The imidazole ring provides water ing emergence and recovery are less common in solubility in acidic solutions and lipid solubility at children and in patients premedicated with benzo- physiological pH order discount zoloft on line slender anxiety. Terefore etomidate is dissolved diazepines or those in whom ketamine is combined in propylene glycol for injection buy cheapest zoloft definition depression bei kindern. Of the nonvola- causes pain on injection that can be lessened by a tile agents buy genuine zoloft depressive symptoms definition, ketamine comes closest to being a “com- prior intravenous injection of lidocaine. Absorption Drug Interactions Etomidate is available only for intravenous admin- Ketamine interacts synergistically (more than addi- istration and is used primarily for induction of gen- tive) with volatile anesthetics but in an additive eral anesthesia (see Table 9–3). Diazepam and midazolam attenuate Although it is highly protein bound, etomidate is ketamine’s cardiostimulatory efects and diazepam characterized by a very rapid onset of action due to prolongs ketamine’s elimination half-life. Etomidate plasma kinetics are well explained suppression in that circumstance appeared. Hepatic microsomal enzymes and plasma esterases rapidly hydrolyze etomidate to an inactive metabolite. Excretion Fentanyl increases the plasma level and prolongs the elimination half-life of etomidate. Opioids The end products of etomidate hydrolysis are pri- decrease the myoclonus characteristic of an etomi- marily excreted in the urine. Cardiovascular Etomidate has minimal efects on the cardiovascu- Mechanisms of Action lar system. A mild reduction in peripheral vascular Propofol induction of general anesthesia may resistance is responsible for a slight decline in arterial involve facilitation of inhibitory neurotransmission blood pressure. Tis receptor, as previously noted, A in large doses, produces relatively light anesthesia is coupled to a chloride channel, and activation of for laryngoscopy, and marked increases in heart rate the receptor leads to hyperpolarization of the nerve and blood pressure may be recorded when etomidate membrane. Propofol (like most general anesthetics) provides the only anesthetic depth for intubation. Ventilation is afected less with etomidate than with barbiturates or benzodiazepines. Even induction Structure–Activity Relationships doses usually do not result in apnea unless opioids Propofol consists of a phenol ring substituted with have also been administered. Cerebral not water soluble, but a 1% aqueous solution (10 Etomidate decreases cerebral metabolic rate, cere- mg/mL) is available for intravenous administration bral blood fow, and intracranial pressure. Tis formulation will mon following etomidate than following propofol ofen cause pain during injection that can be or barbiturate induction. Etomidate lacks analgesic decreased by prior injection of lidocaine or less properties. Propofol formulations can support the 6 Induction doses of etomidate transiently growth of bacteria, so sterile technique must 5 inhibit enzymes involved in cortisol and aldo- be observed in preparation and handling. Sepsis and death have been linked to con- neurosurgical patients has been associated with spo- taminated propofol preparations. Current formula- radic cases of lipemia, metabolic acidosis, and death, tions of propofol contain 0. Excretion additives do not render the product “antimicrobi- Although metabolites of propofol are primarily ally preserved” under United States Pharmacopeia excreted in the urine, chronic kidney failure does standards. Cardiovascular Propofol is available only for intravenous adminis- The major cardiovascular efect of propofol is a tration for the induction of general anesthesia and decrease in arterial blood pressure due to a drop in for moderate to deep sedation (see Table 9–3). Awakening reversed by the stimulation accompanying laryngos- from a single bolus dose is also rapid due to a very copy and intubation. Most fol-induced hypotension include large doses, rapid investigators believe that recovery from propofol is injection, and old age. Propofol markedly impairs the more rapid and is accompanied by less “hangover” normal arterial barorefex response to hypotension. A smaller induction dose is cardiac output are usually transient and insignifcant recommended in elderly patients because of their in healthy patients but may be severe in patients at the smaller Vd. Although tries other than the United States, a device called myocardial oxygen consumption and coronary blood the Diprifusor is ofen used to provide target (con- fow usually decrease comparably, coronary sinus lac- centration) controlled infusion of propofol. The tate production increases in some patients, indicating user must enter the patient’s age and weight and some mismatch between myocardial oxygen supply the desired target concentration. Propofol is a profound respiratory depressant that usually causes apnea following an induction