Serum Bilirubin Concentration Research Articles

Usefulness of liver function tests in postmortem samples

Liver function tests have been investigated in the forensic setting in several biological fluids collected at autopsy. Nevertheless, the results of these investigations have provided diverging information on postmortem stability of liver function markers and postmortem reliability of liver function assessment. The first aim of this study was to determine gamma-glutamyltransferase, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin, total proteins, and albumin in antemortem and postmortem serum samples in a series of cases that underwent forensic investigations and had both samples available. The second aim was to measure total bilirubin and gamma-glutamyltransferase in cerebrospinal fluid. Preliminary results indicated that femoral (and cardiac) blood postmortem serum concentrations of bilirubin, total proteins, and albumin, as well as femoral blood postmortem serum concentrations of gamma-glutamyltransferase, can be considered to reliably reflect antemortem serum concentrations, thus suggesting that postmortem values could be used as surrogates for antemortem levels. Measurable bilirubin levels were demonstrable in cerebrospinal fluid samples in both preservative-free and sodium fluoride tubes, though with levels varying widely and unpredictably, irrespective of liver disease severity.

STEROIDAL SAPONIN TOXICITY IN EASTERN GREY KANGAROOS ( MACROPUS GIGANTEUS): A NOVEL CLINICOPATHOLOGIC PRESENTATION OF HEPATOGENOUS PHOTOSENSITIZATION.

We describe the clinicopathologic features of a mortality event characterized by blindness and dermatitis affecting eastern grey kangaroos ( Macropus giganteus), secondary to hepatogenous photosensitization. Affected animals exhibited photophobic behavior, blindness, ataxia, recumbency, lethargy, ear shaking, and behavior consistent with distress or depression. The photophobia manifested as abnormal shade-seeking during the day, including finding refuge under or in structures used frequently by people. Severely affected kangaroos were jaundiced and had markedly elevated serum bilirubin and gamma glutamyl-transpeptidase concentrations. Blindness in affected animals was attributed to moderate to severe corneal opacity due to corneal edema and inflammation. Skin lesions were typically subtle on gross examination even in cases which had severe necrotizing dermatitis histologically. Histologic lesions in the liver of affected animals included the presence of acicular clefts typical of steroidal saponins. The outbreak was associated with pasture dominated by the invasive grass, Panicum gilvum, which is a recognized source of saponin-induced photosensitization in livestock.

Serum Bilirubin Concentration is Associated with Left Ventricular Remodeling in Patients with Type 2 Diabetes Mellitus: A Cohort Study.

IntroductionPrevious studies have shown that serum bilirubin concentration is inversely associated with the risk of cardiovascular disease. The relationship between serum bilirubin concentration and left ventricular geometry, however, has not been investigated in patients with diabetes mellitus.MethodsIn this cohort study, 158 asymptomatic patients with type 2 diabetes mellitus without overt heart disease were enrolled. Left ventricular structure and function were assessed using echocardiography. Serum bilirubin concentration, glycemic control, lipid profile, and other clinical characteristics were evaluated, and their association with left ventricular geometry was determined. Patients with New York Heart Association Functional Classification greater than I, left ventricular ejection fraction less than 50%, history of coronary artery disease, severe valvulopathy, chronic atrial fibrillation, or creatinine clearance less than 30 ml/min, and those receiving insulin treatment, were excluded.ResultsUnivariate analyses showed that relative wall thickness (RWT) was significantly correlated with diastolic blood pressure (P = 0.003), HbA1c (P = 0.024), total cholesterol (P = 0.043), urinary albumin (P = 0.023), and serum bilirubin concentration (P = 0.009). There was no association between left ventricular mass index and serum bilirubin concentration. Multivariate linear regression analysis showed that log RWT was positively correlated with diastolic blood pressure (P = 0.010) and that log RWT was inversely correlated with log bilirubin (P = 0.003). In addition, the patients with bilirubin less than 0.8 mg/dl had a higher prevalence of concentric left ventricular remodeling compared with those with bilirubin 0.8 mg/dl or more.ConclusionOur study shows that the serum bilirubin concentration may be associated with the progression of concentric left ventricular remodeling in patients with type 2 diabetes mellitus.Electronic supplementary materialThe online version of this article (10.1007/s13300-018-0368-6) contains supplementary material, which is available to authorized users.

