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Zhou Y, Luo Y, Liang H, Wei Z, Ye X, Zhong P, Wu D. Predictors of early neurological deterioration in patients with acute ischemic stroke. Front Neurol 2024; 15:1433010. [PMID: 39233686 PMCID: PMC11371773 DOI: 10.3389/fneur.2024.1433010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 08/08/2024] [Indexed: 09/06/2024] Open
Abstract
Background The present study aimed to develop a reliable and straightforward Nomogram by integrating various parameters to accurately predict the likelihood of early neurological deterioration (END) in patients with acute ischemic stroke (AIS). Methods Acute ischemic stroke patients from Shaoxing People's Hospital, Shanghai Yangpu District Shidong Hospital, and Shanghai Fifth People's Hospital were recruited based on specific inclusion and exclusion criteria. The primary outcome was END. Using the LASSO logistic model, a predictive Nomogram was generated. The performance of the Nomogram was evaluated using the ROC curve, the Hosmer-Lemeshow test, and a calibration plot. Additionally, the decision curve analysis was conducted to assess the effectiveness of the Nomogram. Results It was found that the Nomogram generated in the present study showed strong discriminatory performance in both the training and the internal validation cohorts when their ROC-AUC values were 0.715 (95% CI 0.648-0.782) and 0.725 (95% CI 0.631-0.820), respectively. Similar results were observed in two external validation cohorts when their ROC-AUC values were 0.685 (95% CI 0.541-0.829) and 0.673 (95% CI 0.545-0.800), respectively. In addition, CAD, SBP, neutrophils, TBil, and LDL were found to be positively correlated with the occurrence of END post-stroke, while lymphocytes and UA were negatively correlated. Conclusion Our study developed a novel Nomogram that includes CAD, SBP, neutrophils, lymphocytes, TBil, UA, and LDL and it demonstrated strong discriminatory performance in identifying AIS patients who are likely to develop END.
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Affiliation(s)
- Yang Zhou
- Emergency Department, Shaoxing People's Hospital, Shaoxing, Zhejiang, China
| | - Yufan Luo
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Huazheng Liang
- Suzhou Industrial Park Monash Research Institute of Science and Technology, Suzhou, Jiangsu Province, China
- Southeast University-Monash University Joint Graduate School, Suzhou, Jiangsu Province, China
- Monash University-Southeast University Joint Research Institute, Suzhou, Jiangsu Province, China
| | - Zhenyu Wei
- Department of Neurology, Shanghai Yangpu District Shidong Hospital, Shanghai, China
| | - Xiaofei Ye
- Department of Military Health Statistics, School of Health Service, People's Liberation Army, Naval Medical University, Shanghai, China
| | - Ping Zhong
- Department of Neurology, Shanghai Yangpu District Shidong Hospital, Shanghai, China
| | - Danhong Wu
- Department of Neurology, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
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Satrom KM, Wang J, Lock EF, Snook K, Lund TC, Rao RB. Phototherapy Alters the Plasma Metabolite Profile in Infants Born Preterm with Hyperbilirubinemia. J Pediatr 2024; 274:114175. [PMID: 38945444 DOI: 10.1016/j.jpeds.2024.114175] [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: 01/24/2024] [Revised: 05/24/2024] [Accepted: 06/24/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE To investigate the effects of gestational age (GA) and phototherapy on the plasma metabolite profile of preterm infants with neonatal hyperbilirubinemia (NHB). STUDY DESIGN From a cohort of prospectively enrolled infants born preterm (n = 92), plasma samples of very preterm (VPT; GA, 28 + 0 to 31 + 6 weeks, n = 27) and moderate/late preterm (M/LPT; GA, 32 + 0 to 35 + 6 weeks, n = 33) infants requiring phototherapy for NHB were collected prior to the initiation of phototherapy and 24 hours after starting phototherapy. An additional sample was collected 48 hours after starting phototherapy in a randomly selected subset (n = 30; VPT n = 15; M/LPT n = 15). Metabolite profiles were determined using ultraperformance liquid chromatography tandem mass spectroscopy. Two-way ANCOVA was used to identify metabolites that differed between GA groups and timepoints after adjusting for total serum bilirubin levels (false discovery rate q-value < 0.05). Top impacted pathways were identified using pathway over-representation analysis. RESULTS Phototherapy was initiated at lower total serum bilirubin (mean ± SD mg/dL) levels in VPT compared with M/LPT infants (7.3 ± 1.4 vs 9.9 ± 1.9, P < .01). We identified 664 metabolites that were significant for a phototherapy effect, 191 metabolites significant for GA, and 46 metabolites significant for GA × phototherapy interaction (false discovery rate q-value < 0.05). Longer duration phototherapy had a larger mean effect size (24 hours postphototherapy: d = 0.36; 48 hours postphototherapy: d = 0.43). Top pathways affected by phototherapy included membrane lipid metabolism, one-carbon metabolism, creatine biosynthesis, and oligodendrocyte differentiation. CONCLUSION Phototherapy alters the plasma metabolite profile more than GA in preterm infants with NHB, affecting pathways related to lipid and one-carbon metabolism, energy biosynthesis, and oligodendrocyte differentiation.
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Affiliation(s)
- Katherine M Satrom
- Division of Neonatology, Department of Pediatrics, University of Minnesota; Minneapolis.
| | - Jiuzhou Wang
- Division of Biostatistics, School of Public Health, University of Minnesota; Minneapolis
| | - Eric F Lock
- Division of Biostatistics, School of Public Health, University of Minnesota; Minneapolis
| | - Kirsten Snook
- Division of Neonatology, Department of Pediatrics, University of Minnesota; Minneapolis
| | - Troy C Lund
- Division of Blood and Marrow Transplant, Department of Pediatrics, University of Minnesota; Minneapolis
| | - Raghavendra B Rao
- Division of Neonatology, Department of Pediatrics, University of Minnesota; Minneapolis
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Ye ZT, Tseng SF, Tsou SX, Tsai CW. Spectral analysis with highly collimated mini-LEDs as light sources for quantitative detection of direct bilirubin. DISCOVER NANO 2024; 19:13. [PMID: 38238545 PMCID: PMC10796896 DOI: 10.1186/s11671-024-03957-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024]
Abstract
Because the human eye cannot visually detect the results of direct bilirubin test papers accurately and quantitatively, this study proposes four different highly collimated mini light-emitting diodes (HC mini-LEDs) as light sources for detection. First, different concentrations of bilirubin were oxidized to biliverdin by FeCl3 on the test paper, and pictures were obtained with a smartphone. Next, the red, green, and blue (RGB) channels of the pictures were separated to average grayscale values, and their linear relationship with the direct bilirubin concentration was analyzed to detect bilirubin on the test paper noninvasively and quantitatively. The experimental results showed that when green HC mini-LEDs were used as the light sources and image analysis was performed using the G channel, for a direct bilirubin concentration range of 0.1-2 mg/dL, the G channel determination coefficient (R2) reached 0.9523 and limit of detection was 0.459 mg/dL. The detection method proposed herein has advantages such as rapid analysis, noninvasive detection, and digitization according to RGB grayscale changes in the images of the detection test paper.
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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.
| | - 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
| | - 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
| | - Chun Wei Tsai
- Graduate Institute of Photonics and Optoelectronics, National Taiwan University, No. 1, Sec. 4, Roosevelt Rd., Taipei, 106319, Taiwan, ROC.
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Kasirer Y, Bin-Nun A, Hammerman C, Yosef OB, Marianayagam N, Hammerman-Rozenberg A, Shchors I, Ben-David E. Mildly Elevated Bilirubin Levels are Associated with Increased Magnetic Resonance Imaging Signal Intensity in the Basal Ganglia of Preterm Neonates. Am J Perinatol 2023; 40:1467-1472. [PMID: 34544169 DOI: 10.1055/a-1649-1918] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to test whether mildly elevated bilirubin levels in preterm infants are associated with increased signal intensity (SI) on magnetic resonance imaging (MRI) of the basal ganglia (BG). STUDY DESIGN MRI was performed at term equivalent age in 55 postpreterm infants using a neonatal MRI 1-T scanner. SI of the BG was correlated with mild hyperbilirubinemia. RESULTS BG MRI SI was significantly increased in infants with mild hyperbilirubinemia on T1-weighted image (T1; p = 0.0393) and T2-weighted image (T2; p = 0.0309). We found no effect of gestational age or sepsis on BG MRI intensity; however, there was a significant effect of acidosis on T1 (p = 0.0223) but not on T2 (p = 0.2316). Infants with combined hyperbilirubinemia and acidosis had the most significant increase in SI on both T1 and T2 respectively (p = 0.0072 and 0.0195, respectively). CONCLUSION We found a positive association between increased BG MRI SI and mildly elevated bilirubin levels. The effect was greatly strengthened when hyperbilirubinemia was associated with acidosis. KEY POINTS · Excessive bilirubin is neurotoxic to the neonatal brain. It is deposited in the BG.. · BG MRI SI is increased with bilirubin deposition.. · The premature brain is more vulnerable to bilirubin associated MRI changes..
