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Roupakias S, Kostopoulou E, Gkentzi D, Fouzas S, Sinopidis X. Infantile hemangiomas screening modalities for primary care physicians. Pediatr Investig 2023; 7:199-205. [PMID: 37736361 PMCID: PMC10509409 DOI: 10.1002/ped4.12383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/23/2023] [Indexed: 09/23/2023] Open
Abstract
Infantile hemangiomas are the most common benign vascular tumors in children. They present a characteristic natural history of spontaneous involution after a phase of initial proliferation. A small but significant minority demonstrates incomplete regression or complications and requires prompt intervention. Prediction of the evolution of infantile hemangiomas is challenging because of their morphological and behavioral heterogeneity. The decision between referral for treatment and observation is sometimes difficult, especially among non-expert physicians, with the risk of missing the period for optimizing outcomes in case of delayed intervention. The aim of this review is to update our knowledge, especially of the primary care providers, regarding the ongoing difficulties of the early clinical evaluation of infantile hemangiomas, and to outline the importance of current practical scoring tools for the identification of the lesions which require expert consultation and referral.
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Affiliation(s)
- Stylianos Roupakias
- Department of Pediatric SurgeryUniversity of Patras School of MedicinePatrasGreece
| | - Eirini Kostopoulou
- Department of PediatricsUniversity of Patras School of MedicinePatrasGreece
| | - Despoina Gkentzi
- Department of PediatricsUniversity of Patras School of MedicinePatrasGreece
| | - Sotirios Fouzas
- Department of PediatricsUniversity of Patras School of MedicinePatrasGreece
| | - Xenophon Sinopidis
- Department of Pediatric SurgeryUniversity of Patras School of MedicinePatrasGreece
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Analysis of Therapeutic Decisions for Infantile Hemangiomas: A Prospective Study Comparing the Hemangioma Severity Scale with the Infantile Hemangioma Referral Score. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121851. [PMID: 36553295 PMCID: PMC9777170 DOI: 10.3390/children9121851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/25/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND In view of the high incidence of infantile hemangioma (IH) in infants and young children, a comprehensive and reasonable evaluation scale for referral is urgently needed. This study compared the influence of the Hemangioma Severity Scale (HSS) and the Infantile Hemangioma Referral Score (IHReS) on treatment decisions for infantile hemangioma patients. OBJECTIVE We aimed to establish a reliable and effective evaluation method for referral. METHODS This was a prospective study to determine whether treatment was needed for IH patients after evaluation with the HSS and IHReS. RESULTS A total of 266 consecutive referred IH patients were evaluated for the risk of IH, and the treatment rate was 80.8%. The area under the curve (AUC) of the subject receiver operating characteristic curve (ROC) of treatment decision making after referral by the HSS was 0.703 (95% CI: 0.634-0.772), and after referral by the IHReS was 0.892 (95% CI: 0.824-0.960). LIMITATIONS This was a single-center study. CONCLUSIONS For decisions regarding the treatment of IH patients, the IHReS has a higher efficiency and sensitivity than the HSS. However, the specificity of the IHReS is lower than that of the HSS.
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Gariépy-Assal L, Dubois J, Zwicker K, Pincivy A, Powell J, Zhang Y, Breakey V, Price V, Brandão LR, Carcao M, Kleiber N. Defining vascular anomaly phenotypes in children based on a systematic literature search: A critical step in developing a single severity score for interventional clinical trials. Pediatr Blood Cancer 2022; 69:e29869. [PMID: 35731233 DOI: 10.1002/pbc.29869] [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: 03/19/2022] [Revised: 05/18/2022] [Accepted: 06/16/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Genetically targeted drugs in vascular anomalies (VA) are used despite the absence of a validated severity score. The aim of this study was to evaluate the feasibility of grouping phenotypic VA clinical characteristics into a single severity score. METHODS A systematic literature review including children treated with sirolimus accompanied by a detailed description of phenotype and management was conducted. Demographic data and clinical features were extracted to define distinct categories of phenotypes. RESULTS Children with VA display two main phenotypes regardless of VA subtype, which may overlap. A systemic phenotype results from direct invasion and compression of vital structures generally leading to hospitalization and aggressive management in infancy. A functional phenotype is associated with chronic pain and disability manifesting mainly during early adolescence and managed in the outpatient setting. CONCLUSION The two distinct phenotypes described could be the basis for developing a unified scoring system for VA severity assessment.