Thyroid Storm: A Japanese Perspective.

Background: Thyroid storm (TS) is life threatening. In the mid-2000s, its incidence was poorly defined, peer-reviewed diagnostic criteria were not available, and management and treatment did not seem to be verified based upon evidence and latest advances in medicine.Methods: First, diagnostic criteria were developed based on 99 patients in the literature and seven patients in this study. Then, initial and follow-up surveys were conducted from 2004 through 2008, targeting all hospitals in Japan to obtain and verify information on patients who met diagnostic criteria for TS. Based on these data, the diagnostic criteria were revised, and management and treatment guidelines were created.Results: The incidence of TS in hospitalized patients in Japan was estimated to be 0.20 per 100,000 per year and 0.22% of all thyrotoxic patients. The mortality rate was 10.7%. Multiple organ failure was the most common cause of death, followed by congestive heart failure, respiratory failure, and arrhythmia. In the final diagnostic criteria for TS, the definition of jaundice as serum bilirubin concentration >3 mg/dL was added. Based upon nationwide surveys and the latest information, guidelines for the management and treatment for TS were extensively revised and algorithms were developed.Conclusions: TS remains a life-threatening disorder, with >10% mortality in Japan. New peer-reviewed diagnostic criteria for TS are presented and its clinical features, prognosis, and incidence are clarified based on nationwide surveys. Furthermore, this information helped to establish detailed guidelines for the management and treatment of TS. A prospective prognostic study to validate the guidelines is eagerly anticipated.

Changes in Hepato-Renal Tissues Biomarkers of Alloxan-Induced Diabetic Wistar Rats Co-Administered Monosodium Glutamate and Ascorbic Acid

The present study investigated the capacity of combined administration of monosodium glutamate (MSG) and ascorbic acid to reverse altered hepatorenal functions in Type 1 diabetes mellitus (DM) Wistar rats. Single intra-peritoneal (i.p.) injection of 90 mg/kg body weight (b.w.) of alloxan monohydrate in phosphate buffered saline (pH=7.4) was used to induce DM in the rats. Standard spectrophotometric methods were used to measure hepatorenal biomarkers; namely, serum alanine transaminase (ALT), aspartate transaminase (AST) and alkaline phosphatase (ALP) activities as well as serum total bilirubin, urea and creatinine concentrations. Serum ratios of ALT to AST activities of the experimental rat groups were greater than 1 unit and within the range of 1.26 - 2.69 units. Serum ALP activities of the experimental rat groups were within the range of 84.08 ± 12.73 - 393.33 ± 35.67 IU/L. Pattern of lowered serum bilirubin concentrations in treated DM rat groups were in a dose dependent manner. Serum urea concentrations of DM rats co-administered MSG and ascorbic acid greater than 200 mg/kg b.w. were significantly lower (p<0.05) than those of other experimental rat groups. The present study showed that co-administration of MSG and ascorbic acid at doses greater than 200 mg/kg b.w. ameliorated hepatorenal dysfunction. However, indications showed that the DM rats did not obtained full therapeutic benefits.

Inverse Relationship Between Serum Bilirubin Levels and Diabetic Foot in Chinese Patients with Type 2 Diabetes Mellitus.

BackgroundSeveral studies demonstrated that bilirubin, a potent endogenous antioxidant, is a strong protective factor for many diabetic complications such as nephropathy, retinopathy, neuropathy, and vasculopathy. The purpose of this study was to assess the association between serum bilirubin levels and diabetic foot (DF) in Chinese patients with type 2 diabetes mellitus (T2DM).Material/MethodsThe present cross-sectional study of bilirubin levels in relation to DF was conducted in 1,269 T2DM patients with (n=578) and without (n=691) DF. Blood test results were obtained on hospital admission, including total bilirubin (T-BIL), direct bilirubin (D-BIL), and indirect bilirubin (I-BIL). Data on Wagner classification and amputation procedure in patients with DF were collected by reviewing electronic medical records. Univariate or multivariate analysis were performed to explore the association between bilirubin and DF.ResultsSerum I-BIL levels were shown to play a protective role regarding the presence and severity of DF (OR=0.75, p=0.029 and OR=0.90, p=0.021, respectively). In addition, in a comparison of the lowest and highest tertiles of serum bilirubin concentration, the highest tertile of serum T-BIL (OR=0.51, p=0.011) and I-BIL (OR=0.28, p<0.001) was significantly related with a lower Wagner grade of DF. Patients with DF in the highest tertiles of T-BIL carried a significantly lower risk of amputation events than those in the lowest tertiles (OR=0.47, p=0.025).ConclusionsThe present study provided evidence that decreased serum bilirubin levels were independently associated with the presence and severity of DF and amputation events in patients with DF.

