Jaundice: a Reflection Through Poetry

This poem is a personal reflection on how we disclose cancer diagnoses in medicine. "Jaundice" is based on an experience that I witnessed during my core surgical rotation during medical school. It was created to highlight the importance of assessing a patient's thoughts, feelings, and emotions during these cancer conversations. The impact that these moments can have on a person may be tremendous, despite it being a part of our daily careers as physicians.

Therapeutic effects of synbiotic on neonates with gestational age over 34 weeks admitted for jaundice

BACKGROUND

Hyperbilirubinemia is a common problem in neonates. The aim of this study was to evaluate the effect of synbiotic in addition to routine phototherapy on the treatment of neonatal jaundice.

METHOD

This double-blind clinical trial, was performed on 194, 3-14 days old neonates. Neonates were divided into intervention and placebo groups. The intervention group received 5 drops of oral synbiotic daily along with phototherapy and the placebo group underwent phototherapy plus a placebo. Gestational age, age, weight, sex, initial and daily bilirubin level, frequency of defecation, mode of delivery, and length of hospitalization were assessed.

RESULTS

The rate of bilirubin reduction on the first day of admission was significantly higher in the intervention group (2.9±1.81 vs. 2.06±1.93, p = 0.002). The mean level of bilirubin on the second (9.8±1.92 vs. 10.88±2.26) and third days (8.06±1.54 vs. 9.86±1.7) was lower in the intervention group (p = 0.001). The proportion of discharged patients in the third and fourth days was higher in the intervention group compared to the control (65% vs. 41%, 99% vs. 86.5%, respectively, p = 0.001). However, the duration of hospitalization was shorter in the intervention group compared to the control (2.36±0.5 vs. 2.74±0.74, p = 0.001).

CONCLUSION

Based on our results, daily treatment with 5 drops of synbiotic along with phototherapy can be a safe and effective modality in faster bilirubin reduction, decreasing the hospitalization period and phototherapy. Therefore, it seems that it can be used as an adjunct therapy for neonates with jaundice.

Fetal-maternal incompatibility in the Rh system. Rh isoimmunization associated with hereditary spherocytosis: case presentation and review of the literature

Next to A and B antigens, agglutinogen D exhibits the highest immunogenicity. Following the transfusion of D-positive red blood cells (RBCs), almost 80% of D-negative recipients develop anti-D antibodies (Abs). Subsequently, anti-D immunization further promotes the synthesis of Abs towards other blood group antigens in or outside the Rh system. The D antigen is also involved in 95% of cases of hemolytic disease of the newborn. Transfusions, hemotherapy, grafts, and obstetric history (abortions, ectopic pregnancy, births) are all risk factors for Rh isoimmunization. In the case of ABO compatibility between mother and fetus, Rh-positive fetal RBCs that have reached the maternal bloodstream are not destroyed by group agglutinins, and Rh antigenic sites are not hidden by the maternal immune system. But a Rh-negative mother with a homozygous Rh-positive husband will certainly have a Rh-positive fetus. As it has an irreversible evolution, the Rh isoimmunization once installed cannot be influenced in the sense of decreasing the Ab titer, therefore, injectable globulin has no effect. A particular case was that of a newborn with Rh system incompatibility associated with hereditary spherocytosis The clinical balance at birth reflects the severe jaundice of the female newborn of 3140 g, gestational age 38∕39 weeks, extracted by lower-segment transverse Caesarean section, with a double loop nuchal cord, Apgar score 8. Because the jaundice was severe and atypical (face and upper chest), we considered the possibility of coexistence of hemolytic disease of the newborn by Rh blood group incompatibility associated with hereditary spherocytosis, as it turned out to be true and mentioned. Changes in genes encoding proteins in the structure of the RBC membrane have amplified hemolysis induced by maternal-fetal isoimmunization in the Rh system. Massive hemolysis accentuated by congenital spherocytosis, confirmed later, imposed blood transfusion and dynamic monitoring.

