(18) F-FDG PET/CT for initial staging in breast cancer patients - Is there a relevant impact on treatment planning compared to conventional staging modalities?

OBJECTIVE: To evaluate the impact of whole-body (18) F-FDG PET/CT on initial staging of breast cancer in comparison to conventional staging modalities. METHODS: This study included 102 breast cancer patients, 101 patients were eligible for evaluation. Preoperative whole-body staging with PET/CT was performed in patients with clinical stage ≥ T2 tumours or positive local lymph nodes (n = 91). Postoperative PET/CT was performed in patients without these criteria but positive sentinel lymph node biopsy (n = 10). All patients underwent PET/CT and a conventional staging algorithm, which included bone scan, chest X-ray and abdominal ultrasound. PET/CT findings were compared to conventional staging and the impact on therapeutic management was evaluated. RESULTS: PET/CT led to an upgrade of the N or M stage in overall 19 patients (19 %) and newly identified manifestation of breast cancer in two patients (2 %). PET/CT findings caused a change in treatment of 11 patients (11 %). This is within the range of recent studies, all applying conventional inclusion criteria based on the initial T and N status. CONCLUSIONS: PET/CT has a relevant impact on initial staging and treatment of breast cancer when compared to conventional modalities. Further studies should assess inclusion criteria beyond the conventional T and N status, e.g. tumour grading and receptor status. KEY POINTS: • PET/CT may be relevant in staging breast cancer patients at higher risk for metastases • PET/CT may modify the N and M stage in multiple patients • PET/CT may impact treatment planning in breast cancer patients.

Adjunctive therapies for treatment of severe respiratory failure in newborns.

BACKGROUND: Severe respiratory failure of the newborn requires adjunctive therapies as application of surfactant, inhalation of nitric oxide (iNO), high frequency oscillatory ventilation (HFOV), or extracorporeal membrane oxygenation (ECMO). We designed this study to analyze the the usage and effectiveness of adjunctive therapies and the mortality of severe respiratory failure. PATIENTS AND METHODS: The survey in Germany was done in collaboration with the "Erhebungseinheit für seltene pädiatrische Erkrankungen" (ESPED). 397 patients within 2 years were included into the study. Effectiveness of each adjunctive therapy was judged by the treating physician. RESULTS: The most frequent diagnosis was respiratory distress syndrome (RDS) with 36.8%, followed by pneumonia sepsis (16.4%), meconium aspiration syndrome (MAS) and congenital diaphragmatic hernia (CDH). Surfactant was applied in 77.3% of all cases with a reported effectiveness of 71.6%. More than 40% of all patients were treated with iNO, which led to an improvement in every second case. HFOV was used in every third case with a response rate of about 60%. ECMO was performed on one in 7 patients and was successful with a survival rate of nearly 80%. The overall mortality was 10.3%. 29 patients in total died without ECMO. 10 of them might actually have been contraindicated, but 19 cases with a potential benefit from ECMO were not transferred for ECMO. CONCLUSION: Our study-data suggests that more newborns suffering from respiratory failure should be transferred to centers offering ECMO.

Gynaecological laparoscopic surgery for benign conditions: do women care about incisions?

OBJECTIVE: To determine the relevance of the number and location of incisions in women undergoing gynaecologic laparoscopy due to benign conditions. STUDY DESIGN: This study included 141 women, who underwent gynaecologic laparoscopic surgery with 4 incisions due to benign conditions between November 2010 and November 2011 at the University Medical Centre Mannheim, Germany. Women with malign histology were excluded. Demographic parameters, type and duration of surgery, perioperative complications and duration of hospital stay were analysed. Women were contacted using a standardized telephone survey with an interval of at least 22 weeks after surgery. Patients were interviewed regarding the number, postoperative pain and their preferences for omission of incisions. RESULTS: Eighty-seven women (61.7%) responded to the standardized questionnaire. 38 (43.7%) remembered the number of incisions correctly. 45 of the women (51.7%) thought they had less, 4 (4.6%) thought, they had more incisions as they actually did have. If one of the incisions had to be discarded 28 (32.2%) patients did not have any preferences with regard to the localisation. Of the other 59 patients, 44 (74.6%) would prefer to eliminate the umbilical one. CONCLUSION: The majority of the women remembered fewer incisions than actually used. Most of the patients interviewed would, if possible, eliminate the umbilical incision. Therefore from the patient's perspective the skin scars after conventional laparoscopic surgery seem to be of limited importance and the alleged advantage of omission of additional incision using single site surgery remains debatable.

