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Sharma A, Gupta M, Mahajan R. Infantile hemangiomas: a dermatologist's perspective. Eur J Pediatr 2024:10.1007/s00431-024-05655-8. [PMID: 39052139 DOI: 10.1007/s00431-024-05655-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 05/31/2024] [Accepted: 06/15/2024] [Indexed: 07/27/2024]
Abstract
Infantile hemangioma (IH), the most common vascular tumor in pediatrics, is thought to arise from aberrant stem cell responses to stimuli such as hypoxia. This review explores the diverse manifestations, complications, and management strategies for IH, emphasizing the importance of a multidisciplinary approach. The epidemiology and risk factors associated with IH, including connections to prematurity, low birth weight, and family background, are discussed. The intricate pathogenesis involving hemangioma stem cells, KIAA1429, hypoxia, and the renin-angiotensin system is examined. The natural history and clinical features, as well as extracutaneous involvements such as hepatic IH, PHACES syndrome, and LUMBAR syndrome, are detailed. Complications such as ulceration, functional impairment, hypothyroidism, and cosmetic concerns are highlighted. The differential diagnosis and diagnostic modalities, including colorimeters, high-frequency ultrasonography, and imaging techniques, are discussed. Management approaches, including the use of propranolol, atenolol, corticosteroids, alternative systemic treatments, topical therapy, laser therapy, and surgery, are comprehensively reviewed. The evolving landscape of IH management is underscored, with ongoing research exploring alternative treatments and individualized approaches based on IH characteristics.
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Affiliation(s)
- Apoorva Sharma
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Manavi Gupta
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Rahul Mahajan
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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2
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Gatts J, Chandra S, Krishnan D, Ricci K. Medical Management of Nonmalignant Vascular Tumors of the Head and Neck: Part 1. Oral Maxillofac Surg Clin North Am 2024; 36:103-113. [PMID: 37875385 DOI: 10.1016/j.coms.2023.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Vascular anomalies, broadly classified as nonmalignant tumors and malformations, consist of a multitude of disorders that have a wide range of symptoms and complications as well as overlapping clinical, radiologic, and histologic findings. Although usually difficult, distinguishing between nonmalignant vascular tumors and malformations, as well as the precise diagnosis within these distinctions, is critical because prognosis, therapy, and chronicity of care vary greatly. In contrast to normal endothelial turnover in vascular malformations, vascular tumors are characterized by the abnormal proliferation of endothelial cells and aberrant blood vessels.
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Affiliation(s)
- Jorie Gatts
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA
| | - Srinivasa Chandra
- Department of Oral and Maxillofacial Surgery-Head and Neck Oncology and Microvascular Reconstruction, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Deepak Krishnan
- Department of Surgery, Section of Oral & Maxillofacial Surgery, University of Cincinnati, 200 Albert Sabin Way, ML 0461, Cincinnati, OH 45219, USA; University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kiersten Ricci
- Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7015, Cincinnati, OH 45229, USA; University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA.
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3
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Dahan E, Abou Jaoude L. Infantile Hemangiomas: A Review of Current Treatment Options. Pediatr Ann 2023; 52:e192-e197. [PMID: 37159066 DOI: 10.3928/19382359-20230307-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
This literature review outlines the current pathogenesis, clinical features, and complications of infantile hemangiomas and explores the current treatment modalities, including corticosteroids, surgery, pulsed dye laser, and beta-blockers. Although oftentimes benign, these lesions can potentially lead to physical or cosmetic disfigurement in growing children. The issue of depth and location-dependent treatment for infantile hemangiomas is explored as it reveals which treatments are correlated with better outcomes in specific presentations. For example, beta-blockers were found to be an effective first-line treatment for superficial infantile hemangiomas specifically, whereas the pulsed dye laser procedure was shown to be an effective option for deep hemangiomas, speeding up the involution process when combined with other treatment modalities and reducing scarring in ulcerated hemangiomas. Although the various infantile hemangioma treatment modalities available are appropriately tailored to specific cases of hemangiomas, they are also not without significant, sometimes life-threatening complications. This is why this literature review aims to outline the therapeutic benefits and risks of all treatment modalities to aid in the establishment of optimal case-dependent treatments. [Pediatr Ann. 2023;52(5):192-197.].
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Xu W, Zhao H. Management of infantile hemangiomas: Recent advances. Front Oncol 2022; 12:1064048. [PMID: 36523969 PMCID: PMC9745076 DOI: 10.3389/fonc.2022.1064048] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/10/2022] [Indexed: 11/30/2022] Open
Abstract
Infantile hemangiomas (IHs) are benign vascular tumors commonly observed in children. A small number of cases can manifest as organ or system dysfunction, permanent scarring, or even disfigurement. Currently, diagnosis is mainly based on clinical history, physical examination, and auxiliary inspection. In the treatment of a hemangioma, the functional damage caused by the lesion and complications that may endanger the patient’s life should be given priority. This suggests that identification, diagnosis, and referral to specialists during the early stages of IHs are important factors in preventing related complications and obtaining a better prognosis. During the past few decades, researchers have explored different treatments according to the condition, including oral or topical drugs, topical drug injections, laser surgery, and surgical treatment. However, oral propranolol remains a well-accepted first-line treatment. This article will primarily focus on the recent advances in the clinical diagnosis and treatment of hemangiomas, along with a literature review on the subject.
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Pattanshetti SA, Mahalmani VM, Sarma P, Kaur H, Ali MM, Malik MA, Peters NJ, Prajapat M, Kumar S, Medhi B, Samujh R. Oral Atenolol versus Propranolol in the Treatment of Infantile Hemangioma: A Systematic Review and Meta-Analysis. J Indian Assoc Pediatr Surg 2022; 27:279-286. [PMID: 35733601 PMCID: PMC9208683 DOI: 10.4103/jiaps.jiaps_3_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 05/23/2021] [Accepted: 07/22/2021] [Indexed: 11/04/2022] Open
Abstract
Background Infantile hemangioma (IH) is the most common benign vascular tumor of infancy. Propranolol is considered first-line therapy for IH. However, it is associated with side effects. Therefore, there was a need for alternative therapy. Atenolol, a selective b1-blocker may be free from such side effects. Hence, the present study aims to develop a more accurate estimate of the safety and efficacy of atenolol compared to propranolol in the treatment of IH. Methodology A search of various literature databases (PubMed, Embase, Ovid, Scopus, Cochrane Central, CINAHL, Web of Science, and Google Scholar) was done to identify studies which compared propranolol versus atenolol in the treatment of IH. The combined odds ratio along with corresponding 95% confidence intervals (CIs) were evaluated using a fixed-effects model. Results A total of 300 articles were screened of which five studies including 116 patients in atenolol arm and 138 patients in the propranolol arm were analyzed. Atenolol was comparable to propranolol in terms of efficacy as no significant difference was seen between both the treatment arms in terms of hemangioma activity score (mean difference 0.25 [95% CI;‒0.21, 0.71]) and complete response (odds ratio [OR] =0.43; 95% CI; 0.17, 1.11; P = 0.08,). Atenolol therapy was better than propranolol in terms of safety, i.e., serious/potentially serious side effect, (OR = 0.11; 95% CI; 0.02, 0.51; P = 0.005) and wheezing/bronchial hyperreactivity (OR = 0.11; 95% CI; 0.02, 0.51; P = 0.005). Conclusion The present meta-analysis provides evidence that atenolol has got a comparable efficacy and better safety profile with propranolol.