Optimized Tree Strategy with Principal Component Analysis Using Feature Selection-Based Classification for Newborn Infant's Jaundice Symptoms

One of the most important and difficult research fields is newborn jaundice grading. The mitotic count is an important component in determining the severity of newborn jaundice. The use of principal component analysis (PCA) feature selection and an optimal tree strategy classifier to produce automatic mitotic detection in histopathology images and grading is given. This study makes use of real-time and benchmark datasets, as well as specific approaches for detecting jaundice in newborn newborns. According to research, the quality of the feature may have a negative impact on categorization performance. Additionally, compressing the classification method for exclusive main properties can result in a classification performance bottleneck. As a result, identifying appropriate characteristics for training the classifier is required. By combining a feature selection method with a classification model, this is possible. The major outcomes of this study revealed that image processing techniques are critical for predicting neonatal hyperbilirubinemia. Image processing is a method of translating analogue images to digital formats and manipulating them. The primary goal of medical image processing is to collect information useful for disease detection, diagnosis, monitoring, and therapy. Image datasets can be used to validate the performance of newborn jaundice detection. When compared to conventional approaches, it offers results that are accurate, quick, and time efficient. Accuracy, sensitivity, and specificity, which are common performance indicators, were also predictive.

[Clinical features of Epstein-Barr virus infection associated to liver injury in adolescents and adults]

Epstein-Barr virus (EBV) infection is closely associated to liver injury with diverse clinical features in adolescents and adults. It is often manifested as infectious mononucleosis syndrome, sometimes causing self-limited acute hepatitis, with mild to moderate elevation of liver transaminases, and relative increase in age-related conditions. EBV infection can also cause cholestatic hepatitis, with elevated alkaline phosphatase and γ-glutamyltransferase as the main manifestations, accompanied by varying degrees of jaundice. A small number of patients with severe EBV infection may experience liver failure, and if left untreated in time, it may lead to high mortality. In addition, EBV infection is also associated with chronic hepatitis, liver cirrhosis, autoimmune liver disease, etc.

Hypocalcemia in Jaundiced Neonates Receiving Phototherapy

BACKGROUND

Hyperbilirubinemia is a common problem in neonates. Phototherapy and exchange transfusion are the primary treatment modalities. Less known, but one of the potential complications of phototherapy is hypocalcemia. Most of the neonates with hypocalcemia are asymptomatic. Though asymptomatic, treatment should be initiated immediately when serum calcium level is reduced. This study was conducted to detect the incidence of hypocalcemia in jaundiced neonates receiving phototherapy.

METHODS

It is a hospital-based cross-sectional study conducted from May 2020 to December 2020 in the neonatal intensive care unit of Nepal Medical College Teaching Hospital. A total of 128 full-term neonates with jaundice and a normal serum calcium level before initiating phototherapy were enrolled in the study. Serum calcium level was measured before starting conventional phototherapy and after 48 hours of continuous phototherapy.

RESULTS

Hyperbilirubinemia was present in 23.3% of neonates admitted to the neonatal unit. Hypocalcemia was seen in 26 (20.3%) of term jaundiced neonates receiving phototherapy. Signs of hypocalcemia were present only in 3 (2.3%) neonates.

CONCLUSIONS

Hypocalcemia is a common complication of phototherapy. Serum calcium levels should be monitored in all the full-term neonates receiving phototherapy.

[Study on Irradiation Uniformity of Array Blue LED in Jaundice Treatment Box]

The uniformity of blue LED array in jaundice treatment box is improved. The mathematical model of illumination uniformity algorithm for inner and outer LED arrays layout is established. Taking the actual size of blue light board in jaundice treatment box as an example, the optimal illumination uniformity with best LED arrays layout are obtained through programming iteration and simulation verification. The uniformity of blue light LED improved 42.9 % comparing with tradition LED arrays.

Jaundice as a clinical presentation in liver hydatidosis increases the risk of postoperative biliary fistula

PURPOSE

Echinococcosis, also known as hydatidosis, is a zoonosis that is endemic in many countries worldwide. Liver hydatid cysts have a wide variety of clinical manifestations, among which obstructive jaundice is one of the rarer forms. The aims of the study were to analyze the preoperative management of these patients and to record the kind of surgical treatment performed and the short- and long-term postoperative results.

METHODS

A retrospective two-center observational study of patients operated upon for liver hydatidosis with initial symptoms of obstructive jaundice. Preoperative characteristics, surgical data, and postoperative complications, including biliary fistula, were recorded.

