Mean Total Serum Bilirubin Level Research Articles

Intermittent versus continuous phototherapy among term infants presenting with non-hemolytic moderate hyperbilirubinemia at a tertiary care hospital: a randomized controlled trial.

Objective: To compare the effectiveness of intermittent versus continuous phototherapy among term infants presenting with non-hemolytic moderate hyperbilirubinemia at a tertiary care hospital. Study Design: Single Center, Open Label, Prospective Randomized Controlled Trial. Setting: Department of Neonatology, Sir Sadiq Abbasi Hospital, Bahawalpur, Pakistan. Period: January 2022 to December 2022. Material & Methods: A total of 38 neonates having maternal age between 18-35 years and gestational age at the time birth above or equal to 37 weeks presenting and admitted with non-haemolytic hyperbilirubinemia were included. These neonates (19 in each group) were randomized adopting lottery method to either continuous phototherapy group (CPT) or intermittent phototherapy group (IPT). At the time of enrollment, demographic characteristics like age (days), gender, birth weight (kg), mode of delivery, gestational age (weeks), maternal age (years), total serum bilirubin (mg/dl) in the neonates were noted. Total serum bilirubin levels were recorded after 24 hours of phototherapy. Results: In a total of 38 neonates, 20 (52.6%) were boys. The mean age was calculated to be 3.3±1.8 days. Mode of delivery was cesarean section in 24 (63.2%) neonates. The mean total serum bilirubin levels at baseline was recorded to be 15.5±1.7 mg/dl while comparison of baseline total serum bilirubin levels were not statistically significant different between both study groups (p=0.3715). The mean serum bilirubin levels after 24-hours were recorded to be 11.3±0.9 mg/dl in CPT group versus 11.0±1.1 mg/dl while the difference was noted to be statistically insignificant. (p=0.3637). Conclusion: The intermittent phototherapy yielded relatively similar reduction in total serum bilirubin when compared to continuous phototherapy among neonates with non-haemolytic moderate hyperbilirubinemia.

Effect of Phototherapy on Transcutaneous vs Total Serum Bilirubin Level in Preterm Neonates- A Prospective Cohort Study

Introduction: Neonatal jaundice is one of the most common problems encountered in the first week after birth. Neonates who develop significant hyperbilirubinemia require phototherapy. Delay in the diagnosis and management of jaundice may lead to neonatal morbidity and mortality. Total Serum Bilirubin (TSB) estimation is considered the gold standard method. However, this invasive procedure causes pain, anxiety, and may lead to infection and iatrogenic anaemia, especially in preterm neonates. Transcutaneous Bilirubin (TcB) estimation, which measures bilirubin through the skin, has been proposed as an alternative screening method for hyperbilirubinemia in term and near-term neonates. Aim: To compare TcB to TSB in preterm neonates of 30-34 6/7 weeks gestational age before, during, and after phototherapy. Materials and Methods: This hospital-based prospective cohort study was conducted at SDMCMS&H, Dharwad, Karnataka, India, between December 2019 and November 2020. A total of 100 preterm neonates between 30 to 34 6/7 weeks of gestation with clinically suspected jaundice were enrolled in the study. TSB was measured in the laboratory using the Diazo Method, while TcB was measured using the Drager jaundice meter JM 103. TcB and TSB were measured and compared in preterm neonates with clinically suspected jaundice before phototherapy, during phototherapy (8 to 12 hours after initiation), and after 12- 18 hours of discontinuation of phototherapy. The collected data was analysed statistically using the mean, standard deviation, dependent t-test, Karl Pearson’s correlation coefficient, and scatter plots. Results: This study enrolled 100 neonates diagnosed with neonatal jaundice, of which 57 were males and 43 were females, resulting in a male-to-female ratio of 1:1.3. Phototherapy was administered to neonates with TSB values, with 79% of the babies between 30-32 weeks and 21% between 32-34 weeks. In the present study, TcB and TSB were compared before, during, and after phototherapy, and the results were analysed, showing statistical significance. The mean TcB levels were 12.05, 9.66, and 7.23 before, during, and after phototherapy, respectively. The mean TSB levels were 11.28, 10.16, and 7.65 before, during, and after phototherapy, respectively. Based on Karl Pearson’s correlation coefficient, a positive correlation was found between TcB and TSB before (r=0.8319, p-value <0.001), during (r=0.6069, p <0.001), and after phototherapy (r=0.8154, p<0.001). Conclusion: TcB values are comparable to TSB values and can be adopted as the standard method to measure bilirubin levels in preterm babies in a clinical setting.

