Psychological comorbidities and compliance to interventional treatment of patients with cutaneous vascular malformations

PURPOSE

The aim of this study was to assess qualitatively the psychological stressors affecting patients with cutaneous vascular malformations and hemangiomas (CVM-H) and their impact on compliance to interventional treatment.

METHODS

A retrospective chart review was conducted of all patients with CVM-H treated by interventional neuroradiology at a single academic institution during a five-year period (2009-2014). Psychological complaints were documented during each clinic visit by a neuroradiologist. Compliance to interventional treatment was defined by adherence to the scheduled treatment sessions. Fisher's exact test was used to assess for associations between psychological complaints and compliance.

RESULTS

Seventy-five patients were assessed, of whom 49 (65.3%) were female, with an age range of 2-78 years (mean age 30.2 years). All except one patient older than seven years of age (n = 71; 94.6%) had a psychological complaint, including fear of negative appearance (n = 53; 70.6%), dissatisfaction with appearance (n = 46; 61.3%), low self-esteem (n = 35; 46.6%), anxiety (n = 16; 21.3%), stress (n = 13; 17.3%), bullying (n = 5; 6.6%), and low mood (n = 4; 5.3%). Twenty-three (31%) patients were non-compliant. Low self-esteem was significantly associated with non-compliance (p = 0.0381).

CONCLUSION

There is a high prevalence of psychological comorbidities among patients treated for CVM-H. This has potential implications for interventional treatment, as it was found that low self-esteem is significantly associated with non-compliance. These results suggest the need for early psychological support in these patients in order to maximize compliance to interventional treatment.

Haemangioma family burden: creation of a specific questionnaire

To develop and validate a specific questionnaire to assess burden on families of children with infantile haemangioma (IH): the Haemangioma Family Burden questionnaire (HFB). Items were generated from a literature review and a verbatim report from parents. Subsequently, a study was implemented at the Necker Hospital and the Pellegrin Children's Hospital for psychometric analysis. The HFB was refined via item reduction according to inter-question correlations, consensus among experts and exploratory factor analysis. A 20-item questionnaire, grouped into 5 dimensions, was obtained. Construct validity was demonstrated and HFB showed good internal coherence (Cronbach's α: 0.93). The HFB was significantly correlated with the mental dimension of the Short-Form-12 (r = -0.75), and the Psychological General Well-Being Index (r = -0.61). HFB scores differed significantly according to the size and localization of the IH. A validated tool for assessing the burden on families of children with IH is now available.

[An experience nursing an ambulatory pediatric surgery patient and his mother: the practice of caring]

A seven-year old child was scheduled for excision of hemangioma under local anesthesia. Utilizing the concept of caring, we provided pre- and intra-operative support to both the patient and his mother. Before the operation, we effectively established the self-confidence of the patient by providing sufficient disease-related information and encouragement in a child-oriented approach, in order to enable the patient to overcome fear and pain. This caring approach proved effective during the operation since the patient was fully aware of each surgical step and the levels of pain to be experienced. The mother was also involved throughout the process. She was therefore not only emotionally pacified, but also actively involved in the psychosocial support process. Traditionally, almost all surgical procedures in pediatric patients have been performed under general anesthesia. This report indicates that under appropriate care some of the less invasive surgical procedures in school-age children can be carried out under local anesthesia to avoid the risks involved in general anesthesia.

Quality of Life in Vascular Anomalies

Hemangiomas and vascular malformations that cause disfigurement or functional limitations may affect the quality life of the affected individual and their families. Negative reaction from strangers, social stigmatization, sadness, stress and low self-esteem are some of the commonly reported effects of having such lesions. Extensive and accurate education about the disease process and advice from support groups may improve quality of life. Psychological intervention may be indicated for some individuals and families.

A psychological profile of children with hemangiomas and their families

OBJECTIVE

To assess the psychosocial impact of hemangiomas and their treatment on children with the disease and their families.

DESIGN

Thirty-nine children who were treated for hemangiomas were examined by a questionnaire that addressed the emotional attitudes of the parent and child toward the disease and the related treatment.

SETTING

Two private ambulatory surgery centers (in Latham and Charleston).

RESULTS

Overall, the survey found a negative effect on the child's family, with considerable fear caused in part by adverse public commentary or attitudes--which was ameliorated by education from the primary care provider and specialist. However, the family's perception was that the child was not deeply affected by his or her condition and that treatment (laser, intralesional corticosteroids, oral corticosteroids, surgery, or a combination) did not change the child's emotional response to the disease. However, most parents observed that their child was too young to appreciate his or her malady.

CONCLUSION

Given earlier intervention for children with late-involuting hemangiomas and the advent of more effective therapies, our survey did not seem to indicate that the children experienced significant emotional trauma from their condition; nevertheless, their families experienced appreciable emotional and psychological distress.

