A randomized, controlled trial of oral propranolol in infantile hemangioma

Transdermal delivery of timolol maleate using hydrogel microneedles for the treatment of infantile haemangiomas

Infantile haemangioma (IH), the most prevalent vascular tumour in infants, requires early intervention because of the potential complications in critical areas such as the head and face. Current treatments, including topical timolol maleate (TIM), face challenges such as poor compliance, low drug utilisation, and lengthy treatment durations. In this study, we developed a hydrogel microneedle (MN) using photocurable bovine serum albumin methacryloyl (BSAMA) as a carrier for TIM. Our results showed the controlled release of TIM from BSAMA-TIM MNs, with approximately 69 % release ratio within 72 h. In-vivo studies on nude mice demonstrated that BSAMA-TIM-MNs inhibited the growth of haemangioma xenografts. Our TIM-delivering MNs exhibited high therapeutic efficacy, minimal cytotoxicity, and reduced dosing frequency. In conclusion, BSAMA-TIM MNs provide a promising strategy for treating IH.

Impact of congenital heart disease on clinical outcomes of oral propranolol therapy for Infantile hemangiomas: a propensity score-matched analysis

BACKGROUND

Oral propranolol is the first-line treatment for Infantile hemangioma (IH). However, there is a lack of studies indicating whether the congenital heart disease (CHD) makes a difference in oral propranolol therapy (OPT). Previous studies have only confirmed the safety and efficacy of OPT in asymptomatic CHD children.

OBJECTIVE

This study aimed to evaluate and compare the clinical outcomes in pediatric patients with CHD and those without CHD following OPT and to assess risk factors that may contribute to recurrence.

METHODS

A total of 310 children who received OPT for IH between January 2020 and January 2023 were included in a retrospective study. The study aimed to assess demographic data, clinical symptoms, auxiliary examinations, and treatment effects. To compare clinical outcomes between children with and without CHD, one-to-one propensity score matching (PSM) was applied.

RESULTS

Among the 310 patients, 192 (61.94%) had CHD. After propensity-matching analysis, in the presence of CHD, the age at treatment withdrawal was significantly higher (15.0 months vs. 12.0 months, P < 0.05), the treatment duration was longer (12.0 months vs. 10.0 months, P < 0.05), and the recurrence rate was greater (32.9% vs. 5.3%, P < 0.001). No significant difference in the degree of regression was observed between the CHD and non-CHD groups.

CONCLUSION

Pediatric patients with CHD exhibit a later age at treatment withdrawal, a longer duration of therapy, and a higher recurrence rate compared to those without CHD.

Stress regulatory hormones and cancer: the contribution of epinephrine and cancer therapeutic value of beta blockers

The word "cancer" evokes myriad emotions, ranging from fear and despair to hope and determination. Cancer is aptly defined as a complex and multifaceted group of diseases that has unapologetically led to the loss of countless lives and affected innumerable families across the globe. The battle with cancer is not only a physical battle, but also an emotional, as well as a psychological skirmish for patients and for their loved ones. Cancer has been a part of our history, stories, and lives for centuries and has challenged the ingenuity of health and medical science, and the resilience of the human spirit. From the early days of surgery and radiation therapy to cutting-edge developments in chemotherapeutic agents, immunotherapy, and targeted treatments, the medical field continues to make significant headway in the fight against cancer. However, even after all these advancements, cancer is still among the leading cause of death globally. This urges us to understand the central hallmarks of neoplastic cells to identify novel molecular targets for the development of promising therapeutic approaches. Growing research suggests that stress mediators, including epinephrine, play a critical role in the development and progression of cancer by inducing neoplastic features through activating adrenergic receptors, particularly β-adrenoreceptors. Further, our experimental data has also shown that epinephrine mediates the growth of T-cell lymphoma by inducing proliferation, glycolysis, and apoptosis evasion via altering the expression levels of key regulators of these vital cellular processes. The beauty of receptor-based therapy lies in its precision and higher therapeutic value. Interestingly, the enhanced expression of β-adrenergic receptors (ADRBs), namely ADRB2 (β2-adrenoreceptor) and ADRB3 (β3-adrenoreceptor) has been noted in many cancers, such as breast, colon, gastric, pancreatic, and prostate and has been reported to play a pivotal role in facilitating cancer growth mainly by promoting proliferation, evasion of apoptosis, angiogenesis, invasion and metastasis, and chemoresistance. The present review article is an attempt to summarize the available findings which indicate a distinct relationship between stress hormones and cancer, with a special emphasis on epinephrine, considered as a key stress regulatory molecule. This article also discusses the possibility of using beta-blockers for cancer therapy.

Parental Assessment of Infantile Hemangioma Cosmetic Clinical Outcomes: Results of the Spanish Hemangioma Nationwide Prospective Cohort

BACKGROUND

Functional impairment is the main consideration when it comes to choosing therapy for infantile hemangiomas (IH). However, since most hemangiomas are treated for cosmetic reasons, it is important to know the cosmetic outcome assessed by the parents.

OBJECTIVE

To evaluate the aesthetic outcomes of IH, considering the characteristics of the lesions and the treatments used.

PATIENTS AND METHODS

The Spanish Infantile Hemangioma Nationwide Prospective Cohort (2016-2022) recruited all consecutive patients diagnosed with IH in 12 Spanish hospitals. The children included had two photos of the IH lesion (at both baseline and at the end of the study). A panel of parents blindly assessed all available photos using a scale from 0 (worst cosmetic outcomes) to 10 (best cosmetic outcomes). The different scores - both before and after treatment - as well as the outcomes percent considered excellent (≥9) were described and compared. We analyzed the effect of receiving different therapies and performed causal model analyses estimating the mean treatment effect of parents' assessments.

RESULTS

The median follow-up was 3.1years. A total of 824 photos were evaluated. Baseline aesthetic impact was higher in the propranolol group vs the topical timolol and observation treatment groups (1.85 vs 3.14 vs 3.66 respectively; P<.001). After treatment, the aesthetic impact was similar between both treatment groups (7.59 vs 7.93 vs 7.90; P>.2). The causal model could only be applied to the comparison between topical timolol and observation, revealing no differences whatsoever.

CONCLUSION

This is the first prospective cohort to analyze the aesthetic outcome of IH. The final aesthetic results of the three therapies were similar, with nearly 40% of patients achieving excellent aesthetic outcomes.

Parental Assessment of Infantile Hemangioma Cosmetic Clinical Outcomes: Results of the Spanish Hemangioma Nationwide Prospective Cohort

BACKGROUND

Functional impairment is the main consideration when it comes to choosing therapy for infantile hemangiomas (IH). However, since most hemangiomas are treated for cosmetic reasons, it is important to know the cosmetic outcome assessed by the parents.

OBJECTIVE

To evaluate the aesthetic outcomes of IH, considering the characteristics of the lesions and the treatments used.

PATIENTS AND METHODS

The Spanish Infantile Hemangioma Nationwide Prospective Cohort (2016-2022) recruited all consecutive patients diagnosed with IH in 12 Spanish hospitals. The children included had two photos of the IH lesion (at both baseline and at the end of the study). A panel of parents blindly assessed all available photos using a scale from 0 (worst cosmetic outcomes) to 10 (best cosmetic outcomes). The different scores - both before and after treatment - as well as the outcomes percent considered excellent (>9) were described and compared. We analyzed the effect of receiving different therapies and performed causal model analyses estimating the mean treatment effect of parents' assessments.

RESULTS

The median follow-up was 3.1 years. A total of 824 photos were evaluated. Baseline aesthetic impact was higher in the propranolol group vs the topical timolol and observation treatment groups (1.85 vs 3.14 vs 3.66 respectively; p<0.001). After treatment, the aesthetic impact was similar between both treatment groups (7.59 vs 7.93 vs 7.90; p>0.2). The causal model could only be applied to the comparison between topical timolol and observation, revealing no differences whatsoever.