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Affiliation(s)
- Swapnil Annasaheb Pattanshetti
- Department of Paediatric Surgery, PGIMER, Chandigarh, India,Department of Pediatric Surgery, J.N. Medical College, Belgavi, Karnataka, India
| | - Vidya M Mahalmani
- Department of Pharmacology, PGIMER, Chandigarh, India,Department of Pharmacology, J.N. Medical College, Belgavi, Karnataka, India
| | - Phulen Sarma
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Hardeep Kaur
- Department of Pharmacology, PGIMER, Chandigarh, India
| | | | | | | | | | - Subodh Kumar
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Bikash Medhi
- Department of Pharmacology, PGIMER, Chandigarh, India
| | - Ram Samujh
- Department of Paediatric Surgery, PGIMER, Chandigarh, India,Address for correspondence: Dr. Ram Samujh, Department of Pediatric Surgery, PGIMER, Chandigarh, India. E-mail:
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Abstract
Infantile hemangioma (IH) is the most common benign vascular tumor of infancy, affecting about 5% of infants. It has a characteristic growth pattern of early rapid proliferation followed by progressive involution. Although most IH evolve favorably, complications are observed in 10-15% of cases, justifying treatment. For over 10 years now, propranolol has become the first-line therapy for complicated IH, revolutionizing their management and their prognosis. In this article, we review the clinical features, associations, complications/sequelae and therapeutic approaches for IH, focusing on current medical therapy. Indications for treatment and various treatment options, including propranolol and other oral β-blockers, topical timolol, and corticosteroids are presented. Current controversies regarding oral propranolol such as pre-treatment screening, in- vs out-patient initiation of treatment, early and potential long-term side effects and recommended monitoring are discussed.
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Affiliation(s)
- Caroline Colmant
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada.
| | - Julie Powell
- Division of Pediatric Dermatology, Department of Pediatrics, Sainte-Justine University Hospital Center, University of Montreal, Montreal, QC, Canada
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Seebauer CT, Graus MS, Huang L, McCann AJ, Wylie-Sears J, Fontaine FR, Karnezis T, Zurakowski D, Staffa SJ, Meunier FA, Mulliken JB, Bischoff J, Francois M. Non-β-blocker enantiomers of propranolol and atenolol inhibit vasculogenesis in infantile hemangioma. J Clin Invest 2021; 132:151109. [PMID: 34874911 PMCID: PMC8803322 DOI: 10.1172/jci151109] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
Propranolol and atenolol, current therapies for problematic infantile hemangioma (IH), are composed of R(+) and S(–) enantiomers: the R(+) enantiomer is largely devoid of beta blocker activity. We investigated the effect of R(+) enantiomers of propranolol and atenolol on the formation of IH-like blood vessels from hemangioma stem cells (HemSCs) in a murine xenograft model. Both R(+) enantiomers inhibited HemSC vessel formation in vivo. In vitro, similar to R(+) propranolol, both atenolol and its R(+) enantiomer inhibited HemSC to endothelial cell differentiation. As our previous work implicated the transcription factor sex-determining region Y (SRY) box transcription factor 18 (SOX18) in propranolol-mediated inhibition of HemSC to endothelial differentiation, we tested in parallel a known SOX18 small-molecule inhibitor (Sm4) and show that this compound inhibited HemSC vessel formation in vivo with efficacy similar to that seen with the R(+) enantiomers. We next examined how R(+) propranolol alters SOX18 transcriptional activity. Using a suite of biochemical, biophysical, and quantitative molecular imaging assays, we show that R(+) propranolol directly interfered with SOX18 target gene trans-activation, disrupted SOX18-chromatin binding dynamics, and reduced SOX18 dimer formation. We propose that the R(+) enantiomers of widely used beta blockers could be repurposed to increase the efficiency of current IH treatment and lower adverse associated side effects.
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Affiliation(s)
- Caroline T Seebauer
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, United States of America
| | - Matthew S Graus
- David Richmond Laboratory for Cardiovascular Development, University of Sydney, Sydney, Australia
| | - Lan Huang
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, United States of America
| | - Alex J McCann
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Jill Wylie-Sears
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, United States of America
| | - Frank R Fontaine
- Gertrude Biomedical, Gertrude Biomedical Pty Ltd, Melbourne, Australia
| | - Tara Karnezis
- Gertrude Biomedical, Gertrude Biomedical Pty Ltd, Melbourne, Australia
| | - David Zurakowski
- Department of Anesthesiology, Boston Children's Hospital and Harvard Medical School, Boston, United States of America
| | - Steven J Staffa
- Department of Anesthesiology, Boston Children's Hospital and Harvard Medical School, Boston, United States of America
| | - Frédéric A Meunier
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - John B Mulliken
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, United States of America
| | - Joyce Bischoff
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, United States of America
| | - Mathias Francois
- David Richmond Laboratory for Cardiovascular Development, University of Sydney, Sydney, Australia
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Koh SP, Leadbitter P, Smithers F, Tan ST. β-blocker therapy for infantile hemangioma. Expert Rev Clin Pharmacol 2021; 13:899-915. [PMID: 32662682 DOI: 10.1080/17512433.2020.1788938] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Fifteen percent of proliferating infantile hemangioma (IH) require intervention because of the threat to function or life, ulceration, or tissue distortion. Propranolol is the mainstay treatment for problematic proliferating IH. Other β-blockers and angiotensin-converting enzyme (ACE) inhibitors have been explored as alternative treatments. AREAS COVERED The demonstration of a hemogenic endothelium origin of IH, with a neural crest phenotype and multi-lineage differentiation capacity, regulated by the renin-angiotensin system, underscores its programmed biologic behavior and accelerated involution induced by propranolol, other β-blockers and ACE inhibitors. We review the indications, dosing regimens, duration of treatment, efficacy and adverse effects of propranolol, and therapeutic alternatives including oral atenolol, acebutolol, nadolol, intralesional propranolol injections, topical propranolol and timolol, and oral captopril. EXPERT OPINION Improved understanding of the biology of IH provides insights into the mechanism of action underscoring its accelerated involution induced by propranolol, other β-blockers and ACE inhibitors. More research is required to understand the optimal dosing and duration, efficacy and safety of these alternative therapies. Recent demonstration of propranolol's actions mediated by non-β-adrenergic isomer R-propranolol on stem cells, offers an immense opportunity to harness the efficacy of β-blockers to induce accelerated involution of IH, while mitigating their β-adrenergic receptor-mediated adverse effects.
