Peak Bilirubin Research Articles

Post cardiotomy extracorporeal membrane oxygenation in pediatric patients: Results and neurodevelopmental outcomes.

The increasing complexity of congenital cardiac surgery has led to greater utilization of extracorporeal membrane oxygenation (ECMO) support for children post-surgery. This study aims to identify risk factors for mortality and brain injury in pediatric patients requiring post-cardiotomy ECMO and to evaluate their neurological outcomes. This retrospective study includes pediatric patients with congenital heart diseases who required ECMO after surgery. Risk factors for in-hospital mortality and brain injury were assessed. Neurodevelopmental status was determined using the Pediatric Cerebral Performance Category (PCPC) Scale at discharge and during follow-up. Between October 2014 and May 2021, 2651 pediatric patients underwent cardiac surgery, with 90 (3.4%) requiring ECMO. The mean age was 0.6 years, ranging from 1 day to 13 years and 7 months. ECMO was implemented for 45 patients due to CPB weaning failure (NW-CPB), 24 due to postoperative low-cardiac output syndrome (LCOS), and 21 for extracorporeal cardiopulmonary resuscitation (E-CPR). ECMO weaning was achieved in 73 patients (81%), with an overall mortality rate of 36%. Pre-implant lactate levels (OR: 1.13, 95% CI: 1.03-1.25; p = 0.009) and peak bilirubin levels (OR: 1.04, 95% CI: 0.87-1.24; p = 0.69) were risk factors for in-hospital mortality. Survival rates were 79% for LCOS, 60% for NW-CPB, and 48% for E-CPR. Brain injury incidence was 33%, with E-CPR being a significant risk factor (p = 0.006) and NW-CPB being protective (p = 0.001). Follow-up in November 2023 showed significant improvement in neurodevelopmental status (p < 0.001). Elevated pre-implant lactate and elevated bilirubin levels during ECMO are major risk factors for mortality. E-CPR is the primary risk factor for brain injury. Follow-up revealed significant improvements in neurodevelopmental outcomes.

Improved outcomes of ABO-incompatible living donor liver transplant with biologically related donors.

Liver transplantation is considered to be the only curative treatment for decompensated liver disease. Shortage of liver allografts is a major impediment to the widespread application of this procedure. ABO-incompatible (ABO-I) grafts have been used successfully, thereby increasing the living donor liver transplantation (LDLT) donor pool. However, ABO-I liver transplantation is associated with complications like acute liver rejection, hepatic artery thrombosis, and higher biliary stricture rates, leading to transplant failure, retransplantations, or sepsis-related complications. Various desensitization strategies have been adopted to improve outcomes. Biologically related donor-recipient pairs have the theoretical advantage of favorable HLA (human leukocyte antigen) match. We have analyzed the outcomes of ABO-I LDLT and compared the results of HLA-matched (biologically related) and HLA-unmatched (biologically unrelated) donor-recipient pairs. Retrospective data of 90 cases of ABO-I liver transplant recipients: HLA-matched (n = 35) and HLA-unmatched (n = 55) for comparison of preoperative and postoperative data. Peak bilirubin levels in HLA-unmatched recipients were higher. Platelet count was lower than HLA-matched recipients (7.3 vs. 8.9mg/dL). No significant difference in days-to-normal bilirubin, peak International Normalised Ratio, hospital stay, and discharge-day from transplant between both groups. Postoperatively, HLA-unmatched recipients required more pulse-steroids therapy than HLA-matched: 21/55 (38.2%) versus 11/35 (31.4%). Biliary complications and interventions were more prevalent in the HLA-unmatched group (12/55, 21.8%) than in the HLA-matched group (4/35, 11.4%). Renal complications requiring postoperative hemodialysis were more prevalent in the HLA-unmatched group than the HLA-matched group (9/55 [16.4%] vs. 3/35 [8.6%]). The incidence of vascular complications was similar. ABO-I LDLT is an effective and safe method for increasing the donor pool in the absence of an ABO-compatible liver donor. Long-term outcomes of recipients with biologically related donors are marginally better than biologically unrelated ABO-I LDLT recipients. However, the incidence of antibody-mediated graft rejection and biliary complications is higher in biologically unrelated ABO-I liver recipients.