CONCLUSION

This is the first prospective cohort to analyze the aesthetic outcome of IH. The final aesthetic results of the three therapies were similar, with nearly 40% of patients achieving excellent aesthetic outcomes.

R(+) propranolol decreases lipid accumulation in haemangioma-derived stem cells

Infantile haemangioma (IH), often treated with propranolol, is a benign vascular tumour that undergoes a spontaneous involution to a fibrofatty residuum. We investigated how R(+) propranolol, the nonbeta blocker enantiomer of racaemic propranolol, affects lipid accumulation and adipogenesis in IH. This was motivated by our previous work showing that R(+) propranolol can block blood vessel formation in a preclinical model of IH. Our findings suggest a novel regulatory role for R(+) propranolol in modulating lipid accumulation in haemangioma stem cells. This highlights a novel role for R(+) propranolol in the involuting phase of IH and offers a strategy to reduce fibrofatty residua in IH.

Has Propranolol Eradicated the Need for Surgery in the Management of Infantile Hemangioma?

BACKGROUND

The authors assessed the impact of propranolol as the first-line treatment of infantile hemangioma (IH) on the need for surgery in the management of IH.

METHODS

In this retrospective study, 420 patients with IH referred to a multidisciplinary center between January of 2005 and August of 2014 were included. Clinical data, including sex; age at first consultation and at treatment initiation; location, size, number, aspect, and complications of IH; and type of treatment were collected. Statistical analyses were conducted considering each patient and each tumor independently.

RESULTS

A total of 625 IHs (420 patients) were reviewed; 113 patients had more than 1 IH (26.91%). Median age at first consultation was 7 months. Overall, 243 patients were treated (57.86%) using surgery ( n = 128 patients, 141 IHs), propranolol ( n = 79 patients, 89 IHs), corticosteroids ( n = 51 patients, 56 IHs), or laser ( n = 34 patients, 36 IHs). Propranolol was effective in all but 2 infants with IH. Seven of 79 patients (8.86%) initially treated with propranolol still required surgery, in contrast to 18 of 51 patients (35.29%) initially treated with corticosteroids and 103 of 290 patients (35.51%) with no medical treatment. Since the availability of propranolol, patients were less likely to undergo surgery (48 versus 80 patients; P < 0.001). This demonstrated that the use of propranolol reduced the need for surgery ( P < 0.001; OR, 0.177; 95% CI, 0.079 to 0.396).

CONCLUSIONS

Propranolol dramatically reduced the need for surgery, regarding indications and number of patients. Surgical correction remains important for sequelae management, nonresponders, or strawberry-like IH.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

An endothelial SOX18-mevalonate pathway axis enables repurposing of statins for infantile hemangioma

Infantile hemangioma (IH) is the most common tumor in children and a paradigm for pathological vasculogenesis, angiogenesis, and regression. Propranolol, the mainstay of treatment, inhibits IH vessel formation via a β-adrenergic receptor-independent off-target effect of its R(+) enantiomer on endothelial SOX18 - a member of the SOX (SRY-related HMG-box) family of transcription factors. Transcriptomic profiling of patient-derived hemangioma stem cells uncovered the mevalonate pathway (MVP) as a target of R(+) propranolol. Loss and gain of function of SOX18 confirmed it is both necessary and sufficient for R(+) propranolol suppression of the MVP, including regulation of sterol regulatory element-binding protein 2 (SREBP2) and the rate-limiting enzyme HMG-CoA reductase (HMGCR). A biological relevance of the endothelial SOX18-MVP axis in IH patient tissue was demonstrated by nuclear colocalization of SOX18 and SREBP2. Functional validation in a preclinical IH xenograft model revealed that statins - competitive inhibitors of HMGCR - efficiently suppress IH vessel formation. We propose an endothelial SOX18-MVP axis as a central regulator of IH pathogenesis and suggest statin repurposing to treat IH. The pleiotropic effects of R(+) propranolol and statins along the SOX18-MVP axis to disable an endothelial cell-specific program may have therapeutic implications for other vascular disease entities involving pathological vasculogenesis and angiogenesis.

Recent Advances in Propranolol Hydrochloride Formulations for the Treatment of Infantile Hemangiomas

Infantile hemangiomas (IHs) are a kind of skin soft tissue benign tumors in infants, with a high incidence rate and significant harm. Rapid early proliferation can cause severe cosmetic deformities and organ development disorders. Propranolol Hydrochloride (PRH), a non-selective adrenergic β-receptor blocker, has become the first-line treatment for IHs due to its good efficacy and safety compared to other drugs. To further improve the bioavailability of PRH, deliver it more safely and effectively to the lesion site, and enhance patient compliance, researchers are continually developing new PRH formulations for the treatment of IHs. This article briefly introduced the pathogenesis of IHs and the therapeutic mechanism of PRH. It also provided a detailed overview of various new PRH formulations developed over the past 12 years for the treatment of IHs, including improved oral formulations, topical creams, gels, liposomes/nanoparticles, transdermal patches, microneedles, and targeted injectable formulations. This article summarized the development prospects and technical challenges of these new formulations. It aims to provide a comprehensive review of recent advances in new propranolol formulations and technologies for treating IHs, offering a reference for further research and application. At the same time, it is hoped that various new formulations of PRH can be safely and efficiently used in clinical practice in the future.

Efficacy and safety assessment of propranolol tablets vs. oral solution for infantile hemangioma: a retrospective study in China

Background

Propranolol for infantile hemangiomas (IHs) is effective and relatively safe. However, propranolol has different formulations and there is no consensus on the optimal formulation for IHs. The propranolol oral solution was not used in China until 2022.

Objective

To evaluate the efficacy and safety of propranolol tablets and an oral solution in infants with high-risk IH.

Methods

A retrospective cohort study was conducted involving 234 consecutive patients with a clinical diagnosis of high-risk IH who were treated with propranolol between August 2018 and February 2023 (propranolol tablets, 168 patients; propranolol oral solution, 66 patients). All patients were assessed in the hospital at the initiation of treatment and in the outpatient setting during treatment. The Hemangioma Activity and Severity Index was used to monitor the clinical activity of the hemangioma after propranolol treatment.

Results

Based on the Hemangioma Activity and Severity Index, 66.52% and 69.15% improvement occurred in the propranolol tablet and oral solution groups, respectively. 23.21% of patients in the propranolol tablet group and 42.42% in the oral solution group achieved >75% score improvement (X 2 = 8.557; P = 0.003). Adverse reactions occurred in 34 (20.24%) and 11 patients (16.67%) in the propranolol tablet and oral solution groups, respectively. The most common adverse reaction in the propranolol tablet group was liver function abnormalities due to mild elevation of liver enzymes (X 2 = 4.09; P = 0.045).

Conclusion

Both propranolol tablets and oral solution had positive efficacy in patients with high-risk IHs, but more patients in the propranolol oral solution group achieve >75% score improvement compared to the propranolol tablet group. No life-threatening adverse reactions occurred in either group but liver function abnormalities were more likely to occur in patients treated with propranolol tablets.

Interobserver and Intraobserver Agreement on the Treatment of Infantile Hemangiomas

Importance

Although clinical practice guidelines exist for the treatment of infantile hemangiomas (IHs), recommendations are heterogeneous, and wide practice variations in IH management have been reported.

Objective

To analyze the degree of agreement in treatment choices for IH among pediatric dermatologists in North America and Europe and assess whether there are differences across IH risk categories.

Design, Setting, and Participants

This cross-sectional interrater and intrarater agreement study was conducted through a survey based on the Spanish Academy of Dermatology and Venereology IH prospective cohort. The survey used 50 vignettes of IH cases that were randomly selected from the cohort. It was administered twice in 2023, 1 month apart, to allow for interrater and intrarater agreement assessments. Data were analyzed in January 2024. The study involved pediatric dermatologists from North America (via the Pediatric Dermatology Research Alliance) and Europe (via the European Society of Pediatric Dermatologists).