ETIOLOGICAL FACTORS OF NEONATAL HYPERBILIRUBINEMIA IN TRIBAL COMMUNITY OF MEGHALAYA, INDIA - A CROSS-SECTIONAL STUDY

Objective: To identify the etiological factors of neonatal hyperbilirubinemia in tribal population of Meghalaya, India. Design: Cross sectional study. Setting: Neonatal intensive care unit under (level II NICU) Department of Paediatrics and Neonatology of Nazareth Hospital, Meghalaya, India. Participants: Neonates of Khasi, Jaintia and Garo tribes with neonatal jaundice admitted in NICU of Nazareth Hospital, Meghalaya, India. Main Outcome Measures: Demographic variables of the study population, Mean TSB values of various etiological factors, Effect of various etiological factors in early onset neonatal jaundice, Nature and duration of interventions needed for the neonates studied. Results: In 58.9% of the 409 neonates studied, no cause could be assigned for the development of jaundice. Of the remaining, 19.8% was attributed to low birth weight whereas 19% had ABO incompatibility and 10.8% were premature. 9.3% had sepsis, 8.5% had G6PD deciency while 3.2% were born to mothers with diabetes mellitus. Rh incompatibility was the causative factor in 1.7%. In 1.7%, pre-lacteal feed was associated with jaundice. In 62.3% of cases delayed cord clamping was found to be associated. Conclusions: Total serum bilirubin tends to be higher in female neonates, of term gestation, with birth weight 2500 g or above and with ABO incompatibility. Delayed initiation of breast feeding, those with positive history of neonatal jaundice in older siblings and those with proven neonatal sepsis were also found to have higher levels of bilirubin. Neonates who were given pre-lacteals and those born to diabetic mothers show lower mean total serum bilirubin levels. Most neonates who developed jaundice within 24 hours of life (early onset jaundice) had ABO incompatibility.

Effect of head covering on Phototherapy Induced Hypocalcemia in Jaundiced term neonates

The present study was aimed to assess the effect of head covering on phototherapy induced hypocalcaemia in jaundiced term newborns. This study was conducted in a medical college hospital in South India. All enrolled term neonates were randomly allotted to either the group using a cap (cases) or the group not using a cap (controls) by using closed envelope method. Conventional phototherapy equipment was used and the American Academy of Pediatrics (AAP) guidelines for phototherapy were followed. Serum calcium levels were measured before and after 24 hours and after 48 hours of phototherapy in case phototherapy was continued for a longer period. Results were tabulated and analyzed using student t-test and Chi square test. Out of 110 newborns studied, 58(53%) were boys and 52(47%) were girls. The average age of onset of jaundice was between 25- 48 hours. The mean weight of the neonates was 2993±241g. Mean total serum bilirubin level before phototherapy was 13.43±3.27mg/dl. Mean total serum calcium level before phototherapy was 9.92±0.84mg/dl. Mean total serum calcium levels after 24 hours of phototherapy were 9.37±0.67mg/dl and 9.21±0.71mg/dl in cases and controls respectively (p =0.000). Mean total serum calcium levels after 48 hours of phototherapy were 8.87±0.80 mg/dl and 8.52±0.54mg/dl in cases and controls respectively (p=0.022). Only 3 babies in control group developed hypocalcaemia (Serum calcium <8 mg/dl) and none were symptomatic. There is a reduction in the total serum calcium level after phototherapy which is more as the duration of phototherapy is increased. The reduction in the total serum calcium level after phototherapy is significantly less when the head is covered with a cap during phototherapy than when it is not.

Role of Cord Blood Carboxyhemoglobin in Detecting Significant Hyperbilirubinemia in Term Neonates with ABO Alloimmunization.

This study aimed to assess whether cord blood carboxyhemoglobin (COHb) levels in jaundiced term neonates with and without a positive direct Coombs test (DCT) and in healthy controls could be used as a predictor of severe hyperbilirubinemia. The percentage of cord blood COHb should be higher among neonates with Coombs-positive ABO hemolytic disease than among those with Coombs-negative ABO incompatibility and higher than that of ABO-compatible control neonates. This cross-sectional descriptive study of 198 term neonates comprised three subgroups: group I featured 68 DCT-positive ABO-incompatible neonates (ABO + DCT), group II featured 60 DCT-negative ABO-incompatible neonates with hyperbilirubinemia (ABO-DCT), and group III featured 70 healthy controls. COHb was determined by an OSM3 hemoximeter. Group I differed from groups II and III for cord blood bilirubin, cord blood hemoglobin, and cord blood hematocrit. Groups I and II had higher mean total serum bilirubin (TSB) levels than group III, while there was no difference in the mean TSB levels between groups I and II. There was no significant difference between the COHb group means for groups I, II, and III (p = 0.98). The area under the receiver operating characteristic curve calculated for group I/group III and group II/group III were found to be 0.62 and 0.54, respectively. COHb levels did not prove to be superior to the DCT for predicting the risk of developing severe hyperbilirubinemia in term neonates. · COHb levels do not predict the risk of developing severe hyperbilirubinemia in term neonates.. · COHb levels may predict that ABO incompatibility in early life.. · COHb levels did not prove to be superior to the direct coombs test..

