Multicenter Study of Long-Term Outcomes and Quality of Life in PHACE Syndrome after Age 10

OBJECTIVE

To characterize long-term outcomes of PHACE syndrome.

STUDY DESIGN

Multicenter study with cross-sectional interviews and chart review of individuals with definite PHACE syndrome ≥10 years of age. Data from charts were collected across multiple PHACE-related topics. Data not available in charts were collected from patients directly. Likert scales were used to assess the impact of specific findings. Patient-Reported Outcomes Measurement Information System (PROMIS) scales were used to assess quality of life domains.

RESULTS

A total of 104/153 (68%) individuals contacted participated in the study at a median of 14 years of age (range 10-77 years). There were infantile hemangioma (IH) residua in 94.1%. Approximately one-half had received laser treatment for residual IH, and the majority (89.5%) of participants were satisfied or very satisfied with the appearance. Neurocognitive manifestations were common including headaches/migraines (72.1%), participant-reported learning differences (45.1%), and need for individualized education plans (39.4%). Cerebrovascular arteriopathy was present in 91.3%, with progression identified in 20/68 (29.4%) of those with available follow-up imaging reports. Among these, 6/68 (8.8%) developed moyamoya vasculopathy or progressive stenoocclusion, leading to isolated circulation at or above the level of the circle of Willis. Despite the prevalence of cerebrovascular arteriopathy, the proportion of those with ischemic stroke was low (2/104; 1.9%). PROMIS global health scores were lower than population norms by at least 1 SD.

CONCLUSIONS

PHACE syndrome is associated with long-term, mild to severe morbidities including IH residua, headaches, learning differences, and progressive arteriopathy. Primary and specialty follow-up care is critical for PHACE patients into adulthood.

Factors Affecting β2-Microglobulin Plasma Concentration during Hemodialysis

We studied ten patients on hemodialysis (HD) treated in sequence with cuprophan (CU), ethylenevinylalcohol (EVAL), polyacrylonitrile (A-69) and polysulphone (PSP) membrane dialyzers. ß2-microglobulin (ß2m) was measured by radioimmunoassay in plasma and dialysate samples. Plasma concentrations were corrected for changes in extracellular volume (ECV). We also studied adsorption in vitro by incubating the above membranes with I-125-labelled ß2m. There were no changes in ß2m plasma concentration after HD with CU dialyzers, but a significant decrease was observed with the other membranes tested. Filtration of ß2m across the dialyzer was absent with CU and minimal with EVAL. However, large amounts were recovered from dialysate with the high-permeability dialyzers, AN-69 and PSP. In vitro studies showed that maximal adsorption capacity was obtained with AN-69 (73%) compared to 9% with CU, 4% with EVAL and 7% with PSP. In summary, ß2m clearance with PSP is achieved through greater removal of this protein by mass transport across the membrane. The mechanism by which ß2m is removed from blood during AN-69 dialysis seems to include both adsorption to and filtration by the membrane itself.

"EB, or Not EB?" Neonatal Desquamative Impetigo in a Degloving Pattern

We present the case of a 7-day-old boy with significant, rapidly spreading blistering and desquamation in a "degloving" pattern on the hands that mimicked epidermolysis bullosa but was ultimately diagnosed as bullous impetigo caused by a clinically aggressive strain of Staphylococcus aureus. Bullous impetigo is a desquamating condition caused by local release of S. aureus exfoliative toxin A and is more commonly seen in children. This case highlights the fragility of newborn skin and reviews the major diagnoses that should be considered in an infant with significant blistering.

Tacrolimus monotherapy in membranous nephropathy: A randomized controlled trial

Membranous nephropathy is a common cause of nephrotic syndrome in adults. Although some patients with membranous nephropathy achieve a spontaneous remission, renal function continues to deteriorate in others. We conducted a prospective randomized trial evaluating monotherapy with tacrolimus to achieve complete or partial remission in patients with biopsy-proven membranous nephropathy. Twenty-five patients received tacrolimus (0.05 mg/kg/day) over 12 months with a 6-month taper, whereas 23 patients were in the control group. The probability of remission in the treatment group was 58, 82, and 94% after 6, 12, and 18 months but only 10, 24, and 35%, respectively in the control group. The decrease in proteinuria was significantly greater in the treatment group. Notably, six patients in the control group and only one in the treatment group reached the secondary end point of a 50% increase in their serum creatinine. No patient in the tacrolimus group showed a relapse during the taper period. Nephrotic syndrome reappeared in almost half of the patients who were in remission by the 18th month after tacrolimus withdrawal. We conclude that tacrolimus is a very useful therapeutic option for patients with membranous nephropathy and preserved renal function. The majority of patients experienced remission with a significant reduction in the risk for deteriorating renal function.

