Severe jaundice with life-threatening liver failure after Kratom use: Reversed by plasma exchange.

Kratom is an herbal supplement which is used for its stimulating properties and pain reduction due to interaction with opioid receptors. Kratom overdose may cause fatality. A 56-year-old man was admitted to the emergency department with severe jaundice and liver failure. His total bilirubin reached at 70.6 mg/dL, but extensive workup did not show any liver mass. Family informed that the patient was taking Kratom. Plasma exchange was suggested as an unconventional therapy and consent from the patient was obtained because this procedure has never been performed to treat Kratom toxicity before. After four procedures, his total bilirubin was reduced to 23.9 mg/dL and his clinical condition improved significantly. Finally on day 5 he was discharged at stable condition with a total bilirubin value of 21.3 mg/dL. There is no antidote for Kratom, and treatment is supportive. To our knowledge this is the first report of reversing Kratom poisoning using plasma exchange.

Jaundice as a Diagnostic and Therapeutic Problem: A General Practitioner's Approach.

BACKGROUND: Jaundice is a common clinical finding in clinical practice of hepatologists and general practitioners. It occurs when serum bilirubin levels exceed 3 mg/dL. SUMMARY: In this review, we summarize the pathophysiological mechanism of jaundice, clinical approach to the patient with jaundice, and laboratory and imaging techniques. Clinical presentation of jaundice manifests through yellow skin and sclera coloration. Evaluation of every patient includes detailed medical history and examination. In the laboratory, evaluation of enzymes of hepatic inflammation as well as cholestatic enzymes with serum bilirubin must be included. Additional laboratory analysis and imaging modalities are needed in order to differentiate jaundice etiology. Moreover, imaging is available and needed in further evaluation, and treatment is dependent on the underlying cause. KEY MESSAGES: In this review, we will outline the pathophysiological mechanism of jaundice, clinical approach to the patient with jaundice, and diagnostic and treatment approach to these patients.

Association between Serum Erythrocyte Immune Function Indexes and Blue Light Treatment or the Severity of PJON.

BACKGROUND: The association between serum erythrocyte immune function indexes and blue light treatment effect and severity in child patients with pathological jaundice was testified. METHODS: One hundred and seven children with pathological jaundice and 69 children with physiological jaundice were enrolled to analyze the association between erythrocyte immune function indexes and blue light treatment or disease progression. RESULTS: The area under the ROC curve (AUC) of red blood cell immune complex rosettes (RBC-ICR) and red blood cell C3b receptor rosette (RBC-C3bR) in diagnosing pathological jaundice and assessing the efficacy of blue light therapy overweighed 0.8. Meanwhile, the RBC-ICR values of the child patients were positively correlated with the severity of the disease, and the RBC-C3bR and red blood cell immune affinity receptor (FEER) values were negatively correlated with them (p < 0.05). CONCLUSIONS: The erythrocyte immune function indexes of child patients with pathological jaundice were relevant to the disease severity, and was provided with diagnostic value for pathological jaundice or assessed value for the efficacy of blue light therapy.

Clinical Profile and Outcome Following Exchange Transfusion for Neonatal Jaundice in a Tertiary Care Centre.

INTRODUCTION: Phototherapy has reduced the need for exchange transfusion (ET) to manage jaundiced neonates. Hence there are concerns about increased risk of complication due to lack of opportunity to sustain skills in performing ET. We studied the complications and treatment outcomes of neonates treated for jaundice with ET. METHODOLOGY: A retrospective observational study was conducted from June 2013 to June 2020 in a tertiary care hospital in India. All neonates treated with ET for jaundice were included. RESULTS: Twenty-eight neonates underwent 31 ET during the study period. Their mean gestational age and birth weight were 37 weeks and 3200 g, respectively. Predisposing factor for jaundice observed were Coomb's positive status (11), hepatosplenomegaly suggesting hemolysis (3), cephalhematoma (2) and birth asphyxia (1). Abnormal neurological status before ET was seen in seven neonates. Adverse clinical events that happened during or within 8 h after ET were desaturation (4), tachycardia (3), tachypnea (2), bradycardia (2), shock (2) and temperature instability (2). One neonate developed acute kidney injury after ET and required peritoneal dialysis. Abnormal lab parameters observed during or within 8 h after ET were hypocalcemia (20), anemia (8), hypokalemia (7), hypernatremia (3), thrombocytopenia (3) and hyperkalemia (2). Post ET sepsis was seen in five neonates: two had only blood culture positive sepsis, two had bone and joint infection and one had liver abscess. CONCLUSION: The neonates undergoing ET are at high risk of developing complications which may be life threatening. Hence careful monitoring during the procedure is needed.

