Applicability of the Chronic Liver Failure-Consortium score in patients with cirrhosis and bacterial infections: a single-clinic experience

Background. The frequency and characteristics of acute-on-chronic liver failure (ACLF) are reported in numerous articles from different countries. The aim of the study was to assess the cirrhosis decompensation in patients with bacterial infections based on the Chronic Liver Failure-Consortium (CLIF-C) score in one of the city clinics in Belarus. Materials and methods. The patients underwent laboratory and instrumental studies during the hospitalization. The assessment of the syndrome of acute-on-chronic liver failure was performed using the CLIF-C score. Bacterial infections were diagnosed on the basis of standard criteria. Results. The study included 151 cirrhotic patients, 87 males and 64 females. Median age was 55 years (Q1 = 43; Q3 = 61). Cirrhosis was predominantly due to alcohol addiction — 83 patients (55 %). ACLF was diagnosed in 44 of 151 patients with cirrhosis (29.1 %; 95% confidence interval (CI) 22.0–37.1). Bacterial infections were detected in 67 people (44.4 %; 95% CI 36.3–52.7). Most often patients had liver failure that was detected by an increase in serum bilirubin level. Among individuals with upper gastrointestinal bleedings, number needed to harm for developing ACLF was 3.3 (95% CI 2.2–4.4). The risk of developing ACLF grade 2 and 3 in cirrhotic patients with infections was 8.2, with 95% CI 1.0–69.6 (number needed to harm was 12.9; 95% CI 10.7–15.0). Bacterial infections increase the risk of acute decompensation in patients with cirrhosis (odds ratio = 2.0, p = 0.048). Conclusions. The CLIF-C score is quite applicable in our cohort of patients with cirrhosis.

Validation of visual estimation of neonatal jaundice in low-income and middle-income countries: a multicentre observational cohort study

ObjectiveDetermine the sensitivity and specificity of neonatal jaundice visual estimation by primary healthcare workers (PHWs) and physicians as predictors of hyperbilirubinaemia.DesignMulticentre observational cohort study.SettingHospitals in Chandigarh and Delhi, India; Dhaka, Bangladesh; Durban, South Africa; Kumasi, Ghana; La Paz, Bolivia.ParticipantsNeonates aged 1–20 days (n=2642) who presented to hospitals for evaluation of acute illness. Infants referred for any reason from another health facility or those needing immediate cardiopulmonary resuscitation were excluded.Outcome measuresInfants were evaluated for distribution (head, trunk, distal extremities) and degree (mild, moderate, severe) of jaundice by PHWs and physicians. Serum bilirubin level was determined for infants with jaundice, and analyses of sensitivity and specificity of visual estimations of jaundice used bilirubin thresholds of >260 µmol/L (need for phototherapy) and >340 µmol/L (need for emergency intervention in at-risk and preterm babies).Results1241 (47.0%) neonates had jaundice. High sensitivity for detecting neonates with serum bilirubin >340 µmol/L was found for ‘any jaundice of the distal extremities (palms or soles) OR deep jaundice of the trunk or head’ for both PHWs (89%–100%) and physicians (81%–100%) across study sites; specificity was more variable. ‘Any jaundice of the distal extremities’ identified by PHWs and physicians had sensitivity of 71%–100% and specificity of 55%–95%, excluding La Paz. For the bilirubin threshold >260 µmol/L, ‘any jaundice of the distal extremities OR deep jaundice of the trunk or head’ had the highest sensitivity across sites (PHWs: 58%–93%, physicians: 55%–98%).ConclusionsIn settings where serum bilirubin cannot be measured, neonates with any jaundice on the distal extremities should be referred to a hospital for evaluation and management, where delays in serum bilirubin measurement and appropriate treatment are anticipated following referral, the higher sensitivity sign, any jaundice on the distal extremities or deep jaundice of the trunk or head, may be preferred.