[Tribological assessment of articular cartilage. A system for the analysis of the friction coefficient of cartilage, regenerates and tissue engineering constructs; initial results]. / Tribologische Messungen am Gelenkknorpel. Ein Prüfstand zur Messung der Reibungszahlen von Knorpel gegen Knorpel, Regeneraten und TE-Konstrukten und erste Ergebnisse.

Values for the friction coefficient of articular cartilage are given in ranges of percentage and lower and are calculated as a quotient of the friction force and the perpendicular loading force acting on it. Thus, a sophisticated system has to be provided for analysing the friction coefficient under different conditions in particular when cartilage should be coupled as friction partner. It is possible to deep-freeze articular cartilage before measuring the friction coefficient as the procedure has no influence on the results. The presented tribological system was able to distinguish between altered and native cartilage. Furthermore, tissue engineered constructs for cartilage repair were differentiated from native cartilage probes by their friction coefficient. In conclusion a tribological equipment is presented to analyze the friction coefficient of articular cartilage, in vivo generated cartilage regenerates and in vitro tissue engineered constructs regarding their biomechanical properties for quality assessment.

Clinical characteristics of children with lower respiratory tract infections are dependent on the carriage of specific pathogens in the nasopharynx.

A prospective clinical study was performed to correlate nasopharyngeal carriage of bacteria with the type of lower respiratory tract infections (LRTI) in hospitalised children. To determine bacterial load in nasopharyngeal aspirates (NPA) we used semiquantitative culturing and quantitative TaqMan-PCR for those pathogens difficult to culture. Specimens and clinical data were obtained from 311 children between 0 and 16 years of age with LRTI during the period of 2006-2008. The most common detected potentially pathogenic colonisers were Haemophilus influenzae (32.1 %), Moraxella catharralis (26.7 %), Staphylococcus aureus (17.7 %) and Streptococcus pneumoniae (16.7 %). As expected S. aureus was the most common coloniser in children less than 4 months of age, whereas H. influenzae detection peaked in older children. Co-colonisation with other bacterial pathogens were more often observed in children with S. aureus (46 %) and S. pneumoniae (49 %) than in those with H. influenzae (30 %) or M. catharralis (27 %). Children with S. aureus co-colonisation had higher levels of C-reactive-protein, received antibiotics more frequently and stayed longer in hospital than those with S. aureus single colonisation. In contrast, children with H. influenzae, M. catharralis or S. pneumoniae colonisation suffered more often from pneumonia than children with S. aureus colonisation. Coloniser specific analysis of bacterial quantity revealed no significant reduction of the bacterial carriage from the first to the second NPA. No correlation of a high bacterial load and occurrence of pneumonia could be detected. In conclusion, clinical characteristics in children with LRTIs are associated with a specific bacterial set of colonisers detected in the nasopharynx rather than on their quantity.

Intensified neoadjuvant chemoradiotherapy in locally advanced rectal cancer -- impact on long-term quality of life.

AIMS: In spite of advances in rectal cancer surgery and the use of preoperative 5-fluorouracil-(5-FU) based chemoradiotherapy (CRT) in stage II and III disease distant metastases still occur in about 35-40% of the patients. Intensified preoperative CRT (ICRT) using other drugs in conjunction with 5-FU has been investigated in order to improve the pathological complete remission (pCR) rate and thereby prognosis of patients with locally advanced rectal cancer. However, acute toxicity, especially diarrhea, was reported to be high and no improvement in pCR rates has been observed in randomized trials. Long-term results of these trials are pending. In the present analysis we investigated the impact of ICRT on health related quality of life and long term toxicity. METHODS: The present study included 119 patients with locally advanced rectal cancer who underwent neoadjuvant CRT followed by surgery within controlled clinical trials. Patients received ICRT (n = 83) or standard CRT (n = 36). Evaluation of HRQoL was performed using EORTC QLQ-C30 and QLQ-CR29 questionnaires. RESULTS: The overall rating of global health status/QLQ scale of the EORTC QLQ-C30 questionnaire was identical in both patient groups but patients in the CRT group showed better results in four out of nine function scales. Concerning symptom scales, patients in the CRT arm exhibited significantly less diarrhea (p = 0.028) and less disorders with taste (0.042). CONCLUSIONS: This data suggests that higher gastrointestinal acute toxicity caused by ICRT might lead to a higher risk of long-term deterioration of "gastrointestinal QoL". Future results of randomized trials investigating ICRT versus CRT should be discussed in the light of long-term QoL data.