Exchange transfusion is a treatment done for newborn babies with severe jaundice. This procedure is done by removing baby's blood in small quantities and replacing it with donor's blood. This life-saving procedure is associated with many complications. We did this study to estimate the complications associated with this procedure in our newborn unit. Twenty-eight patients underwent exchange transfusion from June 2013 to June 2020 in our hospital. We found out that temperature disturbance, abnormal heart rate, abnormal breathing and fall in oxygen levels occurred during exchange transfusion. After the procedure blood circulation disturbances, low platelet count, low blood calcium levels and low blood potassium levels were commonly observed. One patient developed renal failure after the procedure and was treated with dialysis. Five patients developed infection after the procedure and were treated with antibiotics. Thus newborn patients undergoing exchange transfusion are at high risk of developing complications which may be life threatening. Hence careful monitoring during the procedure is needed to prevent these complications.

Fifteen-minute consultation: Baby with jaundice in the first 2 weeks of life.

There are multiple causes of jaundice in the first 2 weeks of life. The aim of this article is to help explain what these causes are and why they occur. It discusses how to focus on the history, examination and investigations in such cases. Initial management will vary depending on the clinical context; as such, this article also outlines the initial management of the most common scenarios.

Cholangiopathy After Severe COVID-19: Clinical Features and Prognostic Implications.

INTRODUCTION: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 virus, is a predominantly respiratory tract infection with the capacity to affect multiple organ systems. Abnormal liver tests, mainly transaminase elevations, have been reported in hospitalized patients. We describe a syndrome of cholangiopathy in patients recovering from severe COVID-19 characterized by marked elevation in serum alkaline phosphatase (ALP) accompanied by evidence of bile duct injury on imaging. METHODS: We conducted a retrospective study of COVID-19 patients admitted to our institution from March 1, 2020, to August 15, 2020, on whom the hepatology service was consulted for abnormal liver tests. Bile duct injury was identified by abnormal liver tests with serum ALP > 3x upper limit of normal and abnormal findings on magnetic resonance cholangiopacreatography. Clinical, laboratory, radiological, and histological findings were recorded in a Research Electronic Data Capture database. RESULTS: Twelve patients were identified, 11 men and 1 woman, with a mean age of 58 years. Mean time from COVID-19 diagnosis to diagnosis of cholangiopathy was 118 days. Peak median serum alanine aminotransferase was 661 U/L and peak median serum ALP was 1855 U/L. Marked elevations of erythrocyte sedimentation rate, C-reactive protein, and D-dimers were common. Magnetic resonance cholangiopacreatography findings included beading of intrahepatic ducts (11/12, 92%), bile duct wall thickening with enhancement (7/12, 58%), and peribiliary diffusion high signal (10/12, 83%). Liver biopsy in 4 patients showed acute and/or chronic large duct obstruction without clear bile duct loss. Progressive biliary tract damage has been demonstrated radiographically. Five patients were referred for consideration of liver transplantation after experiencing persistent jaundice, hepatic insufficiency, and/or recurrent bacterial cholangitis. One patient underwent successful living donor liver transplantation. DISCUSSION: Cholangiopathy is a late complication of severe COVID-19 with the potential for progressive biliary injury and liver failure. Further studies are required to understand pathogenesis, natural history, and therapeutic interventions.

Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study.