[Does continuous veno-venous hemodiafiltration therapy reduce mortality due to acute renal failure as compared to intermittent hemodialysis?]

OBJECTIVE

To estimate whether continuous veno-venous hemodiafiltration (CVVHDF) is superior to intermittent hemodialysis (IHD) in terms of survival of adult patients with acute renal failure (ARF) admitted to the Intensive Care Unit.

SELECTION OF STUDIES

Controlled clinical trials (CCT) and systematic reviews comparing CWHDF and IHD for managing ARF in adult patients (age > 19 years). Observational and case series were excluded. SEARCH SOURCES: The basic syntax <<hemodiafiltration OR continuous hemodi* OR continuous dialysis) and acute renal failure and acute renal insuficiency>> was used to search Pub Med and Ovid System databases. A manual search was done by reviewing the references in the corresponding topic of UpToDate.

ANALYSIS

Data were extracted by two author and their methodological quality was assessed according to the Cochrane Renal Group recommendations that include the procedure for assigning, blinding, intention to treat analysis, and follow-up. OUTCOMES VARIABLES: All data relating to mortality were extracted, specifying the time of collection, time and circumstances (mortality in the ICU or hospitalization). Values gathered are expressed as mortality rates in both the experimental group (CVVHDF) and the control group (IHD), indicating the absolute risk reduction (ARR) and its 95% confidence interval. OUTCOMES AGGREGATION: Studies meeting clinical and methodological homogeneity criteria were combined with the fix effect model by using the Review Manager tool from Cochrane Collaboration. Methodological heterogeneity was analyzed by using the chi-squared test for n-1 freedom degrees, with an alpha value of 0.05. A sensitivity analysis was done adjusting for methodological quality to confirm the results obtained.

RESULTS

Seven clinical trials directly comparing the survival of severe ARF patients in a prospective, randomized, and controlled way were identifiec. Almost all published estudies have quality problems because of being too small to study survival rates, treatment allocation problems and high numbers of loss to follow-up, differences in initial severity levels, or to premature study closure. When combining the results, it was observed that mortality was 64% for IHD and 65% for CVVHDF, with a relative risk of 0.98 (95% CI 0.89-1.07), p = 0.65, with no statistically significant heterogeneity between studies included. When excluding from the analysis the most questionable study due to selection bias, high loss to follow-up (21%), and baseline differences in co-variables influencing the study outcomes, the results are not changed, the observed mortality was 67% for extra-renal intermittent depurative techniques versus 65% for continous ones, with a relative risk of 1.03 (95% CI 0.94-1.14), p = 0.54, again with no statistically significant heterogeneity between studies included.

CONCLUSION

CVVHDF does not offer any benefit as compared to IHD in terms of survival and according to available data from the literature. However, continuous techniques bring other potential benefits such as hemodynamic stability, better tolerability of ultrafiltration, and depuration of solutes, which merit a systematic review to estimate and quantify their magnitude, and which would allow for better defining their place in the therapeutic armamentarium available for this high-mortality condition.