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Affiliation(s)
- Sabrina P Koh
- Gillies McIndoe Research Institute , Wellington, New Zealand
| | - Philip Leadbitter
- Gillies McIndoe Research Institute , Wellington, New Zealand.,Centre for the Study & Treatment for Vascular Birthmarks, Wellington Regional Plastic, Maxillofacial and Burns Unit, Hutt Hospital , Wellington, New Zealand.,Department of Paediatrics, Hutt Hospital , Wellington, New Zealand
| | - Fiona Smithers
- Centre for the Study & Treatment for Vascular Birthmarks, Wellington Regional Plastic, Maxillofacial and Burns Unit, Hutt Hospital , Wellington, New Zealand
| | - Swee T Tan
- Gillies McIndoe Research Institute , Wellington, New Zealand.,Centre for the Study & Treatment for Vascular Birthmarks, Wellington Regional Plastic, Maxillofacial and Burns Unit, Hutt Hospital , Wellington, New Zealand.,Department of Surgery, The University of Melbourne , Parkville, Victoria, Australia
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Leung AKC, Lam JM, Leong KF, Hon KL. Infantile Hemangioma: An Updated Review. Curr Pediatr Rev 2021; 17:55-69. [PMID: 32384034 DOI: 10.2174/1573396316666200508100038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/20/2020] [Accepted: 03/20/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Infantile hemangiomas are the most common vascular tumors of infancy, affecting up to 12% of infants by the first year of life. OBJECTIVE To familiarize physicians with the natural history, clinical manifestations, diagnosis, and management of infantile hemangiomas. METHODS A Pubmed search was conducted in November 2019 in Clinical Queries using the key term "infantile hemangioma". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews published within the past 20 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article. RESULTS The majority of infantile hemangiomas are not present at birth. They often appear in the first few weeks of life as areas of pallor, followed by telangiectatic or faint red patches. Then, they grow rapidly in the first 3 to 6 months of life. Superficial lesions are bright red, protuberant, bosselated, or with a smooth surface, and sharply demarcated. Deep lesions are bluish and dome-shaped. Infantile hemangiomas continue to grow until 9 to 12 months of age, at which time the growth rate slows down to parallel the growth of the child. Involution typically begins by the time the child is a year old. Approximately 50% of infantile hemangiomas will show complete involution by the time a child reaches age 5; 70% will have disappeared by age 7; and 95% will have regressed by 10 to 12 years of age. The majority of infantile hemangiomas require no treatment. Treatment options include oral propranolol, topical timolol, and oral corticosteroids. Indications for active intervention include hemorrhage unresponsive to treatment, impending ulceration in areas where serious complications might ensue, interference with vital structures, life- or function-threatening complications, and significant disfigurement. CONCLUSION Treatment should be individualized, depending upon the size, rate of growth, morphology, number, and location of the lesion (s), existing or potential complications, benefits and adverse events associated with the treatment, age of the patient, level of parental concern, and the physician's comfort level with the various treatment options. Currently, oral propranolol is the treatment of choice for high-risk and complicated infantile hemangiomas. Topical timolol may be considered for superficial infantile hemangiomas that need to be treated and for complicated infantile hemangiomas in patients at risk for severe adverse events from oral administration of propranolol.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia
| | - Kam L Hon
- Department of Paediatrics, The Chinese University of Hong Kong, and Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
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10
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Nutzen und Risiken sorgsam abwägen. DER DEUTSCHE DERMATOLOGE 2020. [PMCID: PMC7653979 DOI: 10.1007/s15011-020-3341-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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11
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Treatment of haemangiomas using propranolol in paediatric patients: a retrospective cohort study. Postepy Dermatol Alergol 2020; 37:603-607. [PMID: 32994786 PMCID: PMC7507162 DOI: 10.5114/ada.2020.98282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 06/03/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Haemangioma, one of the most common benign neoplasms of early childhood, is a significant clinical problem due to cosmetic reasons but also because of possible health complications. Aim Presentation of the method and results of treatment of infantile haemangiomas (IHs) using propranolol in a maximum dose of 3 mg/kg/day. Material and methods In 2013 to 2018 there were 108 patients with IHs multidisciplinary diagnosed and treated. 77 of them were girls and 31 were boys; all were between the ages of 2 and 21 months (mean: 6.87 months). Lesions were most often located in the head region (n = 73). The main imaging study assessing the arteriovenous flow was USG, which was used to assess the size of haemangioma and its regression or progression. Also, coagulation parameters were analysed using laboratory tests. Results Reduction of lesions occurred in 103 of 108 patients, which results in a percentage score above 95. In 19 patients, after completion of treatment, there were abnormalities of coagulation in laboratory tests whereas before the treatment, these abnormalities occurred in 82 patients. The average duration of treatment was longer than 12 months and the maximum dose of propranolol of 3 mg/kg/day was achieved after 3 to 5 months of treatment. Side effects occurred totally in 19 patients, with night anxiety and nightmares being the most common. Conclusions After achieving the maximum dose of the drug later than recommended in the Recommendation of the Polish Haemangioma and Vascular Malformations Group criteria, there was no need for longer therapy, while the effectiveness of the treatment remained unchanged. Side effects that occurred were not life-threatening or detrimental to the health of patients.
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Calderón-Castrat X, Velásquez F, Castro R, Ballona R. Oral atenolol for infantile hemangioma: case series of 46 infants. ACTAS DERMO-SIFILIOGRAFICAS 2020. [DOI: 10.1016/j.adengl.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Calderón-Castrat X, Castro R, Casamayor E, Zavala K. Phaces syndrome successfully treated with oral atenolol. Int J Dermatol 2019; 59:e115-e118. [PMID: 31755548 DOI: 10.1111/ijd.14618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/27/2019] [Accepted: 08/09/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Ximena Calderón-Castrat
- Pediatric Dermatology Department, Instituto Nacional de Salud del Niño, San Borja, Peru.,Vascular Anomalies Unit, Instituto Nacional de Salud del Niño, San Borja, Peru.,Pediatric Radiology Department, Instituto Nacional de Salud del Niño, San Borja, Peru
| | - Rosa Castro
- Pediatric Dermatology Department, Instituto Nacional de Salud del Niño, San Borja, Peru.,Vascular Anomalies Unit, Instituto Nacional de Salud del Niño, San Borja, Peru
| | - Elena Casamayor
- Vascular Anomalies Unit, Instituto Nacional de Salud del Niño, San Borja, Peru.,Dermatology Department, IMED-ELCHE Hospital, Alicante, Spain
| | - Karem Zavala
- Pediatric Dermatology Department, Instituto Nacional de Salud del Niño, San Borja, Peru
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14
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Calderón-Castrat X, Velásquez F, Castro R, Ballona R. Oral Atenolol for Infantile Hemangioma: Case Series of 46 Infants. ACTAS DERMO-SIFILIOGRAFICAS 2019; 111:59-62. [PMID: 31759456 DOI: 10.1016/j.ad.2019.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 02/11/2019] [Accepted: 03/03/2019] [Indexed: 01/26/2023] Open
Abstract
Propranolol, a non-selective beta-blocker, remains the first line of treatment for problematic infantile hemangioma. However, although rarely, a subset of patients experience undesirable side effects, raising interest in other selective beta-blockers. We present a large case series of 46 infants treated successfully with oral atenolol, a selective beta-1 blocker.
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Affiliation(s)
- X Calderón-Castrat
- Unidad de Anomalías Vasculares, Servicio de Dermatología Pediátrica, Instituto Nacional de Salud del Niño, San Borja, Perú.
| | - F Velásquez
- Servicio de Dermatología Pediátrica, Instituto Nacional de Salud del Niño, Breña, Perú
| | - R Castro
- Unidad de Anomalías Vasculares, Servicio de Dermatología Pediátrica, Instituto Nacional de Salud del Niño, San Borja, Perú
| | - R Ballona
- Servicio de Dermatología Pediátrica, Instituto Nacional de Salud del Niño, Breña, Perú
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15
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Chen ZY, Wang QN, Zhu YH, Zhou LY, Xu T, He ZY, Yang Y. Progress in the treatment of infantile hemangioma. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:692. [PMID: 31930093 PMCID: PMC6944559 DOI: 10.21037/atm.2019.10.47] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023]
Abstract
Infantile hemangioma (IH) is a common benign tumor, which mostly resolves spontaneously; however, children with high-risk IH need treatment. Currently, the recognized first-line treatment regimen for IH is oral propranolol, but research on the pathogenesis of IH has led to the identification of new therapeutic targets, which have shown good curative effects, providing more options for disease treatment. This article summarizes the applications of different medications, dosages, and routes of administration for the treatment of IH. In addition to drug therapy, this article also reviews current therapeutic options for IH such as laser therapy, surgical treatment, and observation. To provide the best treatment, therapeutic regimens for IH should be selected based on the child's age, the size and location of the lesion, the presence of complications, the implementation conditions, and the potential outcomes of the treatment.
