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Hulzebos CV, Camara JE, van Berkel M, Delatour V, Lo SF, Mailloux A, Schmidt MC, Thomas M, Mackay LG, Greaves RF. Bilirubin measurements in neonates: uniform neonatal treatment can only be achieved by improved standardization. Clin Chem Lab Med 2024; 0:cclm-2024-0620. [PMID: 39066506 DOI: 10.1515/cclm-2024-0620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024]
Abstract
Measurement of total bilirubin (TBil) concentration in serum is the gold standard approach for diagnosing neonatal unconjugated hyperbilirubinemia. It is of utmost importance that the measured TBil concentration is sufficiently accurate to prevent under treatment, unnecessary escalation of care, or overtreatment. However, it is widely recognized that TBil measurements urgently require improvement in neonatal clinical chemistry. External quality assessment (EQA) programs for TBil assess for differences between laboratories and provide supporting evidence of significant differences between various methods, manufacturers and measurement platforms. At the same time, many countries have adopted or only slightly adapted the neonatal hyperbilirubinemia management guidelines from the USA or UK, often without addressing differences in the methodology of TBil measurements. In this report, we provide an overview of the components of bilirubin that are measured by laboratory platforms, the availability of current reference measurement procedures and reference materials, and the role of EQA surveys in this context. Furthermore, the current status of agreement in neonatal bilirubin against clinical decision thresholds is reviewed. We advocate for enhancements in accuracy and comparability of neonatal TBil measurements, propose a path forward to accomplish this, and reflect on the position of the International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) Working Group Neonatal Bilirubin (WG-NB) in this matter.
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Affiliation(s)
- Christian V Hulzebos
- Department of Paediatrics, Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Johanna E Camara
- Chemical Sciences Division, National Institute of Standards and Technology (NIST), Gaithersburg, MD, USA
| | - Miranda van Berkel
- Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Vincent Delatour
- Laboratoire National de Métrologie et d'Essais (LNE), Paris, France
| | - Stanley F Lo
- Department of Pathology and Laboratory Medicine, Children's Wisconsin and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Agnès Mailloux
- Centre National de Référence en Hémobiologie Périnatale, Unit of Biologie, Pole Biology, Hopital Saint Antoine (Public Assistance Hospitals of Paris (AP-HP)), Paris, France
| | | | - Mercy Thomas
- The Royal Children's Hospital, Parkville, VIC, Australia
- School of Health Sciences, Swinburne University of Technology, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | | | - Ronda F Greaves
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
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2
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Balasubramanian H, Bhanushali M, Tripathi V, Srinivasan L, Sakharkar S, Pillai A, Kabra NS. Effect of Minimization of Early Blood Sampling Losses Among Extremely Premature Neonates: A Randomized Clinical Trial. J Pediatr 2024; 269:114002. [PMID: 38447757 DOI: 10.1016/j.jpeds.2024.114002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To evaluate the effect of blood sampling stewardship on transfusion requirements among infants born extremely preterm. STUDY DESIGN In this single-center, randomized controlled trial (RCT), infants born at <28 weeks of gestation and birth weight of <1000 g were randomized at 24 hours of age to two different blood sampling approaches: restricted sampling (RS) vs conventional sampling (CS). The stewardship intervention in the RS group included targeted reduction in blood sampling volume and frequency and point of care testing methods in the first 6 weeks after birth. Both groups received early recombinant erythropoietin from day three of age. Primary outcome was the rate of early red blood cell (RBC) transfusions in the first six postnatal weeks. RESULTS A total of 102 infants (mean gestational age: 26 weeks; birth weight: 756 g) were enrolled. Fidelity to the sampling protocol was achieved in 95% of the infants. Sampling losses in the first 6 weeks were significantly lower in the RS group (16.8 ml/kg vs 23.6 ml/kg, P < .001). The RS group had a significantly lower rate of early postnatal RBC transfusions (41% vs 73%, RR: 0.56 [0.39-0.81], P = .001). The hazard of needing a transfusion during neonatal intensive care unit (NICU) stay was reduced by 55% by RS. Mortality and neonatal morbidities were similar between the two groups. CONCLUSION Minimization of blood sampling losses by approximately one-third in the first 6 weeks after birth leads to substantial reduction in the early red blood cell transfusion rate in infants born extremely preterm and weighing <1000 g at birth. TRIAL REGISTRATION http://www.ctri.nic.in (CTRI/2020/01/022 964).
