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- Small Cell Carcinoma of Lung Presenting With Acute Pancreatitis: Case Report and Review of Literature. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):680A.
Cancer Student/Resident CasesSESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 04:30 PM - 05:30 PMINTRODUCTION: Small cell carcinoma of the lung (SCLC) is an aggressive disease that tends to metastasize early in its course and has a poor prognosis. Pancreatic metastasis generally constitutes a late manifestation of this disease and most patients do not have organ specific symptoms i.e. jaundice, abdominal pain and weight loss. We hereby, present an interesting case of small cell carcinoma of lung, which had acute pancreatitis as the initial manifestation of the disease.CASE PRESENTATION: A 71 year old female with significant history of tobacco abuse presented with complaints of epigastric abdominal pain radiating to the back for 2 days. She also reported weight loss of 40 lbs during the past 4 months. There was no history of alcohol abuse or gall stones. Physical examination was unremarkable except for epigastric tenderness and scleral icterus. Laboratory investigation revealed Amylase 1469 U/L, Lipase 1632 U/L, total bilirubin 3.9 mg/dl, Alkaline Phosphatase 332 IU/L, ALT 79 IU/L and AST 88 IU/L. Diagnosed with acute pancreatitis, she had MRCP which showed hyper intense hepatic nodules on background of iron deposition and mild dilation of biliary system. ERCP revealed displaced major papilla, distal common bile duct indentation which was suspicious for distal bile duct stricture. Shelving was also noted with poor drainage of the contrast for which a plastic biliary stent was placed. Brushing from the common bile duct showed atypical ductal proliferation. CT of the chest revealed 2.5 cm irregular mass in the superior hilar aspect of the right lower lobe of lung with irregular margins. A CT guided biopsy of the liver lesions showed malignant cells with immunostaining positive for TTF-1, chromogranin and synaptophysin; Ki67 revealed nuclear reactivity for about 95% of tumor cells. Flow cytometric studies demonstrated that the tumor cells expressed CD56 (neuroendocrine marker) but were negative for lymphohemotopoietic markers. All these findings were compatible with a diagnosis of metastatic SCLCDISCUSSION: SCLC having acute pancreatitis as the initial presentation is a rare event. Literature review revealed 11 other cases of similar presentation (Table). Possible mechanisms for metastatic cancer inducing pancreatitis include obstruction of the pancreatic duct by metastases or peripancreatic compression secondary to regional lymph node or vascular compromise by neoplastic destruction1. However in some patients there is no evidence of pancreatic metastasis raising the question if this is a paraneoplastic manifestation2.CONCLUSIONS: Small cell carcinoma of lung can present as acute pancreatitis secondary to metastatic or paraneoplatic manifestation.Reference #1: Muranaka T, Teshima K, Honda H, Nanjo T Computed tomography and histologic appearance of pancreatic metastases from distant sources Acta Radiol. 1989 Nov-Dec; 30(6):615-9.Reference #2: Ugur Gonlugur, Arzu Mirici, Muammer Karaayvaz. Pancreatic involvement in small cell lung cancer Radiol Oncol. Mar 2014; 48(1): 11-19.The following authors have nothing to disclose: Faraz Khan Luni, Muhammad Ali Khan, Luis De Las Casas, Yaseen Alastal, Abdullah Alwardi, Youngsook YoonNo Product/Research Disclosure Information.
- Unexplained Hemolysis in a Transplant Patient on Extracorporeal Membrane Oxygenation Support. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):346A.