Differential effects of hepatic cirrhosis on the intrinsic clearances of sorafenib and imatinib by CYPs in human liver

The tyrosine kinase inhibitors sorafenib and imatinib are important in the treatment of a range of cancers but adverse effects in some patients necessitate dosage modifications. CYP3A4 has a major role in the oxidation of sorafenib to its N-oxide and N-hydroxymethyl metabolites and also acts in concert with CYP2C8 to mediate imatinib N-demethylation. CYP3A4 expression and function are impaired in patients with advanced liver disease, whereas the functions of CYP2C enzymes are relatively preserved. We evaluated the biotransformation of sorafenib and imatinib in well-characterized microsomal fractions from 17 control subjects and 19 individuals with hepatic cirrhosis of varying severity. The principal findings were that liver disease impaired the microsomal oxidation of sorafenib to its major metabolites to 40–44% of control (P<0.01), whereas the N-demethylation of imatinib was relatively unimpaired. The impairments in sorafenib biotransformation were correlated with decreased serum albumin concentrations and increased serum bilirubin concentrations in patients with liver disease, but not with the overall grade of liver disease according to the Child-Pugh system. In contrast, there was no relationship between imatinib N-demethylation and clinicopathologic factors in liver disease patients. These findings were accounted for in terms of the differential roles of CYPs 3A4 and 2C8 in the intrinsic clearance of the drugs. CYP3A4 has the major role in the intrinsic clearance of sorafenib but plays a secondary role to CYP2C8 in the intrinsic clearance of imatinib. In agreement with these findings CYP2C protein expression and CYP2C8-mediated paclitaxel 6α-hydroxylation were unimpaired in cirrhotic livers. This information could be adapted in individualized approaches such as in vivo CYP3A4 phenotyping to optimize sorafenib safety and efficacy in cancer patients with liver dysfunction.

High serum bilirubin is associated with lower prevalence of peripheral arterial disease among cardiac patients

Several studies have shown that subjects with higher serum bilirubin may have a lower risk of cardiovascular disorders. We herein investigated whether serum bilirubin concentration is associated with lower extremity ischemia among cardiology patients. In total, 935 patients without a history of angioplasty or bypass surgery of the lower limb arteries and who had bilateral ankle–brachial index measurements were included in the study. Peripheral arterial disease (PAD) was defined to be present when ABI of either or both sides was <0.9. Overall, the serum total bilirubin concentration ranged between 0.1 and 2.7mg/dL (normal range, 0.1–1.0mg/dL). Across the bilirubin tertiles, age did not differ significantly. On the other hand, male patients (median 0.6mg/dL, interquartile range (IQR) 0.4–0.7mg/dL) had significantly higher bilirubin levels than female patients (median 0.5mg/dL, IQR 0.4–0.7mg/dL, P=0.014). Logistic regression analysis showed that, as compared with the lowest bilirubin tertile (0.1–0.4mg/dL), the highest tertile (0.7–2.7mg/dL) was significantly negatively associated with prevalent PAD after adjusting for sex, age, eGFR, white blood cell count, inorganic phosphate, HbA1C, total and HDL cholesterol, triglycerides, current smoking, diabetic medication, and statin use. This association remained significant when only those with serum bilirubin in the normal range were included in the analysis. Among cardiology patients, serum bilirubin concentration was significantly negatively associated with prevalence of PAD. The underlying mechanism and therapeutic indications should be investigated in further investigations.

