A History of Umbilical Vein Catheterization Does Not Preclude Children from a Successful Meso-Rex Bypass

INTRODUCTION

 Umbilical vein catheterization (UVC) can cause portal venous thrombosis, leading to the development of extrahepatic portal venous obstruction (EHPVO) and portal hypertension (PHT). The feasibility of the Meso-Rex bypass (MRB) for the treatment of EHPVO in patients with a history of UVC has been questioned. We compared the feasibility of performing an MRB in patients with or without a history of previous UVC.

METHODS

 A retrospective review of patients with EHPVO and known UVC status explored for a possible MRB at our institution was performed (1997-2022). Patients were categorized in two groups: with (UVC(+)) or without (UVC(-)) a history of UVC for comparison. A p-value less than 0.05 was considered significant.

RESULTS

 One hundred and eighty-seven patients were included (n = 57 in UVC(+); n = 130 in UVC(-)). Patients in the UVC group were significantly younger at surgery and the incidence of prematurity was higher. Other risk factors for the development of EHPVO were similar between the groups, but only history of UVC could predict the ability to receive MRB (odds ratio [OR]: 7.4 [3.5-15.4]; p < 0.001). The success rate of MRB was significantly higher in patients with no history of UVC (28/57 [49.1%] in UVC(+) vs. 114/130 [87.7%] in UVC(-); p < 0.001). However, MRB patency at discharge (25/28 [89.3%] in UVC(+) vs. 106/114 [94.7%] in UVC(-); p = 0.3) was equally high in both groups.

CONCLUSION

 Our results indicate that a history of UVC is not a contraindication to MRB. Half of the patients were able to successfully receive an MRB. Patients with symptomatic PHT from EHPVO should not be excluded from consideration for MRB based on UVC history.

Umbilical vein catheterisation for the family physician working in primary health care

This is part of a series of articles on vascular access in emergencies. The other two articles were on intra osseous lines and central venous lines. These are critical lifesaving emergency skills for the primary care professional. In this article, we will provide an overview of umbilical vein catheterisation highlighting its importance, the indications, contraindications, techniques, complications and nursing considerations. By familiarising healthcare providers with this procedure, we hope to enhance their knowledge and skills, ultimately leading to improved outcomes in the neonatal population.

Isolation and Culture of Human Umbilical Vein Endothelial Cells (HUVECs)

This protocol describes a simple and an economical method for isolation of endothelial cells from human umbilical vein. Umbilical cord is easily available postpartum following informed consent, and the method for its collection is noninvasive with few ethical concerns. Thus, umbilical vein is an ideal source for isolation of endothelial cells of human origin. Endothelial cells are isolated from umbilical vein by collagenase digestion. This is followed by their culture on extracellular matrix (ECM) protein coated tissue culture flasks in presence of endothelial cell growth medium. In the last few decades, human umbilical vein endothelial cells (HUVECs) have come to be regarded as a standard model system by vascular biologists to understand general principles of endothelial cell biology and dysfunction. Here, we describe isolation, culture, as well as validation of HUVECs.

Oleanolic acid rescues critical features of umbilical vein endothelial cells permanently affected by hyperglycemia

Skin wound healing is a physiological process that involves several cell types. Among them, endothelial cells are required for inflammation resolution and neo-angiogenesis, both necessary for tissue restoration after injury. Primary human umbilical vein endothelial cells (C-HUVECs) are derived from the umbilical cord. When women develop gestational diabetes, chronic exposure to hyperglycemia induces epigenetic modifications in these cells (GD-HUVECs), leading to a permanent pro-inflammatory phenotype and impaired angiogenesis in contrast to control cells. Oleanolic acid (OA) is a bioactive triterpenoid known for its epithelial cell migration promotion stimulation and higher tensile strength of wounds. However, the potentially anti-inflammatory and pro-angiogenic properties of OA are still under investigation. We tested OA on C- and GD-HUVECs under inflammatory conditions induced by low levels of the inflammatory cytokine TNF-α. Reduced expression of adhesion molecules VCAM1, ICAM1, and SELE was obtained in OA-pre-treated C- and GD-HUVECs. Additionally, protein VCAM1 levels were also decreased by OA. Coherently, monocyte adhesion assays showed that a lower number of monocytes adhered to GD-HUVEC endothelium under OA pre-treatment when compared to untreated ones. It is noteworthy that OA improved angiogenesis parameters in both phenotypes, being especially remarkable in the case of GD-HUVECs, since OA strongly rescued their poor tube formation behavior. Moreover, endothelial cell migration was improved in C- and GD-HUVECs in scratch assays, an effect that was further confirmed by focal adhesion (FA) remodeling, revealed by paxillin staining on immunocytochemistry assays. Altogether, these results suggest that OA could be an emergent wound healing agent due to its capacity to rescue endothelial malfunction caused by hyperglycemia.

Vasorelaxant effect of (E,E)-farnesol in human umbilical vein ex vivo assays

(E,E)-farnesol is a sesquiterpene acyclic alcohol produced by bacteria, protozoa, fungi, plants, and animals. The literature describes its applications in food, pharmaceutical, and cosmetic industries, and also in the pharmacological context with a vasorelaxant effect. However, its effects on human umbilical vessels remain poorly investigated. Thus, this study aims to investigate, in a new way, the vasorelaxant effect of (E,E)-farnesol in human umbilical veins (HUV) from healthy donors. Rings obtained from isolated HUV were suspended in an organ bath to record their isometric tension in different experimental sections. (E,E)-farnesol (1 μmol/L to 1 mmol/L) promoted vasorelaxant effect in venous preparations contracted by depolarization (KCl 60 mmol/L) or pharmacological agonism (5-HT 10 μmol/L), with EC50 values of 239.9 μmol/L and 424 μmol/L, respectively. In calcium-free solution, this effect was also observable. (E,E)-farnesol was able to suppress contractions evoked by CaCl2 and BaCl2 suggesting a blockade of voltage-dependent (especially L-type) calcium channels. The vasorelaxant efficacy and potency of (E,E)-farnesol were affected in the presence of tetraethylammonium (1 and 10 mmol/L), glibenclamide (10 μmol/L) and BaCl2 (1 mmol/L) indicating a possible involvement of potassium channels (BKCa, KATP and KIR) in this effect. Our data suggest that (E,E)-farnesol has a promising potential to be applicable as a vasodilator in hypertensive conditions in pregnancy that alter HUV reactivity.

The incidence and modifiable risk factors for necrotizing enterocolitis in preterm infants: a retrospective cohort study

OBJECTIVES

To evaluate the incidence and modifiable risk factors for Necrotizing enterocolitis (NEC) in preterm infants born at ≤32 weeks of gestation weighing <1500 grams, at a private tertiary care hospital in Kenya.

MATERIALS AND METHODS

This retrospective cohort study was conducted at the Aga Khan University Hospital Neonatal Intensive Care Unit (NICU). Preterm infants born at ≤ 32 weeks' gestation and weighing <1500 grams admitted to NICU between 2009 and 2019, were recruited into the study. The primary outcome was NEC Bell Stage IIa-IIIb based on Modified Bell's criteria. Maternal and neonatal characteristics were evaluated. The association between variables of interest and NEC was determined using logistic regression analysis and the incidence of NEC for the study period was calculated.

RESULTS

A total of 261 charts of infants born at ≤ 32 weeks' gestation, weighing <1500 were reviewed, and 200 charts met the inclusion criteria. Fifteen preterm infants developed the primary outcome of interest: NEC Stage ≥2a within the first 30 days of admission. The overall incidence of NEC for the study period was 7.5%. Three risk factors were identified as significantly associated with NEC on multivariate logistic regression analysis: antenatal exposure to steroids (OR = 0.056 CI = 0.003-0.964 p = 0.047), cumulative duration of exposure to invasive mechanical ventilation (OR = 2.172 CI = 1.242-3.799 p = 0.007) and cumulative duration of exposure to umbilical vein catheter (OR = 1.344 CI = 1.08-1.672 p = 0.008).

CONCLUSIONS

The overall incidence for the study period of NEC Stage ≥ II a was 7.5%. Exposure to antenatal steroids, duration of mechanical ventilation, and duration of umbilical vein catheterization were three independent modifiable risk factors for NEC Stage II a-Stage III b.

