Infantile Hemangiomas in Twins: A Prospective Cohort Study.

BACKGROUND: Twins have a higher-than-expected risk of infantile hemangiomas (IHs), but the exact reasons for this association are not clear. Comparing concordant and discordant twin pairs might help elucidate these factors and yield more information about IH risk factors. METHODS: A prospective cohort study of twin pairs from 12 pediatric dermatology centers in the United States, Canada, Argentina, and Spain was conducted. Information regarding maternal pregnancy history, family history of vascular birthmarks, zygosity (if known), and pregnancy-related information was collected. Information regarding twins (N = 202 sets) included birthweight, gestational age (GA), presence or absence of IHs, numbers and subtypes of IHs, presence of other birthmarks, and other medical morbidities. RESULTS: Two hundred two sets of twins were enrolled. Concordance for IH was present in 37% of twin pairs. Concordance for IH was inversely related to gestational age (GA), present in 42% of GA of 32 weeks or less, 36% of GA of 33 to 36 weeks, and 32% of GA of 37 weeks or more. Twins of GA of 34 weeks or less were more than two and a half times as likely to be concordant as those of GA of 35 weeks or more (odds ratio (OR) = 2.66, 95% confidence interval (CI) = 1.42-4.99; p < 0.01). In discordant twins, lower birthweight conferred a high risk of IH; of the 64 sets of twins with 10% or greater difference in weight, the smaller twin had IH in 62.5% (n = 40) of cases, versus 37.5% (n = 24) of cases in which the higher-birthweight twin was affected. Zygosity was reported in 188 twin sets (93%). Of these, 78% were dizygotic and 22% monozygotic. There was no statistically significant difference in rates of concordance between monozygotic twins (43%, 18/42) and dizygotic twins (36%, 52/146) (p = 0.50). In multivariate analysis comparing monozygotic and dizygotic twins, adjusting for effects of birthweight and sex, the likelihood of concordance for monozygotic was not appreciably higher than that for dizygotic twins (OR = 1.14, 95% CI = 0.52-2.49). Female sex also influenced concordance, confirming the effects of female sex on IH risk. The female-to-male ratio was 1.7:1 in the entire cohort and 1.9:1 in those with IH. Of the 61 concordant twin sets with known sex of both twins, 41% were female/female, 43% were female/male, and 16% were male/male. CONCLUSIONS: These findings suggest that the origin of IHs is multifactorial and that predisposing factors such as birthweight, sex, and GA may interact with one another such that a threshold is reached for clinical expression.

A novel association between RASA1 mutations and spinal arteriovenous anomalies.

BACKGROUND AND PURPOSE: CM-AVM is a recently recognized autosomal dominant disorder associated with mutations in RASA1. Arteriovenous lesions have been reported in the brain, limbs, and the face in 18.5% of patients. We report a novel association between RASA1 mutations and spinal arteriovenous anomalies. MATERIALS AND METHODS: In a collaborative study, 5 index patients (2 females, 3 males) with spinal AVMs or AVFs and cutaneous multifocal capillary lesions were investigated for the RASA1 gene mutation. RESULTS: All 5 patients were found to have RASA1 mutation (2 de novo, 3 familial), and all had multifocal capillary malformations at birth. Neurologic deficits developed at ages ranging from infancy to early adulthood. All spinal anomalies (2 AVMs at the conus, 1 AVM at the lumbosacral junction, and 1 cervical and 1 cervicothoracic AVF) were complex, extensive, and fast-flow lesions. All patients required treatment based on the clinical and/or radiologic appearance of the lesions. CONCLUSIONS: To our knowledge, an association of RASA1 mutation and spinal AVM/AVF has not been described. MR imaging screening of patients with characteristic CMs and neurologic symptoms presenting at a young age may be useful in detecting the presence of fast-flow intracranial or intraspinal arteriovenous anomalies before potentially significant neurologic insult has occurred.

Rapidly involuting congenital haemangioma associated with transient thrombocytopenia and coagulopathy: a case series.