Serum bilirubin and the risk of chronic obstructive pulmonary disease exacerbations

BackgroundBilirubin is a potent anti-oxidant and higher serum concentrations of bilirubin have been associated with better lung function, slower lung function decline, and lower incidence of chronic obstructive pulmonary disease (COPD). We sought to determine whether elevated bilirubin blood concentrations are associated with lower risk for acute exacerbations of COPD (AECOPD).MethodsWe performed a secondary analyses of data in the Simvastatin for Prevention of Exacerbations in Moderate-to-Severe COPD (STATCOPE) and the Azithromycin for Prevention of Exacerbations of COPD (MACRO) studies. We used time-dependent multivariable Cox proportional hazards analyses, using bilirubin concentrations prior to first AECOPD as the exposure variable and time to first AECOPD as the outcome variable. STATCOPE was used for model development, with validation in MACRO.ResultsIn STATCOPE (n = 853), higher bilirubin was associated with a lower but statistically insignificant hazard for AECOPD, (adjusted hazard ratio [aHR] 0.89 per log10 increase [95%CI: 0.74 to 1.09; p = 0.26]). In the validation MACRO study (n = 1018), higher bilirubin was associated with a significantly lower hazard for AECOPD (aHR 0.80 per log10 increase [95%CI: 0.67 to 0.94; p = 0.008]).ConclusionsBilirubin may be a biomarker of AECOPD risk and may be a novel therapeutic target to reduce AECOPD risk.Trial registrationsClinicalTrials.gov NCT01061671 (registered 02 February 2010) and ClinicalTrials.gov NCT00325897 (registered 12 May 2006).

Defibrotide for the treatment of sinusoidal obstruction syndrome: evaluation of response to therapy and patient outcomes.

Defibrotide is an agent used to treat sinusoidal obstruction syndrome (SOS/VOD) in patients undergoing haemopoietic stem cell transplantation. The aim of this study was to evaluate the effectiveness of defibrotide used within institutional guidelines for the treatment of SOS/VOD in patients undergoing haemopoietic stem cell transplantation (HSCT). Data for 23 patients was retrospectively reviewed to evaluate the effectiveness of defibrotide and the utility of response criteria to direct therapy as specified within institution guidelines. Patients met institutional criteria for a diagnosis of SOS/VOD based on predominantly Baltimore criteria and received defibrotide. Stabilisation or improvement in symptoms and biochemical markers was required for continuation of therapy with defibrotide. Overall, 14 patients responded to therapy. Survival at day 100 post HSCT was 70%. Median serum (total) bilirubin concentrations in all evaluable patients had decreased at days 5 and 10 (p<0.001). There was a proportional reduction in median weight of 4% by day 5 and 6.6% by day 10 (p<0.001). On cessation of defibrotide, there was a decrease in the proportion of patients exhibiting hepatomegaly (p=0.02), ascites (p<0.01) and requiring oxygen supplementation (p<0.01), with 70% survival at day 100 post HSCT. Defibrotide to treat SOS/VOD and continued based on attainment of early response was effective management of this condition. Defibrotide should be considered in any consensus protocol providing guidance on the management of SOS/VOD, with future studies considered to assess appropriate time points for response to therapy during treatment.

Clinical biochemistry profile of biventricular heart failure in a mixed-breed bitch

A six-year old mixed-breed bitch was presented for chronic ascites. A diagnostic work-up was crafted to ascertain the cause of fluid accumulation in the peritoneal cavity. Clinical biochemistry tests for status of the liver and kidneys were performed. Elevations in absolute concentrations of the liver enzymes aspartate aminotransferase (AST) and alkaline phosphatase (ALP) were useful in evaluation of hepatocellular damage associated with right-sided heart failure. Normal levels of serum albumin and bilirubin, however, underscored the preserved functional capacity of the liver in spite of hepatocellular damage. Elevation of blood urea nitrogen, but not creatinine, was significant in appraisal of low cardiac output chronic renal failure resulting from left-sided heart failure. Increase in blood urea nitrogen was a valuable prognostic indicator of subsequent death resulting from biventricular heart failure, in contrast to serum bilirubin or albumin concentrations. Clinical biochemical profiles for liver and kidney functions in heart failure patients allow for estimation of the extent of hepatic and renal complications. Renal dysfunction carries a grave prognosis.

The impact of hemoglobin on the efficacy of phototherapy in hyperbilirubinemic infants.