Secretome of bovine umbilical vein endothelial cells promote wound healing regeneration on the second degree rat model burn injury

Background

Burn injuries are an alarming indicator of the sensitivity of human tissue when confronted with high temperatures or chemicals. The current treatment for burn wounds needs to be improved and more extensive in scope. Significant research advances concerning the therapeutic potential of secretomes over the past two decades have expanded the range of therapies that utilize secretomes to encompass populations other than stem cells.

Aim

This study details how the secretome extracted from the bovine umbilical vein endothelial cell (BUVEC) promotes the healing of burn injuries.

Methods

The 48 rats were divided into four groups, namely the control group with povidone-iodine, the 5% BUVEC-conditioned medium (CM) cream group, the 10% BUVEC-CM cream group, the 15% BUVEC-CM cream group. Animals induced type II burns under anesthesia. Treatment is carried out topically, two times a day. Every day the wound was measured. The animals were put to sleep for samples on days 5, 13, 21, and 19. Samples in the form of skins were soaked in 4% paraformaldehyde and processed with paraffin-embedded for tissue preparations. The research results were processed using two way ANOVA.

Results

The study showed that on day 5, wound closure occurred, whereas in the povidone-iodine group, macroscopically, the wound closed faster. Epithelial repair, increased fibroblasts and collagen, and blood vessel formation greatly increased in the 15% BUVEC-CM group on days 13, 21, and 29.

Conclusion

Taken together, BUVEC secretome promoted fibroblast regeneration, collagen formation, re-epithelialization, and hair follicle regeneration on the burn injury wound healing.

Retrieval of a retained umbilical vein catheter at 6 months

Umbilical venous catheterisation is carried out for the care of neonates who have very low birth weight and are critically ill. It is uncommon for catheter fragments to become fractured and retained. Here, we describe a case of a retained fractured umbilical vein catheter in an infant. An endovascular procedure to retrieve a catheter is the usual management option when the catheter has been accidentally cut and has moved proximally into a major vessel or inside the heart. It is rare to need open exploration and retrieval.

Gross and histological examination of Wharton's Jelly in the equine umbilical cord

Wharton's jelly (WJ) is fundamental for the well-being of the fetus, binding to the umbilical vessels and protecting them from twisting and compression. Gross and microscopic studies have been undertaken on the umbilical cord (UC) of human placentae in both normal and high-risk pregnancies, however there is limited research on equine UC. The aim of this study was to describe microscopically and immunohistochemically the equine UC in normal pregnancies, with particular attention to WJ. Forty-seven healthy mares, with no complications during pregnancy, admitted to the hospital for attending delivery were enrolled. Clinical data was collected at foaling on foal health and placental characteristics. UC samples were collected from three sites (amniotic, allantoic and in the region of vein anastomosis) for histology. The thickness of different layers of arteries and veins and WJ in different UC portions were measured (μm). Wharton's Jelly was weighted (g) and its sections were stained with Masson's trichrome, orcein technique and silver impregnation. Immunohistochemistry was undertaken using antibodies raised-against collagen type I, V, VI and fibrillin. Forty-seven UCs, from 19 colt and 28 filly foals, were analyzed for WJ weight and 8/47 UCs were examined histologically. Warton's jelly was only found in the amniotic portion of the UC closest to the foal's abdomen. The weight of WJ (4.0 ± 3.3 g) did not vary between colts and fillies and it was not correlated with any of the clinical or UC parameters measured. The tunica media of arteries and veins was thicker in the amniotic portion of the UC, as described in human UCs in late pregnancy. This finding could be an adaptation to aid in resisting compression because of fetal movements and UC twisting. The umbilical vein was thicker than the umbilical arteries in the tunica media and tunica adventitia in the sections examined throughout the length of the cord. This preliminary study describes gross and histological WJ's structure in the equine species. However, further studies are required to better characterize UC's changes throughout pregnancy and in the presence of mare's or fetal disease.

Development and Testing of a Hybrid Simulator for Emergent Umbilical Vein Catheter Insertion Simulation Training

INTRODUCTION

Emergent umbilical venous catheter (eUVC) insertion is the recommended vascular access in neonatal resuscitation. Although the theoretical knowledge can be taught, existing models are either unrealistic (plastic) or train only the steps of the task. This study aimed to develop and test a hybrid simulator for eUVC insertion training that would be realistic, reproducible, easy to build, and inexpensive, thereby facilitating detailed learning of the procedure.

METHODS

Development took place in the Poitiers simulation laboratory using a neonatal mannequin into which a real umbilical cord was integrated. In the first phase, pediatric and emergency physicians and residents tested the model. In the second phase, another group of participants tested the hybrid simulator and the same neonatal mannequin associated with an artificial umbilical cord. Participants completed a satisfaction survey.

RESULTS

A real umbilical cord connected to an intra-abdominal reservoir containing artificial blood was added to the mannequin, allowing insertion of the eUVC, drawback of blood, and infusion of fluids using the real anatomical structures. The model was easily reproduced and assembled in less than 30 minutes; the cost of construction and use was evaluated at €115. One hundred two participants tested the model, 60 in the first phase and 42 in the second. The success rate was higher in fully trained compared with untrained participants. All were satisfied, 97% found the model realistic, and 78.6% strongly recommended the use of this model. The participants believed that the hybrid simulator allowed better learning and a gain in performance and self-confidence in comparison with the same mannequin with an artificial umbilical cord.

CONCLUSIONS

A hybrid simulator was developed for eUVC insertion. Participants were satisfied with this model, which was realistic, reproducible, easy to use, inexpensive, and facilitated an understanding of the anatomy and performance of all steps for successful eUVC insertion.

Placental assessment using spectral analysis of the envelope of umbilical venous waveforms in sheep

INTRODUCTION

This study was designed to test the efficacy of an ultrasound flow measurement method to evaluate placental function in a hyperandrogenic sheep model that produces placental morphologic changes and an intrauterine growth restriction (IUGR) phenotype.

MATERIALS AND METHODS

Pregnant ewes were assigned randomly between control (n = 12) and testosterone-treatment (T-treated, n = 22) groups. The T-treated group was injected twice weekly intramuscularly (IM) with 100 mg testosterone propionate. Control sheep were injected with corn oil vehicle. Lambs were delivered at 119.5 ± 0.48 days gestation. At the time of delivery of each lamb, flow spectra were generated from one fetal artery and two fetal veins, and the spectral envelopes examined using fast Fourier transform analysis. Base 10 logarithms of the ratio of the amplitudes of the maternal and fetal spectral peaks (LRSP) in the venous power spectrum were compared in the T-treated and control populations. In addition, we calculated the resistive index (RI) for the artery defined as ((peak systole - min diastole)/peak systole). Two-tailed T-tests were used for comparisons.

RESULTS

LRSPs, after removal of significant outliers, were -0.158 ± 0.238 for T-treated and 0.057 ± 0.213 for control (p = 0.015) animals. RIs for the T-treated sheep fetuses were 0.506 ± 0.137 and 0.497 ± 0.086 for controls (p = 0.792) DISCUSSION: LRSP analysis distinguishes between T-treated and control sheep, whereas RIs do not. LRSP has the potential to identify compromised pregnancies.

Emergency pacing via the umbilical vein of a neonate with congenital complete atrioventricular block: a report of two cases

We report two cases of successful emergency pacing via the umbilical vein in neonates with congenital complete atrioventricular block. The first patient, a neonate with normal cardiac anatomy, underwent emergency temporary pacing via the umbilical vein under echocardiographic guidance. The patient underwent permanent pacemaker implantation on postnatal day 4. The second patient, a neonate with heterotaxy syndrome, underwent emergency temporary pacing through the umbilical vein under fluoroscopic guidance. The patient underwent permanent pacemaker implantation on postnatal day 17.