Cabozantinib Induces Isolated Hyperbilirubinemia in Renal Cell Carcinoma Patients carrying the UGT1A1*28 Polymorphism

Genetic variants of UGT1A1, involved in glucuronidation and clearance of bilirubin, are associated with reduced bilirubin metabolization and drug-induced isolated hyperbilirubinemia. We studied the impact of the UGT1A1*28 polymorphism on drug-induced isolated hyperbilirubinemia in metastatic renal cell carcinoma patients treated with pazopanib, cabozantinib, and axitinib. We genotyped the UGT1A1*28 TA6/TA6-TA6/TA7-TA7/TA7 polymorphism and correlated with median baseline, on-treatment and peak bilirubin levels during therapy, incidence of grade-1- or -2 (G1/2)-hyperbilirubinemia and time-to-G1-hyperbilirubinemia. Of the 66 patients treated with pazopanib, 29 received axitinib and 28 cabozantinib upon progression. Median baseline bilirubin was higher in TA7/TA7-carriers versus TA6/TA6+TA6/TA7-carriers at start of pazopanib (P < .0001), cabozantinib (P < .0001), and axitinib (P = .007). During pazopanib therapy, median bilirubin increased 1.4-fold in TA7/TA7+TA6/TA7-carriers but not in TA6/TA6-carriers. On cabozantinib, bilirubin increased 1.5-fold in TA7/TA7-carriers but not in TA6/TA6+TA6/TA7-carriers. Axitinib did not increase bilirubin in any genotype. Peak bilirubin in TA7/TA7- versus TA6/TA6+TA6/TA7-carriers was higher on pazopanib (P < .0001) or cabozantinib (P < .0001). With pazopanib, G1-hyperbilirubinemia occurred in 57% of TA7/TA7- and 12% of TA6/TA6+TA6/TA7-carriers (P = .0009) and G2-hyperbilirubinemia in 36% and 6% of the patients, respectively (P = .004). On cabozantinib, G1-hyperbilirubinemia occurred in 100% of TA7/TA7- and 5% of TA6/TA6+TA6/TA7-carriers (P < .0001) and G2-hyperbilirubinemia in 33% and 0% of the patients, respectively (P = .04). On axitinib, no correlation between the genotypes and G1/2-hyperbilirubinemia was observed. We validate the previously described impact of the UGT1A1*28 polymorphism on isolated bilirubin increase on pazopanib. We report for the first time that cabozantinib also interferes with UGT1A1 and causes isolated bilirubin increase.

A comparative study of uncomplicated acute non-A-E hepatitis with acute viral hepatitis and acute onset autoimmune hepatitis.

Non-A-E hepatitis (NAEH) not leading to acute liver failure (ALF) is poorly documented. The objective was to compare clinical and laboratory features of uncomplicated acute NAEH with acute viral (AVH) and autoimmune hepatitis (AIH) and histopathology in NAEH and AIH. Cases of hepatocellular jaundice were included. These were grouped into AVH, AIH and NAEH based on clinical, laboratory and, when indicated, liver biopsy findings. NAEH and AIH were followed up at three months. Of 336 patients with hepatocellular jaundice, 15 (5%) were NAEH, 25 (7%) acute AIH and 45(14%) AVH. Among NAEH patients, seven (46.7%) were males with a mean age of presentation 39 years. Jaundice (100%) was the most common presentation of NAEH. Peak bilirubin was 10.7 mg/dL. Peak aspartate and alanine aminotransferase (AST, ALT) were 512 and 670 U/L. Five (33.3%) patients had positive anti-nuclear antibody and one had anti-smooth muscle antibody. Mean immunoglobulin G (IgG) levels were 1829. On liver biopsy, all had ballooning degeneration, four (26.7%) had mild and three (20%) moderate interface hepatitis, four (26.7%) mild lymphoplasmacytic infiltrate, one (6.7%) rosette formation, bridging necrosis in none and stage 1 fibrosis in one. Comparing NAEH with AIH, AIH showed significantly older age at presentation, female predisposition, past history of jaundice, lower ALT, more autoantibodies, higher IgG, higher grade interface hepatitis, lymphoplasmacytic infiltrate, rosette formation and higher bilirubin, AST at three months. NAEH and viral hepatitis had similar features. Etiology of NAEH is unlikely to be autoimmune and is probably viral, unidentified as yet. Uncomplicated NAEH likely has self-limiting course even without specific treatment.

Revisiting the Malignant Masquerade at the Liver Hilum: Have We Made Progress?