dose. Biotransformation Even when used for conscious sedation in sub- The clearance of propofol exceeds hepatic blood anesthetic doses, propofol inhibits hypoxic venti- fow, implying the existence of extrahepatic metabo- latory drive and depresses the normal response to lism. As a result, only properly educated and contributes to relatively rapid recovery afer con- qualifed personnel should administer propofol for tinuous infusions. Propofol-induced depression of upper in inactive metabolites that are eliminated by renal airway refexes exceeds that of thiopental, allowing clearance. The pharmacokinetics of propofol do not intubation, endoscopy, or laryngeal mask placement appear to be afected by obesity, cirrhosis, or kidney in the absence of neuromuscular blockade. Cerebral other competing agents has not yet been established Propofol decreases cerebral blood fow and intracra- in clinical practice. Propofol and thiopen- tal probably provide a similar degree of cerebral pro- Premedication of the Surgical Patient tection during experimental focal ischemia. Unique An extremely anxious 17-year-old woman pres- to propofol are its antipruritic properties. She demands to emetic efects (requiring a blood propofol concen- be asleep before going to the operating room tration of 200 ng/mL) provide yet another reason for and does not want to remember anything. Induction is occasionally accompanied by excitatory What are the goals of administering phenomena such as muscle twitching, spontaneous preoperative medication? Although Anxiety is a normal response to impending sur- these reactions may occasionally mimic tonic–clonic gery. Diminishing anxiety is usually the major goal seizures, propofol has anticonvulsant properties and of preoperative medication. For many patients, the has been used successfully to terminate status epi- preoperative interview with the anesthesiologist lepticus. Propofol may be safely administered to allays fears more eﬀectively than sedative drugs. Propofol decreases intraocular Preoperative medication may also provide relief of pressure. Tolerance does not develop afer long-term preoperative pain or perioperative amnesia. The goals of preoperative medication Fentanyl and alfentanil concentrations may be depend on many factors, including the health and increased with concomitant administration of pro- emotional status of the patient, the proposed sur- pofol. Many clinicians administer a small amount of gical procedure, and the anesthetic plan. For this midazolam (eg, 30 mcg/kg) prior to induction with reason, the choice of anesthetic premedication propofol; midazolam can reduce the required pro- must be individualized and must follow a thorough pofol dose by more than 10%. Some patients dread Fospropofol is a water-soluble prodrug that is intramuscular injections, and others ﬁnd altered metabolized in vivo to propofol, phosphate, and states of consciousness more unpleasant than formaldehyde.
Penciclovir is also available rate is high discount zoloft 25 mg fast delivery anxiety disorders, the genome is small purchase zoloft online from canada depression screening definition, the virus will develop as a cream for treatment of labial herpes simplex generic 25mg zoloft visa depression screening test elderly. The most frequently used combinations employ progression and prolong survival by suppressing the a backbone of two nucleoside analogue reverse replication of the virus. Where resources permit, access to safe websites listed in the Guide to further reading). Protease inhibitors can guide the choice of drug regimen, especially after disturb lipid and glucose metabolism to a degree that virological failure. Zidovudine is well absorbed from conditions is referred to elsewhere in this text. The drug is inactivated development of new infections or worsening mainly by glucuronidation in the liver, but 20% is excreted opportunistic infections, e. Rarely, a syndrome of hepatic necrosis chain, causing premature chain termination. While all nu- with lactic acidosis may occur with zidovudine (and with cleoside reverse transcriptase inhibitors require activation other reverse transcriptase inhibitors). Resistance develops tract (30–40%) and is widely distributed in body water; rapidly when used as monotherapy through the sequential 30–65% is recovered unchanged in the urine. Didanosine may tions at codon 184 selected by lamivudine and emtricita- causepancreatitis,lacticacidosis,hepatomegalywithsteato- bine therapy enhance susceptibility to zidovudine (and sisandperipheralneuropathy. Retinal 2For a comprehensive review, see Kaplan J E, Benson C, Holmes K H et al changes and optic neuritis have also been reported. A nucleoside backbone of lamivudine with been described following cessation of therapy for hepatitis zidovudine (Combivir), abacavir (Kivexa) or emtricita- B infection. The drug is well absorbed from the gastrointestinal Stavudine tract (86%) and excreted mainly by the kidney with min- Stavudine (d4T) inhibits reverse transcriptase by com- imal metabolism; dose