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Affiliation(s)
- Yair Kasirer
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
- Department of Pediatrics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alona Bin-Nun
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
- Department of Pediatrics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Cathy Hammerman
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
- Department of Pediatrics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ortal B Yosef
- Department of Pediatrics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Neelan Marianayagam
- Department of Neurological Surgery, Weill Cornell Medical Center - New York Presbyterian Hospital, New York, New York
| | | | - Irina Shchors
- Department of Neonatology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eliel Ben-David
- Department of Pediatrics, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel
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5
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Holzapfel LF, Arnold C, Tyson JE, Shapiro SM, Reynolds EW, Pedroza C, Stephens EK, Kleinfeld A, Huber AH, Rysavy MA, del Mar Romero Lopez M, Khan AM. Effect of reduced versus usual lipid emulsion dosing on bilirubin neurotoxicity and neurodevelopmental impairment in extremely preterm infants: study protocol for a randomized controlled trial. BMC Pediatr 2023; 23:347. [PMID: 37430233 PMCID: PMC10332033 DOI: 10.1186/s12887-023-04149-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/22/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Bilirubin neurotoxicity (BN) occurs in premature infants at lower total serum bilirubin levels than term infants and causes neurodevelopmental impairment. Usual dose lipid infusions in preterm infants may increase free fatty acids sufficiently to cause bilirubin displacement from albumin, increasing passage of unbound bilirubin (UB) into the brain leading to BN and neurodevelopmental impairment not reliably identifiable in infancy. These risks may be influenced by whether cycled or continuous phototherapy is used to control bilirubin levels. OBJECTIVE To assess differences in wave V latency measured by brainstem auditory evoked responses (BAER) at 34-36 weeks gestational age in infants born ≤ 750 g or < 27 weeks' gestational age randomized to receive usual or reduced dose lipid emulsion (half of the usual dose) irrespective of whether cycled or continuous phototherapy is administered. METHODS Pilot factorial randomized controlled trial (RCT) of lipid dosing (usual and reduced) with treatment groups balanced between cycled or continuous phototherapy assignment. Eligible infants are born at ≤ 750 g or < 27 weeks' gestational age enrolled in the NICHD Neonatal Research Network RCT of cycled or continuous phototherapy. Infants will randomize 1:1 to reduced or usual dose lipid assignment during the first 2 weeks after birth and stratified by phototherapy assignment. Free fatty acids and UB will be measured daily using a novel probe. BAER testing will be performed at 34-36 weeks postmenstrual age or prior to discharge. Blinded neurodevelopmental assessments will be performed at 22-26 months. Intention-to-treat analyses will be performed with generalized linear mixed models with lipid dose and phototherapy assignments as random effects covariates, and assessment for interactions. Bayesian analyses will be performed as a secondary analysis. DISCUSSION Pragmatic trials are needed to evaluate whether lipid emulsion dosing modifies the effect of phototherapy on BN. This factorial design presents a unique opportunity to evaluate both therapies and their interaction. This study aims to address basic controversial questions about the relationships between lipid administration, free fatty acids, UB, and BN. Findings suggesting a reduced lipid dose can diminish the risk of BN would support the need for a large multicenter RCT of reduced versus usual lipid dosing. TRIAL REGISTRATION Clinical Trials.gov, NCT04584983, Registered 14 October 2020, https://clinicaltrials.gov/ct2/show/NCT04584983 Protocol version: Version 3.2 (10/5/2022).
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Affiliation(s)
- Lindsay F. Holzapfel
- Division of Neonatology, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin, MSB 3.236, Houston, TX 77030 US
| | - Cody Arnold
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alta, CA US
| | - Jon E. Tyson
- Division of Neonatology, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin,MSB 2.106, Houston, TX 77030 US
| | - Steven M. Shapiro
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Blvd, MS 2012-SSB, Kansas City, KS 66160 US
| | - Eric W. Reynolds
- Division of Neonatology, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin,MSB 3.254, Houston, TX 77030 US
| | - Claudia Pedroza
- Center for Evidence Based Medicine, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin, MSB 2.106, Houston, TX 77030 US
| | - Emily K. Stephens
- Neonatal Research Network, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin, MSB 3.252, Houston, TX 77030 US
| | - Alan Kleinfeld
- Fluoresprobe Sciences, 3550 General Atomics Ct, B-2-118, San Diego, CA 92121 US
| | - Andrew H. Huber
- Fluoresprobe Sciences, 3550 General Atomics Ct, B-2-118, San Diego, CA 92121 US
| | - Matthew A. Rysavy
- Division of Neonatology, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin,MSB 2.106, Houston, TX 77030 US
| | - Maria del Mar Romero Lopez
- Division of Neonatology, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin, MSB 3.236, Houston, TX 77030 US
| | - Amir M. Khan
- Division of Neonatology, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin, MSB 3.236, Houston, TX 77030 US
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6
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Llido JP, Fioriti E, Pascut D, Giuffrè M, Bottin C, Zanconati F, Tiribelli C, Gazzin S. Bilirubin-Induced Transcriptomic Imprinting in Neonatal Hyperbilirubinemia. BIOLOGY 2023; 12:834. [PMID: 37372119 DOI: 10.3390/biology12060834] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023]
Abstract
Recent findings indicated aberrant epigenetic control of the central nervous system (CNS) development in hyperbilirubinemic Gunn rats as an additional cause of cerebellar hypoplasia, the landmark of bilirubin neurotoxicity in rodents. Because the symptoms in severely hyperbilirubinemic human neonates suggest other regions as privileged targets of bilirubin neurotoxicity, we expanded the study of the potential impact of bilirubin on the control of postnatal brain development to regions correlating with human symptoms. Histology, transcriptomic, gene correlation, and behavioral studies were performed. The histology revealed widespread perturbation 9 days after birth, restoring in adulthood. At the genetic level, regional differences were noticed. Bilirubin affected synaptogenesis, repair, differentiation, energy, extracellular matrix development, etc., with transient alterations in the hippocampus (memory, learning, and cognition) and inferior colliculi (auditory functions) but permanent changes in the parietal cortex. Behavioral tests confirmed the presence of a permanent motor disability. The data correlate well both with the clinic description of neonatal bilirubin-induced neurotoxicity, as well as with the neurologic syndromes reported in adults that suffered neonatal hyperbilirubinemia. The results pave the way for better deciphering the neurotoxic features of bilirubin and evaluating deeply the efficacy of new therapeutic approaches against the acute and long-lasting sequels of bilirubin neurotoxicity.
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Affiliation(s)
- John Paul Llido
- Liver Brain Unit "Rita Moretti", Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, 34149 Basovizza, Italy
- Department of Science and Technology, Philippine Council for Health Research and Development, Bicutan, Taguig City 1631, Philippines
- Department of Life Sciences, University of Trieste, 34139 Trieste, Italy
| | - Emanuela Fioriti
- Liver Brain Unit "Rita Moretti", Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, 34149 Basovizza, Italy
| | - Devis Pascut
- Liver Cancer Unit, Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, 34149 Basovizza, Italy
| | - Mauro Giuffrè
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
- Department of Internal Medicine, Yale School of Medicine, Yale University, New Haven, CT 06510, USA
| | - Cristina Bottin
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Fabrizio Zanconati
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34149 Trieste, Italy
| | - Claudio Tiribelli
- Liver Brain Unit "Rita Moretti", Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, 34149 Basovizza, Italy
| | - Silvia Gazzin
- Liver Brain Unit "Rita Moretti", Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, 34149 Basovizza, Italy
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Diala UM, Usman F, Appiah D, Hassan L, Ogundele T, Abdullahi F, Satrom KM, Bakker CJ, Lee BW, Slusher TM. Global Prevalence of Severe Neonatal Jaundice among Hospital Admissions: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:3738. [PMID: 37297932 PMCID: PMC10253859 DOI: 10.3390/jcm12113738] [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: 03/23/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 06/12/2023] Open
Abstract
Evidence regarding the adverse burden of severe neonatal jaundice (SNJ) in hospitalized neonates in resource-constrained settings is sparse. We attempted to determine the prevalence of SNJ, described using clinical outcome markers, in all World Health Organization (WHO) regions in the world. Data were sourced from Ovid Medline, Ovid Embase, Cochrane Library, African Journals Online, and Global Index Medicus. Hospital-based studies, including the total number of neonatal admissions with at least one clinical outcome marker of SNJ, defined as acute bilirubin encephalopathy (ABE), exchange blood transfusions (EBT), jaundice-related death, or abnormal brainstem audio-evoked response (aBAER), were independently reviewed for inclusion in this meta-analysis. Of 84 articles, 64 (76.19%) were from low- and lower-middle-income countries (LMICs), and 14.26% of the represented neonates with jaundice in these studies had SNJ. The prevelance of SNJ among all admitted neonates varied across WHO regions, ranging from 0.73 to 3.34%. Among all neonatal admissions, SNJ clinical outcome markers for EBT ranged from 0.74 to 3.81%, with the highest percentage observed in the African and South-East Asian regions; ABE ranged from 0.16 to 2.75%, with the highest percentages observed in the African and Eastern Mediterranean regions; and jaundice-related deaths ranged from 0 to 1.49%, with the highest percentage observed in the African and Eastern Mediterranean regions. Among the cohort of neonates with jaundice, the prevalence of SNJ ranged from 8.31 to 31.49%, with the highest percentage observed in the African region; EBT ranged from 9.76 to 28.97%, with the highest percentages reported for the African region; ABE was highest in the Eastern Mediterranean (22.73%) and African regions (14.51%). Jaundice-related deaths were 13.02%, 7.52%, 2.01% and 0.07%, respectively, in the Eastern Mediterranean, African, South-East Asian and European regions, with none reported in the Americas. aBAER numbers were too small, and the Western Pacific region was represented by only one study, limiting the ability to make regional comparisons. The global burden of SNJ in hospitalized neonates remains high, causing substantial, preventable morbidity and mortality especially in LMICs.
