2019 (COVID-19), which may facilitate early clinical diagnosis and management. This study explored the incidence of cutaneous manifestations among hospitalised patients with COVID-19 and investigated its relationships with viral load, co-morbidities, and outcomes.

METHODS

This retrospective study included adult patients admitted to a tertiary hospital for COVID-19 from July to September 2020. Clinical information, co-morbidities, viral load (cycle threshold [Ct] value), and outcomes were analysed.

RESULTS

In total, 219 patients with confirmed COVID-19 were included. Twenty patients presented with new onset of rash. The incidence of new rash was 9.1% (95% confidence interval=6.25%-14.4%). The most common manifestations were maculopapular exanthem (n=6, 42.9%, median Ct value: 24.8), followed by livedo reticularis (n=4, 28.6%, median Ct value: 21.3), varicella-like lesions (n=2, 14.3%, median Ct value: 19.3), urticaria (n=1, 7.1%, median Ct value: 14.4), and acral chilblain and petechiae (n=1, 7.1%, median Ct value: 33.1). The median Ct values for patients with and without rash were 22.9 and 24.1, respectively (P=0.58). There were no significant differences in mortality or hospital stay between patients with and without rash. Patients with rash were more likely to display fever on admission (P<0.01). Regardless of cutaneous manifestations, patients with older age, hypertension, and chronic kidney disease stage ≥3 had significantly higher viral load and mortality (P<0.05).

CONCLUSION

This study revealed no associations between cutaneous manifestation and viral load or clinical outcomes. Older patients with multiple co-morbidities have risks of high viral load and mortality; they should be closely monitored.

1039 RECEIVING ASSISTANCE FROM DOMESTIC ROBOTS: WHAT ARE ELDERS’ PREFERENCES?

Introduction

Aging leads to decline in physical and functional ability. Strengthening the domestic support enables elders to manage their health and living at home and reduce their need for residential service. Domestic robots can potentially provide a broad range of support to the elders. However, relatively little research attention has investigated elders’ preferences on it. This study aims to investigate elders’ preferences on receiving assistance from domestic robots.

Methods

This cross-sectional descriptive study recruited a convenient sample of 365 robotic inexperienced elders (65-99 years old). It used the Assistance Preference Checklist to assess participants’ preferences on receiving assistance from domestic robots in 48 home-based tasks under six aspects including personal care, leisure activities, health assistance, chores, information management, and manipulating objects. It used t-test and one-way analysis of variance to compare the difference in preferences between participants with different demographic and health characteristics.

Results

Overall, participants preferred domestic robots to assist in tasks under the aspect on chores, information management, and manipulating objects. Specifically, males indicated a higher preference for domestic robots to assist in maintaining lawn or raking leaves than females (p = 0.05). Married participants indicated a higher preference for domestic robots to assist in getting information on weather/news than unmarried participants (p = 0.049). In contrast, participants who were partially dependent and fully dependent indicated a higher preference for domestic robots to assist in tasks under the personal care aspect such as shaving, bathing, washing/combing hair, getting dressed, walking, and brushing teeth (p &lt; 0.001), comparing to participants who were physically independent.

Conclusion

This study provides insight for manufacturers to develop domestic robots with specific capabilities which are important to support elders’ living in the community. Moreover, it helps the care providers to identify domestic robots with the required capabilities that meet elders’ specific preferences.

1040 VALIDATION OF THE CHINESE VERSION OF THE ASSISTANCE PREFERENCE CHECKLIST

Introduction

Domestic robots have great potential to be developed as a useful and supportive device for elders in domestic setting. To achieve the intended purpose, the designs of domestic robots should make reference to elders’ preferences. The Assistance Preference Checklist is developed to assess elders’ preferences on receiving assistance from domestic robots. It comprises of 48 home-based task under six categories including personal care, leisure activities, health assistance, chores, information management, and manipulating objects. Altogether, these tasks are considered important for the elders to fulfil their general health needs and maintain their homes. The Assistance Preference Checklist is valid and reliable. To adapt it in the Chinese population, the Assistance Preference Checklist has been translated from English to Chinese according to the standard translation model. This study aims to validate the Chinese version of the Assistance Preference Checklist (the checklist).

Method

This was a validation study. Semantic and content equivalence of the checklist was evaluated by an expert panel (five academic specialized on instrument validation or translation and 15 nurses specialized on geriatrics). Content validity of the checklist was assessed by another expert panel (one academic specialized on instrument validation and two nurses specialized on geriatrics). Internal consistency of the checklist was determined by Cronbach's method on a convenience sample of 50 Chinese-speaking elders in Hong Kong.

Results

The checklist demonstrated good semantic and content equivalence with the original English version. The experts agreed that it was appropriately translated. The checklist demonstrated good content validity by having a content validity index of 1.00. Additionally, the checklist reported satisfactory internal consistency by having a Cronbach's alpha of 0.95.

Conclusion

The Chinese version of the Assistance Preference Checklist is a useful instrument for assessing elders’ preferences on receiving assistance from domestic robots. Findings provide evidence on its validity and reliability.

1047 VALIDATION OF THE CHINESE VERSION OF THE KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING

Introduction

Among the instruments that measure an elder’s functional dependence level, the Katz Index of Independence in Activities of Daily Living has the advantages of being neutral, easy to use, valid, and reliable. It is a six-item instrument rating an elder’s functional dependence level in performing activities of daily living, including bathing, dressing, toileting, transferring, continence, and feeding. Each item can be rated nominally as 1 (does not require assistance to finish the activity) or 0 (requires assistance to finish the activity). By summing the score of the six items, the functional dependence level of an elder can be classified as independent (6 points), partially dependent (3–5 points), or dependent (&lt; 2 points). The instrument has been translated from English to Chinese through forward and backward translation. This study aims to validate the Chinese version of the Katz Index of Independence in Activities of Daily Living (Katz ADL-Chinese).

Method

This was a validation study. The Katz ADL-Chinese was examined by an expert panel (one academic specialized on instrument validation, four academic specialized on translation, fifteen nurses specialized on geriatrics) for its semantic and content equivalence with the original English version. It was evaluated by another expert panel (one academic specialized on instrument validation and two nurses specialized on geriatrics) for its content validity. Moreover, it was tested and re-tested at 1-week interval on 30 Chinese-speaking elders in Hong Kong.