modification is necessary in renal peting with the natural substrate deoxythymidine tri- impairment. Troublesome lipoatrophy has limited its use by which it should be used in combination with tenofovir most authorities outside the developing world. Lactic acidosis and severe hepa- tomegaly with steatosis, including fatal cases, have been Adefovir reported. It is administered as the oral pro- drug (plasma t½ 8 h, intracellular t½ of active metabolite 17 h). Adverse effects are uncommon, but include head- Emtricitabine ache, abdominal pain and diarrhoea. Resistance emerges Emtricitabine has a similar structure, tolerability, efficacy over time (30% after 5 years), but much less commonly and resistance profile. It should not be used in combination than with lamivudine therapy, possibly due to the flexibil- with lamivudine, as it contains the same active constituent. Efavirenz is terato- of 2–4 h, except for fosamprenavir (8 h) and atazanavir genic, so should be avoided in pregnancy. The drugs have broadly similar therapeutic sociated with mutations at codon 103 and 181, which also effects. Nevirapine is initially com- asymptomatic reversible unconjugated hyperbilirubinaemia menced as a once-daily regimen, with a 2-week lead-in pe- with atazanavir and nephrolithiasis with indinavir. Rash (including Stevens– Johnson syndrome) is seen in up to 20% of patients and, Interactions. Due to potentially ase inhibitors (called ritonavir ‘boosting’ or ‘potentiation’), significant drug interactions, etravirine should not be i. Ritonavir boosting is now a recommended treatment Entry inhibitors standard for all protease inhibitor containing regimens. The drugs Adverse effects are usually limited to mild injection-site have considerably longer half-lives when compared to reactions, although hypersensitivity, peripheral neuropa- nucleoside reverse transcriptase inhibitors. Hence by interfering with the uncoating and release of viral a ‘Trofile assay’ is required to determine if a susceptible genome into the host cell. Following the emergence of the 2009 influenza It is recommended as part of a combination regimen in A (H1N1) virus as the predominant circulating strain, re- treatment-experienced patients with multidrug-resistant sistance to amantadine is now almost universal; for this strains. Adverse reactions include dizziness, nervousness, light- Integrase inhibitors headedness and insomnia. Zanamivir is a viral neuraminidase inhibitor that blocks Fixed-dose combinations of antiretroviral drugs are both entry of influenza A and B viruses to target cells and convenient, help to lessen pill burden and may improve the release of their progeny. It is administered as a dry compliance, but the components of the combination powder twice daily in a 5-day course by a special inhaler. The duration of when use in patients with renal or hepatic impairment is symptoms is reduced from about 6 to 5 days, with a smaller proposed. In high-risk groups the reduction in duration of symptoms is a little greater, and fewer patients need Fixed-dose combination antiretrovirals antibiotics. It is also effective for prophylaxis given as a Combivir zidovudine and lamivudine once-daily inhalation. Atripla tenofovir and emtricitabine and • Only those presenting within 48 h of the onset of efavirenz influenza-like symptoms. Kaletra lopinavir and ritonavir Zanamivir retains activity against amantadine-resistant and some oseltamivir-resistant strains. Unwanted effects are uncommon, but bronchospasm may be precipitated in asthmatics, and gastrointestinal dis- turbance and rash are occasionally seen. It reduces the severity and duration of symptoms although their clinical effectiveness is not high. The two caused by influenza A or B in adults and children if com- antiviral drugs oseltamivir and zanamivir were widely menced within 36 h of the onset of symptoms. More spe- used for the public health control of the 2009 influenza cifically, the risk of respiratory complications such as A (H1N1) pandemic. A combined approach that might be appropriate for health-care workers and of ganciclovir-releasing intraocular implant plus oral those especially likely to suffer serious complications from valganciclovir is sometimes considered in patients with pre-existing illness. Oseltamivir is one option for treatment and prophylaxis Adverse reactions include neutropenia and thrombo- of avian H5N1 and 2009 influenza A (H1N1) virus. So far, this mutation appears to be confined mostly to seasonal influenza A H1N1 strains, with Foscarnet finds use i. It is generally less well tolerated than ganciclovir; adverse effects include renal toxicity (usually reversible), Peramivir is an experimental neuraminidase inhibitor nausea and vomiting, neurological reactions and marrow formulated for intravenous use and currently undergoing suppression. Foscarnet causes a contact dermatitis which can lead influenza A (H1N1) infection where oseltamivir or zana- to unpleasant genital ulcerations due to high urine drug mivir therapy has