Cotoneaster manna oral drop for the management of neonatal hyperbilirubinemia; a randomized, double-blinded and placebo controlled clinical trial

Introduction: Neonatal hyperbilirubinemia is a common physiologic condition, which is occurred in early days after birth with an estimated incidence of about 50% in term neonates. Objectives: The aim of this study was to evaluate the effect of Cotoneaster nummularioides manna on reducing neonatal total serum bilirubin (TSB) levels, and shortening hospitalization period. Patients and Methods: One hundred breast-fed term neonates with hyperbilirubinemia were randomly assigned to the intervention group or control group. The Newborns of the intervention group were received Cotoneaster manna drop in the dosage of 1 g/d divided into three doses every 8 hours for at least 3 days and the control group received placebo drops. Total serum bilirubin levels were measured at baseline, at 12, 24 hours and then daily through hospitalization days (day 9). Secondary outcome (discharge from hospital, TSB <10 mg/dL) was also documented with risk ratio calculation. Results: TSB levels were declined in both groups; however, this was more prominent in the manna group than the placebo group. The greatest difference of mean TSB levels between the intervention and control groups was seen on days two (10.01 versus 13.04 mg/dL; mean difference [95% CI]: - 3.03 [-3.60 to -2.46]; P<0.001). On day four, significantly more newborns in the intervention group versus the control group were discharged (70% versus 6.1%; risk ratio = 11.43, 95% CI= 3.76, 34.74). No major side effects were recorded in both groups. Conclusion:Cotoneaster nummularioides manna drop combined with phototherapy was superior to the control group in reducing TSB levels and reaching this observation more rapidly and shortening hospitalization period with no major side effects. Trial Registration: The trial protocol was approved by the Iranian Registry of Clinical trials (identifier: IRCT20160531028188N4; https://en.irct.ir/trial/27765, ethical code #IR.MAZUMS.REC.1394.1316).

Optimal Thermal Control with Sufficient Nutrition May Reduce the Incidence of Neonatal Jaundice by Preventing Body-Weight Loss Among Non-Low Birth Weight Infants Not Admitted to Neonatal Intensive Care Unit

Background: Neonatal jaundice is strongly attributable to excess body-weight loss as a result of insufficient calorific intake. Objectives: To examine the incidence of neonatal jaundice (defined by use of phototherapy) and body-weight loss, as well as their association, among neonates under optimal thermal control with sufficient nutrition, a local protocol for temperature and nutritional regulation. Methods: We retrospectively identified a cohort of 10,544 neonates (birth weight ≥2,500 g) placed in thermo-controlled incubators for 2 h immediately after birth. Neonates were fed with 5% glucose solution 1 h after birth and breastfed every 3 h (with supplementary formula milk if applicable) according to basal maintenance expenditure. Total serum bilirubin levels at day 4 (peak level) were assessed. Phototherapy was performed on the basis of total serum bilirubin level ≥18 mg/dL. Risk ratio (RR) and 95% CI for the use of phototherapy against maximum body-weight loss were estimated using Poisson regression with robust variance. Results: Incidence of phototherapy use was low (0.3%) and the mean total serum bilirubin level was 8.5 mg/dL (SD 2.7 mg/dL), with a low mean maximum body-weight loss (1.9%) and low incidence of excess body-weight loss ≥7% (0.4%). Maximum body-weight loss was associated with risk of neonatal jaundice (RR 1.27; 95% CI 1.04–1.54), and became significant at approximately 4% of maximum body-weight loss. Conclusion: Optimal thermal control and sufficient nutrition may greatly reduce the incidence of neonatal jaundice by preventing neonatal body-weight loss.

Safety of delayed umbilical cord clamping in preterm neonates of less than 34 weeks of gestation: a randomized controlled trial.