Results

Good result was achieved on the testing for semantic and content equivalence. All experts confirmed that the Katz ADL-Chinese was appropriately translated. Good content validity was observed. The context validity index at item-level and scale-level was 1.00, respectively. Good stability was observed as well. The test–retest reliability coefficient was 0.85.

HLA-B*15:11 status and carbamazepine-induced severe cutaneous adverse drug reactions in HLA-B*15:02 negative Chinese

BACKGROUND

HLA-B*15:11 is associated with carbamazepine (CBZ)-induced severe cutaneous adverse drug reactions (SCARs) in Japanese and some Asian populations, but such data remains relatively limited in Chinese. Routine HLA-B*15:02 screening is mandatory before CBZ commencement, however, SCARs related to CBZ were still observed in non-HLA*B-15:02 carriers.

OBJECTIVE

We aimed to find out the prevalence of HLA-B*15:11 in Chinese patients and its associations with CBZ-induced SCARs.

METHOD

We screened 8,328 blood samples collected for HLA allele typing before CBZ commencement during the period of January 2014 to December 2019. In HLA-B*15:02 negative Chinese patients, HLA-B*15:11 status were further screened, and the incidence of SCARs in the CBZ group was compared with the control group without CBZ use.

RESULT

In this cohort, 1416 out of 8328 patients (17%) tested HLA-B*15:02 positive and were advised to avoid CBZ, while 80 (0.96%) were found to be HLA-B*15:11 positive. In 6911 (83%) patients who tested HLA-B*15:02 negative, 70 (1.01%) were HLA-B*15:11 positive. Five out of 70 (7.14%) patients had SCARs. The incidence of SCARs in HLA-B*15:11 carriers who received CBZ was significantly higher than those without CBZ (17.4% [4/23] vs. 2.13% [1/47], P = 0.037*). The odds ratio was 9.68 (95% CI 1.02-92.4, P = 0.048*). These included: one Stevens-Johnson syndrome (SJS), two DRESS, and one MPE after CBZ use, while one developed MPE after phenytoin use in control.

CONCLUSION

HLA-B*15:11 is a potential risk factor of CBZ-induced SCARs in HLA-B*15:02 negative Chinese patients. Further screening of HLA-B*15:11 status in those HLA-B*15:02 negative patients is recommended to avoid undesirable SCARs.

HLA-B*58:01 screening to prevent allopurinol-induced severe cutaneous adverse reactions in Chinese patients with chronic kidney disease

Human leukocyte antigen (HLA)-B*58:01 allele is a significant risk factor for allopurinol-induced severe cutaneous adverse reactions (SCARs) which is potentially fatal. In some studies, chronic kidney disease (CKD) was also implicated to compound the risk of SCARs. We aim to investigate if pre-treatment HLA-B*58:01 screening can prevent allopurinol-induced SCARs in Chinese patients with CKD and its cost-effectiveness. We prospectively recruited Chinese CKD patients who required allopurinol during 2011-2015 and performed pre-treatment HLA testing (HLA screening group). Patients tested positive for HLA-B*58:01 were refrained from allopurinol while those tested negative were prescribed allopurinol. The incidence of SCARs in the HLA screening group was compared with the historical control in previous 5 years and the cost-effectiveness of HLA testing was analyzed. In the historical control (2006-2010), 3605 patients on allopurinol were screened, 22 out of 1027 (2.14%) CKD Chinese patients newly started on allopurinol developed SCARs, including 6 SJS/TEN. In the HLA screening group, 28 out of 192 patients (14.6%) tested HLA-B*58:01 positive were advised to avoid allopurinol; 156 out of 164 HLA-B*58:01-negative patients received allopurinol and none developed SCARs. The incidence rate of SCARs was significantly lower in the HLA screening group compared with controls (0% vs 2.14% respectively, p = 0.037*). The targeted HLA screening approach was associated with lower healthcare costs compared with no HLA screening (US$ 92,430 vs US$ 281,226). Pre-treatment HLA-B*58:01 screening is cost-effective to target on patients with CKD in Chinese to prevent allopurinol-induced SCARs.

Does Secretory Clearance Follow Glomerular Filtration Rate in Chronic Kidney Diseases? Reconsidering the Intact Nephron Hypothesis

Drug‐dose modification in chronic kidney disease (CKD) utilizes glomerular filtration rate (GFR) with the implicit assumption that multiple renal excretory processes decline in parallel as CKD progresses. We compiled published pharmacokinetic data to evaluate if GFR predicts renal clearance changes as a function of CKD severity. For each drug, we calculated ratio of renal clearance to filtration clearance (Rnf). Of 21 drugs with Rnf >0.74 in subjects with GFR >90 mL/min (implying filtration and secretion), 13 displayed significant change in Rnf vs. GFR (slope of linear regression statistically different from zero), which indicates failure of GFR to predict changes in secretory clearance. The dependence was positive (n = 3; group A) or negative (n = 10; group B). Eight drugs showed no correlation (group C). Investigated drugs were small molecules, mostly hydrophilic, and ionizable, with some characterized as renal transporter substrates. In conclusion, dosing adjustments in CKD require refinement; in addition to GFR, biomarkers of tubular function are needed for secreted drugs.

Chronic Kidney Disease Alters Vitamin A Homeostasis via Effects on Hepatic RBP4 Protein Expression and Metabolic Enzymes

Vitamin A, via retinoic acid (RA), is a critical micronutrient. Normally, plasma concentrations are tightly regulated. Concentrations of vitamin A metabolites (13cis-RA, atRA) and relationships between RBP4 and retinoids have never been fully evaluated in adult patients with CKD. We measured retinoid and RBP4 concentrations in plasma and urine from 55 adult patients with CKD and 21 matched healthy subjects. RBP4 and retinol levels were increased approximately twofold in patients with CKD, with a negative correlation between plasma retinol and eGFR (p = 0.006) and plasma RBP4 and eGFR (p = 0.0007). RBP4 renal clearance was higher in patients with CKD than healthy subjects but not associated with eGFR. Circulating concentrations of atRA increased and concentrations of 13cis-RA decreased in subjects with CKD with no change in RA-to-retinol ratio. Increases in circulating retinol, RBP4, and atRA may be due to increased hepatic RBP4 synthesis, retinyl ester hydrolysis, and/or hepatic secretion of RBP4-retinol.