BACKGROUND: The guidelines of the American Academy of Pediatrics (AAP) for monitoring neonatal jaundice recommend universal postnatal screening for hyperbilirubinemia within 48 h from discharge. We observed that neonate with low-risk jaundice were more likely to be readmitted to hospital for phototherapy compared to neonate with high-risk jaundice. The aim of this study was to identify additional factors that increase the risk for jaundice-related readmission. METHODS: This observational case-control study was performed on 100 consecutive neonates with jaundice who were readmitted to hospital for phototherapy treatment and were compared to 100 neonates with jaundice during hospitalization who were not readmitted after discharge. The data retrieved from the medical records of all participants included maternal characteristics, delivery type and noteworthy events, gestational age at delivery, birth weight and weight loss, neonate physical findings, Apgar scores, laboratory findings, length of hospital stay, and administration of phototherapy during hospitalization. The length of time since discharge and readmission for jaundice was also recorded. RESULTS: The risk of readmission decreased by 48% [odds ratio (OR) =0.52; 95% confidence interval (CI) 0.341-0.801] with every day added to the original hospitalization stay, and by 71% (OR = 0.29; 95% CI 0.091-0.891) if phototherapy had been administered during postnatal hospitalization. In contrast, the risk increased by 28% (OR = 1.28; 95% CI 1.164-1.398) with every elevation by 1% in hematocrit, and by 2.78 time (95% CI 1.213-6.345; p = 0.0156) when the delta in infant weight was > 5% (the difference between birth weight and weight at discharge during the postnatal hospitalization). CONCLUSIONS: The risk factors for readmission, such as substantial weight loss (> 5% difference between birth and discharge) and elevated hematocrit should be taken into account in the decision to discharge neonate with low-risk jaundice. The AAP guidelines for decreasing readmission rates of neonatal jaundice by postnatal screening for hyperbilirubinemia alone may be more appropriate for neonate with high-risk jaundice.

Concomitant Existence of Paroxysmal Nocturnal Hemoglobinuria in a Patient with Hb E (HBB: c.79G>A) Trait.

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal disorder that manifests with bone marrow failure, thrombosis and hemolysis. We present a 28-year-old male who presented with weakness, jaundice and transfusion dependence. On initial investigation, he was found to have anemia with jaundice with hemoglobin (Hb) capillary zone electrophoresis suggestive of Hb E (HBB: c.79G>A) trait. The same anomaly was also found in his mother. However, transfusion requirement was an unusual feature in the patient. As his corrected reticulocyte count was raised along with lactate dehydrogenase (LDH), which was suggestive of a hemolytic process, he was worked-up for the same. However, the direct Coombs test was negative. A bone marrow aspiration and biopsy was done to rule out hypersplenism but it revealed erythroid hyperplasia with reduced iron stores despite normal ferritin and iron studies. This was unusual as the patient had anemia requiring transfusions. He had no history of hemoglobinuria but a PNH by flowcytomety revealed a large clone of 81.2% in granulocytes and 88.5% in monocytes. The patient was started on Danazol and steroids for anemia which improved. He was counseled for matched sibling stem cell transplant. He had a full match with his brother. At the time of this study he awaits his transplant.

Neonatal phototherapy and future risk of childhood cancer.

We sought to determine if neonatal phototherapy is associated with a greater risk of childhood cancer. We conducted a retrospective cohort study of 786,998 infants born in hospitals of Quebec, Canada between 2006 and 2016, with 4,660,868 person-years of follow-up over an 11-year period. The exposures were neonatal phototherapy (32,314 or 4.1% of infants) and untreated jaundice (91,855 or 11.7% of infants). The outcome was hospitalization for solid or hematopoietic childhood tumours between 2 months and 11 years of age. We used Cox proportional hazards regression models to compute hazard ratios (HR) and 95% confidence intervals (CI) for the association of phototherapy with childhood cancer, adjusted for infant characteristics. The incidence of childhood cancer was higher for infants with phototherapy (25.1 per 100,000 person-years) and untreated jaundice (23.0 per 100,000) compared to unexposed infants (21.6 per 100,000). Phototherapy appeared to be associated with late onset solid tumours, including brain/central nervous system cancers. Between age 4 and 11 years, children who received neonatal phototherapy had more than 2 times the risk of any solid tumour compared to unexposed children (HR 2.26, 95% CI 1.34-3.81). Results were similar for phototherapy compared against untreated jaundice. A similar trend was however less apparent for hematopoietic cancer. We conclude that neonatal phototherapy may be associated with a slightly increased risk of solid tumours in childhood, but cannot rule out an effect of bilirubin. Minimizing unnecessary exposure to phototherapy through adherence to recommended thresholds for treatment is encouraged.

