Neonatal Phototherapy and Clinical Characteristics: The Danish National Patient Registry 2000-2016

Purpose

Phototherapy is the standard treatment for neonatal hyperbilirubinemia. It is important to collect data on phototherapy to support research related to the efficacy and safety of phototherapy. We explored the registration of phototherapy in the Danish National Patient Registry (DNPR) and the clinical characteristics of neonates treated with phototherapy.

Methods

We identified children born alive in Denmark from 1 January 2000 through 30 November 2016 from the DNPR (N=1,044,502). We calculated the proportion of children registered that received phototherapy during the neonatal period and examined temporal trends, both nationwide and at the level of individual hospitals. In a sub-cohort of children born at Aarhus University Hospital (AUH) in 2002-2016 (N=71,781), we analyzed the proportions of children registered that received phototherapy, according to sex, gestational age, birth weight, and neonatal characteristics, like Apgar score, birth asphyxia, and infections.

Results

We identified 11,295 (1.1%) registered that received phototherapy. The proportions of children registered that received phototherapy differed among hospitals (range: 0 to 4.1%). Nationwide registration was low during the study period, but it increased to 1.8% in 2016. For the AUH sub-cohort the proportion of children registered with phototherapy averaged 4.4% (N=3182, range:3.9-5.1%). The proportion of children registered with phototherapy was inversely correlated with gestational age and birth weight, and positively correlated with neonatal characteristics, including low Apgar score, birth asphyxia, and infections.

Conclusion

Phototherapy was under-reported in the DNPR and the proportions of children registered that received phototherapy differed among hospitals. The non-compulsory policy for reporting treatment and care in hospitals to the DNPR might explain the variation. The most consistent reporting was observed among children born in an university hospital, where 4.4% of children registered that received phototherapy, and phototherapy was inversely associated with gestational age, birth weight, and positively associated with clinical characteristics like birth asphyxia, and infections.

Evaluation of the diagnostic process in neonates with conjugated hyperbilirubinaemia

INTRODUCTION

The Danish Health Authority (DHA) recommends diagnostic evaluation of infants who develop prolonged jaundice and a serum conjugated bilirubin (CB) concentration ≥ 17 μmol/l. This study aimed to assess the efficacy of the programme in identifying infants with biliary atresia (BA) or other liver disease. Infants born in the Central Denmark Region from 2016 to 2021 were investigated.

METHODS

A total of 693 infants were identified in the Central Biochemical Database (Labka). From a review of all medical records, CB measurements, results from diagnostic procedures and the final diagnosis were documented.

RESULTS

Four infants were identified with BA. They had a mean CB concentration of 105 μmol/l. A total of 33 infants were diagnosed with other cholestatic diseases; this group had a mean CB concentration of 58.9 μmol/l. The remaining 656 infants with a mean CB of 20.5 μmol/l recovered spontaneously without any sign of cholestatic disease. Approximately 75% of all HIDA scintigraphies (100/134) were conducted in 647 infants with a maximum CB concentration less-than 30 μmol/l. They all had bile drainage to the intestines. Among these infants, twelve were diagnosed as heterozygote for alfa-1-antitrypsin deficiency.

CONCLUSION

The CB threshold limit recommended by the DHA detected all patients with BA, but its use leads to over-investigation and over-diagnosing.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

[Treatment and follow-up of preterm infants in Denmark]

This review summarises the treatment of preterm infants in Denmark, which is dependent on the collaboration between several medical specialities. The problems of the preterm infants are related to the degree of prematurity, and the treatment should counter these issues, reduce complications related to prematurity and ensure growth and development. Developmental problems are the most common sequelae. There seems to be a dose-effect association between the whole spectrum of gestational age and developmental problems with the highest risk among the extremely preterm children. However, even in this group, most of the children will develop normally.