Relation between endothelial progenitor cells and arterial stiffness in patients with psoriasis

Patients with psoriasis are prone to premature atherosclerosis. We hypothesize that depletion of circulating endothelial progenitor cells (EPC) is related to patients with psoriasis and can contribute to the development of atherosclerosis. Thirty-five plaque-type psoriasis patients (41.9 ± 5.5 years, 30 men) and 20 age- and sex-matched controls were studied. Four subpopulations of EPC, namely, CD34(+) EPC, CD133(+) EPC, CD34(+) /kinase insert domain-containing receptor (KDR)(+) EPC and CD133(+) /KDR(+) EPC were measured by flow cytometry. Arterial stiffness in psoriasis patients was assessed by heart to ankle pulse wave velocity (haPWV), augmentation index (AI) and carotid intima media thickness (IMT). Patients with psoriasis had a lower level of CD34(+) EPC (7.85 ± 2.49% vs 6.26 ± 2.13%, P = 0.02) compared with healthy controls. In patients with psoriasis, level of CD34(+) EPC was negatively related with haPWV (r = -0.43 P = 0.01) and Psoriasis Area and Severity Index (r = -0.39 P = 0.02). Multivariate regression analysis further demonstrated that haPWV was independently associated with level of CD34(+) EPC. Each percentage decrease in CD34(+) EPC accounted for an increase in haPWV of +0.02 m/s. The result demonstrated that patients with psoriasis had reduced CD34(+) EPC compared with controls. Importantly, CD34(+) EPC was independently related with haPWV in these patients. This finding suggests that EPC reduction is associated with the development of arterial stiffness in patients with psoriasis.

Organ Impairment-Drug-Drug Interaction Database: A Tool for Evaluating the Impact of Renal or Hepatic Impairment and Pharmacologic Inhibition on the Systemic Exposure of Drugs

The organ impairment and drug–drug interaction (OI-DDI) database is the first rigorously assembled database of pharmacokinetic drug exposure data from publicly available renal and hepatic impairment studies presented together with the maximum change in drug exposure from drug interaction inhibition studies. The database was used to conduct a systematic comparison of the effect of renal/hepatic impairment and pharmacologic inhibition on drug exposure. Additional applications are feasible with the public availability of this database.

Reactive and infective dermatoses associated with adult-onset immunodeficiency due to anti-interferon-gamma autoantibody: Sweet's syndrome and beyond

Immunodeficiency due to anti-interferon-gamma autoantibody (anti-IFN-γ autoAb) is an emerging adult-onset immunodeficiency syndrome predominantly found in Southeast Asians. It is associated with severe or disseminated infections caused by non-tuberculous mycobacteria (NTM) and other opportunistic pathogens. We describe 3 patients with anti-IFN-γ autoAb who developed reactive and infective dermatoses, and thoroughly review the existing literature on dermatoses associated with the immunodeficiency syndrome. Case 1 developed Sweet's syndrome associated with Mycobacterium chelonae lymphadenitis and penicilliosis. Case 2 suffered from multiple episodes of lobular panniculitis during recurrent infections by NTM, Penicillium marneffei and Burkholderia pseudomallei. Both cases responded to immunomodulating agents including corticosteroid and non-steroidal anti-inflammatory drugs. Case 3 had direct skin invasion by M. chelonae and responded to prolonged anti-mycobacterial therapy. A novel working algorithm is proposed for the diagnosis and treatment of these patients who may be encountered by the dermatologist and histopathologist in clinical practice.

A retrospective analysis of the management of freckles and lentigines using four different pigment lasers on Asian skin

BACKGROUND

The risk of post-inflammatory hyperpigmentation (PIH) is increased during freckles and lentigines treatment in Asians.

OBJECTIVE

To determine the effectiveness and safety of using 595-nm long pulsed dye laser (LPDL), 755-nm LP Alexandrite laser, 532-nm QS Nd:YAG laser and 532-nm LP potassium-titanyl-phosphate (KTP) laser for the treatment of freckles or lentigines in Asian patients.

METHODS

This is a retrospective study of 40 Chinese patients, who were divided into four groups based on treatment modality using four different pigment lasers. Each patient attended between 1 and 4 treatments (mean of 1.8), at 4-6 weeks intervals, depending on clinical response. Lesional clearance and PIH were assessed by two independent clinicians.

RESULTS

Statistically significant improvement of global and focal facial pigmentation was found after treatment with LPDL, QS Nd:YAG and LP KTP lasers. No significant improvement was found after LP Alexandrite laser. PIH risk was 20% after LP Alexandrite treatment, 10% with QS Nd:YAG, and absent after LPDL and LP KTP treatment.

CONCLUSION

A long pulse laser and small spot size appear to reduce the risks of lentigines treatment in darker skin types.

Non-invasive measures of tissue autofluorescence are increased in Type 1 diabetes complications and correlate with a non-invasive measure of vascular dysfunction

OBJECTIVE

To determine if ocular and skin autofluorescence, reflecting advanced glycation end-products, and vascular stiffness correlate in non-diabetic and Type 1 diabetic subjects and if levels differ by diabetes status.

RESEARCH DESIGN AND METHODS

Patients with Type 1 diabetes (n = 69, 19 with and 50 without vascular complications) and 60 subjects without diabetes (control) had ocular and skin autofluorescence and pulse-wave analysis performed in the fasted state. Correlations between measures within groups used the Pearson or Spearman correlation-coefficient and measures between groups were compared by ANOVA.