Gene regulation for inflammation and inflammation resolution differs between umbilical arterial and venous endothelial cells

Systemic inflammation affects the whole vasculature, yet whether arterial and venous endothelial cells differ in their abilities to mediate inflammation and to return to homeostasis after an inflammatory stimulus has not been addressed thoroughly. We assessed gene-expression profiles in isolated endothelial cells from human umbilical arteries (HUAEC) or veins (HUVEC) under basal conditions, after TNF-α stimulation and various time points after TNF-α removal to allow reinstatement of homeostasis. TNF-α regulates the expression of different sets of transcripts that are significantly changed only in HUAEC, only in HUVEC or changed in both. We identified three types of gene regulation, i.e. genes that were significantly regulated after 24 h of TNF-α stimulation but no longer when TNF-α was removed (homeostatic regulation), genes that maintained significantly regulated after TNF-α removal (not homeostatic regulation) and genes that were only significantly regulated when TNF-α was removed (post-regulation). HUAEC and HUVEC quantitatively differed in these types of gene regulation, with relatively more genes being post-regulated in HUAEC. In conclusion our data demonstrate that HUAEC and HUVEC respond intrinsically different to an inflammatory insult. Whether this holds true for all endothelial cells and its relevance for inflammatory insults in different organs during systemic inflammation warrants further studies.

Securement of Umbilical Venous Catheter Using Cyanoacrylate Glue: A Randomized Controlled Trial

OBJECTIVE

To evaluate the role of cyanoacrylate glue in reducing dislodgement of umbilical venous catheters (UVCs).

STUDY DESIGN

This was a single-center, randomized, controlled, nonblinded trial. All infants requiring an UVC according to our local policy were included in the study. Infants with a UVC with a centrally located tip as verified by real-time ultrasound examination were eligible for the study. Primary outcome was the safety and efficacy of securement by cyanoacrylate glue plus cord-anchored suture (SG group) vs securement by suture alone (S group), as measured by reduction in dislodgment of the external tract of the catheter. Secondary outcomes were tip migration, catheter-related bloodstream infection, and catheter-related thrombosis.

RESULTS

In the first 48 hours after UVC insertion, dislodgement was significantly higher in the S group than in the SG group (23.1% vs 1.5%; P < .001). The overall dislodgement rate was 24.6% in the S group vs 7.7% in the SG group (P = .016). No differences were found in catheter-related bloodstream infection and catheter-related thrombosis. The incidence of tip migration was similar in both groups (S group 12.2% vs SG group 11.7%).

CONCLUSIONS

In our single-center study, cyanoacrylate glue was safe and effective for securement of UVCs, and particularly effective in decreasing early catheter dislodgments.

TRIAL REGISTRATION

UMIN-CTR Clinical Trial; Registration number: R000045844.

Steps to improve umbilical vein catheterization in neonatal care

INTRODUCTION

In neonatal units, umbilical vessel catheterization is the preferred method to gain vascular access in the initial management of the newborn because it is quick and easy. The failure rate ranges from to 50%, as the catheter can be found in the portal system in up to 40% of cases, leading to complications. This failure rate warrants the investigation of different methods to reduce the frequency of catheter malposition. We describe different techniques to improve the success rate in umbilical vein catheterization, such as the double catheter technique, positioning the newborn in right lateral decubitus for insertion, liver compression, and ultrasound-guided catheter insertion. The primary objective of the study was to assess the impact of new techniques on the success rate of central umbilical venous catheterization.

MATERIAL AND METHODS

Pre- and post-intervention quasi-experimental study in a level B NICU conducted in January-June 2022 (pre-intervention) and July-December 2022 (post-intervention).

RESULTS

Prior to the introduction of these new catheterization techniques, the failure rate of blind umbilical catheter insertion was 52%. Since the introduction of these measures, the overall failure rate has decreased to 27%.

CONCLUSIONS

After the introduction of the new catheterization and recanalization methods, our success rate in umbilical vein catheterization has increased, and we believe it is necessary to implement them in units with similar failure rates to ours.

Emergency button cannula vs. umbilical catheter as neonatal emergency umbilical vein access - a randomized cross-over pilot study

OBJECTIVES

Establishing immediate intravenous access to a newborn is challenging even for trained neonatologists in an emergency situation. Correct placement of umbilical catheter or an intraosseous needle needs consistent training. We evaluated the time required to correctly place an emergency umbilical button cannula (EUC) or an umbilical catheter (UC) using the standard intersection (S-EUC or S-UC, respectively) or lateral umbilical cord incision (L-EUC) by untrained medical personnel.

METHODS

Single-center cross-over pilot-study using a model with fresh umbilical cords. Video-based teaching of medical students before probands performed all three techniques after assignment to one of three cycles with different sequence, using a single umbilical cord divided in three pieces for each proband.

RESULTS

Mean time required to establish L-EUC was 89.3 s, for S-EUC 82.2 s and for S-UC 115.1 s. Both application routes using the EUC were significantly faster than the UC technique. There was no significant difference between both application routes using EUC (p=0.54).

CONCLUSIONS

Using an umbilical cannula is faster than an umbilical catheter, using a lateral incision of the umbilical vein is an appropriate alternative.

Relationship of Glucose, C-peptide, Leptin, and BDNF in Maternal and Umbilical Vein Blood in Type-1 Diabetes

The study aimed to determine the relationship between glucose, C-peptide, brain-derived neurotrophic factor (BDNF), and leptin between mother and fetus and neonatal weight.

METHODS

In the prospective observational cohort study, we included 66 women with type-1 diabetes mellitus (T1DM). According to the z-score for neonatal weight, patients were divided into healthy-weight neonates (n = 42) and overweight neonates (n = 24). The maternal blood samples were taken during pregnancy and cesarean section when the umbilical vein blood sample was also withdrawn. The maternal vein sera were analyzed for fasting glucose, C-reactive protein (CRP), leptin, BDNF, TSH, FT3, and FT4. The umbilical vein sera were analyzed for glucose, C-peptide, leptin, TSH, thyroid-stimulating protein (FT3), free thyroxine (FT4), and BDNF concentration. The neonatologist measured the skinfold thickness on the third day of neonatal life.

RESULTS

A strong correlation was confirmed between maternal and umbilical vein glucose concentration and maternal glucose and C-peptide in umbilical vein blood. A negative correlation was found between the concentration of BDNF in the umbilical vein and glucose in maternal blood. A strong correlation was seen between BMI and maternal blood leptin concentration, neonatal fat body mass, and umbilical vein blood leptin concentration. Higher BMI elevated BDNF, and TSH increase the odds for overweight neonates in the first trimester of pregnancy. Maternal higher leptin concentration in the first trimester decrease the odds of overweight neonates.

CONCLUSIONS

Maternal glucose concentrations affect the fetus's glucose, C-peptide, and BDNF concentrations. Leptin levels increase in maternal blood due to increased body mass index, and in the neonate, fat body mass is responsible for increased leptin concentrations.

Effect of SARS-CoV-2 infection on fetal umbilical vein flow and cardiac function: a prospective study

OBJECTIVES

To explore whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can affect umbilical vein blood flow (UVBF) and fetal cardiac function.

METHODS

Prospective case-control study of consecutive pregnancies complicated by SARS-CoV-2 infection during the second half of pregnancy matched with unaffected women. Measurements of UVBF normalized for fetal abdominal circumference (UVBF/AC), atrial area (AA) and ventricular sphericity indices (SI) were compared between the two study groups. Chi-square and Mann-Whitney U tests were sued to analyze the data.

RESULTS

Fifty-four consecutive pregnancies complicated and 108 not complicated by SARS-CoV-2 infection were included. The median gestational age at infection was 30.2 (interquartile range [IQR] 26.2 34.1). General baseline and pregnancy characteristics were similar between pregnant women with compared to those without SARS-CoV-2 infection. There was no difference in UVBF/AC (study groups z value -0.11 vs. 0.14 control p 0.751) values between pregnancies complicated compared to those not complicated by SARS-CoV-2 infection. Likewise, there was no difference in the left and right AA (left 1.30 vs. 1.28 p=0.221 and right 1.33 vs. 1.31 p=0.324) and SI (left 1.75 vs. 1.77 p=0.208 and right 1.51 vs. 1.54 p=0.121) between the two groups.

CONCLUSIONS

SARS-CoV-2 infection does not affect UVBF and fetal cardiac function in uncomplicated pregnancies.

