Patients’ exposure to PVC plasticizers from ECMO circuits

N-Acetyl Cysteine-Decorated Nitric Oxide-Releasing Interface for Biomedical Applications

Biomedical devices are vulnerable to infections and biofilm formation, leading to extended hospital stays, high expenditure, and increased mortality. Infections are clinically treated via the administration of systemic antibiotics, leading to the development of antibiotic resistance. A multimechanistic strategy is needed to design an effective biomaterial with broad-spectrum antibacterial potential. Recent approaches have investigated the fabrication of innately antimicrobial biomedical device surfaces in the hope of making the antibiotic treatment obsolete. Herein, we report a novel fabrication strategy combining antibacterial nitric oxide (NO) with an antibiofilm agent N-acetyl cysteine (NAC) on a polyvinyl chloride surface using polycationic polyethylenimine (PEI) as a linker. The designed biomaterial could release NO for at least 7 days with minimal NO donor leaching under physiological conditions. The proposed surface technology significantly reduced the viability of Gram-negative Escherichia coli (>97%) and Gram-positive Staphylococcus aureus (>99%) bacteria in both adhered and planktonic forms in a 24 h antibacterial assay. The composites also exhibited a significant reduction in biomass and extra polymeric substance accumulation in a dynamic environment over 72 h. Overall, these results indicate that the proposed combination of the NO donor with mucolytic NAC on a polymer surface efficiently resists microbial adhesion and can be used to prevent device-associated biofilm formation.

Legacy and Emerging Plasticizers and Stabilizers in PVC Floorings and Implications for Recycling

Hazardous chemicals in building and construction plastics can lead to health risks due to indoor exposure and may contaminate recycled materials. We systematically sampled new polyvinyl chloride floorings on the Swiss market (n = 151). We performed elemental analysis by X-ray fluorescence, targeted and suspect gas chromatography-mass spectrometry analysis of ortho-phthalates and alternative plasticizers, and bioassay tests for cytotoxicity and oxidative stress, and endocrine, mutagenic, and genotoxic activities (for selected samples). Surprisingly, 16% of the samples contained regulated chemicals above 0.1 wt %, mainly lead and bis(2-ethylhexyl) phthalate (DEHP). Their presence is likely related to the use of recycled PVC in new flooring, highlighting that uncontrolled recycling can delay the phase-out of hazardous chemicals. Besides DEHP, 29% of the samples contained other ortho-phthalates (mainly diisononyl and diisodecyl phthalates, DiNP and DiDP) above 0.1 wt %, and 17% of the samples indicated a potential to cause biological effects. Considering some overlap between these groups, they together make up an additional 35% of the samples of potential concern. Moreover, both suspect screening and bioassay results indicate the presence of additional potentially hazardous substances. Overall, our study highlights the urgent need to accelerate the phase-out of hazardous substances, increase the transparency of chemical compositions in plastics to protect human and ecosystem health, and enable the transition to a safe and sustainable circular economy.

Simultaneous and sensitive determination of the main metabolites of the plasticizer DEHP and its substitutes DEHTP, DINCH and TEHTM in human urine by coupling of on-line SPE, UHPLC and tandem mass spectrometry

With the prominent but toxicologically critical plasticizer di-(2-ethylhexyl) phthalate (DEHP) declining, alternative plasticizers are increasingly used leading to a continuously more diverse exposure situation of humans with multiple plasticizers. Therefore, an on-line SPE-LC-MS/MS method for the simultaneous determination of the most relevant urinary biomarkers of exposure to DEHP and the alternative plasticizers 1,2-cyclohexane dicarboxylic acid diisononyl ester (DINCH), di-(2-ethylhexyl) terephthalate (DEHTP) and tri-(2-ethylhexyl) trimellitate (TEHTM) was developed. The method is characterized by a high sensitivity with limits of detection ranging from 0.006 to 0.047 μg L^-1 combined with an easy and straightforward sample preparation procedure. The wide linear working range of the method enables a reliable determination of analyte background levels in the general population as well as its potential use for monitoring studies investigating elevated plasticizer exposure settings. The method was successfully applied to urine samples from ten volunteers without occupational exposure to plasticizers revealing ubiquitous background exposure levels of the common plasticizers DEHP, DEHTP and DINCH.