Role of Probiotics in Neonates with Hyperbilirubinemia Receiving Phototherapy

Study Objectives: To compare the mean duration of phototherapy in neonates with hyperbilirubinemia receiving phototherapy with vs. without probiotics. Study Design and Settings: It was a randomized controlled trial carried at Department of Pediatrics, DHQ Hospital Kasur from Jan 2021 to June 2021. Patients and Methods: The present research involved 94 neonates of both genders aged between 2 to 28 days of life diagnosed of neonatal hyperbilirubinemia (serum bilirubin level ≥15mg/dL and direct bilirubin level ≤1.5 mg/dL). These neonates were allocated into two groups randomly. Neonates in Group-I were given probiotics along with conventional treatment of phototherapy whereas neonates in Group-II received conventional phototherapy alone. Study outcome was described in terms of mean duration of phototherapy (phototherapy was stopped when serum bilirubin level was less than 10 mg/dl during the first week and less than 11 mg/dl after the first week) which was recorded and compared between the groups. An informed written consent was taken from parents of every neonate. Results of the Study: The mean age of the neonates was 6.54±4.96 days while the mean gestational age was 37.31±2.04 weeks. There were 55 (58.5%) baby boys and 39 (41.5%) baby girls with a boys to girls ratio of 1.4:1. The mean weight of the neonates was 2.89±0.49 Kg while the mean serum bilirubin level upon admission was 16.73±1.19 mg/dl. The mean duration of phototherapy was significantly shorter in neonates receiving probiotics along with phototherapy as compared to phototherapy alone (3.13±0.92 vs. 3.81±1.12 days; p=0.002). Similar significant difference was observed across various subgroups based on age, gender, gestational age, weight and serum bilirubin level upon admission. Conclusion: Addition of probiotics to conventional practice of phototherapy alone in jaundiced neonates was found to hasten the recovery evident from significant reduction in the mean duration of phototherapy advocating its routine use in future practice. Keywords: Neonatal Hyperbilirubinemia, Phototherapy, Probiotics

Outcome of Obstructive Jaundice Patients after Endoscopic Retrograde Cholangiopancreatography

Introduction: Obstructive jaundice is frequently encountered worldwide including Bangladesh. Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) is one of the procedures to manage obstructive jaundice. Objectives: To ascertain the outcome of obstructive jaundice patients who underwent ERCP. Materials and Methods: It was a hospital based cross sectional observational study, carried out in Gastroenterology Department of Combined Military Hospital (CMH) Dhaka from May 2017 to May 2019. Total 200 patients were included in the study. Verbal consents were taken from patients. Data were collected with a checklist and analyzed by using SPSS 20. Results: Total 200 patients’ mean age±SD was 56.5±14.5 years with range 21 to 92 years and majority were 41 to 60 years 80(40%) followed by 61 to 80 years 78(39%). Etiology of obstructive jaundice were, benign 137(68.5%) and malignant 63(31.5%). Among the benign: 69(34.5%) were choledocholithiasis, 45(22.5%) biliary stricture, 20(10.0%) papillary stenosis and 3(1.5%) biliary warms. Among the malignant: 24(12.0%) were distal cholangiocarcinoma, 21(10.5%) periampullary tumors, 10(5.0%) Klatskin tumor, 4(2.0%) carcinoma head of pancreas, and 4(2.0%) other malignancy. Mean serum bilirubin level 17.6 mg/dl with minimum 0.6mg/dl, maximum 41.3mg/dl; mean alkaline phosphatase (ALP) level 351.4U/L with minimum 111U/L and maximum 1262U/L; mean alanine aminotransferase (ALT) level 118.8 U/L with minimum 28 U/L, maximum 521 U/L; ERCP were successfully done in 188(94.0%) patients with single attempt 171 (85.5%), repeated sessions 17(8.5%) and 12(6.0%) patients unsuccessful ERCP; complications occurred in 17(8.5%)patients, of whom post-ERCP pancreatitis 9(4.5%) and post procedure cholangitis 4(2.0%)patients. Conclusion: Benign etiologies of obstructive jaundice were more common than malignant one. Both benign and malignant etiology of obstructive jaundice can be successfully managed with ERCP with few complications. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 27-30

Causes of Neonatal Jaundice Requiring Exchange Transfusion

Background: Neonatal jaundice is highly prevalent in Asia and has serious complications, such as kernicterus. Therefore, it is very important to identify the risk factors of jaundice requiring exchange transfusion since it can be helpful in the prevention of the disease and early diagnosis of its complications. Objectives: The present study aimed to identify the causes of neonatal jaundice requiring blood exchange. Methods: The present cross-sectional study was performed on 251 term and preterm neonates. The studied newborns were 2-14 days old (born at ≥ 35 weeks of gestation) with jaundice and bilirubin of more than 17 mg/dL and received exchange transfusion during 2011 - 2020 in Ghaem teaching hospital, Mashhad, Iran. The required data of the study variables, such as hyperbilirubinemia risk factors, laboratory tests, the documented history of the mothers and neonates, and physical examination results, were collected through a questionnaire and the medical records of the patients. Finally, the collected data were analyzed in SPSS software (version 20). Results: Based on the results, the mean value of the total serum bilirubin level in neonates who received exchange transfusion was 27.53 ± 10.05 mg/dL. The blood types of about 40% of mothers and their neonates were O and A/B, respectively. Moreover, 11.4% of mothers were Rh-negative; however, their neonates were Rh-positive. The results also revealed that the causes of exchange transfusion were unknown, ABO incompatibility, Rh incompatibility, glucose-6-phosphate dehydrogenase deficiency (G6PDD), and sepsis in 52.7 %, 24%, 7.1%, 5.3%, and 5.3% of the neonates, respectively. Conclusions: The findings of this study suggest that after unknown causes, the most common causes of exchange transfusion were ABO incompatibility, Rh incompatibility, G6PDD, and sepsis. Therefore, since most of these causes can be recognized, it is recommended to perform related tests and take related measures in the Midwifery Department of the hospital to prevent the occurrence and exacerbation of jaundice. Moreover, it is recommended to perform an early follow-up after the discharge.