Intraperitoneal Extravasation of TPN and Associated Hepatic Hemorrhage as a Complication of a Malpositioned UVC in a Preterm Neonate

Extravasation of total parenteral nutrition (TPN) from a malpositioned umbilical venous catheter (UVC) is a rare cause of ascites in neonates. The gross appearance of the aspirated peritoneal fluid may mimic congenital chylous ascites, delaying an accurate diagnosis of the causative source. UVC malpositioning is associated with complications of various organs as related to the position of the UVC tip. TPN from laterally positioned UVC tips may penetrate into the liver and provoke hepatic damage with subsequent peritoneal fluid accumulation. Factors including biochemical characteristics of the peritoneal fluid, radiographic findings with specific attention to the location of the UVC tip, and clinical timing of ascites presentation have been associated with TPN extravasation from UVCs. This report presents a case of a preterm neonate with intraperitoneal extravasation of TPN and associated hepatic hemorrhage due to a malpositioned UVC while highlighting the cumulative clinical, radiographic, and laboratory findings that should prompt consideration of this complication as the cause of ascites in neonates.

Umbilical venous catheterisation: emergency central venous access which saves lives in coarctation of the aorta

We describe a 9-day-old baby with coarctation of the aorta who required urgent resuscitation including intubation and cardiac compressions. Despite the commencement of prostaglandin E1 (PGE1) to reopen the ductus arteriosus via the intraosseous route, postductal saturations remained unrecordable for a further 45 min. Within 3 min of administration of PGE1 via an umbilical venous catheter (UVC), saturations were recordable at 92%. UVC access was the sentinel intervention that irrevocably altered the clinical prognosis. This baby boy has survived with excellent neurodevelopmental outcome. Clinicians are less familiar with UVCs outside of the newborn period. Our data demonstrate successful placement in neonates up to 28 days of age. We hope this case encourages clinicians to consider the UVC as first-line central venous access in collapsed neonates. In cases of suspected left heart obstruction, we argue that UVCs are the optimal route.

DNA damage analysis in newborns and their mothers related to pregnancy and delivery characteristics

INTRODUCTION

Increased DNA damage is associated with early events in carcinogenesis. The foetus may be more susceptible to effects of environment by transplacental exposure. We aimed to evaluate DNA damage in cells from umbilical cord (arteries and vein) and maternal blood from pregnant women.

METHODS

Fifty eight pregnant women and their offspring were included in this study. They were submitted to an interview to obtain information about personal history, clinical history, and lifestyle habits. Other Information was obtained from medical records. The samples were prepared for Single Cell Gel/Comet assay and Cytokinesis-block Micronucleus Cytome (CBMN-Cyt) assay.

RESULTS

Correlation between DNA damage frequency by Comet assay from newborns and their mothers was statistically significant and was significantly associated with nulliparity and more than 1 h of second stage of labour (umbilical vein and maternal blood). A positive MNi relationship was noticed for age (mother's blood) and inappropriate birth weight for gestational age (maternal blood). When multivariate statistical analyses were applied to measure the degree of association between variables that influenced DNA damage markers in the first evaluation, inadequate birth weight and pregnant weight gain were associated with MNi frequency in maternal and newborns blood, respectively.

DISCUSSION

Significant associations between DNA damage in newborns and pregnant women, and birth and pregnancy events suggest molecular evidence of transplacental genotoxic effects. However, a potentially increased risk of degenerative diseases, such as cancers, in this population should be carefully investigated by further prospective cohort studies.

Clinical characteristics of cirrhosis patients with umbilical vein recanalization: A retrospective analysis

Umbilical Vein Recanalization (UVR) may occur in patients with long-standing portal hypertension and liver cirrhosis. This study aimed to investigate the clinical significance of UVR.Medical records of a cohort of patients with cirrhosis (n = 247) who were hospitalized at the Digestive Medicine Center of the Second Affiliated Hospital of Nanchang University from January 2012 to October 2015 were accessed. The UVR diagnosis was made by ultrasound examination and was confirmed by computerized tomography scan.The UVR incidence was 20.2% (50/247) in the cohort. The size of UVR was 9.9 ± 4.7 mm (range: 5-26.5 mm) in diameter. The UVR and non-UVR groups showed no difference in grades of hepatic encephalopathy (P = .496), Child-Pugh classification (P = .401), the incidence of moderately severe ascites (26% vs 26%, P = 1), the esophageal variceal bleeding rate (32% vs 39%, P = .402), or portal vein thrombosis (8% vs 12%, P = .580). However, the incidence of cavernous transformation of the portal vein was statistically different, that there was 0 case in the UVR group and 8 cases in the non-UVR group (P < .05).Our results suggested that UVR had little impact on the clinical manifestations of patients with liver cirrhosis, the significance of UVR as an intervention method requires further studies.

Modified Meso-Rex bypass with umbilical vein recanalization and intra-operative stenting

PURPOSE

The aim of the study was to evaluate the usefulness of a novel modified Meso-Rex bypass surgical technique with umbilical vein recanalization and intra-operative stenting to treat portal vein cavernous transformation.

METHODS

In total, 13 portal vein cavernous transformation patients underwent Meso-Rex bypass surgery, consisting of bypass grafts between the superior mesenteric vein (SMV) and the recess of Rex as well as through the ligamentum teres hepatis without stent implantation (Group A, n = 9) and umbilical vein recanalization with intra-operative stent implantation (Group B, n = 4).

RESULTS

In Group A, the bypass diameter was 0-6 mm (median 3 mm) and blood flow velocity 25-115 cm/s (median 72 cm/s) 1 month after Meso-Rex bypass surgery, with open bypass times of 0-67 months (median 6 months); 6 patients in this group developed postoperative Meso-Rex bypass occlusions. A patient in Group A treated with ligamentum teres hepatis recanalization needed a thrombectomy and stent implantation during a second surgery 2 days after the Meso-Rex bypass, because of bypass thrombosis and umbilical vein stenosis. In Group B, the average modified Meso-Rex bypass diameter was 5.5-6.5 mm (median 6 mm), and the bypass vessels remained open in all patients, with blood flow rates of 45-100 cm/s (median 76.5 cm/s) 1 month after the modified Meso-Rex bypass, up to the endpoint (15-33 months, median 24 months). The rate of bypass occlusions in Group A and Group B were 22.2% and 0%, 30.0% and 0%, and 55.6% and 0% at 1 month, 3 months, and 1 year, respectively, after bypass surgery.

CONCLUSIONS

Our novel modified Meso-Rex bypass approach for portal vein cavernous transformation treatment was effective with excellent long-term bypass patency.

Cardiac function in fetal growth restriction

Fetal growth restriction (FGR) is defined as the inability of the fetus to reach its growth potential. According to the onset of the disease is defined early (<32 weeks) or late (≥32 weeks). FGR is associated with an increased risk of adverse short- and long-term outcomes, including hypoxemic events and neurodevelopmental delay compared to normally grown fetuses and increased risk of complications in the infanthood and adulthood. The underlying cause of FGR is placental insufficiency leading to chronic fetal hypoxia that affects cardiac hemodynamic with different mechanism in early and late onset growth restriction. In early onset FGR adaptive mechanisms involve the diversion of the cardiac output preferentially in favor of the brain and the heart, while abnormal arterial and venous flow manifest in the case of further worsening of fetal hypoxia. In late FGR the fetal heart shows a remodeling of its shape and function mainly related to a reduction of umbilical vein flow. In this review we discuss the modifications occurring at the level of the fetal cardiac hemodynamic in fetuses with early and late FGR.

Umbilical vein injection for management of retained placenta

BACKGROUND

Retained placenta is a common complication of pregnancy affecting 1% to 6% of all births. If a retained placenta is left untreated, spontaneous delivery of the placenta may occur, but there is a high risk of bleeding and infection. Manual removal of the placenta (MROP) in an operating theatre under anaesthetic is the usual treatment, but is invasive and may have complications. An effective non-surgical alternative for retained placenta would potentially reduce the physical and psychological trauma of the procedure, and costs. It could also be lifesaving by providing a therapy for settings without easy access to modern operating theatres or anaesthetics. Injection of uterotonics into the uterus via the umbilical vein and placenta is an attractive low-cost option for this. This is an update of a review last published in 2011.

