Jaundice Eye Color Index (JECI): quantifying the yellowness of the sclera in jaundiced neonates with digital photography

[Global disease burden of neonatal jaundice from 1990 to 2019]

OBJECTIVES

To examine the global, regional, and national disease burden of neonatal jaundice.

METHODS

The 2019 Global Burden of Disease database was searched to collect incident cases/incidence and deaths/mortality of neonatal jaundice, as well as global socio-demographic index (SDI) and universal health coverage index (UHCI). The epidemiological trend of neonatal jaundice from 1990 to 2019 was analyzed. The correlations between incidence/mortality of neonatal jaundice and SDI and UHCI were evaluated.

RESULTS

From 601 681 in 1990 to 626 005 in 2019, with a 4.04% increase in global incident cases of neonatal jaundice. The overall age-standardized incidence rate exhibited an increase [estimated annual percent change=0.13 (95%CI: 0.03 to 0.23)] during this period. Additionally, deaths due to neonatal jaundice decreased by 58.83%, from 128 119 in 1990 to 52 742 in 2019. The overall age-standardized mortality rate showed a decrease [estimated annual percent change=-2.78 (95%CI: -3.00 to -2.57)] over the same period. Countries with lower SDI, such as India, Pakistan, and Nigeria, reported a higher proportion of neonatal morbidity and mortality. In 2019, a negative correlation was observed between estimated annual percent change in age-standardized mortality rate and SDI (ρ=-0.320, P<0.05) or UHCI (ρ=-0.252, P<0.05).

CONCLUSIONS

The global incidence of neonatal jaundice is on the rise, while the mortality rate is declining. The burden of neonatal jaundice is influenced by social development, economic factors, and the level of medical care.

Identification and Quantification of Jaundice by Trans-Conjunctiva Optical Imaging Using a Human Brain-like Algorithm: A Cross-Sectional Study

Jaundice is caused by excess circulating bilirubin, known as hyperbilirubinemia. This symptom is sometimes caused by a critical hepatobiliary disorder, and is generally identified as yellowish sclera when bilirubin levels increase more than 3 mg/dL. It is difficult to identify jaundice accurately, especially via telemedicine. This study aimed to identify and quantify jaundice by trans-conjunctiva optical imaging. Patients with jaundice (total bilirubin ≥3 mg/dL) and normal control subjects (total bilirubin <3 mg/dL) were prospectively enrolled from June 2021 to July 2022. We took bilateral conjunctiva imaging with a built-in camera on a smartphone (1st generation iPhone SE) under normal white light conditions without any restrictions. We processed the images using an Algorithm Based on Human Brain (ABHB) (Zeta Bridge Corporation, Tokyo, Japan) and converted them into a hue degree of Hue Saturation Lightness (HSL) color space. A total of 26 patients with jaundice (9.57 ± 7.11 mg/dL) and 25 control subjects (0.77 ± 0.35 mg/dL) were enrolled in this study. The causes of jaundice among the 18 male and 8 female subjects (median age 61 yrs.) included hepatobiliary cancer (n = 10), chronic hepatitis or cirrhosis (n = 6), pancreatic cancer (n = 4), acute liver failure (n = 2), cholelithiasis or cholangitis (n = 2), acute pancreatitis (n = 1), and Gilbert's syndrome (n = 1). The maximum hue degree (MHD) optimal cutoff to identify jaundice was 40.8 (sensitivity 81% and specificity 80%), and the AUROC was 0.842. The MHD was moderately correlated to total serum bilirubin (TSB) levels (rS = 0.528, p < 0.001). TSB level (≥5 mg/dL) can be estimated by the formula 21.1603 - 0.7371 × 56.3-MHD2. In conclusion, the ABHB-based MHD of conjunctiva imaging identified jaundice using an ordinary smartphone without any specific attachments and deep learning. This novel technology could be a helpful diagnostic tool in telemedicine or self-medication.

Determinants of neonatal jaundice in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Neonatal jaundice is a common condition characterized by a yellowish discoloration of the skin, conjunctiva, and sclera caused by elevated serum or plasma bilirubin levels during the newborn period. The condition is usually not dangerous, but it can progress to severe hyperbilirubinemia, which can lead to acute bilirubin encephalopathy and kernicterus, a bilirubin-induced neurological damage. Therefore, this study aimed to assess the pooled prevalence of neonatal jaundice and its determinants in Ethiopia.