Correlation between Non-invasive Measurement of Carboxyhemoglobin and Bilirubin Level Measurement in Near- Term and Term Neonates as a Predictor of Neonatal Hemolysis

Background Neonatal hyperbilirubinemia is common in the neonatal period. Yet, serious pathological hyperbilirubinemia may cause kernicterus with detrimental neurologic sequalae. Carbon monoxide (CO) is the byproduct of the breakdown of heme, it is transported as carboxyhemoglobin to the lungs to be exhaled. Thus, carboxyhemoglobin levels increase as a result of hemolysis, and is therefore considered a sensitive index for the degree and severity of the subsequent hyperbilirubinemia. Objectives To correlate between non-invasive carboxyhemoglobin levels and bilirubin levels in near-term and tem neonates starting hour I of life. Subjects and methods A total of 100 near-term and term neonates were studied, by measuring carboxyhemoglobin by a Pulse CO-oximetry and serum bilirubin level (hour l) and transcutaneous bilirubin (TcB) hourly since birth for the I st 6 hours then every 6 hours till the time of discharge in a cross sectional case-control study. Results A cut off value of 4 for non-invasive carboxyhemoglobin with sensitivity of 81.25%, specificity of 95.24% was found to the earliest non-invasive predictor for subsequent jaundice. In patients with proven hemolysis, carboxyhemoglobin when compared to TcB was found to increase significantly in the first 3 hours of life more than TcB, stalting hour 4 till time of discharge it was increased yet statistically insignificant Conclusion We found that non-invasive carboxyhemoglobin is an effective early predictor for subsequent jaundice starting first hour of life. It can be used as a screening tool for hemolytic jaundice especially in hospitals with early discharge policy.

MATERNAL AND FETAL OUTCOME IN RH NEGATIVE PREGNANCY

INTRODUCTION- When Rh negative maternal blood is exposed to Rh positive fetal blood (RBC) in maternal circulation, antibodies against Rh (D) may develop in the mother. These Rh (D) antibody, once produced, remains in the woman's circulation and poses the threat of hemolytic disease (due to destruction of fetal RBCs ) for subsequent Rh-positive fetuses and this event leads to alloimmunization. Coombs test is the most common method to detect alloimmunization done during pregnancy (ICT) and in postnatal period (DCT). Rhesus (Rh) isoimmunization is an important clinical entity in India and other developing countries, which is responsible for fetal anemia and hydrops fetalis, and if not treated, it can result in intrauterine fetal demise, thus timely diagnosis follow-up and management of Rh –ve pregnancy is must. MATERIAL AND METHODS- st th This is a retrospective observational study, done in a private hospital, Gwalior (M.P.), form 1 Jan. 2018 to 30 June 2020. 88 women with Rh-ve pregnancy were studied during this period, Data was recovered from labor room record, OT, PNC, post operative wards for maternal outcome a SNCU for neonatal outcome. RESULTS- In our study the most common age group was 21-25 years (62.5%), most of the patient were Primigravida(42.4%), most of them were unbooked (65.90%) and from Rural area (72.72%). The most common blood group Rh- was o-ve (53.40%). Only 2 patients had positive indirect coombs test. Most of the patients delivered normally, only (28.40%)Patients delivered by LSCS. Preeclampsia was the most common maternal complication found in Rh- Patient (12.5%). 96.59% of Neonates were live born. 2.27% were fresh still born and 1.13% were macerated still born. 24 babies were admitted in SNCU. The most common cause of admission was neonatal jaundice (66.66%). The most (76.13%) of the babies had serum bilirubin level between 10-15 mg/dl. CONCLUSION- We concluded that Rh isoimmunization leads to increased perinatal morbidity for perinatal morbidity. The obstetrician and maternity staff should be familiar to diagnosis and management of with Rhesus incompatibility and they should counsel the Rh negative patient about Importance of checking blood group and Rh type in pregnancy and should educated them about importance of Rh prophylaxis and Hemolytic diseases of fetus and newborn risks of present and future pregnancy. During past few decades there had been major advances in the medical treatment for Rh negative pregnancy.