RESULTS

Of 353 patients operated upon for liver hydatidosis, 44 were included in the study. Thirty-five patients (79.6%) were defined as CE2 or CE3 in the World Health Organization (WHO) classification. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 25 patients (56.8%) and identified intrabiliary communication in 29. Radical surgery was carried out in 29 of the total sample (65.9%). Severe postoperative complications (Clavien-Dindo grade IIIA or higher) were recorded in 25% of patients. The factors associated with greater postoperative morbidity were age above 65 (HR 8.76 [95% CI 0.78-97.85]), cyst location (HR 4.77 [95% CI 0.93-24.42]), multiple cysts (HR 14.58 [95% CI 1.42-149.96]), and cyst size greater than 5 cm (HR 6.88 [95% CI 0.95-50]).

CONCLUSION

The presentation as obstructive jaundice causes greater postoperative morbidity. The main postoperative complication in these cases, despite radical surgery, is biliary fistula. In our series, routine preoperative ERCP did not show any benefit.

A man in his thirties with right ventricular heart failure, jaundice and abdominal pain

BACKGROUND

The combination of jaundice and acute abdominal pain is a common clinical problem associated with a broad array of aetiologies.

CASE PRESENTATION

A 36-year-old male with Down's syndrome and Eisenmenger's syndrome presented with abdominal pain, jaundice and acute liver failure. Initial transabdominal ultrasound and subsequent magnetic resonance cholangiopancreatography (MRCP) revealed gallbladder stones, but no common bile duct stones. During the course of the patient's hospital admission, his liver chemistries were consistently elevated. Thus, endoscopic retrograde cholangiography (ERC) with sphincterotomy was performed, despite the anaesthesiological risk associated with his chronic heart failure. However, the ERC and sphincterotomy did not relieve the patient's symptoms and had no apparent effect on his abnormal liver chemistries. By the end of his hospital stay, the patient recovered spontaneously and was discharged with no final conclusion having been reached. An unexpected turn of events led us to conclude upon a diagnosis a few weeks later.

INTERPRETATION

This case illustrates the challenges of a multidisciplinary approach in a complex patient, and an overlooked detail that became a lesson to learn from.

Unexplained Late-Onset Hemolytic Jaundice Preceded by High Fetal Hemoglobin Level in an Extremely Low Birth Weight Infant

BACKGROUND

Preterm infants sometimes have transient late-onset hemolytic jaundice; however, the etiology has yet to be determined.

CASE PRESENTATION

In our case, fetal hemoglobin (HbF) level increased significantly to 100% at 23 days of age. Levels of methemoglobin and carboxyhemoglobin also increased to 2.9% and 3.5%, respectively, following the elevated HbF level. At 26 days, hemolytic jaundice developed. No abnormality of red blood cell membranes and enzyme activities was found.

CONCLUSIONS

The etiology of late-onset hemolytic jaundice in preterm infants may associate with an impaired switching from HbF to adult hemoglobin (HbA) or reverse switching from HbA to HbF.

Type IV choledochal cyst with polycystic kidney disease: a case report

BACKGROUND

Choledochal cysts are divided into 5 types. Physicians believe that Caroli disease (which refers to type V biliary cysts) is a special type of biliary cyst caused by a mutation in the PKHD1 gene and is associated with autosomal recessive polycystic kidney disease (ARPKD). There is currently no clear association between other types of choledochal cysts and polycystic kidney disease.

CASE PRESENTATION

We report a 65-year-old male patient with jaundice, decreased appetite, and itchy skin. His biochemistry test results indicated obstructive jaundice disease. Cross-sectional imaging showed a type IVA choledochal cyst accompanied by autosomal dominant polycystic kidney disease (ADPKD). Due to economic difficulties, the patient achieved percutaneous transhepatic cholangial drainage (PTCD) instead of surgery.

CONCLUSION

To our knowledge, this is the second case report of the coexistence of type IVA choledochal cysts and ADPKD. We conclude that it is vital to be aware that the above condition is a possibility. This case report will aid earlier diagnosis and management and possibly prevent further damage to liver and kidney function.

Supporting Breastfeeding in Infants Hospitalized for Jaundice

BACKGROUND

Infants readmitted for neonatal hyperbilirubinemia requiring phototherapy are less likely to exclusively breastfeed than infants who are not readmitted for phototherapy. Our aim for this study was to increase breastfeeding exclusivity for infants admitted for neonatal hyperbilirubinemia.

