The review, led by Rajendra Prasad Anne of Kasturba Medical College at Manipal Academy of Higher Education in India, together with colleagues from the United Arab Emirates and India, set out to answer a deceptively simple question: when a newborn needs central venous access on the first day of life, which device is safer? The team searched PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials up to November 2025, capturing both randomised controlled trials and non-randomised studies of interventions. Their primary endpoints were the outcomes that matter most at the bedside: central line-associated bloodstream infection, known as CLABSI, mortality, late-onset sepsis and catheter-related complications such as thrombosis, occlusion, bleeding and tip malposition.

After screening the literature, the researchers pooled seven studies, five randomised trials and two non-randomised studies, encompassing 1,522 neonates. That may sound modest against the scale of neonatal medicine, but in a field where individual trials are small and fragmented, a meta-analysis of this kind carries real weight. The reviewers applied the GRADE framework to rate the certainty of the evidence and used random-effects models to combine results, acknowledging from the outset that the underlying studies differed in populations, protocols and catheter-management practices.

The headline finding is, in one sense, a null result. When the randomised trials were pooled, there was no statistically significant difference between PICCs and UVCs in the risk of central line-associated bloodstream infection. The pooled risk ratio was 0.75, with a 95 percent confidence interval of 0.50 to 1.11, a range that crosses the threshold of no effect. Mortality told a similar story, with a risk ratio of 1.05 and a confidence interval of 0.58 to 1.90. In plain terms, the evidence does not demonstrate that choosing a PICC over an umbilical line in the first day of life reduces bloodstream infections or saves lives, a conclusion that challenges the intuition of teams who have favoured PICCs on infection-prevention grounds.

Beneath that null result, however, the analysis surfaced signals that neonatologists will not be able to ignore. Babies who received PICCs showed a trend toward higher rates of late-onset sepsis, with a risk ratio of 1.36 and a confidence interval of 0.97 to 1.91, hovering just at the edge of statistical significance. Hospital stays also tended to be longer in the PICC groups, by a mean difference of 3.2 days, though the confidence interval of minus 0.2 to 6.6 days included the possibility of no difference. Neither finding is definitive on its own, but both point in the same direction, and both carry clinical consequences if they are real.

The mechanical performance of the two devices diverged more sharply. PICCs were significantly less likely to become malpositioned, meaning their tips wandered from the intended central position less often than umbilical catheters, with a risk ratio of 0.65 and a confidence interval of 0.49 to 0.86. Yet the same fine-bore lines paid a price elsewhere: they were nearly three times as likely to occlude, with a risk ratio of 2.84 and a confidence interval of 1.23 to 6.57. Anyone who has watched a nurse struggle to flush a clotted neonatal PICC will recognise the practical reality behind that number. The review also found that PICC insertion took significantly longer than umbilical catheterisation, a meaningful consideration in the delivery room, where minutes can matter and where the umbilical vein offers an immediate, anatomically obvious route.

One of the most intellectually honest parts of the analysis concerns catheter dwell time. The reviewers noted that PICCs tended to remain in place longer than umbilical catheters in the included studies, and they flagged this as an important unresolved confounder. The logic is straightforward: the longer any central line stays in the body, the greater the cumulative opportunity for microorganisms to colonise it and for bloodstream infection to develop. If PICCs dwell longer, any apparent excess of late-onset sepsis could partly reflect exposure time rather than intrinsic device risk, and conversely, the absence of an infection advantage for PICCs becomes even more striking given their longer residence. Disentangling device effects from dwell-time effects will require trials that standardise catheter duration, something the existing literature has not done.

Why does this matter beyond the neonatal unit? Central line-associated bloodstream infections are among the most feared complications in intensive care, driving antibiotic use, prolonging hospitalisation and, in vulnerable preterm infants whose immune systems are immature, contributing to mortality and long-term neurodevelopmental harm. Late-onset sepsis, which typically strikes after the first seventy-two hours of life, is a leading cause of death and disability in very low birth weight infants. If the choice of access device on day one influences these outcomes, then a simple procedural decision could ripple through an entire lifetime. Conversely, if the devices are truly equivalent on infection outcomes, units can base their choices on other grounds: insertion speed, malposition risk, occlusion rates, staff training and the anticipated duration of therapy.