RESULTS

Lens and skin autofluorescence correlated in control (r = 0.58, P = 0.0001) and in Type 1 diabetes (r = 0.53, P = 0.001). Corneal autofluorescence correlated with lens (r = 0.53, r = 0.52, P = 0.0001) and skin autofluorescence (r = 0.34, P = 0.01 and r = 0.49, P = 0.00001) in control and Type 1 diabetes respectively. In Type 1 diabetes, small and large artery elasticity correlated inversely and systemic vascular resistance correlated positively with skin autofluorescence (all P = 0.001), and with lens and corneal autofluorescence (all P < 0.03). In Type 1 diabetes tissue advanced glycation end-products correlated with C-reactive protein and inversely with the estimated glucose disposal rate and with circulating advanced glycation end-product levels. Relative to non-diabetic subjects, lens, corneal and skin fluorescence were increased (all P < 0.001) and small artery elasticity was decreased in diabetes (P = 0.04). Lens, corneal and skin autofluorescence were greater (all P = 0.0001) in patients with Type 1 diabetes with complications compared to those without complications, but small artery elasticity did not differ significantly.

CONCLUSIONS

Ocular and skin autofluorescence and vascular stiffness correlate in non-diabetic and Type 1 diabetes subjects and are increased in Type 1 diabetes. Tissue advanced glycation end-products correlate with vascular risk factors, including circulating advanced glycation end-products.

Association between HLA-B*58:01 allele and severe cutaneous adverse reactions with allopurinol in Han Chinese in Hong Kong

BACKGROUND

Allopurinol has been reported as a common cause of severe cutaneous adverse reactions (SCARs). Recent studies in various populations suggest that HLA-B*58:01 is a strong genetic marker for allopurinol-induced SCAR, especially in populations with a high frequency of HLA-B*58:01.

OBJECTIVES

To confirm the association link between HLA-B*58:01 and hypersensitivity reactions attributed to allopurinol use in Han Chinese patients in Hong Kong.

METHODS

We performed a case-control study to investigate whether the HLA-B*58:01 allele predisposes to allopurinol-induced SCAR in Han Chinese patients in Hong Kong. The HLA-B*58:01 genotyping was performed in 20 patients with allopurinol-induced SCAR or erythema multiforme major (EMM; n = 1) and in 30 patients tolerant to allopurinol.

RESULTS

All of the 19 patients with allopurinol-induced SCAR examined but not the patient with EMM carried HLA-B*58:01 whereas only four (13%) of the control patients had this allele. The positive rate of the HLA-B*58:01 was significantly higher in the cases than in the allopurinol-tolerant control group [odds ratio (OR) 123·5, 95% confidence interval (CI) 12·8-1195·1; P < 1 × 10(-4) ] and was even higher after removal of the patient with EMM (OR 229·7, 95% CI 11·7-4520·4). The sensitivity and specificity of the HLA-B*58:01 allele for prediction of allopurinol-induced SCAR were 100% and 86·7%, respectively.

CONCLUSIONS

This study confirmed the strong association between the HLA-B*58:01 and allopurinol-induced SCAR in Hong Kong Han Chinese patients. A screening test for the HLA-B*58:01 allele should effectively reduce the risk for allopurinol-induced SCAR in Chinese populations.

What are the learning outcomes of a short postgraduate training course in dermatology for primary care doctors?

BACKGROUND

There are increasing expectations on primary care doctors to shoulder a bigger share of care for patients with common dermatological problems in the community. This study examined the learning outcomes of a short postgraduate course in dermatology for primary care doctors.

METHODS

A self-reported questionnaire developed by the research team was sent to the Course graduates. A retrospective design was adopted to compare their clinical practice characteristics before and after the Course. Differences in the ratings were analysed using the nonparametric Wilcoxon signed rank test to evaluate the effectiveness of the Course in various aspects.

RESULTS

Sixty-nine graduates replied with a response rate of 42.9% (69/161). Most were confident of diagnosing (91.2%) and managing (88.4%) common dermatological problems after the Course, compared to 61.8% and 58.0% respectively before the Course. Most had also modified their approach and increased their attention to patients with dermatological problems. The number of patients with dermatological problems seen by the graduates per day showed significant increase after the Course, while the average percentage of referrals to dermatologists dropped from 31.9% to 23.5%. The proportion of graduates interested in following up patients with chronic dermatological problems increased from 60.3% to 77.9%.

CONCLUSIONS

Graduates of the Course reported improved confidence, attitudes and skills in treating common dermatological problems. They also reported to handle more patients with common dermatological problems in their practice and refer fewer patients.

A comparison of Q-switched and long-pulsed alexandrite laser for the treatment of freckles and lentigines in oriental patients

BACKGROUND

Q-switched (QS) lasers are effective in the treatment of freckles and lentigines in Type I and II skin, with minimal adverse effects. Long pulsed (LP) lasers have been proposed to be more suitable for treatment of darker skin types.

OBJECTIVES

To investigate the efficacy and adverse effects of using QS or LP Alexandrite laser for the treatment of freckles and lentigines in Oriental patients.

METHODS

A prospective split-face study of 20 Chinese patients who were randomly assigned to undergo a single QS (50 nanosecond) or LP (100 microseconds) laser treatment to either side of their face was carried out. Two blinded physicians assessed clinical efficacy using visual analogue scales of pre- and post-treatment photographs. Subjective assessment was evaluated using questionnaires which detailed the degree of pain, erythema and edema sustained during treatment, and improvement and satisfaction levels at 4, 8, and 12 weeks.

RESULTS

There was statistically significant improvement in pigmentation (P < 0.05) in both groups throughout the study, with no statistical difference found between the groups. Postinflammatory hyperpigmentation was more frequently found after QS treatment (22%), compared to LP treatment (6%). Majority of patients reported moderate to marked improvement in pigmentation throughout the study with both pulse widths, and correspondingly high levels of satisfaction rates. More severe pain, erythema and edema were experienced during QS Alexandrite treatment.

CONCLUSION

LP Alexandrite is quick and effective, and carries a lower risk of adverse effects than QS Alexandrite, for the removal of freckles and lentigines in darker skin types.