Common pediatric and adolescent skin conditions

Skin lesions are encountered in all areas of medicine, and it is therefore important for physicians to understand the fundamentals of explaining and diagnosing common skin conditions. This article begins with a discussion of description and documentation of skin lesions based on color, size, morphology, and distribution. Pigmentation disorders such as vitiligo are depicted. Cutaneous growths that are found in the pediatric and adolescent population include acrochordons, dermatofibromas, keloids, milia, neurofibromas, and pyogenic granulomas. Treatment of these growths usually involves observation or curettage with electrodessication.Psoriasis, atopic dermatitis, poison ivy, and eczema are comprised of scaling patches and plaques; poison ivy and atopic dermatitis may also present with bullous and vesicular changes. Therapy typically consists of topical emollients and corticosteroids; phototherapy is reserved for refractory cases. Acne vulgaris is the most common skin disease of the pediatric and adolescent population. This condition can be psychologically debilitating and, therefore, proper treatment is of paramount importance. Therapeutic options include topical as well as oral antibiotics and retinoids. Extreme caution must be used when prescribing retinoids to post-pubescent females, as these agents are teratogenic. Vascular anomalies are most commonly exemplified as port wine stains and hemangiomas. Port wine stains may be treated with pulsed dye laser or may be observed if they are not of concern to the patient or physician. Hemangiomas typically spontaneously regress by age ten; however, there has been recent concern that certain cases may need to be treated. Dermal rashes may be localized or generalized. Treatment of generalized drug eruptions involves elimination of the inciting agent, topical antipruritics, and systemic corticosteroids for severe reactions. Infectious etiologic agents of skin disease include bacteria, fungi, and viruses. Many sexually transmitted diseases are bacterial or viral in origin and present as a rash or ulcer. Impetigo is a bacterial infection which may present as a bullous eruption or as an erosion with a honey colored crust. Other bacterial infections include erythema chronicum migrans, folliculitis, and cellulitis. Fungal infections include the various forms of tinea and are usually treated with topical antifungals; if the infection is located in a hair-bearing area, systemic antifungals are necessary. Viral infections include warts, varicella, molluscum contagiosum, and herpes. Treatment varies from observation or antivirals for varicella to cryosurgery and topical imiquimod for warts. Finally, scabies and lice are infectious agents that can be treated with permethrin and pyrethrin solutions.

Severe renal hypouricemia secondary to hyperbilirubinemia

A 64-year-old man with alcoholic liver cirrhosis had a progressive decrease in the serum uric acid (UA) until it became undetectable, an increase renal UA clearance, mild glycosuria with normal serum glucose and a decrease in the tubular reabsorption of phosphate in association with cholestasis secondary to a gallbladder carcinoma. All these abnormalities returned to normal when the serum bilirubin levels decreased following surgical treatment. This clinical observation suggests that the reversible renal tubular transport defect was secondary to high levels of serum bilirubin.

Effect of calcitriol on insulin secretion in uraemia

To evaluate the role of calcitriol on insulin secretion in uraemia, nine patients on maintenance haemodialysis, never treated with vitamin D nor with calcium-channel blockers, were studied. Baseline glucose, insulin, C peptide, calcium, intact PTH, and calcitriol serum values were measured, and after an oral load of 75 g glucose, insulin and C peptide were also determined at 15, 30, 45, 60, and 120 min. Following 14 days of treatment with oral calcitriol (0.5 microgram/day), the same study protocol was applied. Serum calcitriol values, which were low as expected, increased after therapy, but did not reach the values observed in healthy controls. Despite no change in total serum calcium, intact PTH values decreased significantly (182 vs 88.3 ng/ml, P less than 0.003). Baseline serum insulin was significantly increased after calcitriol (7.5 vs 35 microU/ml, P less than 0.001). Similarly, an enhancement in insulin secretion following calcitriol was observed at 15 min (34 vs 70, P less than 0.01) and 30 min (57 vs 96 microU/ml, P less than 0.01). Computation of the total area under the curve confirmed these results. Changes in C peptide profile paralleled those described for insulin. These data confirm that vitamin D modulates pancreatic beta-cell secretion and suggest that calcitriol may regulate insulin release in uraemic patients.