Distinguishing malignant from benign causes of obstruction at the liver hilum can pose a diagnostic dilemma. This study aimed to determine factors that predict benign causes of hilar obstruction and long-term outcomes after resection. Consecutive patients who underwent surgery for hilar obstruction at a single institution between 1997 and 2022 were retrospectively analyzed. Median follow-up was 26months (range 0-281months). Among 182 patients who underwent surgery for hilar obstruction, 25 (14%) patients were found to have benign disease. Median CA19-9 level after normalization of serum bilirubin was 80U/mL (range 1-5779) and 21U/mL (range 1-681) among patients with malignant and benign strictures, respectively (p = 0.001). Cross-sectional imaging features associated with malignancy were lobar atrophy, soft tissue mass/infiltration, and vascular involvement (all p < 0.05). Factors not correlated with malignancy were jaundice upon presentation, peak serum bilirubin, sex, and race. Preoperative bile duct brushing or biopsy had sensitivity and specificity rates of 82% and 55%, respectively. Among patients who underwent resection with curative intent, grade 3-4 complications occurred in 55% and 29% of patients with malignant and benign strictures, respectively (p = 0.028). Postoperative long-term complications of chronic portal hypertension and recurrent cholangitis occurred in ≥ 10% of patients with both benign and malignant disease (p = non-significant). Strictures at the liver hilum continue to present diagnostic and management challenges. Postoperative complications and long-term sequelae of portal hypertension and recurrent cholangitis develop in a significant number of patients after resection of both benign and malignant strictures.

Risk factors for urinary tract infection in infants with unexplained hyperbilirubinemia: a single center case-control study

BackgroundUrinary tract infection (UTI) is a potential cause of neonatal jaundice. Nevertheless, there remains a lack of consensus regarding appropriate screening practices for UTI in infants with hyperbilirubinemia. This study aimed to analyze a group of jaundiced infants to assess the prevalence of UTI, explore potential risk factors, and examine the impact of UTI on the course and severity of neonatal jaundice.MethodsThis retrospective case-control study was conducted on 150 jaundiced infants (aged &amp;lt; 8 weeks) without a known etiology in the hyperbilirubinemia work-up. All subjects underwent phototherapy treatment and UTI screening by catheterization. They were then classified into UTI and non-UTI groups based on urine culture results, with a positive urine culture indicating the growth of ≥10,000 colony-forming units. The clinical characteristics and jaundice-related parameters of both groups were analyzed.ResultsAmong the 150 jaundiced patients, the prevalence of UTI was 29%. There was a significantly higher male predominance in the UTI group, and patients with UTI also had a significantly longer duration of hospitalization compared to those without UTI. Significant risk factors associated with UTI in jaundiced infants included male gender and a peak total bilirubin level higher than 18 mg/dl during hospitalization. The most common pathogens identified in urine culture were Escherichia coli (41.9%) and Enterococcus faecalis (30.2%).ConclusionIn cases of neonatal jaundice where the underlying cause is not evident, screening for UTI should be performed, particularly when associated risk factors or inadequate response to phototherapy is present.

Propensity score matched analysis and risk stratification of donors with G6PD deficiency in living donor liver transplantation.

Glucose 6 phosphate dehydrogenase (G6PD) deficiency (G6PDd) can trigger hemolysis following surgical stress. Differentiating G6PDd-related post-operative hemolytic episodes (PHE) and post-hepatectomy liver failure may be challenging especially in living donors where donor safety is paramount. We analysed outcomes of our cohort of G6PDd liver donors. G6PDd individuals with no evidence of hemolysis were considered as living donors if there was no alternative family donor. Outcomes of G6PDd donors undergoing left lateral/left lobe donation (Group LL) and right lobe donation (Group RL) were compared with non-G6PDd donors matched in a 1:3 ratio using propensity score matching. 59 G6PDd donors (5.8% of 1011) underwent living donor hepatectomy (LiDH) during the study period. LL-G6PDd donors (22.37%) had higher post-operative peak bilirubin level compared to matched controls, but no difference in morbidity or need for post-operative blood transfusion.RL-G6PDd donors (37.63%) had higher peak bilirubin level, morbidity (16.2% vs. 3.6%, p = 0.017) and more post-operative blood transfusion (21.6% vs. 6.4%, p = 0.023) as compared to matched non-G6PDd cohort. Four RL-G6PDd donors (10.8%) developed PHE. Low G6PD activity (15% vs. 40%, p = 0.034) and lower future liver remnant (FLR) (34.3% vs. 37.8%, p = 0.05) were identified as risk factors for PHE. We report the largest to-date series of G6PDd individuals undergoing LiDH and confirm the safety of LL donation in G6PDd. Our analysis identifies specific risk factors for PHE and suggests that right lobe LiDH be avoided in individuals with less than 25% G6PD activity when the FLR is less than 36%.

Machine learning to predict pediatric choledocholithiasis: A Western Pediatric Surgery Research Consortium retrospective study

BackgroundThe purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm. MethodsA multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset. ResultsA cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935. ConclusionThis multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis.