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Affiliation(s)
| | - Mayuri Bhanushali
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | - Vimmi Tripathi
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | | | - Sachin Sakharkar
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | - Anish Pillai
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
| | - Nandkishor S Kabra
- Department of Neonatology, Surya Children's Hospital, Mumbai, Maharashtra, India
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Oostendorp M, Ten Hove CH, van Berkel M, Roovers L. A Significant Increase in the Incidence of Neonatal Hyperbilirubinemia and Phototherapy Treatment Due to a Routine Change in Laboratory Equipment. Arch Pathol Lab Med 2024; 148:e40-e47. [PMID: 37596896 DOI: 10.5858/arpa.2022-0478-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 08/21/2023]
Abstract
CONTEXT.— Total serum bilirubin (TSB) analysis is pivotal for diagnosing neonatal hyperbilirubinemia. Because of a routine change in laboratory equipment, our TSB assay changed from a diazo to a vanadate oxidase method. Upon implementation, TSB results were substantially higher in newborns than expected based on the validation. OBJECTIVE.— To investigate the application of TSB and intermethod differences in neonates and their impact on phototherapy treatment. DESIGN.— The diazo and vanadate methods were compared directly using neonatal and adult samples. Anonymized external quality control data were analyzed to explore interlaboratory differences among 8 commercial TSB assays. Clinical patient data were extracted from the medical records to investigate the number of newborns receiving phototherapy. RESULTS.— The mean bias of the vanadate versus the diazo TSB method was +17.4% and +3.7% in neonatal and adult samples, respectively. External quality control data showed that the bias of commercial TSB methods compared with the reference method varied from -3.6% to +20.2%. Within-method variation ranged from 5.2% to 16.0%. After implementation of the vanadate TSB method, the number of neonates treated with phototherapy increased approximately threefold. CONCLUSIONS.— Currently available TSB assays lack harmonization for the diagnosis of neonatal hyperbilirubinemia. Between-methods differences are substantially higher in neonatal compared with adult samples, highlighting the importance of including neonatal samples during assay validation. Close collaboration between laboratory specialists and clinicians is essential to prevent overtreatment or undertreatment upon the implementation of novel analyzers or assays. Also, harmonization of TSB assays, with an emphasis on neonatal application, is warranted.
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Affiliation(s)
- Marlies Oostendorp
- From the Departments of Clinical Chemistry and Hematology (Oostendorp), Rijnstate Hospital, Arnhem, the Netherlands
- the Department of Clinical Chemistry, Dicoon BV, Arnhem, the Netherlands (Oostendorp)
| | | | - Miranda van Berkel
- the Department of Laboratory Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands (van Berkel)
| | - Lian Roovers
- Clinical Research (Roovers), Rijnstate Hospital, Arnhem, the Netherlands
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Sist P, Tramer F, Bandiera A, Urbani R, Redenšek Trampuž S, Dolžan V, Passamonti S. Nanoscale Bilirubin Analysis in Translational Research and Precision Medicine by the Recombinant Protein HUG. Int J Mol Sci 2023; 24:16289. [PMID: 38003479 PMCID: PMC10671013 DOI: 10.3390/ijms242216289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 11/26/2023] Open
Abstract
Bilirubin is a toxicological biomarker for hemolysis and liver diseases. The current automated diazo method used in clinical chemistry has limited applicability in rodent models and cannot be used in small animals relevant to toxicology, microphysiological systems, cell cultures, and kinetic studies. Here, we present a versatile fluorometric method for nanoscale analysis of bilirubin based on its highly specific binding to the recombinant bifunctional protein HELP-UnaG (HUG). The assay is sensitive (LoQ = 1.1 nM), accurate (4.5% relative standard error), and remarkably robust, allowing analysis at pH 7.4-9.5, T = 25-37 °C, in various buffers, and in the presence of 0.4-4 mg × L-1 serum albumin or 30% DMSO. It allows repeated measurements of bilirubinemia in murine models and small animals, fostering the 3Rs principle. The assay determines bilirubin in human plasma with a relative standard error of 6.7% at values that correlate and agree with the standard diazo method. Furthermore, it detects differences in human bilirubinemia related to sex and UGT1A1 polymorphisms, thus demonstrating its suitability for the uniform assessment of bilirubin at the nanoscale in translational and precision medicine.
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Affiliation(s)
- Paola Sist
- Department of Life Sciences, University of Trieste, Via Giorgieri 1, 34127 Trieste, Italy; (P.S.); (F.T.); (A.B.)
| | - Federica Tramer
- Department of Life Sciences, University of Trieste, Via Giorgieri 1, 34127 Trieste, Italy; (P.S.); (F.T.); (A.B.)
| | - Antonella Bandiera
- Department of Life Sciences, University of Trieste, Via Giorgieri 1, 34127 Trieste, Italy; (P.S.); (F.T.); (A.B.)
| | - Ranieri Urbani
- Department of Chemical and Pharmaceutical Sciences, University of Trieste, Via Giorgieri 1, 34127 Trieste, Italy;
| | - Sara Redenšek Trampuž
- Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (S.R.T.); (V.D.)
| | - Vita Dolžan
- Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; (S.R.T.); (V.D.)
| | - Sabina Passamonti
- Department of Life Sciences, University of Trieste, Via Giorgieri 1, 34127 Trieste, Italy; (P.S.); (F.T.); (A.B.)