Miscellaneous Case Report Posters IIISESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Hemolysis is a complication of extracorporeal membrane oxygenation (ECMO) support associated with poor outcomes. We present a case of severe hypertriglyceridemia causing spurious hemolysis in a lung transplant patient on ECMO.CASE PRESENTATION: A 20-year-old man who developed bronchiolitis obliterans thirty-three months after bilateral lung transplantation presented with refractory hypercapnic respiratory failure. Veno-venous ECMO was started as a bridge to retransplantation. Four days later he was ambulating with ECMO and mechanical ventilation support. Sirolimus was added to his immunossupressive regimen including mofetil mycophenolate, prednisone, and cyclosporine. Fourteen days after the addition of sirolimus 1 mg daily a progressive increase in plasma-free hemoglobin was noted, with peak level of 560 mg/dl. Haptoglobin and total bilirubin levels were normal (73 mg/dl and 1.3 mg/dl, respectively). LDH level was 385 mg/dl. His blood sample appeared turbid and his lipid profile was markedly abnormal: triglyceride level, 830 mg/dl; total cholesterol level, 210 mg/dl; HDL level, 28 mg/dl; and LDL level, 109 mg/dl. A plasma sample was sent to a specialized laboratory where it was analyzed spectrophotometrically at 8 wavelengths ranging from 415 nm to 700 nm, yielding a free hemoglobin level of 55.6 mg/dl. Patient underwent plasmapheresis and fenofibrate treatment with rapid decline in triglyeride level and simultaneous decrease in plasma free hemoglobin.DISCUSSION: Plasma free hemoglobin concentration is closely monitored during ECMO as a measure of hemolysis. Triglycerides confer turbidity and scatter the light, falsely raising the baseline absorbance of a sample. Hypertriglyceridemia interferes with the measurement of plasma free hemoglobin causing spurious hemolysis. Filtering turbid samples is recommended to minimize interference. Plasmapheresis is effective in rapidly reducing triglyceride levels and has been used for sirolimus-induced hypertriglyceridemia in lung transplant patients.CONCLUSIONS: Spurious hemolysis during ECMO should be suspected when plasma free hemoglobin elevation does not correlate with haptoglobin, LDH and bilirubin levels. Clinicians should be aware of the effect of hypertriglyceridemia causing spurious hemolysis.Reference #1: Fernandez-Bussy S, Akindipe O, Baz M, et al. Sirolimus-induced severe hypertriglyceridemia in a lung transplant recipient. Transplantation. 2010 Feb 27;89(4):481-2Reference #2: Kroll MH, Elin RJ. Interference with Clinical Laboratory Analyses. Clin. Chem Vol. 40, No. 11, 1994DISCLOSURE: The following authors have nothing to disclose: Aida Venado, Pilar Acosta Lara, Keith Wille, Scott Bellot, Enrique Diaz-GuzmanNo Product/Research Disclosure Information.
- Acute Bilateral Renal Cortical Necrosis in ELLP. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):293A.
Critical Care Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Bilateral renal cortical necrosis (BRCN) is a rare but devastating form of acute kidney injury (AKI) disproportionately seen in critical obstetric illness. We present a unique case of BRCN in which the absence of hemolysis hindered the definitive early diagnosis BRCN etiology.CASE PRESENTATION: A 40 year-old female G6P4014 presented at 32 weeks with sudden onset of contractions and vaginal bleeding. Her medical history was significant for preeclampsia. On admission, she was afebrile, blood pressure 157/113 mmHg, with a fetal ultrasound suggested intrauterine fetal demise. Initial lab results revealed normal chemistry, complete blood count, and liver function tests. Vaginal delivery was scheduled for the next day. Overnight, she became altered, pale, diaphoretic and abruptly anuric with a 3g/dL decrease in hemoglobin and increase in creatinine from 0.8 to 1.4 mg/dL. Concern for placental abruption prompted emergent induced vaginal delivery. Peri-partum lab results revealed uptrending liver enzymes (peak AST 743 Units/L, peak ALT 296 Units/L), lactate dehydrogenase 3809 Units/L, D-dimer (>9999), decreased platelets (nadir 33 x10^3/uL), and fibrinogen (nadir 112mg/dL). Serum bilirubin remained normal. Schistocytes and fragmented cells were absent on repeated peripheral smears. A non-contrast CT abdomen suggested bilateral cortical radiolucency consistent with BRCN. DIC was treated with low-dose heparin infusion. The patient was initiated on hemodialysis and had resolution of DIC, transaminitis, and thrombocytopenia several days post-partum.DISCUSSION: Acute BRCN is a rare cause of AKI in pregnancy occurring in less than 1 in 10,000 pregnancies in the developed