Exposures

Participants were asked to choose 1 of 3 treatment options (propranolol, topical timolol, or observation) for each vignette.

Main Outcome and Measure

The primary outcome was the interrater agreement in treatment choices for IH cases, measured using κ statistics (Gwet AC1 coefficient).

Results

The global interobserver agreement among 90 pediatric dermatologists was fair (AC1, 0.38; 95% CI, 0.29-0.46). In North America (45 pediatricians), agreement was moderate (AC1, 0.41; 95% CI, 0.33-0.49), while in Europe (45 pediatricians) it was fair (AC1, 0.37; 95% CI, 0.28-0.46). The degree of agreement varied depending on the risk category of IH, with excellent agreement in high-risk IH and only moderate agreement in intermediate-risk and low-risk IHs. Propranolol was predominantly chosen for high-risk IH, while observation was most frequent for low-risk IH (55.9%). The second survey had 61 respondents, with no significant intrarater differences.

Conclusions and Relevance

The results of this survey study suggest that there is an important variability in the treatment of intermediate-risk and low-risk IH. The study findings support the need for more evidence regarding the role of topical timolol in IH treatment, which may help harmonize treatment approaches and improve consistency in IH management globally.

Cell Fate Regulation During the Development of Infantile Hemangioma

As the most common benign vascular tumor in infants, infantile hemangioma (IH) is characterized by rapid growth and vasculogenesis early in infancy, followed by spontaneous involution into fibrofatty tissues over time. Extensive evidence suggests that IH originates from hemangioma stem cells (HemSCs), a group of stem cells with clonal expansion and multi-directional differentiation capacity. However, the intricate mechanisms governing the cell fate transition of HemSCs during IH development remain elusive. Here we comprehensively examine the cellular composition of IH, emphasizing the nuanced properties of various IH cell types and their correlation with the clinical features of the tumor. We also summarize the current understanding of the regulatory pathways directing HemSC differentiation into endothelial cells (ECs), pericytes, and adipocytes throughout the stages of IH progression and involution. Furthermore, we discuss recent advances in unraveling the transcriptional and epigenetic regulation of EC and adipocyte development under physiological conditions, which offer crucial perspectives for understanding IH pathogenesis.

Propranolol: A Promising Therapeutic Avenue for Classic Kaposi Sarcoma

INTRODUCTION

Kaposi sarcoma (KS) is a low grade angio-proliferative tumor of endothelial origin. Human herpesvirus 8 (HHV8) plays a major role in the pathogenesis of KS. Classic Kaposi sarcoma is commonly seen among elderly of Mediterranean origin. It is usually slowly progressive and is rarely fatal. There is no definitive cure for KS. Beta blockers were used with great success in the treatment of infantile hemangioma. Because of some similarity between infantile hemangioma and KS, topical beta blockers were tried with variable success rate.

OBJECTIVES

We aimed to assess the efficacy and safety of oral propranolol in the treatment of classic KS.

METHODS

Fifteen patients diagnosed with classic KS were prospectively enrolled in the study. Detailed history and full clinical examination were conducted. Histopathological diagnosis with confirmatory immune staining was done for all patients. Oral propranolol in a dose of 60 mg was given per day for 6 months. The patients assessed clinically as complete responders, partial responders, and non-responders.

RESULTS

Nine patients (60%) were partial responders; showed 50% reduction in the number of the existing lesions, and 6 patients (40%) were considered non-responders; 3 with stable disease and 3 with progressive disease. Lymphedema partially improved in 1 patient.

CONCLUSIONS

Oral propranolol is a safe and good option for treatment of patients with non-complicated classic KS, especially elderly with multiple comorbidities.

Efficacy and safety of atenolol vs. propranolol for treatment of infantile haemangioma: a narrative review

Infantile haemangioma (IH) remains the most common benign vascular tumour in childhood. Although most IH can be managed conservatively, a proportion of these lesions can cause disfigurement, ulceration or functional impairment, requiring prompt intervention. Propranolol, a lipophilic nonselective beta blocker, has been regarded as first-line therapy, following a serendipitous discovery of its use for IH in 2008. Although efficacious, it has been associated with adverse effects such as hypoglycaemia, bronchospasm, sleep disturbances and agitation in infant trials. Atenolol, a hydrophilic beta-1 selective blocker, has demonstrated similar efficacy and potentially greater tolerability, being less likely to cause sleep disturbances given its inability to cross the blood-brain barrier, and a decrease in bronchial reactivity. The purpose of this review is to explore and critique current knowledge about the efficacy and safety of propranolol vs. atenolol in children with an IH. In total, seven studies comparing the two beta blockers were identified in our search. Atenolol appeared to be as efficacious as propranolol and was associated with fewer central nervous system and bronchial-related adverse events. Further research exploring the optimal dosing for atenolol, particularly for ulcerated or syndromic IHs, as well as the incidence and management of rebound growth would be beneficial.

Choroidal Hemangioma Treatment with Propranolol - A Case Study in Sturge-Weber Syndrome and Systematic Literature Review

PURPOSE

To examine propranolol efficacy in treating diffuse (DCH) and circumscribed choroidal hemangiomas (CCH) and controlling intraocular pressure (IOP) in patients with Sturge-Weber syndrome (SWS).

METHODS

A SWS patient case treated with propranolol for DCH is presented. Following PRISMA guidelines, we also performed a systematic review using PubMed/Web of Science, analyzing 14 studies detailing propranolol treatment outcomes for DCH, CCH, and IOP control in SWS. Demographic, clinical, treatment, and outcome data were extracted and statistically analyzed. Fisher's exact test was used to compare findings such as retinal detachment rates.

RESULTS

We reviewed patients treated with propranolol, including 8 DCH, 18 CCH, and 16 SWS cases of IOP control. Retinal detachment rates were significantly higher in DCH compared to CCH cases. Post-propranolol, 73% of DCH and CCH cases showed subretinal fluid improvement, and in SWS patients, 94% had IOP reduction.

CONCLUSION

This study underscores the potential utility of propranolol beyond its traditional use in cutaneous hemangioma for treatment of CCH/DCH and IOP control.

Efficacy and safety of propranolol tablets vs. oral solution in neonates with severe infantile hemangiomas: a retrospective study in China

The objective of this study was to evaluate the efficacy and safety of propranolol hydrochloride tablets and oral solution in neonates with severe IHs. A retrospective cohort study included 184 consecutive neonates diagnosed with severe IHs and treated with propranolol from January 2016 to June 2023. Of these, 126 patients received propranolol tablets, and 58 received propranolol oral solution. The primary outcome assessed the treatment response post-discontinuation of propranolol, while the key secondary outcome measured changes in the hemangioma activity score (HAS). Out of 184 participants, 138 (75.5%) were female. The mean age at treatment initiation was 16 days (range: 10-22) for the tablet group and 14 days (range: 8-24) for the oral solution group. Following treatment, effective response rates were 74.6% in the tablet group and 87.9% in the oral solution group (P = 0.04). Improvement in the HAS was 63.95% for the tablet group and 65.57% for the oral solution group (P = 0.35). Adverse reactions included diarrhea in 29.0% of tablet group and 12.9% of oral solution group (P = 0.01), and sleep disturbances in 20.6% of tablet group and 8.6% of oral solution group (P = 0.04). In terms of sequelae, telangiectasia occurred in 34.9% of tablet group and 17.2% of oral solution group (P = 0.01). Propranolol oral solution showed superior efficacy and safety compared to tablets in treating neonates with severe IHs, suggesting it should be prioritized as the preferred treatment option for this vulnerable population.

Cerebral Cavernous Malformation: From Genetics to Pharmacotherapy

INTRODUCTION

Cerebral cavernous malformation (CCM) is a type of cerebrovascular abnormality in the central nervous system linked to both germline and somatic genetic mutations. Recent preclinical and clinical studies have shown that various drugs can effectively reduce the burden of CCM lesions. Despite significant progress, the mechanisms driving CCM remain incompletely understood, and to date, no drugs have been developed that can cure or prevent CCM. This review aims to explore the genetic mutations, molecular mechanisms, and pharmacological interventions related to CCM.

