Health-care resource use and current treatment of adult atopic dermatitis patients in Japan: A retrospective claims database analysis

The real-world evidence on the profiles of patients suffering from atopic dermatitis (AD) in Japan is sparse. A retrospective claim database analysis was conducted to estimate the health-care resource use (HCRU) and current AD treatment. Data from October 2013 to September 2016 were extracted from the JMDC (Tokyo, Japan) claims database. HCRU was assessed by a comparison of AD patients and matched non-AD controls. A multivariate analysis was performed to estimate HCRU attributable to AD. AD patients (n = 39 893) have more claims of certain diagnoses such as rhinitis, viral and fungal infections, sleep disorders and conjunctivitis as well as higher HCRU (outpatient visits, prescriptions of AD-related and non-AD-related medications, phototherapy, laboratory tests) than matched non-AD controls (n = 39 893). Treatment pattern analysis included treatment-naive patients (n = 8478) and previously treated AD patients (n = 30 109). Approximately 20% of previously treated patients were on the continuous systemic treatment during 18-month follow up. Systemic corticosteroids were the most frequently used systemic treatments. Oral cyclosporin was less frequently used in both groups, but for the longest duration. Almost half of previously treated patients with oral cyclosporin continued treatment for more than 3 months. In conclusion, HCRU was higher in AD patients than non-AD controls, indicating a high burden of the disease imposed on AD patients. Continuous administration of systemic treatment, such as oral cyclosporin, systemic corticosteroids and phototherapy, observed in AD patients sheds light on the difficulties of managing AD in Japanese clinical practise.

Comparison of light-emitting diodelights vs fluorescent light phototherpy for the treatment of unconjugated hyperbilirubinemia in preterm infants - Randomised Control Trial

OBJECTIVE

To compare the mean treatment duration of phototherapy when done with light-emitting diodelights versus fluorescent lights for the treatment of unconjugated hyperbilirubinaemia in preterm infants.

METHODS

The randomised controlled trial was conducted at Allied Hospital, Faisalabad, Pakistan, from September 12, 2015, to March 11, 2016, and comprised patients with unconjugated hyperbilirubinaemia. Detailed history, including demographic information, were noted. The patients were divided into two groups using computergenerated random number tables. Group A received light-emitting diode light phototherapy and group B received fluorescent light phototherapy. Initially complete blood count with peripheral film, retic count, coombs test, blood group, serum bilirubin level (total, direct, indirect) were done. Serum bilirubin was checked by bilirubinometre 6hourly till the end of treatment. Data analysis was done using SPSS 20..

RESULTS

There were 460 patients divided into two equal groups of 230(50%) each. Mean age was 32.34}2.28 weeks in Group A and 32.21}2.11weeks in Group B. In Group A, 116(50.43%) subjects were boys and 114(49.57%) were girls. In Group B, 120(52.17%) were boys and 110(47.83%) were girls. Mean duration of treatment was recorded as 36.83+2.09 hours in Group A and 45.66+2.52 hours in Group B. (p=0.0001).

CONCLUSIONS

The mean duration of treatment of phototherapy with light-emitting diodelights lights was significantly shorter compared to fluorescent lights.

Preventive effect of purgative manna on neonatal jaundice: A double blind randomized controlled clinical trial

ETHNOPHARMACOLOGICAL RELEVANCE

Cotoneaster nummularioides Pojark manna (Shir-e-Khesht) is popular in Persian medicine. Different effects of some Cotoneaster species manna include antibacterial, antioxidant, anticancer, and hepatoprotective effects, as well as bilirubin serum levels reduction. Cotoneaster species manna is used in many parts of Iran as a laxative and accelerates the passage of meconium. Neonatal jaundice has relatively costly and sometimes invasive therapeutic interventions, which its prevention from becoming severe cases can be a priority in neonatal medicine.

AIM OF THE STUDY

The aim of this study was to evaluate the effectiveness of an herbal product (Purgative Manna, native to Iran and Asian countries) in preventing severe cases of jaundice and reducing total bilirubin levels in neonates.

MATERIALS AND METHODS

This randomized double-blind controlled clinical trial included full-term babies. Four hundred and forty-five (445) eligible neonates were assigned to two groups using the block balanced randomization method; 222 neonates received the Purgative Manna product as drops, and 223 neonates received placebo drops. The neonates received a dose of 5 drops per kilogram of neonatal weight (divided into three doses per day) for three days. The treatment period was three days, and a 24-h (three times) examination was performed to measure the initial outcome of the trial (i.e., the total serum bilirubin level). The secondary outcomes of this trial were the need for hospitalization due to jaundice and/or phototherapy from 4 to 14 days after birth, the frequency of defecation within 24 h, and the triple complications of diarrhoea, dehydration symptoms, and abdominal colic.

RESULTS

In this study, 220 neonates in the Purgative Manna product group and 222 neonates in the placebo group completed their interventions within the predicted period of the study. At the end of study, the total bilirubin level in the Purgative Manna treated group was significantly lower than that of the placebo group. The difference between the mean total bilirubin levels of the two groups was approximately 2.1 mg/dl on the third day after treatment, with an effect size of 0.79 (95% CI: 0.06-0.98). The relative risk for reducing the need for hospitalization or phototherapy in the group treated with Purgative Manna drops was 0.26, compared with the placebo group. The risk of occurrence of severe jaundice or phototherapy in the Purgative Manna group was 75% lower than that of the placebo group. The median frequency of defecation in the intervention group at three time intervals in the first, second and third days after treatment was 1-2 times more than that of the comparison group (p < 0.001).

CONCLUSIONS

Meanwhile, considering the fact that one in every eight neonates who used the product avoided having a severe and high-risk case of jaundice or the need for phototherapy intervention (even through an exchange transfusion), the use of Purgative Manna drops can be recommended; however, further study is necessary.

The utilization of phototherapy in the department of dermatology, Hospital Kuala Lumpur: A 5-year audit

INTRODUCTION

Ultraviolet phototherapies are important treatment modalities for a wide range of dermatological conditions. We aim to describe the utilization of phototherapy in the Department of Dermatology Hospital Kuala Lumpur.

METHODS

This is a 5-year retrospective audit on patients who underwent phototherapy between 2011 and 2015.

RESULTS

There were 892 patients, M:F=1.08:1, aged from 4- 88 years, with a median age of 38.8 years who underwent phototherapy. Majority (58.9%) had skin phototype IV, followed by type III (37.7%) and type II (0.7%). There were 697(78.1%) who underwent NBUVB, 136 (15.2%) had topical PUVA, 22(2.5%) had oral PUVA, 12(1.4%) had UVA1 and 23(2.6%) had NBUVB with topical or oral PUVA/UVA1 at different time periods. The indications were psoriasis (46.6%), vitiligo (26.7%), atopic eczema (9.8%), pityriasis lichenoides chronica (5.3%), mycosis fungoides (3.9%), lichen planus (2.5%), nodular prurigo (2.2%), scleroderma (1.2%), alopecia areata (0.7%) and others. The median number of session received were 27 (range 1-252) for NBUVB, 30 (range 1-330) for topical PUVA, 30 (range 3-190) for oral PUVA and 24.5 (range 2-161) for UVA1. The acute adverse effects experienced by patients were erythema (18%), pruritus (16.3%), warmth (3.3%), blister formation (3.1%), cutaneous pain (2.4%), and xerosis (0.8%), skin swelling (0.7%) and phototoxicity (0.2%).