Umbilical Cord Milking in Nonvigorous Infants: A Cluster-Randomized Crossover Trial

ABSTRACT Approximately 6 million infants each year require resuscitation at birth. Requiring this intervention is associated with higher risk of hypoxic-ischemic encephalopathy (HIE), cerebral palsy, attention-deficit or hyperactive disorder, autism, neonatal stroke, and death. In infants needing resuscitation, optimal cord management is essential to enhance placental transfusion. Delayed cord clamping (DCC) is used to enable placental transfusion in vigorous infants, but in nonvigorous infants—those who are limp, pale, or have minimal or no breathing—early cord clamping (ECC) is recommended. Another intervention for nonvigorous infants requiring resuscitation is umbilical cord milking (UCM). UCM can improve heart rate, blood pressure, urine output, cerebral oxygenation, and hemoglobin levels, and prevent anemia. In addition, it can achieve placental transfusion without delaying resuscitation as with DCC and can be completed as quickly as ECC. No harm has been observed in studies involving UCM. Despite these benefits, studies are lacking on optimal cord management strategies in nonvigorous infants requiring resuscitation. The aim of this study was to examine whether UCM reduces admission to the neonatal intensive care unit (NICU) versus ECC in nonvigorous newborns. This was a pragmatic, cluster-randomized, crossover trial conducted at 10 hospitals in the United States, Canada, and Poland. Included were viable infants delivered between January 2019 and May 2021 who were between 35 and 42 weeks of gestation and nonvigorous at birth. Nonvigorous was defined as poor tone, pallor, or lack of breathing in the first 15 seconds after birth. Excluded were infants with major congenital or chromosomal anomalies, cardiac defects except small ventricular septal defects, complete placental abruption or cutting through the placenta at delivery, monochorionic multiples, cord anomalies, and the presence of nonreducible nuchal cord. Hospitals were randomized 1:1 to UCM or ECC in period 1 from January 2019 to January 2020, then crossed over to the other intervention during period 2 from February 2020 to May 2021. The primary outcome was NICU admission related to the intervention in the first 24 hours of life. The safety outcome was HIE. A total of 1730 infants were included in the analysis with 872 in the UCM group and 858 in the ECC group. The difference in the frequency of NICU admission was not statistically significant, with 23% in the UCM group and 28% in the ECC group (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.41–1.14). In comparison to the ECC group, UCM was associated with lower odds of abnormal 1-minute Apgar scores (Apgar ≤3, 30% vs 34%; crude OR, 0.72; 95% CI, 0.56–0.92), receipt of cardiorespiratory support in the delivery room (61% vs 71%; modeled OR, 0.57; 95% CI, 0.33–0.99), and therapeutic hypothermia (3% vs 4%; crude OR, 0.58; 95% CI, 0.33–0.99). In addition, there was no significant difference in any grade of HIE, although moderate-to-severe HIE was less common in the UCM group (1% vs 3%; crude OR, 0.48; 95% CI, 0.24–0.96). The UCM group also had increased hemoglobin (modeled mean difference, 0.68 g/dL; 95% CI, 0.31–1.05) and peak serum bilirubin (modeled mean difference, 1.4 mg/dL; 95% CI, 0.5–2.2). In nonvigorous newborns needing resuscitation, UCM was not associated with a reduction in NICU admissions compared with ECC. UCM was associated with a decrease in cardiorespiratory support in the delivery room, fewer cases of moderate-to-severe HIE, lower use of therapeutic hypothermia, and higher hemoglobin.

Left Lobe First With Purely Laparoscopic Approach: A Novel Strategy to Maximize Donor Safety in Adult Living Donor Liver Transplantation.

