The incidence rate and influence factors of hemolysis, lipemia, icterus in fasting serum biochemistry specimens.

OBJECTIVE: Hemolysis, icterus, and lipemia (HIL) of blood samples have been a concern in hospitals because they reflect pre-analytical processes' quality control. However, very few studies investigate the influence of patients' gender, age, and department, as well as sample-related turnaround time, on the incidence rate of HIL in fasting serum biochemistry specimens. METHODS: A retrospective, descriptive study was conducted to investigate the incidence rate of HIL based on the HIL index in 501,612 fasting serum biochemistry specimens from January 2017 to May 2018 in a tertiary university hospital with 4,200 beds in Sichuan, southwest China. A subgroup analysis was conducted to evaluate the differences in the HIL incidence rate by gender, age and department of patients, and turnaround time of specimens. RESULTS: The incidence rate of hemolysis, lipemia and icterus was 384, 53, and 612 per 10,000 specimens. The male patients had a significantly elevated incidence of hemolysis (4.13% vs. 3.54%), lipemia (0.67% vs. 0.38%), and icterus (6.95% vs. 5.43%) than female patients. Hemolysis, lipemia, and icterus incidence rate were significantly associated with the male sex with an odds ratio (OR) of 1.174 [95% confidence interval (CI), 1.140-1.208], 1.757 (95%CI: 1.623-1.903), and 1.303 (95%CI: 1.273-1.333), respectively, (P<0.05). The hospitalized patients had a higher incidence of hemolysis (4.03% vs. 3.54%), lipemia (0.63% vs. 0.36%), and icterus (7.10% vs. 4.75%) than outpatients (P<0.001). Specimens with relatively longer transfer time and/or detection time had a higher HIL incidence (P<0.001). The Pediatrics had the highest incidence of hemolysis (16.2%) with an adjusted OR (AOR) of 4.93 (95%CI, 4.59-5.29, P<0.001). The Neonatology department had the highest icterus incidence (30.1%) with an AOR of 4.93 (95%CI: 4.59-5.29, P<0.001). The Neonatology department (2.32%) and Gastrointestinal Surgery (2.05%) had the highest lipemia incidence, with an AOR of 1.17 (95%CI: 0.91-1.51) and 4.76 (95%CI: 4.70-5.53), both P-value <0.001. There was an increasing tendency of hemolysis and icterus incidence for children under one year or adults aged more than 40. CONCLUSION: Evaluation of HIL incidence rate and HIL-related influence factors in fasting serum biochemistry specimens are impartment to interpret the results more accurately and provide better clinical services to patients.

Intrahepatic Cholestasis of Pregnancy: A Case Study of the Rare Onset in the First Trimester.

Intrahepatic cholestasis of pregnancy (ICP) is a gestation-specific liver disorder, defined most often as the onset of pruritus, usually from the third trimester of pregnancy, associated with abnormal liver test results and/or increased total serum bile acids and spontaneous relief after delivery. The 21-year-old patient was admitted to our ward in the 11th week of pregnancy due to raised liver enzymes. The first onset of pruritus and jaundice appeared a month before hospitalization. Immunology tests and Toxoplasma gondii were negative. We excluded viral etiology, while alpha-1-antitrypsin, serum and urine copper levels, and thyroid hormones were within the reference values. The patient denied she had taken any medicines and herbal preparations before and during pregnancy. Total bile acids in the serum were significantly elevated (242 µmol/L). The abdominal ultrasound revealed a regular finding. Liver biopsy suggested a cholestatic liver disorder. After a presentation of all risks, the patient decided to stop the pregnancy. After a month, the hepatogram was within the reference values. Very rarely an ICP can occur in early pregnancy (first trimester), which calls for close monitoring. The risk of serious adverse fetal outcomes and spontaneous preterm delivery is proportional with increased levels of maternal serum bile acid.

Neurotoxicity of Unconjugated Bilirubin in Mature and Immature Rat Organotypic Hippocampal Slice Cultures.