Sudden vs Pressure Wean From Nasal Continuous Positive Airway Pressure in Infants Born Before 32 Weeks of Gestation: A Randomized Clinical Trial

IMPORTANCE

Nasal continuous positive airway pressure (nCPAP) is a well-established treatment of respiratory distress syndrome in preterm infants. Suboptimal weaning from nCPAP may be associated with lung injury, pulmonary morbidity, and infant weight gain. To our knowledge, the best weaning strategy from nCPAP is unknown.

OBJECTIVE

To compare the effect of sudden wean and pressure wean from nCPAP in very preterm infants.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, clinical, open-label, multicenter trial was conducted at 6 neonatal intensive care units in Denmark from September 2012 to December 2016 and included infants born before 32 weeks of gestation.

INTERVENTIONS

Sudden wean with discontinuation of nCPAP without a prior reduction in pressure. Pressure wean with gradual pressure reduction prior to the discontinuation of nCPAP.

MAIN OUTCOME AND MEASURES

The primary outcome was weight gain velocity from randomization to postmenstrual age 40 weeks. Secondary outcomes included other measures of growth, nCPAP and the duration of oxygen supplementation, postmenstrual age at successful wean and at discharge, successful wean at the first attempt, the number of attempts to wean, and the length of the hospital stay. Prespecified subgroup analyses by gestational age were performed.

RESULTS

Of the 372 randomized infants, 185 (49.7%) were randomized to sudden wean and 187 infants (50.3%) to pressure wean. A total of 177 infants in both groups completed the trial (median gestational age for sudden and pressure wean, 30 weeks [interquartile range, 29-31]; male: sudden wean, 89 [50%]; pressure wean, 96 [54%]). There was no difference in mean [SD] weight gain velocity from randomization to 40 weeks postmenstrual age between the 2 groups (22 [6] g/kg/day). No difference was found in any of the secondary outcomes. More infants born before 28 weeks of gestation were successfully weaned from nCPAP during the first attempt in the pressure wean group compared with the sudden wean group (risk difference, 31%; 95% CI, 13%-50%), but there was no difference in the duration of nCPAP and oxygen supplementation.

CONCLUSIONS AND RELEVANCE

Overall, we found no difference in weight gain velocity or any of the secondary outcomes between very preterm infants who were randomized to sudden wean or pressure wean from nCPAP. However, among infants born before 28 weeks' gestation, infants from the pressure wean group were more often successfully weaned during the first attempt without a longer total duration of nCPAP treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01721629.

Hypothermia at neonatal intensive care unit admission was not associated with respiratory disease or death in very preterm infants

AIM

This study investigated the association between hypothermia and respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD) or death in very preterm infants admitted to a Danish neonatal intensive care unit (NICU).

METHODS

We studied 675 infants born at Aalborg University Hospital before 32 weeks and admitted to the NICU from April 1997 to December 2011. Hypothermia was defined as a core temperature of <36.5°C on admission. The primary outcome was severe RDS or death within the first three days of life, and the secondary outcome was BPD or death before 36 postmenstrual weeks. The multivariable logistic regression was adjusted for early-onset infection, gestational age, Apgar score, sex, treatment year and birth weight.

RESULTS

Infants with hypothermia had a twofold increase (OR) in the odds for RDS or death (2.03), but the adjusted OR was not statistically significant (1.36). They also demonstrated a twofold increase (OR) in the odds for BPD or death (2.28), but again the adjusted OR was not statistically significant (1.03).

CONCLUSION

After adjusting for confounders, we found that the association between hypothermia on admission to the NICU and RDS or death, or BPD or death was statistically insignificant.