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Abstract
Gilbert's syndrome, also known as benign hyperbilirubinaemia, was described more than 100 years ago. It has usually been considered a physiological abnormality characterised by a mild elevation of the systemic level of unconjugated bilirubin, in the absence of any underlying liver or overt haemolytic disease. However, since the re-discovery of the potent antioxidant effects of bilirubin in the late 1980s, as well as multiple intracellular signalling pathways affected by bilirubin, an ever-increasing body of evidence suggests that individuals with Gilbert's syndrome may benefit from the mild hyperbilirubinaemia and are actually protected from the development of a wide variety of "diseases of civilisation" such as cardiovascular diseases, certain cancers, and autoimmune or neurodegenerative diseases. This review analyses the current state of medical knowledge given recent discoveries in this rapidly developing field, as well as their possible clinical significance, and provides a new perspective on this condition.
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Affiliation(s)
- Libor Vítek
- 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.
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Lee ZM, Chang LS, Kuo KC, Lin MC, Yu HR. Impact of Protein Binding Capacity and Daily Dosage of a Drug on Total Serum Bilirubin Levels in Susceptible Infants. CHILDREN (BASEL, SWITZERLAND) 2023; 10:926. [PMID: 37371159 DOI: 10.3390/children10060926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
Hyperbilirubinemia is a common pathological condition in neonates. Free bilirubin can penetrate the blood-brain barrier (BBB), which can lead to bilirubin neurotoxicity. In the context of predicting the risk of bilirubin neurotoxicity, although the specificity and sensitivity of free bilirubin levels are higher than those of total serum bilirubin (TSB), free bilirubin is not widely monitored in clinical practice. The threshold TSB levels at which phototherapy must be administered have been established previously. However, TSB levels are not well correlated with neurodevelopmental outcomes. Currently, TSB levels are commonly used to guide phototherapy for neonatal hyperbilirubinemia. Some clinical drugs can displace bilirubin from its albumin-binding sites, and consequently upregulate plasma bilirubin. Daily dosages play a vital role in regulating bilirubin levels. A drug with both a high protein binding capacity and high daily dosage significantly increases bilirubin levels in infants. Premature or very low birth weight (VLBW) infants are vulnerable to the upregulation of bilirubin levels as they exhibit the lowest reserve albumin levels and consequently the highest bilirubin toxicity index. Because bilirubin is involved in maintaining the balance between pro-oxidant and antioxidant agents, the downregulation of bilirubin levels is not always desirable. This review provides insights into the impact of protein binding capacity and daily dosage of drugs on the bilirubin levels in susceptible infants.
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Affiliation(s)
- Zon-Min Lee
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
- Department of Pharmacy, Tajen University, Pingtung 907, Taiwan
| | - Ling-Sai Chang
- Kawasaki Disease Center and Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Kuang-Che Kuo
- Division of Pediatric Infection, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan
| | - Meng-Chiao Lin
- Department of Pharmacy, St Joseph's hospital, Yunlin 632401, Taiwan
| | - Hong-Ren Yu
- Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Graduate Institute of Clinical Medical Science, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan
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Li Y, Zhao J, Yu X. Feasibility analysis of TCB, hs-CRP, and UCB/ALB as outcome measures for dynamic assessment during phototherapy of neonates with Hyperbilirubinemia. Biotechnol Genet Eng Rev 2023:1-14. [PMID: 37035928 DOI: 10.1080/02648725.2023.2199245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Hyperbilirubinemia (HY) is a common condition in neonates that requires phototherapy treatment. This study aimed to evaluate the effectiveness of transcutaneous bilirubin measurements (TCB), hypersensitive C-reactive protein (hs-CRP), and unconjugated bilirubin (UCB)/albumin (ALB) as indicators of HY during neonatal phototherapy. A research group of 67 neonates with pathological HY and a control group of 55 healthy neonates were selected from a hospital between June 2020 and May 2021. TCB, hs-CRP, and UCB/ALB tests were performed before, during (at 3 days of treatment), and after (at 6 days of treatment) phototherapy in the research group and at admission in the control group. The study also included a 1-year prognostic follow-up on the research group. The study observed the difference in TCB, hs-CRP, and UCB/ALB test results between both groups and their assessment effect on adverse reactions, treatment effects, and poor prognosis in phototherapy. TCB, hs-CRP, and UCB/ALB levels were higher in the research group than in the control group and gradually decreased during phototherapy (P < 0.05). The combined TCB, hs-CRP, and UCB/ALB assay had 100.0% sensitivity and 64.58% specificity (P < 0.001) for predicting adverse reactions, 88.24% sensitivity and 80.00% specificity (P < 0.001) for predicting the effect of phototherapy, and 90.91% sensitivity and 88.89% specificity (P < 0.001) for predicting poor prognosis. The combined TCB, hs-CRP, and UCB/ALB assay showed superior assessment of adverse effects, clinical outcomes, and poor prognosis in HY neonates treated with phototherapy. TCB, hs-CRP, and UCB/ALB could be used as dynamic disease assessment indicators for HY to better prevent and treat the occurrence of HY.