A prospective study of the impact of laser treatment on vascular lesions

BACKGROUND

Vascular lesions, especially on exposed sites, can be unsightly and may cause significant psychological distress. Lasers are effective in treating such lesions, but relatively few studies have been performed looking at psychological scoring before and after laser therapy.

OBJECTIVES

To assess the change in psychological distress in patients with vascular lesions following laser treatment.

PATIENTS AND METHODS

A prospective study was performed with patients recruited over a 3-month period. Psychological distress was measured using subjective scores on a standard questionnaire before treatment and at a 6-month follow-up. Each patient was treated every 4-8 weeks with an appropriate laser by the same dermatologist until discharge. Forty-two patients were recruited with one of four diagnoses: telangiectasia, port wine stain (PWS), vascular spider or cherry angioma, which occurred mainly on facial or exposed sites.

RESULTS

Following laser treatment, there was a significant decrease in subjective scores of patients with telangiectasia and vascular spiders. Patients with PWS showed objective improvement but this was not reflected in their subjective scores. Psychological distress had reduced significantly in patients with less severe vascular lesions.

CONCLUSIONS

Laser treatment of minor vascular lesions leads to objective improvement, which is paralleled by psychological benefit, but objective benefit in PWS may not be perceived as beneficial by patients.

Update on hemangiomas and vascular malformations

Hemangiomas and vascular malformations are frequently encountered in pediatric practice, especially hemangiomas and port-wine stains. These lesions may cause physical and psychological complications and it is important to recognize which lesions need to be treated and how. Great progress has been made in the classification of vascular anomalies. Angiogenesis and molecular genetics are areas of active research; recent findings relating to hemangiomas and vascular malformations are presented. New clinical features of hemangiomas are described, such as association of extensive facial hemangiomas with various malformations and the occurrence of Kasabach-Merritt phenomenon, not with common hemangiomas, but with other vascular tumors (Kaposiform hemangioendothelioma and tufted angioma). Interferon alfa is effective for treatment of complicated hemangiomas but may cause serious neurological side effects. It is to be hoped that early diagnosis of Sturge-Weber syndrome will soon be possible with new, noninvasive, functional imaging techniques. New issues surrounding pulsed dye laser therapy for port-wine stains are also discussed in this article.

New clinical observations in hemangiomas

Much research in endothelial biology is aimed at developing methods to stimulate productive angiogenesis or inhibit unwanted angiogeneseis. Hemangiomas provide a model for endothelial proliferation and involution. This article is intended to update the reader with new information regarding hemangiomas of infancy, the most common tumor of childhood. Topics such as possible origin, management issues, and psychosocial stresses are addressed. This field is constantly changing, but an effort has been made to include most of the recently reported articles. Our hope is that this information will enable physicians caring for patients with hemangiomas to better address the concerns of their patients and families.

Growing up with a facial hemangioma: parent and child coping and adaptation

OBJECTIVE

To better understand the experiences, challenges, and adaptations of parents with children who have disfiguring facial hemangiomas.

DESIGN

Qualitative, descriptive.

METHODS

In-depth interviews were performed with the parent(s) of 25 children, aged 5 months to 8 years. Each child was referred to the Pediatric Dermatology Practice, Department of Dermatology, University of California, San Francisco, with a facial hemangioma of 1 cm diameter or greater. Interviews were ethnographic in style, centering on the description by parents of the particular challenges faced, supports received, and adaptive strategies developed in coping with their child's hemangioma. Analysis was by open coding of interview transcripts. Coded statements were organized within common categories and these further gathered into 4 principal themes: 1) parental emotion and adaptation; 2) experiences with public reactions; 3) issues related to parent-child interactions; and 4) expressed satisfaction/dissatisfaction with medical care.

RESULTS

Disfiguring facial hemangiomas were found to be associated with parental reactions of disbelief, fear, and mourning, particularly during the growth phase. Reactions of strangers forced parents to confront varied aspects of social stigmatization. A broad array of effects on the parent-child interaction were observed, often connected with variables extrinsic to the hemangioma, including especially the support and acceptance by the extended family. Half of those studied expressed substantial dissatisfaction with aspects of their medical care.

CONCLUSIONS

Disfiguring facial hemangiomas in young children are frequently associated with parental reactions of loss and grief, despite the generally benign nature of the lesion and the prognosis for eventual involution. Physicians are faced with specific challenges in providing effective anticipatory guidance and support to parents.

Psychosocial adjustment in children with port-wine stains and prominent ears

OBJECTIVE

To evaluate psychosocial adjustment in children with port-wine stain (PWS) and children with prominent ears (PE).