Surfactant Need by Gestation for Very Preterm Babies Initiated on Early Nasal CPAP: A Danish Observational Multicentre Study of 6,628 Infants Born 2000-2013

BACKGROUND

In recent years, early nasal continuous positive airway pressure (nCPAP) as respiratory support for preterm infants is being advocated as an alternative to prophylactic surfactant and treatment with mechanical ventilation. A number of infants treated with early nCPAP do not need treatment with surfactant, but few studies provide data on this. Since the 1990s, the first approach to respiratory support to preterm infants in Denmark has been early nCPAP combined with surfactant administration by the INSURE method by which the infant is intubated and surfactant administration is followed by rapid extubation to nCPAP if possible.

OBJECTIVES

To investigate how often surfactant was administered in preterm infants with a gestational age below 34 weeks treated with early nCPAP as a first approach to respiratory support.

METHODS

An observational multicentre study including all inborn infants with a gestational age below 34 weeks admitted to 1 of the 4 level 3 neonatal intensive care units in Denmark in the period from 2000 to 2013.

RESULTS

A total of 6,628 infants were included in this study. We found that surfactant was administered in 1,056 of 1,799 (59%; 95% CI: 57-61%), in 821 of 2,864 (29%; 95% CI: 27-31%), and in 132 of 1,796 (7%; 95% CI: 6-8%) of the infants with a gestational age from 24 to 27, 28 to 31, and 32 to 33 weeks and 6 days, respectively.

CONCLUSIONS

A large proportion of preterm infants treated with early nCPAP as the first approach to respiratory support was never treated with surfactant.

Autologous chondrocyte implantation (ACI) for cartilage defects of the knee: A guideline by the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU)

BACKGROUND

Autologous chondrocyte implantation (ACI) is an established and well-accepted procedure for the treatment of localised full-thickness cartilage defects of the knee.

METHODS

The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Trauma (DGOU) describes the biology and function of healthy articular cartilage, the present state of knowledge concerning therapeutic consequences of primary cartilage lesions and the suitable indication for ACI.

RESULTS

Based on best available scientific evidence, an indication for ACI is given for symptomatic cartilage defects starting from defect sizes of more than three to four square centimetres; in the case of young and active sports patients at 2.5cm(2), while advanced degenerative joint disease needs to be considered as the most important contraindication.

CONCLUSION

The present review gives a concise overview on important scientific background and the results of clinical studies and discusses the advantages and disadvantages of ACI.

LEVEL OF EVIDENCE

Non-systematic Review.

UGT1A1*28 Genotypes and Respiratory Disease in Very Preterm Infants: A Cohort Study

BACKGROUND

Respiratory disease in the very preterm infant is frequent and often severe. Bilirubin is both a potent neurotoxin and antioxidant, and may have a clinical impact on preterm respiratory disease. The Gilbert genotype, the UGT1A1*28 allele, is the major known genetic cause of variation in bilirubin.

OBJECTIVES

To study the association between respiratory disease in the very preterm infant and the UGT1A1*28 allele.

METHODS

This is a cohort study of 1,354 very preterm infants (gestational age <32 weeks) born in Jutland, Denmark in 1997-2011. Genotypes were obtained from the Danish Neonatal Screening Biobank, and clinical information was obtained from the databases of two tertiary neonatal intensive care units. Outcomes were the need for surfactant therapy, any need for and duration of supplementary oxygen and bronchopulmonary dysplasia (BPD).

RESULTS

Per UGT1A1*28 allele, odds were increased for any need of supplementary oxygen (odds ratio 1.26; 1.05-1.50) and for BPD (odds ratio 1.71; 1.23-2.39), the need of supplementary oxygen increased by 6.38 days (1.87-10.89), and chance per day of no longer needing supplementary oxygen was reduced (hazard rate 0.84; 0.76-0.93). No effect was observed for need of surfactant treatment (odds ratio 1.08; 0.91-1.28). Hardy-Weinberg equilibrium was unlikely for the cohort (p < 0.012). This could be explained by death prior to genotype sampling. In tests of robustness this failed to explain the primary results.

CONCLUSIONS

Compared to the common genotype, UGT1A1*28 genotypes were associated with an increased need of oxygen supplementation and risk of BPD in very preterm newborns.