BackgroundPhototherapy is the routine treatment for neonatal hyperbilirubinemia. Absorption of light in the skin transforms the native Z,Z-bilirubin to photobilirubins. This study investigates whether the hemoglobin concentration has an impact on efficacy of phototherapy, expressed by the decline of total serum bilirubin concentration (TsB).MethodsA trial was conducted on 93 infants, gestational age ≥33 weeks, with uncomplicated hyperbilirubinemia. The infants were treated with conventional phototherapy using LED light for 24 h. The median light irradiance was 66.8 μW/cm2/nm.ResultsThe median decrease in TsB after 24 h was 121 (57-199) μmol/l; the median hemoglobin was 12.0 (7.0-14.7) mmol/l. There was a significant effect of hemoglobin concentration on the decrease in TsB of -3.61 μmol/mmol hemoglobin (P=0.022), after adjusting for initial TsB and postnatal age. That is, assuming the same initial TsB and postnatal age, for each mmol/l increase in hemoglobin, the decrease in TsB was 3.61 μmol/l smaller. In our hemoglobin range, the decrease in TsB is reduced by 28 μmol/l (23%).ConclusionIncreasing hemoglobin levels led to a decrease in the efficacy of phototherapy. Our data provide additional support for the conclusion that the transformation of bilirubin to photobilirubins takes place mainly in the superficial capillaries of the skin.

Outcomes of biliary atresia in the Nordic countries – a multicenter study of 158 patients during 2005–2016

Background/purposeBiliary atresia is the most common reason for newborn cholestasis and pediatric liver transplantation. Even after normalization of serum bilirubin after portoenterostomy, most patients require liver transplantation by adulthood due to expanding fibrosis. We addressed contemporary outcomes of biliary atresia in the Nordic countries. MethodsData on center and patients characteristics, diagnostic practices, surgical treatment, adjuvant medical therapy after portoenterostomy, follow-up and outcomes were collected from all the Nordic centers involved with biliary atresia care during 2005–2016. ResultsOf the 154 patients, 148 underwent portoenterostomy mostly by assigned surgical teams at median age of 64 (interquartile range 37–79) days, and 95 patients (64%) normalized their serum bilirubin concentration while living with native liver. Postoperative adjuvant medical therapy, including steroids, ursodeoxycholic acid and antibiotics was given to 137 (93%) patients. Clearance of jaundice associated with young age at surgery and favorable anatomic type of biliary atresia, whereas annual center caseload >3 patients and diagnostic protocol without routine liver biopsy predicted early performance of portoenterostomy. The cumulative 5-year native liver and overall survival estimate was 53% (95% CI 45–62) and 88% (95% CI 83–94), respectively. Portoenterostomy age <65days and annual center caseload >3 patients were predictive for long-term native liver survival, while normalization of serum bilirubin after portoenterostomy was the major predictor of both native liver and overall 5-year survival. ConclusionsThe outcomes of biliary atresia in the Nordic countries compared well with previous European studies. Further improvement should be pursued by active measures to reduce patient age at portoenterostomy. Retrospective prognosis studyLevel II.

Persisting hyperbilirubinemia in patients with paroxysmal nocturnal hemoglobinuria (PNH) chronically treated with eculizumab: The role of hepatocanalicular transporter variants.

Eculizumab-treated paroxysmal nocturnal hemoglobinuria (PNH) patients (pts) show a dramatic decrease in serum lactate dehydrogenase (LDH) activities and bilirubin concentrations. However, some pts remain hyperbilirubinemic, possibly indicating an inadequate response due to extravascular hemolysis. Mutation analyses of hepatocanalicular transporter/nuclear receptor variants (ABCB4, ABCB11, ATP8B1, NR1H4) were performed in eight (five of eight males; mean age 38years [range 26-68years]) out of the 174 pts with PNH/-clone at our department due to a persistent increase in total bilirubin concentrations (median 3.4mg/dL; range 2.1-8.1mg/dL) during chronic eculizumab treatment and normal/or slightly increased serum aminotransferase activities. Median observation time was 70.1months (range 10.6-135.2months). All pts were treated according to German PNH guidelines. Homozygous and heterozygous procholestatic variants in the ABCB4, ABCB11, and ATP8B1 genes were identified in all eight pts. All carried the common ABCB4 c.787A>T polymorphism. The A(TA)7 TAA variant in the UGT1A1 promoter causing Gilbert syndrome was detected in three pts (5/8). Hyperbilirubinemia in PNH pts treated with eculizumab might not only be due to an insufficient response but rather a combination of mutations in hepatocanalicular transporter variants, Gilbert syndrome, and extravascular hemolysis. Our findings warrant further studies concerning transporter and enzyme variants in PNH to determine their clinical significance.