world (3). In our case, the presence of DIC, partial HELLP syndrome and placental abruption obscures an exact etiology of BRCN, but effects were likely cumulative. While HELLP accounts for up to 60% of severe AKI in pregnancy (3), in the absence of hemolysis (i.e., ELLP), it is usually more benign and managed conservatively. BRCN can be difficult to recognize initially, but the sudden development of oliguria/anuria is highly suggestive. Partial recovery of renal function occurs in up to 40%, but the majority remain dialysis dependent.CONCLUSIONS: BRCN remains an important differential to consider in the complex oliguric/anuric obstetric patient. Pre-eclampsia, DIC, placental abruption, TTP-HUS and HELLP are important risk factors. Following delivery, treatment is primarily supportive with most patients remaining dialysis dependent.Reference #1: Gupta A et al. Acute Oliguric Renal Failure in HELLP Syndrome: Case report and Review of Literature Renal Failure, 2012; 34(5):653-656Reference #2: Mwoko R, Plecas D, Garovic VD. Acute kidney injury in the pregnant patient. ClinNephrol. 2012; 78(6):478-86Reference #3: Drakeley AJ, Le Roux PA, Anthony J, Penny J. "Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit". Am J Obstet Gynecol. Feb 2002; 186(2).DISCLOSURE: The following authors have nothing to disclose: Caleb Hsieh, Nikhil Barot, Jimmy GordonNo Product/Research Disclosure Information.
- Not All Upper Gastrointestinal Bleeding Is Made Equal. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):292A.
Critical Care Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: The triad of biliary colic, upper gastrointestinal bleeding, and obstructive jaundice is rare and is classically seen in Hemobilia. Bleeding can be massive and a high index of suspicion potentially lifesavingCASE PRESENTATION: A 46 year old female presented to the ED with colicky epigastric pain and hematemesis. She also had been experiencing fatigue and itching . Her past medical history was notable for complicated laparoscopic cholecystectomy about 8 months ago. Physical examination was significant for icterus and epigastric tenderness. Laboratory evaluation revealed anemia, leukocytosis, elevated direct bilirubin, alkaline phosphatase, transaminases, amylase, and lipase. Abdomenal ultrasound revealed a dilated common bile duct (CBD). Esophagogastroduodenoscopy (EGD) showed blood in the duodenum without any obvious bleeding source. Following this, endoscopic retrograde cholangiopancreatography (ERCP) noted hemobilia. The cholangiogram was significant for presence of a markedly dilated CBD and intra hepatic bile ducts. Multiple balloon sweeps were performed with removal of large amount of clots. A fully covered biliary metal stent was placed in the CBD to facilitate biliary drainage as well as to tamponade a possible bleeding source as she had persistent hemobilia during the procedure. The patient stabilized initially with no further drop in hemoglobin and resolution of her jaundice. However, after two days she had a sudden drop in hemoglobin following which a CT of the abdomen revealed a 2.1 x 1.2 cm pseudoaneurysm of the hepatic artery. The previously placed biliary stent was abutting the pseudoaneurysm. Successful coil embolization of the pseudoaneursym was performed following which the patient's symptoms improved. The diagnosis of hemobilia caused by pseudoaneurysm of the hepatic artery was establishedDISCUSSION: Hemobilia is an unusual cause of upper gastrointestinal bleeding. Etiologies include trauma after hepatobiliary procedures, hepatobiliary neoplasms and vascular lesions of the hepatic artery, cystic artery or portal vein. The clinical presentation of hemobilia is usually obscure and the diagnosis of hemobilia requires a high index of suspicion in patients presenting with upper gastrointestinal bleeding in context of prior manipulation of the biliary system. The classic hemobilia triad includes upper gastrointestinal hemorrhage, biliary colic and obstructive jaundice. In patients who have obstructive jaundice or cholangitis, ERCP should be performed for biliary drainage until a definitive therapy for hemobilia can be undertaken. Abdominal angiogram is diagnostic and therapeutic in the majority of cases. Surgical management is reserved for patients who fail angiographic embolization.CONCLUSIONS: Hemobilia is an unusual cause of upper gastrointestinal bleeding. Early diagnosis is key in reducing mortality and morbidity related to this condition.Reference #1: Baillie J. Hemobilia. Gastroenterol Hepatol (N Y). 2012 Apr;8(4):270-2.The following authors have nothing to disclose: Ahmed Abuzaid, Mohamed ELkhashabNo Product/Research Disclosure Information.