Do structural changes in the tumour bed after intraoperative radiotherapy (IORT) of breast cancer complicate the evaluation of mammograms in a long-term follow-up?

The purpose of the study was to assess whether postoperative changes in the tumour bed after intraoperative radiotherapy (IORT) with low-energy X-rays complicate the mammographic evaluation. 54 patients receiving breast-conserving surgery and IORT were compared to a control group of 48 patients with conventional breast-conserving treatment. All patients were included in routine follow-ups (≥3 years) with mammography accompanied by ultrasound. By retrospective consensus reading the mammographic changes in the tumour bed were classified as absent, low or distinct. Using the same grading it was classified whether mammographic evaluation was complicated due to postoperative changes. Focusing the yearly follow-ups within a period of four years, distinct changes were found significantly more often after IORT (52-62% vs. 7-30%). After IORT the evaluation was significantly more often distinctly complicated in each follow-up, except for year 1 (16-21% vs. 0-8%). In the IORT group the distribution of findings was nearly stable over time. In the control group it changed over time and a distinctly complicated evaluation was no longer seen in the follow-ups of years 3 and 4. Overall, further non-routine diagnostic procedures due to unclear findings in the tumour bed became necessary in 7% (IORT) vs. 8% (control group) of the patients (p=0.86). Evaluation of mammograms is complicated after IORT. In contrast to conventionally treated patients postoperative changes and difficulties of evaluation do not decrease over time. Overall, after IORT the diagnostic uncertainty does not seem to be increased in ultrasound supported mammographic follow-ups. The topic needs further evaluation with larger study samples.

Scintigraphic evaluation of rhBMP-2-biocoated implants reveals no ectopic bone formation.

The main objectives of the study described below were of two-fold nature: (1) to examine if rhBMP-2-biocoated implants in a pig model could lead to ectopic bone formation and (2) if quantitative and/or qualitative differences could be found between adhesively and covalently bonded BMP II using the scintigraphic method. In order to examine these central questions, 26 Göttingen minipigs were allocated to three groups with a control group (n=7) and two study groups (n=9 each) receiving one of three implant types: (a) chromosulfuric acid treated titanium surface as control, (b) non-covalently bonded BMP-2, and (c) covalently bonded and immobilized rhBMP-2. Each animal received four barbell-shaped implants, one in the proximal and distal metaphysis of each femur. The scintigraphic analyses were conducted after four, eight, and 12 weeks postoperatively. The visual (qualitative) analysis failed to show ectopic bone formation in any of the three groups. The statistical analysis of the relative values for bone formation yielded no significant differences between the groups, although the limitation in the applied methods do not enable one to draw conclusions regarding the histomophometric results.

[Non-invasive imaging modalities for preoperative axillary lymph node staging in patients with breast cancer]. / Nichtinvasive bildgebende Verfahren zum präoperativen axillären Lymphknotenstaging beim Mammakarzinom.

In the last decade sentinel lymph node biopsy has become a well-established method for axillary lymph node staging in patients with breast cancer. Using preoperative imaging modalities it can be tested whether patients are suitable for sentinel node biopsy or if they should directly undergo an axillary dissection. The imaging modalities used must be mainly characterized by a high positive predictive value (PPV). For this question B-mode ultrasound is the best evaluated method and provides clear morphological signs for a high PPV (>90%) but the sensitivity barely exceeds 50%. It has not yet been proven whether other modalities such as duplex sonography, magnetic resonance imaging, computed tomography (CT) or scintigraphy might achieve a higher sensitivity while still maintaining a high PPV. There is only some evidence that positron emission tomography (PET) might achieve a higher sensitivity. This should be confirmed by further studies because PET or PET/CT will play an increasing role for an initial whole body staging in patients with breast cancer in the near future.

Long-term follow-up-findings in mammography and ultrasound after intraoperative radiotherapy (IORT) for breast cancer.

