PubMed · 15731120
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Peter Lapsley. 2005-02-24. Itching for a solution.. https://doi.org/10.1136/bmj.38391.604826.7c
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Acquired inhibitors of coagulation factors, particularly to factor V (FV) and thrombin, after topical bovine thrombin exposure may result in clinically important coagulopathies. While bovine thrombin is commonly used in pediatric patients for surgical hemostasis, the reported cases of acquired inhibitors in children are few. We report two cases of children who developed factor inhibitors after bovine thrombin exposure. One child developed a FV inhibitor at 3 months of age after exposure to bovine thrombin during cardiac surgery. The inhibitor resolved with intravenous immunoglobulin (IVIG) and steroids. The other child developed concomitant FV and bovine thrombin inhibitors after cardiac surgery at age 11 years. The presence of these inhibitors complicated post-operative anti-coagulation management, but the inhibitors were transient. In addition to these two cases, we identified all the pediatric patients with bovine thrombin-induced inhibitors who were reported in the world's literature, and reviewed their clinical characteristics. These cases underscore the fact that bovine thrombin can be antigenic in infants and children and can result in significant coagulopathies.
Iatrogenic nasal vestibular stenosis is an uncommon complication of supportive care in neonates. There is minimal literature describing this entity; previous treatment strategies focus on correction with local flaps or skin grafts. We describe symptomatic iatrogenic vestibular stenosis treated successfully with endoscopic lysis of synechiae and nasal stenting. Three children with nasal stenosis were identified from 2003 to 2004 at a large academic tertiary care medical center. All patients were born premature (25-34 weeks). Two developed vestibular stenosis after extended use of nasal CPAP; one developed unilateral nasal stenosis 4 years after use of a nasal feeding tube. Age at time of surgical repair was from 4 months to 5 years. Two patients (4 and 5 months) presented with nasal airway obstruction, and difficulty breathing during feeding. One patient (5 years) presented with right-sided nasal obstruction and nasal whistling. Endoscopic lysis of nasal synechiae and release of vestibular scarring was performed in all three cases without complication. Nasal stenting with a modified endotracheal tube was used for 4-6 weeks. Topical Mitomycin C was utilized in two patients. All patients had complete resolution of airway symptoms after stent removal and all three remain asymptomatic 1 year after repair with no recurrence of vestibular stenosis. Nasal vestibular stenosis is a rare complication following supportive care in premature infants, causing airway and feeding difficulties in the obligate nasal breather. This can be successfully corrected with endoscopic repair, nasal stenting and application of Mitomycin C.
Efficient transdermal drug delivery of large hydrophilic drugs is challenging. Here we report that the short synthetic peptide, ACSSSPSKHCG, identified by in vivo phage display, facilitated efficient transdermal protein drug delivery through intact skin. Coadministration of the peptide and insulin to the abdominal skin of diabetic rats resulted in elevated systemic levels of insulin and suppressed serum glucose levels for at least 11 h. Significant systemic bioavailability of human growth hormone was also achieved when topically coadministered with the peptide. The transdermal-enhancing activity of the peptide was sequence specific and dose dependent, did not involve direct interaction with insulin and enabled penetration of insulin into hair follicles beyond a depth of 600 microm. Time-lapse studies suggested that the peptide creates a transient opening in the skin barrier to enable macromolecular drugs to reach systemic circulation.