METHOD

Thirty-two children aged 7 to 16 years with facial PWS and 42 children with PE were evaluated using the Harter Self-Perception Profile, the Revised Children's Manifest Anxiety Scale, the Children's Depression Inventory, the Disfigurement Perception Scale, and the Child Behavior Checklist. Results were compared with normative data for the local population or with a control group. Profile scores were correlated with severity of the PWS or prominence of the ears.

RESULTS

Children with PE had poorer self-perception, higher concentration anxiety, and more internalizing and externalizing symptoms, and they were more withdrawn and had more social problems than children with PWS. The children with PWS functioned as well as or better than nondisfigured peers on measurements of psychosocial adjustment, while children with PE scored lower than nondisfigured peers on measures of self-perception and parent-rated social and attention problems. There was no correlation between degree of disfigurement and level of psychosocial adjustment.

CONCLUSIONS

Psychosocial adjustment varied according to the nature of the disfigurement or deformity and was unrelated to the severity of the disfigurement.

Cerebral dominance for speech and handwriting of patients with cortical vascular malformations

Lateralization of speech dominance was established using amobarbital for 22 patients with vascular malformations lateralized to the left cerebral hemisphere. Patients' histories were negative for clinically evident neurological events (e.g., seizures or hemorrhage) prior to adulthood. The vascular lesions were categorized as high flow arteriovenous malformations (AVMs) (n = 4), low flow AVMs (n = 6), cavernous hemangiomas (n = 10), or venous angiomas (n = 2) by reviewing angiographic findings and surgical pathology for those patients whose lesions were excised. Three of the malformations encroached upon primary language areas. The frequency of right hemisphere speech dominance was not significantly elevated in comparison with the normal population, even though the incidence of nonright-handedness was. Ninety-five percent of the patients were left hemisphere dominant for speech: only one patient, with a parietal lobe cavernous hemangioma, was found to be right hemisphere dominant for speech. This malformation did not involve the primary language areas. These findings suggest that vascular malformations do not affect speech dominance as readily as other neurological diseases, but frequently affect manual dominance.

Early excision of nasal hemangiomas: the L-approach

The presence of a nasal hemangioma may have a severe negative effect on the personality of a child. Early surgery in the involution phase has proved to be beneficial in this respect. The treatment of a consecutive series of nine patients who had surgery shortly after they were first seen for consultation is discussed. An extended rhinotomy (L-approach) was used in four of these patients. The results were uniformly good.

Pulsed dye laser therapy for port-wine stains in children: psychosocial and ethical issues

The port-wine stain is a disfiguring vascular birthmark that commonly occurs on the face. Amelioration of this condition in children was difficult or impossible until the introduction of the flashlamp-pumped pulsed dye laser in the late 1980s. This article provides an interdisciplinary social and ethical examination of pulsed dye laser therapy for port-wine stain in childhood. Specific issues raised relate to the management of pain during therapy, rationale for care, expectations of treatment, the high costs of care, equity, marketing pressures, and therapeutic activism. Laser therapy in the dermatologic care of children is an exciting innovation that has transformed clinical practice and raised important social, ethical, and health policy issues.

Psychosocial development of children with hemangiomas: home, school, health care collaboration

Hemangiomas are among the most common neoplasms of childhood and often found on the face, head, and neck. In a society that places great importance on physical appearance, sustaining a hemangioma can significantly influence the psychosocial development of children. The purpose of this article is to briefly discuss the etiology of hemangiomas and provide practical suggestions for educators, health care professionals, and parents to foster the psychosocial development of children with a hemangioma.

Behavioral adjustment and self-concept of young children with hemangiomas

This study was conducted to determine the behavioral responses and self-concepts of young children with self-limited but transiently disfiguring capillary hemangiomas involving the head and neck. Nineteen children with hemangiomas, age 3 to 5 years, and their parents were compared with an age-matched control group without lesions. Responses to a parental checklist, informal interview, and self-concept test showed few differences between young children with hemangiomas and those without this neoplasm.

Society's reactions to facial disfigurements

There is a paucity of thorough research on society's reaction to dentofacial anomalies, or to other forms of facial disfigurement. The author reviews the studies of the social effects of dental appearance that do exist, and then reports some results of his own researches into reaction to facial disfigurement. It appears from these studies that facial disfigurement (including dentofacial anomalies) can indeed be a cause of social disadvantage.

The necessity for treatment of childhood port-wine stains

The pulsed tunable dye laser has recently become available for the treatment of children with port-wine stains. Parental reactions and psychosocial implications of untreated port-wine stains in children are reviewed. It is recommended that children with port-wine stains be treated as early as possible to prevent adverse sequelae to their psychological development.