CONCLUSION

Narrow-band UVB was the most frequently prescribed phototherapy modality in our center. The most common indication for phototherapy in our setting was psoriasis. Acute adverse events occurred in a third of patients, although these side effects were mild.

Provision of respiratory support compared to no respiratory support before cord clamping for preterm infants

BACKGROUND

Placental transfusion (by means of delayed cord clamping (DCC), cord milking, or cord stripping) confers benefits for preterm infants. It is not known if providing respiratory support to preterm infants before cord clamping improves outcomes.

OBJECTIVES

To assess the efficacy and safety of respiratory support provided during DCC compared with no respiratory support during placental transfusion (in the form of DCC, milking, or stripping) in preterm infants immediately after delivery.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL, 2017, Issue 5), MEDLINE via PubMed (1966 to 19 June 2017), Embase (1980 to 19 June 2017), and CINAHL (1982 to 19 June 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials.

SELECTION CRITERIA

Randomized, cluster randomized, or quasi-randomized controlled trials enrolling preterm infants undergoing DCC, where one of the groups received respiratory support before cord clamping and the control group received no respiratory support before cord clamping.

DATA COLLECTION AND ANALYSIS

All review authors assisted with data collection, assessment, and extraction. Two review authors assessed the quality of evidence using the GRADE approach. We contacted study authors to request missing information.

MAIN RESULTS

One study fulfilled the review criteria. In this study, 150 preterm infants of less than 32 weeks' gestation undergoing 60 second DCC were randomized to a group who received respiratory support in the form of continuous positive airway pressure (CPAP) or positive pressure ventilation during DCC and a group that did not receive respiratory support during the procedure. Mortality during hospital admission was not significantly different between groups with wide confidence intervals (CI) for magnitude of effect (risk ratio (RR) 1.67, 95% CI 0.41 to 6.73). The study did not report neurodevelopmental disability and death or disability at two to three years of age. There were no significant differences between groups in condition at birth (Apgar scores or intubation in the delivery room), use of inotropic agents (RR 1.25, CI 0.63 to 2.49), and receipt of blood transfusion (RR 1.03, 95% CI 0.70 to 1.54). In addition, there were no significant differences in the incidences of any intraventricular haemorrhage (RR 1.50, 95% CI 0.65 to 3.46) and severe intraventricular haemorrhage (RR 1.33, 95% CI 0.31 to 5.75). Several continuous variables were reported in subgroups depending on method of delivery. Unpublished data for each group as a whole was made available and showed peak haematocrit in the first 24 hours and duration of phototherapy did not differ significantly. Overall, the quality of evidence for several key neonatal outcomes (e.g. mortality and intraventricular haemorrhage) was low because of lack of precision with wide CIs.

AUTHORS' CONCLUSIONS

The results from one study with wide CIs for magnitude of effect do not provide evidence either for or against the use of respiratory support before clamping the umbilical cord. A greater body of evidence is required as many of the outcomes of interest to the review occurred infrequently. Similarly, the one included study cannot answer the question of whether the intervention is or is not harmful.

Fluid supplementation for neonatal unconjugated hyperbilirubinaemia

BACKGROUND

Neonatal hyperbilirubinaemia is a common problem which carries a risk of neurotoxicity. Certain infants who have hyperbilirubinaemia develop bilirubin encephalopathy and kernicterus which may lead to long-term disability. Phototherapy is currently the mainstay of treatment for neonatal hyperbilirubinaemia. Among the adjunctive measures to compliment the effects of phototherapy, fluid supplementation has been proposed to reduce serum bilirubin levels. The mechanism of action proposed includes direct dilutional effects of intravenous (IV) fluids, or enhancement of peristalsis to reduce enterohepatic circulation by oral fluid supplementation.

OBJECTIVES

To assess the risks and benefits of fluid supplementation compared to standard fluid management in term and preterm newborn infants with unconjugated hyperbilirubinaemia who require phototherapy.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 5), MEDLINE via PubMed (1966 to 7 June 2017), Embase (1980 to 7 June 2017), and CINAHL (1982 to 7 June 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

We included randomised controlled trials that compared fluid supplementation against no fluid supplementation, or one form of fluid supplementation against another.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group using the Covidence platform. Two review authors independently assessed the eligibility and risk of bias of the retrieved records. We expressed our results using mean difference (MD), risk difference (RD), and risk ratio (RR) with 95% confidence intervals (CIs).

MAIN RESULTS

Out of 1449 articles screened, seven studies were included. Three articles were awaiting classification, among them, two completed trials identified from the trial registry appeared to be unpublished so far.There were two major comparisons: IV fluid supplementation versus no fluid supplementation (six studies) and IV fluid supplementation versus oral fluid supplementation (one study). A total of 494 term, healthy newborn infants with unconjugated hyperbilirubinaemia were evaluated. All studies were at high risk of bias for blinding of care personnel, five studies had unclear risk of bias for blinding of outcome assessors, and most studies had unclear risk of bias in allocation concealment. There was low- to moderate-quality evidence for all major outcomes.In the comparison between IV fluid supplementation and no supplementation, no infant in either group developed bilirubin encephalopathy in the one study that reported this outcome. Serum bilirubin was lower at four hours postintervention for infants who received IV fluid supplementation (MD -34.00 μmol/L (-1.99 mg/dL), 95% CI -52.29 (3.06) to -15.71 (0.92); participants = 67, study = 1) (low quality of evidence, downgraded one level for indirectness and one level for suspected publication bias). Beyond eight hours postintervention, serum bilirubin was similar between the two groups. Duration of phototherapy was significantly shorter for fluid-supplemented infants, but the estimate was affected by heterogeneity which was not clearly explained (MD -10.70 hours, 95% CI -15.55 to -5.85; participants = 218; studies = 3; I² = 67%). Fluid-supplemented infants were less likely to require exchange transfusion (RR 0.39, 95% CI 0.21 to 0.71; RD -0.01, 95% CI -0.04 to 0.02; participants = 462; studies = 6; I² = 72%) (low quality of evidence, downgraded one level due to inconsistency, and another level due to suspected publication bias), and the estimate was similarly affected by unexplained heterogeneity. The frequencies of breastfeeding were similar between the fluid-supplemented and non-supplemented infants in days one to three based on one study (estimate on day three: MD 0.90 feeds, 95% CI -0.40 to 2.20; participants = 60) (moderate quality of evidence, downgraded one level for imprecision).One study contributed to all outcome data in the comparison of IV versus oral fluid supplementation. In this comparison, no infant in either group developed abnormal neurological signs. Serum bilirubin, as well as the rate of change of serum bilirubin, were similar between the two groups at four hours after phototherapy (serum bilirubin: MD 11.00 μmol/L (0.64 mg/dL), 95% CI -21.58 (-1.26) to 43.58 (2.55); rate of change of serum bilirubin: MD 0.80 μmol/L/hour (0.05 mg/dL/hour), 95% CI -2.55 (-0.15) to 4.15 (0.24); participants = 54 in both outcomes) (moderate quality of evidence for both outcomes, downgraded one level for indirectness). The number of infants who required exchange transfusion was similar between the two groups (RR 1.60, 95% CI 0.60 to 4.27; RD 0.11, 95% CI -0.12 to 0.34; participants = 54). No infant in either group developed adverse effects including vomiting or abdominal distension.