Interference in the anti-Xa heparin activity assay due to hemolysis and icterus during pediatric extracorporeal life support.

Chromogenic anti-Xa assays for unfractionated heparin monitoring (heparin activity) are susceptible to interference from hemolysis and icterus. The purpose of this study was to better understand the effect of hemolysis and icterus on anti-Xa heparin activity and to predict the magnitude of the error. Increasing levels of hemoglobin and unconjugated bilirubin were added to pooled normal plasma or buffer containing known levels of heparin. Increased plasma hemoglobin or bilirubin produced falsely increased residual factor Xa activity as measured by the absorbance change (OD/min) in the Stago heparin activity assay. This increased absorbance change slope resulted in falsely lower estimates of heparin activity. The falsely lower heparin activity measurement occurred even when heparin was not present, indicating it was not due to heparin neutralization. In a sample containing 0.62 ± 0.06 U/mL heparin and 228 mg/dL hemoglobin, the measured heparin activity was 0.41 ± 0.03 U/mL, underestimating heparin activity by 0.21 ± 0.07 U/mL. Interference occurred if plasma hemoglobin was above 70 mg/dL or bilirubin was above 16 mg/dL, which happened in 16%-26% of samples from pediatric patients on extracorporeal life support (ECLS). In conclusion, hemolysis and icterus were common in ECLS patients, leading to underestimates of unfractionated heparin activity and potentially higher doses of heparin than intended. The magnitude of the heparin activity measurement error could be predicted based on plasma hemoglobin and bilirubin levels until these levels exceeded the technical limits of the assay, ~230 mg/dL hemoglobin and 55 mg/dL bilirubin.

Plants used for the treatment of icterus (jaundice) in Central India: A review.

Jaundice is one of the most common medical condition affecting infants, children, and adults. Jaundice is not a disease but it is a visible sign and symptom of liver disease which occurs when there is an increase in the amount of bilirubin circulating in the blood due to the abnormal metabolism and excretion in the urine. Medicinal plants are being used long ago by our ancestors for the treatment of jaundice. At the present era, consumption of these herbal medicines is increasing at a high speed, due to its less or no side effect and cost-effectiveness as compared to synthetic medicines. This review describes approximately 55 medicinal plants which are used by rural and tribal people of different area of Chhattisgarh for curing jaundice. The data was collected from different kinds of literature survey from the year 1993 to 2018. This review has been conferred in a systematic way which includes plant's vernacular name, botanical name along with its family, part used and ethnomedicinal uses in a tabulated form and also the description of scientific evidence behind the folklore uses of some medicinal plants along with their mechanism of action which have been reported in different kinds of literature. The current study may be useful for the development of new medicines for the treatment of jaundice.

Jaundice in infants and children: causes, diagnosis, and management.

Jaundice is caused by an accumulation of bilirubin in the blood. The presentation in infants and children can be indicative of a wide range of conditions, with some self-limiting and others potentially life-threatening. This article aims to provide a concise review of the common medical and surgical causes in children and discuss their diagnosis and management.

Preoperative biliary drainage in resectable pancreatic cancer: a systematic review and network meta-analysis.

BACKGROUND: Controversy remains about the best pre-operative management of jaundice in patients with resectable pancreatic head cancer (RPC) undergoing planned pancreaticoduodenectomy (PD). OBJECTIVE: The aim of this study was to compare rates of post-operative complications in patients undergoing four pre-operative approaches (POA): preoperative biliary drainage with plastic stent (PBD-PS), metal stent (PBD-MS), and percutaneous transhepatic drain (PBD-PT), or no pre-operative biliary drainage (NPBD). METHOD: A study was included in the systematic review if it assessed the effects of PBD on post-operative outcomes in jaundiced patients with RPC. Endpoints were the rate of any post-operative complication, wound infection, intra-abdominal infection and post-operative bleeding. A network meta-analysis (NMA) was performed to rank the POAs from the best to worst, for each outcome. RESULTS: Thirty-two studies were included in the systematic review. Ten out of 32 studies included in the systematic review reported at least one of the 4 outcomes of interest and thus were used for NMA. The calculated odds ratios and P-scores ranked NPBD as the best approach. There was insufficient evidence to determine the best modality of PBD among PBD-PS, PBD-MS and PBD-PT. CONCLUSIONS: No preoperative biliary drainage may be the best management of preoperative jaundice in patients with RPC before PD. Further studies are needed to determine the best modality in patients that need PBD.