METHODS

Scopus, PubMed, Google Scholar, Embase, and CINAHL databases were searched for studies published between January 1, 2010 and July 30, 2021. A weighted DerSimonian Laird random-effects model was used to estimate the pooled prevalence of neonatal jaundice and its associated factors. The I² was used to calculate the degree of heterogeneity. The funnel plot and Egger's regression test were used to assess publication bias.

RESULTS

Totally 697 articles were generated from various databases, and the review included a total of eight articles. The pooled prevalence of neonatal jaundice was 30.96% [95% confidence interval (CI) 16.61%-45.31%)] in Ethiopia. This review showed that prolonged labor [adjusted odd ratio (AOR) = 3.39; 95% CI 2.41-4.77), low birth weight (AOR = 5.12; 95% CI 3.11-8.72), birth asphyxia (AOR = 3.75; 95% CI 2.11-6.66), cephalohematoma (AOR = 7.07; 95% CI 2.72-18.38), ABO incompatibility (AOR = 6.05; 95% CI 2.95-12.42), Rhesus (RH) incompatibility (AOR = 3.77; 95% CI 2.04-6.96), male sex (AOR = 4.53; 95% CI 3.39-6.07), and neonatal sepsis (AOR = 2.47; 95% CI 1.49-4.08) were identified as a determining factor for neonatal jaundice in Ethiopia.

CONCLUSIONS

In low- and middle-income countries, neonatal jaundice is a significant healthcare burden, accounting for a significant portion of global childhood mortality and morbidity. However, some low-cost, effective, practical, and dependable solutions have been implemented. Prolonged labor, ABO incompatibility, RH incompatibility, birth asphyxia, neonatal sepsis, low birth weight, cephalohematoma, and male sex were identified as risk factors for neonatal jaundice in Ethiopia.

National Early Warning Score (NEWS) Outperforms Quick Sepsis-Related Organ Failure (qSOFA) Score for Early Detection of Sepsis in the Emergency Department

Background: Prompt recognition of sepsis is critical to improving patients’ outcomes. We compared the performance of NEWS and qSOFA scores as sepsis detection tools in patients admitted to the emergency department (ED) with suspicion of sepsis. Methodology: A single-center 12-month retrospective study comparing NEWS using the recommended cut-off of ≥5 and qSOFA as sepsis screening tools in a cohort of patients transported by emergency medical services (EMS) to the Lausanne University Hospital (LUH). We used the Sepsis-3 consensus definition. The primary study endpoint was the detection of sepsis. Secondary endpoints were ICU admission and 28-day all-cause mortality. Results: Among 886 patients admitted to ED by EMS for suspected infection, 556 (63%) had a complete set of vital parameters panel enabling the calculation of NEWS and qSOFA scores, of whom 300 (54%) had sepsis. For the detection of sepsis, the sensitivity of NEWS > 5 was 86% and that of qSOFA ≥ 2 was 34%. Likewise, the sensitivities of NEWS ≥ 5 for predicting ICU admission and 28-day mortality were higher than those of qSOFA ≥ 2 (82% versus 33% and 88% versus 37%). Conversely, the specificity of qSOFA ≥ 2 for sepsis detection was higher than that of NEWS ≥ 5 (90% versus 55%). The negative predictive value of NEWS > 5 was higher than that of qSOFA ≥ 2 (77% versus 54%), while the positive predictive value of qSOFA ≥ 2 was higher than that of NEWS ≥ 5 (80% versus 69%). Finally, the accuracy of NEWS ≥ 5 was higher than that of qSOFA ≥ 2 (72% versus 60%). Conclusions: The sensitivity of NEWS ≥ 5 was superior to that of qSOFA ≥ 2 to identify patients with sepsis in the ED and predict ICU admission and 28-day mortality. In contrast, qSOFA ≥ 2 had higher specificity and positive predictive values than NEWS ≥ 5 for these three endpoints.