AUTHORS' CONCLUSIONS

There is no evidence that IV fluid supplementation affects important clinical outcomes such as bilirubin encephalopathy, kernicterus, or cerebral palsy in healthy, term newborn infants with unconjugated hyperbilirubinaemia requiring phototherapy. In this review, no infant developed these bilirubin-associated clinical complications. Low- to moderate-quality evidence shows that there are differences in total serum bilirubin levels between fluid-supplemented and control groups at some time points but not at others, the clinical significance of which is uncertain. There is no evidence of a difference between the effectiveness of IV and oral fluid supplementations in reducing serum bilirubin. Similarly, no infant developed adverse events or complications from fluid supplementation such as vomiting or abdominal distension. This suggests a need for future research to focus on different population groups with possibly higher baseline risks of bilirubin-related neurological complications, such as preterm or low birthweight infants, infants with haemolytic hyperbilirubinaemia, as well as infants with dehydration for comparison of different fluid supplementation regimen.

Correlation Between Severity Index and Quality of Life Index in Patients With Psoriasis Assessed Before and After Phototherapy

Psoriasis is a common disease whose impact on the life of patients is well documented. The authors investigated the correlation between clinical severity and quality of life in patients with psoriasis before and after phototherapy. Twenty men and women were assessed before and after 32 phototherapy sessions, employing the Dermatology Life Quality Index (DLQI) questionnaire and the Psoriasis Area Severity Index (PASI). A positive and moderate correlation was found between PASI and DLQI after phototherapy (r=0.48, P=.03). This result was not observed before treatment (r=0.13, P=.57). The clinical signs reduction obtained with phototherapy was associated with clinical improvement in patient quality of life. The negative findings for the pretreatment phase suggest a possible acceptance by patients through strategies establishment to improve the handling of the disease, which has a chronic character, and change in the disease's perception after therapy.

The utility of inpatient rebound bilirubin levels in infants readmitted after birth hospitalization for hyperbilirubinemia

BACKGROUND AND OBJECTIVES

There are few data evaluating the role of inpatient rebound bilirubin levels in the management of infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. The goal of the present study was to evaluate the clinical utility of inpatient rebound bilirubin levels within this patient population.

METHODS

A retrospective cohort study was conducted of 226 infants readmitted after their birth hospitalization for indirect hyperbilirubinemia. Data from 130 infants with rebound bilirubin levels drawn at a mean of 6.1±2.4 hours after discontinuation of phototherapy were compared with data from 96 infants without rebound bilirubin levels. The primary outcome was readmission to the hospital, and secondary outcomes included length of stay and discharge time. A subgroup analysis compared characteristics of children who required repeat phototherapy versus those who did not.

RESULTS

Overall, 5 of 130 patients from the rebound group were readmitted compared with 4 of 96 patients from the no-rebound group (P=.98). Length of stay was significantly longer for patients with rebound bilirubin levels (27.7 vs 23.2 hours; P=.001). Patients with bilirubin levels lowered to ≤14 mg/dL were less likely to receive repeat phototherapy than those with levels>14 mg/dL (2 of 129 vs 12 of 97; P=.001).

CONCLUSIONS

Early inpatient rebound bilirubin levels do not successfully predict which patients will require hospital readmission for repeat phototherapy. Children with bilirubin levels lowered to ≤14 mg/dL with phototherapy are unlikely to receive repeat phototherapy.

Trends in systemic psoriasis treatment therapies from 1993 through 2010

BACKGROUND

Moderate-to-severe psoriasis generally requires systemic therapy, and is often undertreated.

OBJECTIVE

To determine and analyze what courses of treatment and in what frequency are being utilized to combat psoriasis in the United States.

METHODS

Analysis of data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) of the National Center for Health Statistics. Data were analyzed to examine the prevalence of different therapy techniques to combat psoriasis from 1993 through 2010. The trends for phototherapy, methotrexate (MTX), retinoids, cyclosporine A (CSA), systemic steroids, and biologics were all analyzed over the entire 18-year period and independently before and after the introduction of biologics in 2002.

RESULTS

From 1993 to 2010, the trend for total systemic treatments has not significantly increased (P=0.5). Frequency of phototherapy treatments significantly decreased from 1993 to 2010 (P<0.001). Since the introduction of biologics in 2002, their frequency has significantly increased, becoming the most frequently used treatment from 2008-2010 (P<0.0001).

LIMITATIONS

Severity of psoriasis was not recorded in the NAMCS and NHAMCS.

CONCLUSIONS

The frequency of systemic treatments to treat psoriasis has not significantly increased from 1993 to 2010. Despite the introduction of biologics, it appears that little progress has been made in reducing under-treatment of moderate-to-severe psoriasis.

Review of home phototherapy

BACKGROUND

Outpatient phototherapy is a safe, effective, and low-cost treatment modality for moderate to severe psoriasis. Barriers to outpatient phototherapy including patient inconvenience, patient co-pays, decreased physician compensation, and insurance disincentive structures have led to decreased use and underutilization of phototherapy. Home phototherapy can potentially overcome many of the barriers associated with outpatient treatment but is not widely used because of concerns over safety and efficacy, lack of resident and physician education, and lack of insurance coverage.

PURPOSE

The purpose of this study is to review the use of phototherapy with emphasis on the safety, efficacy, and practical use of home phototherapy.

METHODS

A comprehensive Pubmed literature search was done using the keywords NB-UVB, narrowband UVB, BB-UVB, broadband UVB, PUVA, psoralen and UVA, UVA, history of phototherapy, mechanism of phototherapy, phototherapy in dermatology, home phototherapy, and phototherapy for psoriasis. All relevant articles were reviewed.

CONCLUSIONS

Home NB-UVB phototherapy can be as safe, effective, and cost-effective as outpatient phototherapy. Further, home UVB is more convenient for patients, has higher patient satisfaction, and a lower treatment burden compared to outpatient phototherapy. Home NB-UVB should be considered as a treatment option for patients eligible for phototherapy.

A survey of the optical hazards associated with hospital light sources with reference to the Control of Artificial Optical Radiation at Work Regulations 2010

Workplace exposure to coherent and incoherent optical radiation from artificial sources is regulated under the Artificial Optical Radiation Directive (AORD) 2006/25/EC, now implemented in the UK under the Control of Artificial Optical Radiation at Work Regulations (AOR) 2010. These regulations set out exposure limit values. Implementing the AOR (2010 Health and Safety Statutory Instrument No 1140 www.legislation.gov.uk/uksi/2010/1140/pdf/uksi_20101140_en.pdf) requirements in a hospital environment is a potentially complex problem because of the wide variety of sources used for illumination, diagnosis and therapy. A survey of sources of incoherent optical radiation in a large hospital is reported here. The survey covers examples of office lighting, operating theatre lighting, examination lamps, and sources for ultraviolet phototherapy and visible phototherapies, including photodynamic therapy and neonatal blue-light therapy. The results of the survey are used to inform consideration of the strategy that a hospital might reasonably adopt both to demonstrate compliance with the AOR (2010) and to direct implementation effort.

Do utilization management controls for phototherapy increase the prescription of biologics?

The use of phototherapy for psoriasis has declined because of inconvenience, managed care disincentives, and poor reimbursements. However, phototherapy is safer than other options, and the efficacy rates for different methods of phototherapy are among the highest of all available treatment options. Phototherapy is also one of the least costly treatments for moderate-to-severe psoriasis. We hypothesize that utilization management controls on phototherapy shift patients to more expensive and risky systemic treatments. Reducing disincentives on phototherapy will benefit both patients and payors, while increasing physicians' ability to manage this debilitating disease.