ObjectiveThere is concern regarding the safety of delayed cord clamping (DCC) in babies born at less than 34 weeks' gestation. Therefore, the primary objective of this study was to compare the rates of hyperbilirubinemia and polycythemia during initial 7 days in infants born at less than 34 weeks' gestation and randomized to receive DCC by 120 seconds or early cord clamping (ECC) within less than 30 seconds.MethodsOne hundred pregnant women were randomly subjected to DCC or ECC at the time of birth in a tertiary referral hospital setting. Blood samples were obtained from each newborn at 48 hours and 7 days for hematocrit measurement. Serum bilirubin levels were estimated once the infant had clinically significant jaundice or at 72 hours. For the statistical analysis, the χ2 test, student's t-test, or Wilcoxon rank sum test was used.ResultsThe hematocrit was significantly higher in the DCC group than in the ECC group (P<0.001). None of the babies had polycythemia. Mean total serum bilirubin level was 6.6 mg/dL in the DCC group and 8.7 mg/dL in the ECC group (P<0.001). There was no increased risk of hyperbilirubinemia in the DCC group.ConclusionDCC benefits preterm neonates with no significant adverse effects.

The Therapeutic Effect of Zinc Sulfate on Neonatal Hyperbilirubinemia

Background: Approximately 60% of term neonates and 80% of preterm ones suffer from hyperbilirubinemia in theirfirst week of life. This study sought to characterize the therapeutic effect of oral zinc sulfate on neonatalhyperbilirubinemia.Methods: In this randomized, double-blind, placebo-controlled clinical trial, 70 term neonates with total serumbilirubin (TSB) level ≥ 20 mg/dl were enrolled. Thirty-four cases were treated with phototherapy and zinc (10 mg/day,single dose) as case, while the remainder received phototherapy plus placebo. TSB level was measured at the onset ofthe intervention, as well as 12, 24 and 48 h after the intervention and compared with each other.Results: The mean TSB levels were significantly lower in the zinc group after 12, 24 and 48 h (P=0.038, 0.005, 0.001,respectively). The mean durations of phototherapy in the case and control groups were 2.03±0.174 and 2.33±0.478days, respectively, being significantly less in the case group (P=0.002).Conclusion: This study revealed that oral zinc sulfate at a single dose of 10 mg/day diminished TSB level and durationof phototherapy.

INVESTIGATING THE ACCURACY OF AN UPGRADED TRANSCUTANEOUS BILIRUBIN SCREENING TOOL BY SITE OF TESTING

Abstract BACKGROUND: Severe neonatal hyperbilirubinemia continues to occur in healthy term infants. The incidence has decreased as a result of guidelines by the Canadian Pediatric Society (CPS) and American Academy of Pediatrics (AAP), requiring all healthy newborns to receive either a transcutaneous bilirubin (TCB) or total serum bilirubin (TSB) at discharge. Several studies have investigated the effectiveness of TCB tools. However, discrepancies still exist on the agreement between TCB and TSB by site and treatment. OBJECTIVES: The aim of this study was to determine the accuracy and agreement of TCB and TSB by site and treatment using the JM-105. DESIGN/METHODS: A multi-site prospective clinical trial of term infants requiring TSB measurements. Pearson’s correlation coefficient was used to determine the accuracy between TSB and TCB measurements by site and treatment. Bland-Altman Plots of the agreement between TSB and TCB values by site and treatment were generated. RESULTS: Paired TSB and TCB measurements from the forehead and sternum were collected from 75 term infants between 36-44 weeks gestational age. Bland-Altman Plots by site demonstrated the mean difference between TSB and TCB on the forehead to be -1.72 μmol/L ± 24.64 μmol/L (-66.7 μmol/L to 49.00 μmol/L) and sternum to be 1.2 μmol/L ± 37.99 μmol/L (-82.00. μmol/L to 136.33 μmol/L). The mean TSB level was 131.43 μmol/L ± 54.88 μmol/L (31 μmol/L – 285 μmol/L), mean TCB level on the forehead was 132.40 μmol/L ±57.029 μmol/L,(19 μmol/L-284.5 μmol/L) and mean TCB level on the sternum was 121.32 μmol/L ±58.27 μmol/L, (13.5 μmol/L-261.6 μmol/L). Paired t-tests revealed no significant mean differences between TCB and TSB measurements by site and treatment. The correlation between the TSB and TCB values from the forehead (Pearson’s correlation r =0.877, p<0.01) were higher than the correlation between TSB and TCB values from the sternum (r= 0.646, p<0.01). The correlation between TSB and TCB values on the forehead (r=0.879, p<0.01) and sternum (r=0.747, p<0.01) were higher prior to phototherapy. The mean difference between TSB and TCB after phototherapy on the forehead was 25.77 μmol/L ± 48.36 μmol/L and sternum was 95.69 μmol/L ± 73.72 μmol/L. CONCLUSION: The JM-105 is an accurate TCB screening tool for physicians to use in healthy newborns by site. After the initiation of phototherapy the forehead may be a more appropriate site of measure with an overestimate of bilirubin levels. Additional research is required to obtain a greater understanding of the impact of phototherapy and site on TCB screening tools.