Effect of Ursodeoxycholic Acid on Indirect Hyperbilirubinemia in Neonates Treated With Phototherapy.

BACKGROUND: Hyperbilirubinemia is a common neonatal problem. The present study aimed to investigate the effect of ursodeoxycholic acid in reducing indirect hyperbilirubinemia of infants under phototherapy. METHODS: This double-blind randomized clinical trial was conducted on neonates with jaundice, who had received phototherapy in the hospitals affiliated with the Shiraz University of Medical Sciences in 2013. A total of 80 neonates were enrolled in the study and were randomly divided into 2 groups. The intervention group (n =  0) with indirect hyperbilirubinemia received 10 mg · kg(-1) · day(-1) divided every 12 hours Ursobil (capsule 300 mg) in addition to phototherapy, whereas the control group (n =  0) received only phototherapy. Total bilirubin levels were measured every 12 hours until reaching <10 mg/dL, and then phototherapy was disrupted. The duration of phototherapy was measured. The 2 groups were compared regarding total bilirubin levels at different time points and duration of phototherapy using the generalized estimating equation (GEE) test. RESULTS: The mean of total bilirubin in the intervention group was 12 ± 1.6, 10 ± 1.1, and 9.8 ± 0.2 mg/dL 12, 24, and 48 hours after the beginning of phototherapy, respectively. On the contrary, these measures were 14.4 ± 1.3, 12.5 ± 1.4, and 10.1 ± 1.1 mg/dL in the control group, respectively, (P < 0.05). The mean time required for phototherapy to decrease the bilirubin level to < 10 mg/dL was 15.5 ± 6 and 44.6 ± 13.3 hours in the case and the control group, respectively, (P = 0.001). CONCLUSIONS: Ursodeoxycholic acid had additive effect with phototherapy in neonates with indirect hyperbilirubinemia. This drug also reduced the time period needed for phototherapy and, consequently, decreased the hospitalization period.

Using Automatic Item Generation to Improve the Quality of MCQ Distractors.

UNLABELLED: CONSTRUCT: Automatic item generation (AIG) is an alternative method for producing large numbers of test items that integrate cognitive modeling with computer technology to systematically generate multiple-choice questions (MCQs). The purpose of our study is to describe and validate a method of generating plausible but incorrect distractors. Initial applications of AIG demonstrated its effectiveness in producing test items. However, expert review of the initial items identified a key limitation where the generation of implausible incorrect options, or distractors, might limit the applicability of items in real testing situations. BACKGROUND: Medical educators require development of test items in large quantities to facilitate the continual assessment of student knowledge. Traditional item development processes are time-consuming and resource intensive. Studies have validated the quality of generated items through content expert review. However, no study has yet documented how generated items perform in a test administration. Moreover, no study has yet to validate AIG through student responses to generated test items. APPROACH: To validate our refined AIG method in generating plausible distractors, we collected psychometric evidence from a field test of the generated test items. A three-step process was used to generate test items in the area of jaundice. At least 455 Canadian and international medical graduates responded to each of the 13 generated items embedded in a high-stake exam administration. Item difficulty, discrimination, and index of discrimination estimates were calculated for the correct option as well as each distractor. RESULTS: Item analysis results for the correct options suggest that the generated items measured candidate performances across a range of ability levels while providing a consistent level of discrimination for each item. Results for the distractors reveal that the generated items differentiated the low- from the high-performing candidates. CONCLUSIONS: Previous research on AIG highlighted how this item development method can be used to produce high-quality stems and correct options for MCQ exams. The purpose of the current study was to describe, illustrate, and evaluate a method for modeling plausible but incorrect options. Evidence provided in this study demonstrates that AIG can produce psychometrically sound test items. More important, by adapting the distractors to match the unique features presented in the stem and correct option, the generation of MCQs using automated procedure has the potential to produce plausible distractors and yield large numbers of high-quality items for medical education.