Treatment policy for psoriasis and eczema: a survey among dermatologists in the Netherlands and Belgian Flanders

Today, many therapies are available for the treatment of psoriasis and eczema. One of the oldest topical therapies is coal tar. Coal tar has been used for decades, but over the past years, the use of coal tar has decreased for several reasons, including the supposed carcinogenicity of coal tar. We investigated the current and past treatment policies for psoriasis and eczema with special emphasis on the use of tar products; a postal survey was conducted among all dermatologists in two European countries: the Netherlands (n = 360) and the Flemish speaking part of Belgium (Flanders) (n = 328). This study was conducted as part of the ongoing LATER-study ("Late effects of coal tar treatment in eczema and psoriasis; the Radboud study"). All practising dermatologists received a questionnaire. Dermatologists were asked to describe their treatment policies in mild/moderate psoriasis, severe psoriasis, mild/moderate eczema and severe eczema. The response rate to the questionnaire was 62.5% for the Dutch dermatologists and 45.7% for the Flemish dermatologists. Almost all dermatologists prescribe topical corticosteroids. In eczema, most of the dermatologists prescribe the recently introduced calcineurin inhibitors (95%). Coal tar is a second choice topical therapy. Dutch dermatologists mainly use tar in the treatment of eczema (72% vs. 48% in Flanders), whereas in Flanders, tar is mainly prescribed in psoriasis (60% vs. 41% in Holland). Flemish dermatologists very frequently prescribe PUVA in psoriasis (93% vs. 63%). Topical treatment, especially topical corticosteroids, is the mainstay in psoriasis and eczema. Coal tar still is an important (second choice) therapy for the topical treatment of psoriasis and eczema, but its use varies from country to country. Despite the carcinogenicity of PUVA, this photochemotherapy is frequently prescribed by dermatologists, mainly in Flanders.

Current state of vitiligo therapy ? evidence-based analysis of the literature

Vitiligo is a skin disease with a worldwide prevalence ranging from 0.5% to 4%. Conservative therapies include photochemotherapy, phototherapy with UVB radiation (broadband UVB 290-320 nm, narrow band UVB 311 nm), systemic steroids and pseudocatalase. Modern therapeutic options include treatment with topical immunomodulators (tacrolimus, pimecrolimus), analogues of vitamin D3, excimer laser and surgery/transplantation. Our analysis compares these therapies for vitiligo and the evidence levels supporting their effectiveness.

CONCLUSIONS

The face and neck respond best to all therapeutic approaches, while the acral areas are least responsive. For generalized vitiligo, phototherapy with UVB radiation is most effective with the fewest side effects; PUVA is the second best choice.Topical corticosteroids are the preferred drugs for localized vitiligo. They may be replaced by topical immunomodulators which display comparable effectiveness and fewer side effects. The effectiveness of vitamin D analogues is controversial with limited data. Surgical therapy can be very successful, but requires an experienced surgeon and is very demanding of time and facilities, thus limiting its widespread use. L-phenylalanine therapy appears effective on the face but enjoys neither widespread use nor extensive data support. No single therapy for vitiligo can be regarded as the most effective as the success of each treatment modality depends on the type and location of vitiligo.

Evaluation of discharge management in the prediction of hyperbilirubinemia: the Jerusalem experience

OBJECTIVE

We evaluated our program for prediction and follow-up of hyperbilirubinemia in preventing plasma total bilirubin (PTB) > or = 25 mg/dL and in limiting readmission for hyperbilirubinemia.

STUDY DESIGN

Term and near-term neonates were screened before discharge for risk factors for hyperbilirubinemia. A PTB test was performed when visible jaundice was apparent. Formal postdischarge follow-up was integrated with a possibly unique religious/cultural support system complemented by ritual circumciser (mohel) home visits and a high rate of jaundice awareness in the community.

RESULTS

During 2001-2002, 18,079 term and near-term healthy neonates were cared for in our well baby nurseries. Three hundred forty-two (1.9%) were treated with phototherapy, and 4 with exchange transfusion. Seventy-four (21.6%) of these (0.41% of total) were readmitted for hyperbilirubinemia. Forty-two percent of those readmitted had not been regarded as sufficiently jaundiced to warrant a predischarge bilirubin determination. In only 1 neonate did the PTB exceed > or = 25.0 mg/dL (0.006%). No infant had signs of bilirubin encephalopathy.

CONCLUSIONS

Our practice was successful in keeping the number of readmitted neonates low and limiting those with extreme hyperbilirubinemia to the minimum. Local customs, rituals, and practices may be successfully adapted as adjuncts in the detection and prevention of hyperbilirubinemia.

A pilot study of adherence with light treatment for seasonal affective disorder

Non-adherence with antidepressant medication regimens is now recognised as a substantial problem when evaluating depression outcome. Given the behavioural demands of light treatment (LT), it might be expected that non-adherence would be even more pronounced in LT, a form of intervention for seasonal affective disorder (SAD). However, little research has focused upon the extent to which patients in light treatment protocols adhere to set regimens. Nineteen patients with SAD were allocated to either treatment with bright white light (intervention) or dim red light (control condition) in a four-week protocol. Light exposure was estimated automatically (without participants' knowledge) with elapsed time meters built into the light box. Daily diaries were also used to measure self-reported light box use. Participants were instructed to use the light box for 30 min each day during week 1, 45 during week 2 and one hour during weeks 3 and 4 (total duration of prescribed light exposure 1365 min). The results indicated that mean duration of light box operation for the entire sample was 59.3% of the prescribed 1365 min. Six of nineteen (31.6%) patients dropped out of treatment. Amongst those completing treatment, adherence to the prescribed duration of exposure averaged 83.3% (S.D.=31.4). A trend was found for the intervention condition to generate a lower dropout rate, as well as a trend for the degree of adherence to be greater in the intervention condition. Importantly, there was no association between adherence as measured automatically and the higher rates of self-reported adherence as measured in diaries. In summary, the results of this pilot study suggest that adherence with light treatment is of a similar order of magnitude to antidepressant medication adherence. Patient self-report was found to be unrelated to objectively estimated duration of light box use, a finding with significant research and clinical implications. Future research studies should routinely measure and evaluate adherence with light therapy and evidence-based techniques for maximising treatment adherence should be incorporated into routine clinical practice.

Limited availability of psoriasis and phototherapy care: an analysis of advertisements

Because the number of dermatologists remains stable, patients with medical dermatologic conditions such as psoriasis may find it increasingly difficult to access dermatological treatment. Measuring the competition in the marketing of dermatologic care may provide insight into the availability of dermatology services. The purpose of this study was to determine to what extent dermatologists are using the Yellow Pages to advertise to patients with psoriasis. We performed a quantitative and qualitative assessment of dermatologists' Yellow Pages advertisements in small cities and the ten largest metropolitan regions in the country. Per capita, more advertisements were found in smaller markets than larger markets and a higher percentage was descriptive rather than just a name, address and phone number. Cosmetic and surgical advertisements were more common than psoriasis ads in both markets. Cosmetic ads were more prevalent in larger markets. In all regions, psoriasis and psoriasis treatment ads were least common. These findings raise the concern that incentive structures in the United States healthcare system do not adequately support delivery of dermatologic care for psoriasis. Efforts to promote psoriasis care should be encouraged.

Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization

OBJECTIVE

This study was undertaken to compare the use of glyburide with insulin for the treatment of gestational diabetes mellitus (GDM) unresponsive to diet therapy.