Medical devices as a source of phthalate exposure: a review of current knowledge and alternative solutions

Phthalates are a group of phthalic acid esters used as plasticisers in a large number of products to improve their flexibility, softness, and extensibility. Their wide use in medical devices, however, raises a lot of concern, as they can enter the organism and have toxic effects on human liver, thyroid, kidneys, lungs, reproductive, endocrine, nervous, and respiratory system and are associated with asthma, obesity, autism, and diabetes. The aim of this review is to summarise current knowledge about phthalate migration from medical devices during different medical procedures and possible impact on patient health. It also looks at alternative plasticisers with supposedly lower migration rates and safer profile. Not enough is known about which and how many phthalates make part of medical devices or about the health impacts of alternative plasticisers or their migration rates.

Effects of DEHP, DEHT and DINP Alone or in a Mixture on Cell Viability and Mitochondrial Metabolism of Endothelial Cells In Vitro

Plasticizers are chemicals in high demand, used in a wide range of commercial products. Human are exposed through multiple pathways, from numerous sources, to multiple plasticizers. This is a matter of concern, as it may contribute to adverse health effects. The vascular system carries plasticizers throughout the body and therefore can interact with the endothelium. The aim of the study was to evaluate the in vitro toxicity on endothelial cells by considering the individual and the mixture effects of bis-(2-ethylhexyl) phthalate (DEHP), diisononyl phthalate (DINP) or bis-(2-ethylhexyl) terephthalate (DEHT). In this study, their cytotoxicity on HMEC-1 cells was evaluated on cell function (viability, cell counting, total glutathione and intracellular adenosines) and mitochondrial function (mitochondrial respiration). Results showed cellular physiological perturbations induced with all the condition tested, excepted for DEHT. Plasticizers induced a cytotoxicity by targeting mitochondrial respiration, depleting mitochondrial ATP production and increasing glycolytic metabolism. Additionally, delayed effects were observed between the cellular and the mitochondrial parameters. These results suggest that endothelial cells could go through a metabolic adaptation to face plasticizer-induced cellular stress, to effectively maintain their cellular processes. This study provides additional information on the adverse effects of plasticizers on endothelial cells.

Ex Vivo Model to Assess the Exposure of Patients to Plasticizers from Medical Devices during Pre-CAR-T Cells’ Apheresis

Background: The treatment of relapsed or refractory leukemia remains a major problem. Among the new therapeutic approaches, the use of modified T lymphocytes, called chimeric antigen receptor T cells (CAR-T cells), seems promising. The first step of their preparation is leukapheresis, which involves the collection of mononuclear cells from the patient. This medical procedure requires numerous medical devices (MDs) made of plasticized polyvinylchloride (PVC). These compounds can leach out of the devices during contact with the patient’s blood. The aim of our study was to evaluate the migration of the plasticizers contained in the MD during a simulated pre-CAR-T cell leukapheresis procedure, and to measure the patient’s and their lymphocytes’ exposure to them. Methods: The qualitative and quantitative composition of the MD used for pre-CAR-T cell apheresis was determined by gas chromatography–mass spectrometry (GC–MS). Then, an ex vivo leukapheresis model using an ethanol/water simulant was performed to evaluate the plasticizers’ migration under simulated clinical conditions of pre-CAR-T cells’ cytapheresis. The plasticizers released into the simulant were quantified by GC–MS. Results: Diethylhexylphthalate (DEHP) was found in the apheresis kit, with amounts ranging from 25% to 59% (g/100 g of PVC). Bis(2-ethylhexyl) adipate was detected at trace levels. A total of 98.90 ± 11.42 mg of DEHP was released into the simulant, corresponding to an exposure dose of 1.4 mg/kg for a 70 kg patient. Conclusions: Patients undergoing a pre-CAR-T cell apheresis are mainly exposed to DEHP, which can impact their health because of its endocrine disruption effect, but could also lead to a decrease in CAR-T cells’ efficiency/quality.

Long-term normothermic machine preservation of human livers: what is needed to succeed?