Are circulating metabolites important in drug-drug interactions?: Quantitative analysis of risk prediction and inhibitory potency

The potential of metabolites to contribute to drug-drug interactions (DDIs) is not well defined. The aim of this study was to determine the quantitative role of circulating metabolites in inhibitory DDIs in vivo. The area under the plasma concentration-time curve (AUC) data related to at least one circulating metabolite was available for 71% of the 102 inhibitor drugs identified. Of the 80 metabolites characterized at steady state, 78% had AUCs >10% of that of the parent drug. A comparison of the inhibitor concentration/inhibition constant ([I]/K(i)) ratios of metabolites and the respective parent drugs showed that 17 of the 21 (80%) reversible inhibitors studied had metabolites that were likely to contribute to in vivo DDIs, with some metabolites predicted to have inhibitory effects greater than those of the parent drug. The in vivo drug interaction risks associated with amiodarone, bupropion, and sertraline could be identified from in vitro data only, when data pertaining to metabolites were included in the predictions. In conclusion, cytochrome P450 (CYP) inhibitors often have circulating metabolites that contribute to clinically observed CYP inhibition.

Phaeochromocytoma in the Hong Kong Chinese population

OBJECTIVE

To review the clinical manifestations of phaeochromocytoma in a Hong Kong Chinese population.

DESIGN

Retrospective review. SETTING. Five public hospitals in Hong Kong.

PATIENTS

Seventeen patients with operated phaeochromocytoma between 1994 and 2003 were reviewed retrospectively.

RESULTS

Six patients (35%) were men, 11 (65%) were women. The mean age at presentation was 47 (range, 17-72) years. The diagnosis post-presentation was delayed by 1 to 132 months. Over 70% of the patients had hypertension. The most frequent symptoms were headache (53%), palpitations (53%), and sweating (41%); all these symptoms were present in 24% of the patients. Four (24%) had hereditary phaeochromocytoma/paraganglioma syndrome. The sensitivity of 24-hour urinary catecholamine measurements was 82%. Mean urinary adrenaline and noradrenaline concentrations were respectively 7- and 8-fold greater than the upper reference limits. Computed tomography and metaiodobenzylguanidine scintigraphy were the most widely used means for tumour localisation (sensitivity, 100% and 87% respectively). Approximately 65% of the patients had intra-adrenal tumours; 53% were on right side, 18% were bilateral. All the patients were prescribed phenoxybenzamine (dosage range, 20-120 mg/day) preoperatively. Two thirds of the patients had improved blood pressure 1 year after the operation. No malignancy was reported after a mean follow-up period of 7 years.

CONCLUSION

Our series of patients with phaeochromocytomas commonly had a high frequency of normotension and extra-adrenal tumours. A high index of clinical suspicion and appropriate biochemical investigations are necessary to make the diagnosis, especially for patients manifesting adrenal incidentaloma and extra-adrenal lesion.

An 18-month follow-up study after randomized treatment of phimosis in boys with topical steroid versus placebo

OBJECTIVE

To evaluate the treatment of phimosis using topical steroid.

MATERIAL AND METHODS

This was a follow-up study after a prospective, randomized, double-blind study. A total of 137 boys with phimosis were randomly assigned to either betamethasone treatment or placebo for 4 weeks, with application of the cream twice daily. Non-responders to treatment were offered steroid treatment for a further 4 weeks. All patients were invited to a follow-up examination after 18 months.

RESULTS

The mean pre-treatment phimosis grades in the steroid and control groups were 5.08+/-0.66 and 4.97+/-0.70, respectively. At the 4-week follow-up, 49 boys (74%) in the steroid group were cured, compared to only 31 (44%) in the control group. Fourteen boys were circumcised after another 4 weeks of treatment; 43 of the remaining 57 boys (17 in the steroid group; 40 in the control group) had been cured. After a total of 92 boys took part in the 18-month follow-up study: 79 had been cured and 13 had suffered a relapse. Twenty-six patients did not took part in the follow-up investigation. No side-effects were noted.

CONCLUSIONS

When treatment is necessary for phimosis, we recommend application of topical steroid as first-line treatment because surgery can then be avoided in 85% of cases. This first randomized, double-blind, follow-up study shows that the treatment effect persists for at least 18 months.

Minimal invasive surgery in pediatric solid tumors

BACKGROUND

There is only limited experience of using the minimally invasive surgery (MIS) technique in resecting pediatric solid tumors. In this paper, we report our experience of using the MIS technique in the management of pediatric solid tumors.

METHODS

A retrospective review was undertaken on all children who had undergone MIS for their solid tumors between 1995 and 2005.

RESULTS

Over a 10-year period, there were 38 patients who had undergone MIS for tumor resection. The mean age at the time of surgery was 7.5 years (range, 1 day to 15 years). There were 22 ovarian tumors, 4 sacrococcygeal tumors, 3 adrenal tumors, 3 retroperitoneal tumors, 1 kidney tumor, 1 liver mass, 1 intra-abdominal testicular tumor, and 3 intrathoracic masses. Thirty of 38 patients had undergone a successful resection using the MIS technique (78.9%). Eight patients required a conversion to the open procedure because of limited intraperitoneal space in 7 and excessive bleeding in 1. Of the 28 successfully MIS-resected intra-abdominal tumors, 18 required enlargement of the umbilical incision and 5 required an additional Pfannenstiel incision for tumor retrieval. Enlargement of the thoracic port site for specimen retrieval was required in the 2 successfully MIS-resected intrathoracic masses. The mean operation time was 171 minutes (range, 45-275). There was no postoperative complication encountered. On an average follow-up of 3.1 years, there was no recurrence observed, even in the 7 patients with malignant tumors, and all patients with successful MIS tumor excision had good cosmetic results.

CONCLUSIONS

With the advance of laparoscopic instruments and techniques, a variety of pediatric solid tumors can be resected safely by the MIS technique. This has the potential benefit of a more rapid postoperative recovery and better cosmetic results. The role of the MIS technique in resecting malignant tumors is uncertain, as the number of cases in the current series is too small to draw any conclusion.

Advanced da Vinci Surgical System simulator for surgeon training and operation planning

BACKGROUND

Although patients benefit considerably from minimally invasive surgery, the use of new instruments such as robotic systems is challenging for surgeons, and extensive training is required.