STUDY DESIGN

A retrospective study was performed among women with singleton pregnancies who had GDM diagnosed, with fasting plasma glucose 140 mg/dL or less on glucose tolerance testing, between 12 and 34 weeks who failed diet therapy from 1999 to 2002. We identified 584 women and compared those treated with insulin between 1999 and 2000 with women treated with glyburide between 2001 and 2002. Maternal and neonatal outcomes and complications were assessed. Statistical methods included univariate analyses and multivariable logistic regression.

RESULTS

In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide. The 2 groups were similar with regard to age, nulliparity, and historical GDM risk factors; however, women in the insulin group had a higher mean body mass index (31.9 vs 30.6 kg/m 2 , P=.04), a greater proportion identified themselves as white (43%, 28%, P<.001) and fewer as Asian (24%, 37%, P=.001), and they had a significantly higher mean fasting on glucose tolerance test (105.4 vs 102.4 mg/dL , P=.005) compared with the glyburide group. There were no significant differences in birth weight (3599+/-650 g vs 3661+/-629 g, P=.3), macrosomia (24%, 25%, P=.7), or cesarean delivery (35%, 39 %, P=.4). Women in the glyburide group had a higher incidence of preeclampsia (12%, 6%, P=.02), and neonates in the glyburide group were more likely to receive phototherapy (9%, 5%, P<.05), and less likely to be admitted to the neonatal intensive care unit (NICU) (15%, 24%, P=.008) though they had a longer NICU length of stay (4.3+/-9.6 vs 8.0+/-10.1, P=.002). Posttreatment glycemic control data were available for 122 women treated with insulin and 137 women treated with glyburide. More women in the glyburide group achieved mean fasting and postprandial goals (86%, 63%, P<.001). These findings remained significant in logistic regression analysis.

CONCLUSION

In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study.

A randomized, triple-blind, placebo-controlled trial of prophylactic oral phenobarbital to reduce the need for phototherapy in G6PD-deficient neonates

OBJECTIVE

Decreased conjugation is probably more important than hemolysis for causing jaundice in G6PD-deficient neonates. The role of enzyme inducers, like phenobarbital, in G6PD deficiency is unclear. This randomized controlled trial was performed to evaluate Phenobarbital's role in reducing the need for phototherapy among G6PD-deficient neonates.

STUDY DESIGN

This stratified, randomized, triple-blinded, placebo-controlled trial was conducted in a level III NICU. Consecutive babies with gestation >/=34 weeks and birth weight >/=1800 g were screened from cord blood. G6PD-deficient neonates, who were otherwise healthy, were enrolled. Rh isoimmunization, maternal Phenobarbital use and lack of parental consent were exclusion criteria. Subjects were randomly allocated to receive 5 mg/kg day of oral phenobarbital/ placebo for first 3 days. They were monitored daily for total serum bilirubin (TSB) until declining TSB was documented twice. The primary outcome was requirement for phototherapy and secondary outcomes were duration of phototherapy, need for exchange transfusion, peak TSB and adverse effects. Sample size of 56 could detect a decline in phototherapy requirement from 40 to 5% with 80% power and 5% error.

RESULTS

Of 2370 babies screened, 63 were G6PD-deficient. Of them, 56 eligible babies were allocated to phenobarbital (n=27) or placebo (n=29). The mean age of administration of the first dose was 18.55+/-7.3 h. In total, 44% in phenobarbital group and 41% in placebo group required phototherapy (p=1.0). There was no significant difference in exchange transfusion rates (18.5 vs 10%, p=0.46). No baby had adverse reactions.

CONCLUSION

Prophylactic oral phenobarbital does not decrease the need for phototherapy or exchange transfusions in G6PD-deficient neonates.

Length-of-stay policies and ascertainment of postdischarge problems in newborns

OBJECTIVE

The purpose of this study was to evaluate the effects of an early postpartum discharge program and a subsequent legislative mandate for 48 hours of hospital coverage on incidence of newborn jaundice and feeding problems. We tested the hypothesis that heightened postdischarge ascertainment (rather than short stays) is responsible for apparent increases in these outcomes.

METHODS

Interrupted time series analysis was conducted on retrospective data from the automated medical records of a large Massachusetts health maintenance organization (HMO). A population of 20,366 mother-infant pairs with normal vaginal deliveries between October 1990 and March 1998 was identified. The interventions included a new HMO protocol in 1994 of 1 hospital overnight after delivery, plus a nurse home visit, then the Massachusetts' 1996 minimum coverage law. Postpartum length of stay, clinical evaluation on day 3 or 4 of life, health center visits up to day 21, health center diagnoses of jaundice or feeding problems, bilirubin testing and test severity, rehospitalizations, and emergency department visits were measured.

RESULTS

Postpartum stays <2 nights rose from 28% of newborns before implementation of the program to 70% immediately after implementation. Later, this rate fell from 66% before the mandate to 21% just after the law went into effect. Day 3 or 4 evaluation rose from 24.5% to 64% after the program, then dropped somewhat to 53% after the mandate. Controlling for longer-term trends in health center visits, implementation of the early discharge program was associated with approximately 1 extra visit for every 4 newborns within the first 21 days of life. The state mandate did not affect health center visit rates. Jaundice diagnoses were flat at 8% of newborns during the baseline, then rose to a constant 11% throughout the program and postmandate periods. Bilirubin testing of newborns also rose by 3.4 percentage points at the time of program implementation, and the proportion of tested newborns with results calling for at least consideration of phototherapy rose by 6 percentage points. Phototherapy use rose from a flat 1.8% to 2.4% of newborns after program implementation. Feeding problem diagnoses more than doubled at the time of program implementation and remained elevated after the mandate. Rehospitalizations overall and specifically for jaundice were constant over time, whereas more rare emergency department visits for jaundice dropped from 0.3% of newborns to 0 on program implementation.

CONCLUSIONS

Sudden increases in jaundice-related measures and identification of infant feeding problems were not associated with changes in length of stay in this setting. Instead, these increases seem to be the result of more frequent evaluation of newborns during the critical day 3 to 4 period and may also have been elevated by a new climate of concern about neonatal vulnerability. "Ascertainment bias" may have confounded findings in previous reports that raised concerns about the safety of early discharge.

Treatment of rosacea with intense pulsed light

Rosacea is a chronic disease that affects millions of men and women. Topical and oral antibiotics are effective, yet often leave individuals with treatment plateau associated erythema and persistent flushing. We investigated the use of intense pulsed light for treatment of the redness, flushing, and breakouts associated with rosacea. Thirty-two consecutive patients of Fitzpatrick skin types I-III underwent 1 to 7 treatments with intense pulsed light. Patients were assessed clinically and photographically. In addition, patients completed a detailed questionnaire regarding their response to treatment. Following treatment, eighty-three percent of patients had reduced redness, 75% noted reduced flushing and improved skin texture, and 64% noted fewer acneiform breakouts. Complications were minimal and transitory. It appears that intense pulsed light is an effective treatment for the signs and symptoms of rosacea and represents a new category of therapeutic options for the rosacea patient.

Phototherapy use in jaundiced newborns in a large managed care organization: do clinicians adhere to the guideline?

OBJECTIVE

In 1994, the American Academy of Pediatrics (AAP) published a practice guideline with age-specific thresholds for phototherapy for healthy term newborns with hyperbilirubinemia. The purpose of this study was to examine adherence to the guideline in a large managed care organization.