Extreme neonatal hyperbilirubinemia and a specific genotype: a population-based case-control study

OBJECTIVES

Extreme hyperbilirubinemia (plasma bilirubin ≥ 24.5 mg/dL) is an important risk factor for severe bilirubin encephalopathy. Several risk factors for hyperbilirubinemia are known, but in a large number of patients, a causal factor is never established. UGT1A1 is the rate-limiting enzyme in bilirubin's metabolism. The genotype of Gilbert syndrome, the UGT1A1*28 allele, causes markedly reduced activity of this enzyme, but its association with neonatal hyperbilirubinemia is uncertain and its relationship with extreme hyperbilirubinemia has not been studied. We examined whether the UGT1A1*28 allele is associated with extreme hyperbilirubinemia.

METHODS

The UGT1A1*28 allele was assessed in a case-control study of 231 white infants who had extreme hyperbilirubinemia in Denmark from 2000 to 2007 and 432 white controls. Cases were identified in the Danish Extreme Hyperbilirubinemia Database that covers the entire population. Genotypes were obtained through the Danish Neonatal Screening Biobank. Subgroup analysis was done for AB0 incompatible cases.

RESULTS

No association was found between the UGT1A1*28 allele and extreme hyperbilirubinemia. With the common genotype as reference, the odds ratio of extreme hyperbilirubinemia was 0.87 (range, 0.68-1.13) for UGT1A1*28 heterozygotes and 0.77 (range, 0.46-1.27) for homozygotes. Also, no association was found for AB0 incompatible cases.

CONCLUSIONS

The UGT1A1*28 allele was not associated with risk for extreme hyperbilirubinemia in this study.

The Danish neonatal clinical database is valuable for epidemiologic research in respiratory disease in preterm infants

BACKGROUND

We examined the quality of the information on the use of surfactant and the use of and duration of nasal continuous positive airway pressure (nCPAP), oxygen supplementation, and mechanical ventilation in the Danish Neonatal Clinical Database (NeoBase).

METHODS

We included all neonates born with a gestational age < 32 weeks admitted to a Neonatal Intensive Care Unit (NICU) at two university hospitals in 2005. On discharge, the clinicians complete a structured form with information related to the delivery and course of stay in the NICU. These forms were entered into the NeoBase. The nurses' daily bedside documentation was used as reference standard. Concordance was used as a measure of agreement between the NeoBase and the reference standard. For the dichotomous variables the concordance was defined as the sensitivity of the information registered in the NeoBase. For the continuous variables, it was based on the discrepancy in days between the NeoBase and the reference standard. The percentage of concordance was described as high (> 90), moderate (70-90) or low (< 70).

RESULTS

Overall, 153 infants participated in the study. Concordance was high for all dichotomous variables. The NeoBase slightly underestimated the duration of nCPAP and mechanical ventilation. The duration of oxygen therapy was neither over- nor underestimated in the NeoBase. Concordance was low for all continuous variables if we assumed that the registered information was identical. It was 100% for duration of mechanical ventilation and moderate for nCPAP and oxygen supplementation if we allowed for a discrepancy of 1 day.

CONCLUSION

The NeoBase is a valuable tool for clinical and epidemiologic research and quality assurance regarding neonatal respiratory disease.

Percutaneous antegrade scaphoid screw placement: a feasibility and accuracy analysis of a novel electromagnetic navigation technique versus a standard fluoroscopic method

BACKGROUND

Central screw positioning in the scaphoid provides biomechanical advantages.

METHODS

A prospective randomized study of six fluoroscopically guided and six electromagnetically navigated screw (ENS) placements was performed on human cadavers. Accuracy of screw position was determined. Intraoperative fluoroscopy exposure times, readjustments of drilling directions, complete restarts and complications were documented.