The purpose of this study was to assess mammographic and sonographic findings in a long-term follow-up (>or=3 years) after breast-conserving surgery (BCS) and IORT, either applied as boost or exclusively. Follow-up-findings of 54 patients were retrospectively evaluated and compared to a control group of 48 patients, treated with BCS and whole-breast radiotherapy. After IORT patients had a higher incidence of fat necroses manifesting as oil cysts in the late follow-up mammograms (n = 31 vs n = 8); furthermore, oil cysts were larger in the IORT group (median 4.5 vs 1.4 cm(2)). In 25 IORT patients the oil cysts arose from partially organized hematomas/seromas, which in this group were generally more frequent (n = 38 vs n = 9) and larger (median 3.6 vs 1.8 cm(2)). After IORT a decreasing incidence of hematomas/seromas was reciprocal to an increasing incidence of oil cysts, and the size of both entities correlated with each other. Liquid lesions with polypoid inner wall thickening on ultrasound, attributed to organized hematomas/seromas or fat necroses, appear more frequently after IORT (n = 15 vs n = 1). In conclusion, IORT is associated with a high incidence of large oil cysts, which arise from likewise large partially organized wound cavities. On ultrasound pronounced partial organization with polypoid inner wall thickening is a frequent finding in those cavities.

Long-term outcome in patients with short bowel syndrome after longitudinal intestinal lengthening and tailoring.

OBJECTIVES: Longitudinal intestinal lengthening and tailoring (LILT) is a well-established surgical treatment for short bowel syndrome. It has been shown to enhance peristalsis, decrease bacterial overgrowth, and extend mucosal contact time for nutrients. We present the results of a long-term follow-up of patients who underwent LILT and define prognostic parameters for the survival of these patients. PATIENTS AND METHODS: Between 1987 and 2006, 53 patients underwent LILT in our institution. The main diagnoses were gastroschisis, intestinal volvulus, intestinal atresias, and necrotizing enterocolitis. LILT was performed at a mean age of 24 months (range 4144 months). The follow-up time was 79.76 months (range 6234 months). RESULTS: After LILT, 41 of 53 patients survived, and 36 of 41 surviving patients were successfully weaned from parenteral nutrition (PN). In long-term follow-up 79% stayed free of PN. The overall survival rate was 77.36%. Weight gain occurred in 58% of the patients after LILT. The quality of life after LILT is on a high level, with most patients having normal physical strength and participating in normal social life and education. Prognostic factors for survival after LILT in short bowel syndrome are length of small intestine (0.06582 + 0.0131 x bowel cm), length of large bowel (P = 0.039), preoperative liver function, and successful weaning from PN within 18 months postoperatively (P = 0.0032). CONCLUSIONS: Patients undergoing LILT in short bowel syndrome have a high survival rate, weight gain, and a high quality of life. Autologous gastrointestinal reconstruction remains therefore the first choice in the treatment of patients with short bowel syndrome.

The diagnosis of Sézary syndrome on peripheral blood by flow cytometry requires the use of multiple markers.

BACKGROUND: Diagnosis of Sézary syndrome (SS)-defining blood involvement is hampered by the lack of Sézary cell-specific markers and nonspecific morphology of the tumour cells. OBJECTIVES: To identify the most reliable and easy to use markers for the diagnosis of SS-defining blood involvement. METHODS: We studied 17 patients with SS and 11 control patients. We used flow cytometry for the detection of T-cell antigens (CD3, CD4, CD7 and CD8), expression of the Sézary cell-associated marker CD158k and T-cell receptor (TCR)-Vbeta chain. Additionally, Sézary cells were identified by peripheral blood smear for lymphocytes with cerebriform nuclei. RESULTS: It was not possible to diagnose blood involvement in all patients with SS by a single marker or method, although none of the markers was increased in the control population. Sézary cells were detected by blood smears in 13 of 17 (76%), by flow cytometry by their CD4+ CD7- CD3(dim) phenotype (> 1000 cells microL(-1)) in 13 of 17 (76%) and by expression of CD158k in 11 of 17 (65%) patients with SS. A specific T-cell clone was identified by identical TCR-Vbeta chain expression in 12 of 17 (71%) patients with SS. The identification of Sézary cells in individual patients varied for the different markers investigated. CONCLUSIONS: The combination of identifying CD4+ CD7- CD3(dim) cells, TCR-Vbeta chain and CD158k expression allowed a definite identification of SS-defining blood involvement in every individual patient. All of these markers can be measured by flow cytometry which would avoid time-consuming analysis of blood smears. These markers would also be suitable to monitor tumour cell load during therapy.