OBJECTIVES

To assess the use of umbilical vein injection (UVI) of saline solution with or without uterotonics compared to either expectant management or with an alternative solution or other uterotonic agent for retained placenta.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (14 June 2020), and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing UVI of saline or other fluids (with or without uterotonics), either with expectant management or with an alternative solution or other uterotonic agent, in the management of retained placenta. We considered quasi-randomised, cluster-randomised, and trials reported only in abstract form.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. We calculated pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs), and presented results using 'Summary of findings' tables.

MAIN RESULTS

We included 24 trials (n = 2348). All included trials were RCTs, one was quasi-randomised, and none were cluster-randomised. Risk of bias was variable across the included studies. We assessed certainty of evidence for four comparisons: saline versus expectant management, oxytocin versus expectant management, oxytocin versus saline, and oxytocin versus plasma expander. Evidence was moderate to very-low certainty and downgraded for risk of bias of included studies, imprecision, and inconsistency of effect estimates. Saline solution versus expectant management There is probably little or no difference in the incidence of MROP between saline and expectant management (RR 0.93, 95% CI 0.80 to 1.10; 5 studies, n = 445; moderate-certainty evidence). Evidence for the following remaining primary outcomes was very-low certainty: severe postpartum haemorrhage 1000 mL or greater, blood transfusion, and infection. There were no events reported for maternal mortality or postpartum anaemia (24 to 48 hours postnatal). No studies reported addition of therapeutic uterotonics. Oxytocin solution versus expectant management UVI of oxytocin solution might slightly reduce in the need for manual removal compared with expectant management (mean RR 0.73, 95% CI 0.56 to 0.95; 7 studies, n = 546; low-certainty evidence). There may be little to no difference between the incidence of blood transfusion between groups (RR 0.81, 95% CI 0.47 to 1.38; 4 studies, n = 339; low-certainty evidence). There were no maternal deaths reported (2 studies, n = 93). Evidence for severe postpartum haemorrhage of 1000 mL or greater, additional uterotonics, and infection was very-low certainty. There were no events for postpartum anaemia (24 to 48 hours postnatal). Oxytocin solution versus saline solution UVI of oxytocin solution may reduce the use of MROP compared with saline solution, but there was high heterogeneity (RR 0.82, 95% CI 0.69 to 0.97; 14 studies, n = 1370; I² = 54%; low-certainty evidence). There were no differences between subgroups according to risk of bias or oxytocin dose for the outcome MROP. There may be little to no difference between groups in severe postpartum haemorrhage of 1000 mL or greater, blood transfusion, use of additional therapeutic uterotonics, and antibiotic use. There were no events for postpartum anaemia (24 to 48 hours postnatal) (very low-certainty evidence) and there was only one event for maternal mortality (low-certainty evidence). Oxytocin solution versus plasma expander One small study reported UVI of oxytocin compared with plasma expander (n = 109). The evidence was very unclear about any effect on MROP or blood transfusion between the two groups (very low-certainty evidence). No other primary outcomes were reported. For other comparisons there were little to no differences for most outcomes examined. However, there was some evidence to suggest that there may be a reduction in MROP with prostaglandins in comparison to oxytocin (4 studies, n = 173) and ergometrine (1 study, n = 52), although further large-scale studies are needed to confirm these findings.

AUTHORS' CONCLUSIONS

UVI of oxytocin solution is an inexpensive and simple intervention that can be performed when placental delivery is delayed. This review identified low-certainty evidence that oxytocin solution may slightly reduce the need for manual removal. However, there are little or no differences for other outcomes. Small studies examining injection of prostaglandin (such as dissolved misoprostol) into the umbilical vein show promise and deserve to be studied further.

A study of the effects of hydroxyapatite bioceramic extract on Ang/Tie2 system of umbilical vein endothelial cells

OBJECTIVE:

We aimed to investigate the effects of hydroxyapatite bioceramic extract on Ang/Tie2 system and cell proliferation of umbilical vein endothelial cells.

METHODS:

Human umbilical vein endothelial cells (HUVECs) were used in this research. There are two induvial groups, control group and hydroxyapatite bioceramics extract treatment group. Cell Counting Kit-8 (CCK-8) was used to evaluate cell proliferation. Western blot and real time quantitative PCR (Q-PCR) were used to evaluate the protein and mRNA expression levels of Ang1, Ang2 and Tie2 in Ang/Tie2 system, respectively. All the results were statistically analyzed by Spss19.0. All data were presented as mean ± standard error of mean (SEM). Student’s t-test was performed to determine the differences among grouped data.

RESULTS:

Hydroxyapatite bioceramics extract showed no effect on the cell morphology and cell proliferation of HUVECs. Interestingly, we found that both Ang2 and Tie2 protein and mRNA level were markedly increased by hydroxyapatite bioceramics extract.

CONCLUSIONS:

Hydroxyapatite bioceramic extract showed no cytotoxicity to HUVECs, and might regulate vascular remodeling by mediating Ang/Tie2 system.

A review of umbilical venous catheter-related complications at a tertiary neonatal unit in Singapore

INTRODUCTION

Umbilical venous catheters (UVCs), commonly inserted in neonates for vascular access, are not without complications.

METHODS

A single-centre retrospective cohort study that reviewed complications related to UVC insertion in neonates was conducted in a tertiary neonatal unit in Singapore from January 2016 to July 2017. Ideal UVC position was defined as catheter tip within 0.5 cm above or below the diaphragm. Catheter-related sepsis was defined as clinical or biochemical abnormalities suggesting any new-onset or worsening sepsis 72 hours before or after removal of UVCs, with or without positive culture. Catheter-associated bloodstream infection (CABSI) was defined as positive microbiological growth in one or more blood cultures obtained from a symptomatic infant up to two days after UVC placement or within 48 hours of catheter removal.

RESULTS

108 patients had UVC insertions. Mean gestational age and birth weight were 30.4 ± 4.0 weeks and 1,536.2 g ± 788.9 g, respectively. Mean UVC duration was 6.6 days. The UVC was in an ideal position in 27 (25.0%), deep in 13 (12.0%) and short in 35 (32.4%) neonates. One-third of the UVCs (n = 33) were malpositioned. Catheter-related sepsis was observed in 16 (14.8%) neonates, with 5 (4.6%) having CABSI. The most common organism was coagulase-negative Staphylococcus. Other complications include peritoneal extravasation in 3 (2.8%) patients, with two requiring surgical intervention. Venous thrombosis occurred in 2 (1.9%) neonates and was managed conservatively.

CONCLUSION

Although complication rates were in line with international norms, UVCs were associated with serious complications and should be judiciously used.

Effects of novel brominated flame retardants and metabolites on cytotoxicity in human umbilical vein endothelial cells

Novel brominated flame retardants (NBFRs) have been widely used and frequently detected in various environmental matrices. In this study, 2-ethylhexyl-2,3,4,5-tetrabromobenzoate (TBB), bis-(2-ethylhexyl) tetrabromophthalate (TBPH) and their metabolites (namely 2,3,4,5-tetra-bromo benzoic acid (TBBA) and mono(2-ethylhexyl) tetrabromophthalate (TBMEHP)) were exposed to human umbilical vein endothelial cells (HUVECs). Metabolites can induce stronger cytotoxicity than parent compounds with EC50 at 47.3 (TBBA), 8.6 μg/ml (TBMEHP) vs > 200 μg/mL for parent compounds. Gene expression of platelet endothelial cell adhesion molecule-1, the gene associated with blood platelet kinetics, was significantly induced under TBBA and TBMEHP exposure. The in vivo test was consistent with gene expression result that the number of platelets in mouse blood was significantly increased after gavaged with 0.8 μg/mL TBBA and TBMEHP. In addition, TBB or TBPH were exposed to mice via gavage, and higher concentrations of TBBA (4 h, 60.8 ± 12.9 ng/mL, 8 h, 69.4 ± 2.24 ng/mL) in mouse blood were found than those of TBMEHP (4 h, 17.2 ± 4.01 ng/mL, 8 h, 12.8 ± 3.20 ng/mL), indicating that TBB was more readily in vivo metabolized than TBPH. The in vivo metabolism of TBB and TBPH and the stronger toxicity of their metabolites underscore the potential risk through NBFR exposure and the importance of understanding NBFR metabolism process.