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Affiliation(s)
- Yanbi Li
- Department of Paediatrics, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei, China
| | - Jihua Zhao
- Department of Paediatrics, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei, China
| | - Xinqiao Yu
- Department of Paediatrics, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi, Hubei, China
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8
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Westenberg LEH, Been JV, Willemsen SP, Vis JY, Tintu AN, Bramer WM, Dijk PH, Steegers EAP, Reiss IKM, Hulzebos CV. Diagnostic Accuracy of Portable, Handheld Point-of-Care Tests vs Laboratory-Based Bilirubin Quantification in Neonates: A Systematic Review and Meta-analysis. JAMA Pediatr 2023; 177:479-488. [PMID: 36912856 PMCID: PMC10012043 DOI: 10.1001/jamapediatrics.2023.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Importance Quantification of bilirubin in blood is essential for early diagnosis and timely treatment of neonatal hyperbilirubinemia. Handheld point-of-care (POC) devices may overcome the current issues with conventional laboratory-based bilirubin (LBB) quantification. Objective To systematically evaluate the reported diagnostic accuracy of POC devices compared with LBB quantification. Data Sources A systematic literature search was conducted in 6 electronic databases (Ovid MEDLINE, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) up to December 5, 2022. Study Selection Studies were included in this systematic review and meta-analysis if they had a prospective cohort, retrospective cohort, or cross-sectional design and reported on the comparison between POC device(s) and LBB quantification in neonates aged 0 to 28 days. Point-of-care devices needed the following characteristics: portable, handheld, and able to provide a result within 30 minutes. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline. Data Extraction and Synthesis Data extraction was performed by 2 independent reviewers into a prespecified, customized form. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was performed of multiple Bland-Altman studies using the Tipton and Shuster method for the main outcome. Main Outcomes and Measures The main outcome was mean difference and limits of agreement in bilirubin levels between POC device and LBB quantification. Secondary outcomes were (1) turnaround time (TAT), (2) blood volumes, and (3) percentage of failed quantifications. Results Ten studies met the inclusion criteria (9 cross-sectional studies and 1 prospective cohort study), representing 3122 neonates. Three studies were considered to have a high risk of bias. The Bilistick was evaluated as the index test in 8 studies and the BiliSpec in 2. A total of 3122 paired measurements showed a pooled mean difference in total bilirubin levels of -14 μmol/L, with pooled 95% CBs of -106 to 78 μmol/L. For the Bilistick, the pooled mean difference was -17 μmol/L (95% CBs, -114 to 80 μmol/L). Point-of-care devices were faster in returning results compared with LBB quantification, whereas blood volume needed was less. The Bilistick was more likely to have a failed quantification compared with LBB. Conclusions and Relevance Despite the advantages that handheld POC devices offer, these findings suggest that the imprecision for measurement of neonatal bilirubin needs improvement to tailor neonatal jaundice management.