Rapidly involuting congenital haemangioma (RICH) may present with thrombocytopenia, low fibrinogen and elevated fibrin degradation products and D-dimers. Such complications have rarely been reported. We wished to define the clinical characteristics of the thrombocytopenia and coagulopathy associated with RICH, to emphasize the transient nature of this haematological complication and to distinguish these abnormalities from true Kasabach-Merritt phenomenon (KMP). We present a case series of seven patients with large RICH who presented with thrombocytopenia and coagulopathy during the first week of life. Clinical and haematological characteristics were recorded retrospectively. Two of the patients were treated with embolization due to early signs of high-output cardiac failure; four patients received oral corticosteroids in the range of 2 mg kg(-1) daily; one patient did not receive any treatment in the neonatal period, although the tumour was excised at 6 months of age. Two patients with platelet counts lower than 10 x 10(9) L(-1) received a platelet transfusion. There were no bleeding complications and only one patient presented with petechiae. In all seven patients, platelet counts started to increase at > 2 weeks of age and the coagulopathy resolved. We conclude that RICH may present with thrombocytopenia and coagulopathy similar to mild KMP early in the neonatal period. However, in contrast to true KMP, these abnormal laboratory findings are self-limited and are usually not complicated by bleeding problems.

Four common glomulin mutations cause two thirds of glomuvenous malformations ("familial glomangiomas"): evidence for a founder effect.

BACKGROUND: Glomuvenous malformation (GVM) ("familial glomangioma") is a localised cutaneous vascular lesion histologically characterised by abnormal smooth muscle-like "glomus cells" in the walls of distended endothelium lined channels. Inheritable GVM has been linked to chromosome 1p21-22 and is caused by truncating mutations in glomulin. A double hit mutation was identified in one lesion. This finding suggests that GVM results from complete localised loss of function and explains the paradominant mode of inheritance. OBJECTIVE: To report on the identification of a mutation in glomulin in 23 additional families with GVM. RESULTS: Three mutations are new; the others have been described previously. Among the 17 different inherited mutations in glomulin known up to now in 43 families, the 157delAAGAA mutation is the most common and was present in 21 families (48.8%). Mutation 108C-->A was found in five families (11.8%), and the mutations 554delA+556delCCT and 1179delCAA were present together in two families (4.7% each). Polymorphic markers suggested a founder effect for all four mutations. CONCLUSIONS: Screening for these mutations should lead to a genetic diagnosis in about 70% of patients with inherited GVM. So far, a mutation in glomulin has been found in all GVM families tested, thus demonstrating locus homogeneity.

Slowed glycogen utilization enhances exercise endurance in patients with heart failure.

OBJECTIVES: The objective of the study was to investigate the impact of alteration of glycogen stores and metabolism on exercise performance in patients with heart failure. BACKGROUND: In normal subjects, muscle glycogen depletion results in increased exertional fatigue and reduced endurance. Skeletal muscle biopsies have revealed reduced glycogen content in patients with congestive heart failure (CHF). Whether glycogen depletion contributes to reduced endurance and abnormal ventilation in these patients is unknown. METHODS: Bicycle exercise tests with measurement of respiratory gases were performed following dietary manipulations to induce glycogen depletion (60% protein, 40% fat) and slow glycogen utilization (60% carbohydrate, 30% fat, 10% protein) in 13 patients with CHF (left ventricular ejection fraction 22+/-6%; age 48+/-9 years) and 7 control subjects (age 45+/-5 years). Maximal exercise, exercise at 75% of peak workload until exhaustion and 1-min cycles of supramaximal exercise at 133% of peak were performed on three occasions over a two-week period. RESULTS: Significant changes in resting respiratory quotients (RQs) in normal (Baseline: 0.78+/-0.03; Depleted: 0.69+/-0.05) and CHF subjects (Baseline: 0.84+/-0.05; Depleted: 0.72+/-0.05) were observed (both p<0.05). Peak Vo2 (oxygen consumption) in both groups was unchanged. The ventilatory response to exercise was analyzed by correlating CO2 production (V(CO2)) to minute ventilation (VE) in each test. The slopes of these correlations were not affected in either group. With glycogen depletion, exercise endurance was reduced from 17 to 6.1 min (57+/-19%) in normal subjects versus a reduction of 9.4 to 8.1 min (11+/-19%) in patients (p<0.05). With slowed glycogen use, CHF patients increased exercise endurance from 9.4 to 16.5 min (65%) versus 17 to 20.6 min (18%) in normal subjects (p<0.05). CONCLUSIONS: Glycogen depletion minimally affects maximal exercise performance, endurance or ventilation in CHF patients, whereas slowed glycogen utilization markedly enhances exercise endurance. Therapeutic interventions that increase or slow use of glycogen stores may have clinical benefit.

Use of telemonitoring to decrease the rate of hospitalization in patients with severe congestive heart failure.

We investigated whether the application of a home-based telemonitoring system could decrease hospital admissions and emergency room visits in 30 patients with severe congestive heart failure compared with 51 patients with congestive heart failure who received standard therapy. Emergency room visits (1 vs 11) and hospitalizations (13 vs 36) were decreased in the telemonitored group (both p <0.05).