METHODS

We conducted a retrospective cross-sectional analysis of linked computerized databases from 11 Northern California Kaiser Permanente Medical Care Program hospitals. Newborn infants included were at least 37 weeks of gestation, had birth weights of at least 2500 g, and were born between January 1, 1995, and December 31, 1996. The primary outcome variable for the study was receipt of phototherapy according to the guideline. Total serum bilirubin (TSB) and infant age in hours at the time of bilirubin measurement were used to classify infants into 3 groups according to the AAP guideline: recommend phototherapy (R), consider phototherapy (C), and did not recommend phototherapy (N). Group R included infants with TSB levels of at least 15 mg/dL before 48 hours of age, at least 18 mg/dL before 72 hours, or at least 20 mg/dL after 72 hours. Group C included infants not in group R, with TSB levels of at least 12 mg/dL before 48 hours, 15 mg/dL before 72 hours, or at least 17 mg/dL after 72 hours. Group N included infants who were in neither group R nor group C and also did not have significant jaundice before 24 hours of age. Phototherapy codes from electronic databases were validated by chart review for a subset of 550 infants.

RESULTS

Compared with chart review, phototherapy codes in the database were 94.4% sensitive (95% confidence interval [CI]: 89.1%-97.5%) and 100% specific (95% CI: 99.25%-100%). Among the 47 801 infants eligible, 2.3% received phototherapy. Phototherapy was administered to 54% of 1194 infants in group R (range across hospitals: 27%-77%), 16% of 2245 infants in group C (range: 5%-37%), and 0.2% of 44 362 infants in group N (range: 0.1%-0.6%). The predictors of phototherapy for group R, the group for whom phototherapy was recommended, determined by logistic regression were increasing TSB levels (odds ratio [OR]: 1.6/mg/dL; 95% CI: 1.4-1.7), reaching the AAP threshold at 24 to 47.9 hours of age compared with 48 hours or more (OR: 7.1; 95% CI: 4.3-11.9), gestational age of 37 weeks compared with 38 weeks or more (OR: 1.6; 95% CI: 1.1-2.3), age when phototherapy was first recommended (OR: 0.7/d; 95% CI: 0.6-0.8), and facility of birth (OR: 0.2-2.7). The facility of birth was a strong predictor of phototherapy use in all groups (R, C, and N).

CONCLUSIONS

Clinicians provided phototherapy to only 54% of term infants with hyperbilirubinemia for whom it was recommended by the AAP. There is marked interhospital variation in phototherapy use in this large managed care system. Improved adherence to the guideline would require only a slight increase in the total rate of phototherapy use if unnecessary use for infants with lower levels of TSB were simultaneously decreased.

Neonatal hyperbilirubinemia and its association with thyroid hormone levels and urinary iodine excretion

OBJECTIVE

To investigate, if, urinary iodine contents as a marker of iodine deficiency and hypothyroidism are associated with the incidence of neonatal hyperbilirubinemia.

METHODS

One hundred neonates with total serum bilirubin > or = 15 mg/dl and with no known cause of jaundice were included in the study as a jaundice group. An equal number (n = 100) of non-jaundiced neonates (bilirubin < or = 14.9 mg/dl) with matching for age, gestation period and weight were enrolled in the study as a control group.

RESULTS

Thirteen neonates (13%) in the study group had urinary iodine levels < 100 mg/dl as against only 2 (2%) in the control group (p < 0.05). Thirty-four (34/200-17%) neonates i.e. 17 each in the study and control groups had serum TSH > 5 mU/ml and hence an indirect indicator of iodine deficiency in the study population. The mean serum levels of total T3, T4 and TSH in the study neonates were 1.52 +/- 1.23 ng/ml, 15.8 +/- 12.0 micrograms/dl & 3.13 +/- 3.0 mU/ml respectively and did not differ significantly from the mean levels in the control group. Only one neonate in the study group had serum TSH > 20 mU/ml which was suggestive of hypothyroidism, but had normal T3 & T4. Seven neonates in the study group and 8 in the control group had low T4. There was no significant correlation between the maternal and neonatal urine iodine levels, thyroid functions and the bilirubin levels (p > 0.01).

CONCLUSION

The jaundiced babies had lower urine oidine levels than the control population. Since, there was no significant difference in the levels of the thyroid hormones, no cause and effect relationship could be inferred between iodine deficiency and jaundice.

An automated treatment for jet lag delivered through the internet

Seventy percent of persons who suffer from psychiatric illness do not receive treatment. Cost-effective, automated treatment can be delivered through the Internet but can be complicated by the lack of professional supervision. This open study piloted a fully automated, publicly available treatment for jet lag as a means of highlighting some of the issues involved in delivering treatment over the Internet. Twenty study participants rated the severity of their jet lag symptoms and their adherence to a light-exposure schedule calculated to accelerate adaptation to a new time zone. A significant negative correlation was observed between how closely participants followed the light-exposure schedules and the severity of their jet lag symptoms.

Ninety-six points of light: phototherapy practices of members of The Photomedicine Society

BACKGROUND

Phototherapy is an effective and relatively safe treatment for many skin diseases. Recent concern has focused on an apparent decline in phototherapy usage in the US.

OBJECTIVE

To determine the current state of phototherapy as practiced globally.

METHODS

Cross-sectional survey of members of the Photomedicine Society.

RESULTS

Data derived from responses of 96 members showed all to have been in practice for more than five years, providing phototherapy within two years of completing residency. Usage of narrow-band ultraviolet B, ultraviolet A-1 (UVA-1), bath-psoralens plus UVA, and photodynamic therapy was markedly greater among phototherapists in Europe compared to their counterparts in North America and Asia.

CONCLUSIONS

Worldwide, there are fewer younger dermatologists who incorporate phototherapy in their practices. European phototherapists have led the world in usage of the newer phototherapy modalities.

Phototherapy utilization for psoriasis is declining in the United States

Phototherapy is an established treatment modality for psoriasis. The use of phototherapy for psoriasis appears to be in decline in nonfederal and non-university-based settings. We used data from the National Ambulatory Medical Care Survey to estimate the number of visits for phototherapy and psoralen ultraviolet A-range (PUVA) light therapy from 1993 to 1998. There were 873,000 visits for UV light therapy in 1993-1994, 189,000 in 1995-1996, and 53,000 in 1997-1998 (P <.0001). There were 175,000 psoralen visits in 1993-1994, 61,000 in 1995-1996, and 25,000 in 1997-1998 (P =.0053). Similar decreases in phototherapy visits occurred in our university-based practice. The decline in phototherapy represents decreased utilization of a safe and effective treatment for psoriasis.

Effect of publication of the "Practice Parameter for the management of hyperbilirubinemia" on treatment of neonatal jaundice

The aim of this study was to evaluate the change in the treatment of neonatal jaundice following introduction of the "American Academy of Pediatrics' Practice Parameter for the management of hyperbilirubinemia in the healthy term newborn". In a historical control observation cohort study, we examined the rate of phototherapy and exchange transfusions among full-term (> or = 37 wk gestation) and near-term (gestational age between 35 and 37 wk and birthweight > 2000 g) infants in two community hospitals. The study included all consecutive infants born during two 15-mo study periods immediately before and after the introduction of the new guidelines. Data were prospectively recorded in a computerized database. The rate of phototherapy significantly decreased in the second study period from 7.9% (514/6499) to 2.9% (251/8650) (p < 0.0001) among full-term infants, and from 20.9% (102/489) to 9.4% (47/502) (p < 0.0001) in near-term infants. The use of exchange transfusion was significantly higher (p < 0.001) in the first compared to the second period: 0.2% (15/6499) vs 0.03% (3/8650). A significant decrease was found when the data from each hospital were analyzed separately.