On AI Approaches for Promoting Maternal and Neonatal Health in Low Resource Settings: A Review

A significant challenge for hospitals and medical practitioners in low- and middle-income nations is the lack of sufficient health care facilities for timely medical diagnosis of chronic and deadly diseases. Particularly, maternal and neonatal morbidity due to various non-communicable and nutrition related diseases is a serious public health issue that leads to several deaths every year. These diseases affecting either mother or child can be hospital-acquired, contracted during pregnancy or delivery, postpartum and even during child growth and development. Many of these conditions are challenging to detect at their early stages, which puts the patient at risk of developing severe conditions over time. Therefore, there is a need for early screening, detection and diagnosis, which could reduce maternal and neonatal mortality. With the advent of Artificial Intelligence (AI), digital technologies have emerged as practical assistive tools in different healthcare sectors but are still in their nascent stages when applied to maternal and neonatal health. This review article presents an in-depth examination of digital solutions proposed for maternal and neonatal healthcare in low resource settings and discusses the open problems as well as future research directions.

Changes to Eye Whiteness and Eyelid/Brow Position With Topical Oxymetazoline in Aesthetic Patients

BACKGROUND

Oxymetazoline hydrochloride 0.1% ophthalmic solution has recently been approved in the United States for the treatment of ptosis.

OBJECTIVES

The aim of this study was to assess the upper and lower eyelid position as well as the brow position and the color of the sclera following the ophthalmic administration of oxymetazoline hydrochloride 0.1%.

METHODS

In this prospective cohort study, consecutive patients presenting with ptosis received topical oxymetazoline 0.1%. The primary outcome was measurement of the upper eyelid height (margin-to-reflex distance 1 [MRD1]) and lower eyelid height (MRD2) relative to the center of pupil, along with assessment of brow height, measured on photographs at baseline and 2 hours after instillation of oxymetazoline. The secondary outcome was the assessment of the color of the sclera (eye whiteness) before and after treatment with a novel color space algorithm.

RESULTS

Twenty-nine patients participated in the study. The mean [SD] MRD1 at baseline was 2.3 [0.6] mm. At 2 hours following oxymetazoline treatment, the mean MRD1 significantly increased to 4.2 [0.9] mm (P < 0.01). The mean MRD2 also significantly increased from 5.3 [0.9] mm to 5.7 [1.0] mm (P < 0.01). Brow position did not change with treatment (P = 0.4). Following treatment, the eye sclera became significantly whiter, with a mean ΔEab (color change) of 9.7 [3.9], with 57 out of 58 eyes experiencing a significant change in color. A change of ΔEab ≥2 is considered visually perceptible to the human eye.

CONCLUSIONS

Within 2 hours of use, oxymetazoline significantly improves the size of the palpebral aperture (MRD1 + MRD2) and also makes the eye appear significantly whiter.

LEVEL OF EVIDENCE: 4

Smartphones’ Skin Colour Reproduction Analysis for Neonatal Jaundice Detection

Abstract In recent years, smartphone-based colour imaging systems are being increasingly used for Neonatal jaundice detection applications. These systems are based on the estimation of bilirubin concentration levels that correlates with newborns’ skin colour images corresponding to total serum bilirubin (TSB) and transcutaneous bilirubinometry (TcB) measurements. However, the colour reproduction capacity of smartphone cameras are known to be influenced by various factors including the technological and acquisition process variabilities. To make an accurate bilirubin estimation, irrespective of the type of smartphone and illumination conditions used to capture the newborns’ skin images, an inclusive and complete model, or data set, which can represent all the possible real world acquisitions scenarios needs to be utilized. Due to various challenges in generating such a model or a data set, some solutions tend towards the application of reduced data set (designed for reference conditions and devices only) and colour correction systems (for the transformation of other smartphone skin images to the reference space). Such approaches will make the bilirubin estimation methods highly dependent on the accuracy of their employed colour correction systems, and the capability of reducing device-to-device colour reproduction variability. However, the state-of-the-art methods with similar methodologies were only evaluated and validated on a single smartphone camera. The vulnerability of the systems in making an incorrect jaundice diagnosis can only be shown with a thorough investigation of the colour reproduction variability for extended number of smartphones and illumination conditions. Accordingly, this work presents and discuss the results of such broad investigation, including the evaluation of seven smartphone cameras, ten light sources, and three different colour correction approaches. The overall results show statistically significant colour differences among devices, even after colour correction applications, and that further analysis on clinically significance of such differences is required for skin colour based jaundice diagnosis.