The practical implications cut in different directions. For teams that need immediate central access at resuscitation, the umbilical venous catheter remains the fastest and most familiar option, and the new analysis gives no reason to abandon it. For infants expected to need weeks of parenteral nutrition or prolonged antibiotic courses, the PICC’s lower malposition rate and longer usable lifespan may still justify its placement, provided teams are prepared for occlusions and for the longer insertion procedure. What the review does not support is the assumption that switching early from an umbilical line to a PICC will, by itself, lower infection rates. The authors conclude plainly that current evidence does not demonstrate a reduction in CLABSI, mortality or late-onset sepsis when neonatal PICCs are used instead of UVCs for early central venous access.

Like all meta-analyses, this one inherits the limitations of its ingredients. Seven studies and roughly fifteen hundred infants is a small evidence base for a question of this importance, and the two non-randomised studies included are inherently vulnerable to selection bias, since clinicians may choose one device over the other based on how sick a baby appears. The GRADE assessment reflects that uncertainty. Still, the work exemplifies a quiet revolution in neonatology: the systematic aggregation of small trials to extract answers that no single centre could deliver alone. The review was registered prospectively on PROSPERO under number CRD42024604746 and received no external funding, and the authors declare no competing interests. For the parents of the roughly 1,500 infants whose data underpin this analysis, and for the millions more who will pass through neonatal units, the message is a call for better trials, not a final answer. Until those arrive, the humble umbilical catheter, inserted in the first minutes of life, remains a formidable and entirely defensible first choice.

Subject of Research: Comparative safety of peripherally inserted central catheters versus umbilical venous catheters for central venous access in newborns

Article Title: Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes

Article References: Anne, R. P., Vardhelli, V., RD, R., & Murki, S. (2026). Peripherally inserted central catheter versus umbilical venous catheter for central venous access in neonates on the first day of life: a systematic review and meta-analysis of central line-associated bloodstream infections and clinical outcomes. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07761-y

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07761-y

Keywords: neonatology, central venous access, PICC, umbilical venous catheter, CLABSI, late-onset sepsis, meta-analysis, systematic review, premature infants, catheter complications, neonatal intensive care, bloodstream infection

Malignant ascites, the pathological accumulation of fluid within the peritoneal cavity driven by cancer involving the peritoneal membrane, increased vascular permeability, or lymphatic blockage, accounts for roughly 10 to 15 percent of all ascites cases and carries a poor prognosis. The condition produces a cascade of debilitating symptoms: abdominal fullness and bloating, pain, nausea, difficulty breathing, reduced mobility, and loss of appetite, all of which erode quality of life at a stage when patients and their families have limited time together. Unlike ascites caused by cirrhosis or heart failure, dietary modification and diuretics tend to be ineffective in the malignant form, leaving fluid evacuation as the mainstay of palliative treatment.

Repeated large-volume paracentesis addresses the symptom but never the underlying cause, so the procedure must be performed regularly, at considerable cost to both patients and health systems and with a cumulative risk of procedural complications. Tunneled indwelling peritoneal catheters, or IPCs, have emerged as an alternative that allows drainage at home. The United Kingdom’s National Institute for Health and Care Excellence approved first-generation devices as cost-effective in 2012 and reaffirmed that judgment in 2022, but many supporting studies involved small patient numbers, and clear criteria identifying which patients are most likely to benefit have been lacking.

The new analysis, led by Krasen Zdravkov Ivanov of University Hospital Saint Ekaterina in Sofia, Bulgaria, together with Hans-Ulrich Laasch of the University of Manchester, examined a large single-center cohort treated with a second-generation device. Patients were eligible if their ascites required at least two drainage procedures per month. Exclusion criteria included active peritoneal infection, deranged clotting with an INR above 1.8 or platelet counts below 50,000 per microliter, loculated ascites, an ECOG performance status of 4 with estimated survival under three weeks, and known allergy to catheter components. Every patient underwent history and physical examination, laboratory testing, and abdominal ultrasound at least 48 hours before implantation.

The technical details of the procedure are central to its success. The Aspira catheter is a 15.5-French, 72-centimeter fenestrated silicone tube with 50 drainage holes on its intraperitoneal end. A single experienced interventionalist performed all insertions using an antegrade tunneling technique under sterile conditions, with local anesthesia and perioperative intravenous ceftriaxone. After ultrasonography identified an implantation site away from scars, tumor masses, bowel, and other organs, typically in the iliac fossa, a subcutaneous tunnel of roughly five to eight centimeters was fashioned, the abdominal cavity was punctured under ultrasound guidance, and a peel-away sheath fitted with a leakage-preventing valve was placed over a guidewire. Correct positioning of the catheter tip in the pelvis was confirmed with ultrasound or X-ray. Technical success was achieved in all 124 patients without exception.

