Beta-blockers for the treatment of problematic hemangiomas

OBJECTIVE:

To examine treatment indications, efficacy and side effects of oral beta-blockers for the treatment of problematic hemangiomas.

METHODS:

A retrospective review of patients with hemangiomas presenting to the Alberta Children’s Hospital Vascular Birthmark Clinic (Calgary, Alberta) between 2009 and 2011 was conducted. The subset of patients treated with oral beta-blockers was further characterized, investigating indication for treatment, response to treatment, time to resolution of indication, duration of treatment, occurrence of rebound growth and side effects of therapy.

RESULTS:

Between 2009 and 2011, 311 new patients with hemangiomas were seen, of whom 105 were treated with oral beta-blockers. Forty-five patients completed beta-blocker treatment while the remainder continue to receive therapy. Indications for treatment were either functional concerns (68.6%) or disfigurement (31.4%). Functional concerns included ulceration (29.5%), periocular location with potential for visual interference (28.6%), airway interference (4.8%), PHACES syndrome (3.8%), auditory interference (0.95%) and visceral location with congestive heart failure (0.95%). The median age at beta-blocker initiation was 3.3 months; median duration of therapy was 10.6 months; and median maximal treatment dose was 1.5 mg/kg/day for propranolol and 1.6 mg/kg/day for atenolol. Ninety-nine patients (94.3%) responded to therapy with size reduction, colour changes, softened texture and/or healing of ulceration. Rebound growth requiring an additional course of therapy was observed in 23 patients. Side effects from beta-blockers included cool extremities (26.7%), irritability (17.1%), lower gastrointestinal upset (14.3%), emesis (11.4%), hypotension (10.5%), poor feeding (7.6%), lethargy (4.8%), bronchospasm (0.95%) and rash (0.95%). Side effects did not result in complete discontinuation of beta-blocker treatment in any case; however, they prompted a switch to a different beta-blocker preparation in some cases. Resolution of the primary indication, requiring a median time of three months, occurred in 87 individuals (82.9%).

CONCLUSIONS:

Treatment of infantile hemangiomas with oral beta-blocker therapy is highly effective and well tolerated, with more than 94% of patients demonstrating a response to treatment and 90% showing resolution of the primary functional indication for treatment.     

"Learning curves" of cardiac surgery in relation to risk stratification and hospital location

AIM: The purpose of this study was to determine any significant differences in "learning curves" between private and public hospitals when the same senior surgeon was responsible during the initial phases of open-heart surgery programs development, in relation to risk stratification and hospital location. METHODS: A prospective review of 610 patients records was performed at a newly-opened cardiothoracic program in a public University Hospital (PUH) in the periphery of Greece, and a private institution (PI) with an experienced intensive care unit (ICU) in the capital city of Athens. Preoperative risk stratification, mortality and postoperative length of stay (LOS) were analysed between 1999 to 2001. RESULTS: At PUH 298 patients were operated and 312 patients at PI. There were 136 low risk (EuroSCORE 0-2) and 474 medium and high-risk patients (EuroSCORE > or =3). There was no significantly elevated mortality or learning curve in low risk surgery either at PUH (57 patients with 1 death) or PI (79 patients and 1 death). In medium and high-risk surgery at PI there was no mortality in 68 patients operated by the senior surgeon and no learning curve in all 233 such patients. In 240 medium and high-risk patients at PUH there was a learning curve despite the involvement of the same senior surgeon. In 1999 and 2000 the observed mortality (OM) in 150 patients was 15.33%, EuroSCORE 5.98, and in 2001 in 91 patients OM 3.29%, EuroSCORE 5.95 with p=0.00.8 when "experienced" ICU staff was employed. LOS was significantly reduced in 97 patients in 2001 at PUH (8.7 d +/- 2.81 vs 11.07 days +/- 7.9 in 1999 and 2000, p=0.046) confirming the existence of a learning curve at the PUH. No such change was observed at PI (8.2 days vs 7.8, p=0.45). CONCLUSION: No mortality differences or learning curve characteristics were detected for low risk operations either at PUH or PI. For medium and high risk surgery there appears to be a learning curve in PUH but not in PI despite senior surgeon involvement in both. The presence of an experienced ICU appears to play a critical role in the outcome of operations in newly opened cardiothoracic programs.     

Characteristics of a donor population in western Venezuela

To determine the characteristics of blood donors in western Venezuela, we collected data from 1983 to 1985 on 31,320 volunteer donors at the Blood Bank of the State of Zulia in Maracaibo. Fifty-nine percent of the donors were blood group O, 30 percent were group A, 9 percent were group B, and 2 percent were group AB. Most of the donors (93%) were Rh positive. One percent of donors had positive reactions to hepatitis B surface antigen, 3.15 percent for syphilis, 1.43 percent for antibodies to Trypanosoma cruzi, and 0.32 percent to human immunodeficiency virus antibodies. About one-half of the donors were between 18 and 30 years old, and only 10 percent were women. To determine if iron deficiency anemia was a cause for the small size of the female donor pool, we measured serum ferritin in 50 first-time female donors. Ten of these (20%) had serum ferritin values below normal, and the distribution of serum ferritin levels of all 50 was very similar to that reported for frequent donors in Europe and the United States, with a clustering of ferritin values between 10 and 70 ng per ml. The data indicate that blood donors in western Venezuela are markedly different from those in the United States and that iron supplementation may be indicated for female Venezuelan donors.     