failed or the inhalational or oral routes concentrations; this is potentially preventable with good are considered unreliable. It Ganciclovir resembles aciclovir in its mode of action, but is has also been used i. Fomivirsen Valganciclovir is an oral prodrug of ganciclovir that provides systemic concentrations almost as high as those Fomivirsen, an antisense oligonucleotide, is available in following i. Over 50% of patients with hepatitis C re- coexisting illnesses, such as immunosuppression. Systemic spond to the combination of pegylated interferon plus absorption by the inhalational route is negligible. Hepatitis D (d agent co-infection with hepatitis virus) and, when combined with interferon a-2b or peg- B) requires a much larger dose of interferon to obtain a interferon, for chronic hepatitis C infection (see below). It response, and relapse may yet occur when the drug is with- does not cross the blood–brain barrier, so is unlikely to drawn.
The rationale behind the use of preoperative exercise is the improvement in exercise tolerance and functional capacity of the patient buy zoloft master card clinical depression symptoms yahoo. A recent meta-analysis concluded that inspiratory muscle training discount zoloft 50mg without prescription anxiety in the bible, aerobic activity cheap zoloft 50mg with visa anxiety stomach problems, and/or resistance training are asso- ciated with reduction of postoperative complications after abdominal surgery though evidence for association with length of stay was unclear. A recent Cochrane review concluded that preoperative immunonutrition reduces complications and length of hospital stay in patients undergoing gastrointestinal surgery but the evidence in those subset of patients who may need critical care is equivocal. Reduced fasting times are now almost universally recommended (with few exceptions) to avoid this metabolic effect. The theoretical risk of aspiration with reduced fasting times does not have any substantive evidence. In adult patients who fast for 2–4 hours, the gastric volumes are lower and pH is higher than in patients fasting for more than 4 hours. Similarly in children who fast between 2 hours and 4 hours, the gastric pH is higher than in patients with >4 hours fasting. Avoidance of Mechanical Bowel Preparation This was earlier used routinely before colorectal surgery to reduce the fecal content in the gut. This however has adverse effects such as dyselectrolytemia, 156 Yearbook of Anesthesiology-6 dehydration and discomfort. A single daily dose of enoxaparin 20 mg is started the night before surgery (along with compression stockings) and continued for the entire duration of hospital stay. Other authors have recommended that all patients undergo risk stratification using a screening tool such as Caprini score. It is suggested that all patient with a Caprini score >4 receive appropriate thromboprophylaxis. The direct-acting oral anticoagulants, comprising dabigatran, rivaroxaban and apixaban, may be used in hip or knee arthroplasty. Antibiotic Prophylaxis A single preoperative dose of antibiotic covering both aerobic and nonaerobic pathogens typically 1st generation cephalosporin or amoxicillin-clavulanic is recommended within 60 minutes of skin incision. Additional doses are recommended in obesity, prolonged surgery (4 hours) or severe blood loss (>1500 mL). Longer course of antibiotics are no longer recommended as they are associated with risk of infections such as with C. The patients are shifted to the preoperative area in a wheelchair to promote active mobilization up to the immediate preoperative period. Enhanced Recovery After Surgery 157 Perioperative Anesthesia Technique Balanced anesthesia technique with use of short acting opioids (Remifentanil/ Fentanyl) should be used to allow quick recovery. For maintenance of anesthesia, inhalational agents like sevoflurane/desflurane or intravenous propofol infusion can be used. Nitrous oxide is best avoided especially in long duration and laparoscopic surgeries to avoid bowel distention and postoperative nausea vomiting. There is moderate evidence to suggest intraoperative use of lung protective ventilation using low tidal volumes (5–7 mL/kg). For laparoscopic surgeries, uses of epidural needs to be individualized as benefits are less clear. Surgical Approach Use of laparoscopic and minimally invasive technique is preferred. For open procedures, either a transverse or a smaller vertical incision is recommended. Use of nasogastric tube in the postoperative period does not prevent bowel leak or wound dehiscence but may lead to complications like pneumonia and is best avoided. Avoidance of nasogastric tube and abdominal drain helps in early mobilization of the patients. High Inspired Oxygen High inspired oxygen is shown to improve blood flow at the anastomotic site and reduces risk of wound infections. In a review on this topic, it was reported that administration of 80% FiO2 doubled the subcutaneous tissue oxygen tension and halved the rate of local