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Affiliation(s)
- Laurence Gariépy-Assal
- Pediatric Residency Program, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Josée Dubois
- Department of Radiology, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada.,Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Canada.,Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Kelley Zwicker
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Alix Pincivy
- Library, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Julie Powell
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Canada.,Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Dermatology, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Yang Zhang
- Canadian Economic Analysis Department, Bank of Canada, Ottawa, Ontario, Canada
| | - Vicky Breakey
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Pediatric Hematology/Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Victoria Price
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Pediatric Hematology-Oncology, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Leonardo R Brandão
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Manuel Carcao
- Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Niina Kleiber
- Vascular Anomaly Team, CHU Sainte-Justine, Université de Montréal, Canada.,Vascular Anomalies Canada, Anomalies Vasculaires, Montréal, Quebec, Canada.,Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada.,Research Center, CHU Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montréal, Quebec, Canada
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Chitpiromsak K, Techasatian L, Jetsrisuparb C. Utility of the Infantile Hemangioma Referral Score (IHReS) as a decision-making tool for referral to treatment. BMJ Paediatr Open 2021; 5:e001230. [PMID: 34604545 PMCID: PMC8444243 DOI: 10.1136/bmjpo-2021-001230] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The general paediatricians and primary care physicians sometimes face immense difficulty in referral judgements regarding which infantile hemangiomas (IHs) require referrals and when is the appropriate time to refer IHs for treatment. This resulted in the treatment being delayed beyond IHs' critical timeframe. The Infantile Hemangioma Referral Score (IHReS) has been recently developed, with the aim to solve this problem. OBJECTIVES The objective of the present study is to evaluate the reliability of IHReS and to assess the possibility of using this instrument in our country where a similar problem of delaying treatment of IHs is currently existing. METHODS The present study was a prospective, cross-sectional study. Thirteen selected clinical cases were used to assess the reliability of IHReS among physicians who may have had the chance to deal with patients with IHs. The target physicians across the country were asked to participate in the study via an online platform (Google Forms) to decide whether to refer patients with IHs for treatment or observe. There were 3 steps of assessment: step 1, usual practice evaluation; step 2, using IHReS; step 3, retesting by using IHReS. RESULTS Substantial agreement was observed after using IHReS (step 2) for interrater reliability, with Fleiss' Kappa values of 0.80 and 0.78 among IH experts and non-expert physicians, respectively. Regarding repeatability, in the test-retest assessments, Cohen's Kappa coefficient values revealed almost perfect agreement in intrarater repeatability for both experts and non-expert physicians (1.00). CONCLUSION IHReS is a simple, easy-to-assess tool for non-expert physicians. The benefit in the increase of interrater agreement was found in both IH experts and non-expert physicians. It has had the reliability to be used in making referral decisions regarding patients with IH for treatment among Thai physicians. Using IHReS can improve clinical outcomes by identifying which patient needs early intervention to minimise the possible complications.
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Tiemann L, Hein S. Infantile Hemangioma: A Review of Current Pharmacotherapy Treatment and Practice Pearls. J Pediatr Pharmacol Ther 2020; 25:586-599. [PMID: 33041713 DOI: 10.5863/1551-6776-25.7.586] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Infantile hemangioma (IH) is the most common vascular tumor of infancy, affecting as many as 5% to 10% of all infants. The exact cause is unclear, but specific risk factors, such as low birth weight, prematurity, female sex, white race, and family history are associated with IH development. Most IHs are benign and self-resolving, but a small subset of patients with IHs are at risk of severe or life-threatening outcomes. Systemic and topical β-blockers are effective and safe for use in pediatric patients and considered first-line treatment for both complicated and uncomplicated IHs. Recently published guidelines provide a thorough review of IH and management. This article focuses on IH pharmacotherapy and provides practice pearls to support health care providers in IH medication management.
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Léauté-Labrèze C, Baselga Torres E, Weibel L, Boon LM, El Hachem M, van der Vleuten C, Roessler J, Troilius Rubin A. The Infantile Hemangioma Referral Score: A Validated Tool for Physicians. Pediatrics 2020; 145:peds.2019-1628. [PMID: 32161112 DOI: 10.1542/peds.2019-1628] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Infantile hemangiomas (IHs) are common; some cases require timely referral and treatment to prevent complications. We developed and validated a reliable instrument for timely and adequate referral of patients with IH to experts by nonexpert primary physicians. METHODS In this multicenter, cross-sectional, observational study, we used a 3-stage process: (1) development of the Infantile Hemangioma Referral Score (IHReS) tool by IH experts who selected a representative set of 42 IH cases comprising images and a short clinical history, (2) definition of the gold standard for the 42 cases by a second independent committee of IH experts, and (3) IHReS validation by nonexpert primary physicians using the 42 gold standard cases. RESULTS A total of 60 primary physicians from 7 different countries evaluated the 42 gold standard cases (without reference to the IHReS tool); 45 primary physicians evaluated these cases using the IHReS questionnaire, and 44 completed retesting using the instrument. IHReS had a sensitivity of 96.9% (95% confidence interval 96.1%-97.8%) and a specificity of 55.0% (95% confidence interval 51.0%-59.0%). The positive predictive value and negative predictive value were 40.5% and 98.3%, respectively. Validation by experts and primary physicians revealed substantial agreement for interrater reliability and intrarater repeatability. CONCLUSIONS IHReS, a 2-part algorithm with a total of 12 questions, is an easy-to-use tool for primary physicians for the purpose of facilitating correct and timely referral of patients with IH. IHReS may help practitioners in their decision to refer patients to expert centers.