Fetal Oxygen and Glucose Consumption in Human Pregnancy Complicated by Fetal Growth Restriction

In healthy pregnancy, glucose and oxygen availability are essential for fetal growth and well being. However, how substrate delivery and fetal uptake are affected in human pregnancy complicated by fetal growth restriction (FGR) is still unknown. Here, we show that the human FGR fetus has a strikingly reduced umbilical uptake of both oxygen and glucose. In 30 healthy term and 32 FGR human pregnancies, umbilical volume flow (Qumb) and parallel umbilical vein (uv) and artery (ua) blood samples were obtained at elective Cesarean section to calculate fetal glucose and oxygen uptake as Qumb · Δ (uv-ua) differences. Umbilical blood flow was significantly lower in FGR pregnancy (-63%; P<0.001) but not when normalized for fetal body weight. FGR pregnancy had significantly lower umbilical oxygen delivery and uptake, both as absolute values (delivery: -78%; uptake: -78%) and normalized (delivery: -50%; uptake: -48%) for fetal body weight (all P<0.001). Umbilical glucose absolute delivery and uptake were significantly reduced (delivery: -68%; uptake: -72%) but only glucose uptake was decreased when normalized for fetal body weight (-30%; P<0.05). The glucose/oxygen quotient was significantly increased (+100%; P<0.05) while glucose clearance was significantly decreased (71%; P<0.001) in FGR pregnancy (both P<0.05). The human fetus in FGR pregnancy triggers compensatory mechanisms to reduce its metabolic rate, matching the proportion of substrate consumption relative to oxygen delivery as a survival strategy during complicated pregnancy.

Ketamine ameliorates hypoxia-induced endothelial injury in human umbilical vein endothelial cells

OBJECTIVES

Hypoxia leads to endothelial cell inflammation, apoptosis, and damage, which plays an important role in the complications associated with ischemic cardiovascular disease. As an oxidoreductase, p66Shc plays an important role in the regulation of reactive oxygen species (ROS) production and apoptosis. Ketamine is widely used in clinics. This study was designed to assess the potential protective effect of ketamine against hypoxia-induced injury in human umbilical vein endothelial cells (HUVECs). Moreover, we explored the potential mechanism by which ketamine protected against hypoxia-induced endothelial injury.

METHODS

The protective effects of ketamine against hypoxia-induced injury was assessed using cell viability and adhesion assays, quantitative polymerase chain reaction, and western blotting.

RESULTS

Our data showed that hypoxia reduced HUVEC viability, increased the adhesion between HUVECs and monocytes, and upregulated the expression of endothelial adhesion molecules at the protein and mRNA levels. Moreover, hypoxia increased ROS accumulation and upregulated p66Shc expression. Furthermore, hypoxia downregulated sirt1 expression in HUVECs. Alternatively, ketamine was shown to reverse the hypoxia-mediated reduction of cell viability and increase in the adhesion between HUVECs and monocytes, ameliorate hypoxia-induced ROS accumulation, and suppress p66Shc expression. Moreover, EX527, a sirt1 inhibitor, reversed the protective effects of ketamine against the hypoxia-mediated reduction of cell viability and increase in adhesion between HUVECs and monocytes.

CONCLUSION

Ketamine reduces hypoxia-induced p66Shc expression and attenuates ROS accumulation via upregulating sirt1 in HUVECs, thus attenuating hypoxia-induced endothelial cell inflammation and apoptosis.

An unusual presentation of epigastric pain due to thrombophlebitis of a recanalised umbilical vein - case report

INTRODUCTION

The umbilical vein can become recanalised due to portal hypertension in patients with liver cirrhosis but the condition is rarely clinically significant. Although bleeding from this enlarged vein is a known complication, the finding of thrombophlebitis has not been previously described.

CASE REPORT

We report the case of a 62-year-old male with a history of liver cirrhosis due to alcoholic liver disease presenting to hospital with epigastric pain. A CT scan of the patients abdomen revealed a thrombus with surrounding inflammatory changes in a recanalised umbilical vein. The patient was managed conservatively and was discharged home the following day.

CONCLUSION

Thrombophlebitis of a recanalised umbilical vein is a rare cause of abdominal pain in patients with liver cirrhosis.

BDE-209 induces autophagy and apoptosis via IRE1α/Akt/mTOR signaling pathway in human umbilical vein endothelial cells

Recently, the essentiality and fatalness of cardiovascular diseases is attracting much attention. Polybrominated diphenyl ethers (PBDEs) are persistent environmental pollutants, which could induce the toxic effect and have been implicated in the occurrence and development of cardiovascular diseases. However, it is unclear how autophagy and apoptosis induced by BDE-209 in endothelial cells are regulated. The aim of the present study was to investigate the effects of BDE-209 on human umbilical vein endothelial cells (HUVECs) and elucidate the mechanisms involved. HUVECs were treated with a wide range concentration of BDE-209 for 24 h. The appearance of autophagy was tested by the testing index such as outcomes of monodansylcadaverine (MDC) staining and lysotracker staining, observation of autophagosomes and conversion between autophagy marker light chain 3 (LC3)-I and LC3-II. Besides, the apoptotic cell rate was detected with flow cytometry. In addition, BDE-209 induced endoplasmic reticulum (ER) stress was detected by transmission electron microscopy (TEM). Our data suggest that the exposure of BDE-209 could induce autophagy, which was confirmed by MDC staining, transmission electron microscopy observation, lysotracker staining and LC3-I/LC3-II conversion. Besides, the ER stress-related inositol-requiring enzyme 1α (IRE1α)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signaling pathway could be activated by reactive oxygen species (ROS) to regulate autophagy. Moreover, the apoptosis of endothelial cells was alleviated when autophagy was blocked by 3-Methyladenine (3-MA). The results demonstrated that BDE-209 could induce the production of ROS and ER stress, activate autophagy through IRE1α/AKT/mTOR signaling pathway and ultimately induce apoptosis of vascular endothelial cells. These findings indicate that exposure to PBDE is possible to be a potential risk factor for cardiovascular diseases.

Tylophorine reduces protein biosynthesis and rapidly decreases cyclin D1, inhibiting vascular smooth muscle cell proliferation in vitro and in organ culture

BACKGROUND

Tylophorine (TYL) is an alkaloid with antiproliferative action in cancer cells. Vascular smooth muscle cell (VSMC) proliferation and neointima formation contribute to restenosis after percutaneous coronary interventions.

HYPOTHESIS/PURPOSE

Our goal was to examine the potential of TYL to inhibit VSMC proliferation and migration, and to dissect underlying signaling pathways.

STUDY DESIGN AND METHODS

TYL was administered to platelet-derived growth factor (PDGF-BB)-stimulated, serum-stimulated, quiescent and unsynchronized VSMC of rat and human origin. BrdU incorporation and resazurin conversion were used to assess cell proliferation. Cell cycle progression was analyzed by flow cytometry of propidium iodide-stained nuclei. Expression profiles of proteins and mRNAs were determined using western blot analysis and RT-qPCR. The Click-iT OPP Alexa Fluor 488 assay was used to monitor protein biosynthesis.

RESULTS

TYL inhibited PDGF-BB-induced proliferation of rat aortic VSMCs by arresting cells in G1 phase of the cell cycle with an IC₅₀ of 0.13 µmol/l. The lack of retinoblastoma protein phosphorylation and cyclin D1 downregulation corroborated a G1 arrest. Inhibition of proliferation and cyclin D1 downregulation were species- and stimulus-independent. TYL also decreased levels of p21 and p27 proteins, although at later time points than observed for cyclin D1. Co-treatment of VSMC with TYL and MG132 or cycloheximide (CHX) excluded proteasome activation by TYL as the mechanism of action. Comparable time-dependent downregulation of cyclin D1, p21 and p27 in TYL- or CHX-treated cells, together with decreased protein synthesis observed in the Click-iT assay, suggests that TYL is a protein synthesis inhibitor. Besides proliferation, TYL also suppressed migration of PDGF-activated VSMC. In a human saphenous vein organ culture model for graft disease, TYL potently inhibited intimal hyperplasia.