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Affiliation(s)
- Zhao-Yang Chen
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Qing-Nan Wang
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Yang-Hui Zhu
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Ling-Yan Zhou
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Ting Xu
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Zhi-Yao He
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
| | - Yang Yang
- Department of Pharmacy, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu 610041, China
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16
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Yang K, Peng S, Chen L, Chen S, Ji Y. Efficacy of propranolol treatment in infantile hepatic haemangioma. J Paediatr Child Health 2019; 55:1194-1200. [PMID: 30628130 DOI: 10.1111/jpc.14375] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 12/15/2018] [Accepted: 12/16/2018] [Indexed: 01/21/2023]
Abstract
AIM The aim of this study was to assess the efficacy of propranolol treatment in multifocal and diffuse infantile hepatic haemangioma (IHH). METHODS A retrospective study of symptomatic or potentially symptomatic IHH was performed in our hospital between 2011 and 2016. RESULTS Thirteen patients were identified: 2 patients had diffuse lesions, and 11 patients had multifocal lesions, including 2 patients who had combined lesions that shared features of both multifocal and diffuse lesion patterns. Eleven (84.6%) patients had cutaneous infantile haemangioma. Hepatomegaly was the predominant clinical presentation. Hypothyroidism was identified in three patients, including one patient who had documented congestive heart failure (CHF). The median age at diagnosis and the median duration of treatment were 2.0 months (range 1.2-26.0) and 24.0 months (range 4.0-30.0). The median duration of follow-up was 30.0 months (range 3.0-48.0). For patients with hypothyroidism, the thyroid hormone level was normal after 4 weeks of propranolol and levothyroxine treatment. All but one patient responded well to propranolol treatment. The patient who failed to respond to treatment died of CHF and abdominal compartment syndrome induced by hepatomegaly. No significant side effects of propranolol were observed during follow-up. CONCLUSIONS Most multifocal and diffuse IHH respond well to propranolol. However, progressive cases may be fatal despite aggressive treatments. Our data suggest that propranolol may be considered the first-line treatment for multifocal and diffuse IHH due to its efficacy.
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Affiliation(s)
- Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Suhua Peng
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Linwen Chen
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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17
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Gumina ME, Yan AC. Atenolol as an alternative to propranolol for the management of sleep disturbances in the treatment of infantile hemangiomas. Pediatr Dermatol 2019; 36:556-557. [PMID: 30983047 DOI: 10.1111/pde.13839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Infantile hemangiomas are the most common tumors of infancy and are often managed with oral beta-blockers to address or prevent associated complications. However, treatment with propranolol can occasionally be associated with sleep disturbances, which in some cases are severe enough to warrant discontinuation or replacement with another agent. We herein report four cases in which treatment with propranolol resulted in significant sleep disturbances prompting substitution with atenolol, which in some cases resolved these issues.
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Affiliation(s)
- Megan E Gumina
- Section of Dermatology, Division of General Pediatrics, Department of Pediatrics and Dermatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Albert C Yan
- Section of Dermatology, Division of General Pediatrics, Department of Pediatrics and Dermatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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18
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Abstract
Infantile hemangiomas (IH) are a common benign tumor of infancy, most being uncomplicated and not requiring therapy. Some IH may require treatment; the pediatric provider must be familiar with morphology, distribution, natural history, and associations of IH. Several treatment options are available for IH: current standard of care, oral propranolol. Other therapies include wound care; topical beta-blocker therapy for small, superficial, and uncomplicated IH; treatment of IH residua. In addition to functional compromise and other complications, potential for permanent deformity and eventual psychosocial stigmatization are important when considering the need for treatment of IH in a neonate or infant.
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19
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Satterfield KR, Chambers CB. Current treatment and management of infantile hemangiomas. Surv Ophthalmol 2019; 64:608-618. [PMID: 30772366 DOI: 10.1016/j.survophthal.2019.02.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 01/27/2019] [Accepted: 02/04/2019] [Indexed: 12/19/2022]
Abstract
Infantile hemangiomas, otherwise known as infantile capillary hemangiomas, strawberry hemangiomas, or strawberry nevi, are nonmalignant vascular tumors that commonly affect children. The natural disease course typically involves growth for up to a year, followed by regression without treatment over a period of years with no cosmetic or functional sequelae. Less commonly, however, infantile hemangiomas can become a threat to vision or even life depending on location and size of the lesion. In addition, infantile hemangiomas, particularly those involving the face, may be disfiguring and result in lifelong sequelae. β-blockers have become a mainstay of therapy given their relatively low-risk profile and efficacy. Other treatment modalities previously described in the literature include corticosteroids (both intralesional and systemic), imiquimod, vincristine, bleomycin A5, and interferon α. More recently, angiotensin-converting enzyme inhibitors such as captopril have been used. Laser therapy and, less commonly, surgical excision are also available treatment options. We review current recommended management and treatment of capillary hemangiomas and discuss the benefits and risks of all previously reported treatment modalities.
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Affiliation(s)
- Kellie R Satterfield
- Department of Medicine, Scripps Mercy Hospital, San Diego, California, USA; Department of Ophthalmology, University of Washington, Seattle, Washington DC, USA
| | - Christopher B Chambers
- Department of Ophthalmology, University of Washington, Seattle, Washington DC, USA; Department of Oculoplastic and Reconstructive Surgery, University of Washington, Seattle, Washington DC, USA.
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20
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Dakoutrou M, Alexopoulos A, Miligkos M, Georgiadou E, Kanaka-Gantenbein C, Kakourou T. Atenolol treatment for severe infantile hemangiomas: comparison with a propranolol group of our centre. J Eur Acad Dermatol Venereol 2019; 33:e199-e200. [PMID: 30707776 DOI: 10.1111/jdv.15464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- M Dakoutrou
- First Department of Pediatrics, University of Athens, "Aghia Sofia" Children's Hospital, Athens, Greece
| | - A Alexopoulos
- First Department of Pediatrics, University of Athens, "Aghia Sofia" Children's Hospital, Athens, Greece
| | - M Miligkos
- First Department of Pediatrics, University of Athens, "Aghia Sofia" Children's Hospital, Athens, Greece
| | - E Georgiadou
- First Department of Pediatrics, University of Athens, "Aghia Sofia" Children's Hospital, Athens, Greece
| | - C Kanaka-Gantenbein
- First Department of Pediatrics, University of Athens, "Aghia Sofia" Children's Hospital, Athens, Greece
| | - T Kakourou
- First Department of Pediatrics, University of Athens, "Aghia Sofia" Children's Hospital, Athens, Greece
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21
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Laurens C, Abot A, Delarue A, Knauf C. Central Effects of Beta-Blockers May Be Due to Nitric Oxide and Hydrogen Peroxide Release Independently of Their Ability to Cross the Blood-Brain Barrier. Front Neurosci 2019; 13:33. [PMID: 30766473 PMCID: PMC6365417 DOI: 10.3389/fnins.2019.00033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 01/15/2019] [Indexed: 01/29/2023] Open
Abstract
Propranolol is the first-line treatment for infants suffering from infantile hemangioma. Recently, some authors raised the question of potential neurologic side effects of propranolol due to its lipophilic nature and thus its ability to passively cross the blood-brain barrier (BBB) and accumulate into the brain. Hydrophilic beta-blockers, such as atenolol and nadolol, where therefore introduced in clinical practice. In addition to their classical mode of action in the brain, circulating factors may modulate the release of reactive oxygen/nitrogen species (ROS/RNS) from endothelial cells that compose the BBB without entering the brain. Due to their high capacity to diffuse across membranes, ROS/RNS can reach neurons and modify their activity. The aim of this study was to investigate other mechanisms of actions in which these molecules may display a central effect without actually crossing the BBB. We first performed an oral treatment in mice to measure the accumulation of propranolol, atenolol and nadolol in different brain regions in vivo. We then evaluated the ability of these molecules to induce the release of nitric oxide (NO) and hydrogen peroxide (H2O2) ex vivo in the hypothalamus. As expected, propranolol is able to cross the BBB and is found in brain tissue in higher amounts than atenolol and nadolol. However, all of these beta-blockers are able to induce the secretion of signaling molecules (i.e., NO and/or H2O2) in the hypothalamus, independently of their ability to cross the BBB, deciphering a new potential deleterious impact of hydrophilic beta-blockers in the brain.