RESULTS

The ENS method provided a mean time benefit of 7.34 min compared with the standard method and the mean screw length ratio (SLR coronar: ENS 0.96 ± 0.04 mm, SFF: 0.92 ± 0.04 mm, P = 0.065; SLR sagittal: ENS 0.98 ± 0.02 mm, SFF: 0.91 ± 0.04 mm, P = 0.009) and the screw axis deviation angle (AD coronar: ENS 3.33 ± 2.34°, SFF: 10.33 ± 2.58°, P = 0.002; AD sagittal: ENS 2.83 ± 0.98°, SFF: 11.00 ± 6.16°, P = 0.002) were lower. Using the electromagnetic navigation procedure no drilling readjustments or restarts were required, no cortical breach occurred.

CONCLUSIONS

Compared with the standard fluoroscopic technique, the ENS method used in this study showed higher accuracy, less complications, required less operation and radiation exposure time.

[Autologous chondrocyte implantation (ACI) for cartilage defects of the knee: a guideline by the working group "Tissue Regeneration" of the German Society of Orthopaedic Surgery and Traumatology (DGOU)]

Autologous chondrocyte transplantation/implantation (ACT/ACI) is an established and recognised procedure for the treatment of localised full-thickness cartilage defects of the knee. The present review of the working group "Clinical Tissue Regeneration" of the German Society of Orthopaedics and Traumatology (DGOU) describes the biology and function of healthy articular cartilage, the present state of knowledge concerning potential consequences of primary cartilage lesions and the suitable indication for ACI. Based on current evidence, an indication for ACI is given for symptomatic cartilage defects starting from defect sizes of more than 3-4 cm2; in the case of young and active sports patients at 2.5 cm2. Advanced degenerative joint disease is the single most important contraindication. The review gives a concise overview on important scientific background, the results of clinical studies and discusses advantages and disadvantages of ACI.

Identification of molecular markers for articular cartilage

OBJECTIVE

The aim of the current study was to identify molecular markers for articular cartilage (AC) that can be used as tools for the quality control of tissue engineered (TE) cartilage.

DESIGN

A genome-wide expression analysis was performed using RNA isolated from articular and growth plate (GP) cartilage, both extracted from the knee joints of 6 weeks old minipigs. After confirming the specific expression for selected genes by RT-PCR, these were used as molecular markers for the quality control of TE cartilage.

RESULTS

Albeit several known chondrocyte markers were expressed to a similar extent in articular and GP cartilage, our genome-wide expression analysis led us to identify genes being selectively expressed in either GP or articular chondrocytes. These findings led us to perform a RT-PCR expression analysis for the corresponding genes to demonstrate the absence of GP-specific markers in TE cartilage, while common or AC markers were expressed.

CONCLUSIONS

Taken together, these results provide important novel insights into chondrocyte biology in general and AC in particular. In addition, it is reasonable to speculate, that some of the identified genes play distinct roles in the regulation of articular chondrocyte differentiation and/or function, thereby raising the possibility that they may serve as targets for non-operative therapies of osteoarthritis (OA).

Long term results after implantation of tissue engineered cartilage for the treatment of osteochondral lesions in a minipig model

In present study we determined the long term in vivo integration and histological modeling of an in vitro engineered cartilage construct. Tissue engineered autologous cartilagenous tissue was cultured on calcium phosphate cylinders and implanted into osteochondral defects into the femoral condyles in minipigs. Radiological follow-up was performed at 2, 8, 26 and 52 weeks, condyles were harvested 26 and 52 weeks post-implantation. Thickness of cultivated tissue (1.10 +/- 0.55 mm) was comparable to in situ cartilage and cells produced in vitro cartilage specific proteins. In vivo, 26 and 52 weeks post-implantation defects were resurfaced with hyaline-like tissue, the implants were well integrated with no gap at the interface between the engineered neocartilage and the adjacent articular cartilage. Synthesis of type II collagen was detected 26 and 52 weeks after implantation. The modified ICRS score increased from 26 to 52 weeks. Histomorphometric evaluation revealed a decrease in cellularity in tissue engineered cartilage from 2.2-fold of native cartilage after 26 weeks to 1.5-fold after 52 weeks. In conclusion, these findings demonstrate the integration and maturation of tissue engineered cartilage pellets attached on a bone substitute carrier implanted in osteochondral defects over a long time.