[Research and Design of a Blue and Green Light Emitting Diode Phototherapy System Based on Fly Eye Lens for Jaundice].

Light emitting diode(LED)can be used in the treatment of jaundice.Blue and green LED irradiation affected with the newborn is currently considered the most effective treatment of the jaundice in the world.A jaundice phototherapy system with blue and green LED as light source utilizing fly eye lens array was built to achieve uniform illumination in the present study.AMC7150 chip was used to build the constant current drive module,and AT89C52 MCU and LCD12864 LCD screen were used to build the human-computer interaction module.Based on national particular phototherapy equipment requirements(YY0669-2008)for the safety,we designed and implemented a phototherapy system which spot area was 250mm×500mm,blue light irradiance reached 2mW/cm2,green light irradiance reached 1.5mW/cm2,and the uniformity of light was over 90%.Compared with the traditional system,the new one designed in this study has better therapeutic effect,higher biological safety,easier to achieve man-machine interaction,and more economical and convenient.

Chest shielding for prevention of a haemodynamically significant patent ductus arteriosus in preterm infants receiving phototherapy.

BACKGROUND: Patent ductus arteriosus (PDA) is associated with mortality and morbidity in preterm infants. Phototherapy is a common treatment for jaundice in preterm infants. However, phototherapy has been associated with failure of closure of the ductus arteriosus in preterm infants. OBJECTIVES: To determine if chest shielding of preterm infants receiving phototherapy reduces the incidence of clinically and/or haemodynamically significant PDA and reduces morbidity secondary to PDA. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2015, Issue 3), MEDLINE, EMBASE, CINAHL, previous reviews, cross-references, abstracts, proceedings of scientific meetings, and trial registries through March 2015. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster-RCTs, or quasi-RCTs of chest shielding during phototherapy compared to sham shielding or no shielding for the prevention of a haemodynamically or clinically significant PDA in preterm infants. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed studies for eligibility and quality and extracted data. We defined a clinically significant PDA as the presence of a PDA with clinical signs of an effect on organ function attributable to the ductus arteriosus. We defined a haemodynamically significant PDA as clinical and/or echocardiographic signs of a significant ductus arteriosus effect on blood flow. MAIN RESULTS: We included two small trials enrolling very preterm infants (Rosenfeld 1986; Travadi 2006). We assessed both as at high risk of bias. No study reported clinically significant PDA, defined as the presence of a PDA with clinical symptoms or signs attributable to the effect of a ductus arteriosus on organ function. Rosenfeld 1986 reported a non-significant reduction in haemodynamically significant PDA with left atrial to aortic root ratio greater than 1.2 (risk ratio (RR) 0.23, 95% confidence interval (CI) 0.05 to 1.01; 74 infants) but a statistically significant risk difference (RD -0.18, 95% CI -0.34 to -0.03; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 3 to 33). Rosenfeld 1986 reported a significant reduction in PDA detected by murmur (RR 0.50, 95% CI 0.29 to 0.88; RD -0.30, 95% CI -0.52 to -0.08; NNTB 3, 95% CI 2 to 12; 74 infants). Rosenfeld 1986 reported a significant reduction in treatment with indomethacin (RR 0.12, 95% CI 0.02 to 0.88; RD -0.21, 95% CI -0.35 to -0.06; NNTB 5, 95% CI 3 to 17; 74 infants), and only one infant had a ductal ligation in the no-shield group. There were no other significant outcomes, including mortality to discharge or 28 days, days in oxygen, days on mechanical ventilation, days in hospital, intraventricular haemorrhage, retinopathy of prematurity, or exchange transfusion. AUTHORS' CONCLUSIONS: The available evidence is very low quality and insufficient to assess the safety or efficacy of chest shield during phototherapy for prevention of PDA in preterm infants. Further trials of chest shielding are warranted, particularly in settings where infants are not receiving prophylactic or early echocardiographic targeted cyclo-oxygenase inhibitors for PDA.