BACKGROUND: The physiopathology of bilirubin-induced neurological disorders is not completely understood. OBJECTIVES: The aim of our study was to assess the effect on bilirubin neurotoxicity of the maturity or immaturity of exposed cells, the influence of different unconjugated bilirubin (UCB) and human serum albumin (HSA) concentrations, and time of UCB exposure. METHODS: Organotypic hippocampal slices were exposed for 48 h to different UCB and HSA concentrations after 14 (mature) or 7 (immature) days of in vitro culture. Immature slices were also exposed to UCB and HSA for 72 h. The different effects of exposure time to UCB on neurons and astrocytes were evaluated. RESULTS: We found that 48 h of UCB exposure was neurotoxic for mature rat organotypic hippocampal slices while 72 h of exposure was neurotoxic for immature slices. Forty-eight-hour UCB exposure was toxic for astrocytes but not for neurons, while 72-h exposure was toxic for both astrocytes and neurons. HSA prevented UCB toxicity when the UCB:HSA molar ratio was ≤1 in both mature and immature slices. CONCLUSIONS: We confirmed UCB neurotoxicity in mature and immature rat hippocampal slices, although immature ones were more resistant. HSA was effective in preventing UCB neurotoxicity in both mature and immature rat hippocampal slices.

Clinical Indicators of Fatal Dengue in Two Endemic Areas of Colombia: A Hospital-Based Case-Control Study.

According to the World Health Organization, 98% of fatal dengue cases can be prevented; however, endemic countries such as Colombia have recorded higher case fatality rates during recent epidemics. We aimed to identify the predictors of mortality that allow risk stratification and timely intervention in patients with dengue. We conducted a hospital-based, case-control (1:2) study in two endemic areas of Colombia (2009-2015). Fatal cases were defined as having either 1) positive serological test (IgM or NS1), 2) positive virological test (RT-PCR or viral isolation), or 3) autopsy findings compatible with death from dengue. Controls (matched by state and year) were hospitalized nonfatal patients and had a positive serological or virological dengue test. Exposure data were extracted from medical records by trained staff. We used conditional logistic regression (adjusting for age, gender, disease's duration, and health-care provider) in the context of multiple imputation to estimate exposure to case-control associations. We evaluated 110 cases and 217 controls (mean age: 35.0 versus 18.9; disease's duration pre-admission: 4.9 versus 5.0 days). In multivariable analysis, retro-ocular pain (odds ratios [OR] = 0.23), nausea (OR = 0.29), and diarrhea (OR = 0.19) were less prevalent among fatal than nonfatal cases, whereas increased age (OR = 2.46 per 10 years), respiratory distress (OR = 16.3), impaired consciousness (OR = 15.9), jaundice (OR = 32.2), and increased heart rate (OR = 2.01 per 10 beats per minute) increased the likelihood of death (AUC: 0.97, 95% confidence interval: 0.96, 0.99). These results provide evidence that features of severe dengue are associated with higher mortality, which strengthens the recommendations related to triaging patients in dengue-endemic areas.

Jaundice in a Service member Returning From Taiwan; Diagnostic Challenges in a Case of Acute Hepatitis E.

When the evaluation of newly elevated liver enzymes is unrevealing, a common diagnosis of exclusion is drug-induced liver injury. A 39-year-old active duty service member who presented with jaundice after returning from a mission in Thailand was found to have an acute hepatitis and developing acute liver failure. He was ultimately diagnosed with acute hepatitis E, but his diagnosis was initially confounded by multiple exposures to supplements known to cause drug-induced liver injury. This case illustrates the importance of broadened serologic testing in patients with acute liver injury returning from countries endemic with hepatitis E and also highlights the challenges in diagnosis of acute hepatitis E with currently available testing.

Liver failure associated with mahogany seed extract consumption.

A 45-year-old woman presented to the emergency department with jaundice of 2 weeks' duration. This was associated with mahogany seed extract (Skyfruit supplement) consumption for 6 months prior to admission. Examination was normal apart from scleral icterus and grade 2 encephalopathy. Liver function tests showed a hepatocellular pattern of derangement: alanine transaminase, 1267 U/L (10-36); aspartatetransaminase, 1255 U/L (10-30); alkaline phosphatase, 124 U/L (22-104); bilirubin, 258 µmol/L (3-21) with a prolonged prothrombin time of 16.8 s (9.2-11.0). Viral hepatitis work-up was largely unremarkable and liver biopsy showed moderate inflammatory infiltrates (mostly lymphocytic with scattered eosinophils) in the periportal region and lobule with bridging necrosis, favouring drug-induced liver injury. Withdrawal of the drug resulted in normalisation of liver function.

Diagnòstic diferencial de la icterícia en el lactant / No disponible

No disponible

Jaundice in the emergency department: meeting the challenges of diagnosis and treatment [digest].