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Affiliation(s)
- Udochukwu M. Diala
- Department of Paediatrics, Faculty of Clinical Sciences, College of Health Sciences, University of Jos, University of Jos Lamingo Campus, Jos 930232, Nigeria
| | - Fatima Usman
- Department of Paediatrics, Faculty of Clinical Services, College of Health Sciences, Bayero University, Aminu Kano Teaching Hospital Campus, Kano 700006, Nigeria
| | - Duke Appiah
- Department of Public Health, School of Population and Public Health, Faculty of Public Health, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
| | - Laila Hassan
- Department of Paediatrics, Faculty of Clinical Sciences, College of Medical Sciences, Ahmadu Bello University, Main Campus, Zaria 810211, Nigeria
| | - Tolulope Ogundele
- Department of Paediatrics, Obafemi Awolowo University Teaching Hospital, Ile-Ife 220005, Nigeria
| | - Fatima Abdullahi
- Department of Paediatrics, Faculty of Clinical Sciences, College of Medical Sciences, Ahmadu Bello University, Main Campus, Zaria 810211, Nigeria
| | - Katherine M. Satrom
- Department of Pediatrics, Faculty of Medical School, School of Medicine, University of Minnesota, University of Minnesota Twin Cities Campus, Minneapolis, MN 55455, USA
| | - Caitlin J. Bakker
- Dr. John Archer Library and Archives, University of Regina, Regina, SK S4S 0A2, Canada
| | - Burton W. Lee
- National Institute of Health, Bethesda, MD 20892, USA
| | - Tina M. Slusher
- Department of Pediatrics, Faculty of Medical School, School of Medicine, University of Minnesota, University of Minnesota Twin Cities Campus, Minneapolis, MN 55455, USA
- Hennepin Healthcare, Minneapolis, MN 55415, USA
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Satrom KM, Rao RB, Tkáč I. Neonatal hyperbilirubinemia differentially alters the neurochemical profiles of the developing cerebellum and hippocampus in a preterm Gunn rat model. NMR IN BIOMEDICINE 2023:e4946. [PMID: 37009906 DOI: 10.1002/nbm.4946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 06/19/2023]
Abstract
Neonatal hyperbilirubinemia (NHB) can lead to brain injury in newborn infants by affecting specific regions including the cerebellum and hippocampus. Extremely preterm infants are more vulnerable to bilirubin neurotoxicity, but the mechanism and extent of injury is not well understood. A preterm version of the Gunn rat model was utilized to investigate severe preterm NHB. Homozygous/jaundiced Gunn rat pups were injected (i.p.) on postnatal day (P) 5 with sulfadimethoxine, which increases serum free bilirubin capable of crossing the blood-brain barrier and causing brain injury. The neurochemical profiles of the cerebellum and hippocampus were determined using in vivo 1 H MRS at 9.4 T on P30 and compared with those of heterozygous/non-jaundiced control rats. Transcript expression of related genes was determined by real-time quantitative PCR. MRI revealed significant morphological changes in the cerebellum of jaundiced rats. The concentrations of myo-inositol (+54%), glucose (+51%), N-acetylaspartylglutamate (+21%), and the sum of glycerophosphocholine and phosphocholine (+17%) were significantly higher in the cerebellum of the jaundiced group compared with the control group. Despite the lack of morphologic changes in the hippocampus, the concentration of myo-inositol (+9%) was higher and the concentrations of creatine (-8%) and of total creatine (-3%) were lower in the jaundiced group. In the hippocampus, expression of calcium/calmodulin dependent protein kinase II alpha (Camk2a), glucose transporter 1 (Glut1), and Glut3 transcripts were downregulated in the jaundiced group. In the cerebellum, glial fibrillary acidic protein (Gfap), myelin basic protein (Mbp), and Glut1 transcript expression was upregulated in the jaundiced group. These results indicate osmotic imbalance, gliosis, and changes in energy utilization and myelination, and demonstrate that preterm NHB critically affects brain development in a region-specific manner, with the cerebellum more severely impacted than the hippocampus.
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Affiliation(s)
- Katherine M Satrom
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Raghavendra B Rao
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA
| | - Ivan Tkáč
- Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, MN, USA
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Holzapfel L, Arnold C, Tyson J, Shapiro S, Reynolds E, Pedroza C, Stephens E, Kleinfeld A, Huber A, Rysavy M, Khan A, Lopez MDMR. Effect of Reduced Versus Usual Lipid Emulsion Dosing on Bilirubin Neurotoxicity and Neurodevelopmental Impairment in Extremely Preterm Infants: Study Protocol for a Randomized Controlled Trial. RESEARCH SQUARE 2023:rs.3.rs-2566352. [PMID: 36945475 PMCID: PMC10029123 DOI: 10.21203/rs.3.rs-2566352/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Background : Bilirubin neurotoxicity ( BN ) occurs in premature infants at lower total serum bilirubin levels than term infants and causes neurodevelopmental impairment. Usual dose lipid infusions in preterm infants may increase free fatty acids sufficiently to cause bilirubin displacement from albumin, increasing passage of unbound bilirubin ( UB ) into the brain leading to BN and neurodevelopmental impairment not reliably identifiable in infancy. These risks may be influenced by whether cycled or continuous phototherapy is used to control bilirubin levels. Objective : To assess differences in wave V latency measured by brainstem auditory evoked responses ( BAER ) at 34-36 weeks gestational age in infants born ≤750 g or <27 weeks' gestational age randomized to receive usual or reduced dose lipid emulsion (half of the usual dose) irrespective of whether cycled or continuous phototherapy is administered. Methods : Pilot factorial randomized controlled trial ( RCT ) of lipid dosing (usual and reduced) with treatment groups balanced between cycled or continuous phototherapy assignment. Eligible infants are born at ≤750 g or <27 weeks' gestational age enrolled in the NICHD Neonatal Research Network RCT of cycled or continuous phototherapy. Infants will randomize 1:1 to reduced or usual dose lipid assignment during the first 2 weeks after birth and stratified by phototherapy assignment. Free fatty acids and UB will be measured daily using a novel probe. BAER testing will be performed at 34-36 weeks postmenstrual age or prior to discharge. Blinded neurodevelopmental assessments will be performed at 22-26 months. Intention-to-treat analyses will be performed with generalized linear mixed models with lipid dose and phototherapy assignments as random effects covariates, and assessment for interactions. Bayesian analyses will be performed as a secondary analysis. Discussion : Pragmatic trials are needed to evaluate whether lipid emulsion dosing modifies the effect of phototherapy on BN. This factorial design presents a unique opportunity to evaluate both therapies and their interaction. This study aims to address basic controversial questions about the relationships between lipid administration, free fatty acids, UB, and BN. Findings suggesting a reduced lipid dose can diminish the risk of BN would support the need for a large multicenter RCT of reduced versus usual lipid dosing. Trial Registration : Clinical Trials.gov, NCT04584983, Registered 14 October 2020, https://clinicaltrials.gov/ct2/show/NCT04584983 Protocol Version : Version 3.2 (10/5/2022).
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Yu J, Liu Y, Jiang Y, Gao B, Wang J, Guo Y, Xie L, Miao Y. Development and evaluation clinical-radiomics analysis based on T1-weighted imaging for diagnosing neonatal acute bilirubin encephalopathy. Front Neurol 2023; 14:956975. [PMID: 36864921 PMCID: PMC9971958 DOI: 10.3389/fneur.2023.956975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 01/27/2023] [Indexed: 02/16/2023] Open
Abstract
Purpose To investigate the value of clinical-radiomics analysis based on T1-weighted imaging (T1WI) for predicting acute bilirubin encephalopathy (ABE) in neonates. Methods In this retrospective study, sixty-one neonates with clinically confirmed ABE and 50 healthy control neonates were recruited between October 2014 and March 2019. Two radiologists' visual diagnoses for all subjects were independently based on T1WI. Eleven clinical and 216 radiomics features were obtained and analyzed. Seventy percent of samples were randomly selected as the training group and were used to establish a clinical-radiomics model to predict ABE; the remaining samples were used to validate the performance of the models. The discrimination performance was assessed by receiver operating characteristic (ROC) curve analysis. Results Seventy-eight neonates were selected for training (median age, 9 days; interquartile range, 7-20 days; 49 males) and 33 neonates for validation (median age, 10 days; interquartile range, 6-13 days; 24 males). Two clinical features and ten radiomics features were finally selected to construct the clinical-radiomics model. In the training group, the area under the ROC curve (AUC) was 0.90 (sensitivity: 0.814; specificity: 0.914); in the validation group, the AUC was 0.93 (sensitivity: 0.944; specificity: 0.800). The AUCs of two radiologists' and the radiologists' final visual diagnosis results based on T1WI were 0.57, 0.63, and 0.66, respectively. The discriminative performance of the clinical-radiomics model in the training and validation groups was increased compared to the radiologists' visual diagnosis (P < 0.001). Conclusions A combined clinical-radiomics model based on T1WI has the potential to predict ABE. The application of the nomogram could potentially provide a visualized and precise clinical support tool.
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Affiliation(s)
- Jinhong Yu
- Department of Radiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China,Department of Radiology, Dalian Woman and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Yangyingqiu Liu
- Department of Radiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yuhan Jiang
- Department of Radiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Bingbing Gao
- Department of Radiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jingshi Wang
- Department of Radiology, Dalian Woman and Children's Medical Center (Group), Dalian, Liaoning, China
| | - Yan Guo
- GE Healthcare, Life Science China, Shenyang, Liaoning, China
| | - Lizhi Xie
- MRI Research, GE Healthcare, Beijing, China
| | - Yanwei Miao
- Department of Radiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China,*Correspondence: Yanwei Miao ✉
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11
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Models of bilirubin neurological damage: lessons learned and new challenges. Pediatr Res 2022:10.1038/s41390-022-02351-x. [PMID: 36302856 DOI: 10.1038/s41390-022-02351-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Jaundice (icterus) is the visible manifestation of the accumulation of bilirubin in the tissue and is indicative of potential toxicity to the brain. Since its very first description more than 2000 years ago, many efforts have been undertaken to understand the molecular determinants of bilirubin toxicity to neuronal cells to reduce the risk of neurological sequelae through the use of available chemicals and in vitro, ex vivo, in vivo, and clinical models. Although several studies have been performed, important questions remain unanswered, such as the reasons for regional sensitivity and the interplay with brain development. The number of new molecular effects identified has increased further, which has added even more complexity to the understanding of the condition. As new research challenges emerged, so does the need to establish solid models of prematurity. METHODS This review critically summarizes the key mechanisms of severe neonatal hyperbilirubinemia and the use of the available models and technologies for translational research. IMPACT We critically review the conceptual dogmas and models used for studying bilirubin-induced neurotoxicity. We point out the pitfalls and translational gaps, and suggest new clinical research challenges. We hope to inform researchers on the pro and cons of the models used, and to help direct their experimental focus in a most translational research.