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Affiliation(s)
| | - Anne Abot
- Enterosys SAS, Prologue Biotech, Toulouse, France
| | | | - Claude Knauf
- INSERM U1220 Institut de Recherche en Santé Digestive, CHU Purpan, Université Toulouse III Paul Sabatier, Toulouse, France
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22
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Krowchuk DP, Frieden IJ, Mancini AJ, Darrow DH, Blei F, Greene AK, Annam A, Baker CN, Frommelt PC, Hodak A, Pate BM, Pelletier JL, Sandrock D, Weinberg ST, Whelan MA. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics 2019; 143:peds.2018-3475. [PMID: 30584062 DOI: 10.1542/peds.2018-3475] [Citation(s) in RCA: 207] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Infantile hemangiomas (IHs) occur in as many as 5% of infants, making them the most common benign tumor of infancy. Most IHs are small, innocuous, self-resolving, and require no treatment. However, because of their size or location, a significant minority of IHs are potentially problematic. These include IHs that may cause permanent scarring and disfigurement (eg, facial IHs), hepatic or airway IHs, and IHs with the potential for functional impairment (eg, periorbital IHs), ulceration (that may cause pain or scarring), and associated underlying abnormalities (eg, intracranial and aortic arch vascular abnormalities accompanying a large facial IH). This clinical practice guideline for the management of IHs emphasizes several key concepts. It defines those IHs that are potentially higher risk and should prompt concern, and emphasizes increased vigilance, consideration of active treatment and, when appropriate, specialty consultation. It discusses the specific growth characteristics of IHs, that is, that the most rapid and significant growth occurs between 1 and 3 months of age and that growth is completed by 5 months of age in most cases. Because many IHs leave behind permanent skin changes, there is a window of opportunity to treat higher-risk IHs and optimize outcomes. Early intervention and/or referral (ideally by 1 month of age) is recommended for infants who have potentially problematic IHs. When systemic treatment is indicated, propranolol is the drug of choice at a dose of 2 to 3 mg/kg per day. Treatment typically is continued for at least 6 months and often is maintained until 12 months of age (occasionally longer). Topical timolol may be used to treat select small, thin, superficial IHs. Surgery and/or laser treatment are most useful for the treatment of residual skin changes after involution and, less commonly, may be considered earlier to treat some IHs.
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Affiliation(s)
- Daniel P Krowchuk
- Departments of Pediatrics and Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina;
| | - Ilona J Frieden
- Departments of Dermatology and Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | - Anthony J Mancini
- Departments of Pediatrics and Dermatology, Feinberg School of Medicine, Northwestern University and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David H Darrow
- Departments of Otolaryngology and Pediatrics, Eastern Virginia Medical School and Children's Hospital of the King's Daughters, Norfolk, Virginia
| | - Francine Blei
- Donald and Barbara Zucker School of Medicine, Northwell Health, New York City, New York
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Aparna Annam
- Department of Radiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Cynthia N Baker
- Department of Pediatrics, Kaiser Permanente Medical Center, Los Angeles, California
| | - Peter C Frommelt
- Department of Pediatrics, Cardiology, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Amy Hodak
- American Board of Pediatrics, Chapel Hill, North Carolina
| | - Brian M Pate
- Department of Pediatrics, University of Kansas School of Medicine-Wichita, Wichita, Kansas
| | | | - Deborah Sandrock
- St Christopher's Hospital for Children and College of Medicine, Drexel University, Philadelphia, Pennsylvania
| | - Stuart T Weinberg
- Departments of Biomedical Informatics and Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee; and
| | - Mary Anne Whelan
- College of Physicians and Surgeons, Columbia University, New York City, New York
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23
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Wang Q, Xiang B, Chen S, Ji Y. Efficacy and safety of oral atenolol for the treatment of infantile haemangioma: A systematic review. Australas J Dermatol 2018; 60:181-185. [PMID: 30515761 DOI: 10.1111/ajd.12966] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/10/2018] [Indexed: 02/05/2023]
Abstract
Recently, several studies have reported their experience in using oral atenolol in patients with infantile haemangioma (IH), especially as an alternative to propranolol, but the efficacy and safety of oral atenolol has not been evaluated. We searched PubMed (Medline), Central, Embase, Web of Science and EBSCOhost (until May 2018) for the eligible studies reporting more than 10 IH patients who were treated with oral atenolol with detailed original data, including outcomes, regimens and adverse events (AEs). The data was standardised and analysed by using R software with meta-package. A total of 9 of 141 identified articles, including 341 infantile haemangioma patients treated with oral atenolol therapy, were included. The pooled response rate of atenolol was 0.90 (95% CI: 0.85-0.93), and the rebound rate was 0.11 (95% CI: 0.08-0.16). Among the 341 patients, 44 patients were switched to atenolol therapy from propranolol due to adverse events. The response rate of subsequent atenolol treatment was 90.9% (40/44). Regarding AEs, 141 patients reported 177 episodes of AEs, and the pooled rate was 0.26 (95% CI: 0.12-0.47). Gastrointestinal symptoms (e.g. constipation, diarrhoea and vomiting) were the most frequent AEs (22.6%). Widely known propranolol-related AEs, including hypoglycaemia, bronchospasm, bradycardia and hypotension, were not recorded. Overall, atenolol appears to be an effective and safe therapy for the treatment of IH and may be a promising alternative to propranolol.
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Affiliation(s)
- Qi Wang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, China
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24
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Wang JY, Ighani A, Ayala AP, Akita S, Lara-Corrales I, Alavi A. Medical, Surgical, and Wound Care Management of Ulcerated Infantile Hemangiomas: A Systematic Review [Formula: see text]. J Cutan Med Surg 2018; 22:495-504. [PMID: 29673261 DOI: 10.1177/1203475418770570] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Ulcerated infantile hemangiomas may present a therapeutic challenge, especially if there is concurrent hemorrhage or infection. The aim of this study was to systematically review the published evidence on the treatment of ulcerated hemangiomas, focusing on wound healing as the outcome of interest. We searched MEDLINE, Embase, SCOPUS, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science from inception to July 2016. Seventy-seven studies met our inclusion criteria. One study was a randomized controlled trial, 30 were observational studies, and 46 were case reports or case series. There is significant heterogeneity among the methods used. We reviewed 1239 patients in total. Of the 197 treated with oral propranolol, 191 (97.0%) achieved complete ulcer healing. Thirty-one patients failed corticosteroid therapy (oral, intralesional, or topical) and were subsequently successfully treated with other therapies. Surgical resections were typically performed for larger hemangiomas and those causing complications. None of the therapies discussed appear to offer significant advantages over others. Therefore, treatment decisions should be individualized based on location of disease, extent, symptoms, feasibility, cost, and parental preference.