[Balloon assisted cement application for stable fixation of pedicle screws in osteoporosis]

In Germany more than 40,000 patients suffer from osteoporotic vertebral fractures every year. Most of these fractures do not require operative stabilisation. However, if surgical stabilisation is necessary, stable fixation of transpedicular implants will be difficult to obtain. In a case study we report on the possibility of a kyphoplasty-guided technique for stable pedicle screw fixation.

[Osteochondritis dissecans of the knee joint]

Osteochondritis dissecans is a disorder with a prevalence of 0.01 to 0.06 %. Men between 16 and 36 years of age are most commonly affected by it. In the western hemisphere, the knee is affected by this progressive disorder in 75 % of the cases, specifically the medial femoral condyle (70 - 80 %). The etiology is uncertain, although genetic defects, micro-trauma, ossification disorders and ischemia have been implicated. Pathogenetically, Osteochondritis dissecans is classified in four stages, whereas in stage one, there is merely a subchondrial edema. Without therapy this could lead to stage 4, with a free osteochondral joint fragment. Treatment is analogous with the stage of the disorder. Whereas conservative treatment may yield full recovery during stage 1, starting in stage 2, invasive treatment should be considered. When the cartilage surface remains intact retrograde procedures are indicated. If the cartilage is injured anterograde therapies, like the chondral or osteochondral transplantation, should be used.

[Imaging in rheumatology. Degenerative diseases of the spine]

Degeneration of the spine is a common reason for pain in the musculoskeletal system. Radiography is an important tool for diagnosis and differential diagnosis. Cost efficacy and economy of time are advantages in using conventional x-rays. Although narrowing of intervertebral disc spaces, irregular ossification of the vertebral end-plate as well as osteophytes, facet joint osteoarthritis and spondylolisthesis can be observed, early changes in the discs or the subdiscal bone can not be detected by x-rays. Moreover, 3-dimensional imaging is not possible. Computer tomography (CT) and magnetic resonance imaging (MRI) are reliable for identifying disorders of the spine and soft-tissue. Differentiation between inflammation, trauma and tumor is possible. There is still a problem with the relationship between the information obtained by x-rays or MRI and clinical symptoms. Therefore, interpretation of radiological examinations assumes a knowledge of clinical symptoms and the different kinds of diseases which are possible.

[Conventional X-rays and conventional tomography in orthopaedics. Current status]

Although sonography, computed tomography (CT) and magnetic resonance imaging (MRI) are common tools in radiology, conventional X-rays still have a place in orthopaedic diagnostic investigation. The advantages of radiographic imaging are high local resolution concerning bone, economy of time besides relatively low costs and worldwide experience. The conventional X-ray is indispensable for planning surgical procedures and clinical monitoring. For several pathological processes an X-ray is sufficient for diagnosis and therapy (i.e. degeneration, fracture). Early changes of the bone (i.e. osteonecrosis) cannot be detected by X-ray. CT and MRI have closed the diagnostic gap. Indications for conventional tomography are rare.

[Clinical relevance of multislice CT of the spine after osteosynthesis]

PURPOSE

To examine the clinical relevance of multislice CT (MSCT) scans in postoperative checks of the spine after osteosynthesis.

MATERIAL AND METHODS

The results of x-rays (apical lateral) in 30 patients having spinal surgery involving osteosynthesis (5 x metastasis, 20 x fractures, 3 x spondylolisthesis, 2 x scoliosis) were correlated to those of MSCT (140 kV, 200 mAs, collimation 4 x 1 mm, pitch 0.75; VolumeZoom, Siemens, Erlangen, Germany) with multiplanar reconstruction. Two radiologists independently checked the conventional x-ray and multislice CT scans for anatomical positioning, damage of osteosynthetic material, and intraspinal dislocation of bone fragments.