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Affiliation(s)
| | - Eulalia Baselga Torres
- Department of Dermatology, Universitat Autònoma de Barcelona and Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Lisa Weibel
- Department of Pediatric Dermatology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Laurence M Boon
- Center for Vascular Anomalies, Division of Plastic Surgery, Cliniques Universitaires St Luc, Brussels, Belgium
| | - Maya El Hachem
- Pediatric Dermatology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Catharina van der Vleuten
- Expertise Center for Hemangioma and Vascular Malformations, Department of Dermatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jochen Roessler
- Center of Pediatrics and Adolescent Medicine, Medical Center-University Freiburg, Freiburg, Germany; and
| | - Agneta Troilius Rubin
- Centre for Laser and Vascular Anomalies, Department of Dermatology, Skåne University Hospital, Malmö, Sweden
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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: 195] [Impact Index Per Article: 39.0] [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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Onnis G, Dreyfus I, Mazereeuw-Hautier J. Factors associated with delayed referral for infantile hemangioma necessitating propranolol. J Eur Acad Dermatol Venereol 2018; 32:1584-1588. [DOI: 10.1111/jdv.14842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/18/2018] [Indexed: 01/21/2023]
Affiliation(s)
- G. Onnis
- Reference Centre for Rare Skin Diseases; Dermatology Department; CHU Larrey; Paul Sabatier University; Toulouse France
| | - I. Dreyfus
- Reference Centre for Rare Skin Diseases; Dermatology Department; CHU Larrey; Paul Sabatier University; Toulouse France
| | - J. Mazereeuw-Hautier
- Reference Centre for Rare Skin Diseases; Dermatology Department; CHU Larrey; Paul Sabatier University; Toulouse France
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Moyakine AV, Herwegen B, van der Vleuten CJM. Use of the Hemangioma Severity Scale to facilitate treatment decisions for infantile hemangiomas. J Am Acad Dermatol 2017; 77:868-873. [PMID: 28818436 DOI: 10.1016/j.jaad.2017.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/30/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Hemangioma Severity Scale (HSS) assesses the severity of an infantile hemangioma (IH). OBJECTIVE First, to compare HSS scores between patients with IH for whom propranolol treatment was indicated at their first visit and those who were not treated. Second, to assess suitable cutoff values for the need for propranolol treatment. METHOD All patients with IH who attended our tertiary referral center since 2008 and were 0 to 6 months of age at their first visit were included. They were divided into propranolol and no-propranolol groups on the basis of choice of treatment at their first visit. HSS scores were assessed, and median scores were compared. RESULTS A total of 657 children (342 in the propranolol group) were included. The median HSS score (25th-75th percentile) in the propranolol group was 10 (range, 8-14) compared with 7 (range, 4-9) in the no-propranolol group (P < .001). Cutoff values of 6 or lower (no indication for treatment) and 11 or higher (indication for treatment) resulted in 94% sensitivity and 89% specificity, respectively. LIMITATIONS HSS scoring was not completely blinded. CONCLUSION The HSS with cutoff values of 6 or lower and 11 or higher could be used as a triage tool for propranolol treatment. Patient age, IH type, and parental preference may also contribute to treatment decisions.
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Affiliation(s)
- Andre Vadimovich Moyakine
- Department of Dermatology, Hecovan Expertise-Center for Hemangioma and Vascular Malformations, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Bjorn Herwegen
- Department of Dermatology, Hecovan Expertise-Center for Hemangioma and Vascular Malformations, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina Joanna Maria van der Vleuten
- Department of Dermatology, Hecovan Expertise-Center for Hemangioma and Vascular Malformations, Radboud University Medical Center, Nijmegen, The Netherlands
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Blei F. Update March 2017. Lymphat Res Biol 2017. [DOI: 10.1089/lrb.2017.29019.fb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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