Genetic Variations in Bilirubin Metabolism Genes and Their Association with Unconjugated Hyperbilirubinemia in Adults.

The present study was undertaken to investigate the genotype and allele frequencies of the variants in the four bilirubin metabolism genes (UGT1A1, OATP2, HMOX1, and BLVRA) and their association with hyperbilirubinemia. Genotyping of 17 genetic variants was performed in 115 adults with hyperbilirubinemia and 150 controls by PCR-RFLP, GeneScan analysis, and direct DNA sequencing. Genetic polymorphisms of the UGT1A1 promoter, specifically the T-3279G phenobarbital-responsive enhancer module and (TA)7 dinucleotide repeat, as well as the intron and coding region variants of the OATP2, HMOX1, and BLVRA genes, were significantly higher among the cases than the controls. Further, nearly 82% of the cases showed the presence of significantly four or more variants as compared to 37% of the controls (P < 0.0001) and the mean total serum bilirubin levels also increased according to the number of variants co-expressed. This study demonstrates that polymorphisms in the bilirubin metabolism genes had a significant effect on bilirubin levels and could be genetic risk factors for hyperbilirubinemia.

Efficacy of prophylactic phototherapy for prevention of hyperbilirubinemia in very low birth weight newborns

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Jaundice is a common clinical condition in newborn occurring in approximately 60% of term and 80% of preterm infants. Unconjugated hyperbilirubinemia is universally common in all preterm infants especially in newborns with very low biLth weight. Low birth weight and premature infants are at major risk for exaggerated hyperbilirubinemia that can lead to bilirubin encephalopathy. Significant heterogeneity in the approach to the treatment of jaundiced neonates exists throughout the world. Phototherapy is the most common treatment for neonatal hyperbilirubinemia and could be most effective in preventing the sequelae of hyperbilirubinemia if initiated prophylactically. This randomized clinical trial has been proposed with the objective of assessing the efficacy of prophylactic photo therapy in preventing significant rise of unconjugated hyperbilirubinemia in premature neonates weighing less than 1500 gram and therefore to decrease the need for exchange transfusion and finally to reduce hospital stay due to hyperbilirubinemia. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This randomized controlled clinical trial enrolled sixty newborns with birth weight less than 1500 gram. They were divided into two groups: 1) Prophylactic group, in whom phototherapy was started within 24 hours of birth and continued for 7 days and 2) Control group in whom therapeutic phototherapy was started considering serum bilirubin level and other clinical condi­tions as per institutional guidelines. Mean value of total serum bilirubin (TSB), duration of phototherapy, the need for exchange transfusion and duration of hospital stay in both groups were analyzed.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; The maximum mean TSB level in prophylactic group was observed on 7th day and in control group it was observed on 3rd day of life. The total serum bilirubin levels were significantly lower in the 3rd and 5th days of life in the prophylactic group in comparison to control group (P value 0.001). Total serum bilirubin level exceeded therapeutic range in 6 (21 %) and 14 (50 %) newborns of the prophylactic group and control groups respectively (P value 0.026). No documented side effects of prophylactic photo­therapy was observed.&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; The use of prophylactic photo therapy for infants weighing less than 1500 grn is effec­tive and sate when compared to the control group, considering satisfactory maintenance of low total serum bilimbin levels during first 7 days of life.&lt;/p&gt;