METHODS

Literatures on the genetic mechanisms and pharmacological treatments of CCM can be searched in PubMed and Web of Science.

RESULTS

Germline and somatic mutations mediate the onset and development of CCM through several molecular pathways. Medications such as statins, fasudil, rapamycin, and propranolol can alleviate CCM symptoms or hinder its progression by specifically modulating the corresponding targets.

CONCLUSIONS

Understanding the molecular mechanisms underlying CCM offers potential for targeted therapies. Further research into novel mutations and treatment strategies is essential for improving patient outcomes.

Neonatal Cutaneous Vascular Anomalies

Vascular anomalies are broadly classified into 2 categories: vascular tumors and vascular malformations. Vascular anomalies frequently present as cutaneous lesions in infants. This review summarizes vascular anomalies that most commonly present as dermatologic lesions in the neonatal period, with a focus on the clinical findings, pathophysiology and histology, relevant radiographic findings, and management of common vascular anomalies such as infantile hemangiomas, congenital hemangiomas, and Kaposiform hemangioendothelioma, along with vascular malformations, including capillary, lymphatic, venous, and arteriovenous malformations.

Formulation and Release of Active Pharmaceutical Ingredients Using a Supramolecular Self-Healing Two-Component Gel

A two-component low-molecular-weight gelator (LMWG) formed from a modified amino acid and an aldehyde was formulated with active pharmaceutical ingredients (APIs). Basic APIs (propranolol, atropine) can be mixed with the LMWG prior to gel assembly while acidic APIs (naproxen, rosuvastatin) inhibit assembly by disrupting the LMWG imine bond and were loaded by diffusion after gel assembly. For diffusion-loaded gels, the API in the liquid-like phase was rapidly released, with the remainder, interacting with gel fibres, retained in the gel. Rosuvastatin release was particularly low with Saturation Transfer Difference (STD) NMR indicating interactions between the aromatic ring and the self-assembled gel network. Propranolol also interacted with the gel via its aromatic unit, and its release led to gel erosion. Using agarose as a polymer gelator additive reinforced the gel, restricting erosion. In contrast, atropine was readily released over a period of hours - it is primarily in the liquid-like phase with STD NMR indicating no interactions with the gel network. The atropine-loaded gel retained its thixotropic properties. Overall, APIs must be carefully chosen to optimise formulation/release. Of the APIs investigated, atropine has most potential for further development. Atropine has applications in treating myopia, and our results suggest potential ophthalmic applications of supramolecular gels.

Neurodevelopmental Effects of Propranolol Treatment During Infancy in Infantile Hemangioma Patients

INTRODUCTION AND AIM

Propranolol is an effective treatment option for infantile hemangiomas, but there is still insufficient information about neurodevelopmental side effects of propranolol. In our study, the neurodevelopmental levels of infantile hemangioma patients receiving propranolol treatment were examined using the Bayley-III test.

METHOD

In our single-center, cross-sectional study, patients were recruited between 1 January 2020 and 31 December 2023. In total, 40 children (n1) diagnosed with hemangioma who received propranolol treatment and 31 children (n2) who were only under observation were included. A control group of 31 healthy children (n3) matched for age and gender was also included. The demographic, clinical, perinatal, and postnatal characteristics of the total 102 children were recorded from their medical records. Neurodevelopmental levels were assessed with the Bayley-III test. The significance level was set at (p < 0.05).

RESULTS

The Bayley-III test composite and percentile scores were used to evaluate the neurodevelopmental levels. Significant differences in motor functions were found between the treated and untreated groups compared to the healthy control group (p = 0.006 and p = 0.006). However, no significant differences were found in cognitive, language, and social-emotional skills. Cognitive, language, and motor functions were associated with maternal education level, and additionally, cognitive functions were also associated with paternal education level.

CONCLUSIONS

Propranolol has a relatively safer side effect profile, and therefore, it has been described as a safe agent. In our study, no significant effect of propranolol on neurodevelopment was observed. The difference in motor skills shown was mainly between the healthy control group (n3) and the treated and untreated group (n1 and n2), which led to the conclusion that the relevant difference could be due to factors other than propranolol itself.

Efficacy and safety of oral propranolol and topical timolol in the treatment of infantile hemangioma: a meta-analysis and systematic review

BACKGROUND

Propranolol, a nonselective β-blocker, is the first-line treatment for infantile hemangioma (IH). Topical timolol has recently been proposed as a novel IH treatment with fewer adverse effects. This study was conducted to compare the efficacy and safety of oral propranolol and topical timolol for treating IH.

METHODS

Studies were included after searching PubMed, Embase, Web of Science, and the Cochrane Library via the keywords of "propranolol", "timolol", "infantile hemangioma" and their synonyms. A meta-analysis with pooled odds ratios was performed using the fixed-effect model.

RESULTS

Seven articles with 2071 patients were included in this meta-analysis. Compared with topical timolol, oral propranolol had a greater response rate (OR = 2.12, P < 0.001), but it was also associated with a greater risk of adverse events (OR = 2.31, P < 0.001). For superficial IH, timolol demonstrated similar efficacy to propranolol (OR = 1.28, P = 0.34) but with fewer adverse events (OR = 2.30, P = 0.001). Additionally, compared with topical timolol, propranolol at a dosage of 2 mg/kg/d had a better response rate (OR = 2.62, P < 0.001), whereas the 1.0∼1.5 mg/kg/d propranolol group showed no significant difference (OR = 1.34, P = 0.38).

CONCLUSION

Oral propranolol presents superior therapeutic efficacy in the treatment of IH compared to topical timolol. However, topical timolol can serve as an alternative to oral propranolol for treating superficial IH, providing similar efficacy with fewer adverse effects. Additionally, propranolol at a dosage of 2 mg/kg/d offers greater efficacy with a comparable safety profile, whereas the 1.0∼1.5 mg/kg/d propranolol dosage shows no significant difference in efficacy compared to timolol but is associated with more adverse events.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024603724, identifier CRD42024603724.

Propranolol or Beta-Blockers for Cerebral Cavernous Malformation: a Systematic Review and Meta-analysis of Literature in Both Preclinical and Clinical Studies

Cerebral cavernous malformation (CCM), either sporadic or familial, is a devastating vascular malformation affecting the central nervous system that can present with intracerebral hemorrhage, seizure, and new focal neurologic deficits resulting in substantial morbidity and mortality. To date, there is no effective evidence-based preventive regimen. There have been several preclinical and clinical studies investigating the potential mechanisms and benefits of beta-blockers, especially on propranolol. We aimed to conduct a systematic review on the published literature investigating the use of beta-blockers in the treatment of CCM, including both preclinical and clinical studies between 2008 and 2023 using public databases. A total of 2 preclinical studies and 6 clinical studies met the inclusion/exclusion criteria and were included. Data was extracted and synthesized from 5 clinical studies for meta-analysis. The meta-analysis failed to demonstrate a statistically significant protective effect of beta-blockers in preventing intracerebral hemorrhage or developing focal neurologic deficits in subjects with CCM (overall effect = 0.78 (0.20, 3.11), p = 0.73). Overall, there was a paucity of high quality clinical trials, partially due to limited cases of CCM. Addressing this gap may require collaborative efforts at a national or international level. In this review, we summarized all barriers and opportunities on this topic. Additionally, we proposed establishing an evidence-based approach on the use of beta-blockers in preventing recurrent hemorrhage and focal neurological deficits in patients with CCM.

Optimizing Propranolol Therapy for Infantile Hemangiomas: The Role of the Multidisciplinary Team

BACKGROUND

Oral propranolol therapy is currently the first choice for infants with infantile hemangiomas (IHs) requiring systemic treatment. This study aims to evaluate the safety and effectiveness of oral propranolol therapy for IHs and to assess the role of a multidisciplinary medical team in supporting optimal treatment.