Although short-term machine perfusion (≤24 h) allows for resuscitation and viability assessment of high-risk donor livers, the donor organ shortage might be further remedied by long-term perfusion machines. Extended preservation of injured donor livers may allow reconditioning, repairing, and regeneration. This review summarizes the necessary requirements and challenges for long-term liver machine preservation, which requires integrating multiple core physiological functions to mimic the physiological environment inside the body. A pump simulates the heart in the perfusion system, including automatically controlled adjustment of flow and pressure settings. Oxygenation and ventilation are required to account for the absence of the lungs combined with continuous blood gas analysis. To avoid pressure necrosis and achieve heterogenic tissue perfusion during preservation, diaphragm movement should be simulated. An artificial kidney is required to remove waste products and control the perfusion solution's composition. The perfusate requires an oxygen carrier, but will also be challenged by coagulation and activation of the immune system. The role of the pancreas can be mimicked through closed-loop control of glucose concentrations by automatic injection of insulin or glucagon. Nutrients and bile salts, generally transported from the intestine to the liver, have to be supplemented when preserving livers long term. Especially for long-term perfusion, the container should allow maintenance of sterility. In summary, the main challenge to develop a long-term perfusion machine is to maintain the liver's homeostasis in a sterile, carefully controlled environment. Long-term machine preservation of human livers may allow organ regeneration and repair, thereby ultimately solving the shortage of donor livers.

Enhancement of the anticoagulant capacity of polyvinyl chloride tubing for cardiopulmonary bypass circuit using aluminum oxide nanoscale coating applied through atomic layer deposition

For cardiopulmonary bypass, the polyvinyl chloride (PVC) circuit which can initiate the activation of platelets and the coagulation cascade after blood cell contacting is the possible detrimental effect. Surface coating of the PVC tubing system can be an effective approach to enhance circuit's hemocompatibility. In this study, aluminum oxide (Al₂ O₃ ) thin films were deposited through thermal atomic layer deposition (T-ALD) or plasma-enhanced ALD (PE-ALD) on PVC samples, and the anticoagulation of the Al₂ O₃ -coated PVC samples was demonstrated. The results revealed that Al₂ O₃ deposition through ALD increased surface roughness, whereas T-ALD had a relative hydrophilicity compared with blank PVC and PE-ALD. Whole blood immersion tests showed that blood clots formed on blank PVC and that a large amount of red blood cells was found on PE-ALD substrates, whereas less blood cells were noted in T-ALD samples. Both T-ALD and PE-ALD Al₂ O₃ films did not cause activation of blood cells, as evidenced in CD3⁺ /CD4⁺ /CD8⁺ , CD61⁺ /CD62P⁺ , and CD45⁺ /CD42b⁺ populations. Analysis of serum coagulation factors showed that a lower amount of prothrombin was absorbed on T-ALD Al₂ O₃ samples than that on blank PVC. For albumin and fibrinogen immersion tests, immunostaining and scanning electron microscopy further revealed that a thin albumin layer was absorbed on T-ALD Al₂ O₃ substrates but not on PVC samples. This study revealed that deposition of Al₂ O₃ films by T-ALD can improve anticoagulation of the PVC tubing system.

Specification and Evaluation of Plasticizer Migration Simulants for Human Blood Products: A Delphi Study

Potentially toxic plasticizers are commonly added to polyvinyl chloride medical devices for transfusion in order to improve their flexibility and workability. As the plasticizers are not chemically bonded to the PVC, they can be released into labile blood products (LBPs) during storage. Ideally, LBPs would be used in laboratory studies of plasticizer migration from the medical device. However, short supply (i.e., limited stocks of human blood in collection centres) has prompted the development of specific simulants for each type of LBP in the evaluation of new transfusion devices. We performed a Delphi study with a multidisciplinary panel of 24 experts. In the first (qualitative) phase, the panel developed consensus definitions of the specification criteria to be met by each migration simulant. Next, we reviewed the literature on techniques for simulating the migration of plasticizers into LBPs. A questionnaire was elaborated and sent out to the experts, and the replies were synthesized in order to obtain a consensus. The qualitative study established specifications for each biological matrix (whole blood, red blood cell concentrate, plasma, and platelet concentrate) and defined the criteria required for a suitable LBP simulant. Ten criteria were suggested: physical and chemical characteristics, opacity, form, stability, composition, ability to mimic a particular clinical situation, ease and safety of use, a simulant–plastic interaction correlated with blood, and compatibility with analytical methods. The questionnaire data revealed a consensus on the use of natural products (such as pig’s blood) to mimic the four LBPs. Opinions diverged with regard to synthetic products. However, an isotonic solution and a rheological property modifier were considered to be of value in the design of synthetic simulants. Consensus reached by the Delphi group could be used as a database for the development of simulants used to assess the migration of plasticizers from PVC bags into LBPs.