CONCLUSION

A significant decrease in the use of phototherapy and exchange transfusion occurred after the publication of the new practice parameters. This trend was observed for both term and preterm newborns, although the new guidelines were not intended for infants born before term.

Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization

OBJECTIVE

To investigate biological and health services predictors of extreme neonatal hyperbilirubinemia in a health maintenance organization.

DESIGN

Nested case-control study.

SETTING

Eleven Northern California Kaiser Permanente hospitals.

SUBJECTS

The cohort consisted of 51,387 newborns born at 36 weeks or later weighing 2000 g or more. Cases were newborns with peak total serum bilirubin levels greater than or equal to 428 micromol/L (> or =25 mg/dL) (n = 73). Controls were a random sample of newborns from the cohort with peak bilirubin levels less than 428 micromol/L (<25 mg/dL) (n = 423).

MEASUREMENTS

Review of medical records and telephone interviews.

RESULTS

Early jaundice was most strongly associated with case status (odds ratio [OR] = 7.3). After excluding subjects with early jaundice, the strongest predictors of hyperbilirubinemia were family history of jaundice in a newborn (OR = 6.0), exclusive breastfeeding (OR = 5.7), bruising (OR = 4.0), Asian race (OR = 3.5), cephalhematoma (OR = 3.3), maternal age of 25 years or older (OR = 3.1), and lower gestational age (OR = 0.6/week). These variables identified 61% of newborns as very low risk (about 1/4200). However, the risk in the remaining 39% was still low (1/370). More cases (79%) than controls (59%) had newborn length-of-stay and follow-up consistent with the American Academy of Pediatrics guidelines, but phototherapy use within 8 hours of the time that the guidelines recommend was uncommon in both cases (26%) and controls (33%). There were no apparent cases of kernicterus.

CONCLUSIONS

Prevention of extreme hyperbilirubinemia may require closer follow-up than is currently recommended by the American Academy of Pediatrics and more use of phototherapy than was observed in this study. To prevent extreme hyperbilirubinemia (> or =428 micromol/L [> or =25 mg/dL]) in 1 newborn, many newborns would need to receive these interventions.

Effect of low intensity monochromatic light therapy (890 nm) on a radiation-impaired, wound-healing model in murine skin

BACKGROUND AND OBJECTIVE

The use of low intensity laser and monochromatic light diodes as a therapeutic modality has become popular in a variety of clinical applications, including the promotion of wound repair. Despite this, the clinical evidence base for such application remains sparse; in contrast, recent studies have demonstrated a number of quantifiable photobiological effects associated with such therapy. In the present study, the effect of low intensity monochromatic light irradiation (MLI) at various radiant exposures upon a radiation-impaired wound model in murine skin was investigated.

STUDY DESIGN/MATERIALS AND METHODS

Male Balb/c mice (n = 50; age matched at 10 weeks) were randomly allocated to five experimental groups (n = 10 each group). In Group 1, mice were left untreated; in Groups 2-5, a well-defined area on the dorsum was exposed to 20 Gy X-ray irradiation. At 72 hours postirradiation, all mice were anaesthetised and a 7-mm-square area wound was made on the dorsum. All wounds were videotaped alongside a marker scale until closure was complete. In Groups 3-5, mice were treated with MLI (0.18, 0.54, and 1.45 J/cm2, respectively) three times weekly using a GaAlAs 890 nm multidiode (n = 60) array unit (270 Hz; maximum rated output, 300 mW; Anodyne, Denver, CO). Subsequently, the area of each wound was measured from video using an image analysis system (Fenestra 2.1), and results were analysed using repeated measure and one-factor ANOVA statistical tests.

RESULTS

X-ray irradiation caused a significant delay (P = 0.0122) in healing by day 7. MLI at 0.18 J/cm2 and 0.54 J/cm2 had no effect upon the rate of wound closure. However, a highly significant (P = 0.0001) inhibition occurred following MLI irradiation at 1.45 J/cm2 by day 16.

CONCLUSION

These findings provide little evidence of the putative stimulatory effects of monochromatic light irradiation in vivo, but, rather, reveal the potential for an inhibitory effect at higher radiant exposures.

An insight into the contributions of self-shielding and lamp reflectors to patient exposure in phototherapy units

Calibration of phototherapy equipment can prove to be difficult. One problem is that the self-shielding produced by a patient reduces the irradiance relative to that determined when the cabinet is empty. A model has been developed to determine the factor to apply to the irradiance measured with the cabinet empty to give the irradiance with the patient present, i.e. the self-shielding correction factor. The model assumes that the cabinet consists of a number of discrete infinite line sources backed by perfect mirrors. The patient is treated as a barrier that prevents some of these sources being seen by the detector in the mirror it faces. The model was tested using a Waldmann 8001 K unit and three UV meters for UVA and UVB sources. The measurements suggested some modifications to the model--for UVA multiple reflections were important and for UVB the reflectors were only 30% efficient. The correction factors obtained were 0.87 for UVA and 0.96 for UVB.

[Double phototherapy with Wallaby optic fibers versus conventional phototherapy. Case reports]

The authors have valued the efficacy of the double phototherapy with fiberoptic Wallaby vs conventional phototherapy in 2 groups of term infants, without any complication at birth, utilized respectively as study group and control group. While conventional phototherapy produced a bilirubin reduction of 0.60 +/- 0.26% per hour (with a total reduction of 28.1 +/- 11.1%), the double phototherapy was statistically more effective (p < 0.05) then conventional phototherapy causing a bilirubin reduction of 0.73 +/- 0.28% (with a total reduction of 33.3 +/- 9.5%). At 24 hour after the interruption of the treatment 9 newborns of the study group (36%) and 7 of the control group (28%) presented a rebound effect (increase of the bilirubinemia more than 17 mumol/l), but without a statistical difference (p > 0.05). Our study shows that double phototherapy with Wallaby fiberoptic and conventional phototherapy represent a valid strategy in the treatment of the non haemolytic neonatal hyperbilirubinemia, because, compared to conventional phototherapy, double phototherapy is more effective and reduces the period of the treatment, showing a simple management of the jaundiced newborn.

Therapeutic approaches to neonatal jaundice: an international survey

Jaundice is one of the most common clinical phenomena in the neonatal period and a frequent indication for treatment with phototherapy, exchange transfusion, or drugs. The present study documents the variability in approaches to the treatment of this condition. A mail questionnaire was sent to neonatal units worldwide. One hundred and eight answers (49% response rate) were received from Europe (n = 72), North America (n = 28), Africa (n = 7), and Asia (n = 1). The neonatal intensive care units represented by the respondents had 31 +/- 18 beds [mean +/- SD], and 638 +/- 519 admissions per year. All units offered phototherapy, 106/108 performed exchange transfusion, while 44/108 used some form of drug therapy. There was considerable variability among the units in their approaches to the jaundiced neonate. This applied to all aspects of care, including type of phototherapy lights used, practical implementation of phototherapy, use of fluid supplementation, and use of prophylactic phototherapy. The majority used written protocols for investigation and treatment of neonatal jaundice and would let their decision on whether to treat be influenced by the infant's clinical state. There was great variability between units in the level of serum bilirubin that would trigger therapy. This applied across weight groups and to phototherapy as well as exchange transfusion. The significant heterogeneity in our approach to the treatment of jaundiced neonates suggests that our understanding of the biology of neonatal jaundice is inadequate and that further research will be necessary in order to provide a more solid biological foundation for therapy.