Screening methods for neonatal hyperbilirubinemia: benefits, limitations, requirements, and novel developments

Severe neonatal hyperbilirubinemia (SNH) is a serious condition that occurs worldwide. Timely recognition with bilirubin determination is key in the management of SNH. Visual assessment of jaundice is unreliable. Fortunately, transcutaneous bilirubin measurement for screening newborn infants is routinely available in many hospitals and outpatient settings. Despite a few limitations, the use of transcutaneous devices facilitates early recognition and appropriate management of neonatal jaundice. Unfortunately, however, advanced and often costly screening modalities are not accessible to everyone, while there is an urgent need for inexpensive yet accurate instruments to assess total serum bilirubin (TSB). In the near future, novel icterometers, and in particular optical bilirubin estimates obtained with a smartphone camera and processed with a smartphone application (app), seem promising methods for screening for SNH. If proven reliable, these methods may empower outpatient health workers as well as parents at home to detect jaundice using a simple portable device. Successful implementation of ubiquitous bilirubin screening may contribute substantially to the reduction of the worldwide burden of SNH. The benefits of non-invasive bilirubin screening notwithstanding, any bilirubin determination obtained through non-invasive screening must be confirmed by a diagnostic method before treatment. IMPACT: Key message: Screening methods for neonatal hyperbilirubinemia facilitate early recognition and timely treatment of severe neonatal hyperbilirubinemia (SNH). Any bilirubin screening result obtained must be confirmed by a diagnostic method. What does this article add to the existing literature? Data on optical bilirubin estimation are summarized. Niche research strategies for prevention of SNH are presented. Impact: Transcutaneous screening for neonatal hyperbilirubinemia contributes to the prevention of SNH. A smartphone application with optical bilirubin estimation seems a promising low-cost screening method, especially in low-resource settings or at home.

Diversity in Primate External Eye Morphology: Previously Undescribed Traits and Their Potential Adaptive Value

Comparative examinations of external eye morphology in primates initially focused on communicative functions of the eye. Subsequent work has failed to find consistent associations between specific eye morphologies and communicative functions. In this article, we review the field of primate external eye morphology and inspect publicly available and unpublished photographs. We identify and describe five commonly occurring traits that have not received attention so far. We cross-examined the clinical and psychological literature to propose potential adaptive functions. These potential adaptive functions include communicative functions, but also photoregulatory functions and photoprotective functions.

Knowledge, Observation and Practices Related to Neonatal Jaundice in a Rural Community in Kano, Nigeria

BACKGROUND

Neonatal jaundice (NNJ) is a common condition and when not adequately treated leads to acute bilirubin encephalopathy/kernicterus. This largely preventable condition is an important cause of death and disability in low- and middle-income countries. Education, early detection and effective management are key for prevention and require an understanding of community knowledge and practices to foster appropriate behavior to prevent severe NNJ. Therefore, the aim of this study was to identify knowledge, observation for jaundice (both active and passive) and practices related to NNJ in northern Nigeria.

METHODS

This descriptive, correlational and cross-sectional study enrolled 298 household members with an average age of 29.8 years in Kano, Nigeria. A structured questionnaire regarding knowledge of, potential sequelae and causes and local practices related to NNJ was administered and data were analyzed using descriptive and Chi-square statistics.

RESULTS

Participants reported: 85% NNJ to be a sign of illness; 3% understood that NNJ could cause brain damage; 94% did not actively observe for jaundice in their newborns; 56% did not know what causes NNJ; 88% would seek care if their newborn developed jaundice. Significant relationships between educational levels and what study participants would do if a newborn develops jaundice and between occupation, educational level and knowledge about causes of NNJ were noted, consistent with a difference in active jaundice observation between ethnic groups.

CONCLUSION

A public health approach to NNJ with a strong community education program is a crucial next step in the fight to eliminate severe NNJ.