Evaluate outcome of left-lobe graft (LLG) first combined with purely laparoscopic donor hemihepatectomy (PLDH) as a strategy to minimize donor risk. An LLG first approach and a PLDH are 2 methods used to reduce surgical stress for donors in adult living donor liver transplantation (LDLT). But the risk associated with application LLG first combined with PLDH is not known. From 2012 to 2023, 186 adult LDLTs were performed with hemiliver grafts, procured by open surgery in 95 and PLDH in 91 cases. LLGs were considered first when graft-to-recipient weight ratio ≥0.6%. Following a 4-month adoption process, all donor hepatectomies, since December 2019, were performed laparoscopically. There was one intraoperative conversion to open (1%). Mean operative times were similar in laparoscopic and open cases (366 vs 371 minutes). PLDH provided shorter hospital stays, lower blood loss, and lower peak aspartate aminotransferase. Peak bilirubin was lower in LLG donors compared with right-lobe graft donors (1.4 vs 2.4 mg/dL, P < 0.01), and PLDH further improved the bilirubin levels in LLG donors (1.2 vs 1.6 mg/dL, P < 0.01). PLDH also afforded a low rate of early complications (Clavien-Dindo grade ≥ II, 8% vs 22%, P = 0.007) and late complications, including incisional hernia (0% vs 13.7%, P < 0.001), compared with open cases. LLG was more likely to have a single duct than a right-lobe graft (89% vs 60%, P < 0.01). Importantly, with the aggressive use of LLG in 47% of adult LDLT, favorable graft survival was achieved without any differences between the type of graft and surgical approach. The LLG first with PLDH approach minimizes surgical stress for donors in adult LDLT without compromising recipient outcomes. This strategy can lighten the burden for living donors, which could help expand the donor pool.

Hyperbilirubinemia as a Risk Factor for Mortality and Morbidity in Trauma Patients.

Hyperbilirubinemia is frequently reported in trauma patients. However, few studies have investigated the effects of hyperbilirubinemia on patients' clinical trajectories. This study aimed to evaluate the relationship between hyperbilirubinemia and patient outcomes following trauma. Our study included 387 patients who were admitted to the trauma bay with severe trauma between January 2017 and December 2021. We categorized patients into two groups based on their peak bilirubin levels: the low-bilirubin (LB) group, with levels below 3 mg/dL, and the high-bilirubin (HB) group, with levels above 3 mg/dL. We then compared the rates of complications and mortality between these two groups. The incidence of pneumonia (10.8% vs. 32.3%, p < 0.001), acute kidney injury (AKI) (2.8% vs. 19.2%, p < 0.001), sepsis (2.8% vs. 10.1%, p = 0.003), and wound infections (8.3% vs. 30.3%, p < 0.001) was significantly higher in the HB group. Additionally, the mortality rate was significantly higher (4.2% vs. 10.1%, p = 0.028) in the HB group. Multivariate analysis revealed that the higher the bilirubin level, the greater the risk of complications (pneumonia: odds ratio [OR] = 3.238; 95% confidence interval [CI] = 1.68-6.22; p < 0.001, AKI: OR = 4.718; 95% CI = 1.65-13.44; p = 0.004, sepsis: OR = 3.087; 95% CI = 1.00-9.52; p = 0.04, wound infection: OR = 3.995; 95% CI = 2.073-7.700; p < 0.001). In conclusion, hyperbilirubinemia was associated with poorer outcomes in trauma patients.

Parental detection of neonatal jaundice using a low-cost colour card: a multicentre prospective study

BackgroundSince most infants are usually discharged before age 48–72 hours, peak bilirubin levels will almost always occur after discharge. Parents may be the first to observe the onset of jaundice...

Hyperbilirubinemia Among Infants Born Preterm: Peak Levels and Association with Neurodevelopmental Outcomes

To describe the distribution of peak bilirubin levels among infants born before 29weeks of gestation in the first 14days of life and to study the association between quartiles of peak bilirubin levels at different gestational ages and neurodevelopmental outcomes. Multicenter, retrospective, nationwide cohort study of neonatal intensive care units in the Canadian Neonatal Network and Canadian Neonatal Follow-Up Network, including neonates born preterm at 220/7 to 286/7weeks of gestation born between 2010 and 2018. Peak bilirubin levels were recorded during the first 14days of age. Main outcome was significant neurodevelopmental impairment, defined as cerebral palsy with Gross Motor Function Classification System ≥3, or Bayley III-IV scores of <70 in any domain, or visual impairment, or bilateral hearing loss requiring hearing aids. Among 12 554 included newborns, median gestational age was 26weeks (IQR 25-28) and birth weight was 920 g (IQR 750-1105 g). The median peak bilirubin values increased as gestational age increased (112mmol/L [6.5mg/dL] at 22weeks and 156mmol/L [9.1mg/dL] at 28weeks). Significant neurodevelopmental impairment was identified in 1116 of 6638 (16.8%) of children. Multivariable analyses identified an association between peak bilirubin in the highest quartile and neurodevelopmental impairment (aOR 1.27, 95% CI 1.01-1.60) and receipt of hearing aid/cochlear implant (aOR 3.97, 95%CI: 2.01-7.82) compared with the lowest quartile. In this multicenter cohort study, peak bilirubin levels in neonates of <29weeks of gestation increased with gestational age. Peak bilirubin values in the highest gestational age-specific quartile were associated with significant neurodevelopmental and hearing impairments.