There are approximately 52,000 visits a year to emergency departments for patients presenting with jaundice. While many of these patients will not have immediately life-threatening pathology, it is essential that the emergency clinician understands the pathophysiology of jaundice, as this will guide the appropriate workup to detect critical diagnoses. Patients who present with jaundice could require intravenous antibiotics, emergent surgery, and, in severe cases, organ transplantation. This issue will focus on the challenge of evaluating and treating the jaundiced patient in the ED using the best available evidence from the literature. [Points & Pearls is a digest of Emergency Medicine Practice.].

Does time taken to achieve jaundice-clearance influence survival of the native liver in post-Kasai biliary atresia?

BACKGROUND: We reviewed the time taken for post-portoenterostomy (PE) biliary atresia (BA) patients to obtain jaundice-clearance (total bilirubin ≤ 1.2 mg/dL; JC) post-PE to determine if JC time (JCT) is prognostic for survival of the native liver (SNL). METHODS: The subjects were 66 BA patients treated with PE at our institute between 1989, the year when liver transplantation (LTx) became available in Japan, and 2014. JCT was used to create three groups (≤ 30 days: n = 14; 31-60 days: n = 31; ≥ 61 days: n = 21). Medical records were reviewed retrospectively to evaluate: age at onset of symptoms, duration of symptoms pre-PE, age and weight at PE, serum liver function tests, incidence of cholangitis, and micro-bile duct size at PE. RESULTS: Age at onset of symptoms, age and weight at PE, duration of symptoms pre-PE, and micro-bile duct size were similar for all patients in all three groups. JCT and SNL appeared to correlate because preoperative total bilirubin (7.1, 9.6, 10.2 mg/dL; P < 0.05) was significantly lower in the JCT ≤ 30 days group (P < 0.05) while there was a significant decrease in SNL (P < 0.03) and a significant increase in LTx (P < 0.01) in the JCT ≥ 61 days group. All LTx subjects who achieved JC were found to have developed cholangitis within 3 months of PE. CONCLUSION: During the follow-up of post-PE subjects, longer JCT and cholangitis occurrence within 3 months of PE would appear to be negative prognostic factors for SNL while preoperative total bilirubin would appear to be a positive prognostic factor for SNL.

Improved binary dragonfly optimization algorithm and wavelet packet based non-linear features for infant cry classification.

BACKGROUND AND OBJECTIVE: Infant cry signal carries several levels of information about the reason for crying (hunger, pain, sleepiness and discomfort) or the pathological status (asphyxia, deaf, jaundice, premature condition and autism, etc.) of an infant and therefore suited for early diagnosis. In this work, combination of wavelet packet based features and Improved Binary Dragonfly Optimization based feature selection method was proposed to classify the different types of infant cry signals. METHODS: Cry signals from 2 different databases were utilized. First database contains 507 cry samples of normal (N), 340 cry samples of asphyxia (A), 879 cry samples of deaf (D), 350 cry samples of hungry (H) and 192 cry samples of pain (P). Second database contains 513 cry samples of jaundice (J), 531 samples of premature (Prem) and 45 samples of normal (N). Wavelet packet transform based energy and non-linear entropies (496 features), Linear Predictive Coding (LPC) based cepstral features (56 features), Mel-frequency Cepstral Coefficients (MFCCs) were extracted (16 features). The combined feature set consists of 568 features. To overcome the curse of dimensionality issue, improved binary dragonfly optimization algorithm (IBDFO) was proposed to select the most salient attributes or features. Finally, Extreme Learning Machine (ELM) kernel classifier was used to classify the different types of infant cry signals using all the features and highly informative features as well. RESULTS: Several experiments of two-class and multi-class classification of cry signals were conducted. In binary or two-class experiments, maximum accuracy of 90.18% for H Vs P, 100% for A Vs N, 100% for D Vs N and 97.61% J Vs Prem was achieved using the features selected (only 204 features out of 568) by IBDFO. For the classification of multiple cry signals (multi-class problem), the selected features could differentiate between three classes (N, A & D) with the accuracy of 100% and seven classes with the accuracy of 97.62%. CONCLUSION: The experimental results indicated that the proposed combination of feature extraction and selection method offers suitable classification accuracy and may be employed to detect the subtle changes in the cry signals.

Jaundice in the emergency department: meeting the challenges of diagnosis and treatment.