Psychological disabilities amongst patients with port wine stains

In a questionnaire study to assess psychological disabilities in 110 patients with port wine stains, 71 completed questionnaires were analysed. The questionnaire revealed a high level of psychological morbidity resulting from a feeling of stigmatization amongst these patients that was not apparent in casual social intercourse. In contrast, standard psychological screening tests for psychiatric illness, depression or anxiety revealed that these patients had similar or less evidence of morbidity than controls or other patient groups. It would appear that patients with port wine stains suffer a considerable degree of psychological morbidity which they suppress. This may be related to a need to hide their port wine stain.

Port-wine stain--a surgical and psychological problem

Patients with large and small port-wine stains have been studied using an intensive interview technique. Those with large defects were shown to have reality problems in common. In addition, their experiences were found to be tempered by individual life events and personality dynamics. Those with small port-wine stains who sought treatment showed no reality problems but experienced great individual psychological problems, which in this study are proved to be the same type. The implications of these findings for prophylaxis against mental illness as well as factors to take into consideration when treating these patients are discussed.

Patient's evaluation of argon laser therapy of port wine stain, decorative tattoo, and essential telangiectasia

One hundred fourteen patients were studied to assess their perception of the results of argon laser therapy for port wine stains (PWS), tattoos, or essential telangiectasia of legs. At least 1 yr following treatment patients were surveyed using a 30-item mail questionnaire. A 91% response rate was achieved. The findings indicate that patients with PWS and tattoo treated with argon laser are moderately satisfied with the results and 85% of them would have treatment again. Laser therapy of these lesions should be continued. Treatment results of essential telangiectasia of the legs are disappointing and only 49% of patients would have treatment again. Discontinuance of argon laser therapy using the described techniques is recommended.

[Psychosocial problems and their management in patients with port-wine stain of the face]

Psychosocial problems and coping in 20 patients with facial naevus flammeus and their families are described. They can be divided into two groups, one of 15 patients in whom coping strategies are regressive, and one of 5 patients in whom they are progressive. In the regressive patients the self-esteem is unstable and social contacts are difficult. The progressive patients are hardly aware of negative reactions from their environment and are scarcely affected in their social contacts. The indication for treatment is discussed.

Perceptual discrimination of vowels in aphasia

In the present study 3 hypotheses were investigated: first, the notion that an aphasic impairment of vowel perception is not associated with particular aphasic syndromes or lesion sites, second, that it is a disorder comparable to a general impairment of perception in a normal speaker caused by some form of interference, and third, that perceptual phonemic discrimination is a separate process from the phonemic discriminative function necessary for speech production. The hypotheses were tested by means of a vowel discrimination test administered to 50 German-speaking aphasic patients (roughly equally divided between Broca's, mixed non-fluent, Wernicke's and mixed fluent groups); the same test, masked by white noise at -10 dB was also administered to 20 normal native speakers of German. Results were in support of all 3 hypotheses. First, aphasic patients' error patterns were similar across fluent and nonfluent groups and for all lesion sites. Second, the error distributions of aphasics with slight auditory impairment resembled those of normal subjects in the -10 dB white noise condition, while distributions of aphasics with severe auditory impairment were indicative of an added component of guessing behaviour. And third, the patients' performance on the discrimination task differed from that shown on a comparable repetition test. (It was argued that repetition involves a patient's expressive capacity in addition to his perceptual capacity). The differentiation of perceptual and expressive phonemic discrimination was further supported by an analysis of the speech errors occurring in the spontaneous (purely expressive) speech and in the repetition (expressive plus perceptual) tasks of 16 French Canadian and 5 English Canadian aphasics.

Social issues and body image concerns of port wine stain patients undergoing laser therapy

When applying lasers to treatment of port wine stains and other flaws of appearance, the physician needs to have an appreciation of the psychological and social aspects of body image as well as the physical aspect. A number of aspects of our society impinge upon port wine stain patients to make their condition psychologically burdensome. Fortunately, the 82 patients in our sample have received extraordinary support from family members in coping with their affliction. As a group they do not display an unusual degree of emotional disturbance in comparision with a normal control population. However, their initial expectations tend to be unrealistically perfectionistic, and many seem to be unwilling to absorb the fact that laser treatment is accompanied by certain hazards and limitations. An especially conscientious adherence to the canons of informed consent with these patients is therefore recommended.

Acquired ocular-motor apraxia and right-sided cortical angioma

A case of acquired ocular-motor apraxia featured by failure in voluntary initiation of lid closure, horizontal and vertical eye movements is reported. Electrographic and neuropsychological assessment pointed out several signs referable to bilateral frontal and right parietal lobe involvement, confirmed by neuroradiological finding.

Phonological processing in reading: data from alexia

The reading of four subjects suffering from a phonological reading impairment as a result of a cerebral lesion was tested. A double dissociation observed in their results is strong evidence for the existence of two functionally independent kinds of phonological processing in reading--a graphemic and a phonetic one.