METHOD

We developed a computer-based simulator of the da Vinci Surgical System, modelling the robot and designing a new interface.

RESULTS

The simulator offers users a two-handed interface to control a realistic model of the da Vinci robot. The simulator can be applied (i) to provide an environment in which to practice simple surgical skills and (ii) to serve as a visualization platform on which to validate port placement and robot pose for operation planning.

CONCLUSIONS

Virtual reality is a useful technique for medical training. The simulator is currently in its early stages, but this preliminary work is promising.

Laparoscopy in the management of pediatric vesicoureteral reflux

The prevalence of vesicoureteral reflux (VUR) has been estimated as. 4 to 1.8% among the pediatric population. In children with urinary tract infection the prevalence is typically from 30-50% with higher incidence occurring in infancy. When correction of VUR is determined to be necessary, traditionally open ureteral reimplantation by a variety of techniques has been the mainstay of treatment. This approach is justified because surgical correction affords a very high success rate of 99% in experienced hands and a low complication rate. In that context the purpose of this review article is to highlight the use of laparoscopy and robot-assisted techniques to perform ureteric reimplantation for the management of pediatric VUR. A detailed review of recent literature on the subject is performed to find out various aspects of minimally invasive surgery in the treatment of VUR, highlighting evolution of management approaches, operative steps, complications, results and the current status in clinical practice. We also share our experience on the subject.

Preoperative endoscopic retrograde cholangiopancreatographic treatment of complicated choledochal cysts in children: a retrospective case series

We report our experience with endoscopic retrograde cholangiopancreatography-(ERCP-)based interventions in children with complicated choledochal cysts that are refractory to conservative management. Between 1999 and 2006, 42 children (12 boys, 30 girls; median age 3 years, range 2-14.5 years) were admitted for surgical treatment of choledochal cysts. Seven of these patients (16.7%; one boy, six girls; median age 3 years, range 2-12 years) showed signs of complicated choledochal cysts, and presented with pancreatitis/cholangitis (n = 4) and obstructive jaundice (n = 3). The anatomical classification of the cysts was type Ic (n = 3), type If (n = 3), and type IV (n = 1). ERCP was successfully performed in 6/7 patients, and therapeutic interventions included removal of debris (n = 3), sphincterotomy (n = 3), and stent placement (n = 4). One patient required blood transfusion for post-sphincterotomy bleeding. The patient in whom the ERCP failed underwent ultrasound-guided percutaneous transhepatic biliary drainage. Definitive surgery was performed after a median interval of 10 days (range 7-68 days) after the ERCP intervention.

Inflammatory myofibroblastic tumor of the bladder in children: what can be expected?

Inflammatory myofibroblastic tumor of the bladder is an uncommon condition of unknown neoplastic potential. In adults the tumor is seen in association with instrumentation of the lower genitourinary tract, while in children it appears to run an idiopathic course. Its clinical and radiological presentation in children resembles sarcoma. The case of a 10-year-old girl with inflammatory myofibroblastic tumor is presented, outlining the histological and immunhistochemical features to allow differentiation between sarcomas, the most important differential diagnosis. An outcome meta-analysis of the literature identified 35 cases of inflammatory myofibroblastic tumor in the bladder of children. Conservative surgery is the strategy of choice. There is no evidence of recurrence or metastasis at a median follow up of 1.5 years.

Drug profiling using planar microelectrode arrays

Microelectrode arrays (MEAs) with evenly distributed multiple sensor spots have been designed for specific applications. Using the MEAs, we determined the relative profiles of potassium channel openers (KCOs) on cultured embryonic Sprague-Dawley rat cardiac myocytes. KCO, pinacidil (PIN), cromakalim (CROM), SDZ PCO400 (SDZ), or its vehicle, was added to the myocytes cumulatively. The action potential signal shapes in the presence of PIN and SDZ show that the changes in voltage over time and the magnitudes of the associated voltage change were reduced concentration-dependently. CROM affected sodium influx more than PIN and SDZ. The comparisons of changes in the rate of beating and propagation speed in the presence of KCOs were made using their corresponding pD(2) values (the negative log of EC(50)). All KCOs caused concentration-dependent reductions in the rate of beating and propagation speed, with SDZ being the most potent. In addition to the signal shapes, rate of beating, and propagation speed, the origin of excitation and the excitation pattern inside the culture can be also extracted. The results show that the present system can differentiate the effects of different KCOs on myocytes. It might be possible to utilise the MEA as a means to classify drug action based upon a combined interpretation of the three different datasets gained from the extracellular recordings. The combination of these observations might be used as 'drug signatures' when profiling drugs in the future.

Quantum diffusion of H on Pt(111): step effects

Using a linear optical diffraction technique, we have systematically investigated the defect effects on quantum surface diffusion of hydrogen on Pt(111) surfaces. The quantum tunneling effect was clearly observed for hydrogen diffusion at low temperatures as manifested by a leveling off of the diffusion coefficient on flat surfaces. The strong influence of surface defects on the quantum diffusion is in good agreement with the creation of an inhomogeneous surface with adsorption sites of different binding energies.

A hepaticojejunostomy: technical errors with 'twists and turns'

Excision of a choledochal cyst followed by biliary reconstruction with a Roux-en-Y hepaticojejunostomy is the treatment of choice for type I and IV choledochal cysts. We present a rare complication which was identified 8 years after the original reconstructive surgery. Conventional imaging modalities failed to identify the pathology. Only a contrast enhanced CT scan supported by image rendering software allowed for the visualization of the underlying chronic obstruction of part of the mesentery.

Nocturnal Enuresis in Adolescents and Adults is Associated With Childhood Elimination Symptoms

PURPOSE

Since nocturnal enuresis in adults and adolescents is rarely monosymptomatic, we identified the prevalence of childhood bladder and bowel dysfunction, and compared findings to those in a normative cohort.

MATERIALS AND METHODS

Childhood and current bladder and bowel dysfunction were investigated in 56 consecutive adolescents and adults attending a public nocturnal enuresis service and in 293 normative adults using a self-administered questionnaire. Analysis involved descriptive statistics, the chi-square and Kruskal-Wallis tests, and regression analysis with p <0.05 considered significant.