Hypothermia at 10 degrees C reduces neurologic injury after hypothermic circulatory arrest in the pig

BACKGROUND: We have previously reported that sensory, motor neocortex, and hippocampus are selectively vulnerable to injury in an acute porcine model of HCA at 18 degrees C. This study was undertaken to assess whether further cooling to 10 degrees C can reduce neurological injury during HCA. METHODS: Twelve piglets underwent 75 minutes of HCA at 18 degrees C (n = 6) and 10 degrees C (n = 6). Four served as normal controls. After gradual rewarming and 80 minutes of reperfusion, treatment animals were sacrificed and brains were perfusion-fixed and cryopreserved. Regional patterns of neuronal apoptosis after HCA were characterized by in situ DNA fragmentation using TUNEL histochemistry. Hematoxylin and eosin histology was used to characterize cell damage morphologically. TUNEL-positive cells were scored on a scale of 0 to 5. Grade 0: no TUNEL-positive cells; Grade 1: < 10%; Grade 2: 10% to 25%, Grade 3: 25% to 50%, Grade 4: 50% to 75%; and Grade 5: > 75%. RESULTS: TUNEL-positive cells indicating DNA fragmentation were scored in the motor and sensory neocortex, hippocampus, cerebellum, thalamus, and medulla of animals treated with 18 degrees C and 10 degrees C HCA and were significantly greater than in normal controls. Profound cooling to 10 degrees C resulted in a significant reduction of neuronal injury in the neocortex and hippocampus. CONCLUSIONS: This data support that cerebral protection may be better at very cold temperatures compared to 18 degrees C hypothermia. Regions selectively vulnerable to neuronal injury are offered more neural protection by profound hypothermia. These affects are observed in the acute state, suggesting activation of the apoptotic mechanisms at early stages can be inhibited by profound hypothermia.     

The role of ascorbic acid in the prevention of atrial fibrillation after elective on-pump myocardial revascularization surgery: a single-center experience--a pilot study

Atrial fibrillation (AF) is a common arrhythmia that occurs postoperatively in cardiac surgery. There is evidence for the role of oxidative stress in the etiology of AF. In our study, we examined whether antioxidant ascorbic acid (vitamin C), could help in the reduction of the incidence of postoperative AF. Patients who were scheduled to undergo elective isolated on-pump coronary artery bypass grafting (CABG) were included in our study. One hundred and seventy patients were randomly divided in two groups: Group A (n=85) received vitamin C preoperatively and postoperatively whereas Group B (n=85) did not receive any (control group). The incidence of AF was 44.7% in the vitamin C group and 61.2% in the control group (P=0.041). The hospitalization time, the intensive care unit stay and the time interval for the conversion of AF into sinus rhythm was significantly shorter in the vitamin C group. Patients that developed AF also had longer hospital length of stay (9.5±2.8?days vs. 6.7±1.9, P=0.034). Supplementation of vitamin C reduces the incidence of postCABG AF, and decreases the time needed for rhythm restoration and length of hospital stay.     

Biosimilar vs originator insulins: Systematic review and meta‐analysis

Biosimilar insulins have expanded the treatment options for diabetes. We compared the clinical efficacy and safety of biosimilar insulins with those of originator insulins by conducting a meta‐analysis. A random‐effects meta‐analysis was performed on randomized controlled trials comparing biosimilar and originator insulins in adults with diabetes. Studies were obtained by searching electronic databases up to December 2017. Ten trials, in a total of 4935 patients, were assessed (2 trials each on LY2963016, MK‐1293, Mylan's insulin glargine and SAR342434, and 1 trial each on FFP‐112 and Basalog). The meta‐analysis found no differences between long‐acting biosimilar and originator insulins with regard to reduction in glycated haemoglobin at 24 weeks (0.04%, 95% confidence interval [CI] –0.01, 0.08; P for efficacy = .14, I² = 0%) or at 52 weeks (0.03%, 95% CI –0.04, 0.1), or reduction in fasting plasma glucose (0.08 mmol/L, 95% CI 0.36, 0.53), hypoglycaemia (odds ratio 0.99, 95% CI 0.96, 1.03), mortality, injection site reactions, insulin antibodies and allergic reactions. Analyses stratified by type of diabetes and prior insulin use yielded similar findings. Similarly, no significant differences were found between short‐acting biosimilar and originator insulins. In summary, our meta‐analysis showed no significant differences in clinical efficacy and safety, including immune reactions, between biosimilar and originator insulins. Biosimilar insulins can increase access to modern insulin therapy and reduce medical costs.