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Affiliation(s)
- Jane Y Wang
- 1 Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Arvin Ighani
- 1 Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ana P Ayala
- 2 Gerstein Science Information Centre, University of Toronto, Toronto, ON, Canada
| | - Sadanori Akita
- 3 Department of Plastic Surgery, Wound Repair and Regeneration, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Irene Lara-Corrales
- 4 Department of Pediatric Medicine, Section of Dermatology, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Afsaneh Alavi
- 5 Division of Dermatology, Women's College Hospital, University of Toronto, Toronto, ON, Canada
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25
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Intolerable side effects during propranolol therapy for infantile hemangioma: frequency, risk factors and management. Sci Rep 2018. [PMID: 29523832 PMCID: PMC5844887 DOI: 10.1038/s41598-018-22787-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Currently, propranolol is the most preferred systemic therapy for problematic infantile hemangiomas (IHs). However, the side effects such as bronchial hyperreactivity may be intolerable. The aim of this study was to evaluate the frequency, risk factors and management of intolerable side effects (ISEs) during propranolol therapy. In total, 1260 children were studied. The incidence of ISEs was 2.1% (26 patients). Severe sleep disturbance was the most common reason for propranolol cessation, accounting for 65.4% of cases. In total, 23 and 3 patients received atenolol and prednisolone as second-line therapy, respectively. Treatment response was observed in 92.3% (24/26) of cases (showing excellent or good response to therapy). No toxicity-related permanent treatment discontinuation occurred during atenolol or prednisolone therapy. In the univariate analysis, younger age, premature birth, and lower body weight were associated with ISEs (P < 0.05). In the multivariate analysis, only age (95% confidence interval [CI]: 1.201–2.793, P = 0.009) and body weight (95% CI: 1.036–1.972, P = 0.014) were associated with ISEs. Our study suggests that ISEs are rare in patients with IHs who are treated with propranolol. Predictive factors for ISEs include younger age and lower body weight. Atenolol and prednisolone are effective and safe alternatives to propranolol in the treatment of refractory IHs.
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26
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Adams DM, Ricci KW. Infantile Hemangiomas in the Head and Neck Region. Otolaryngol Clin North Am 2018; 51:77-87. [DOI: 10.1016/j.otc.2017.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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27
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Peng SH, Yang KY, Chen SY, Ji Y. [Research progresses in the pathogenesis, diagnosis and treatment of infantile hemangioma with PHACE syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1291-1296. [PMID: 29237532 PMCID: PMC7389804 DOI: 10.7499/j.issn.1008-8830.2017.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/27/2017] [Indexed: 06/07/2023]
Abstract
Infant hemangioma, the most common benign tumor in children, is characterized by rapid proliferation, followed by slower spontaneous involution. However, some patients with facial segmental hemangioma are associated with PHACE syndrome. PHACE syndrome is characterized by vascular nerve and vascular cutaneous lesions of multiple systemic systems, often resulting in structural and functional impairments. Recent studies have demonstrated that the possible pathogeneses of PHACE syndrome mainly include hypoxia, abnormality of mesodermal vascular endothelial cells, genetic abnormality, and abnormality of interstitial mesenchymal stem cells. The current medications for hemangioma with PHACE syndrome include beta blockers, glucocorticoids, and mTOR inhibitors. This review article mainly describes the pathogenesis, diagnoses and treatments of PHACE syndrome, in order to provide directions for diagnosis and treatment of this disorder.
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Affiliation(s)
- Su-Hua Peng
- Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China.
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28
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Lang F, Press UP. [Infantile hemangioma of the eyelid]. Ophthalmologe 2017; 114:1171-1180. [PMID: 29147770 DOI: 10.1007/s00347-017-0604-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hemangiomas are one of the most common vascular tumors in infancy. In most cases no therapy is necessary and spontaneous regression is observed; however, if they arise in the periocular region, immediate action is required as rapid growth frequently leads to obstruction of the visual field with the risk of developing amblyopia and orbital suppression up to permanent disfigurement and stigmatization of those affected. Novel pharmaceutical treatment options led to a significant paradigm shift in the treatment of pediatric hemangiomas.
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Affiliation(s)
- F Lang
- Zentrum für Augenheilkunde, Abteilung für rekonstruktive Lid, Orbita und Tränenwegschirurgie, Brüderkrankenhaus Trier, Nordallee 1, 54292, Trier, Deutschland.
| | - U P Press
- Zentrum für Augenheilkunde, Abteilung für rekonstruktive Lid, Orbita und Tränenwegschirurgie, Brüderkrankenhaus Trier, Nordallee 1, 54292, Trier, Deutschland
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29
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Wang C, Li Y, Xiang B, Xiong F, Li K, Yang K, Chen S, Ji Y. Quality of life in children with infantile hemangioma: a case control study. Health Qual Life Outcomes 2017; 15:221. [PMID: 29145889 PMCID: PMC5689165 DOI: 10.1186/s12955-017-0772-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 09/28/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Infantile hemangioma (IH) is the most common vascular tumor in children. It is controversial whether IHs has effects on the quality of life (QOL) in patients of whom IH poses no threat or potential for complication. Thus, we conducted this study to evaluate the q QOL in patients with IH and find the predictors of poor QOL. METHODS The PedsQL 4.0 Genetic Core Scales and the PedsQL family information form were administered to parents of children with IH and healthy children both younger than 2-year-old. The quality-of-life instrument for IH (IH-QOL) and the PedsQL 4.0 family impact module were administered to parents of children with IH. We compared the PedsQL 4.0 Genetic Core Scales (GCIS) scores of the two groups. Multiple step-wise regression analysis was used to determine factors that influenced QOL in children with IH and their parents. RESULTS Except for physical symptom, we found no significant difference in GCIS between patient group and healthy group (P = 0.409). The internal reliability of IH-QOL was excellent with the Cronbach's alpha coefficient for summary scores being 0.76. Multiple step-wise regression analysis showed that the predictors of poor IH-QOL total scores were hemangioma size, location, and mother's education level. The predictors of poor FIM total scores were hemangioma location and father's education level. The predictors of poor GCIS total scores were children's age, hemangioma location and father's education level. CONCLUSION The findings support the feasibility and reliability of the Chinese version of IH-QOL to evaluate the QOL in children with IH and their parents. Hemangioma size, location and education level of mother are important impact factors for QOL in children with IH and their parents.
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Affiliation(s)
- Chuan Wang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37 Guo-Xue-Xiang, Chengdu, Sichuan Province, 610041, China
| | - Yanan Li
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37 Guo-Xue-Xiang, Chengdu, Sichuan Province, 610041, China
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37 Guo-Xue-Xiang, Chengdu, Sichuan Province, 610041, China
| | - Fei Xiong
- Department of Child Health, West China Second University Hospital, Sichuan University, Sichuan Province, Chengdu, China
| | - Kai Li
- Division of Oncology, Department of Pediatric Surgery, Children's Hospital of Fudan University, Shanghai, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37 Guo-Xue-Xiang, Chengdu, Sichuan Province, 610041, China
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, #37 Guo-Xue-Xiang, Chengdu, Sichuan Province, 610041, China.