RESULTS

Adolescents and adults attending a public nocturnal enuresis service had significantly higher childhood scores than normative adults, and significantly more childhood urgency, frequency, urge incontinence, infrequent voiding and small volume, high urge voids. Infrequent bowel action and fecal soiling in childhood were also significantly more common in those with nocturnal enuresis than in controls. Adult symptoms of urge incontinence, general bowel symptoms and nocturnal enuresis were significantly more common in adults and adolescents with nocturnal enuresis. Significant associations were found between childhood symptoms and adult overactive bladder, and childhood emptying dysfunction and adult voiding dysfunction. Higher childhood scores in adults and adolescents with nocturnal enuresis correlated significantly with current adult symptoms of urge, urge leakage, stress incontinence, hesitancy, incomplete emptying and UTI within the last year.

CONCLUSIONS

Significant childhood bladder and bowel symptoms along with more adult urge and bowel dysfunction were found in adults and adolescents with nocturnal enuresis. The association with adult urgency and urinary tract infection supports the likelihood of underlying bladder and or voiding dysfunction in unremitting nocturnal enuresis.

Renal and Bladder Functional Status at Diagnosis as Predictive Factors for the Outcome of Primary Vesicoureteral Reflux in Children

PURPOSE

We studied the relationship between renal and bladder functional status at diagnosis and spontaneous resolution of reflux in young children with primary vesicoureteral reflux.

MATERIALS AND METHODS

Children with grade III or greater vesicoureteral reflux were recruited for the study. At entry each patient underwent voiding cystourethrogram, renal ultrasound, isotope renogram, and natural filling and conventional filling urodynamic studies. Patients were then divided into 4 groups-group 1 had normal renal and bladder function, group 2 had abnormal renal and normal bladder function, group 3 had normal renal and abnormal bladder function, and group 4 had abnormal renal and bladder function. Correlation between renal and bladder functional status with reflux resolution at a minimum followup of 24 months was evaluated.

RESULTS

A total of 82 patients (mean age 3.8 years) were prospectively evaluated and followed. There were 18 patients (13 males and 5 females) in group 1, 19 (13 and 6) in group 2, 19 (18 and 1) in group 3 and 26 (22 and 4) in group 4. Complete resolution of vesicoureteral reflux occurred in 17 patients (94%) in group 1 and 7 (37%) in group 2. None of the patients from group 3 or group 4 achieved complete vesicoureteral reflux resolution. Reflux grade remained unchanged in 15 patients (79%) in group 3 and 20 (77%) in group 4.

CONCLUSIONS

Resolution of vesicoureteral reflux significantly correlated with renal and bladder functional status at diagnosis. Normal renal and bladder function at diagnosis is highly predictive of complete resolution of vesicoureteral reflux, whereas abnormal renal and bladder function is prognostic for persistence of reflux.

Seven-day is more effective than 4-day ranitidine bismuth citrate-based triple therapy in eradication of Helicobacter pylori in children: a prospective randomized study

BACKGROUND

Helicobacter pylori infection is common in paediatric population. To date, there is still no universally accepted recommendation on the treatment of this infection in children. Ranitidine bismuth citrate-based triple therapy has been shown to be effective in H. pylori eradication in adults but its use has rarely been validated in children.

AIM

To investigate the efficacy of ranitidine bismuth citrate-based triple therapy in eradication of H. pylori in children and to determine the shortest duration of treatment required.

PATIENTS AND METHODS

We conducted a prospective randomized study comparing ranitidine bismuth citrate plus amoxicillin plus clarithromycin given for 4 days vs. 7 days in H. pylori-infected children diagnosed by (13)C-urea breath test. Eradication was evaluated by repeat (13)C-urea breath test at 6 weeks after treatment.

RESULTS

A total of 206 children were recruited (median age 12 years, 97 boys and 109 girls). Ninety-eight (47.6%) and 108 (52.4%) children were randomized to receive 7-day and 4-day regimen respectively. The eradication rate of 4-day treatment arm was 77.8% (both intention-to-treat and per protocol) compared with 88.8% (intention-to-treat, P = 0.036) and 89.7% (per protocol, P = 0.022) of 7-day regimen. There was no statistical difference in terms of side effects between the two groups.

CONCLUSIONS

Seven-day ranitidine bismuth citrate-based triple therapy is an effective and well-tolerated treatment for eradication of H. pylori in children.

PinQ: a valid, reliable and reproducible quality-of-life measure in children with bladder dysfunction

OBJECTIVE

Recently, a cross-cultural continence-specific paediatric quality-of-life measurement tool (PinQ) has been developed and tested psychometrically. The aim of this study was to evaluate the test re-test reliability of this new tool in a cohort of children with bladder dysfunction in order to evaluate the reproducibility of scores. A secondary aim was to compare the parent-completed proxy version with child-reported scores.

METHODS

PinQ was translated and back-translated from English into Chinese and Dutch and scrutinized for cultural and linguistic appropriateness or ambiguity. Forty children aged 6-15 years from both countries were asked to self-complete the measure at first consultation and then again 14 days later. No new treatment was implemented between data collection points. On the initial visit, parents also completed a proxy version of PinQ. Intraclass correlations (one-way random effects model) were used to analyze the data.

RESULTS

The intraclass correlation coefficient (ICC) for comparison between items and factors showed little variability in scoring. One item was not reproducible and was removed from the tool. Overall proxy scores varied little from the child-reported scores. However, the impact on the child of his/her parent's concern about the bladder problem was poorly perceived (ICC=0.18) as was the impact on the child's sense of self-worth (0.17).

CONCLUSION

PinQ has been shown to be reliable under test re-test conditions when completed by children from the age of 6 years. Proxy PinQ suggests that parents accurately evaluate the effect of bladder dysfunction on wellbeing in their children. A 20-item measurement tool will now be introduced clinically and subjected to sensitivity testing for treatment outcome and diagnostic grouping.