Blue rubber bleb nevus (Bean syndrome): evolution of four cases and clinical response to pharmacologic agents.

Blue rubber bleb nevus (BRBN) syndrome is a rare disorder characterized by distinctive cutaneous and gastrointestinal vascular malformations. The latter may lead to bleeding complications. We followed four affected children for at least 5 years. The evolution of their disease and the value of pharmacologic agents (steroids, interferon) in the management of some of these patients are discussed.

Low incidence of myocardial recovery after left ventricular assist device implantation in patients with chronic heart failure.

BACKGROUND: Mechanical, histological, and biochemical improvement has been described in patients after left ventricular assist device (LVAD) support. Explantation of the LVADs without heart transplantation has been described in selected patients who received this therapy as a bridge to transplantation. METHODS AND RESULTS: A retrospective review of patients receiving a mechanical bridge to transplantation at Columbia Presbyterian Hospital after July 21, 1991, was performed to determine the incidence of patients in whom the device was successfully explanted. From August 1, 1996, to February 1, 1998, we prospectively attempted to identify potential explant candidates by the use of exercise testing. During this time, we recruited 39 consecutive patients after insertion of the Thermo Cardiosystems vented electric device to participate in the following study. Approximately 3 months after device implantation, a maximal exercise test with hemodynamic monitoring and respiratory gas analysis was performed with the LVAD in the automated mode. The electric device was interfaced with a pneumatic console such that the rate could be decreased to 20 cycles/min. Hemodynamic measurements were recorded as the device rate was decreased. A repeat exercise test was then performed if the patient remained hemodynamically stable. A retrospective chart review of 111 LVAD recipients at our institution identified only 5 successful explant patients. Eighteen of the 39 patients were studied. Fifteen patients exercised with maximal device support. At peak exercise, VO2 averaged 14.5+/-3.6 mL. kg-1. min-1; LVAD flow, 8.0+/-1.3 L/min; Fick cardiac output, 11.4+/-3.3 L/min; and pulmonary capillary wedge pressure, 13+/-4 mm Hg. Seven patients remained normotensive and could exercise at a fixed rate of 20 cycles/min. In these patients, peak VO2 declined from 17.3+/-3.9 to 13.0+/-6.1 mL. kg-1. min-1. In one of these patients, the device was explanted. CONCLUSIONS: Significant myocardial recovery after LVAD therapy in patients with end-stage congestive heart failure occurs in a small percentage of patients. Most of these patients have dilated cardiomyopathy. Exercise testing may be a useful modality to identify those patients in whom the device can be explanted.

Manifestaciones cutáneas: clave diagnóstica en pacientes oncológicos pediátricos con candiasis sistémica / Cutaneous manifestations: diagnostic keys in pediatroc oncologic patients with systemic candidiasis

Se describen tres pacientes con leucemia aguda y neutropenia prolongada que presentaron lesiones cutáneas en el curso de una candidiasis sistémica.Se destaca el valor de la biopsia de la lesión para su estudio microbiológico y anatomopatológico a fin de confirmar el diagnóstico de la infección candidiásica y orientar la terapéutica en pacientes pediátricos inmunocomprometidos

Manifestaciones cutáneas: clave diagnóstica en pacientes oncológicos pediátricos con candiasis sistémica / Cutaneous manifestations: diagnostic keys in pediatroc oncologic patients with systemic candidiasis

Se describen tres pacientes con leucemia aguda y neutropenia prolongada que presentaron lesiones cutáneas en el curso de una candidiasis sistémica.Se destaca el valor de la biopsia de la lesión para su estudio microbiológico y anatomopatológico a fin de confirmar el diagnóstico de la infección candidiásica y orientar la terapéutica en pacientes pediátricos inmunocomprometidos

Método rapido para el análisis de variantes genomicas del virus del papiloma / Rapid method for variant genome analysis of papilloma virus

Se ha desarrollado un método rápido y eficiente para la extracción de ADN de virus del papiloma presente en tumores. La cantidad y la calidad del ADN extraído permitió realizar el análisis directo del genoma viral con tres enzimas de restricción. Se discute la utilidad de esta técnica para realizar estudios clínicos

Método rapido para el análisis de variantes genomicas del virus del papiloma / Rapid method for variant genome analysis of papilloma virus

Se ha desarrollado un método rápido y eficiente para la extracción de ADN de virus del papiloma presente en tumores. La cantidad y la calidad del ADN extraído permitió realizar el análisis directo del genoma viral con tres enzimas de restricción. Se discute la utilidad de esta técnica para realizar estudios clínicos (AU)

[Incontinentia pigmenti. Concerning 9 new cases, 2 of them associated with different genetic syndromes]. / Incontinencia pigmenti. Acerca de nueve observaciones, dos de ellas asociadas a diferentes síndromes genéticos.

