Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.

Differences of the midline-crossing venous drainage pattern in supraumbilical and infraumbilical regions: Angiographic study using fresh cadavers.

Current clinical and anatomical studies show that the venous problem associated with the deep inferior epigastric perforator flap results from poor midline-crossing. We examined the venous anatomy of the infraumbilical midline area and the dynamic venous flow of the deep inferior epigastric perforator flap in nine fresh cadavers. All nine abdominal specimens were harvested between the subcostal margin and the groin crease. Two specimens were used to analyze the abdominal venous anatomy, one of which was divided into two hemi-abdominal specimens. The remaining seven specimens were harvested as deep inferior epigastric perforator flaps with one major paraumbilical perforator. Venous cannulation and serial angiographic agent injection were performed in several conditions. Each specimen was radiographed using a soft X-ray system. For additional information, computed tomography (CT) angiography-visualized superficial inferior epigastric veins (SIEVs) and the supraumbilical branch were analyzed. We noted that the venous drainage between the bilateral SIEVs was easier to configure in the supraumbilical area than in the infraumbilical area. Only one to two short polygonal venous networks connect the bilateral superficial inferior epigastric veins in the supraumbilical area; however, long and multiple polygonal venous networks connect the bilateral superficial inferior epigastric veins in the infraumbilical area, which could be a predisposing factor for venous congestion. The mean distance from the umbilicus upper border to evident supraumbilical midline crossover was 18.39±4.03 mm (range: 10.10-28.49) in CT angiograms. In cadaver specimens, the mean distance was 10.87±4.85 mm (range: 4.6-18.9). Supraumbilical midline crossover was more favorable than infraumbilical midline crossover in venous flow.

Concurrent müllerianosis of the urinary bladder and the umbilicus presenting with umbilical bleeding: a rare case report and review of the literature.

BACKGROUND: Müllerianosis is a very rare neoplasm composed of two or three Müllerian derived tissues (endosalpinx, endometrium and endocervix). We report the first case of concurrent müllerianosis of the urinary bladder and the umbilicus presenting with umbilical bleeding. CASE PRESENTATION: A 43-year-old Asian premesopausal female, gravida 1, para 1, presented with intermittent umbilical bleeding. An umbilical nodule and a bladder tumor on the posterior wall of the urinary bladder were identified. She underwent transurethral resection of the bladder tumor and excision of the umbilical nodule successively. Diagnosis of müllerianosis was confirmed by the histological and immunological features. No tumor recurrence was noted at 6 months of follow-up. CONCLUSIONS: Müllerianosis is extremely rare and mainly reported in the urinary bladder, and generally affects women of reproductive age. Despite the common presentations of müllerianosis of the urinary bladder including irritative voiding symptoms, abdominal/pelvic pain and gross hematuria, our rare case had no symptom except umbilical bleeding. The possibility of concurrent bladder müllerianosis should be considered when müllerianosis is found at other location. We suggest a surgical intervention to establish the correct pathological diagnosis because it is essential to exclude malignant neoplasms of the urinary bladder. The majority of patients have a favorable prognosis.

Point-of-care ultrasound use in umbilical line placement: a review.

Point-of-care ultrasound (POCUS) has become a novel tool for assessing umbilical catheter tip location in the neonate. This review analyzes the current evidence on the efficacy and utility of POCUS for identifying umbilical catheter positioning. Medline, EMBASE, and Cochrane searches were performed until October 2018. Eight studies were identified comparing POCUS to x-ray in assessing umbilical catheter tip location in the last 10 years. POCUS was shown to be feasible and appears to be a superior imagining modality to x-rays in assessing umbilical line tip location. POCUS is more accurate in determining umbilical catheter positioning, allows for more rapid line umbilical catheter placement, and reduces the time to treatment as well as radiation exposure to the neonate when compared with x-ray. The available studies support further education in training neonatal providers to become proficient in POCUS for assessing umbilical lines.