- Predictors of Time-to-Wean Among African Americans With Acute Respiratory Distress Syndrome. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):204A.
ARDS/Lung Injury PostersSESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Studies have attempted to identify predictors of weaning outcome in acute respiratory distress syndrome (ARDS), but reports have been inconsistent due to different criteria for ARDS and heterogeneous patient populations. The primary objective of this study was to determine the predictors of time to wean from mechanical ventilation (TTW) in a cohort of African Americans with acute respiratory distress syndrome as defined by the Berlin Criteria.The following characteristics were retrospectively collated on day one of mechanical ventilation among 119 patients with acute respiratory distress syndrome; age, sex, body mass index, Acute Physiology and Chronic Health Evaluation (APACHE) II, peak airway pressure, respiratory rate, tidal volume, positive end-expiratory pressure (PEEP), arterial oxygen tension (PaO2), fractional inspired oxygen (FiO2), arterial carbon dioxide tension (PaCO2), oxygenation index (OI), serum creatinine, serum bilirubin, serum albumin, platelet count, Glasgow Coma Scale, and the use of vasopressors. Oxygenation index (OI) was calculated as (mean airway pressure X FiO2 X 100) ÷ PaO2. Rapid shallow breathing index (RSBI) was calculated as respiratory frequency (in breaths per minute) divided by tidal volume (in liters). Time-to-event analyses were used to model TTW. Kaplan-Meier estimates were used to determine the cumulative probability of successful weaning within the hospital stay and log-rank tests for comparison of the TTW between groups.RESULTS: The TTW was shorter in patients with a normal creatinine level (0.6 to 1.4 mg/dL), APACHEII<25, a rapid shallow breathing index (RSBI) of < 105, serum albumin >2mg/dl, Oxygenation index (OI) <15, and those not on vasopressors. We found an interaction between RSBI and OI (p = 0.025) such that patients with an RSBI of <105 and OI of < 15 had a median TTW of 10 days versus 14 day in patients with OI >15.In our patient population, a predictive model based on respiratory variables (RSBI and OI), disease severity (APACHEII), serum albumin and cardiovascular function on day 1 of ventilation is able to reliably predict time to wean from mechanical ventilation with ARDS.With escalating cost of care and limited resources in the intensive care unit, prompt liberation from mechanical ventilation are encouraged. A good knowledge of the estimated time frame of the likelihood of liberation from mechanical ventilation will be crucial in cost projection and resource management.DISCLOSURE: The following authors have nothing to disclose: Anthony Otekeiwebia, Marilyn Foreman, Marsheleen Henriques-Forsythe, Priscilla Pemu, Ingrid PinzonNo Product/Research Disclosure Information.
- Disseminated Bacillus Calmette-Guerin (BCG-osis) in an Immunocompetent Adult After Intravesical BCG Immunotherapy. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):191A.