MATERIALS AND METHODS

Clinical data were retrospectively reviewed from medical records in 150 Japanese infants with IH treated with propranolol orally at Toranomon Hospital. Patients with problematic IH, such as tumor-type IH or IH with ulceration, were eligible for inclusion. Treatment was managed by a medical team consisting of pediatricians, dermatologists, pediatric nurses, pharmacists, and nutritionists. Patients' general conditions and vital signs, such as blood pressure, pulse rate, respiratory rate, and blood sugar, were closely monitored before, one hour, and two hours after drug administration.

RESULTS

Close collaboration among multidisciplinary medical team members allowed for accurate patient evaluation, contributing to the early detection of side effects, even if asymptomatic. When side effects were suspected, pediatricians and dermatologists discussed the need to reduce or discontinue the medication. Of the 150 patients, no one experienced severe side effects. Although five cases (3.3%) were suspected of having mild side effects (i.e., hypotension, n = 3; hypotension and hypoglycemia, n = 1; inspiratory stridor, n = 1), treatment could be continued by adjusting the dosage. One hundred twenty patients have completed the oral propranolol therapy with successful outcomes.

CONCLUSIONS

This study provided additional evidence of the safety and effectiveness of oral propranolol therapy in 150 Japanese infants with IH. A well-functioning multidisciplinary medical team is essential for optimal patient treatment.

Neurobiology of cancer: Adrenergic signaling and drug repurposing

Cancer neuroscience, as an emerging converging discipline, provides us with new perspectives on the interactions between the nervous system and cancer progression. As the sympathetic nervous system, in particular adrenergic signaling, plays an important role in the regulation of tumor activity at every hierarchical level of life, from the tumor cell to the tumor microenvironment, and to the tumor macroenvironment, it is highly desirable to dissect its effects. Considering the far-reaching implications of drug repurposing for antitumor drug development, such a large number of adrenergic receptor antagonists on the market has great potential as one of the means of antitumor therapy, either as primary or adjuvant therapy. Therefore, this review aims to summarize the impact of adrenergic signaling on cancer development and to assess the status and prospects of intervening in adrenergic signaling as a therapeutic tool against tumors.

Non-coding RNA in infantile hemangioma

Infantile hemangioma (IH) is the most common benign vascular tumor of infancy, but its pathogenesis has not been fully discovered. From the cellular perspective, CD133+ stem cells orchestrate the proliferation and development of IH. Regarding molecular mechanisms, hypoxia inducible factor-1α, renin-angiotensin system, and vascular endothelial growth factor are current study hotspots, while non-coding RNAs (ncRNAs) might be essential factors participating in this network. Therefore, this article reviewed published studies concerning the roles of ncRNAs in IH and listed noted miRNAs, lncRNAs, and circRNAs. Other ncRNAs, such as snRNAs, snoRNAs, and tsRNAs, though have not been examined in IH, are mentioned as well to discuss their potential functions. Due to the continuous development of sequencing technologies and computational pipelines for ncRNAs annotation, relevant studies will provide evidence to gradually enhance acknowledgments of ncRNAs' role in IH. The pathogenesis of IH might be revealed and the treatment protocol would be optimized in the future. IMPACT: Non-coding RNAs (ncRNAs) play critical roles in infantile hemangioma. This article thoroughly reviewed all ncRNAs (miRNAs, lncRNAs, and circRNAs) mentioned in previous studies regarding the pathogenesis of infantile hemangioma. Other ncRNAs are promising subjects for further investigation. This review introduced the emerging ncRNAs that need to be explored in IH.

Effective Treatment With Oral Propranolol for Congenital Intracranial Hemangioma in a Neonate: A Case Report and Literature Review

Congenital intracranial hemangiomas are rare benign vascular tumors that develop before birth. Although various treatments, including surgery, steroids, interferon-α, thalidomide, bevacizumab, or propranolol, have been reported, no standard therapy has been established. We report the case of a neonate with congenital intracranial hemangioma and central nervous system symptoms requiring therapeutic intervention. Early postnatal oral propranolol treatment was safe and effective. The neurological prognosis is good post-treatment; however, follow-up is needed to determine the long-term neurological prognosis.

Rebound Growth of Infantile Hemangiomas after Propranolol versus Atenolol Treatment: A Retrospective Study

INTRODUCTION

Propranolol is the first-line treatment for complicated infantile hemangioma (IH). Rebound growth following propranolol discontinuation is reported in 6-25% of patients. Atenolol is considered an effective alternative to propranolol. We aimed to compare the incidence of IH rebound growth following discontinuation of atenolol and propranolol and to identify associated risk factors.

METHODS

We reviewed the medical records of all the patients diagnosed with IH and treated with oral propranolol or atenolol during 2009-2019 in our tertiary center. Inclusion criteria were completion of at least 3 months of initial treatment and at least 3 months of follow-up after discontinuation of initial treatment.

RESULTS

Of 445 patients in total, 267 (60%) were treated with propranolol and 178 (40%) with atenolol. The incidence of rebound growth was similar between the groups: 59 (22.1%) and 40 (22.5%), respectively. Patients treated with atenolol required a shorter duration of treatment after rebound growth until growth arrest (9.41 ± 5.61 vs. 14.79 ± 10.02 months, p < 0.001). For the patients who initiated atenolol before the age of 5 months, the adjusted odds ratio (aOR) for regrowth was 0.6 (95% CI: 0.33-1.08). As duration of treatment increased, the risk of rebound growth increased; the aOR was 1.24 (95% CI: 1.10-1.38). No other significant risk factors for rebound growth were identified.

CONCLUSIONS

The incidence of rebound growth was similar following treatment with two oral β-receptor blockers. Treatment initiation after the age of 5 months and long duration of treatment may increase the risk for regrowth. These findings should be further investigated as they may impact clinical decisions on treating IH.

Vascular anomalies in childhood. Review and update

Vascular anomalies are changes in vascularization that usually appear in the foetal stage, at birth or in early childhood. They can cause chronic pain, motor impairment, cosmetic changes or coagulopathy and may be fatal in some cases, but in every case they have a negative impact on the quality of life of the child and the family. Up to 150 different subtypes have been described. They can involve arteries, capillaries, veins, lymphatic vessels or a combination thereof. They may be associated with additional malformations and frequently cause musculoskeletal and soft tissue hypertrophy or hypotrophy. They can develop anywhere in the body, invade any tissue and affect the function of various organs. The prevalence of the different subtypes varies greatly, from 1/20 to 1/1 000 000. Subtypes considered rare diseases (incidence <1/2000) continue to affect more than 500 000 people in the European Union. Differentiating between vascular tumours and vascular malformations is critical, especially in paediatric patients. They are completely different diseases, although they are often grouped under the umbrella term of vascular anomalies. The diagnostic algorithm used in the clinical evaluation of vascular anomalies should be based on a thorough history-taking and detailed physical examination. Future knowledge in this field will be based above all on genetic findings and therapeutic innovations. New molecules and their indications are being explored with the aim of reducing the aggressiveness of previous treatments and increasing the life expectancy and quality of life of patients who do not respond to conventional treatments.