infection. Supplemental oxygen administration was not associated with clinically significant side effects. However, there is lack of consensus on duration and concentration of perioperative oxygen. Perioperative Fluid Administration Fluid therapy is an integral part of enhanced recovery program. Goal of fluid management is to provide optimal circulatory volume (without over/under hydration) referred to as “zero balance approach’’. Recent studies have shown that excessive fluid administration can be associated with poor healing of intestinal anastomosis and prolonged ileus. Evidence suggests that it can increase postoperative morbidity and lengthen the hospital stay after major abdominal surgery. Hypotension associated with general anesthesia or epidural should be treated with vasoconstrictors rather than fluids. The reason behind this change is two-fold, one is the cause of this hypotension, which is vasodilatation and loss of 158 Yearbook of Anesthesiology-6 body’s physiological ability to compensate for it due to effects of anesthesia and second is the change in practice of prolonged preoperative fasting period. A well prepared patient with 2 hours fasting will remain euvolemic and well hydrated. Management of anesthesia induced hypotension using vasoconstrictors is associated with reduced postoperative complications and length of stay in the hospital. A recent meta-analysis of goal directed fluid therapy on bowel function after abdominal surgery shows that it facilitates gut recovery. Though, in the setting of enhanced recovery protocol, its value still needs to be proven. Early feeding reduces anastomotic dehiscence, infection and length of hospital stay. A balanced salt solution is the ideal fluid in the perioperative period as normal saline has been associated with sodium load, hyperchloremia, metabolic acidosis and poor outcomes. Indications and role of colloid therapy are not very clear in the context of enhanced recovery. Prevention of Hypothermia Hypothermia is a common problem encountered in open abdominal procedures due to altered physiological mechanisms of thermoregulation under the effects of general as well as regional anesthesia and rapid infusion of intravenous fluids. Hypothermia not only alters drug metabolism but also impairs immunity and has adverse effects on coagulation and cardiovascular system. Studies show that hypothermia can lead to increased metabolic demand, cardiovascular complications, wound infection and increased demand for blood transfusion. Preventive measures include monitoring of temperature throughout the peri- operative period using esophageal probe to monitor core temperature, use of passive as well as active warming techniques. Use of several layers of drapes and fluid air warming systems along with warming of intravenous fluids can be used in sync to maintain normothermia. Nausea and Vomiting Prophylaxis Incidence of nausea and vomiting ranges from 10% to 20% in fast-track surgeries. Nausea and vomiting not only causes significant patient dissatisfaction but can also result in higher risk of aspiration and bowel dehiscence. Total intravenous anesthesia with propofol, should also be considered instead of volatile anesthetics.
Most authorities also use local or the differential diagnosis of infantile orbital tumors order zoloft cheap depression test india. Its natu- systemic corticosteroids or intralesional injection of cortico- ral course is similar to the superﬁcial variant order zoloft 100mg otc bipolar depression 2, with fairly rapid steroids to hasten regression of capillary hemangioma of the growth followed by regression generic 50 mg zoloft otc mood disorder questionnaire. However, occasional complications of Complications intralesional corticosteroids include central retinal artery obstruction (16,17), linear perilymphatic subcutaneous fat The main complications of periocular capillary hemangioma atrophy (18,19), eyelid depigmentation (20), eyelid necrosis are strabismus and amblyopia. As an alterna- ondary to tumor impingement on the rectus muscles or sec- tive, topical corticosteroids have been occasionally used ondary to amblyopia. Intralesional interferon -2a and -2b have also been tumor obstructing the pupil or a result of the anisometropia used for capillary hemangioma that is unresponsive to corti- induced by the compression of the globe by the tumor. Laser therapy has been advocated for refractive error often persists even after the hemangioma has some cutaneous hemangiomas (30–32). Finally, although surgical removal has historically been discouraged, there is a valid argument to manage selected Differential Diagnosis periorbital capillary hemangiomas by surgical resection When the eyelid skin is involved by the typical red lesion, the (33–36). An indication for surgical resection may be a circum- diagnosis is generally quite evident. The differential diagnosis scribed subcutaneous hemangioma that is enlarging in a very of deeper capillary hemangioma includes several other child- young infant. Such a