Factors affecting beta 2-microglobulin plasma concentration during hemodialysis

We studied ten patients on hemodialysis (HD) treated in sequence with cuprophan (CU), ethylenevinylalcohol (EVAL), polyacrylonitrile (A-69) and polysulphone (PSP) membrane dialyzers. beta 2-microglobulin (beta 2m) was measured by radioimmunoassay in plasma and dialysate samples. Plasma concentrations were corrected for changes in extracellular volume (ECV). We also studied adsorption in vitro by incubating the above membranes with I-125-labelled beta 2m. There were no changes in beta 2m plasma concentration after HD with CU dialyzers, but a significant decrease was observed with the other membranes tested. Filtration of beta 2m across the dialyzer was absent with CU and minimal with EVAL. However, large amounts were recovered from dialysate with the high-permeability dialyzers, AN-69 and PSP. In vitro studies showed that maximal adsorption capacity was obtained with AN-69 (13%) compared to 9% with CU, 4% with EVAL and 7% with PSP. In summary, beta 2m clearance with PSP is achieved through greater removal of this protein by mass transport across the membrane. The mechanism by which beta 2m is removed from blood during AN-69 dialysis seems to include both adsorption to and filtration by the membrane itself.

Beta-2-microglobulin in the assessment of renal function in full term newborns following perinatal asphyxia

In order to evaluate the clinical usefulness of serum and urinary beta 2 microglobulin (beta 2-m) determination as a marker of renal damage following perinatal asphyxia, twenty asphyxiated and twenty healthy full term newborns were studied. Renal function was monitored on the first and third day after birth by traditional tests such as creatinine (Cr), endogenous creatinine clearance (Ccr), and fractional Na excretion (FeNa), as well as by serum and urinary beta 2 microglobulin. The value of different tests for the diagnosis of oliguria and of acute renal failure was determined. Eleven asphyxiated neonates developed oliguria and five ARF in contrast to none of the controls. Both traditional tests of renal function, and determinations of beta 2-m with the exception of serum beta 2-m, were significantly different (p less than 0.01) between controls and asphyxiated neonates. When stratified analysis was performed, only serum cr, urinary beta 2-m/cr ratio, and Fe beta 2-m were able to discriminate oliguria from preserved diuresis on the first day of life. For ARF, only Ccr and Fe beta 2-m were different, again on the first day of life. Urinary beta 2-m/creatinine ratio and Fe beta 2-m appear to be more sensitive and specific for the early detection of proximal tubular renal dysfunction following perinatal asphyxia than usual tests of renal function.

Atrial natriuretic peptide inhibits angiotensin II-induced contraction of isolated glomeruli and cultured glomerular mesangial cells of rats: the role of calcium

We examined the contractile effect of angiotensin II on isolated rat glomeruli and cultured glomerular mesangial cells, as well as the possible involvement of calcium in this contraction. In addition, the effect of rat atrial natriuretic peptide (ANP) on angiotensin II-induced contraction was studied. Computer-assisted image analysis was used to measure glomerular cross-sectional area and planar mesangial cell surface area in several experimental conditions. Angiotensin II induced a decrease in glomerular cross-sectional area and planar mesangial cell surface area that was both time and dose dependent. This effect was partially blocked by preincubation with verapamil or TMB-8, the latter compound being more effective. Incubation with ANP prevented angiotensin II-induced reduction of glomerular cross-sectional area and planar mesangial cell surface area and reversed contraction in mesangial cells. Incubation with TMB-8 impaired the effect of ANP. These data suggest that angiotensin II could exert part of its physiologic effects in the kidney through calcium-dependent mesangial and glomerular contraction. ANP inhibited this contraction, possibly explaining some of its renal effects.

Atrial natriuretic peptide inhibits glomerular contraction induced by angiotensin II and platelet activating factor

Isolated rat glomeruli were incubated with angiotensin II, PAF and atrial natriuretic peptide (ANP). Angiotensin II and PAF produced a significant glomerular contraction as evidenced by the decrease in glomerular cross-sectional area. The addition of ANP abolished this effect. These results suggest that ANP could modulate glomerular filtration rate, not only by inducing changes in intrarenal hemodynamics, but also by preventing the effect of some hormones on the filtration surface and subsequently on the ultrafiltration coefficient.

Adenosine induces a calcium-dependent glomerular contraction

Glomeruli isolated from rat kidney cortex were incubated with adenosine in the presence or absence of verapamil and calcium and their change in cross-sectional area was recorded. Adenosine induced a 10% decrease in glomerular cross-sectional area. This decrease was blocked by verapamil or a calcium-free medium. The results suggest that the effect of adenosine in the kidney could be due to glomerular constriction, and that this constriction depends on the entry of calcium into glomerular cells.