Novel radiological technique to recognize acute liver failure caused by yellow phosphorous containing rodenticides.

Yellow phosphorous rodenticide (YPR) poisoning is the commonest cause for acute liver failure (ALF) in southern and western India. Due to medicolegal issues, history of YPR ingestion may not be available. As early recognition of YPR poisoning is important and there are no specific biochemical assays, other early predictors to identify this entity is necessary. We evaluated the diagnostic role of plain computed tomography (CT) in identifying YPR-induced ALF. All patients admitted to the liver unit with a diagnosis of ALF underwent a plain CT scan abdomen. Demographic details, clinical history, laboratory parameters, liver attenuation index (LAI) calculated on CT scan, treatment details, need for liver transplantation and clinical outcome were analyzed. Parameters for YPR-induced ALF (ALF-YPR) and other causes (ALF-OTH) were compared. Ability of LAI to distinguish ALF-YPR and ALF-OTH was analyzed using receiver operating characteristic (ROC) curve analysis. Twenty-four patients (15 female [62.5%]) were included in the study. Thirteen patients (54%) had YPR poisoning, while the rest formed the ALF-OTH group (11,46%). ALF-YPR patients had higher transaminase levels, lower peak serum bilirubin levels. ALF-YPR livers had significantly lower LAI as compared to ALF-OTH (- 30 vs. - 8, p = 0.001). On ROC curve analysis, an LAI greater than - 18 ruled out YPR as the cause for ALF with 91% sensitivity and 85% specificity. On regression analysis, LAI was the only independent factor predicting ALF-YPR (odds ratio - 0.86, [0.76, 0.96] p = 0.008). Our data shows that LAI on plain abdominal CT scan can be used to quickly recognize ALF-YPR in unclear cases so that necessary treatment protocol can be activated, or patient transfer arranged. Our analysis shows that an LAI greater than - 18 can reliably rule out YPR ingestion as the cause for ALF.

Perioperative risk factors for neurological impairment in infants with acute liver failure following liver transplantation

Neurological impairment is not rare in infants with acute liver failure (ALF). This study aimed to investigate the perioperative risk factors for neurological impairment following liver transplantation (LT) in infantile ALF. Retrospective analysis was performed in infants who were younger than 1 year with ALF who subsequently underwent LT at our hospital between January 2005 and December 2016. Patients were considered to have neurological impairment if the Pediatric Cerebral Performance Category score was between 2 and 5 at the age of 6 years. A comparison between the groups of infants with and without neurological impairment was performed, and factors with p < .10 in the comparison were analyzed using univariate logistic regression analysis for neurological impairment. Twenty-six infants survived until 6 years of age, and 31% (8/26) of them had neurological impairment. Patients with neurological impairment were significantly younger in age at ALF onset, had significantly higher pre-LT bilirubin and prothrombin time/international normalized ratio, and stayed significantly longer in the intensive care unit than those without neurological impairment. Total bilirubin (odds ratio (OR) = 1.12, 95% confidence interval (CI) 1.02-1.22, p = .012), indirect bilirubin (OR = 1.10, 95% CI 1.01-1.20, p = .025), direct bilirubin (OR = 1.22, 95% CI 1.01-1.47, p = .040), and age in month at ALF (OR = 0.76, 95% CI 0.58-0.999, p = .049) showed significant association with neurological impairment. High pre-LT peak bilirubin value and younger age at ALF onset can be perioperative risk factors for neurological impairment after LT in infantile ALF.

Benefits of laparoscopic liver resection in elderly patients.

The indications of laparoscopic liver resection (LLR) have expanded to high-risk patients, such as elderly people. However, to date, little evidence has been established of the safety and feasibility of LLR in elderly patients. The short-term outcomes of LLR in elderly patients as compared to non-elderly patients were investigated. Data of a total of 297 patients who underwent LLR were reviewed. Among these 297 patients, 181 patients were < 75years age (non-elderly) and 116 patients were ≥ 75years age (elderly), and the surgical outcomes were compared between the groups. In addition, we evaluated the risk factors for postoperative morbidity (Clavien-Dindo grade ≥ IIIa) utilizing the preoperative, operative, and postoperative variables RESULTS: The preoperative liver/renal function, frequency of anti-thrombotic drug use, number of comorbidities, and American Society of Anesthesiologists-physical status classification were more unfavorable in elderly patients than in non-elderly patients. No significant inter-group differences were observed in the operation time, blood loss, conversion rate, postoperative morbidity, or 30-day mortality. The 3-year overall survival rate was comparable between the two groups. Multivariate analysis identified anti-thrombotic drug use, operation time > 7h, and peak serum total bilirubin > 2mg/dl within postoperative day 3 as independent risk factors for Clavien-Dindo ≥ IIIa postoperative morbidity (P = 0.016, P < 0.001, and P = 0.001, respectively). LLR in elderly patients may provide comparable short-term outcomes to those in non-elderly patients.