tumor is destined to become very large Chapter 8 Vascular Tumors of the Eyelids 133 before it regresses and early complete surgical removal can avoid more difﬁcult management of a larger tumor and worse amblyopia. An eyelid crease incision, with removal of the mass intact if possible, and closure of the skin with ﬁne absorbable sutures can achieve a very satisfactory outcome (35). However, surgical resection should generally be avoided for larger superﬁcial lesions that have extensive involvement of the epi- dermis. Interferon-alfa treatment of facial infantile haemangiomas: with emphasis on the sight-threatening varieties. Early surgical intervention as deﬁn- of the eyelid, scalp, and digits in premature triplets. A unique microvascular phenotype shared by juvenile hemangiomas and human placenta. Local injection of steroids for juvenile hemangiomas which disturb the visual axis. Steroid injection versus con- servative treatment of anisometropia amblyopia in juvenile adnexal heman- gioma. Capillary haemangioma of the eyelids and orbit: a clinical review of the safety and efﬁcacy of intralesional steroid. Bilateral retinal embolization associated with intralesional corticosteroid injection for capillary heman- gioma of infancy. Diagnosis and treatment of an oph- thalmic artery occlusion during an intralesional injection of corticosteroid into an eyelid capillary hemangioma. Linear subcutaneous fat atrophy after corticosteroid injection of periocular hemangiomas. Perilymphatic subcutaneous atrophy in adnexal heman- gioma: a complication of intralesional corticosteroid injection. Eyelid depigmentation following corticosteroid injec- tion for infantile ocular adnexal hemangioma. Eyelid necrosis following intralesional corticosteroid injection for capillary hemangioma. Adrenal suppression and growth retardation after injection of periocular capillary hemangioma with corticosteroids. Adrenal suppression and failure to thrive after steroid injections for periocular hemangioma. Treatment of periocular capillary heman- gioma with topical clobetasol propionate. Corticosteroid resistant orbital heman- gioma with proptosis treated with interferon alfa-2-a and partial tarsorrha- phy. Recombinant interferon alfa-2b in the treatment of vision-threatening capillary hemangiomas in childhood. Chapter 8 Vascular Tumors of the Eyelids 135 ■ Eyelid Congenital Capillary Hemangioma: Superﬁcial Type The superﬁcial type of capillary hemangioma (strawberry hemangioma) has typical clinical features and can show dramatic spontaneous regression. The upper eyelid is being everted showing diffuse involvement of involved tarsal conjunctiva. It is necessary to evert the eyelid in such cases to determine the full extent of the lesion. This can look similar to hemorrhage into a lymphangioma, but the lesion had slowly progressed and had no acute bleeding episodes. Chapter 8 Vascular Tumors of the Eyelids 137 ■ Eyelid Congenital Capillary Hemangioma: Regression of Superﬁcial Type Figure 8. Same child at age 3 years, showing complete resolution of ing larger capillary hemangioma that rapidly developed on left upper the lesion. Chapter 8 Vascular Tumors of the Eyelids 139 ■ Eyelid Congenital Capillary Hemangioma: Surgical Removal Sometimes a capillary hemangioma can be resected entirely with a good result without waiting for it to grow to a large size. Acquired capillary haemangioma of the eyelid in an adult treated with cutting diathermy. Br J Ophthalmol 2000;84: gioma) is a common cutaneous lesion in middle aged and older 1322. It occurs in varying numbers in virtually all adults, but the lesions are small and often ignored. The num- ber varies from 1 to 2 in children to hundreds in some elderly individuals. It occurs most commonly on the trunk and extremities, but can occasionally affect the eyelids and peri- ocular region. It can range in size from barely visible to a dome-shaped red mass 5 mm in diameter (3). Clinical Features Solitary acquired hemangioma of the eyelid appears as a dis- tinct red to red-blue papule that may range from 0. Eyelid acquired heman- gioma has been observed to develop and rapidly enlarge dur- ing pregnancy (6). Pathology In its early stages, acquired hemangioma is very similar histopathologically to the congenital capillary hemangioma of infancy, having numerous newly formed capillaries with nar- row lumina and prominent endothelial cells arranged in a lob- ular fashion in the subpapillary region (3). In a fully matured lesion, the vascular lumina become dilated, the endothelial cells more ﬂattened, and the stroma becomes edematous and hyalinized. Some authorities consider the acquired heman- gioma to be closely related to pyogenic granuloma, but it gen- erally shows less endothelial proliferation than the latter (4). The term “capillary hemangioma of the pyogenic granuloma type” has been applied to this lesion (3). Management Management of most acquired hemangiomas is simple peri- odic observation, because they are generally small and have no malignant potential.