Effects of oral zinc sulfate on hyperbilirubinemia in low-birth-weight neonates

Background: Hyperbilirubinemia is one of the most common and persistent problems encountered in preterm newborns. This condition in preterm infant is more likely to be associated with neurological damage rather than terms. So far, no major studies have precisely assessed the effects of zinc sulfate on hyperbilirubinemia in low-birth-weight (LBW) neonates. Therefore, in this study, we aimed to evaluate these effects in LBW infants. Methods: This randomized, double-blind, clinical trial (IRCT201401041162N22) was performed on 61 icteric LBW neonates, hospitalized in the neonatal intensive care unit (NICU) of Imam Reza Hospital in Mashhad, Iran from May 24, 2014 to May 24, 2015. The neonates were randomly divided into case and control groups, and the total serum bilirubin (TSB) level was measured at 0, 24, 48, 72, 96, and 120 h after treatment. The subjects received either 10 mg of zinc sulfate or placebo twice per day for five days (or by the end of treatment). The termination point of phototherapy was defined as a bilirubin level below 50% of the starting point. The collected data were analyzed, using SPSS version 20. Chi-square, t-test, and repeated measures ANOVA were carried out to compare the findings between the two groups. Results: The mean TSB level was 14.87±2.65 and 14.73±3.22 mg/dl in the control and case groups. The mean decline in TSB level was only significant at 24 h after the treatment (2.71 and 2.13 mg/dl in the case and control groups, respectively; P=0.04), while being statistically insignificant on other days of the assessment. Also, similar findings were reported regarding the duration of treatment in the case and control groups (58.84±14.97 and 65.60±16.59 h in the case and control groups, respectively). Conclusion: The present study showed that administration of oral zinc sulfate in icteric LBW infants could significantly reduce TSB level only at 24 h following the treatment.

Phenobarbital and Phototherapy Combination Enhances Decline of Total Serum Bilirubin and May Decrease the Need for Blood Exchange Transfusion in Newborns with Isoimmune Hemolytic Disease.

OBJECTIVEThe objective of this study was to evaluate the effect of phenobarbital and phototherapy combination on the total serum bilirubin of the newborn infants with isoimmune hemolytic disease (IHD) and its impact on blood exchange transfusion rates.PATIENTS AND METHODThis single-blinded, prospective, randomized, controlled trial was conducted between March 2013 and December 2014 at the pediatric ward of two Military Hospitals in Jordan. A total of 200 full-term neonates with IHD were divided randomly into two groups: (1) the phenobarbital plus phototherapy group (n = 103), and (2) the phototherapy-only group (n = 97). Infants in group 1 received an oral dose of 2.5 mg/kg phenobarbital every 12 hours for 3 days in addition to phototherapy. The total serum bilirubin was observed.RESULTSOf the total 200 included newborn infants, 186 infants completed the study: 97 infants were included in group 1 and 89 infants in group 2. The difference between the mean total serum bilirubin levels at 24, 48, and 72 hours after starting the trial was clinically and statistically significant at P < 0.05. The differences between the two groups were also statistically significant at P < 0.05. Of the total 186 who completed the study, only 22 underwent blood exchange transfusion [7 from group 1, and 15 from group 2 (P = 0.0478)].CONCLUSIONIn a limited-resources setting, phenobarbital in combination with phototherapy may be helpful to newborn infants with IHD, as it results in a faster decline in total serum bilirubin, thus decreasing the need for blood exchange transfusion than phototherapy alone.

Combined effects of the UGT1A1 and OATP2 gene polymorphisms as major risk factor for unconjugated hyperbilirubinemia in Indian neonates.

Genetic association studies have linked a number of single nucleotide polymorphisms (SNPs) with unconjugated hyperbilirubinemia. The present study was undertaken to validate the association of SNPs with development of hyperbilirubinemia in Indian neonates. Genotyping of five SNPs in two candidate genes was performed in 126 infants with hyperbilirubinemia and 181 controls by PCR-RFLP, Gene Scan analysis and direct DNA sequencing. Genetic polymorphisms of the UGT1A1 promoter, specifically the -3279 T➔G phenobarbital responsive enhancer module (rs4124874) and (TA)7 dinucleotide repeat (rs8175347) as well as the coding region variants (rs2306283 and rs4149056) of the OATP2 gene were significantly higher among the cases than the controls. The presence of the mutant haplotypes either in homozygous, heterozygous or compound heterozygous state had a significant effect on neonatal hyperbilirubinemia as well as on the requirement of phototherapy than those with the wild haplotype. Further, a significantly higher number of hyperbilirubinemic cases had ≥3 variants than the controls (73.80% vs 40.36%, p<0.0001) and the mean total serum bilirubin levels and requirement of phototherapy also increased according to the number of variants co-expressed. This study demonstrates that UGT1A1 and OATP2 polymorphisms were associated with altered bilirubin metabolism and could be genetic risk factors for neonatal hyperbilirubinemia.