Antibacterial plasticizers based on bio-based engineering elastomers for medical PVC: synthesis, characterization and properties

Antibacterial plasticizers for medical PVC have been synthesized by the modification of bio-based engineering elastomers with a quaternary ammonium salt. PVC blended with such plasticizers showed good antibacterial properties and biocompatibility.

An update on the hazard of and exposure to diethyl hexyl phthalate (DEHP) alternatives used in medical devices

The use of the plasticizer diethyl hexyl phthalate (DEHP) in PVC medical devices is being questioned due to its potential reprotoxic effects in patients exposed as a result from migration from the device. This article reviews new information on migration and toxicity data of eleven alternative plasticizers that have previously been evaluated by the Danish EPA and the EU SCENIHR (Scientific Committee on Emerging and Newly Identified Health Risks). The new toxicity data did not justify the reconsideration of the critical NOAELs as established by SCENIHR and Danish EPA. The dataset on oral toxicity studies is rather complete for most substances; however, in particular for reproductive toxicity and endocrine disruption, data gaps still exist for many alternatives. Toxicity data on intravenous exposure are lacking and these are essential to conclude on hazard characteristics of alternatives that are poorly absorbed via the oral exposure route. Migration data are emerging for a few alternatives but still sparse for the majority of the alternatives. Taking all data on migration and toxicity in consideration, 1,2-cyclohexanedicarboxylic acid, diisononylester (DINCH), and tris(2-ethylhexyl)benzene-1,2,4-tricarboxylate display a more favorable profile compared to DEHP. For these promising alternatives, a risk assessment for use in medical devices should be conducted. As a next step, we recommend the (further) generation of relevant migration data and, where needed, relevant toxicity data for the alternative substances, in order to be able to conduct a benefit-risk analysis of DEHP and the alternatives as obligatory in the new European Union Medical Device Regulation.

Quantification of bis(2-ethylhexyl) phthalate released by medical devices during respiratory assistance and estimation of patient exposure

Bis(2-ethylhexyl) phthalate (DEHP) migration from polyvinyl chloride (PVC) has been studied with infusion, transfusion and extracorporeal oxygenation devices, but no study has been conducted to estimate its migration via respiratory medical devices (MDs). This work aims to develop an ex vivo model to quantify DEHP released doses by these MDs, which will then be used to estimate newborns DEHP exposure from respiratory assistance MDs. We followed the Frensh National Research and Safety Institute (INRS) recommendations for the validation of a collecting and analysing method of DEHP in air, which will be used to quantify DEHP in air passing through PVC respiratory assistance MDs. The developed method met all the validation criteria for DEHP determination in air. DEHP in air passing through MDs on the sixth day reached a cumulative quantity of 122.86 μg when using a flow rate of 4 L min^-1 of non-humidified air while it was of 49.22 μg; 58.12 μg and 29.61 μg with flow rates of 2 L min^-1 of humidified air, 2 L min^-1 of dry air and 4 L min^-1 of humidified air, respectively. Model application to two patients undergoing two different respiratory procedure demonstrated that noninvasive ventilation patient received higher dose of inhaled DEHP, confirmed by DEHP metabolites quantification in urine. Although the protective effect of air humidifiers on DEHP exposure was demonstrated, the effect of flow rate is difficult to be established. This developed method should be tested to verify its capacity to collect and quantify other plasticizers used in PVC MDs.

How does continuous venovenous hemofiltration theoretically expose (ex-vivo models) inpatients to diethylhexyladipate, a plasticizer of PVC medical devices?