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12
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Action spectrum of phototherapy in hyperbilirubinemic neonates. Pediatr Res 2022; 92:816-821. [PMID: 34789840 DOI: 10.1038/s41390-021-01743-9] [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] [Received: 05/07/2021] [Revised: 08/16/2021] [Accepted: 08/27/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Phototherapy with blue light matching plasma absorption spectrum of the bilirubin-albumin complex with peak at 460 nm is standard treatment of neonatal hyperbilirubinemia. AIM To demonstrate clinically the action (efficacy) spectrum of phototherapy in hyperbilirubinemic neonates, through determination of the fraction of total serum bilirubin (TSB) decreased by phototherapy with peak emission wavelengths ≥478 nm (blue-green) compared with that of light of 459/452 nm (blue). METHODS TSB values were compiled from three earlier trials, in which hyperbilirubinemic neonates were randomized to receive 24 h of either blue-green light (478/490/497 nm) (intervention groups) or blue light (459/452/459 nm) (control groups) with equal irradiance and exposed body surface areas. Ratios (efficacy) between the decrease in TSB between intervention and control groups were calculated and graphed versus peak wavelengths, demonstrating the course of the action spectrum. RESULTS Calculated efficacy ratios were 1.31, 1.18, and 1.04 for light with peak wavelengths of 478, 490, and 497 nm, respectively. The action spectrum increases from 452/459 to maximum at 478 nm, from where it decreases to 1.18 and finally to 1.04. CONCLUSION For optimal phototherapeutic treatment, neonates need to be exposed to light with peak wavelength some 20 nm longer than is presently used. IMPACT The action (efficacy) spectrum of phototherapy for hyperbilirubinemic neonates has its peak wavelength at 478 nm. The peak wavelength of this action spectrum is 20 nm longer than the wavelength presently believed to be most efficient. The peak is also different from the peak found in vitro. For optimal phototherapeutic effect, neonates need to be treated with light of wavelengths some 20 nm longer than are presently used.
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13
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Uchida Y, Takahashi Y, Morimoto Y, Greimel P, Tosaki A, Kumagai A, Nishikubo T, Miyawaki A. Noninvasive monitoring of bilirubin photoisomer excretion during phototherapy. Sci Rep 2022; 12:11798. [PMID: 35821401 PMCID: PMC9276810 DOI: 10.1038/s41598-022-16180-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/06/2022] [Indexed: 11/09/2022] Open
Abstract
Lumirubin is the most prevalently excreted hydrophilic bilirubin photoisomer in phototherapy for neonatal jaundice caused by excess hydrophobic unconjugated bilirubin (ZZ-bilirubin). We developed a simple method to estimate the amount of lumirubin by monitoring the reverse photoisomerization of lumirubin to ZZ-bilirubin. Although lumirubin formation was long considered irreversible, exposure to blue light in the presence of the fluorescent protein UnaG, which binds specifically and tightly to ZZ-bilirubin, enables the reverse photoisomerization of lumirubin. This reaction was first detected using a fluorescence assay of neonatal urine sampled during phototherapy and purified lumirubin. The phenomenon of reverse photoisomerization of lumirubin was validated using liquid chromatography–mass spectrometry, which confirmed that lumirubin is reconverted to ZZ-bilirubin in the presence of UnaG. Analyses of 20 urine samples from 17 neonates revealed a significant correlation (correlation coefficient [r] = 0.978; 95% confidence interval 0.867–0.979; P < .001) between lumirubin and ZZ-bilirubin concentration before and after reverse photoisomerization. In general, the rate of photo-reconversion of lumirubin to ZZ-bilirubin is approximately 40%. In conclusion, we demonstrate here that lumirubin can be photo-reconverted to ZZ-bilirubin via exposure to blue light in the presence of UnaG. Utilizing this approach, urinary lumirubin levels can be estimated using an easy-to-perform fluorescence assay.
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Affiliation(s)
- Yumiko Uchida
- Division of Neonatal Intensive Care, Maternal, Fetal and Neonatal Medical Center, Nara Medical University Hospital, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan.
| | - Yukihiro Takahashi
- Division of Neonatal Intensive Care, Maternal, Fetal and Neonatal Medical Center, Nara Medical University Hospital, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Yukihiro Morimoto
- R&D Division, Ushio Inc., Himeji, Japan.,SANKEN, Osaka University, Osaka, Japan
| | - Peter Greimel
- Cell Function Dynamics, Brain Science Institute, RIKEN, Wako, Japan
| | - Asako Tosaki
- Cell Function Dynamics, Brain Science Institute, RIKEN, Wako, Japan
| | - Akiko Kumagai
- Cell Function Dynamics, Brain Science Institute, RIKEN, Wako, Japan
| | - Toshiya Nishikubo
- Division of Neonatal Intensive Care, Maternal, Fetal and Neonatal Medical Center, Nara Medical University Hospital, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Atsushi Miyawaki
- Cell Function Dynamics, Brain Science Institute, RIKEN, Wako, Japan
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14
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Hegyi T, Kleinfeld A. Neonatal hyperbilirubinemia and the role of unbound bilirubin. J Matern Fetal Neonatal Med 2021; 35:9201-9207. [PMID: 34957902 DOI: 10.1080/14767058.2021.2021177] [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: 10/19/2022]
Abstract
BACKGROUND Neonatal jaundice occurs in more than 80% of newborn infants. Although mild jaundice is physiologic and possibly neuroprotective, severe hyperbilirubinemia can lead to neurologic dysfunction and death. Hyperbilirubinemia is due to an imbalance between bilirubin production and the developing excretory capacity in the first days of life. Management utilizes total serum bilirubin (TSB) levels, although recent advances suggest a role for unbound bilirubin. GOALS The goal of this review is to examine bilirubin biology, toxicology, and clinical effects, discuss preventive and therapeutic measures, describe neurodevelopmental consequences, and propose that, with the advent of new technology, unbound bilirubin is the optimal measurement for the management. METHODS Comprehensive review on neonatal hyperbilirubinemia. RESULTS Neonatal hyperbilirubinemia can be prevented by tin mesoporphyrin to limit heme oxygenase activity, a key enzyme in bilirubin production, or restricting bilirubin's absorption from the gastrointestinal tract. Treatment modalities include removing bilirubin from the body by exchange transfusion, binding to immunoglobulin, or converting it to a water-soluble isomer with phototherapy. While these approaches have evolved during the past decades, the diagnosis, intervention indications, and prognosis have consistently relied on TSB concentration despite its poor ability to predict an outcome. CONCLUSIONS Total serum bilirubin is inadequate to optimize care of the term and preterm infant with hyperbilirubinemia. A rapid, accurate, and more effective indicator of bilirubin neurotoxicity is needed to manage jaundiced infants and for the universal screening of newborn infants. Future measurements of free bilirubin unattached to albumin will improve the management of neonatal hyperbilirubinemia.
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Affiliation(s)
- Thomas Hegyi
- Department of Pediatrics, Division of Neonatology, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, USA
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15
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Waddell J, Rickman NC, He M, Tang N, Bearer CF. Choline supplementation prevents the effects of bilirubin on cerebellar-mediated behavior in choline-restricted Gunn rat pups. Pediatr Res 2021; 89:1414-1419. [PMID: 33027804 PMCID: PMC8024424 DOI: 10.1038/s41390-020-01187-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Bilirubin is produced by the breakdown of hemoglobin and is normally catabolized and excreted. Neurotoxic accumulation of serum bilirubin often occurs in premature infants. The homozygous Gunn rat lacks uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1), the enzyme needed to biotransform bilirubin. This rodent model of hyperbilirubinemia emulates many aspects of bilirubin toxicity observed in the human infant. We demonstrate that choline supplementation in early postnatal development is neuroprotective in the choline-restricted Gunn rat, when hyperbilirubinemia is induced on postnatal day 5. METHODS We first compared behaviors and cerebellar weight of pups born to dams consuming regular rat chow to those of dams consuming choline-restricted diets. Second, we measured behaviors and cerebellar weights of pups born to choline-restricted dams, reared on a choline-restricted diet, supplemented with or without choline, and treated with or without sulfadimethoxine (SDMX). RESULTS A choline-restricted diet did not change the behavioral outcomes, but cerebellar weight was reduced in the choline-restricted group regardless of genotype or SDMX administration. SDMX induced behavioral deficits in jj pups, and choline supplementation improved most behavioral effects and cerebellar weight in SDMX-treated jj rats. CONCLUSIONS These results suggest that choline may be used as a safe and effective neuroprotective intervention against hyperbilirubinemia in the choline-deficient premature infant. IMPACT This article investigates the effect of neonatal jaundice/bilirubin neurotoxicity on cerebellar-mediated behaviors. This article explores the potential use of choline as an intervention capable of ameliorating the effect of bilirubin on the choline-restricted developing brain. This article opens the door for future studies on the action of choline in the presence of hyperbilirubinemia, especially in preterm neonates.
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Affiliation(s)
- Jaylyn Waddell
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Nicholas C Rickman
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - Min He
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, 21218, USA
| | - Ningfeng Tang
- Department of Orthopedics, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Cynthia F Bearer
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA.
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Paul HA, Adams BJ, Venner AA. Improving quality of transcutaneous bilirubin measurements: Value of in-house developed quality control. Pract Lab Med 2021; 24:e00206. [PMID: 33598521 PMCID: PMC7868991 DOI: 10.1016/j.plabm.2021.e00206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 01/24/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Quality assurance (QA) plays an integral role in Point of Care Testing (POCT) programs. Quality control (QC) is an important QA program component to ensure high quality results and enhanced patient care. The measurement of transcutaneous bilirubin (TcB) in the POCT setting is an essential part of newborn care in Alberta, Canada. However, there is currently no available commercial QC material for TcB meters. An in-house developed QC material has been in use within a single TcB POCT program within Alberta. The objective of this study was to determine the performance of this QC material by other POCT staff and clinical end-users to assess whether its use could be expanded. DESIGN AND METHODS Two levels of QC material were measured by POCT staff and clinical end-users across 12 different sites using the Dräger Jaundice Meter JM-103® and JM-105® meters. RESULTS The performance of the QC material was acceptable when tested by POCT staff, was stable and reliable over time, and had an acceptable CV (≤8%). However, the data does not support use of the QC material by clinical end-users. CONCLUSIONS The use of the QC material could be expanded into other TcB settings for use by POCT staff. Additional training and experience with the QC material by end-users is needed to facilitate QC use in the clinical setting.