RESULTS

By correlating conventional spinal x-rays with MSCT, additional diagnostic information was gained. In 9 of 30 patients MSCT revealed the extraosseal location of a screw tip (x-ray, 5/30), in 8/30 patients a narrowing of the spinal canal by osteosynthetic material was detected in MSCT (x-ray, 4/30), in 2/30 patients osteal fragments were detected in the vertebral canal by MSCT (x-ray, 0/30). In MSCT and in conventional x-ray a fracture of the osteosynthesis was correctly diagnosed in 3 patients. One patient underwent corrective surgery for dislocated osteosynthetic material, which was solely diagnosed with MSCT.

CONCLUSION

Due to the high degree of additional diagnostic information MSCT seems to be the method of choice for postoperative spinal surgery involving osteosynthesis.

[Effects of low-frequency pulsed electromagnetic fields on the proliferation of chondrocytes]

Chondrocytes isolated from the human cartilage of 5 patients between the ages 23 and 56 were exposed to low frequency pulsed electromagnetic fields (9 mT; 3 Hz) for a daily period of 60 minutes on 5 consecutive days and then every 48 hours for the next 6 days (11 days in total). Cell viability was estimated using trypan blue exclusion and proliferation was estimated by counting the cells in a haemacytometer. Cell morphology was compared for control purposes by directly observing the cells under a light microscope after staining cells in a haematoxylin and eosin solution. The results were statistically analysed and compared to a control sample. Data revealed that exposing cells isolated from human cartilage to pulsed electromagnetic fields (9 mT; 3 Hz) led to a significantly higher number of cells in comparison to the control sample. Among the cells from the 5 patients, growth varied between 1.1 to 3.0 folds compared to the control sample. The difference in cell viability between the exposed cells and the control sample was, however, not significant. Some morphological variations were revealed when the cells were observed under a light microscope. The exposed cells were thinner and longer than the control cells which were large and flat. The exposed cells tended to grow in a more uniform direction while the control cells grew in all directions. These differences in morphology and growth may be related to the higher density of the exposed cells.

Lymph node metastasis from carcinoma in situ of the penis: a case report

Lymph node metastasis from carcinoma in situ of the penis is rare. We report a case of carcinoma in situ of the penis that was initially managed with circumcision and topical 5-fluorouracil. Subsequently inguinal and para-aortic lymph node metastasis developed, which was treated successfully with systemic chemotherapy and right inguinal lymph node dissection. The patient is free of disease 7 years after initial diagnosis and 3 years after the diagnosis of nodal metastasis.

Disease-related effects of perioperative blood transfusions associated with 125I seed implantation for prostate carcinoma

In some retrospective studies perioperative transfusions during oncologic surgery have been shown to decrease the time interval between surgery and local and/or distant recurrence of cancer. This study examines the disease-related effect, if any, of perioperative blood transfusions among 108 patients with localized carcinoma of the prostate treated by radioactive iodine-125 seed implantation of the prostate and lymphadenectomy. When all subjects were analyzed, there was no statistical difference of local and distant failure between the transfused and nontransfused groups. Patients with well-differentiated tumors had statistically fewer local recurrences (0% vs 22%, p = 0.036) if they were transfused perioperatively. However, the difference in distant metastases (0% vs 11%) was not statistically significant (p = 0.21). In contrast, patients with moderately and poorly differentiated disease receiving transfusions had more local recurrences and metastases, though this was not statistically significant. Our data suggest that there is no obvious evidence that perioperative blood transfusions have an adverse effect on local recurrence or distant metastases for iodine-125 seed implantation of carcinoma of the prostate.