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Affiliation(s)
- Lauren E H Westenberg
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jasper V Been
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sten P Willemsen
- Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jolande Y Vis
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Andrei N Tintu
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Peter H Dijk
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Christian V Hulzebos
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
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Aune A, Vartdal G, Jimenez Diaz G, Gierman LM, Bergseng H, Darj E. Iterative Development, Validation, and Certification of a Smartphone System to Assess Neonatal Jaundice: Development and Usability Study. JMIR Pediatr Parent 2023; 6:e40463. [PMID: 36853753 PMCID: PMC10015352 DOI: 10.2196/40463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 12/16/2022] [Accepted: 01/16/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Medical device development is an area facing multiple challenges, resulting in a high number of products not reaching the clinical setting. Neonatal hyperbilirubinemia, manifesting as neonatal jaundice (NNJ), is an important cause of newborn morbidity and mortality. It is important to identify infants with neonatal hyperbilirubinemia at an early stage, but currently there is a lack of tools that are both accurate and affordable. OBJECTIVE This study aimed to develop a novel system to assess the presence of NNJ. The device should provide accurate results, be approved as a medical device, be easy to use, and be produced at a price that is affordable even in low-resource settings. METHODS We used an iterative approach to develop a smartphone-based system to detect the presence of NNJ. We performed technical development, followed by clinical and usability testing in parallel, after which we initiated the regulatory processes for certification. We updated the system in each iteration, and the final version underwent a clinical validation study on healthy term newborns aged 1 to 15 days before all documentation was submitted for conformity assessment to obtain Conformité Européenne (CE) certification. We developed a system that incorporates a smartphone app, a color calibration card, and a server. RESULTS Three iterations of the smartphone-based system were developed; the final version was approved as a medical device after complying with Medical Device Regulation guidelines. A total of 201 infants were included in the validation study. Bilirubin values using the system highly correlated with total serum or plasma bilirubin levels (r=0.84). The system had a high sensitivity (94%) to detect severe jaundice, defined as total serum or plasma bilirubin >250 µmol/L, and maintained a high specificity (71%). CONCLUSIONS Our smartphone-based system has a high potential as a tool for identifying NNJ. An iterative approach to product development, conducted by working on different tasks in parallel, resulted in a functional and successful product. By adhering to the requirements for regulatory approval from the beginning of the project, we were able to develop a market-ready mobile health solution.
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Affiliation(s)
- Anders Aune
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Picterus AS, Trondheim, Norway
| | | | - Gabriela Jimenez Diaz
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Picterus AS, Trondheim, Norway
| | | | - Håkon Bergseng
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neonatology, St.Olav Hospital, Trondheim, Norway
| | - Elisabeth Darj
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
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10
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Satrom KM, Farouk ZL, Slusher TM. Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities. Front Pediatr 2023; 11:1001141. [PMID: 36861070 PMCID: PMC9969105 DOI: 10.3389/fped.2023.1001141] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 01/17/2023] [Indexed: 02/15/2023] Open
Abstract
Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.
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Affiliation(s)
- Katherine M Satrom
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Zubaida L Farouk
- Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria.,Centre for Infectious Diseases Research, Bayero University, Kano, Nigeria
| | - Tina M Slusher
- Department of Pediatrics, Global Health Program, Critical Care Division, University of Minnesota, Minneapolis, MN, United States.,Department of Pediatrics, Hennepin Healthcare, Minneapolis, MN, United States
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Ye ZT, Kuo HC, Tseng SF, Chung SR, Tsou SX. Using Blue Mini-LEDs as a Light Source Designed a Miniaturized Optomechanical Device for the Detection of Direct Bilirubin. NANOSCALE RESEARCH LETTERS 2022; 17:111. [PMID: 36417033 PMCID: PMC9684399 DOI: 10.1186/s11671-022-03750-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 11/15/2022] [Indexed: 05/30/2023]
Abstract
This study developed a miniaturized optomechanical device (MOD) for the feasibility study of direct bilirubin in urine using high-collimation blue mini-light-emitting diodes (Mini-LEDs) as the light source. The constructed MOD used optical spectroscopy to analyze different concentrations of direct bilirubin using the absorbance spectrum to achieve a noninvasive method for detection. The experimental results showed that between the absorbance and different concentrations of direct bilirubin at the blue Mini-LEDs central wavelength (462 nm) was the optimum fitting wavelength; in the direct bilirubin concentration range from 0.855 to 17.1 μmol/L, the coefficient of determination (R2) was 0.9999, the limit of detection (LOD) of 0.171 μmol/L, and the limit of quantitation (LOQ) of 0.570 μmol/L. Therefore, we propose using blue Mini-LEDs as a light source to design a MOD to replace the invasive blood sampling method with a spectroscopic detection of direct bilirubin concentration corresponding to absorbance.