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Affiliation(s)
- Heather Anne Paul
- Alberta Precision Laboratories, 3535, Research Rd NW, Calgary, AB, T2L 2K8, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330, Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Brenda Joanne Adams
- Alberta Precision Laboratories, 3535, Research Rd NW, Calgary, AB, T2L 2K8, Canada
| | - Allison Anne Venner
- Alberta Precision Laboratories, 3535, Research Rd NW, Calgary, AB, T2L 2K8, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330, Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
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Okumura A, Kitai Y, Arai H, Hayakawa M, Maruo Y, Kusaka T, Kunikata T, Kumada S, Morioka I. Auditory brainstem response in preterm infants with bilirubin encephalopathy. Early Hum Dev 2021; 154:105319. [PMID: 33530022 DOI: 10.1016/j.earlhumdev.2021.105319] [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: 12/01/2020] [Revised: 01/09/2021] [Accepted: 01/17/2021] [Indexed: 11/19/2022]
Abstract
AIM To clarify auditory brainstem response (ABR) in preterm infants with bilirubin encephalopathy and the relationships between ABR and clinical variables. METHOD We retrospectively reviewed the ABR waveforms of 56 preterm infants with BE and graded them as "no response", "abnormal interwave separation", or "normal". Patient backgrounds, the peak total bilirubin level, the bilirubin/albumin ratio, verbal communication ability, and newborn hearing screening test results from an automated ABR evaluation had been collected during an earlier nationwide survey. RESULTS The frequency of abnormal ABR findings decreased with age. Verbal communication tended to be poorer in patients with more severe ABR abnormalities. ABR findings improved in 7 of 29 infants with available serial ABR data. Both gestational age and the peak total bilirubin level were relatively lower in patients with than in those without improved ABR findings. Newborn hearing screening using automated ABR evaluation yielded data consistent with manual ABR findings in 16 of 20 patients who underwent both examinations. CONCLUSIONS ABR abnormalities in preterm infants with bilirubin encephalopathy may improve over time, especially in those with a lower gestational age and peak total bilirubin level. Newborn hearing screening using automated ABR may fail to detect abnormalities in some infants.
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Affiliation(s)
- Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, 1-1 Yazako Karimata, Nagakute, Aichi 480-1195, Japan.
| | - Yukihiro Kitai
- Department of Pediatric Neurology, Bobath Memorial Hospital, 1-6-5 Higashinakahama, Joto-ku, Osaka 536-0023, Japan
| | - Hiroshi Arai
- Department of Pediatric Neurology, Bobath Memorial Hospital, 1-6-5 Higashinakahama, Joto-ku, Osaka 536-0023, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8560, Japan
| | - Yoshihiro Maruo
- Department of Pediatrics, Shiga University of Medical Science, Seta-Tsukinowa-cho, Otsu, Shiga 520-2192, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Tetsuya Kunikata
- Division of Neonatal Medicine, Department of Pediatrics, Saitama Medical University Hospital, 38 Morohongo Moroyama-machi, Iruma-gun, Saitama 350-0495, Japan
| | - Satoko Kumada
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, 2-6-1 Musashidai, Fuchu, Tokyo 183-0042, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, 30-1, Oyaguchi-Kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
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The effectiveness of phototherapy using blue-green light for neonatal hyperbilirubinemia - Danish clinical trials. Semin Perinatol 2021; 45:151358. [PMID: 33358025 DOI: 10.1016/j.semperi.2020.151358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The effectiveness of phototherapy for neonatal hyperbilirubinemia based on Danish clinical trials is presented. Randomized controlled trials on the quality of light showed that blue-green fluorescent light (peak emission at 490 nm) was more efficient than blue fluorescent light (peak emission at 452 nm); blue-green light-emitting diode (LED) light (peak emission at 478 nm) was more efficient than blue LED light (peak emission at 459 nm); and blue-green LED light (peak emission at 497 nm) was equivalent to blue LED light (peak emission at 459 nm). Bilirubin-reducing effects correlated with irradiance, dependent on hemoglobin concentration, and independent of rotating infants. Phototherapy from both above and below was more efficient than therapy applied only from above at high levels of irradiance. In conclusion, we estimate and recommend the use of blue-green LED light (peak emission at 480 nm) rather than blue light (peak emission at 460 nm) for treating of neonatal hyperbilirubinemia.
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Pal S, Sardar S, Sarkar N, Ghosh M. An observational prospective study to compare transcutaneous bilirubin with serum bilirubin in preterm newborn requiring phototherapy. J Clin Neonatol 2021. [DOI: 10.4103/jcn.jcn_206_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Okumura A, Ichimura S, Hayakawa M, Arai H, Maruo Y, Kusaka T, Kunikata T, Kumada S, Morioka I. Neonatal Jaundice in Preterm Infants with Bilirubin Encephalopathy. Neonatology 2021; 118:301-309. [PMID: 33744898 DOI: 10.1159/000513785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 12/15/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study is to clarify bilirubin parameters and its treatment in preterm infants with bilirubin encephalopathy (pBE). METHODS We asked the responders to an earlier nationwide Japanese survey on pBE to provide additional information. pBE was diagnosed based on the criteria used in the nationwide survey. We collected data on serum total bilirubin (TB), direct bilirubin (DB), albumin, and unbound bilirubin (UB) levels during the first 8 weeks of life, and on phototherapy and exchange transfusion treatments. RESULTS We obtained clinical data from 75 patients with pBE from 58 hospitals (response rate of 59%), who were born between 2002 and 2016. The average peak TB level was 12.6 mg/dL (215 μmol/L), and the average age at peak attainment was 19.7 days after birth. Albumin level was <2.5 g/dL in 44 patients, and the peak DB level was ≥2 mg/dL (34.2 μmol/L) in 20 patients. The average peak bilirubin/albumin (B/A) (mg/g) ratio was 3.8 (molar ratio of 0.475), and the average age at peak attainment was 18.6 days. The average peak UB level was 0.67 μg/dL (11.5 nmol/L). The median duration of phototherapy was 6 days, and the median day of the last session was 12. The peak TB level occurred after the last day of phototherapy in 30 of the 61 patients available for comparison. CONCLUSIONS Most patients with pBE lacked marked elevations in serum TB levels and the B/A ratio, the peaks of which were sometimes delayed to >4 weeks after birth.
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Affiliation(s)
- Akihisa Okumura
- Department of Pediatrics, Aichi Medical University, Nagakute, Japan,
| | - Shintaro Ichimura
- Department of Perinatal and Neonatal Medicine, Aichi Medical University, Nagakute, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Nagoya, Japan
| | - Hiroshi Arai
- Department of Pediatric Neurology, Bobath Memorial Hospital, Osaka, Japan
| | - Yoshihiro Maruo
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Tetsuya Kunikata
- Division of Neonatal Medicine, Department of Pediatrics, Saitama Medical University Hospital, Iruma-Gun, Saitama, Japan
| | - Satoko Kumada
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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Gazzin S, Dal Ben M, Montrone M, Jayanti S, Lorenzon A, Bramante A, Bottin C, Moretti R, Tiribelli C. Curcumin Prevents Cerebellar Hypoplasia and Restores the Behavior in Hyperbilirubinemic Gunn Rat by a Pleiotropic Effect on the Molecular Effectors of Brain Damage. Int J Mol Sci 2020; 22:ijms22010299. [PMID: 33396688 PMCID: PMC7795686 DOI: 10.3390/ijms22010299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 01/08/2023] Open
Abstract
Bilirubin toxicity to the central nervous system (CNS) is responsible for severe and permanent neurologic damage, resulting in hearing loss, cognitive, and movement impairment. Timely and effective management of severe neonatal hyperbilirubinemia by phototherapy or exchange transfusion is crucial for avoiding permanent neurological consequences, but these therapies are not always possible, particularly in low-income countries. To explore alternative options, we investigated a pharmaceutical approach focused on protecting the CNS from pigment toxicity, independently from serum bilirubin level. To this goal, we tested the ability of curcumin, a nutraceutical already used with relevant results in animal models as well as in clinics in other diseases, in the Gunn rat, the spontaneous model of neonatal hyperbilirubinemia. Curcumin treatment fully abolished the landmark cerebellar hypoplasia of Gunn rat, restoring the histological features, and reverting the behavioral abnormalities present in the hyperbilirubinemic rat. The protection was mediated by a multi-target action on the main bilirubin-induced pathological mechanism ongoing CNS damage (inflammation, redox imbalance, and glutamate neurotoxicity). If confirmed by independent studies, the result suggests the potential of curcumin as an alternative/complementary approach to bilirubin-induced brain damage in the clinical scenario.
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Affiliation(s)
- Silvia Gazzin
- Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, ss14, Km 163.5, Basovizza, 34149 Trieste, Italy; (M.D.B.); (M.M.); (S.J.); (C.T.)
- Correspondence:
| | - Matteo Dal Ben
- Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, ss14, Km 163.5, Basovizza, 34149 Trieste, Italy; (M.D.B.); (M.M.); (S.J.); (C.T.)
| | - Michele Montrone
- Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, ss14, Km 163.5, Basovizza, 34149 Trieste, Italy; (M.D.B.); (M.M.); (S.J.); (C.T.)
| | - Sri Jayanti
- Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, ss14, Km 163.5, Basovizza, 34149 Trieste, Italy; (M.D.B.); (M.M.); (S.J.); (C.T.)
| | - Andrea Lorenzon
- SPF Animal Facility, CBM Scarl, Bldg. Q2, AREA Science Park, ss14, Km 163.5, Basovizza, 34149 Trieste, Italy; (A.L.); (A.B.)
| | - Alessandra Bramante
- SPF Animal Facility, CBM Scarl, Bldg. Q2, AREA Science Park, ss14, Km 163.5, Basovizza, 34149 Trieste, Italy; (A.L.); (A.B.)
| | - Cristina Bottin
- Department of Medical Sciences, Ospedale di Cattinara, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Rita Moretti
- Neurology Clinic, Department of Medical, Surgical, and Health Sciences, University of Trieste, Strada di Fiume 447, 34149 Trieste, Italy;
| | - Claudio Tiribelli
- Fondazione Italiana Fegato-Onlus, Bldg. Q, AREA Science Park, ss14, Km 163.5, Basovizza, 34149 Trieste, Italy; (M.D.B.); (M.M.); (S.J.); (C.T.)