Variable Clinical Presentations of ABO Incompatibility in Dizygotic Twins.

Newborns with ABO blood group incompatibility can have a spectrum of clinical presentations from remaining asymptomatic to severe hemolytic anemia with jaundice. This case presentation discusses dizygotic twins who demonstrated both ends of the clinical spectrum. Similar cases in which there is such extreme variation between twins were not attainable in the current literature, which prompted the authors to present it as a rare occurrence and one that was unexpected based on their past experience with ABO incompatibility both in singletons and in twins.

A Prospective Study on Exchange Transfusion in Neonatal Unconjugated Hyperbilirubinemia--in a Tertiary Care Hospital, Nepal.

BACKGROUND: An exchange transfusion involves replacing patient's blood with donor blood in order to remove abnormal blood components and circulating toxins while maintaining adequate circulating blood volume. OBJECTIVE: To observe the incidence, causes of jaundice requiring Exchange and any adverse event of exchange transfusion in newborns with unconjugated hyperbilirubinemia. METHOD: Prospective study undertaken at Neonatal Intensive Care Unit (NICU) of Manipal Teaching Hospital, Pokhara, Nepal from March 2014 to April 2015. For both mothers and neonates blood group and Rh typing and for all newborns pre and post exchange complete blood count with peripheral smear, serum bilirubin, hemoglobin, calcium, potassium, random blood sugar, C-reactive protein and blood culture and where ever required Direct Coombs test, reticulocyte count, G6PD activity and thyroid function test were done. The incidence, indications, positive outcome, complications and mortality were noted. RESULT: Out of 481 cases of unconjugated hyperbilirubinemia 29 (6%) required exchange transfusion. 55.2% Pathological Jaundice [13.8% ABO incompatibility, sepsis and hypothyroidism was commonest causes] and 44.8% exaggerated physiological jaundice [27.6% with no underlying pathology, 10.3% preterms 3.4% cephalhematoma] required exchange transfusion. Post transfusion, bilirubin level decreased significantly (p < 0.001). The commonest adverse events noted were anemia (89.7% / p < 0.018), hyperglycemia(51.7% / p < 0.001), hypocalcaemia (48.3% / p < 0.001)), sepsis(10.3%), hypernatremia (13.8%), hyperkalaemia, bradycardia, apnea and feed intolerance (6.9%). None of them had kernicterus and there was no mortalities. CONCLUSION: Exchange transfusion is an effective procedure to decrease bilirubin levels but is associated with many complications. Hypothyroidism was one of the commonest cause of jaundice requiring Exchange transfusion.

Identification of the traditional methods of newborn mothers regarding jaundice in Turkey.

AIMS AND OBJECTIVES: To detect traditional methods applied for the treatment of newborn jaundice by mothers in Turkey. BACKGROUND: Traditional methods are generally used in our society. Instead of using medical services, people often use already-known traditional methods to treat the disease. In such cases, the prognosis of the disease generally becomes worse, the treatment period longer and healthcare costs higher, and more medicine is used. DESIGN: A cross-sectional descriptive study. METHODS: The participants of this study were 229 mothers with newborn babies aged 0-28 days in one university hospital and one public children's hospital in Sanliurfa. The study was conducted between March and May 2012. In this research, the Beliefs and Traditional Methods of Mothers for Jaundice Questionnaire, which was formed by searching the relevant literature, is used as a data collection tool. The data are evaluated by percentage distributions. RESULTS: Mothers apply conventional practices in cases of health problems such as jaundice, and application of these methods is important to mothers. Moreover, mothers reported applying hazardous conventional methods in cases of neonatal jaundice, such as cutting the area between the baby's eyebrows with a blade, cutting the back of the ear and the body and burning the body, which are not applied in different cultures. CONCLUSIONS: Education regarding the effects of conventional methods being applied in families should be provided, and the results of this study should serve to guide further studies in assessing the effects of such education. RELEVANCE TO CLINICAL PRACTICE: This approach can support beneficial practices involving individual care and prevent the negative health effects of hazardous practices.