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30
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Alexopoulos A, Thanopoulou I, Dakoutrou M, Georgiadou E, Chrousos GP, Kakourou T. Atenolol treatment for severe Infantile Hemangiomas: a single-centre prospective study. J Eur Acad Dermatol Venereol 2017; 32:e117-e119. [PMID: 28921662 DOI: 10.1111/jdv.14590] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- A Alexopoulos
- First Department of Pediatrics, "Aghia Sofia" Children's Hospital, University of Athens, Athens, Greece
| | - I Thanopoulou
- First Department of Pediatrics, "Aghia Sofia" Children's Hospital, University of Athens, Athens, Greece
| | - M Dakoutrou
- First Department of Pediatrics, "Aghia Sofia" Children's Hospital, University of Athens, Athens, Greece
| | - E Georgiadou
- First Department of Pediatrics, "Aghia Sofia" Children's Hospital, University of Athens, Athens, Greece
| | - G P Chrousos
- First Department of Pediatrics, "Aghia Sofia" Children's Hospital, University of Athens, Athens, Greece
| | - T Kakourou
- First Department of Pediatrics, "Aghia Sofia" Children's Hospital, University of Athens, Athens, Greece
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Abstract
Vascular anomalies comprise a spectrum of diseases that are broadly classified as tumors and malformations. Diagnosis is often challenging, given a wide range of clinical presentations with overlapping signs and symptoms. Accurate diagnosis is critical to determine prognosis and to generate a management plan, which frequently involves multiple subspecialists during different phases of treatment. An updated classification system provides structure and clear, consistent terminology, allowing for improved diagnosis, provider communication, and collaboration. Historically, treatment of vascular anomalies was primarily surgical and medical therapies were limited or ineffective. Recent discoveries of pharmacologic agents effective in treating vascular anomalies have broadened our medical therapeutic options, limiting the need for unnecessary or high-risk procedures and improving patients' quality of life.
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Affiliation(s)
- Kiersten W Ricci
- Division of Hematology, Hemangioma and Vascular Malformation Center, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Mei-Zahav M, Blau H, Hoshen M, Zvulunov A, Mussaffi H, Prais D, Stafler P, Steuer G, Lapidoth M, Amitai DB. Propranolol treatment for infantile hemangioma does not increase risk of childhood wheezing. Pediatr Pulmonol 2017; 52:1071-1075. [PMID: 28267266 DOI: 10.1002/ppul.23683] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/25/2017] [Accepted: 02/08/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Propranolol is the treatment of choice for infantile hemangiomas requiring medical intervention. Although contraindicated in asthma, its bronchoconstrictive effect in infants and children has not been extensively studied. We aimed to assess the incidence of wheezing episodes in infants and children treated with propranolol for infantile hemangiomas. STUDY DESIGN A retrospective case-control study. SETTING a tertiary pediatric hospital. PATIENTS All Children followed for infantile hemangioma between 2009 and 2014. Children followed conservatively served as control group and were matched 1:1 for gender and month of birth by random matching to children treated with propranolol. INTERVENTIONS All respiratory episodes (asthma, wheezing, stridor, and pneumonia) and respiratory associated hospitalizations were recorded from hospital records, from the primary care physician visits records and pharmacy prescriptions. The main outcome measure was the incidence of respiratory episodes in the treatment and the control groups. RESULTS A total of 1828 clinic visits were reviewed for 683 children. In addition, primary care physician visits records were available in 80% of them. Two hundred and sixteen children were treated with propranolol. Incidence of respiratory episodes and recurrent respiratory episodes was similar in the propranolol and control groups (8.3% vs 12%, P = 0.265; 3.7% vs 6.5%, P = 0.274, respectively). Time to first episode was similar in the treatment and control groups (5.03 ± 3.32 vs 4.45 ± 3.21 months, respectively, P = 0.09). Respiratory hospital admission rate was similar in both groups. CONCLUSIONS Propranolol treatment does not exacerbate wheezing episodes in infants and children.
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Affiliation(s)
- Meir Mei-Zahav
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Hannah Blau
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Moshe Hoshen
- Clalit Research Institute, Chief Physician's Office, Clalit Health Services, Tel Aviv, Israel
| | - Alex Zvulunov
- Pediatric Dermatology Unit, Schneider Children's Medical Center, Petach Tikva, Israel.,Faculty of Health Sciences, Medical School for International Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Huda Mussaffi
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Dario Prais
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Patrick Stafler
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Guy Steuer
- Kathy and Lee Graub Cystic Fibrosis Center Pulmonary Institute, Schneider Children's Medical Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Israel
| | - Moshe Lapidoth
- Sackler School of Medicine, Tel Aviv University, Israel.,Laser Unit, Department of Dermatology, Rabin Medical Center, Petah Tikva, Israel
| | - Dan Ben Amitai
- Sackler School of Medicine, Tel Aviv University, Israel.,Pediatric Dermatology Unit, Schneider Children's Medical Center, Petach Tikva, Israel
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Bayart CB, Tamburro JE, Vidimos AT, Wang L, Golden AB. Atenolol Versus Propranolol for Treatment of Infantile Hemangiomas During the Proliferative Phase: A Retrospective Noninferiority Study. Pediatr Dermatol 2017; 34:413-421. [PMID: 28556385 DOI: 10.1111/pde.13177] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND/OBJECTIVES The nonselective beta-blocker propranolol is the current criterion standard for treatment of infantile hemangiomas (IHs) and the first therapy that the U.S. Food and Drug Administration has approved for the condition, but concern about adverse effects, such as bronchospasm, hypoglycemia, and sleep disturbances, has sparked interest in the use of alternative agents such as the selective β1 antagonist atenolol. Our aim was to compare the efficacy and adverse effect profiles of atenolol with those of propranolol in the treatment of IHs in a retrospective noninferiority trial. METHODS Twenty-seven children with IHs treated with atenolol according to the Cleveland Clinic foundation's standardized clinical assessment and management plan (SCAMP) met inclusion criteria and were compared with a matched group of 53 children with IHs treated with propranolol. Three reviewers assessed response to therapy using a modified version of the previously validated Hemangioma Activity Score (HAS). RESULTS The mean change in HAS was -2.94 ± 1.20 for patients treated with atenolol and -2.96 ± 1.42 for those treated with propranolol. There was no statistically significant difference in pre- and posttreatment modified HAS scores between the two groups (p = 0.60). There was no significant difference in the overall rate of adverse effects (p = 0.10), although 11% of patients treated with propranolol experienced reactive airway symptoms, whereas this was not seen in any of the patients treated with atenolol. CONCLUSION Our study supports previous findings that atenolol is at least as effective as propranolol for treatment of IHs and poses less risk of bronchospasm. Our SCAMP proposes guidelines for dosing and monitoring parameters.