CONCLUSION

This unique activity profile renders TYL an interesting lead for the treatment of vasculo-proliferative disorders, such as restenosis.

Prenatal Diagnosis of Agenesis of Ductus Venosus: A Retrospective Study of Anatomic Variants, Associated Anomalies and Impact on Postnatal Outcome

PURPOSE

 To assess the anatomic variants, associated anomalies and postnatal outcome of fetuses with a prenatally diagnosed agenesis of ductus venosus (ADV).

MATERIALS AND METHODS

 Retrospective study of 119 cases with agenesis of ductus venosus diagnosed by prenatal ultrasound in two tertiary referral centers from 2006 to 2014. The type and location of the umbilical venous drainage site was noted. Charts were reviewed for associated structural or chromosomal anomalies, pregnancy outcome and postnatal course.

RESULTS

 In 24 cases (20.2 %) ADV was an isolated finding, while 95 cases (79.8 %) had associated anomalies. We identified 84 cases (70.6 %) with intrahepatic and 35 cases (29.4 %) with extrahepatic drainage of the umbilical vein. 58.8 % of neonates were alive at follow-up. There was no statistical association between drainage site and associated anomalies or outcome. Postnatal outcome was determined by the presence and severity of associated anomalies. There was no adverse outcome in the isolated group related to ADV. Overall, there were 6 persistent portosystemic shunts, 3 of them with a spontaneous closure, and one total agenesis of the portal venous system with lethal outcome.

CONCLUSION

 Postnatal outcome in cases with ADV mainly depends on the presence of associated anomalies. In isolated cases the prognosis is generally good, but neonates with a prenatally diagnosed portosystemic shunt should be followed until its occlusion. Portal venous system agenesis is rare but should be ruled out on prenatal ultrasound.

Reference percentiles for paired arterial and venous umbilical cord blood gases: An indirect nonparametric approach

BACKGROUND

Reference intervals for arterial and venous umbilical cord blood gas (UCBG) parameters are scarce, are mainly focused on pH, pO2, pCO2 and base deficit, and are usually assessed using parametric tests, despite a generally skewed data distribution. Here, the purpose is to determine reference percentiles for nine parameters of concomitant arterial and venous UCBG (CAV-UCBG) from neonates at birth, using nonparametric tests.

METHODS

Results of CAV-UCBG, assayed over a 4.5-year period, were extracted from a hospital laboratory database for pH, pCO2, pO2, oxygen saturation, concentration of total oxygen, total carbon dioxide, hydrogen carbonate, total haemoglobin, and acid-base excess. Exclusion criteria were: a venous-arterial pH difference <0.02, an arterial-venous pCO2 <0.7 kPa, and a venous pCO2 <2.9 kPa. Nonparametric bivariate kernel density estimations were used for the selection of plots within the 95% percentile surface of the pCO2-to-pH relationship (NBKDE-95P). Outliers from skewed data were removed using an adjusted-Tukey method, and percentiles were calculated according to the CLSI EP28-A3 nonparametric method.

RESULTS

Overall, 31% (5033/16164) of CAV-UCBG were discarded using the three exclusion criteria. Then, 6% (670/11131) of CAV-UCBG were excluded from the NBKDE-95P, and 0.1 to 3.5% outliers were subsequently removed. Depending on the parameter, the 2.5th and 97.5th percentiles from the whole group were similar or slightly narrower compared to reference intervals from other studies, while those from female and male neonates did not differ substantially.

CONCLUSIONS

Using an indirect nonparametric approach, this study proposes new percentiles for parameters from concomitant arterial and venous umbilical cord blood gases.

Hepatic Complications of Umbilical Venous Catheters in the Neonatal Period: The Ultrasound Spectrum

OBJECTIVES

Umbilical venous catheterization is commonly used in the neonatal period; however, it has some complications. In this study, we evaluated neonates who underwent umbilical venous catheterization and developed hepatic complications. Furthermore, we aimed to define all of the possible lesions and to clarify the imaging findings of umbilical venous catheter-induced hepatic injury.

METHODS

Two hundred forty-four neonates who underwent umbilical venous catheterization between March 2013 and September 2015 in a single tertiary care referral center were included in this study. To determine whether they had any hepatic complications, all patients underwent abdominal grayscale and Doppler ultrasound examinations, and their clinical data were recorded.

RESULTS

The frequency of liver-related complications from umbilical venous catheterization was 33.6% (82 of 244). Air in the portal venous system was the most frequent complication (20.1% [49 of 244]). Left portal venous thrombosis was noted in 6.1% (15 of 244). Parenchymal lesions in the liver related to umbilical venous catheterization were seen in 7.4% of patients (18 of 244) as follows: single nodular echogenic lesions (4.1% [10 of 244]), branching small nodular echogenic lesions (2.1% [5 of 244]), and large irregular heterogeneous lesions with laceration and perihepatic fluid (1.2% [3 of 244]). There was no statistical significance for any type of complication according to the gestational age (P > .05).

CONCLUSIONS

Hepatic complications due to umbilical venous catheters are not uncommon in the neonatal period. Ultrasound is the best imaging modality for confirming the diagnosis and for follow-up.

Growth Inhibition of Human Endothelial Cells by Human Recombinant Tumor Necrosis Factor Alpha and Interferon-Gamma

We investigated the effect of recombinant tumor necrosis factor-alpha (rTNF- α) on the proliferative response of human umbilical vein endothelial cells (HUVEC) to normal human serum (NHS), in the absence or the presence of interferon (IFN)- γ. rTNF- α significantly impaired NHS-stimulated HUVEC growth at a dose as low as 0.1 U/ml. The inhibitory effect of rTNF- α was dose-dependent up to 50-100 U/ml and was already evident after 2 h of incubation. Doses of rTNF- α in the range of 10 U/ml completely suppressed 3H-thymidine uptake stimulated by 7.5% NHS, and the effect was partially overcome by 10-20% NHS. rTNF- α was not cytotoxic at doses up to 1000 U/ml. rIFN- γ was also effective in suppressing NHS-stimulated3H-thymidine incorporation, and at low doses (0.1 U/ml) rIFN- γ and rTFN- α showed an additive effect. The effect of TFN- α and IFN- γ in antagonizing the proliferative response of vascular endothelium to the variety of growth factors contained in human serum could be relevant in a variety of pathologic conditions involving endothelium damage and proliferation.

Plasma Filtration on Mediators of Thrombotic Microangiopathy: An in Vitro Study

Objectives.

Sepsis-induced thrombotic microangiopathy is successfully treated by plasma exchange therapy However, certain putative mediators of thrombotic microangiopathy may not be removed by plasma filtration.

Methods.

We conducted an in vitro study to determine whether plasma filtration can remove ultra-large von Willebrand factor (ULvWF) multimers and other mediators. In separate experiments, human umbilical venous endothelial cell (HUVEC) supernatant enriched with ULvWF or human whole blood was passed through a therapeutic plasma exchange (TPE 2000, PRISMA) filter and samples were taken for measurement of ULvWF, vWF ristocetin cofactor, vWF antigen and PAI-1.

Results.

The sieving coefficients for vWF and PAI-1 were above 0.9. The ULvWF was gradually eliminated, and nearly disappeared after four circulations.

Conclusion.

The TPE 2000 filter can directly remove potential mediators of sepsis-induced thrombotic microangiopathy.