METHODS

Using the Model for Improvement, we conducted 3 plan-do-study-act cycles to improve exclusive breastfeeding (EB). Our outcome measure was to increase the percentage of EB for infants hospitalized for phototherapy from 30% to 80% in 12 months. Our process measure was to increase lactation consultations from 60% to 80%. Balancing measures included the development of >10% weight loss, acute bilirubin encephalopathy, readmissions, and length of stay. Interventions involved staff breastfeeding education, automated orders for lactation consultations, and use of bilirubin blankets during breastfeeding. Data were analyzed by using run charts and statistical process control.

RESULTS

A total of 92 infants with neonatal hyperbilirubinemia were admitted from December 2016 to August 2019, with 61 in the postintervention period. After implementation of an automated order for lactation consultation, EB improved from 30% to 60% and completed lactation consultations increased from 60% to 90%. Infants who received a lactation consultation within the first shift during their hospitalization were 4 times more likely to have EB during hospitalization than infants who did not (odds ratio 3.8; confidence interval: 1.17-12.39.) No infant experienced >10% weight loss, acute bilirubin encephalopathy, or a readmission, and length of stay did not significantly change.

CONCLUSIONS

Early involvement of trained lactation consultants safely improves rates of EB for infants hospitalized with neonatal hyperbilirubinemia.

An Unusual Presentation of Weil's Disease

Leptospirosis is a potentially fatal disease which can cause multi-organ dysfunction. It can have different rare presentations. Acute pancreatitis is one such rare gastrointestinal manifestation which present as an acute abdomen. Simultaneous presence of features of both acute pancreatitis and acute hyponatremia in a case of Weil's disease characterised by combination of jaundice, acute kidney injury, hypotension and hemorrhagic manifestation is very rare.

High-throughput chinmedomics strategy for discovering the quality-markers and potential targets for Yinchenhao decoction

BACKGROUND

Yinchenhao decoction (YCHD) has been widely applied in the clinic for various kinds of liver disease, especially for the therapy of dampness-heat jaundice syndrome (DHJS). Some studies have investigated the pharmacological activity and compositions of YCHD. However, its Q-markers and the action targets are still unrevealed.

PURPOSE

This work aims to clarify the therapeutic effect of YCHD against DHJS and discover the quality-markers (Q-markers) of YCHD based on the high-throughput chinmedomics strategy and then predict the potential targets and action mechanism of YCHD against DHJS.

METHODS

Ultra-high performance liquid chromatography/mass spectrometry (UPLC-MS) combined with pattern recognition method was utilized to analyze serum samples and urine samples. Multivariate data analysis and network pharmacology technology were used to identify the effective components and biomarkers associated with therapeutic effects.

RESULTS

With the high sensitivity UPLC-MS technology, a total of 69 compounds from YCHD were identified and 41 of them were absorbed in blood. Besides, 34 urine biomarkers from DHJS were identified. Of note, we utilized chinmedomics technology on the correlation analysis of urine biomarkers and absorbed components to determine 9 core-compounds as the Q-markers responsible for the efficacy of YCHD. Finally, a total of 12 potential targets were discovered.

CONCLUSION

This work provides a powerful method for clarifying the efficacy of TCM and discovering the effective ingredients as Q-markers.

[Clinical features and ABCC2 genotypic analysis of an infant with Dubin-Johnson syndrome]

Dubin-Johnson syndrome (DJS) is an autosomal recessive disorder resulting from biallelic mutations of ABCC2 gene, with long-term or intermittent conjugated hyperbilirubinemia being the main clinical manifestation. This paper aims to report the clinical features and ABCC2 genotypes of an infant with DJS. A 9.5-month-old male infant was referred to the hospital due to abnormal liver function discovered over 9 months. The major clinical presentation was prolonged jaundice since neonatal period. A series of biochemistry analysis revealed markedly elevated total bilirubin, conjugated bilirubin and total bile acids. The patient had been managed in different hospitals, but the therapeutic effects were unsatisfactory due to undetermined etiology. Physical examination revealed jaundiced skin and sclera, and a palpable liver 3 cm below the right subcostal margin with medium texture. The spleen was not enlarged. Genetic analysis revealed a splice-site variant c.3988-2A>T and a nonsense variant c.3825C>G (p.Y1275X) in the ABCC2 gene of the infant, which were inherited from his mother and father respectively. The former had not been previously reported. Then ursodeoxycholic acid and phenobarbital were given orally. Half a month later, as a result, his jaundice disappeared and the biochemistry indices improved. However, the long-term outcome needs to be observed. Literature review revealed that neonates/infants with DJS presented with cholestatic jaundice soon after birth as the major clinical feature, and the ABCC2 variants exhibited marked heterogeneity.