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Okumura A, Morioka I, Arai H, Hayakawa M, Maruo Y, Kusaka T, Kunikata T, Kumada S. A nationwide survey of bilirubin encephalopathy in preterm infants in Japan. Brain Dev 2020; 42:730-737. [PMID: 32654953 DOI: 10.1016/j.braindev.2020.06.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/23/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To examine the clinical characteristics of bilirubin encephalopathy in preterm infants (pBE) in Japan. METHODS We performed a two-step nationwide questionnaire survey. The initial survey determined the number of children with pBE. Using a structured questionnaire, the second survey clarified the clinical manifestations and characteristics of children with pBE, including the perinatal history, neonatal complications, neurological features, verbal communication, diet, and magnetic resonance imaging (MRI) and auditory brainstem response (ABR) findings. RESULTS The initial survey included 190 pBE infants, indicating an incidence of approximately 10 per year. Clinical information was available for 142 of them. The median gestational age was 26 weeks and the median birthweight was 883 g. As to neonatal complications, 20% had none, 25% had one complication, 54% had two or more. Head control was observed in 45% and functional gait in 8%. Purposeful hand use was seen in 41% of patients and verbal communication in 40%. MRI showed T2 hyperintensities in the globi pallidi in 111 of 136 patients, especially between 7 and 18 months of corrected age. ABR abnormalities were present in 88 of 117 patients. CONCLUSIONS pBE was infrequent but constantly observed during the study period, especially in very preterm infants, even in those with no severe neonatal complications. Severely impaired gross motor function and relatively preserved manual function and verbal communication were characteristic. MRI and ABR abnormalities will facilitate diagnosis.
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Affiliation(s)
| | - Ichiro Morioka
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroshi Arai
- Department of Pediatric Neurology, Bobath Memorial Hospital, Japan
| | - Masahiro Hayakawa
- Division of Neonatology, Center for Maternal-Neonatal Care, Nagoya University Hospital, Japan
| | - Yoshihiro Maruo
- Department of Pediatrics, Shiga University of Medical Science, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Faculty of Medicine, Kagawa University, Japan
| | - Tetsuya Kunikata
- Division of Neonatal Medicine, Department of Pediatrics, Saitama Medical University Hospital, Japan
| | - Satoko Kumada
- Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Japan
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Hansen TWR, Wong RJ, Stevenson DK. Molecular Physiology and Pathophysiology of Bilirubin Handling by the Blood, Liver, Intestine, and Brain in the Newborn. Physiol Rev 2020; 100:1291-1346. [PMID: 32401177 DOI: 10.1152/physrev.00004.2019] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Bilirubin is the end product of heme catabolism formed during a process that involves oxidation-reduction reactions and conserves iron body stores. Unconjugated hyperbilirubinemia is common in newborn infants, but rare later in life. The basic physiology of bilirubin metabolism, such as production, transport, and excretion, has been well described. However, in the neonate, numerous variables related to nutrition, ethnicity, and genetic variants at several metabolic steps may be superimposed on the normal physiological hyperbilirubinemia that occurs in the first week of life and results in bilirubin levels that may be toxic to the brain. Bilirubin exists in several isomeric forms that differ in their polarities and is considered a physiologically important antioxidant. Here we review the chemistry of the bilirubin molecule and its metabolism in the body with a particular focus on the processes that impact the newborn infant, and how differences relative to older children and adults contribute to the risk of developing both acute and long-term neurological sequelae in the newborn infant. The final section deals with the interplay between the brain and bilirubin and its entry, clearance, and accumulation. We conclude with a discussion of the current state of knowledge regarding the mechanism(s) of bilirubin neurotoxicity.
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Affiliation(s)
- Thor W R Hansen
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; and Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Ronald J Wong
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; and Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - David K Stevenson
- Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; and Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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24
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Arnold C, Tyson JE, Pedroza C, Carlo WA, Stevenson DK, Wong R, Dempsey A, Khan A, Fonseca R, Wyckoff M, Moreira A, Lasky R. Cycled Phototherapy Dose-Finding Study for Extremely Low-Birth-Weight Infants: A Randomized Clinical Trial. JAMA Pediatr 2020; 174:649-656. [PMID: 32338720 PMCID: PMC7186919 DOI: 10.1001/jamapediatrics.2020.0559] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 02/12/2020] [Indexed: 01/16/2023]
Abstract
Importance Cycled (intermittent) phototherapy (PT) might adequately control peak total serum bilirubin (TSB) level and avoid mortality associated with usual care (continuous PT) among extremely low-birth-weight (ELBW) infants (401-1000 g). Objective To identify a cycled PT regimen that substantially reduces PT exposure, with an increase in mean peak TSB level lower than 1.5 mg/dL in ELBW infants. Design, Setting, and Participants This dose-finding randomized clinical trial of cycled PT vs continuous PT among 305 ELBW infants in 6 US newborn intensive care units was conducted from March 12, 2014, to November 14, 2018. Interventions Two cycled PT regimens (≥15 min/h and ≥30 min/h) were provided using a simple, commercially available timer to titrate PT minutes per hour against TSB level. The comparator arm was usual care (continuous PT). Main Outcomes and Measures Mean peak TSB level and total PT hours through day 14 in all 6 centers and predischarge brainstem auditory-evoked response wave V latency in 1 center. Mortality and major morbidities were secondary outcomes despite limited power. Results Consent was requested for 452 eligible infants and obtained for 305 (all enrolled) (mean [SD] birth weight, 749 [152] g; gestational age, 25.7 [1.9] weeks; 81 infants [27%] were multiple births; 137 infants [45%] were male; 112 [37%] were black infants; and 107 [35%] were Hispanic infants). Clinical and demographic characteristics of the groups were similar at baseline. After a preplanned interim analysis of 100 infants, the regimen of 30 min/h or more was discontinued, and the study proceeded with 2 arms. Comparing 128 infants receiving PT of 15 min/h or more with 128 infants receiving continuous PT among those surviving to 14 days, mean peak TSB levels were 7.1 vs 6.4 mg/dL (adjusted difference, 0.7; 95% CI, 0.4-1.1 mg/dL) and mean total PT hours were 34 vs 72 (adjusted difference, -39; 95% CI, -45 to -32). Wave V latency adjusted for postmenstrual age was similar in 37 infants receiving 15 min/h or more of PT and 33 infants receiving continuous PT: 7.42 vs 7.32 milliseconds (difference, 0.10; 95% CI, -0.11 to 0.30 millisecond). The relative risk for death was 0.79 (95% CI, 0.40-1.54), with a risk difference of -4.5% (95% CI, -10.9 to 2.0). Morbidities did not differ between groups. Conclusions and Relevance Cycled PT can substantially reduce total PT with little increase in peak TSB level. A large, randomized trial is needed to assess whether cycled PT would increase survival and survival without impairment in small, preterm infants. Trial Registration ClinicalTrials.gov Identifier: NCT01944696.
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Affiliation(s)
- Cody Arnold
- McGovern Medical School, University of Texas, Houston
| | - Jon E. Tyson
- McGovern Medical School, University of Texas, Houston
| | | | - Wally A. Carlo
- Birmingham School of Medicine, University of Alabama, Birmingham
| | | | - Ronald Wong
- Stanford University School of Medicine, Stanford, California
| | - Allison Dempsey
- McGovern Medical School, University of Texas, Houston
- Now at University of Colorado School of Medicine, Aurora
| | - Amir Khan
- McGovern Medical School, University of Texas, Houston
| | | | - Myra Wyckoff
- University of Texas Southwestern Medical School, Dallas
| | - Alvaro Moreira
- University of Texas Health Science Center at San Antonio
| | - Robert Lasky
- McGovern Medical School, University of Texas, Houston
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Tan N, Hu S, Hu Z, Wu Z, Wang B. Quantitative proteomic characterization of microvesicles/exosomes from the cerebrospinal fluid of patients with acute bilirubin encephalopathy. Mol Med Rep 2020; 22:1257-1268. [PMID: 32468033 PMCID: PMC7339682 DOI: 10.3892/mmr.2020.11194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 05/06/2020] [Indexed: 01/10/2023] Open
Abstract
Severe hyperbilirubinemia causes neurotoxicity and may lead to acute bilirubin encephalopathy (ABE) during the critical period of central nervous system development. The aim of the present study was to identify differentially expressed proteins (DEPs) in microvesicles/exosomes (MV/E) isolated from the cerebrospinal fluid (CSF) of patients with ABE. Co-precipitation was used to isolate the MV/E from the CSF of patients with ABE and age-matched controls. Isobaric tagging for relative and absolute quantification-based proteomic technology combined with liquid chromatography/tandem mass spectrometry was used to identify DEPs in the MV/E. Bioinformatics analysis was subsequently performed to investigate Gene Ontology functional annotation and Kyoto Encyclopedia of Genes and Genomes enriched signaling pathways of these DEPs. A total of four proteins were selected for further validation via western blotting. A total of 291 dysregulated proteins were identified by comparing the patients with ABE with the controls. Bioinformatics analysis indicated the involvement of immune-inflammation-associated cellular processes and signaling pathways in the pathophysiology of ABE. In conclusion, the present study identified the proteomic profile of MV/E isolated from the CSF of patients with ABE. These results may provide an improved understanding of the pathogenesis of ABE and may help to identify early diagnostic biomarkers and therapeutic targets.