Nine girls with Incontinentia Pigmenti are presented, two of them associated to different genetic syndromes. All the patients are female, characteristic of genetic transmission, linked to dominant x, lethal for males; one of the patients also presents the Larsen Syndrome and another has got her illness associated to the Chotzen Syndrome; in these cases we can observe the coexistence of two syndromes, genetically determined. A revision of the clinical, histopathological and genetic characteristics of this disease is made.

Hipoplasia dermica focal en una recien nacida. / Focal dermal hypoplasia in a newborn infant

Se presenta un caso de hipoplasia dermica focal en una recien nacida internada en nuestro Hospital. En su primer examen se comprueban lesiones ectodermicas ampollares y ulceradas repartidas en tronco y miembros con disposicion lineal, zoniforme y alteraciones mesodermicas oculares y esqueleticas

Hipoplasia dermica focal en una recien nacida. / Focal dermal hypoplasia in a newborn infant

Se presenta un caso de hipoplasia dermica focal en una recien nacida internada en nuestro Hospital. En su primer examen se comprueban lesiones ectodermicas ampollares y ulceradas repartidas en tronco y miembros con disposicion lineal, zoniforme y alteraciones mesodermicas oculares y esqueleticas

Sifilis congenita, periodo 1975-1979 en el Hospital de Ninos de Buenos Aires. / Congenital syphilis, period 1975-1979 in the Hospital de Ninos de Buenos Aires

Los autores refieren la estadistica del periodo comprendido entre 1975 y 1979 de ninos internados con diagnostico de sifilis congenita precoz, en el Hospital de Ninos de Buenos Aires. Durante ese periodo se trataron 54 pacientes, en su gran mayoria provenientes de la ciudad de Buenos Aires y su conurbano, pertenecientes en general, a grupos socioeconomicos con menores posibilidades. Las manifestaciones clinicas mas frecuentes fueron hepatomegalia en 51 ninos, ictericia en 49, esplenomegalia en 47 y anemia en 36, mientras que las expresiones dermatologicas predominantes fueron el penfigoide en 27 ninos, la roseola y la sifilides papulosas en 24. En los 54 pacientes, la VDRL fue reactiva con valores que oscilaron entre las 16 y 1.024 unidades, obteniendose la curacion de los mismos con el empleo de penicilina G. sodica con una dosis total de 3.000.000 de unidades

Displasia ectodermica hipohidrotica. / Hypohidrotic ectodermal dysplasia

La displasia ectodermica hipohidrotica o anhidrotica es una enfermedad genetica ligada al X o que se transmite por herencia autosomica recesiva caracterizada por ausencia del sudor, denticion defectuosa e hipotricosis, que constituyen la triada caracteristica. Estos enfermos presentan una facie llamativa, con frente olimpica, puente nasal prominente y aplanado, procesos alveolomaxilares hipoplasicos, mejillas hundidas y marcados pliegues delgados periarticulares. La piel es seca, fina y arrugada, con hiperpigmentacion.Las alteraciones del cabello y el vello consisten en alopecia de grado variable, con pelo ralo, escaso, rubio, fino, seco o fragil.Se presentan tres pacientes afectados con esta enfermedad, detallandose sus caracteristicas clinicas, histologicas y geneticas

Sifilis congenita, periodo 1975-1979 en el Hospital de Ninos de Buenos Aires. / Congenital syphilis, period 1975-1979 in the Hospital de Ninos de Buenos Aires

Los autores refieren la estadistica del periodo comprendido entre 1975 y 1979 de ninos internados con diagnostico de sifilis congenita precoz, en el Hospital de Ninos de Buenos Aires. Durante ese periodo se trataron 54 pacientes, en su gran mayoria provenientes de la ciudad de Buenos Aires y su conurbano, pertenecientes en general, a grupos socioeconomicos con menores posibilidades. Las manifestaciones clinicas mas frecuentes fueron hepatomegalia en 51 ninos, ictericia en 49, esplenomegalia en 47 y anemia en 36, mientras que las expresiones dermatologicas predominantes fueron el penfigoide en 27 ninos, la roseola y la sifilides papulosas en 24. En los 54 pacientes, la VDRL fue reactiva con valores que oscilaron entre las 16 y 1.024 unidades, obteniendose la curacion de los mismos con el empleo de penicilina G. sodica con una dosis total de 3.000.000 de unidades