Identifying Potential Diagnostic and Therapeutic Targets for Infantile Hemangioma Using WGCNA and Machine Learning Algorithms

Infantile hemangioma (IH) is the most common benign vascular tumor during infancy and childhood and is characterized by abnormal vascular development. It is the most common vascular tumor and its related mechanisms and treatments remain a problem. IH-related biomarkers have been identified using transcriptome analysis and can be used to predict clinical outcomes. This study aimed to identify the key target genes for IH treatment and explore their possible roles in the IH pathophysiology. Gene records were acquired from the Gene Expression Omnibus database. Utilizing integrated weighted gene co-expression network examination, gene clusters were determined. Single-sample gene set enrichment analysis was performed to gauge immune infiltration. Essential genes were identified via Random Forest and Least Absolute Selection and Shrinkage Operator analyses. Ultimately, a set of five pivotal genes associated with the ailment was identified (NETO2, IDO1, KDR, MEG3, and TMSB15A). A nomogram for predicting IH diagnosis was constructed based on hub genes. The calibration curve showed valid agreement between the prediction and conclusion that the key genes in the model were clinically significant. Neuropilin and Tolloid-like 2 (NETO2) are closely associated with tumor development. The role value of NETO2 expression levels increased in hemangioma-derived endothelial cells (HemECs). After silencing NETO2, the growth and migration of cancer cells were significantly restrained. This study revealed the critical role of NETO2 in IH development, suggesting that targeting NETO2 may be effective in improving the therapeutic outcome of IH.

Oral propranolol for the treatment of hemangiomas in high-risk infants: safety and cost analysis of outpatient-initiated therapy

Objectives

To investigate the safety and cost analysis of oral propranolol treatment for high-risk infantile hemangiomas starting from the outpatient setting.

Methods

A total of 41 high-risk infantile hemangioma patients from outpatient settings and 43 from inpatient settings were selected for the study. After routine pre-treatment examinations, patients were administered propranolol in a stepwise incremental dosing regimen over three consecutive days in the outpatient clinic. Changes in heart rate, blood pressure and PR interval before and after medication were compared. On the 10th day post-medication, liver and kidney functions, fasting blood glucose, tumor ultrasonography, and electrocardiogram were re-evaluated. The costs of treatment starting from the outpatient clinic (including pre-treatment examinations and the first three days of treatment) were calculated and compared with those of similarly managed inpatient cases.

Results

The majority of patients exhibited a reduction in heart rate and blood pressure, as well as an extended PR interval after treatment of medication (P < 0.05), which remained within normal limits without clinical symptoms. On the 10th day post-medication, statistical differences in blood biochemistry and electrocardiograms were observed when compared to pre-treatment values (P < 0.05), but all values remained within normal ranges. No severe adverse reactions such as hypoglycemia occurred. Additionally, the cost of treatment from the outpatient clinic was significantly lower than that of inpatient care.

Conclusion

Oral propranolol treatment for high-risk infantile hemangiomas starting from the outpatient setting is associated with few adverse reactions and significantly reduced treatment costs. It is worthy of broader application in hospitals without dermatology wards.

Once a day administration of R(+) propranolol is sufficient to block vasculogenesis in a xenograft model of infantile hemangioma

OBJECTIVES

Infantile hemangioma (IH) is a benign vascular tumor that occurs in 5% of infants, predominantly in female and preterm neonates. Propranolol is the mainstay of treatment for IH. Given the short half-life of propranolol regarding β-adrenergic receptor inhibition as well as its side effects, propranolol is administered to infants 2-3 times daily with 1 mg/kg/dose. We previously demonstrated propranolol inhibits IH vessel formation via an effect of its R(+) enantiomer on the endothelial-specific transcription factor SRY box 18 (SOX18). In light of this, we hypothesized that R(+) propranolol inhibition of SOX18 is long-lived compared to the beta-blocker effects, and therefore administration of R(+) propranolol once a day would be sufficient to block IH vessel formation.

METHODS

We tested the effect of one dose versus two doses of R(+) propranolol in a xenograft model of IH wherein patient-derived hemangioma stem cells (HemSC) were implanted subcutaneously into nude mice. Mice were treated for 7 days with 2 × 12.5 mg/kg/day (n=12) versus 1 × 25 mg/kg/day (n=14) as well as PBS (vehicle control) (n=16) via intraperitoneal injections. The doses were estimated to correlate with those given to infants with IH.

RESULTS

Treatment with R(+) propranolol significantly inhibited vasculogenesis in our IH xenograft model at both 2 × 12.5 mg/kg/day and 1 × 25 mg/kg/day, compared to vehicle controls. No significant difference was observed between the two treatment regimens.

CONCLUSIONS

Our results suggest implications for the clinical management of infants with IH: Administration of R(+) propranolol can possibly minimize or omit concerning β-adrenergic side effects while only requiring one dose per day.

The burden of treatment of propranolol for infantile hemangiomas: A mixed methods study

The burden of treatment (BOT) related to propranolol treatment for infantile hemangiomas (IH) has never previously been explored. A modified validated questionnaire, the Treatment Burden Questionnaire, and one-on-one semi-structured interviews were used to assess the BOT for propranolol for IH. Out of 80 caregivers, the overall burden score was very low at 1.2 out of 10; thematic analysis of interviews grouped themes into administration, monitoring, financial, and associated anomalies. The BOT of propranolol for IH is very low but could be reduced further by offering age-based risk stratification related to feeding frequency and risk of hypoglycemia, pragmatic advice around timing of doses before sleep, and reducing frequency of vital sign monitoring.

Insights into the mechanisms of angiogenesis in infantile hemangioma

Infantile hemangioma (IH) is the most common benign tumor in infants and usually resolves on its own. However, a small portion of IH cases are accompanied by serious complications and other problems, impacting the physical and psychological health of the children affected. The pathogenesis of IH is highly controversial. Studies have shown that abnormal blood vessel formation is an important pathological basis for the development of IH. Compared with that in normal tissues, the equilibrium of blood vessel growth at the tumor site is disrupted, and interactions among other types of cells, such as immune cells, promote the rapid proliferation and migration of vascular tissue cells and the construction of vascular networks. Currently, propranolol is the most common systemic drug used to inhibit the growth of IHs and accelerate their regression. The purpose of this review is to provide the latest research on the mechanisms of angiogenesis in IH. We discuss the possible roles of three major factors, namely, estrogen, hypoxia, and inflammation, in the development of IH. Additionally, we summarize the key roles of tumor cell subpopulations, such as pericytes, in the proliferation and regression of IH considering evidence from the past few years, with an emphasis on the possible mechanisms of propranolol in the treatment of IH. Angiogenesis is an important event during the development of IH, and an in-depth understanding of the molecular mechanisms of angiogenesis will provide new insights into the biology and clinical treatment of IH.

KLF2 Orchestrates Pathological Progression of Infantile Hemangioma through Hemangioma Stem Cell Fate Decisions

Infantile hemangioma (IH) is the most prevalent vascular tumor during infancy, characterized by a rapid proliferation phase of disorganized blood vessels and spontaneous involution. IH possibly arises from a special type of multipotent stem cells called hemangioma stem cells (HemSCs), which could differentiate into endothelial cells, pericytes, and adipocytes. However, the underlying mechanisms that regulate the cell fate determination of HemSCs remain elusive. In this study, we unveil KLF2 as a candidate transcription factor involved in the control of HemSCs differentiation. KLF2 exhibits high expression in endothelial cells in proliferating IH but diminishes in adipocytes in involuting IH. Using a combination of in vitro culture of patient-derived HemSCs and HemSCs implantation mouse models, we show that KLF2 governs the proliferation, apoptosis, and cell cycle progression of HemSCs. Importantly, KLF2 acts as a crucial determinant of HemSC fate, directing their differentiation toward endothelial cells while inhibiting adipogenesis. Knockdown of KLF2 induces a proadipogenic transcriptome in HemSCs, leading to impaired blood vessel formation and accelerated adipocyte differentiation. Collectively, our findings highlight KLF2 as a critical regulator controlling the progression and involution of IH by modulating HemSC fate decisions.

Infantile Hepatic Hemangioma: A Novel Approach Using Propranolol and Transarterial Embolization

Benign vascular tumors, or hemangiomas, are common in young children. The most frequent way to identify them on the skin is as bright red surface lesions, although they can also be detected deeper as subcutaneous lesions. Visceral involvement, particularly of the liver, is commonly observed in patients with multiple cutaneous hemangiomas. Since most hemangiomas are self-limited, they can be clinically monitored. Despite this, hepatic hemangiomas can result in significant consequences, such as severe hepatomegaly, which can induce abdominal compartment syndrome, inadequate ventilation, and renal vein compression, as well as significant arteriovenous shunts that compromise the functioning of the heart. Depending on the patient's findings, management may range from routine follow-up to liver transplantation. Here, we present a case of hypothyroidism, hepatomegaly, and cardiac failure in a two-month-old female newborn with infantile hepatic hemangioma. The patient's symptoms were managed with the use of levothyroxine, propranolol, and transcatheter arterial embolization (TAE).