Bilirubin concentration is positively associated with haemoglobin concentration and inversely associated with albumin to creatinine ratio among Indigenous Australians: eGFR Study

Low serum bilirubin concentrations are reported to be strongly associated with cardio-metabolic disease, but this relationship has not been reported among Indigenous Australian people who are known to be at high risk for diabetes and chronic kidney disease (CKD).Hypothesis: serum bilirubin will be negatively associated with markers of chronic disease, including CKD and anaemia among Indigenous Australians.Method: A cross-sectional analysis of 594 adult Aboriginal and Torres Strait Islander (TSI) people in good health or with diabetes and markers of CKD. Measures included urine albumin: creatinine ratio (ACR), estimated glomerular filtration rate (eGFR), haemoglobin (Hb) and glycated haemoglobin (HbA1c). Diabetes was defined by medical history, medications or HbA1c≥6.5% or ≥48mmol/mol. Anaemia was defined as Hb<130g/L or <120g/L in males and females respectively. A multivariate regression analysis examining factors independently associated with log-bilirubin was performed.Results: Participants mean (SD) age was 45.1 (14.5) years, and included 62.5% females, 71.7% Aboriginal, 41.1% with diabetes, 16.7% with anaemia, 41% with ACR>3mg/mmol and 18.2% with eGFR<60mL/min/1.73m2. Median bilirubin concentration was lower in females than males (6 v 8μmol/L, p<0.001) and in Aboriginal than TSI participants (6 v 9.5μmol/L, p<0.001). Six factors explained 35% of the variance of log-bilirubin; Hb and cholesterol (both positively related) and ACR, triglycerides, Aboriginal ethnicity and female gender (all inversely related).Conclusion: Serum bilirubin concentrations were positively associated with Hb and total cholesterol, and inversely associated with ACR. Further research to determine reasons explaining lower bilirubin concentrations among Aboriginal compared with TSI participants are needed.

Phototherapy for neonatal hyperbilirubinemia.

Approximately 60years ago in England, phototherapy for neonatal hyperbilirubinemia was used in clinical practice. It was introduced in Japan approximately 50years ago. At that time, the mechanism underlying the serum bilirubin concentration decrease by phototherapy was still unknown. The mechanism was identified by chemists, biochemists, and pediatricians. Clarification started with the report that unconjugated bilirubin was excreted into bile after photoirradiation in Gunn rats. After confirmation of the molecular structure of bilirubin on X-ray analysis, the mechanism for bile excretion of unconjugated bilirubin was verified based on geometric configurational photoisomers in the Gunn rat. Finally, the reaction and excretion of structural bilirubin photoisomers was proved to be the main mechanism for the decrease in serum bilirubin during phototherapy for neonatal hyperbilirubinemia, which differs from the mechanism in the Gunn rat. The most effective and safest light source and the optimal method to evaluate phototherapy, however, remain unknown. Moreover, as for bronze baby syndrome, which is a well-known adverse reaction to phototherapy, the etiology is unclear. Hence, we review phototherapy for hyperbilirubinemia including a fundamental understanding of the bilirubin photochemical reactions, and discuss the subclinical carcinogenic risk of phototherapy and the increased mortality rate of extremely low-birthweight infants due to aggressive phototherapy, which is becoming an increasing problem.