[Clinical and genetic analysis of an infant with progressive familial intrahepatic cholestasis type II]

Progressive familial intrahepatic cholestasis type II (PFIC-2) is an autosomal recessive disorder caused by biallelic variants of ABCB11 gene. This paper reports the clinical and laboratory features of a pediatric patient with PFIC-2. The patient was a 2.4-month-old male infant with jaundice and hepatomegaly as the main clinical manifestations. The serum levels of total bilirubin, direct bilirubin and total bile acids were increased, while the serum γ-glutamyl transpeptidase (GGT) level was normal. Next generation sequencing revealed two missense variants, c.1493T>C(p.Ile498Thr) and c.1502T>G(p.Val501Gly), in the ABCB11 gene of the patient, which were inherited from his father and mother, respectively. The latter was a novel variant which was predicted to be pathogenic by using a variety of bioinformatic tools, and the affected p.Val501 residue was highly conserved in 112 homologous peptides.

[Clinical and genetic analysis of an infant with progressive familial intrahepatic cholestasis type II]

Progressive familial intrahepatic cholestasis type II (PFIC-2) is an autosomal recessive disorder caused by biallelic variants of ABCB11 gene. This paper reports the clinical and laboratory features of a pediatric patient with PFIC-2. The patient was a 2.4-month-old male infant with jaundice and hepatomegaly as the main clinical manifestations. The serum levels of total bilirubin, direct bilirubin and total bile acids were increased, while the serum γ-glutamyl transpeptidase (GGT) level was normal. Next generation sequencing revealed two missense variants, c.1493T>C(p.Ile498Thr) and c.1502T>G(p.Val501Gly), in the ABCB11 gene of the patient, which were inherited from his father and mother, respectively. The latter was a novel variant which was predicted to be pathogenic by using a variety of bioinformatic tools, and the affected p.Val501 residue was highly conserved in 112 homologous peptides.

Preliminary clinical application of integrated 125I seeds stents in the therapy of malignant lower biliary tract obstruction

PURPOSE

To evaluate the clinical efficacy of percutaneous trans-hepatic integrated 125I seed stents implantation for malignant lower biliary tract obstruction.

METHODS

Thirty-two patients with malignant lower biliary obstruction were randomly divided into two groups. One group underwent the therapy with integrated 125I seed stents (Test group, n = 13), and another group received conventional metal stents implantation for treatment (Control group, n = 19). The pre- and post-operative changes in biochemical indices, white blood cell count, IgG level, stent patency, survival time, tumor size and complications were compared between the two groups. RECIST 1.1 (Response Evaluation Criteria In Solid Tumors) was used to evaluate therapeutic effects. The average follow-up time was 12.3 months.

RESULTS

The differences between pre- and post-operative (30 days) intragroup biochemical indices had statistically significant difference (P < 0.05), but there were no significant differences (P > 0.05) in leukocyte counts and IgG levels. As to the median time of stent patency and patients' survival, there were significant differences (P < 0.05) between Control and Test groups (3.9 months vs. 8.1 months, 139 days vs. 298 days, respectively). Three months after the operation, the average tumor size was reduced in the Test group, but was increased in the Control group (P < 0.05). There was no significant difference in the incidence of complications between the two groups. The evaluation results using RECIST 1.1 showed that there were statistically significant differences between the two groups in terms of the rates of remission, control, and progression (χ2 = 17.5, P < 0.05).

CONCLUSIONS

The study indicates that integrated 125I seed stents are effective in reducing jaundice symptoms, inhibiting tumor growth, improving stent patency and prolonging patient survival, which may serve as a safer and more feasible method in treating malignant lower biliary obstruction with minimal invasiveness.

Coxsackie B Virus Infection as a rare cause of Acute Renal Failure and Hepatitis

We report a 37 year female patient, admitted with complains of fever, jaundice and myalgia of seven days. There was no history of trauma, drug abuse, seizure or vigorous exercise nor history of renal and musculoskeletal disease. Here we have discussed the clinical features, biochemical derangements, diagnosis of coxsackie B virus, multi organ involvement and need of urgent hemodialysis for appropriate management of the case.