[The effect of human albumin in association with intensive phototherapy in the management of neonatal jaundice]

BACKGROUND

The effectiveness of phototherapy in lowering serum bilirubin levels in neonates varies inversely with the rate and degree of hemolysis. Combining this therapy with albumin perfusion could enhance its effectiveness. This study examines total, unconjugated and unbound fractions of bilirubin in infants treated by phototherapy alone or by phototherapy plus albumin.

PATIENTS AND METHODS

The files of 211 neonates treated from January 1990 to March 1991 for severe neonatal jaundice were analysed. Jaundice was due to ABO incompatibility in 113 cases and hereditary hemolytic anemia in 6 cases; its cause was unknown in 92 patients. Other causes of jaundice such as Rh incompatibility, premature delivery before 34 gestational weeks and neonatal infections were excluded from the study. All 211 neonates were given phototherapy from admission with similar light energy. 114 babies (group I) received only phototherapy, while the 97 others (group II) were also given human albumin, (1.5 g/kg), during the first 2 hours of phototherapy.

RESULTS

The decrease in serum unconjugated and unbound bilirubin after 4 hours of phototherapy was 34% in group I and 45% in group II (p < 0.0005). There was no difference between both groups after 24 hours of phototherapy. Other factors such as the initial concentration of serum unconjugated and unbound bilirubin, age at the onset of therapy, and ethnic skin color also influenced the decrease in bilirubin after 4 and 24 hours of phototherapy, in addition to albumin perfusion.

CONCLUSIONS

Albumin perfusion plus phototherapy appears to induce a rapid and early decrease in unconjugated, unbound bilirubin, the fraction that is potentially neurotoxic, while phototherapy alone acts over a longer period.

Home phototherapy: use and attitudes among community pediatricians

Rather than using home phototherapy (HP), many pediatricians admit neonates to the hospital for the treatment of unconjugated hyperbilirubinemia. This study investigates the concerns and experiences of pediatricians related to HP use. A questionnaire was sent to 150 pediatricians in the Philadelphia, PA, area and 94 returned questionnaires. Of the responders, 30 of 94 had used HP. Twenty-nine users and 62 of 64 nonusers answered detailed questions regarding HP. Few practitioners follow American Academy of Pediatrics guidelines in selection of HP candidates. Among 29 pediatricians, prematurity (7), Rh incompatibility (13), positive direct Coombs (21), and ABO incompatibility (22) were not considered contraindications, although the American Academy of Pediatrics recommends all as contraindications. Almost all (29/30) HP users identified at least one problem with home treatment. The most commonly reported problems were parental anxiety, blood testing difficulties, and reimbursement issues. Nonusers (62) were asked their reasons for not using HP. The most common replies related to concerns about noncompliance (25), medical-legal issues (23), and administrative difficulties (22), none of which were cited as problems by HP users.

Usage patterns of phototherapy in seasonal affective disorder

We mailed a questionnaire to patients affected with seasonal affective disorder (SAD) to determine patterns of self-selected light use and efficacy of treatment. Data obtained from 127 patients who responded indicate that despite, inconvenience and other use-limiting factors, many patients with SAD derive sustained benefit from phototherapy over months. No consistent pattern or duration of effective treatment emerged. Development of a less cumbersome means of delivering phototherapy and reimbursement by insurance companies remain concerns to patients.

Impact of eligibility criteria on phototherapy program size and cost

To determine the effect of eligibility criteria on phototherapy program size and cost, 786 births in a large Health Maintenance Organization were prospectively studied. Four sets of criteria were compared, including those of the American Academy of Pediatrics and the health maintenance organization's own criteria. With all criteria sets, hospital-based phototherapy treatment was indicated for 13 (1.7%) infants and no phototherapy was indicated for 687 (87.4%) infants. Treatment varied substantially according to criteria set for the remaining 86 (10.9%) infants. From 14% to 100% of these infants would have received treatment, depending on the criteria applied; of those potentially treated, from 30% to 80% would have received home treatment. Estimated annual discretionary phototherapy costs (1985 dollars) ranged from $15,168 with the health maintenance organization criteria to almost five to six times this amount ($70,232 to $90,800) with the other criteria. Differences in costs were due mainly to the number of infants treated. This study illustrates the way in which modest variation in standards of care can potentially have a relatively large effect on medical care costs. As a case study of how health maintenance organizations reduce costs, the study shows that although the health maintenance organization anticipated costs savings due to substituting outpatient care for hospital care, most savings occurred because of a reduction in the number of infants treated.

[Effect of phototherapy on the frequency of the use of exchange transfusion in the treatment of neonatal jaundice]

The authors analysed an incidence of performed exchange blood transfusions at the newborn babies ward prior to and after introduction of phototherapy into practice. This analysis included the causes of jaundice in newborn. The study included the causes of jaundice in newborn. The study involved 8,937 newborn babies delivered between 1981 and 1985. Prior to phototherapy (period between January, 1981 and July, 1980), 45 blood transfusions and 9 retransfusions were performed. During the period II (between July, 1983 and December, 1985), i.e. phototherapy, 30 blood transfusions and 1 retransfusion were effected despite of the higher number of delivered babies. The obtained results have shown favourable effect of the phototherapy in jaundice of perinatal period, especially in jaundice unconnected with blood Rh factor conflict and in premature babies. Phototherapy decreased the number of performed transfusions and retransfusions.

Phototherapy: the hospital as risk factor

In a retrospective study over six years the incidence of phototherapy was examined in two groups of healthy neonates who were born spontaneously and at term in hospital. They were comparable in all respects except that one group was cared for at home and the other group was cared for in hospital. It appeared that the infants in hospital received phototherapy seven times more often than those at home, and surveillance at home was not inferior to that in hospital. There is no reason to assume that neonatal jaundice occurred more often in neonates in hospital than in those at home. Thus the difference in the frequency of treatment with phototherapy between the two groups is ascribed to the influence of the hospital environment, which may encourage intervention.

Use or abuse of phototherapy for physiological jaundice of newborn infants

To investigate the need for and effects of phototherapy in full-term otherwise healthy babies with physiological jaundice, 40 consecutive babies with serum bilirubin levels of 250 mumol/l or more were assigned at random to two treatment groups. Phototherapy was started in the early group (n = 20) when serum bilirubin was 250 mumol/l and in the late group (n = 20) when serum bilirubin reached 320 mumol/l; however, only 3 of the late group required treatment. Phototherapy prevented a further rise in bilirubin in almost all treated babies, but the difference in peak bilirubin level between early and late treatment groups was not significant. Early phototherapy produced a more rapid decline in bilirubin; levels fell to below 250 mumol/l in a median of 28 h with early treatment and 54 h with late treatment. In each group the ratio of boys to girls was 2/1 and boys remained jaundiced for significantly longer. Phototherapy therefore curtailed the rise and duration of hyperbilirubinaemia, but the effect was small. Jaundice subsided spontaneously in most of these mature infants, especially girls. Phototherapy can separate mother from baby, and it is physiologically stressful. Treatment may be safely withheld until serum bilirubin exceeds 320 mumol/l.