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Affiliation(s)
- Ning Tan
- Department of Pediatrics, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
| | - Shuiwang Hu
- Guangdong Provincial Key Laboratory of Proteomics, Department of Pathophysiology, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Zhen Hu
- National and Local Joint Engineering Laboratory for High‑through Molecular Diagnosis Technology, Translational Medicine Institute, Collaborative Research Center for Post‑doctoral Mobile Stations of Central South University, Affiliated The First People's Hospital of Chenzhou, Southern Medical University, University of South China, Chenzhou, Hunan 423000, P.R. China
| | - Zhouli Wu
- Department of Neonatology, Affiliated The First People's Hospital of Chenzhou, Southern Medical University, University of South China, Chenzhou, Hunan 423000, P.R. China
| | - Bin Wang
- Department of Pediatrics, Zhujiang Hospital, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
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26
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Use of serum bilirubin/albumin ratio for early prediction of bilirubin induced neurological dysfunction. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2019. [DOI: 10.1186/s43054-019-0010-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Kernicterus or bilirubin encephalopathy is a preventable cause of handicap, still occurs in our country. The aim of the current study was to assess the role of bilirubin/albumin ratio in improving the morbidity of the cases with unconjugated hyperbilirubinemia and to estimate of the cutoff value for B/A ratio for prevention and early management of bilirubin-induced neurological dysfunction.
Results
The mean gestational age was 37.1 ± 2.11 weeks; the mean age of onset of jaundice was 2.36 ± 1.04 days; the mean level of total bilirubin was 26.14 ± 7.36 mg/dl. At chosen cutoff value of bilirubin albumin ratio (B/A) 6.68, sensitivity was 82% while specificity was 64% and accuracy was 95%.
Conclusion
Bilirubin encephalopathy still occurs in significant number in our country though it is a preventable cause of handicapping. TSB is a sensitive but not a specific indicator of ABE, B/A ratio is more specific indicator of the neurologic outcome and should be utilized in the decision of early intervention.
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Das S, van Landeghem FKH. Clinicopathological Spectrum of Bilirubin Encephalopathy/Kernicterus. Diagnostics (Basel) 2019; 9:diagnostics9010024. [PMID: 30823396 PMCID: PMC6468386 DOI: 10.3390/diagnostics9010024] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 02/17/2019] [Accepted: 02/25/2019] [Indexed: 12/31/2022] Open
Abstract
Bilirubin encephalopathy/kernicterus is relatively rare, but continues to occur despite universal newborn screening. What is more interesting is the spectrum of clinical and even neuropathological findings that have been reported in the literature to be associated with bilirubin encephalopathy and kernicterus. In this review, the authors discuss the array of clinicopathological findings reported in the context of bilirubin encephalopathy and kernicterus, as well as the types of diagnostic testing used in patients suspected of having bilirubin encephalopathy or kernicterus. The authors aim to raise the awareness of these features among both pediatric neurologists and neuropathologists.
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Affiliation(s)
- Sumit Das
- Division of Neuropathology, University of Alberta and Stollery Children's Hospital, Edmonton, AB T6G 2B7, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2B7, Canada.
| | - Frank K H van Landeghem
- Division of Neuropathology, University of Alberta and Stollery Children's Hospital, Edmonton, AB T6G 2B7, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2B7, Canada.
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28
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Cayabyab R, Ramanathan R. High unbound bilirubin for age: a neurotoxin with major effects on the developing brain. Pediatr Res 2019; 85:183-190. [PMID: 30518884 DOI: 10.1038/s41390-018-0224-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 01/30/2023]
Abstract
Neonatal hyperbilirubinemia is one of the most frequent diagnoses made in neonates. A high level of unconjugated bilirubin that is unbound to albumin is neurotoxic when the level exceeds age-specific thresholds or at lower levels in neonates with neurotoxic risk factors. Lower range of unbound bilirubin results in apoptosis, while moderate-to-high levels result in neuronal necrosis. Basal ganglia and various brain stem nuclei are more susceptible to bilirubin toxicity. Proposed mechanisms of bilirubin-induced neurotoxicity include excessive release of glutamate, mitochondrial energy failure, release of proinflammatory cytokines, and increased intracellular calcium concentration. These mechanisms are similar to the events that occur following hypoxic-ischemic insult in neonates. Severe hyperbilirubinemia in term neonates has been shown to be associated with increased risk for autism spectrum disorders. The neuropathological finding of bilirubin-induced neurotoxicity also includes cerebellar injury with a decreased number of Purkinje cells, and disruption of multisensory feedback loop between cerebellum and cortical neurons which may explain the clinical characteristics of autism spectrum disorders. Severe hyperbilirubinemia occurs more frequently in infants from low- and middle-income countries (LMIC). Simple devices to measure bilirubin, and timely treatment are essential to reduce neurotoxicity, and improve outcomes for thousands of neonates around the world.
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Affiliation(s)
- Rowena Cayabyab
- Keck School of Medicine of University of Southern California, Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Rangasamy Ramanathan
- Keck School of Medicine of University of Southern California, Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Los Angeles, CA, USA.
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29
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Le Pichon JB, Riordan SM, Shapiro SM. Hyperbilirubinemia and the Risk for Brain Injury. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00010-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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30
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Bilirubin binding in jaundiced newborns: from bench to bedside? Pediatr Res 2018; 84:494-498. [PMID: 29967530 DOI: 10.1038/s41390-018-0010-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 02/23/2018] [Accepted: 03/22/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bilirubin-induced neurologic dysfunction (BIND) is a spectrum of preventable neurological sequelae in jaundiced newborns. Current total plasma bilirubin (BT) concentration thresholds for phototherapy and/or exchange transfusion poorly predict BIND. METHODS The unbound (free) bilirubin (Bf) measured at these BT thresholds provides additional information about the risk for BIND. Bf can be readily adapted to clinical use by determining Bf population parameters at current BT thresholds. These parameters can be established using a plasma bilirubin binding panel (BBP) consisting of BT, Bf, and two empiric constants, the maximum BT (BTmax) and the corresponding equilibrium association bilirubin constant (K). RESULTS BTmax and K provide the variables needed to accurately estimate Bf at BT < BTmax to obtain Bf at threshold BT in patient samples. Once Bf population parameters are known, the BBP in a newborn can be used to identify poor bilirubin binding (higher Bf at the threshold BT compared with the population) and increased risk of BIND. CONCLUSION The BBP can also be used in jaundice screening to better identify the actual BT at which intervention would be prudent. The BBP is used with current BT thresholds to better identify the risk of BIND and whether and when to intervene.
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31
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Watchko JF. Emergency release uncross-matched packed red blood cells for immediate double volume exchange transfusion in neonates with intermediate to advanced acute bilirubin encephalopathy: timely but insufficient? J Perinatol 2018; 38:947-953. [PMID: 29997396 DOI: 10.1038/s41372-018-0168-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 06/14/2018] [Accepted: 06/18/2018] [Indexed: 11/09/2022]
Abstract
Given the urgency of double volume exchange transfusion (ExT) in an infant with intermediate to advanced stages of acute bilirubin encephalopathy (ABE), it has been suggested that emergency release uncross-matched packed red blood cells (ER-PRBC) be used. The efficacy of an ExT in removing bilirubin from the brain, however, is a direct function of the mass of albumin exchanged. The very low albumin content of ER-PRBC may fail to be neuroprotective. Predicted changes in total serum bilirubin (TSB), serum albumin, the bilirubin/albumin (B/A) ratio, plasma volume (PV), and bilirubin equilibration from the extravascular space during ER-PRBC ExT are described. ExT using ER-PRBC is efficacious in lowering the TSB. However, this result is falsely reassuring as significant concurrent serum albumin loss, resultant hypoalbuminemia, contraction of PV, limited bilirubin clearance from the extravascular space, and sustained B/A ratio elevations above recommended ExT treatment thresholds suggest that bilirubin neurotoxicity will continue.
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Affiliation(s)
- Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA.
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32
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Affiliation(s)
- M Jeffrey Maisels
- Beaumont Children's Hospital; Oakland University William Beaumont School of Medicine; Royal Oak MI USA
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33
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Amin SB, Wang H. Bilirubin Albumin Binding and Unbound Unconjugated Hyperbilirubinemia in Premature Infants. J Pediatr 2018; 192:47-52. [PMID: 29132818 PMCID: PMC5732858 DOI: 10.1016/j.jpeds.2017.09.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/12/2017] [Accepted: 09/15/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the associations between unbound bilirubin (UB) and total serum bilirubin (TSB), bilirubin:albumin molar ratio (BAMR), and bilirubin albumin binding affinity (Ka) as a function of gestational age (GA) in infants born at 24-33 weeks GA. STUDY DESIGN In a prospective observational study, TSB and UB were measured twice daily at least 8 hours apart during the first postnatal week. Serum albumin was measured to calculate BAMR on each day. The highest UB on each day, corresponding TSB, and serum albumin were used to calculate the Ka on each day. RESULTS For the 166 infants studied, peak UB significantly correlated with concomitant Ka (r = -0.44, P = .001) but not with concomitant TSB or BAMR after adjusting for GA. On multiple regression analyses, there was a significant association of concomitant Ka (-0.06, 95% CI -0.08 to -0.04, P = .0001), but not concomitant TSB or BAMR with peak UB after controlling for GA, birth weight, race, and sex. GA group was a significant effect modifier for the association between Ka and peak UB (0.03, 95% CI 0.02-0.04, P < .001). Interaction analyses showed the association between concomitant Ka and peak UB was significant for the 24-30 weeks GA group infants, but not for the 301/7-33 weeks GA group infants. CONCLUSIONS Peak UB was primarily associated with a decrease in binding affinity in infants ≤30 weeks GA. Interventions aimed at improving binding affinity may be important in decreasing the risk of bilirubin-induced neurotoxicity.