There are approximately 52,000 visits a year to emergency departments for patients presenting with jaundice. While many of these patients will not have immediately life-threatening pathology, it is essential that the emergency clinician understands the pathophysiology of jaundice, as this will guide the appropriate workup to detect critical diagnoses. Patients who present with jaundice could require intravenous antibiotics, emergent surgery, and, in severe cases, organ transplantation. This issue will focus on the challenge of evaluating and treating the jaundiced patient in the ED using the best available evidence from the literature.

Vitamin B12 deficiency: unusual cause of jaundice in an adolescent.

Vitamin B12 deficiency in vegans is a known cause of megaloblastic anaemia. We report an adolescent girl who presented with jaundice and weight loss for 6 months secondary to vitamin B12 deficiency, leading to megaloblastic anaemia. Replacement with vitamin B12 reversed her symptoms, resulting in weight gain, and normalised her haemoglobin, red blood cell morphology, bilirubin levels and serum vitamin B12 levels.

New concepts on the clinical course and stratification of compensated and decompensated cirrhosis.

The clinical course of cirrhosis has been typically described by a compensated and a decompensated state based on the absence or, respectively, the presence of any of bleeding, ascites, encephalopathy or jaundice. More recently, it has been recognized that increasing portal hypertension and several major clinical events are followed by a marked worsening in prognosis, and disease states have been proposed accordingly in a multistate model. The development of multistate models implies the assessment of the probabilities of more than one possible outcome from each disease state. This requires the use of competing risks analysis which investigates the risk of several competing outcomes. In such a situation, the Kaplan-Meier risk estimates and the Cox regression may be not appropriate. Clinical states of cirrhosis presently considered as suitable for a comprehensive multistate model include: in compensated cirrhosis, early (mild) portal hypertension with hepatic venous pressure gradient (HVPG) >5 and <10 mmHg, clinically significant portal hypertension (HVPG ≥ 10 mmHg) without gastro-esophageal varices (GEV), and GEV; in decompensated cirrhosis, a first variceal bleeding without other decompensating events, any first non-bleeding decompensation and any second decompensating event; and in a late decompensation state, refractory ascites, sepsis, renal failure, recurrent encephalopathy, profound jaundice, acute on chronic liver failure, all predicting a very short survival. In this review, we illustrate how competing risks analysis and multistate models may be applied to cirrhosis.

Different clinical presentations of choledochal cyst among infants and older children: A 10-year retrospective study.

Choledochal cyst is a rare and often benign congenital cystic dilation throughout the biliary tree. Due to the benign nature of choledochal cyst among early-diagnosed patients, the clinical assumption and diagnosis seem to be of utmost significance. Therefore, we sought to assess different clinical manifestations of choledochal cyst and relevant laboratory findings in infants and older children.Retrospectively, medical records of all patients with the diagnosis of choledochal cyst between 2005 and 2015 were reviewed. Demographic data, initial clinical presentation, positive findings on physical examination, history of any remarkable behavior such as persistent and unexplained crying and poor feeding, and diagnostic imaging modalities were listed. In addition, laboratory values for total and direct bilirubin, alkaline phosphatase, alanine transaminase, aspartate transaminase, prothrombin time, and partial thromboplastin time (PTT) were recorded for each patient. Patients were divided into 2 groups; younger than 1-year-old (infants), and 1 year to 18 years old (older children). Demographic data, clinical data, and laboratory values were compared between the infants and older children.Thirty-two patients with a diagnosis of choledochal cyst were included in the study: 9 patients (28.12%) were infants and 23 patients (71.87%) were older children. Abdominal pain was the most common presenting symptom (62.5%), followed by nausea/vomiting (59.4%) and jaundice (28.1%). None of the patients presented with the classic triad of abdominal pain, jaundice, and right upper quadrant mass. Seventeen older children (73.91%) presented with nausea and vomiting, while 2 subjects (22.22%) in the infantile group presented with this feature (P = .01). Similarly, abdominal pain was found in 20 older children (86.95%); however, none of the infants presented with abdominal pain at diagnosis (P < .001). By contrast, the abdominal mass was more detected in infants than the older children (33.33% vs. 0%, P = .01). In terms of laboratory values, the median PTT was 44 and 36 s in infants and older children, respectively (P = .04).Infants were more likely to present with abdominal mass and older children were more likely to have nausea, vomiting, and abdominal pain. Furthermore, infants had more prolonged PTT than older children, implying a potential bleeding tendency.

The effect of self-explanation of pathophysiological mechanisms of diseases on medical students' diagnostic performance.