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Affiliation(s)
- Zhi Ting Ye
- Department of Mechanical Engineering, Advanced Institute of Manufacturing with High-Tech Innovations, National Chung Cheng University, 168, University Rd., Min-Hsiung, Chia-Yi, 62102 Taiwan, ROC
| | - Hsin-Ching Kuo
- Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan, ROC
| | - Shen Fu Tseng
- Department of Mechanical Engineering, Advanced Institute of Manufacturing with High-Tech Innovations, National Chung Cheng University, 168, University Rd., Min-Hsiung, Chia-Yi, 62102 Taiwan, ROC
| | - Shu-Ru Chung
- Department of Materials Science and Engineering, National Formosa University, No. 64, Wunhua Rd., Huwei Township, 632 Yunlin County Taiwan, ROC
| | - Shang-Xuan Tsou
- Department of Mechanical Engineering, Advanced Institute of Manufacturing with High-Tech Innovations, National Chung Cheng University, 168, University Rd., Min-Hsiung, Chia-Yi, 62102 Taiwan, ROC
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12
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Miller WG, Myers G, Cobbaert CM, Young IS, Theodorsson E, Wielgosz RI, Westwood S, Maniguet S, Gillery P. Overcoming challenges regarding reference materials and regulations that influence global standardization of medical laboratory testing results. Clin Chem Lab Med 2022; 61:48-54. [PMID: 36239374 DOI: 10.1515/cclm-2022-0943] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Standardized results for laboratory tests are particularly important when their interpretation depends on fixed medical practice guidelines or common reference intervals. The medical laboratory community has developed a roadmap for an infrastructure to achieve standardized test results described in the International Organization for Standardization standard 17511:2020 In vitro diagnostic medical devices - Requirements for establishing metrological traceability of values assigned to calibrators, trueness control materials and human samples. Among the challenges to implementing metrological traceability are the availability of fit-for-purpose matrix-based certified reference materials (CRMs) and requirements for regulatory review that differ among countries. A workshop in December 2021 focused on these two challenges and developed recommendations for improved practices. DISCUSSION The participants agreed that prioritization of measurands for standardization should be based on their impact on medical decisions in a clinical pathway. Ensuring that matrix-based CRMs are globally available for more measurands will enable fit-for-purpose calibration hierarchies for more laboratory tests. Regulation of laboratory tests is important to ensure safety and effectiveness for the populations served. Because regulations are country or region specific, manufacturers must submit recalibration changes intended to standardize results for regulatory review to all areas in which a measuring system is marketed. RECOMMENDATIONS A standardization initiative requires collaboration and planning among all interested stakeholders. Global collaboration should be further developed for prioritization of measurands for standardization, and for coordinating the production and supply of CRMs worldwide. More uniform regulatory submission requirements are desirable when recalibration is implemented to achieve internationally standardized results.
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Affiliation(s)
- W Greg Miller
- Department of Pathology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ian S Young
- Centre for Public Health, Queens University Belfast, Belfast, Northern Ireland
| | - Elvar Theodorsson
- Department of Biomedical and Clinical Science, Clinical Chemistry, Linköping University, Linköping, Sweden
| | - Robert I Wielgosz
- Bureau International des Poids et Mesures (BIPM), Sèvres Cedex, France
| | - Steven Westwood
- Bureau International des Poids et Mesures (BIPM), Sèvres Cedex, France
| | | | - Philippe Gillery
- Laboratory of Biochemistry-Pharmacology-Toxicology, University Hospital of Reims, Reims, France
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13
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Singh A, Murki S, Sharma D, Vardhelli V, Subramanian S, Mekarthi A. Development and evaluation of a novel method "bilirubin color card" for screening of treatable jaundice in neonates: prospective comparative diagnostic study. J Matern Fetal Neonatal Med 2022; 35:9830-9833. [PMID: 35350962 DOI: 10.1080/14767058.2022.2056442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Various methods of screening or diagnosis of severe hyperbilirubinemia like transcutaneous bilirubinometer and laboratory testing havemethodological or practical limitations. In this perspective, we designed and evaluated an invasive but simple screening Color Card method in rapid assessment of various levels of bilirubin categories. OBJECTIVE This prospective comparative diagnostic study objectives were to create "Color Card" initially by yellow color shades that fall into 4 bilirubin categories, i.e. TSB up to 7 mg/dl, 7.1 to 12 mg/dl, 12.1 to 18 mg/dl and >18 mg/dl from the samples analyzed by diazo method, and to study its sensitivity and specificity for the diagnosis of moderate or severe hyperbilirubinemia in comparison to total serum bilirubin (TSB) by diazo method. RESULTS Out of total 188 samples obtained, 134 were unique patients. The specificity, negative predictive value and accuracy of the color card for the observations made by observer 1 comparing with lab TSB were >95% for clinically important categories of <7 mg/dl and >18 mg/dl. The overall accuracy of color card in measuring various TSB ranges varied from 75% to 96.8%. The agreement between two observers was 85.6% (Cohen's kappa co-efficient: 0.61, p-value: .0001) overall and was 92.3%, 86%, 84%, 81.2% for each of the four bilirubin categories in ascending order. CONCLUSION Bilirubin color card has good accuracy and may be very useful in the low resource settings, especially in the first referral units and community settings, where laboratory TSB estimation is not available easily. However, it requires centrifugation and easier methods of centrifugation will make this method simpler.