Efficacy of kangaroo mother care combined with neonatal phototherapy in newborns with non-pathological jaundice: A meta-analysis.

The kangaroo-mother care method (KMC) is a skin-to-skin contact-centered care approach with numerous benefits for neonates, but its impact on the treatment of jaundiced neonates is unknown. This study aimed to investigate the efficacy of KMC combined with neonatal phototherapy (NNPT) in treating neonates with non-pathological jaundice. Relevant articles were searched in PubMed, Embase, Web of Science, and Cochrane Library databases from database establishment to April 2022. The outcomes included, without limitation, serum bilirubin levels, and duration of phototherapy. This meta-analysis included five studies (4 randomized controlled trials and 1 observational study) involving four hundred eighty-two neonates with non-pathological jaundice. The results showed that the group receiving KMC combined with NNPT had lower serum bilirubin at 72 h after intervention [weighted mean difference (WMD) = -1.51, p = 0.03], shorter duration of phototherapy [standard mean difference (SMD) = -1.45, p < 0.001] and shorter duration of hospitalization (SMD = -1.32, p = 0.002) compared to NNPT group. There was no difference in peak bilirubin in both groups of neonates (WMD = -0.12, p = 0.62). KMC combined with NNPT helped to treat non-pathological jaundice in newborns compared to NNPT alone.

Measures of Structural Racism Predict ICU Admission Following Intensive Chemotherapy for AML

INTRODUCTION: Recent observational studies have revealed that real-world complications of intensive chemotherapy for frontline treatment of acute myeloid leukemia (AML) far exceed those reported in clinical trials. A 2017 analysis of over 40,000 AML patients found that 26% of patients who received induction chemotherapy were admitted to the intensive care unit (ICU), with increased mortality for non-white patients (Halpern, JAMA Oncology 2016). In a newly created Chicago AML registry (Abraham, Blood 2022), higher ICU admission rate was noted following induction chemotherapy for non-white patients. The current study aims to i) describe treatment complications based on race/ethnicity and ii) examine structural racism (SR) measures as risk factors for ICU admission following intensive chemotherapy in a diverse real-world patient population. METHODS: Using the Chicago AML registry, we compared ethnoracial differences in treatment complications including infections, thrombosis, renal or liver dysfunction (defined as peak creatinine >1.5 g/dL or peak bilirubin >1.2 mg/dL), respiratory failure requiring ventilatory support and hemodynamic instability needing pressor support. We then examined associations of race/ethnicity and previously published measures of census tract disadvantage, affluence, and segregation (referred to as SR measures) with ICU admission. These structural barriers were examined alongside known predictors of treatment mortality including disease characteristics and comorbidities. Additional outcomes included duration of ICU stay and mortality. RESULTS: In this cohort of 573 patients who underwent intensive induction chemotherapy for AML, 30-day complications differed based on race/ethnicity. Renal dysfunction was highest in non-Hispanic black (NHB) patients with an incidence of 27.8% with 6% initiating dialysis compared to 17.6% of non-Hispanic white (NHW) and 11.3% of Hispanic patients with 2% needing dialysis. Hepatotoxicity was highest in Hispanic patients (64%) vs. NHB (51%) and NHW (47%). Infectious complications were highest in NHB with microbiologically documented infections in 50.6% compared to 39.7% in NHW and 32.6% in Hispanic. Venous thrombosis occurred in 14.5% of NHB patients, compared to 14.7% of NHW and 13.3% Hispanic patients. In total, 141 (24.6%) patients required ICU admission during intensive induction with rates differing significantly by race and ethnicity (p = 0.014). Average length of stay in the ICU was 7.8 days for NHB patients, 6.7 days for NHW and 6.0 days for Hispanics. Due to low 30-day mortality, we were unable to detect differences between ethnoracial groups. Mechanical ventilation was utilized in 32% of NHB compared to 26% of NHW and 20% of Hispanic patients admitted to the ICU. Vasopressor were required in 31% of NHB patients vs. 27% of NHW patients. Predictors of ICU admission in our dataset included non-white race, unmarried status, living in a neighborhood with lower % of NHW residents, and WBC > 50,000/µL at diagnosis. Additional census tract variables including higher disadvantage and lower affluence conferred nonsignificant risk. Interestingly, comorbidities, ELN Score and baseline creatinine > 1.5 g/dL were not predictors of ICU admission. CONCLUSIONS: In a real-world population of AML patients, we show variation in the spectrum of treatment complications based on race/ethnicity. Moreover, with detailed individual and neighborhood socioeconomic position (SEP) data, measures of SR predicted ICU admission following induction chemotherapy. Other significant predictors include marital status - an individual measure of SEP, and hyperleukocytosis, which may indicate delay in medical presentation. High comorbidity index did not predict increased rate of ICU admission similar to prior studies (Tawfik, J Geriatr Oncol, 2016), while renal dysfunction was a non-significant predictor. Collectively our results suggest that there is a need to incorporate individual and neighborhood SR measures to identify patients at risk of clinical decline when stressed with intensive therapies. An algorithmic approach to identify 'high risk’ patients based on clinical/molecular and structural factors could prompt more detailed assessment of fitness prior to initiation of chemotherapy and directly influence leukemia outcome disparities. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Prevalence of 563 C – T&amp; 131 C-G G6PD polymorphisms in term and late preterm neonates with significant unconjugated hyperbilirubinemia from a tertiary level care neonatal unit in Uttarakhand