The cohort, with a mean age of 60.6 years and a strong female majority at 67.7 percent, reflected the typical epidemiology of malignant ascites: ovarian cancer was the most common primary malignancy at 19.4 percent, followed by breast cancer at 18.5 percent and colon cancer at 14.5 percent. Adenocarcinoma accounted for more than three-quarters of tumor types, peritoneal carcinomatosis was the leading mechanism at 42.7 percent, and the fluid was predominantly an exudate. Nearly three-quarters of patients were actively receiving chemotherapy, radiotherapy, or immunotherapy, while the remainder were on supportive or palliative care.

Symptom outcomes were striking. Using the Edmonton Symptom Assessment System modified for ascites, researchers found statistically significant improvement in every symptom measured at 30 days, including pain, general weakness, nausea, depression, anxiety, drowsiness, appetite, sense of well-being, shortness of breath, abdominal bloating, and impaired mobility, all with p-values below 0.001. The largest average changes were in abdominal bloating, which improved by 8.1 points on the 10-point scale, impaired mobility by 6.3 points, and pain by 6.0 points. Significant improvements in fluid-volume symptoms such as shortness of breath and bloating persisted at 90 days, although anxiety, appetite, well-being, and mobility gains were no longer statistically significant at that point, a pattern the authors attribute partly to cancer progression and the side effects of ongoing anticancer therapy. The mean number of hospital visits fell by 45.4 percent between the 30-day and 90-day periods, from 1.1 to 0.6 per interval. The mean duration of catheter use was 103.3 days.

Safety results were also reassuring. Twenty-six patients, or 21.0 percent, experienced catheter-related complications, but most were minor and easily managed. These included cellulitis in seven patients treated successfully with antibiotics, ascites leakage at the implantation site within 48 hours in five patients corrected with sutures, valve defects in two patients whose valves were replaced without removing the catheter, and subcutaneous hematomas in two patients. Ten complications, or 8.1 percent, were classified as moderate because they required catheter removal: one device obstruction from adjacent tumor overgrowth, one dislocation, and eight cases of secondary bacterial peritonitis. All patients recovered after systemic antibiotics or device replacement, and no infection-related deaths occurred. Notably, patients with serous and fibrinous ascites fluid experienced complications more frequently, an observation that may help guide aftercare intensity.

Beyond the numbers, the study’s practical contribution is a treatment algorithm to help clinicians select candidates most likely to benefit, an area where formal guidelines have been notably absent. The authors emphasize that adequate control of ascites symptoms can determine whether a patient is well enough to continue treatment for the underlying malignancy, and that reliable home drainage helps patients return home sooner and spend quality time with loved ones. They also highlight device-specific advantages, including a valve system that nearly eliminates fluid spillage during implantation, an infection control benefit as well as a slip hazard reduction, the option of retrograde tunneling to improve cuff fixation, and repairability that avoids removal and reinsertion in cases of accidental damage.

The authors acknowledge the limitations of a single-center, retrospective, non-comparative design, and note that the number of patients with quality-of-life data declined at 90 days. Nevertheless, they conclude that tunneled indwelling peritoneal catheters combine a high rate of technical success, durable clinical benefit, and manageable complications, offering physicians an effective, cost-conscious approach to caring for one of the most vulnerable populations in oncology.

Subject of Research: Clinical outcomes of tunneled indwelling peritoneal catheters for malignant ascites palliation

Article Title: Clinical outcomes following insertion of second-generation (Aspira®) tunneled indwelling peritoneal catheters to treat malignant ascites

Article References: Ivanov, K. Z., & Laasch, H.-U. (2026). Clinical outcomes following insertion of second-generation (Aspira®) tunneled indwelling peritoneal catheters to treat malignant ascites. CVIR Oncology, 2(1), Article 16. https://doi.org/10.1007/s44343-026-00047-1

Image Credits: AI Generated

DOI: 10.1007/s44343-026-00047-1

Keywords: malignant ascites, peritoneal catheter, palliative care, paracentesis, oncology, interventional radiology, quality of life, catheter complications, Aspira drainage system, cancer symptoms, peritoneal carcinomatosis, Clinical