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Affiliation(s)
- Abhishek Singh
- Department of Neonatology, Paramitha Mother and Child Care, Hyderabad, India
| | - Srinivas Murki
- Department of Neonatology, Paramitha Mother and Child Care, Hyderabad, India
| | - Deepak Sharma
- Department of Neonatology, NIMS Medical College, Jaipur, India
| | | | - Sreeram Subramanian
- Department of Neonatology, Paramitha Mother and Child Care, Hyderabad, India
| | - Abhinav Mekarthi
- Department of Neonatology, Paramitha Mother and Child Care, Hyderabad, India
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14
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Thomas M, Greaves RF, Tingay DG, Loh TP, Ignjatovic V, Newall F, Oeum M, Tran MTC, Rajapaksa AE. Current and emerging technologies for the timely screening and diagnosis of neonatal jaundice. Crit Rev Clin Lab Sci 2022; 59:332-352. [PMID: 35188857 DOI: 10.1080/10408363.2022.2038074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Neonatal jaundice is one of the most common clinical conditions affecting newborns. For most newborns, jaundice is harmless, however, a proportion of newborns develops severe neonatal jaundice requiring therapeutic interventions, accentuating the need to have reliable and accurate screening tools for timely recognition across different health settings. The gold standard method in diagnosing jaundice involves a blood test and requires specialized hospital-based laboratory instruments. Despite technological advancements in point-of-care laboratory medicine, there is limited accessibility of the specialized devices and sample stability in geographically remote areas. Lack of suitable testing options leads to delays in timely diagnosis and treatment of clinically significant jaundice in developed and developing countries alike. There has been an ever-increasing need for a low-cost, simple to use screening technology to improve timely diagnosis and management of neonatal jaundice. Consequently, several point-of-care (POC) devices have been developed to address this concern. This paper aims to review the literature, focusing on emerging technologies in the screening and diagnosing of neonatal jaundice. We report on the challenges associated with the existing screening tools, followed by an overview of emerging sensors currently in pre-clinical development and the emerging POC devices in clinical trials to advance the screening of neonatal jaundice. The benefits offered by emerging POC devices include their ease of use, low cost, and the accessibility of rapid response test results. However, further clinical trials are required to overcome the current limitations of the emerging POC's before their implementation in clinical settings. Hence, the need for a simple to use, low-cost POC jaundice detection technology for newborns remains an unsolved challenge globally.
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Affiliation(s)
- Mercy Thomas
- New Vaccines, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Newborn Research Centre, Royal Women's Hospital, Melbourne, Australia.,Department of Nursing, Royal Children's Hospital, Melbourne, Australia
| | - Ronda F Greaves
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia.,Victorian Clinical Genetics Services, Melbourne, Australia.,International Federation of Clinical Chemistry and Laboratory Medicine-Emerging Technologies Division (C-ETPLM), Milan, Italy
| | - David G Tingay
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Newborn Research Centre, Royal Women's Hospital, Melbourne, Australia.,Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Neonatology, Royal Children's Hospital, Melbourne, Australia
| | - Tze Ping Loh
- International Federation of Clinical Chemistry and Laboratory Medicine-Emerging Technologies Division (C-ETPLM), Milan, Italy.,Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Hematology, Murdoch Children's Research Institute, Melbourne, Australia
| | - Fiona Newall
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of Nursing, Royal Children's Hospital, Melbourne, Australia
| | - Michelle Oeum
- New Vaccines, Murdoch Children's Research Institute, Melbourne, Australia
| | - Mai Thi Chi Tran
- International Federation of Clinical Chemistry and Laboratory Medicine-Emerging Technologies Division (C-ETPLM), Milan, Italy.,National Children's Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Anushi E Rajapaksa
- New Vaccines, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Newborn Research Centre, Royal Women's Hospital, Melbourne, Australia.,Think Project Global, Melbourne, Australia
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15
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5 Tage altes Neugeborenes mit „Gelbsucht“. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-021-01401-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Wang Q, Zhang T, Lin Y, Jiang L, Zhou W, Zong X. Accuracy and Reliability of Whole Blood Bilirubin Measurements Using a Roche Blood Gas Analyzer for Neonatal Hyperbilirubinemia Screening and Risk Stratification. Front Pediatr 2022; 10:910566. [PMID: 35859945 PMCID: PMC9289128 DOI: 10.3389/fped.2022.910566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Accurate bilirubin measurements are essential for appropriate management of neonatal hyperbilirubinemia. This study aimed to evaluate the accuracy and reliability of whole blood bilirubin measurements obtained using a Roche blood gas analyzer (Roche TBiL), with total serum bilirubin (TSB) measurements determined by the Ortho VITROS 4600 chemistry system (Ortho TSB) serving as a reference. MATERIALS AND METHODS Medical records of hospitalized neonates that underwent simultaneous Roche TBiL and Ortho TSB measurements were reviewed for eligibility selection and data collection. The correlations and differences between two sets of results were determined using Passing-Bablok regression analysis and a Bland-Altman plot, respectively. For eligible newborns, the risk of developing severe hyperbilirubinemia was assessed using the Bhutani nomogram. Weighted kappa analysis was used to evaluate the agreement between risk prediction by the two methods. RESULTS We obtained 618 paired Roche TBiL and Ortho TSB results from 309 neonates. Roche TBiL and Ortho TSB measurements showed a good correlation (r = 0.923; 95% CI: 0.905-0.938). Passing-Bablok regression analysis yielded the following equation: Roche TBiL = 0.794 × Ortho TSB + 1.255 mg/dL, with a slope of 0.794 (95% CI: 0.763-0.825) and intercept of 1.255 (95% CI: 1.042-1.417). The average difference between the two methods was 0.1 ± 1.448 mg/dL. A total of 207 neonates were eligible for evaluation of the agreement between the risk-grading methods. Although kappa analysis showed good agreement between the methods, with a weighted kappa of 0.681 (95% CI: 0.610-0.751) across all populations, the values for approximately half of the neonates at intermediate and high risk of hyperbilirubinemia (33/72) were underestimated by Roche TBiL. CONCLUSION Our results indicate that Roche TBiL and Ortho TSB measurements in the neonatal population are not consistent. As a point-of-care and trace blood assay, Roche blood gas bilirubin measurements can facilitate primary screening of neonatal hyperbilirubinemia, but it seems to lack accuracy regarding risk stratification, particularly for high-risk newborn individuals.