Half-Day Urotherapy Improves Voiding Parameters in Children with Dysfunctional Emptying

OBJECTIVES

Children with voiding dysfunction benefit from intensive bladder emptying re-education; however, hospitalization for such training is not always financially viable or realistic. The aim of this study was to evaluate whether half-day voiding re-education in pairs improved immediate and mid-term voiding parameters.

METHODS

48 children (mean age, 8.9 years; 54% male) identified in the urotherapy clinic as having either (1) abnormal uroflow curves, (2) a postvoid residual urine (PVRU)>10% of voided volume, or (3) proven dysfunctional voiding, were recruited and age- and gender-matched. Training over a half day included postural instruction, abdominal wall muscle pattern recognition, pelvic floor muscle relaxation training, and supervised voiding. Data from the initial clinic visit was compared to that after training, and at 1 and 3 mo follow-up. Families completed a questionnaire after the session.

RESULTS

Urine flow curves were abnormal in 76.2% of initial clinic visit voids, 14% of patients after the half-day training session, and 11.7% of children at the 3-mo follow-up. Initial emptying efficiency (voided volume as a percentage of total bladder volume for that void) and mean PVR significantly improved following half-day training with gains maintained at both follow-up visits.

CONCLUSION

Training children in pairs over a half day resulted in significantly improved bladder emptying that was sustained at the 3-mo follow-up.

Development of a validated quality of life tool specific to children with Bladder dysfunction

AIMS

To date there have not been any generic or continence-specific measurement tools that allow clinicians to investigate quality of life in children with bladder dysfunction. The aim of this research was to create a cross-cultural tool to assess and measure the wider psychosocial impact of current and new interventions for bladder dysfunction in children.

MATERIALS AND METHODS

The study was conducted in three parts: expert consultation with continence clinicians; design and administration of a child-completed international questionnaire; item analysis, validity and reliability testing, and design of a new tool.

RESULTS

The need for a pediatric incontinence QoL measure evaluation was strongly endorsed by clinicians. Data from 156 child-completed questionnaires collected in 10 countries was analyzed for item characteristics and found to be free of item correlation and ceiling and floor effects. Factor analysis revealed 2 factors, which were labeled intrinsic and extrinsic. Rasch analyses showed the internal validity of both subscales was reasonable good. Cronbach's alpha for each factor was 0.91 and 0.72. After analysis, items were selected for the new tool, PinQ, and evaluated for ambiguity, clarity, comprehension level required, choice of words and phrases, and age-appropriate concepts. Twenty-one items were finally selected and randomly positioned within the tool.

CONCLUSIONS

A cross-cultural tool that quantifies the holistic effect of bladder dysfunction in children has been designed and tested for validity.

Dysfunctional elimination symptoms in childhood and adulthood

PURPOSE

The dysfunctional elimination syndrome (DES) is rare in adulthood. We evaluate the natural history of DES to identify aspects of the disorder that may be carried into adulthood.

MATERIALS AND METHODS

A 2-part questionnaire was devised and self-administered to 191 consecutive women attending a urogynecological clinic (UG) and to 251 normal women. The first section asked for recall of childhood symptoms known to be associated with DES, while the lat-ter section explored current bladder and bowel problems. Data sets from the normal cohort (55) reporting current bladder problems were excluded. Descriptive statistics, chi-square and Mann-Whitney-U tests were used to compare variables.

RESULTS

UG patients had significantly higher childhood DES scores than normal women. Overall 41.7% of UG patients could be labeled as having dysfunctional elimination as an adult. Symptoms reported significantly more often in childhood by UG patients than by control women were frequent urinary tract infection, vesicoureteral reflux, frequency, urge incontinence, slow and intermittent urine flow, small volume high urge voids, hospitalization for constipation, frequent fecal soiling and nocturnal enuresis. Higher DES scores correlated significantly with current adult urgency, urge leak, stress incontinence, incomplete emptying, post-void leak, hesitancy, nocturia and nocturnal enuresis. Constipation and fecal incontinence in adulthood also showed a significant association with high DES scores. Logistic regression revealed childhood urgency to be associated with adult DES.

CONCLUSIONS

Childhood lower urinary tract dysfunction may have a negative impact on bladder and bowel function later life.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis

OBJECTIVES

For the past 60 years, successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) has been performed via a thoracotomy. However, a number of reports have described adverse musculoskeletal sequelae following thoracotomy in infants and young children. Until now, only a few scattered case reports have detailed an individual surgeon's success with thoracoscopic repair of EA/TEF. This multi-institutional review represents the largest experience describing the results with this approach.

METHODS

A cohort of international pediatric surgeons from centers that perform advanced laparoscopic and thoracoscopic operations in infants and children retrospectively reviewed their data on primary thoracoscopic repair in 104 newborns with EA/TEF. Newborns with EA without a distal TEF or those with an isolated TEF without EA were excluded.

RESULTS

In these 104 patients, the mean age at operation was 1.2 days (+/-1.1), the mean weight was 2.6 kg (+/-0.5), the mean operative time was 129.9 minutes (+/-55.5), the mean days of mechanical ventilation were 3.6 (+/-5.8), and the mean days of total hospitalization were 18.1 (+/-18.6). Twelve (11.5%) infants developed an early leak or stricture at the anastomosis and 33 (31.7%) required esophageal dilatation at least once. Five operations (4.8%) were converted to an open thoracotomy and one was staged due to a long gap between the 2 esophageal segments. Twenty-five newborns (24.0%) later required a laparoscopic fundoplication. A recurrent fistula between the esophagus and trachea developed in 2 infants (1.9%). A number of other operations were required in these patients, including imperforate anus repair in 10 patients (7 high, 3 low), aortopexy (7), laparoscopic duodenal atresia repair (4), and various major cardiac operations (5). Three patients died, one related to the EA/TEF on the 20th postoperative day.

CONCLUSIONS

The thoracoscopic repair of EA/TEF represents a natural evolution in the operative correction of this complicated congenital anomaly and can be safely performed by experienced endoscopic surgeons. The results presented are comparable to previous reports of babies undergoing repair through a thoracotomy. Based on the associated musculoskeletal problems following thoracotomy, there will likely be long-term benefits for babies with this anomaly undergoing the thoracoscopic repair.