R(+) Propranolol decreases lipid accumulation in hemangioma-derived stem cells

Background

Infantile hemangioma (IH) is a benign vascular tumor that undergoes an initial rapid growth phase followed by spontaneous involution. A fibrofatty residuum remains in many tumors and often necessitates resection. We recently discovered that R(+) propranolol, the non-β blocker enantiomer, inhibits blood vessel formation of IH patient-derived hemangioma stem cells (HemSC) xenografted in mice. HemSC are multipotent cells with the ability to differentiate into endothelial cells, pericytes, and adipocytes.

Objectives

We investigated how R(+) propranolol affects HemSC adipogenic differentiation and lipid accumulation, in vitro and in a preclinical murine model for IH.

Methods

We conducted a 10-day adipogenesis assay on 4 IH patient-derived HemSCs. Oil Red O (ORO) staining was used to identify the onset and level of lipid accumulation in HemSC while quantitative real-time polymerase chain reaction was conducted to determine the temporal expression of key factors implicated in adipogenesis. 5-20µM R(+) propranolol treatment was added to HemSC induced to undergo adiogenesis for 4 and 8 days, followed by quantification of lipid-stained areas and transcript levels of key adipogenic factors. We immunostained for lipid droplet-associated protein Perilipin 1 (PLIN1) in HemSC-xenograft sections from mice treated with R(+) propranolol and quantified the area using ImageJ.

Results

We found that different patient-derived HemSC exhibit a robust and heterogenous adipogenic capacity when induced for adipogenic differentiation in vitro. Consistently across four IH patient-derived HemSC isolates, R(+) propranolol reduced ORO-stained areas and lipoprotein lipase (LPL) transcript levels in HemSC after 4 and 8 days of adipogenic induction. In contrast, R(+) propranolol had no significant inhibitory effect on transcript levels encoding adipogenic transcription factors. In a pre-clinical HemSC xenograft model, PLIN1-positive area was significantly reduced in xenograft sections from mice treated with R(+) propranolol, signifying reduced lipid accumulation.

Conclusions

Our findings suggest a novel regulatory role for the R(+) enantiomer of propranolol in modulating lipid accumulation in HemSC. This highlights a novel role of R(+) propranolol in the involuting phase of IH and a strategy to reduce fibrofatty residua in IH.

What is already known about this topic?

Propranolol is the mainstay treatment for infantile hemangioma (IH), the most common tumor of infancy, but its use can be associated with concerning β-blocker side effects.R(+) propranolol, the enantiomer largely devoid of β-blocker activity, was recently shown to inhibit endothelial differentiation of hemangioma-derived stem cells (HemSC) in vitro and reduce blood vessel formation in a HemSC-derived xenograft murine model of IH.

What does this study add?

R(+) propranolol inhibits lipid accumulation in HemSC in vitro.R(+) propranolol does not affect mRNA transcript levels of key adipogenic transcription factors in differentiating HemSC in vitro.R(+) propranolol reduces lipid accumulation in a pre-clinical xenograft murine model of IH.

What is the translational message?

The R(+) enantiomer of propranolol could be advantageous in terms of reduction in β-adrenergic side effects and fibrofatty tissue formation in the involuting phase of IH.Less fibrofatty residua might reduce the need for surgical resection.Disfigurement and associated psychosocial impacts might be improved in this young patient cohort.

Regimen for accelerated propranolol initial dosing (RAPID)

BACKGROUND

Infantile hemangiomas are common vascular tumors in children. Propranolol has proven effective in treating infantile hemangiomas and while generally safe, has potential risk for more serious side effects of hypoglycemia, hypotension, bradycardia, bronchospasm, and cardiovascular or respiratory compromise. Current prescribing guidelines recommend initiating propranolol doses at 1 mg/kg/day, with up-titration to 2 mg/kg/day. This study aims to compare the incidence of adverse events in infants and children treated with propranolol initiated at 1 mg/kg/day versus being initiated directly at 2 mg/kg/day.

METHODS

A retrospective cohort study was conducted using medical records of patients receiving propranolol therapy for infantile hemangiomas between October 2018-March 2021 at the Children's Hospital of Philadelphia. Patients were categorized by initial propranolol dosage: 1 or 2 mg/kg/day. The primary outcome measures included parent-reported adverse events, hypotension (defined by the Pediatric Advanced Life Support criteria), and bradycardia (defined as <1st percentile for age) following propranolol initiation.

RESULTS

Out of the 244 patients identified, 123 were initiated at the 1 mg/kg/day dose, and 121 at the 2 mg/kg/day dose. There was no significant difference in the incidence of adverse events between the two groups (p = .057). Additionally, among patients initiated at 2 mg/kg/day, there were no significant differences in the incidence of age-related or weight-related adverse events for those younger than 2 months or those in the 1st or 2nd quartile for weight (p = .53).

CONCLUSION

Infants and children initiated at 2 mg/kg/day did not demonstrate an increased incidence of adverse events associated with propranolol compared to those initiated at 1 mg/kg/day. These findings provide clinical evidence for the practice of accelerated propranolol initiation dosing.

Treatment of telangiectasias with a 595-nm pulsed dye laser following hemangioma involution: a retrospective analysis

Telangiectasias are the most frequent type of sequelae of infantile hemangiomas after involution. Few studies have reported the treatment of telangiectasias with 595-nm pulsed dye lasers. Therefore, the objective of this study was to assess the efficacy and safety of a 595-nm pulsed dye laser for treating residual telangiectasias following hemangioma involution. This is a retrospective case series that analyzes the medical records and reviews the charts of 22 patients who had undergone 595-nm pulsed dye laser treatment for residual telangiectasias. Pre- and post-treatment digital images were independently assessed, and the changes were scored to ascertain the efficacy of the treatment (0 = no change, 4 = complete improvement). Of the 22 patients, 59.1% experienced complete resolution of telangiectasias following treatment. No serious complications or side effects were reported. The observations indicate that the 595-nm pulsed dye laser is effective and safe for treating residual telangiectasias following hemangioma involution.

Practical surgical technique using the SMISS approach for lip reduction in involuted lip infantile hemangiomas

BACKGROUND

Lip infantile hemangiomas tend to show less volumetric regression and are more susceptible to visible sequelae in the involuted stage. Some of them still require surgical management after propranolol therapy. This study aimed to evaluate the efficacy and safety of the Stepwise, Multi-Incisional, and Single-Stage (SMISS) approach applied to lip reduction for those with involuted lip hemangiomas.

METHODS

A retrospective review was performed to evaluate patients with lip hemangioma who received previous propranolol treatment and underwent the aforementioned procedure. Demographic characteristics, lesion morphology, and medical history were reviewed. The Visual Analog Scale was applied to assess the postoperative appearance. Complications within 12 months postoperatively were recorded.

RESULTS

A total of 18 patients with lip hemangioma were eligible. All patients received oral propranolol therapy before surgery, with treatment duration ranging from 6.0 to 23.0 months. Their age at surgery ranged from 2.5 to 9.0 years. The median Visual Analog Scale scores were 8.0, ranging from 4.0 to 10.0. No severe complications were reported.

CONCLUSIONS

This modified technique based on the SMISS approach has proven reliable and effective in improving the aesthetic outcome for involuted lip infantile hemangiomas. Practical surgical techniques still play an important part in the propranolol era.

Knowledge of community pharmacists on infantile haemangioma: Gaps and lack confidence to deliver propranolol still need to be filled

AIM

To evaluate the knowledge, practices and self-confidence of community pharmacists, pharmacy technicians and pharmacy students about infantile haemangioma (IH) and propranolol treatment.