Rebound hyperbilirubinaemia in neonates admitted to Mofid Children’s Hospital, Tehran, Iran

Introduction and aim. Approximately 60% of term neonates and 80% of preterm neonates develop hyperbilirubinaemia in the first week of life. Rebound hyperbilirubinaemia may occur after cessation of phototherapy, especially when the Coombs test is positive, in premature infants, and in those treated with phototherapy for less than 72 hours. The main aim of this study was to evaluate the billirubin level 24 and 48 hours after cessation of phototherapy in neonates admitted to our hospital with jaundice. We also evaluated haemoglobin (Hb) levels and duration of phototherapy for a possible association with rebound hyperbilirubinaemia. Patients and methods. The study was a clinical trial in term neonates (gestational age ≥37 weeks) with hyperbilirubinaemia who were admitted to the Deptartment of Neonatology at Mofid Children’s Hospital, Tehran, Iran. Exclusion criteria were neonatal infection, glucose-6-phosphate dehydrogenase deficiency, a history of neonatal exchange transfusion, and parental refusal. Phototherapy was delivered via a Philips TL 45/20W at 15 - 20 cm distance from the skin. We discharged patients after cessation of phototherapy. Total serum bilirubin (TSB) was checked in the neonates 24 and 48 hours after cessation of phototherapy. We included patients in whom follow-up tests were completed at 24 and 48 hours after discharge. Chi-square and Student’s t-tests were used for data analysis using SPSS version 13.0 (SPSS Inc., Chicago, IL, USA). Results. Twenty-five girls and 37 boys were included in the study. The mean admission age was 5.4 (standard deviation (SD) 0.5) days for girls and 8.0 (SD 0.6) days for boys (p=0.041). The mean Hb values for the girls and the boys were 15.0 (SD 0.39) g/dl and 15.9 (SD 0.36) g/dl, respectively (p=0.108). The mean TSB levels for the girls and the boys were 322.6 (SD 9.4) µmol/l and 322.3 (SD 7.3) µmol/l, respectively (p>0.05). The mean admission and pre-discharge TSB levels of 322.3 (SD 5.6) µmol/l and 187.9 (SD 3.2) µmol/l were significantly different (p=0.0). The mean TSB levels 24 and 48 hours later were 197.8 (SD 4.6) and 195.1 (SD 5.3) µmol/l, respectively, with no significant difference between them (p>0.05). Conclusion. We found no significant differences between mean TSB levels at the time of termination of phototherapy and 24 and 48 hours later. We therefore do not recommend checking for rebound bilirubinaemia after phototherapy.

Percutaneous Placement of Self-Expandable Metallic Stents in Patients with Obstructive Jaundice Secondary to Metastatic Gastric Cancer after Gastrectomy

ObjectiveTo evaluate the outcomes of patients undergoing percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy.Materials and MethodsFifty patients (mean age, 62.4 years; range, 27-86 years) who underwent percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy were included. The technical success rate, clinical success rate, complication rate, stent patency, patient survival and factors associated with stent patency were being evaluated.ResultsThe median interval between the gastrectomy and stent placement was 23.1 months (range, 3.9-94.6 months). The 50 patients received a total of 65 stents without any major procedure-related complications. Technical success was achieved in all patients. The mean total serum bilirubin level, which had been 7.19 mg/dL ± 6.8 before stent insertion, decreased to 4.58 mg/dL ± 5.4 during the first week of follow-up (p < 0.001). Clinical success was achieved in 42 patients (84%). Percutaneous transhepatic biliary drainage catheters were removed from 45 patients (90%). Infectious complications were noted in two patients (4%), and stent malfunction occurred in seven patients (14%). The median stent patency was 233 ± 99 days, and the median patient survival was 179 ± 83 days. Total serum bilirubin level after stenting was an independent factor for stent patency (p = 0.009).ConclusionPercutaneous transhepatic placement of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy is a technically feasible and clinically effective palliative procedure.

Letter to the Editor Pancreatobiliary and peripancreatobiliary tuberculosis: a rare cause of obstructive jaundice