Self-explanation while diagnosing clinical cases fosters medical students' diagnostic performance. In previous studies on self-explanation, students were free to self-explain any aspect of the case, and mostly clinical knowledge was used. Elaboration on knowledge of pathophysiological mechanisms of diseases has been largely unexplored in studies of strategies for teaching clinical reasoning. The purpose of this two-phase experiment was to investigate the effect of self-explanation of pathophysiology during practice with clinical cases on students' diagnostic performance. In the training phase, 39 4th-year medical students were randomly assigned to solve 6 criterion cases (3 of jaundice; 3 of chest pain), either self-explaining the pathophysiological mechanisms of the findings (n = 20) or without self-explaining (n = 19). One-week later, in the assessment phase, all students solved 6 new cases of the same syndromes. A repeated-measures analysis of variance on the mean diagnostic accuracy scores showed no significant main effects of study phase (p = 0.34) and experimental condition (p = 0.10) and no interaction effect (p = 0.42). A post hoc analysis found a significant interaction (p = 0.022) between study phase and syndrome type. Despite equal familiarity with jaundice and chest pain, the performance of the self-explanation group (but not of the non-self-explanation group) on jaundice cases significantly improved between training and assessment phases (p = 0.035) whereas no differences between phases emerged on chest pain cases. Self-explanation of pathophysiology did not improve students' diagnostic performance for all diseases. Apparently, the positive effect of this form of self-explanation on performance depends on the studied diseases sharing similar pathophysiological mechanisms, such as in the jaundice cases.

Scrub Typhus in a Tertiary Care Hospital in North India.

Scrub typhus, a zoonotic disease caused by the bacterium Orientia tsutsugamushi, has become endemic in many parts of India. We studied the clinical profile of this infection in 228 patients that reported to this tertiary care center from July 2013 to December 2014. The median age of patients was 35 years (interquartile range = 24.5-48.5 years), and 111 were males and 117 females. A high-grade fever occurred in 85%, breathlessness in 42%, jaundice in 32%, abdominal pain in 28%, renal failure in 11%, diarrhea in 10%, rashes in 9%, and seizures in 7%. Common laboratory abnormalities at presentation were a deranged hepatic function in 61%, anemia in 54%, leukopenia in 15%, and thrombocytopenia in 90% of our patients. Acute kidney injury (32%), acute respiratory distress syndrome (ARDS) (25%), and disseminated intravascular coagulation (DIC) (16%) were the commonest complications. A hepatorenal syndrome was seen in 38% and multiple organ dysfunction syndrome (MODS) in 20% patients. The overall case fatality rate was 13.6%. In univariate analysis, ARDS requiring mechanical ventilation, acute kidney injury requiring hemodialysis, hypotension requiring inotropic support, central nervous system dysfunction at presentation, and MODS were inversely associated with survival. Survival was significantly higher in patients that presented with a duration of fever < 10 days compared with those that presented ≥ 12 days (P < 0.05) after onset. In conclusion, scrub typhus has become a leading infectious disease in north India and an important cause of infectious fever. An increasing awareness of this disease coupled with prompt management will go a long way in reducing both morbidity and mortality from this disease.

Effects of haemolysis, icterus and lipaemia on coagulation tests as performed on Stago STA-Compact-Max analyser.

INTRODUCTION: Haemolysis, icterus and lipaemia (HIL) may affect haemostasis test results. This may be influenced by the level of interfering substance and the reagents and end-point detection system used. METHODS: We assessed the influence of HIL on prothrombin time, activated partial thromboplastin time and fibrinogen assay using a viscosity-based detection analyser. RESULTS: Spontaneous haemolysis that occurred during sample collection and processing had no effect on PT with either a rabbit tissue factor extract or recombinant human tissue factor reagents. In contrast, addition of mechanically haemolysed cells impacted on PT for the highest haemoglobin concentration. For APTTs determined with STA®-Cephascreen® reagent, there was no significant difference between results in haemolysed and nonhaemolysed samples. For the other two reagents studied, APTTs were statistically significantly shorter in haemolysed samples compared with nonhaemolysed samples. This bias was clinically significant only for STA®-PTT Automate. For all three APTT reagents, the impact of haemolysis was sufficient to impact patient management decisions, and in some samples, the effects of lipaemia and icterus were not clinically significant. CONCLUSION: Overall, our results confirm that PT and fibrinogen were not clinically significantly affected by HIL. The APTTs of some haemolysed samples were falsely normal. Haemolysed samples for APTT determination should be rejected.