METHODS

A national survey was conducted in France from May 2022 to October 2022. A 42-item online questionnaire was used to assess pharmacists' knowledge of the epidemiology, clinical features and management of IH and propranolol treatment.

RESULTS

The survey included 255 participants. The mean age was 34.9 years (±9.0); 225 (88%) were women. In all, 193 (76%) practised in urban pharmacies. Altogether, 83 participants (33%) had delivered oral propranolol solution for IH in the last 6 months. Participants' median score for self-confidence regarding propranolol dispensing was five (interquartile range, 2.5-6) on a scale of 1 to 10. Overall, 96 (38%) had more than 50% correct answers on the questionnaire. Multinomial regression models showed high scores on the questionnaire associated with high self-confidence when delivering oral propranolol solution, low number of years since graduation and having already delivered propranolol treatment.

CONCLUSION

This study highlights a lack of knowledge of IH and modalities of propranolol treatment by community pharmacists and slight self-confidence when delivering propranolol. Greater cooperation between healthcare professionals could improve the proper use of medicine.

Drug repurposing for cancer therapy

Cancer, a complex and multifactorial disease, presents a significant challenge to global health. Despite significant advances in surgical, radiotherapeutic and immunological approaches, which have improved cancer treatment outcomes, drug therapy continues to serve as a key therapeutic strategy. However, the clinical efficacy of drug therapy is often constrained by drug resistance and severe toxic side effects, and thus there remains a critical need to develop novel cancer therapeutics. One promising strategy that has received widespread attention in recent years is drug repurposing: the identification of new applications for existing, clinically approved drugs. Drug repurposing possesses several inherent advantages in the context of cancer treatment since repurposed drugs are typically cost-effective, proven to be safe, and can significantly expedite the drug development process due to their already established safety profiles. In light of this, the present review offers a comprehensive overview of the various methods employed in drug repurposing, specifically focusing on the repurposing of drugs to treat cancer. We describe the antitumor properties of candidate drugs, and discuss in detail how they target both the hallmarks of cancer in tumor cells and the surrounding tumor microenvironment. In addition, we examine the innovative strategy of integrating drug repurposing with nanotechnology to enhance topical drug delivery. We also emphasize the critical role that repurposed drugs can play when used as part of a combination therapy regimen. To conclude, we outline the challenges associated with repurposing drugs and consider the future prospects of these repurposed drugs transitioning into clinical application.

Infantile hemangioma: the common and enigmatic vascular tumor

Infantile hemangioma (IH) is a benign vascular tumor that occurs in 5% of newborns. The tumor follows a life cycle of rapid proliferation in infancy, followed by slow involution in childhood. This unique life cycle has attracted the interest of basic and clinical scientists alike as a paradigm for vasculogenesis, angiogenesis, and vascular regression. Unanswered questions persist about the genetic and molecular drivers of the proliferating and involuting phases. The beta blocker propranolol usually accelerates regression of problematic IHs, yet its mechanism of action on vascular proliferation and differentiation is unclear. Some IHs fail to respond to beta blockers and regrow after discontinuation. Side effects occur and long-term sequelae of propranolol treatment are unknown. This poses clinical challenges and raises novel questions about the mechanisms of vascular overgrowth in IH.

Infantile Hemangiomas and Vascular Anomalies

Vascular anomalies represent a diverse group of disorders of abnormal vascular development or proliferation. Vascular anomalies are classified as vascular tumors and vascular malformations. Significant advances have been made in the understanding of the pathogenesis, natural history, and genetics of vascular anomalies, allowing for improvements in management including targeted molecular therapies. Infantile hemangiomas are the most common vascular tumor of childhood and follow a distinct natural history of proliferation and involution. Although benign, infantile hemangiomas can be associated with important complications. The use of beta-blockers has revolutionized the management of infantile hemangiomas. Other vascular tumors include pyogenic granulomas, congenital hemangiomas, and kaposiform hemangioendotheliomas, among others. Vascular malformations are categorized based on the type of involved vessel, including capillary malformations, venous malformations, lymphatic malformations, arteriovenous malformations, and mixed vascular malformations. Expert multidisciplinary management of vascular anomalies is critical to optimize outcomes in these patients. [Pediatr Ann. 2024;53(4):e129-e137.].

Pediatric Beta Blocker Therapy: A Comprehensive Review of Development and Genetic Variation to Guide Precision-Based Therapy in Children, Adolescents, and Young Adults

Beta adrenergic receptor antagonists, known as beta blockers, are one of the most prescribed medications in both pediatric and adult cardiology. Unfortunately, most of these agents utilized in the pediatric clinical setting are prescribed off-label. Despite regulatory efforts aimed at increasing pediatric drug labeling, a majority of pediatric cardiovascular drug agents continue to lack pediatric-specific data to inform precision dosing for children, adolescents, and young adults. Adding to this complexity is the contribution of development (ontogeny) and genetic variation towards the variability in drug disposition and response. In the absence of current prospective trials, the purpose of this comprehensive review is to illustrate the current knowledge gaps regarding the key drivers of variability in beta blocker drug disposition and response and the opportunities for investigations that will lead to changes in pediatric drug labeling.

An endothelial SOX18-mevalonate pathway axis enables repurposing of statins for infantile hemangioma

Infantile hemangioma (IH) is the most common tumor in children and a paradigm for pathological vasculogenesis, angiogenesis and regression. Propranolol is the mainstay of treatment for IH. It inhibits hemangioma vessel formation via a β-adrenergic receptor independent off-target effect of its R(+) enantiomer on the endothelial specific transcription factor sex-determining region Y (SRY) box transcription factor 18 (SOX18). Transcriptomic profiling of patient-derived hemangioma stem cells uncovered the mevalonate pathway (MVP) as a target of R(+) propranolol. Loss of SOX18 function confirmed R(+) propranolol mode of action on the MVP. Functional validation in preclinical IH models revealed that statins - targeting the MVP - are potent inhibitors of hemangioma vessel formation. We propose a novel SOX18-MVP-axis as a central regulator of IH pathogenesis and suggest statin repurposing to treat IH. Our findings reveal novel pleiotropic effects of beta-blockers and statins acting on the SOX18-MVP axis to disable an endothelial specific program in IH, which may impact other scenarios involving pathological vasculogenesis and angiogenesis.

Graphical abstract

Historical and contemporary management of infantile hemangiomas: a single-center experience

Objective: This study explores the 22-year evolution of Infantile Hemangiomas (IHs) treatment strategies at a single-center hospital, aiming to establish an individualized IHs management protocol. Methods: Retrospective review of IHs infants 2000-2022 at the Department of Plastic Surgery, Jiangxi Provincial Children's Hospital. Results: In our study of 27,513 IHs cases, 72.2% were female, with the median age at first hospital visit being 25 days. The majority of cases had localized and superficial lesions primarily on the head, face, and neck (67.5%). Ulceration rates fell from 21.1% to 12.6% with the introduction of propranolol. Management strategies have shifted over time, with the proportion of cases undergoing expectant management dropping from 32.9% to 12.4%. Since 2008, 26.1% of patients were treated with oral propranolol, largely replacing corticosteroids. Topical β-blockers have been used in 12.1% of cases, leading to a reduction in local injection therapy from 20.8% to 13.2%. Laser therapy, introduced in 2016, has been used in 13.8% of cases, while surgical excision has dropped from 25.0% to 8.5% due to alternative treatment options. Combination therapy was used in 8.8% of cases post-2015, indicating a rising trend. Drawing from the evolution of IHs management strategies, an individualized protocol for the management of IHs was successfully established. Conclusion: Treatment for IHs has evolved over recent decades, with less invasive medical interventions increasingly replacing more invasive methods. Furthermore, a personalized treatment protocol established in this study could boost the cure rate of IHs while minimizing potential side effects and complications.