Abdominoplasty with simultaneous laparoscopic umbilical hernia repair: A practical approach to preserve the umbilical vascularization.

BACKGROUND: Umbilical necrosis is a well-known complication of abdominoplasty, the risk of this complication can be increased when an associated umbilical hernia requires further dissection in peri-umbilical region, potentially leading to umbilical devascularisation. Multiple minimally invasive open techniques were described to avoid this problem. The combined approach of abdominoplasty with laparoscopic umbilical hernia repair is one promising solution to avoid devascularising the umbilicus. METHODS: A retrospective evaluation of patients who underwent concomitant abdominoplasty with laparoscopic umbilical hernia repair from 2007 to 2017 was carried out. All patients were followed up and evaluated for complications, including the incidence of umbilical skin necrosis. RESULTS: A total of 47 patients were included in this study. The average operative duration was 3.3hours with an average hospital stay of 2.5 days. No cases of postoperative umbilical necrosis were encountered. A mean follow-up period was 2.4 years showed no cases of hernia or rectus abdominis diastasis recurrence. Minor complications included 4 cases of dehiscence, one hematoma. There was no major complications. CONCLUSION: The concomitant use of laparoscopic umbilical hernia repair and abdominoplasty is a feasible approach to reduce the risks of umbilical devascularization. Especially in larger hernias and in patients with higher risk of recurrence.

Neoumbilicoplasty With a Pedicled Deep Inferior Epigastric Perforator Island Flap.

Management of the umbilicus is a common dilemma at the time of abdominoplasty and abdominal wall reconstruction. It is not uncommon for underlying pathologies, such as hernias and surgical scars, to result in a disfigured or obliterated native umbilicus or make the blood supply to the umbilical stalk unreliable. In these scenarios, the umbilicus is often sacrificed. Staged neoumbilical reconstruction may be offered and typically utilizes a small skin flap and full-thickness skin graft (Ann Plast Surg 2009;63:358-360). Our technique, in contrast, permits reconstruction of the neoumbilicus in the immediate setting utilizing normally discarded skin with a robust blood supply from a deep inferior epigastric artery perforator. In this series of 13 consecutive neoumbilicoplasties, the pedicled deep inferior epigastric artery perforator island flap provided reliable results and favorable aesthetic outcomes.

Umbilical necrosis rates after abdominal-based microsurgical breast reconstruction.

BACKGROUND: Umbilical stalk necrosis represents a rare, yet important complication after abdominal-based microsurgical breast reconstruction, which is both underrecognized and understudied in the literature. Once identified, umbilical reconstruction can be an extremely challenging problem. METHODS: All consecutive breast free flaps at a single institution from February 2004 to February 2016 were reviewed, excluding non-abdominal-based flaps. Patients were divided based on the development of umbilical necrosis postoperatively. Demographics, surgical characteristics, and other complications were compared between the groups. RESULTS: A total of 918 patients met the inclusion criteria, with 29 developing umbilical necrosis identified (3.2%). Patients developing necrosis tended to be older (49.4 yrs versus 52.9 yrs; P < 0.01); have higher BMI (31.3 versus 27.8; P < 0.01); and were more likely to be smokers (27.5% versus 11.6%; P = 0.01). Umbilical necrosis was also associated with increased flap weight (830 g versus 656 g; P < 0.01), decreased time of perforator dissection (151 min versus 169 min; P = 0.02); bilateral cases (68.9% versus 44.7%; P < 0.01), and increased number of perforators per flap (2.5 versus 2.2; P = 0.03). There was no association with flap type (deep inferior epigastric perforator, superficial inferior epigastric artery, or free TRAM), diabetes, previous abdominal surgery, or use of preoperative imaging. Umbilical necrosis was not associated with any concomitant complications. CONCLUSIONS: Umbilical stalk necrosis was found to occur in 3.2% of patients and was associated with several preoperative comorbidities and intraoperative characteristics. This information should help influence intraoperative decision-making to prevent the development of this undesirable complication.