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Affiliation(s)
- Cheryl B Bayart
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Pediatrics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Joan E Tamburro
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Pediatrics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Allison T Vidimos
- Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lu Wang
- Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Alex B Golden
- Department of Cardiology, Connecticut Children's Medical Center, Hartford, Connecticut
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Ji Y, Chen S, Xiang B, Yang Y, Qiu L. Safety and tolerance of propranolol in neonates with severe infantile hemangiomas: a prospective study. Sci Rep 2017; 7:1503. [PMID: 28473717 PMCID: PMC5431448 DOI: 10.1038/s41598-017-01321-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 03/29/2017] [Indexed: 02/05/2023] Open
Abstract
Although the efficacy of propranolol for the treatment of infantile hemangiomas (IHs) has been well documented, there is a paucity of clinical data regarding the safety and tolerance of propranolol in neonates. A prospective study of 51 patients less than 30 days of age with severe IH was conducted. All patients were admitted to the hospital for monitoring during initial propranolol treatment at day 0 with dose adjustments at days 7 and 28. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), blood glucose (BG) levels and potential side effects were evaluated during treatment. There were significant decreases in mean heart rate and SBP after the initiation of propranolol therapy (P < 0.05). In contrast, no significant differences in mean DBP and BG levels were observed after each dose during hospitalization (P > 0.05). Bradycardia and hypotension were noted in at least 1 recorded instance in 11.8% and 5.9% of patients, respectively. These hemodynamic changes were not persistent and were asymptomatic. Two patients who had a history of neonatal pneumonia reported severe bronchial hyperreactivity during treatment. This study demonstrated that propranolol administered to properly selected young infants was safe and well tolerated. However, close monitoring should be considered in high-risk young patients.
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Affiliation(s)
- Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Siyuan Chen
- Pediatric Intensive Care Unit, Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, 610041, China.
| | - Bo Xiang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Yang Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
| | - Liqing Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu, 610041, China
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35
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Chang L, Gu Y, Yu Z, Ying H, Qiu Y, Ma G, Chen H, Jin Y, Lin X. When to stop propranolol for infantile hemangioma. Sci Rep 2017; 7:43292. [PMID: 28225076 PMCID: PMC5320547 DOI: 10.1038/srep43292] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/23/2017] [Indexed: 12/29/2022] Open
Abstract
There is no definitive conclusion regarding the optimal timing for terminating propranolol treatment for infantile hemangioma (IH). A total of 149 patients who underwent detailed color Doppler ultrasound examination were included in this study. The characteristics and propranolol treatment of all patients were summarized and analyzed. Patients were divided into two groups according to the lesion regression rate. Among the 149 patients, 38 were assigned to the complete regression group, and 111 were assigned to the partial regression group. The age at which propranolol treatment started, duration of follow-up after treatment discontinuation and rate of adverse events were not significantly different between the two groups. The duration of oral propranolol treatment was shorter in the complete regression group. The age at which propranolol was terminated was younger in the complete regression group, and this group had a lower recurrence rate. Propranolol is safe and effective for the treatment of IHs that require intervention, but it should be stopped at an appropriate time, which is determined primarily by the lesion regression rate after propranolol treatment. Ultrasound is helpful in determining when to stop propranolol for IH.
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Affiliation(s)
- Lei Chang
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yifei Gu
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Zhang Yu
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Hanru Ying
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yajing Qiu
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Gang Ma
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Hui Chen
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Yunbo Jin
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaoxi Lin
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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36
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Abstract
[This corrects the article DOI: 10.1097/MD.0000000000003291.][This corrects the article DOI: 10.1097/MD.0000000000003731.][This corrects the article DOI: 10.1097/MD.0000000000003791.][This corrects the article DOI: 10.1097/MD.0000000000003805.][This corrects the article DOI: 10.1097/MD.0000000000003827.][This corrects the article DOI: 10.1097/MD.0000000000003863.][This corrects the article DOI: 10.1097/MD.0000000000003878.][This corrects the article DOI: 10.1097/MD.0000000000003879.][This corrects the article DOI: 10.1097/MD.0000000000003884.][This corrects the article DOI: 10.1097/MD.0000000000003900.][This corrects the article DOI: 10.1097/MD.0000000000003513.][This corrects the article DOI: 10.1097/MD.0000000000003631.][This corrects the article DOI: 10.1097/MD.0000000000003644.][This corrects the article DOI: 10.1097/MD.0000000000003692.][This corrects the article DOI: 10.1097/MD.0000000000003701.][This corrects the article DOI: 10.1097/MD.0000000000003706.][This corrects the article DOI: 10.1097/MD.0000000000003712.][This corrects the article DOI: 10.1097/MD.0000000000003767.][This corrects the article DOI: 10.1097/MD.0000000000003781.][This corrects the article DOI: 10.1097/MD.0000000000003808.][This corrects the article DOI: 10.1097/MD.0000000000003831.][This corrects the article DOI: 10.1097/MD.0000000000003837.][This corrects the article DOI: 10.1097/MD.0000000000003839.][This corrects the article DOI: 10.1097/MD.0000000000003842.][This corrects the article DOI: 10.1097/MD.0000000000003843.][This corrects the article DOI: 10.1097/MD.0000000000003847.][This corrects the article DOI: 10.1097/MD.0000000000003848.][This corrects the article DOI: 10.1097/MD.0000000000003850.][This corrects the article DOI: 10.1097/MD.0000000000003861.][This corrects the article DOI: 10.1097/MD.0000000000003862.][This corrects the article DOI: 10.1097/MD.0000000000003864.][This corrects the article DOI: 10.1097/MD.0000000000003866.][This corrects the article DOI: 10.1097/MD.0000000000003871.][This corrects the article DOI: 10.1097/MD.0000000000003872.][This corrects the article DOI: 10.1097/MD.0000000000003880.][This corrects the article DOI: 10.1097/MD.0000000000003878.][This corrects the article DOI: 10.1097/MD.0000000000003873.][This corrects the article DOI: 10.1097/MD.0000000000003876.][This corrects the article DOI: 10.1097/MD.0000000000003879.][This corrects the article DOI: 10.1097/MD.0000000000003881.][This corrects the article DOI: 10.1097/MD.0000000000003884.][This corrects the article DOI: 10.1097/MD.0000000000003885.][This corrects the article DOI: 10.1097/MD.0000000000003888.][This corrects the article DOI: 10.1097/MD.0000000000003889.][This corrects the article DOI: 10.1097/MD.0000000000003891.][This corrects the article DOI: 10.1097/MD.0000000000003893.][This corrects the article DOI: 10.1097/MD.0000000000003894.][This corrects the article DOI: 10.1097/MD.0000000000003897.][This corrects the article DOI: 10.1097/MD.0000000000003899.][This corrects the article DOI: 10.1097/MD.0000000000003900.][This corrects the article DOI: 10.1097/MD.0000000000003901.][This corrects the article DOI: 10.1097/MD.0000000000003902.][This corrects the article DOI: 10.1097/MD.0000000000003903.][This corrects the article DOI: 10.1097/MD.0000000000003904.][This corrects the article DOI: 10.1097/MD.0000000000003908.][This corrects the article DOI: 10.1097/MD.0000000000003910.][This corrects the article DOI: 10.1097/MD.0000000000003912.][This corrects the article DOI: 10.1097/MD.0000000000003916.][This corrects the article DOI: 10.1097/MD.0000000000003917.][This corrects the article DOI: 10.1097/MD.0000000000003918.][This corrects the article DOI: 10.1097/MD.0000000000003920.][This corrects the article DOI: 10.1097/MD.0000000000003921.][This corrects the article DOI: 10.1097/MD.0000000000003923.][This corrects the article DOI: 10.1097/MD.0000000000003924.][This corrects the article DOI: 10.1097/MD.0000000000003925.][This corrects the article DOI: 10.1097/MD.0000000000003934.][This corrects the article DOI: 10.1097/MD.0000000000003941.][This corrects the article DOI: 10.1097/MD.0000000000003944.][This corrects the article DOI: 10.1097/MD.0000000000003970.].
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