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Affiliation(s)
- Qing Wang
- Department of Clinical Laboratory, The General Hospital of Tianjin Medical University, Tianjin, China
| | - Tianyi Zhang
- Department of Emergency Medicine, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yuanxi Lin
- Department of Emergency Medicine, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Li Jiang
- Department of Clinical Laboratory, The General Hospital of Tianjin Medical University, Tianjin, China
| | - Wenlong Zhou
- College of Medical Laboratory Science, Tianjin Medical University, Tianjin, China
| | - Xiaolong Zong
- Department of Clinical Laboratory, The Second Hospital of Tianjin Medical University, Tianjin, China
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17
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Sampurna MTA, Rani SAD, Sauer PJJ, Bos AF, Dijk PH, Hulzebos CV. Diagnostic Properties of a Portable Point-of-Care Method to Measure Bilirubin and a Transcutaneous Bilirubinometer. Neonatology 2021; 118:678-684. [PMID: 34818231 DOI: 10.1159/000518653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/17/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recently, the Bilistick®, a point-of-care instrument to measure bilirubin levels, has been developed. It is fast and cheaper than transcutaneous bilirubin (TCB)-measuring devices, but data on diagnostic properties are scarce. OBJECTIVE This study aimed to compare the performance of the Bilistick® (BM-BS 1.0 - FW version 2.0.1) and the JM-105 bilirubinometer for measuring bilirubin. METHOD This is a prospective study in infants born after ≥32 weeks' gestation, and/or a birth weight of ≥1,500 g, and a postnatal age ≤14 days in Surabaya, Indonesia. Bilirubin was measured with the Bilistick® System (BM-BS 1.0 - FW version 2.0.1), transcutaneously (TCB) with the JM-105 bilirubinometer, and in serum (TSB) with a routine laboratory technique. Mean differences and 95% limits of agreement (LOA) and correlations were calculated. RESULT We enrolled 149 neonates and 126 had paired measurements of Bilistick® bilirubin, TCB, and TSB. Bilistick® failed in 16 (10.7%) infants. Mean Bilistick® bilirubin-TSB difference was -11 µmol/L (95% LOA: -101 to 79 µmol/L) and r = 0.738 (p < 0.001). Mean TCB-TSB difference was 26 μmol/L (95% LOA: -33 to 88) and r = 0.785 (p < 0.001). The sensitivity, specificity, PPV, and NPV for Bilistick® bilirubin for a TSB above treatment thresholds were 0.74, 0.84, 0.67, and 0.88, respectively, and for TCB 0.92, 0.64, 0.54, and 0.95, respectively. CONCLUSION The Bilistick® System (BM-BS 1.0 - FW version 2.0.1) underestimates TSB, whereas TCB overestimates TSB in jaundiced Indonesian infants. Further improvement of Bilistick®'s diagnostic accuracy with less false-negative readings is essential to increase its use.
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Affiliation(s)
- Mahendra Tri Arif Sampurna
- Department of Pediatrics, Faculty of Medicine Universitas Airlangga, Dr. Soetomo General Hospital Surabaya, Surabaya, Indonesia
| | - Siti Annisa Dewi Rani
- Department of Pediatrics, Faculty of Medicine Universitas Airlangga, Dr. Soetomo General Hospital Surabaya, Surabaya, Indonesia
| | - Pieter J J Sauer
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Arend F Bos
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter H Dijk
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Christian V Hulzebos
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
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