Pre-expanded Paraumbilical Perforator Flap.

The paraumbilical perforator flap is the first and the most famous perforator flap. Pre-expansion increases the flap dimension and reduces the flap thickness and donor site morbidities, making the paraumbilical perforator flap a more effective option for upper extremity reconstruction. Pre-expanded pedicled paraumbilical perforator flaps can achieve excellent function and aesthetic outcomes in patients with extensive scar contracture and giant melanocytic nevi in the upper extremity. Although this technique requires multiple procures, each operation is relatively simple and has a low complication rate, when properly planned and performed.

Maternal and fetal Doppler velocimetry in women diagnosed with fear of childbirth.

AIM: This study aimed to investigate maternal and fetal Doppler flow parameters in term pregnant women diagnosed with fear of childbirth (FOC). MATERIALS AND METHODS: Women between 20 and 40 years with full-term singleton pregnancies (≥37 gestational weeks) were included in the study. All patients were questioned with Turkish form of Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A. Women with W-DEQ scores ≥85 were defined as FOC. Forty women diagnosed with FOC (FOC group) and 45 women with W-DEQ scores <85 (control group) underwent Doppler waveform analysis and the pulsatility index (PI) and resistance index (RI) values for uterine, umbilical, and mid cerebral arteries were recorded. RESULTS: Both groups had similar PI and RI values for umbilical and mid cerebral arteries (P > 0.05). However, PI and RI values for both right and left uterine arteries were higher in FOC group than control group (P < 0.05, for right uterine artery PI; P< 0.001, for left uterine artery RI; and P< 0.01, for others). CONCLUSION: It may be suggested that the presence of FOC in term pregnant women seems to have a negative effect on uterine blood flow parameters. When diagnosed with FOC, the women should be referred to a specialist for psychoeducation and psychosomatic support to decrease her fear and to minimize the negative impact of fear on the fetus.

Restricción selectiva del crecimiento intrauterino en la gestación gemelar monocorial: diagnóstico y manejo / Selective intrauterine growth restriction in monochorionic-diamniotic twins: diagnosis and management

La Restricción Selectiva del Crecimiento Intrauterino se produce en 10 a 19% de los gemelos monocoriónicos, y se asocia con un aumento importante de la mortalidad y la morbilidad perinatal. La evolución clínica está dada en gran parte por la presencia de anastomosis vaculares y la distribución placentaria asimétrica. Se propuso una clasificación en tres tipos según el Doppler de la arteria umbilical del gemelo más pequeño, la que sé que se correlaciona con distintos comportamientos clínicos y características de la placenta, lo que ayuda en el asesoramiento y conducta obstétrica. Los del tipo I tienen un pronóstico favorable por el resultado perinatal satisfactorio por lo que se recomienda un seguimiento cercano por ecografía y Doppler. Los de tipo II tienen un mal pronóstico y el tipo III un pronóstico intermedio e impredecible. En estos dos últimos se puede realizar un manejo expectante hasta que se observe deterioro del feto pequeño, considerando la posibilidad de la coagulación con láser o la oclusión del cordón (feticidio selectivo). Ambas conductas aparentemente aumentan las posibilidades de supervivencia del feto de peso normal.

Selective intrauterine growth restriction occurs in 10-19% of monochorionic twins, and is associated with increased mortality important and perinatal morbidity. The clinical course is given largely by the presence of placental vascular anastomosis and asymmetric distribution. It classified into three types according to the proposed Doppler umbilical artery smaller twin, the one that correlates with different clinical behaviors and characteristics of the placenta, which helps in counseling and obstetric conduct. The type I have a favorable prognosis for satisfactory perinatal outcome so closely monitored by ultrasound and Doppler is recommended. The type II has a poor prognosis and type III intermediate and unpredictable prognosis. In these last two you can make an expectant management until deterioration of the small fetus is observed, considering laser coagulation or cord occlusion (selective feticide). Both behaviors appear to increase the chances of survival of the fetus of normal weight.