Case 1: The Icteric Infant 12 Hours After Birth

The nursery notifies the medical team of a term female infant born at 40 weeks’ gestation via vacuum-assisted vaginal delivery. Maternal prenatal care was unremarkable. Prenatal laboratory findings are significant for maternal rubella nonimmune status and maternal blood type B positive, antibody negative. Events surrounding the delivery are notable for category II tracings on fetal monitor, 3+ meconium, and 1 detachment (“pop-off”) during vacuum application. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. At approximately 12 hours after birth, the medical team is notified of a transcutaneous bilirubin measurement that is outside the normal clinical range. The infant appears jaundiced on physical examination. The total serum bilirubin concentration is 20.6 mg/dL (1821 μmol/L). The neonate is transferred to the NICU for close observation and initiation of triple phototherapy. ### Diagnosis and Hospital Course Hyperbilirubinemia observed in the first 24 hours after birth is considered pathologic, or non-physiologic jaundice, and warrants urgent evaluation. Blood dyscrasias and hemolysis should be suspected in cases of severe hyperbilirubinemia and should prompt …

Serum amyloid A in the diagnosis of feline sepsis

Systemic inflammatory response syndrome (SIRS) and sepsis can be challenging to diagnose in cats. Retrospectively, we investigated the diagnostic and prognostic potential of serum amyloid A (SAA), a major feline acute-phase protein (APP), in a population of critically ill cats with SIRS related to trauma or sepsis. A total of 56 SIRS cats (trauma n = 27; sepsis n = 29) were included and compared with healthy controls ( n = 18). SAA concentration was significantly increased in SIRS cats compared to controls, confirming its potential for the detection of systemic inflammation in this species. Significantly higher values of SAA were detected in cats belonging to the sepsis group; however, according to the results of the receiver operating characteristic curve analysis, the value of using SAA (>81 mg/L) to discriminate septic cats was only moderate (AUC = 0.76). Additionally, cats with sepsis had significantly higher serum bilirubin concentrations and toxic neutrophil changes compared to the trauma group. Overall, 38 of 56 cats were survivors; 18 of 56 were non-survivors, with 83% of the non-survivors (15 of 18) belonging to the sepsis group. Serum bilirubin concentration, but not SAA, was able to predict outcome. Prospective studies are needed to assess the potential of SAA in the diagnosis of feline sepsis and outcome prediction.

Update on Phototherapy in Jaundiced Neonates.

Even relatively low serum bilirubin concentrations can cause neurodevelopmental impairment in extremely low birth weight (EBWL) infants, while sequelae from hyperbilirubinemia in late preterm and term infants are rare and occur only at very high serum bilirubin levels. Phototherapy is the current treatment of choice. To present an update on the most important issues involved in phototherapy for jaundiced infants. Light absorption by bilirubin in the skin transforms the native Z,Z-bilirubin to conformational photoisomers Z,E-bilirubin and E,Z-bilirubin and structural photoisomers E,Z-lumirubin and E,E-lumirubin. Formation and excretion of Z,E-bilirubin and E,Z-lumirubin are both important routes of elimination of bilirubin through bile and urine, although the precise contributions of the various photoisomers to the overall elimination of bilirubin are unknown. It appears that the photoisomers of bilirubin are predominantly formed in the plasma, and the rate of formation is affected by the hemoglobin concentration. Phototherapy lights with an emission spectrum of 460-490 nm provide the most efficient bilirubin-reducing light. LEDs should replace fluorescent tubes and halogen spotlights as the preferred light sources. Recent data raise concerns that sick ELBW infants under prolonged phototherapy may have an increased risk of death, though survivors may benefit from reduced rates of neurodevelopmental impairment. Comparison of the efficacy of cycled vs. continuous phototherapy has given divergent results. Changing the infant's position does not increase the efficacy of phototherapy. During the last decade, we have made progress in our understanding of how and where phototherapy works and in its practical applications.

The use of icterometer in assessing neonatal jaundice.

A study was made to assess neonatal jaundice by icterometer compared with serum bilirubin concentration, which was determined by Mercko photometric test, on 98 newborns with jaundice born in the Dr. Hasan Sadikin General Hospital, Bandung, throughout October 1975 until March 1976. A good correlation between bilirubin concentration as determined by the icterometer and actual serum bilirubin concentration was found, so that the icterometer could be used in Indonesian newborns. None of the icterometer values grade 3 or less had actual serum bilirubin concentrations more than 15 mg.%, so that grade 3 or less did not necessarily require additional serum bilirubin determination. On the contrary 46.7% and 81.8% of newborns with icterometer values of grades 3½ and 4 respectively have bilirubin concentrations more than 15 mg.%. Therefore, grade 3½ or more required further photometric bilirubin determination with a view to possible treatment.