The Evaluation of Conventional MRI, Diffusion Tensor Imaging, and Arterial Spin Labeling Imaging for Early Brain Damage Caused by Neonatal Hyperbilirubinemia

Purpose: To evaluate the early bilirubin-induced neurologic dysfunction (BIND) by T1 weighted imaging (T1WI), diffusion tensor imaging (DTI), and arterial spin labeling (ASL).Methods: Forty newborns: hyperbilirubinemia with BIND (BIND group, n=13), hyperbilirubinemia without BIND (non-BIND group, n=17), and healthy newborns (HC group, n=10). The MRI parameters of globus pallidus were measured, including the T1WI signal values from conventional MRI, apparent diffusion coefficient (ADC), the fractional anisotropy (FA), relative anisotropy (RA) and volume ratio (VR) value from DTI, and the relative cerebral blood flow (rCBF) value from ASL. The group differences were analyzed by ANOVA with Bonferroni correction. The diagnosis efficiencies were assessed by the receiver operating characteristic curve (ROC). The correlation between those parameters and serum bilirubin level was evaluated by Pearson’s correlation coefficient.Results: 1）The mean signal values of globus pallidus on T1WI and DTI parameters were significantly different among the groups (p < 0.05). The difference in T1WI between the non-BIND group and the BIND group was not significant (p >0.05). The rCBF of globus pallidus was not significantly different among the three groups (p > 0.05). 2) The T1WI, FA, and RA values were positively while the VR value was negatively correlated with serum bilirubin level (r =0.763, 0.585, 0.586, -0.544 respectively, p < 0.05). The ADC value and rCBF were not correlated with serum bilirubin (r = -0.050, -0.275 respectively, p > 0.05). 3) The area under curve (AUC) of T1WI, FA, RA, VR was 0.953, 0.897, 0.897, 0.860 respectively. And the AUC of the diagnosis method, combined T1WI, FA, RA and VR, was 0.987.Conclusion: The index, combined T1WI and DTI parameters, was important for diagnosing early hyperbilirubinemia brain injury. ASL might not have function on diagnosing early hyperbilirubinemia brain injure.

Clinical Outcomes of Early Endoscopic Transpapillary Biliary Drainage for Acute Cholangitis Associated with Disseminated Intravascular Coagulation

Acute cholangitis (AC) is often associated with disseminated intravascular coagulation (DIC), and endoscopic transpapillary biliary drainage (EBD) under endoscopic retrograde cholangiopancreatography (ERCP) is a treatment of choice. However, no evidence exists on the outcomes of EBD for AC associated with DIC. Therefore, we retrospectively evaluated the treatment outcomes of early EBD and compared endoscopic biliary stenting (EBS) and endoscopic nasobiliary drainage (ENBD). We included 62 patients who received early EBD (EBS: 30, ENBD: 32) for AC, associated with DIC. The rates of clinical success for AC and DIC resolution at 7 days after EBD were 90.3% and 88.7%, respectively. Mean hospitalization period was 31.7 days, and in-hospital mortality rate was 4.8%. ERCP-related adverse events developed in 3.2% of patients (bleeding in two patients). Comparison between EBS and ENBD groups showed that the ENBD group included patients with more severe cholangitis, and acute physiology and chronic health evaluation II score, systemic inflammatory response syndrome score, and serum bilirubin level were significantly higher in this group. However, no significant difference was observed in clinical outcomes between the two groups; both EBS and ENBD were effective. In conclusion, early EBD is effective and safe for patients with AC associated with DIC.

Prolonged Jaundice in Newborn

Prolonged jaundice is defined as a serum bilirubin level higher than 85 μmol/L (5 mg/dl), which persists at postnatal 14 days in term infants and 21 days following the birth in preterm infants. It affects 2–15% of all newborns and 40% of breastfed infants. Although underlying cause can not be found in the majority of prolonged jaundice cases, this may also be the first sign of a serious causative pathology. Tests performed to determine the underlying cause and failure to determine the etiology cause anxiety for both families and physicians. The most important point is to determine whether prolonged jaundice is of a benign cause or is due to a substantial disease. For this reason, health care providers should not take unnecessary tests in normal infants, but should also recognize infants with a causative pathology. Neonatal jaundice still maintains its importance in neonatal clinical practice, since early diagnosis and treatment is feasible.