Continuous venovenous hemofiltration (CVVH) is widely used in intensive care units to treat patients with acute kidney injury requiring renal replacement therapy. The medical devices (MD) used for CVVH include a hemofilter and tubings made of plasticized PVC. Due to its known reprotoxicity, diethylhexyl phthalate (DEHP) has been replaced by alternatives such as diethylhexyladipate (DEHA) in some of these tubings. The migration of DEHA from hemofiltration systems has not been assessed and thus the level of patient exposure to this DEHP-alternative remains unknown. In this study, 2 CVVH models were used to evaluate the potential migration of DEHA from PVC tubings, allowing the determination of (Rachoin and Weisberg, 2019) the highest rates of DEHA able to migrate into a simulant flowing in a marketed adult CVVH circuit by disregarding any metabolisation and (Krieter et al., 2013) the clinical-reflecting exposure of patients to this plasticizer and its metabolites by assessing their migration into blood. In the first model, we showed that patients undergoing a CVVH procedure may be exposed to high rates of DEHA. Moreover, DEHA is continuously hydrolyzed into its primary metabolite MEHA (monoethylhexyladipate), which may reach cytotoxic level in the patients' blood. When looking from a « safer » MD perspective, DEHA might not be the best alternative plasticizer for CVVH tubings. However, to reflect clinical conditions, this study should be completed by an in-vivo evaluation (biomonitoring) of the oxidized metabolites of DEHA in urines of inpatients undergoing CVVH.

Replacing Di(2-ethylhexyl) Terephthalate by Di(2-ethylhexyl) 2,5-Furandicarboxylate for PVC Plasticization: Synthesis, Materials Preparation and Characterization

The worldwide regulatory demand for the elimination of non-phthalate compounds for poly(vinyl chloride) (PVC) plasticization has intensified the search for alternatives. Concomitantly, sustainability concerns have highlighted sugar-based 2,5-furandicarboxylic acid as one key renewable-chemical for the development of several products, namely di(2-ethylhexyl) 2,5-furandicarboxylate (DEHF) plasticizer. This study addresses the use of DEHF under a realistic scenario of the co-existence of both DEHF and entirely fossil-based plasticizers. More precisely, original PVC blends using mixtures of non-toxic DEHF and di(2-ethylhexyl) terephthalate ester (DEHT) were designed. The detailed structural, thermal, and mechanical characterization of these materials showed that they all have a set of interesting properties that are compatible with those of commercial DEHT, namely a low glass transition (19.2-23.8 °C) and enhanced elongation at break (up to 330%). Importantly, migration tests under different daily situations, such as for example exudation from food/beverages packages and medical blood bags, reveal very low weight loss percentages. For example, in both distilled water and phosphate buffered saline (PBS) solution, weight loss does not exceed ca. 0.3% and 0.2%, respectively. Viability tests show, for the first time, that up to 500 μM of DEHF, a promising cytotoxic profile is observed, as well as for DEHT. Overall, this study demonstrates that the combination of DEHF and DEHT plasticizers result in a noticeable plasticized PVC with an increased green content with promising cytotoxic results.

New SPE-LC-MS/MS method for the simultaneous determination in urine of 22 metabolites of DEHP and alternative plasticizers from PVC medical devices

DiEthylHexylPhthalate (DEHP) can leach out of plasticized PVC medical devices (MD) and may enter into contact with patients. This phthalate is known for its reprotoxic and endocrine disrupting effects. Its use in medical devices (MD) has been restricted and alternative plasticizers have been developed. Nevertheless, no published clinical studies exist concerning patient exposure to these alternative plasticizers during medical care. This is particularly worrisome when high-risk populations, such as newborns, are exposed to these new plasticizers in intensive care units. Our study aimed to develop a novel sensitive and selective method to simultaneously identify and quantify DEHP and 17 other plasticizer metabolites (free or glucuronide conjugates), which are specific biomarkers of DEHTP, TOTM, DINP, DINCH and DEHA exposure in human urine. This robust method uses turbulent-flow online extraction technology coupled to high performance liquid chromatography - tandem mass spectrometry. Special care was taken to address two major problems in plasticizer analysis: contamination and chromatographic separation of interfering analogue structures. The validation was assessed in synthetic urine and the linearity of response was demonstrated for all compounds (R² > 0.99), with limits of quantification from 0.01 to 0.1 ng/ml. Accuracies ranged from 86% to 117% and inter- and intra-day precisions were <20%. The clinical applicability and suitability of our new method was assessed in patients in a neonatal intensive care unit to measure urinary concentrations of DEHP and alternative plasticizer metabolites. These metabolites were found in the majority of urine samples, with a median detection frequency of 95.2% (ranging from 12.5% to 100%). The high sensitivity, selectivity and ruggedness make the method suitable for large-scale biomonitoring studies of high-risk and general populations.