Tuberculosis (TB) is one of the most common and well-described infectious diseases, with a worldwide distribution and a vast spectrum of clinical manifestations. Tuberculosis involvement of the bile duct, pancreatic, periportal and/or peripancreatic lymph nodes is, however, surprising rare [1]. Patients with TB of the bile duct, pancreatic, periportal and/or peripancreatic lymph nodes usually present with protracted illness and obstructive jaundice, which may be confused with cholangiocarcinoma or pancreatic malignancies. During a 13-year period we encountered 6 patients with TB of the bile duct, pancreatic, periportal and/or peripancreatic lymph nodes. We describe our experience with the management of this condition and emphasize the importance of a tissue diagnosis in all patients with obstructive jaundice to avoid missing this rare but curable disease, which can elude diagnosis and might prove to be potentially fatal if left untreated. Records of all patients with obstructive jaundice treated in the Department of General Surgery, Zhongshan Hospital, Medical School of Fudan University between January 1995 and January 2008 were retrieved and reviewed retrospectively, to find patients with a histologically proven diagnosis of TB of the bile duct, pancreatic, periportal and/or peripancreatic lymph nodes. Demographic details, presentation, clinic and radiologic findings, endoscopic and surgical treatment, complications, and follow-up were recorded. Written informed consent was obtained from all patients or patients’ relatives, and this study was approved by the local ethical committees. During the above-mentioned period, of a total of 1400 patients treated for various types of obstructive jaundice in our department, there were 6 (0.43%) patients with TB of the bile duct, pancreatic, periportal and/or peripancreatic lymph nodes. There were 4 males and 2 females with a mean age of 41.3 (range: 24– 54 years). These patients were symptomatic for a mean duration of 2 weeks (range 1 week to 4 weeks). The main presenting symptoms were: jaundice (n = 6); epigastric (upper abdominal) pain (n = 4); anorexia and weight loss (n = 3); fever (n = 4) (Table I). All patients were previously healthy and none gave a history of any recent or past contact with tuberculosis. Two patients had a history of alcohol abuse while one was a known diabetic. Chest radiographs were normal in 5 patients and one patient with pulmonary TB. Human immunodeficiency virus status was negative in all patients. The mean total serum bilirubin level was raised at 192 μmol/l (range: 89–253 μmol/l; normal: 2–24 μmol/l). The mean serum alkaline phosphatase, γ-glutamyl transpeptidase, and alanine transaminase levels Corresponding author: Dr Houbao Liu Zhongshan Hospital of Fudan University No. 180, Fenglinqiao Rd 200032 Shanghai, China Phone: +86-21-64041990 E-mail: drhoubao.liu@gmail.com Letter to the Editor

ACUTE BILIRUBIN ENCEPHALOPATHY IN HEALTHY TERM NEONATES REQUIRING EXCHANGE TRANSFUSION

During the 2- year period, 140 term newborn infants underwent ET; 7 of these patients were excluded; 133 patients were followed and 69 patients were selected without BIND, and 64 were assigned to the group with BIND. This study showed that 48% of jaundiced newborn infants who underwent exchange transfusion, manifested bilirubin induced neurological dysfunction. Unsuccessful breast feeding was found to be a statistically signifi cant risk factor for BIND(p:0.001), sex, route of delivery, family history of jaundice, mean maternal age, number of gravity, parity, abortion, and babies mean admission age ,mean age at jaundice presentation, amount of weight loss, mean total serum bilirubin level were not found to signifi cantly infl uence BIND. Conclusion Of the healthy term neonates who developed jaundice within the fi rst week of life, 48% without hemolysis who underwent exchange transfusion demonstrated BIND. It is still not clear whether acute bilirubin encephalopathy affects neurodevelopmental outcome or not. Unsuccessful breast feeding was found to be a statistically signifi cant risk factor.

Cholecystitis, cholelithiasis and hyperbilirubinemia after esophagectomy.

A high incidence of hyperbilirubinemia and an increased incidence of gallbladder disorders after esophagectomy have been reported. Moreover, several studies have documented an increased incidence of gallbladder disease in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis and cholestasis and hyperbilirubinemia associated with total parenteral nutrition after esophagectomy. We retrospectively studied 42 patients who underwent esophagectomy. These patients were divided into 2 groups: the hyperbilirubinemia group and the non-hyperbilirubinemia group. The incidence of cholecystitis or cholestasis after the surgery was compared between the 2 groups. The mean total serum bilirubin level of the hyperbilirubinemia group (2.40±0.35mg/dL) was significantly higher than that of the non-hyperbilirubinemia group (1.20±0.34mg/dL; p<0.0001). No significant differences were observed between the 2 groups with respect to the mean duration for which total parenteral nutrition was required around the time of the operation (i.e. pre- and postoperatively) and the incidence rate of cholecystitis or cholestasis after esophagectomy. Hyperbilirubinemia after esophagectomy was frequently observed; however, it may not contribute to gallbladder problems. We suggest that parenteral modalities such as tube feeding should be initiated soon after surgery to prevent gallbladder problems after esophagectomy.