Bilirubin estimates from smartphone images of newborn infants' skin correlated highly to serum bilirubin levels

AIM

Neonatal jaundice is an important cause of morbidity and mortality, and identifying the condition remains a challenge. This study evaluated a novel method of estimating bilirubin levels from colour-calibrated smartphone images.

METHODS

A cross-sectional prospective study was undertaken at two hospitals in Norway from February 2017 to March 2019, with standardised illumination at one hospital and non-standardised illumination at the other hospital. Healthy term-born infants with a normal birthweight were recruited up to 15 days of age. The main outcome measures were bilirubin estimates from digital images, plus total bilirubin in serum (TSB) and transcutaneous bilirubin (TcB).

RESULTS

Bilirubin estimates were performed for 302 newborn infants, and 76 had severe jaundice. The correlation between the smartphone estimates and TSB was measured by Pearson's r and was .84 for the whole sample. The correlation between the image estimates and TcB was 0.81. There were no significant differences between the hospitals. Sensitivity was 100%, and specificity was 69% for identifying severe jaundice of more than 250 µmol/L.

CONCLUSION

A smartphone-based tool that estimated bilirubin levels from digital images identified severe jaundice with high sensitivity and could provide a screening tool for neonatal jaundice.

Accurate device-independent colorimetric measurements using smartphones

Smartphones provide an ideal platform for colorimetric measurements due to their low cost, portability and image quality. As with any imaging-based colorimetry system, ambient light and device variations introduce error which must be dealt with. We propose a novel processing method consisting of a one-time calibration stage to account for inter-phone variations, and an innovative use of ambient light subtraction with image pairs to account for variation in ambient light. Data collection is kept very simple, making it particularly useful for use in the field, since nothing additional is required in the images. Ambient subtraction is first demonstrated for a range of colors and phones (Samsung S8 and LG Nexus 5X), and the Subtracted Signal to Noise Ratio (SSNR) is defined as a metric for assessing whether an image pair is appropriate at the time of image capture. The experimentally determined SSNR threshold below which to suggest retaking the images is 3.4. The classification accuracy for results using the proposed calibration pipeline is then compared to the simplest image metadata-based alternative and is found to be greatly superior. Finally, a custom colorcard is shown to improve the accuracy of device-independent results for known smaller ranges of colors over a standard colorcard, making this a possible application-specific modification to the overall processing pipeline.

Smartphone screening for neonatal jaundice via ambient-subtracted sclera chromaticity

Jaundice is a major cause of mortality and morbidity in the newborn. Globally, early identification and home monitoring are significant challenges in reducing the incidence of jaundice-related neurological damage. Smartphone cameras are promising as colour-based screening tools as they are low-cost, objective and ubiquitous. We propose a novel smartphone method to screen for neonatal jaundice by imaging the sclera. It does not rely on colour calibration cards or accessories, which may facilitate its adoption at scale and in less economically developed regions. Our approach is to explicitly address three confounding factors in relating colour to jaundice: (1) skin pigmentation, (2) ambient light, and (3) camera spectral response. (1) The variation in skin pigmentation is avoided by imaging the sclera. (2) With the smartphone screen acting as an illuminating flash, a flash/ no-flash image pair is captured using the front-facing camera. The contribution of ambient light is subtracted. (3) In principle, this permits a device- and ambient-independent measure of sclera chromaticity following a one-time calibration. We introduce the concept of Scleral-Conjunctival Bilirubin (SCB), in analogy with Transcutaneous Bilirubin (TcB). The scleral chromaticity is mapped to an SCB value. A pilot study was conducted in the UCL Hospital Neonatal Care Unit (n = 37). Neonates were imaged using a specially developed app concurrently with having a blood test for total serum bilirubin (TSB). The better of two models for SCB based on ambient-subtracted sclera chromaticity achieved r = 0.75 (p<0.01) correlation with TSB. Ambient subtraction improved chromaticity estimates in proof-of-principle laboratory tests and screening performance within our study sample. Using an SCB decision threshold of 190μmol/L, the sensitivity was 100% (specificity 61%) in identifying newborns with TSB>250μmol/L (area under receiver operating characteristic curve, AUROC, 0.86), and 92% (specificity 67%) in identifying newborns with TSB>205μmol/L (AUROC 0.85). These results are comparable to modern transcutaneous bilirubinometers.