The K+-channel opener NS1619 increases endothelial NO-synthesis involving p42/p44 MAP-kinase

Ca2+-activated K+ channels with large conductance (BKCa) have been shown to play an important role in the regulation of vascular tone. We examined the role of the p42/p44 MAP-kinase (p42/p44MAPK) on nitric oxide (NO) production in human endothelial cells induced by the BKCa-opener NS1619. Using DiBAC-fluorescence imaging a concentration-dependent (2.5-12.5 µM) hyperpolarization induced by NS1619 was observed. A significant increase of intracellular Ca2+-concentration by NS1619 was seen using Fura-2-fluorescence-imaging, which was blocked by 2-APB, or reduction of extracellular Ca2+ (n=30; p<0.05). A cGMP-radioimmunoassay was used to examine NO synthesis. NS1619 significantly increased cGMP levels which was inhibited by LNMMA, iberiotoxin, BAPTA, 2-APB, reduction of extracellular Ca2+, PD 98059, or U0126 (cGMP (pmol/mg protein): NS1619 3.25 ± 0.85; NS1619 + L-NMMA 0.86 ± 0.02; NS1619 + iberiotoxin 0.99 ± 0.09; NS1619 + BAPTA 0.93 ± 0.29; NS1619 + 2-APB 0.99 ± 0.31; NS1619 + Ca2+-reduction 1.17 ± 0.06; NS1619 + PD98059 1.06 ± 0.49; NS1619 + U0126 1.10 ± 0.24; n=10; p<0.05). The phosphorylation of eNOS and p42/p44MAPK was examined by immunocytochemistry. Phosphorylation of p42/p44MAPK was significantly increased after 10 minutes of NS1619 stimulation, whereas eNOS phosphorylation was not changed over a period of 1 to 30 minutes. NS1619-induced hyperpolarization was not affected by treatment with PD 98059 or U0126. Additionally, NS1619 inhibited endothelial proliferation involving a NO-dependent mechanism. Our data demonstrate that NS1619 causes a transmembrane Ca2+-influx leading to an increased NO production involving p42/p44MAPK. This rise of NO formation is responsible for the NS1619 induced reduction of endothelial cell growth.

Inhibition of endothelial cell tube formation by the low molecular weight heparin, tinzaparin, is mediated by tissue factor pathway inhibitor

Heparin and low molecular weight heparins (LMWHs) have both antithrombotic and anti-angiogenic activities. The antiangiogenic activity of LMWH may be associated with the release of endothelial tissue factor pathway inhibitor (TFPI), an important endogenous inhibitor of tissue factor/Factor VIIa (TF/fVIIa).To evaluate the effects of LMWH, tinzaparin, and TFPI in a model of angiogenesis-mediated processes, we compared the effects of tinzaparin, and recombinant TFPI in inhibiting either basic fibroblast growth factor-2 (FGF2) or TF/fVIIainduced endothelial cell tube formation in human umbilical vein endothelial cells (HUVEC).Our results show that tinzaparin and recombinant TFPI both blocked endothelial tube formation induced by either FGF2 or TF/fVIIa, in a concentration-dependent manner. Endothelial tube formation was only marginally inhibited by a potent and specific anti-Factor Xa, recombinant tick anticoagulant protein (rTAP). A monoclonal anti-TFPI antibody reversed the inhibitory effects of either tinzaparin or recombinant-TFPI on HUVEC tube formation. Tinzaparin fractions in the range of 8,000 to 12,600 Da were most effective in stimulating the release of TFPI from HUVEC. These results suggest that the inhibitory effect of the LMWH tinzaparin on endothelial tube formation is associated with stimulation of the release of TFPI, but not to anti-Factor Xa activity.

Early planned removal of umbilical venous catheters to prevent infection in newborn infants

BACKGROUND

Lengthy duration of use may be a risk factor for umbilical venous catheter-associated bloodstream infection in newborn infants. Early planned removal of umbilical venous catheters (UVCs) is recommended to reduce the incidence of infection and associated morbidity and mortality.

OBJECTIVES

To compare the effectiveness of early planned removal of UVCs (up to two weeks after insertion) versus an expectant approach or a longer fixed duration in preventing bloodstream infection and other complications in newborn infants.To perform subgroup analyses by gestational age at birth and prespecified planned duration of UVC placement (see "Subgroup analysis and investigation of heterogeneity").

SEARCH METHODS

We used the standard Cochrane Neonatal search strategy including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4), Ovid MEDLINE, Embase, and the Maternity & Infant Care Database (until May 2017), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared effects of early planned removal of UVCs (up to two weeks after insertion) versus an expectant approach or a longer fixed duration in preventing bloodstream infection and other complications in newborn infants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and independently undertook data extraction. We analysed treatment effects and reported risk ratio (RR) and risk difference (RD) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We planned to use a fixed-effect model in meta-analyses and to explore potential causes of heterogeneity in sensitivity analyses. We assessed the quality of evidence for the main comparison at the outcome level using GRADE methods.

MAIN RESULTS

We found one eligible trial. Participants were 210 newborn infants with birth weight less than 1251 grams. The trial was unblinded but otherwise of good methodological quality. This trial compared removal of an umbilical venous catheter within 10 days after insertion (and replacement with a peripheral cannula or a percutaneously inserted central catheter as required) versus expectant management (UVC in place up to 28 days). More infants in the early planned removal group than in the expectant management group (83 vs 33) required percutaneous insertion of a central catheter (PICC). Trial results showed no difference in the incidence of catheter-related bloodstream infection (RR 0.65, 95% CI 0.35 to 1.22), in hospital mortality (RR 1.12, 95% CI 0.42 to 2.98), in catheter-associated thrombus necessitating removal (RR 0.33, 95% confidence interval 0.01 to 7.94), or in other morbidity. GRADE assessment indicated that the quality of evidence was "low" at outcome level principally as the result of imprecision and risk of surveillance bias due to lack of blinding in the included trial.

AUTHORS' CONCLUSIONS

Currently available trial data are insufficient to show whether early planned removal of umbilical venous catheters reduces risk of infection, mortality, or other morbidity in newborn infants. A large, simple, and pragmatic randomised controlled trial is needed to resolve this ongoing uncertainty.

Electrostatic Endothelial Cell Seeding Technique for Small-Diameter (<6 MM) Vascular Prostheses: Feasibility Testing

Multiple studies have indicated the importance of surface charge in the adhesion of multiple cardiovascular cell lines including platelets and endothelial cells on the substrate materials (1,4,7-10,12-15). It is the purpose of this article to report a feasibility study conducted using an electrostatic endothelial cell seeding technique. The feasibility study was conducted using human umbilical vein endothelial cells (HUVEC), a static pool apparatus, a voltage source, and a parallel plate capacitor. The HUVEC concentration and seeding times were constant at 560,000 HUVEC/ml and 30 min, respectively. Scanning electron microscopy examination of the endothelial cell adhesion indicated that an induced temporary positive surface charge on e-PTFE graft material enhances the number and the maturation (flattening) of HUVECs adhered. The results indicated that the total number of endothelial cells adhered (70.9 mm2) was increased from 9198 ± 1194 HUVECs on the control (no induced surface charge) e-PTFE to 22,482 ± 4814 HUVECs (2.4 × control) on the maximum induced positive surface charge. The total number of cells in the flattened phase of adhesion increased from 837 ± 275 to 6785 ± 1012 HUVECs (8.1 ×) under identical conditions. Thus, the results of the feasibility study support the premise that electrostatic interaction is an important factor in both the endothelial cell adhesion and spreading processes and suggest that the electrostatic seeding technique may lead to an increased patency of small diameter (<6 mm) vascular prostheses.

Electrostatic Endothelial Cell Transplantation within Small-Diameter (<6 MM) Vascular Prostheses: A Prototype Apparatus and Procedure

This article presents a novel, clinically relevant electrostatic endothelial cell transplantation (seeding/sodding) device (U.S. & Foreign Patent Protections Pending) for small-diameter (<6 mm) vascular prostheses. The prototype apparatus was designed and built to tissue engineer 4.0 mm, I.D. GORE-TEX® (W.L. Gore & Associates, Inc.) standard wall graft segments varying in length from 4 to 12 cm. The prototype electrostatic endothelial cell transplantation apparatus is composed of an external and internal conductor, aluminum base, end supports, pillow blocks, filling apparatus, electric motor drive system, and a voltage source. The cylindrical capacitor arrangement of the device along with an electrical potential applied across the internal and external conductors creates the unique feature of this endothelial cell transplantation technique, an electric field within the cylindrical capacitor (within the graft lumen) which in turn induces a temporary positive surface charge on the graft (dielectric material) luminal surface. Multiple studies have shown that a positively charged substrate is more conducive to endothelial cell adhesion and morphological maturation (flattening) (1,2, 7,8,10,13-15). This induced positive surface charge dissipates immediately upon removal from the electrostatic endothelial cell transplantation device. Thus, after endothelial cell adhesion the graft luminal surface reverts back to its natural (nonthrombogenic) negative surface charge.