Downregulation of dynamin-related protein 1 contributes to impaired autophagic flux and angiogenic function in senescent endothelial cells.

OBJECTIVE: Recent studies have shown that altered mitochondrial dynamics impairs the function in senescent endothelial cells (ECs). However, the underlying molecular mechanism remains to be elucidated. Herein, we investigated the role and underlying mechanism of mitochondrial fission protein dynamin-related protein 1 (DRP1) in vascular aging. APPROACH AND RESULTS: We found that DRP1 expression is decreased in senescent ECs, accompanied with long interconnected mitochondria and impaired angiogenic function. In addition, there was marked increase of autophagosomes but not of autolysosomes (assessed as punctate dual fluorescent mCherry-GFP (green fluorescent protein) tandem-tagged light chain 3 expression) in senescent ECs, indicating impaired autophagic flux. DRP1 knockdown or pharmacological inhibition in young ECs resulted in elongated mitochondria, suppressed autophagic flux, premature senescence, and impaired angiogenic function. In contrast, adenoviral-mediated overexpression of DRP1 in senescent ECs restored autophagic flux and improved angiogenic function. EC senescence was associated with the increase of mitochondrial reactive oxygen species and antioxidant N-acetyl-cysteine restored autophagosome clearance and improved angiogenic function. Consistently, en face staining of old rat thoracic aorta revealed a decrease of DRP1 expression and increase of autophagosomes accumulation. Furthermore, in vivo knockdown of Drp1 in common carotid arteries significantly impaired the autophagosome clearance. Importantly, downregulation of Drp1 directly abrogated microvessels outgrowth from ex vivo aortic rings. CONCLUSIONS: These results suggest that loss of DRP1 during senescence exacerbates ECs dysfunction by increasing mitochondrial reactive oxygen species and subsequently inhibiting autophagic flux.

Myocardial Infarction-Associated SNP at 6p24 Interferes With MEF2 Binding and Associates With PHACTR1 Expression Levels in Human Coronary Arteries.

OBJECTIVE: Coronary artery disease (CAD), including myocardial infarction (MI), is the main cause of death in the world. Genome-wide association studies have identified dozens of single nucleotide polymorphisms (SNPs) associated with CAD/MI. One of the most robust CAD/MI genetic associations is with intronic SNPs in the gene PHACTR1 on chromosome 6p24. How these PHACTR1 SNPs influence CAD/MI risk, and whether PHACTR1 itself is the causal gene at the locus, is currently unknown. APPROACH AND RESULTS: Using genetic fine-mapping and DNA resequencing experiments, we prioritized an intronic SNP (rs9349379) in PHACTR1 as causal variant. We showed that this variant is an expression quantitative trait locus for PHACTR1 expression in human coronary arteries. Experiments in endothelial cell extracts confirmed that alleles at rs9349379 are differentially bound by the transcription factors myocyte enhancer factor-2. We engineered a deletion of this myocyte enhancer factor-2-binding site using CRISPR/Cas9 genome-editing methodology. Heterozygous endothelial cells carrying this deletion express 35% less PHACTR1. Finally, we found no evidence that PHACTR1 expression levels are induced when stimulating human endothelial cells with vascular endothelial growth factor, tumor necrosis factor-α, or shear stress. CONCLUSIONS: Our results establish a link between intronic SNPs in PHACTR1, myocyte enhancer factor-2 binding, and transcriptional functions at the locus, PHACTR1 expression levels in coronary arteries and CAD/MI risk. Because PHACTR1 SNPs are not associated with the traditional risk factors for CAD/MI (eg, blood lipids or pressure, diabetes mellitus), our results suggest that PHACTR1 may influence CAD/MI risk through as yet unknown mechanisms in the vascular endothelium.