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Affiliation(s)
- Sanjiv B Amin
- Department of Pediatrics, Division of Neonatology, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Hongyue Wang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Bockor L, Bortolussi G, Vodret S, Iaconcig A, Jašprová J, Zelenka J, Vitek L, Tiribelli C, Muro AF. Modulation of bilirubin neurotoxicity by the Abcb1 transporter in the Ugt1-/- lethal mouse model of neonatal hyperbilirubinemia. Hum Mol Genet 2017; 26:145-157. [PMID: 28025333 DOI: 10.1093/hmg/ddw375] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/27/2016] [Indexed: 01/20/2023] Open
Abstract
Moderate neonatal jaundice is the most common clinical condition during newborn life. However, a combination of factors may result in acute hyperbilirubinemia, placing infants at risk of developing bilirubin encephalopathy and death by kernicterus. While most risk factors are known, the mechanisms acting to reduce susceptibility to bilirubin neurotoxicity remain unclear. The presence of modifier genes modulating the risk of developing bilirubin-induced brain damage is increasingly being recognised. The Abcb1 and Abcc1 members of the ABC family of transporters have been suggested to have an active role in exporting unconjugated bilirubin from the central nervous system into plasma. However, their role in reducing the risk of developing neurological damage and death during neonatal development is still unknown.To this end, we mated Abcb1a/b-/- and Abcc1-/- strains with Ugt1-/- mice, which develop severe neonatal hyperbilirubinemia. While about 60% of Ugt1-/- mice survived after temporary phototherapy, all Abcb1a/b-/-/Ugt1-/- mice died before postnatal day 21, showing higher cerebellar levels of unconjugated bilirubin. Interestingly, Abcc1 role appeared to be less important.In the cerebellum of Ugt1-/- mice, hyperbilirubinemia induced the expression of Car and Pxr nuclear receptors, known regulators of genes involved in the genotoxic response.We demonstrated a critical role of Abcb1 in protecting the cerebellum from bilirubin toxicity during neonatal development, the most clinically relevant phase for human babies, providing further understanding of the mechanisms regulating bilirubin neurotoxicity in vivo. Pharmacological treatments aimed to increase Abcb1 and Abcc1 expression, could represent a therapeutic option to reduce the risk of bilirubin neurotoxicity.
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Affiliation(s)
- Luka Bockor
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Giulia Bortolussi
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Simone Vodret
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Alessandra Iaconcig
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
| | - Jana Jašprová
- Institute of Medical Biochemistry and Laboratory Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jaroslav Zelenka
- Department of Biochemistry and Microbiology, University of Chemistry and Technology Prague, Technicka 3, 166 28 Prague, Czech Republic
| | - Libor Vitek
- Institute of Medical Biochemistry and Laboratory Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic.,Fourth Department of Internal Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Claudio Tiribelli
- Centro Studi Fegato, Fondazione Italiana Fegato, AREA Science Park, Campus Basovizza Trieste, Italy and
| | - Andrés F Muro
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Trieste, Italy
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Prevalence of Hypoalbuminemia and Elevated Bilirubin/Albumin Ratios in a Large Cohort of Infants in the Neonatal Intensive Care Unit. J Pediatr 2017; 188:280-286.e4. [PMID: 28669611 DOI: 10.1016/j.jpeds.2017.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/28/2017] [Accepted: 06/01/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To provide descriptive data on serum albumin levels and the bilirubin to albumin (B/A) ratio in neonates admitted to the neonatal intensive care unit, assess the effect of gestational and chronological age on serum albumin and the B/A ratio, and evaluate the association between extreme values and mortality. STUDY DESIGN Using a retrospective cohort design, we queried the Pediatrix clinical data warehouse for all infants born between 23 and 41 weeks of gestation from 1997 to 2014 who had a report of both a serum albumin and total serum bilirubin (TSB) level on the same day between birth and 14 days of life. RESULTS There were 382 190 paired albumin and bilirubin levels across 164 401 neonates (15% of the 1 072 682 infants in the clinical data warehouse). Both gestational age and postnatal age were independent factors that influenced the values for serum albumin, TSB, and B/A ratio (ANOVA; P < .0001). TSB and B/A ratios values above birth weight-specific thresholds for exchange transfusions were uncommon (<6% of infants). Hypoalbuminemia (<2.5 mg/dL) was common (29% of infants). Neonates with serum albumin levels <2.5 g/dL or with B/A ratio levels exceeding exchange thresholds were at higher risk of death compared with infants who did not exceed these levels. This association was independent of other risk factors (estimated gestational age, birth weight, sex, and the presence of a major anomaly). CONCLUSION Both gestational age and postnatal age influence TSB, albumin, and B/A ratios; hypoalbuminemia and extreme B/A ratios are associated with an increased risk of death.
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Unconjugated free bilirubin in preterm infants. Early Hum Dev 2017; 106-107:25-32. [PMID: 28183002 DOI: 10.1016/j.earlhumdev.2017.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/23/2016] [Accepted: 01/08/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hyperbilirubinemia guidelines are based on total serum bilirubin (TSB), in combination with either gestational age (GA) or birth weight (BW), postnatal age and specific risk factors. However, TSB is a poor predictor of bilirubin-induced neurotoxicity (BIND). Free unconjugated bilirubin (UCBfree) and the UCBfree/TSB ratio are more directly related to BIND, but data on their postnatal courses are unknown. AIMS To characterize the postnatal courses of UCBfree and UCBfree/TSB ratio, and assess their relationships with clinical characteristics. SUBJECTS 72 preterm infants≤32weeks GA, admitted to the University Medical Center Groningen, The Netherlands. STUDY DESIGN During the first postnatal week, bilirubin plasma parameters were analyzed and their relationship with clinical parameters was analyzed. Postnatal changes were analyzed using Generalized Estimating Equations. Data are expressed as medians [ranges]. RESULTS Less than 10% of the cohort (GA: 29 [26-31] weeks; BW: 1165 [600-1975] g) showed hyperbilirubinemic risk factors. We observed a large variation in UCBfree (27 [1-197] nmol/L), that could partly be explained by postnatal age and gender, but not by other risk factors. Maximal UCBfree levels of 50 [13-197] nmol/L occurred at day 4 and were higher in males. In contrast to TSB, UCBfree/TSB ratios (0.19 [0.01-1.04]) were higher in infants with low GA/BW. CONCLUSION UCBfree levels vary considerably in preterm infants, despite a low incidence of hyperbilirubinemic risk factors and similar TSB-based phototherapy treatment. UCBfree could not be predicted by GA or BW, but UCBfree/TSB ratios are highest in the smallest preterms, while they have the lowest TSB levels.
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Jain L. Why the Premature Brain Is More Prone to Bilirubin-induced Injury. Clin Perinatol 2016; 43:xv-xvi. [PMID: 27235215 DOI: 10.1016/j.clp.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lucky Jain
- Emory University School of Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA 30322, USA.
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Watchko JF. Measurement of Circulating Unbound Bilirubin: Will It Ever Be a Part of Routine Neonatal Care? J Pediatr 2016; 173:6-7. [PMID: 27063804 DOI: 10.1016/j.jpeds.2016.03.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/15/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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Abstract
Bilirubin-induced neurotoxicity in preterm neonates remains a clinical concern. Multiple cellular and molecular cascades likely underlie bilirubin-induced neuronal injury, including plasma membrane perturbations, excitotoxicity, neuroinflammation, oxidative stress, and cell cycle arrest. Preterm newborns are particularly vulnerable secondary to central nervous system immaturity and concurrent adverse clinical conditions that may potentiate bilirubin toxicity. Acute bilirubin encephalopathy in preterm neonates may be subtle and manifest primarily as recurrent symptomatic apneic events. Low-bilirubin kernicterus continues to be reported in preterm neonates, and although multifactorial in nature, is often associated with marked hypoalbuminemia.
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Affiliation(s)
- Jon F Watchko
- Division of Newborn Medicine, Department of Pediatrics, Magee-Womens Hospital, Children's Hospital of Pittsburgh, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA.
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Abstract
Although hyperbilirubinemia is extremely common among neonates and is usually mild and transient, it sometimes leads to bilirubin-induced neurologic damage (BIND). The auditory pathway is highly sensitive to the effects of elevated total serum/plasma bilirubin (TB) levels, with damage manifesting clinically as auditory neuropathy spectrum disorder. Compared to full-term neonates, preterm neonates are more susceptible to BIND and suffer adverse effects at lower TB levels with worse long-term outcomes. Furthermore, although standardized guidelines for management of hyperbilirubinemia exist for term and late preterm neonates, similar guidelines for neonates less than 35 weeks gestational age are limited.
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Affiliation(s)
- Cristen Olds
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, 801 Welch Road, CA 94305, USA
| | - John S Oghalai
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, 801 Welch Road, CA 94305, USA.
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Kaplan M, Hammerman C, Bhutani VK. The Preterm Infant: A High-Risk Situation for Neonatal Hyperbilirubinemia Due to Glucose-6-Phosphate Dehydrogenase Deficiency. Clin Perinatol 2016; 43:325-40. [PMID: 27235211 DOI: 10.1016/j.clp.2016.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Prematurity and glucose-6-phosphate dehydrogenase (G6PD) deficiency are risk factors for neonatal hyperbilirubinemia. The 2 conditions may interact additively or synergistically, contributing to extreme hyperbilirubinemia, with the potential for bilirubin neurotoxicity. This hyperbilirubinemia is the result of sudden, unpredictable, and acute episodes of hemolysis in combination with immaturity of bilirubin elimination, primarily of conjugation. Avoidance of contact with known triggers of hemolysis in G6PD-deficient individuals will prevent some, but not all, episodes of hemolysis. All preterm infants with G6PD deficiency should be vigilantly observed for the development of jaundice both in hospital and after discharge home.
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Affiliation(s)
- Michael Kaplan
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem, P.O. Box 12271, Jerusalem, 9112102 Israel; Department of Neonatology, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel.
| | - Cathy Hammerman
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem, P.O. Box 12271, Jerusalem, 9112102 Israel; Department of Neonatology, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel
| | - Vinod K Bhutani
- Department of Pediatrics, Stanford University School of Medicine, 750 Welch Road, Suite 315, Palo Alto, CA 94305, USA
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