Gene-expression signature of adhesion/growth-regulatory tissue lectins (galectins) in transitional cell cancer and its prognostic relevance.

AIMS: Lectins, and especially galectins, appear to be important in malignancy-associated processes. The aim was to analyse comprehensively the presence of galectins in urothelial tumours. METHODS AND RESULTS: Non-cross-reactive antibodies against seven family members from the three subgroups (prototype: galectin-1, -2 and -7; chimera type: galectin-3; tandem-repeat type: galectin-4, -8 and -9) were used. Gene expression was monitored in specimens of normal urothelium, fresh tumour tissue and cell lines by real-time polymerase chain reaction (PCR). The presence and evidence of tumour-associated up-regulation were shown for galectin-1 and -3. This was less clear-cut for galectin-4 and -8. Galectin-7 was expressed in all cell lines; galectin-2 and -9 were detected at comparatively low levels. Galectin-2, -3 and -8 up-regulation was observed in superficial tumours, but not in muscle-invasive tumours (P < 0.05). Immunoreactivity correlated with tumour grading for galectin-1, -2 and -8, and disease-dependent mortality correlated with galectin-2 and -8 expression. Binding sites were visualized using labelled galectins. CONCLUSIONS: The results demonstrate a complex expression pattern of the galectin network in urothelial carcinomas. Galectin-1, -2, -3 and -8 are both potential disease markers and also possible targets for bladder cancer therapy.

Early mammographic and sonographic findings after intraoperative radiotherapy (IORT) as a boost in patients with breast cancer.

The aim of this study was to evaluate mammographic and sonographic changes at the surgical site within the first 2 years after IORT as a boost followed by whole-breast radiotherapy (WBRT), compared with a control group treated with WBRT alone. All patients had breast-conserving surgery for early-stage breast cancer. Group A: n = 27, IORT (20 Gy) followed by WBRT (46 Gy). Group B (control group): n = 27, WBRT alone (56-66 Gy). Mammography: fat necrosis in 14 group A versus four group B patients (P < 0.001); parenchymal scarring classified as unorganized at the last follow-up in 16 vs seven cases, respectively (P = 0.03). Ultrasound: overall number of patients with circumscribed findings 27 vs 18 (P < 0.001); particular hematomas/seromas in 26 vs 13 patients (P < 0.001). Synopsis of mammography and ultrasound: overall postoperative changes were significantly higher classified in group A (P = 0.01), but not judged to have a significantly higher impact on interpretation. Additional diagnostic procedures, due to unclear findings at the surgical site, were performed on four patients of both groups. Within the first 2 years after IORT as a boost, therapy-induced changes at the original tumor site are significantly more pronounced compared with a control group. There is no evidence that the interpretation of findings is complicated after IORT.

[MDCT after balloon kyphoplasty: analysis of vertebral body architecture one year after treatment of osteoporotic fractures]. / MDCT nach Ballonkyphoplastie: Analyse der Wirbelkörperarchitektur 1 Jahr nach Behandlung osteoporotischer Sinterungsfrakturen.

PURPOSE: To evaluate the value of MDCT in the monitoring of vertebral body architecture after balloon kyphoplasty and observe morphological changes of the vertebral body. MATERIAL AND METHODS: During a period of 26 months, 66 osteoporotic fractures of the vertebral bodies were treated with percutanous balloon kyphoplasty. The height of the vertebral body, width of spinal space, sagittal indices, kyphosis und COBB angle, and cement leakage were evaluated by computed tomography before and after treatment and in a long-term follow up. Statistical analysis was performed by calculating quantitative constant parameters of descriptive key data. In addition, parametric and distribution-free procedures were performed for all questions. RESULTS: After kyphoplasty, the treated vertebral bodies showed a significant gain in the height of the leading edge (0.15 cm; p < 0.0001) and in the central part of the vertebral body (0.17 cm; p < 0.0001). The height of the trailing edge did not change significantly. A corresponding gain in the sagittal index was found. The index remained stable during follow-up. Treated vertebral bodies as well as untreated references showed a comparable loss of height over the period of one year. The shape of the vertebral bodies remained stable. In comparison to these findings, treated vertebral bodies showed a reduced loss of height. A significant change in kyphosis und the COBB angle was noted. In total, pallacos leakage was detected in 71 % of cases. CONCLUSION: MDCT is an accurate method for evaluating vertebral body architecture after treatment with balloon kyphoplasty. Morphological changes in the vertebral bodies, and complications such as pallacos leakage and progression of osteoprosis can be accurately documented. The significant increase in the vertebral body height after treatment is closely correlated with a gain in the sagittal index and reduced kyphosis and COBB angle.