Objectives: This study aimed to estimate the frequency of Glucose-6-phosphate dehydrogenase (G6PD) Mediterranean variant (563 C-&gt;T) and G6PD Odisha (131 C-&gt;G) variants along with the prevalence of G6PD deficiency quantitatively. This study also estimated peak serum total bilirubin level and duration of phototherapy and correlated with the G6PD levels and G6PD mutations. Methods: All the consecutive term and late pre-term neonates of either gender with significant hyperbilirubinemia were enrolled after written informed consent and were screened for G6PD deficiency (quantitatively). These neonates were also evaluated for G6PD gene polymorphisms. Exclusion criteria: Neonates with congenital anomalies or conjugated hyperbilirubinemia and those who received treatment before enrollment were excluded from this study. Results: A total of 150 infants with hyperbilirubinemia were enrolled. Males were two-thirds. Median G6PD levels were 11.9 units/gm of Hb (Inter quartile range [IQR]: 9.4–16.2). The prevalence of G6PD deficiency in our study population was 24% among the whole population and 30.6% in male infants. As per the World Health Organization (WHO) classification, majority (94%) were in class IV, 5.3% (n=8) had WHO Class III. All the eight infants in Class III were males. Mean (SD) and median serum bilirubin levels were 16.7 (1.1) mg/dL. Median duration of phototherapy was 24 h. Gene polymorphisms were done in 119 neonates. G6PD Mediterranean mutations were seen in 6.7% and G6PD Orissa mutations were seen in 4.2% neonates. There was a good correlation between G6PD deficiency and serum total bilirubin, mean duration of phototherapy and gender. Conclusion: This study reported 24% prevalence of G6PD deficiency among the study population with 6.7% prevalence of G6PD Mediterranean mutations and 4.2% prevalence of G6PD Orissa mutations.

Etiology, outcome and prognostic indicators of acute liver failure in Asian children.

Outcome of pediatric acute liver failure (PALF) in countries with limited availability of LT is not well described. We evaluated the outcome and prognostic indicators of PALF in Malaysia where emergency LT for ALF is limited. In this retrospective review on children < 18years with PALF, we compared clinical and laboratory parameters between survival after supportive treatment and after LT or succumbed without LT. The predictive values of Liver Injury Unit (LIU; peak laboratory values for international normalized ratio [INR], ammonia, total bilirubin) and upon admission (aLIU) on outcome of PALF was evaluated using receiver operator characteristic (ROC) curves. Of 77 children (39 males [51%]; median age 2.8years) with PALF, the overall survival was 55% (n = 42); 52% (n = 40) survived with supportive management, 2.6% (n = 2) after LT. As compared to children who survived without LT, children who had LT/died had lower hemoglobin, aspartate transferase, γ-glutamyl transpeptidase (GGT), and higher serum bilirubin, alkaline phosphatase, ammonia, and serum sodium (p < 0.05). On multivariate analysis, significant independent predictor for death or LT were peak bilirubin > 452μmol/L and peak GGT < 96IU/L. The C-index of LIU and aLIU score were 0.79 and 0.68, respectively, indicating that LIU score was a good model in predicting outcome of PALF. Overall survival of PALF remained poor. High peak bilirubin and low GGT predict poor outcome of PALF. LIU score is a good model in predicting outcome of PALF and maybe useful in selecting children for emergency LT.