[Risk profiling of postoperative complications in 17,644 total knee replacements]. / Identifizierung von Risikofaktoren postoperativer Komplikationen in der primären Knieendoprothetik.

AIM: Postoperative complications following primary total knee replacement performed between 2000 and 2002 were assessed to determine perioperative patient- and procedure-related risks associated with the procedure. METHODS: For this analysis, the data collected during postoperative hospitalization for 17,644 total knee arthroplasties were assessed. The analysis included two steps. First, using logistic regression, we identified and quantified significant risk factors for the occurrence of general postoperative complications. Second, univariate analysis was utilized to qualitatively and quantitatively analyze the influence of these significant risk factors on the occurrence of major complications (hematoma, cardiovascular complication, deep venous thrombosis, pulmonary embolism, joint infection, and pneumonia). RESULTS: General postoperative complications were reported in 11.3%. Major postoperative complications occurred in 7.2% with hematoma in 2.9%, cardiovascular complications in 1.8%, deep venous thrombosis in 1.2%, pulmonary embolism in 0.2%, joint infection in 0.8%, and pneumonia in 0.3%. Patient-related risk factors such as age, surgery time, gender, high ASA classification as well as procedure-related risk factors such as allogeneic blood transfusions and lateral release significantly increased the rate of postoperative complications. Males were more prone to hematoma, joint infection, and pneumonia in the immediate postoperative course than females, who were more in danger of developing deep venous thrombosis. Allogeneic blood transfusions increased the risk for postoperative hematoma, infection, and cardiovascular complication. Regional anesthesia was shown to decrease the risk for the occurrence of postoperative deep venous thrombosis and pulmonary embolism. CONCLUSIONS: Postoperative complications in total knee replacement are increased in males and elder patients. Increased time of surgery and allogeneic blood transfusions also represent important risk factors for postoperative complications following primary total knee replacement.

Extraction of di-ethylhexyl-phthalate from perfusion lines of various material, length and brand by lipid emulsions.

BACKGROUND: The plasticizer di-ethylhexyl-phthalate (DEHP) is extracted especially by lipid emulsions from polyvinylchloride infusion systems. The aim of this study was to systematically examine the extraction from perfusion lines commonly used in our hospital for lipid emulsion infusions. METHODS: Perfusion lines made from polyvinylchloride of various lengths and brands, polyethylene, polyvinylchloride/polyethylene (PVC/PE) and polyvinylchloride/polyurethane (PVC/PU), were perfused with lipid emulsions according to the circumstances of newborns on an intensive care unit, i.e. high temperature, 24-hour duration and low quantities. Concentration of di-ethylhexyl-phthalate was determined with gas chromatograph mass spectrometry. RESULTS: The lipid emulsions before perfusion had a contamination with DEHP of 0.82 microg/ml. Pure PVC lines of 1.5 m length leached between 74 microg/ml and 107 microg/ml. Sterilization of the lines did not influence DEHP extraction. After perfusion of DEHP-free PVC lines and PVC-free lines, the emulsions had a contamination with DEHP of 0.23 microg/ml and 0.11 microg/ml, respectively. PVC/PU co-extruded lines leached 73 microg/ml. PVC/PE lines leached 41.6 microg/ml. CONCLUSIONS: Lipid emulsions contain a production-inherent load of DEHP. Perfusion through PVC-perfusion lines extracts a varying large amount of DEHP depending on length and brand of the perfusion lines. Co-extruded PVC/PU and PVC/PE lines, intended to avoid DEHP contamination, leach a similar amount of DEHP and thus do not avoid the DEHP toxicity issue. The load accumulated by a baby on an intensive care unit easily reaches several milligrams of DEHP per day. As its effect upon biologic systems has been proven, and alternatives (PE or PU perfusion lines) are available, PVC and PVC co-extruded perfusion lines should be abandoned for infusions, especially in babies.