Infectious Disease Student/Resident CasesSESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AMINTRODUCTION: Bacillus Calmette-Guerin (BCG) is a live attenuated bacterium derived from Mycobacterium bovis. When given intravesicularly, BCG is an effective form of immunotherapy for early-stage bladder cancer. Intravesical BCG treatment is usually well tolerated. Infrequently, systemic absorption of BCG can result in disseminated infection. We describe a case of disseminated Mycobacterium bovis infection in an immunocompetent adult after intravesical BCG immunotherapy.CASE PRESENTATION: A 56 year old man with stage I renal cell carcinoma, stage 0 bladder carcinoma, and stage III carcinoma of the renal pelvis status post left nephroureterectomy, presented with several weeks of unremitting fever, without cough or shortness of breath. He had recently completed five cycles of BCG immunotherapy after transurethral resection of a bladder tumor. His physician prescribed isoniazid, pyridoxine, rifampin, and ethambutol for presumed BCG-osis. He presented to the hospital two months later with fever and 20 pound weight loss. Liver function tests (LFTs) were elevated: AST= 78 units/L, ALT= 59 units/L, alkaline phosphatase= 547 units/L, and total bilirubin= 1.7 mg/dl. Absolute neutrophil count was 1650 cells/mm3. Serologies for hepatitis A, B, and C, and Quantiferon Gold test were negative. Computed tomography (CT) of the abdomen showed new periportal edema with hepatic nodules, small ascites, and reactive mesenteric nodes. Chest CT showed interlobular septal thickening, with ground-glass nodules in the upper lobes as well as small bilateral pleural effusions. Bronchoalveolar lavage from bronchoscopy was negative for AFB stain and culture. Cytology showed no malignant cells. Medications were held and laboratory values improved. After discharge, he completed six months of antimycobacterial therapy. Repeat CT of the chest and abdomen five months later showed resolution of the lung and abdominal findings.DISCUSSION: BCG-osis is an uncommon adverse effect of intravesical BCG immunotherapy. Risk factors include recent bladder tumor resection and traumatic installation, though the latter is not always noted. Systemic illness can occur at any time. Patients who present within three months of intravesical therapy are stratified to early-presentation disease, and can be immunocompetent, as was our patient. Organisms are generally susceptible to isoniazid, rifampin, and ethambutol and resistant to pyrazinamide. Response is usually favorable though LFTs should be monitored.CONCLUSIONS: BCG immunotherapy can cause disseminated BCG-osis in immunocompetent adults treated for bladder cancer. Persistent unexplained fever following intravesical BCG should prompt a clinical suspicion for BCG-osis.Reference #1: Gonzalez OY, Musher DM, Brar I, et al. Spectrum of Bacille Calmette-Guerin (BCG) Infection after Intravesical BCG Immunotherapy. Clinical Infectious Diseases 2003; 36:140-8.DISCLOSURE: The following authors have nothing to disclose: Richard May, Chinenye Emuwa, Amee Patrawalla, Andrew BermanNo Product/Research Disclosure Information.
- Toxic Shock Syndrome: An Unrecognized Organism. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):171A.
Infectious Disease Student/Resident Case Report Posters IISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Streptococcal toxic shock syndrome (STSS) is a rapidly fatal disease causing hypotension with multi organ dysfunction (MODS) early in the course of infection which by definition is caused by Group A streptococcus (GAS).1 We describe a case of STSS in which the causative organism was not a GAS.CASE PRESENTATION: A 71-year-old woman with hepatitis C and primary biliary cirrhosis had sudden onset of slurred speech & left arm /facial numbness. She had some swelling of her leg that occurred a few days ago after a fall. On admission her vitals were; temperature 97.7 F; heart rate 107/min; blood pressure 109/64 mm Hg; respirations 24/min. Physical exam was significant for bilateral mottling on the flanks and legs. The white cell count was 3.4 Thou/mm3 , platelets 44 Thou/mm3; creatinine 2.36 mg/dL (Baseline of 1 mg/dL ); blood urea nitrogen 50 mg/dL ; bicarbonate 14 meq/L; INR 1.88; AST 275 IU/L H; total bilirubin 4.1 mg/dL; lactate 12.2 mmol/L and myoglobin 58631 ng/mL. Glucose was 53 mg/dl and the patient's speech improved after administration of dextrose. The CT head, chest, and abdomen were unremarkable. Fluid resuscitation was initiated, blood cultures were drawn, and the patient was started on Vancomycin and Zosyn for suspected sepsis. The VBG showed pH of 7.04, Co2 of 35 and bicarbonate of 11 meq/L. Her condition rapidly deteriorated 6 hours after admission with her lactate increasing to 15.3 mmol/L & myoglobin increased to 123044 ng/mL . She got drowsy, hemodynamically unstable and was intubated. Pressors and bicarbonate drip were initiated. During this time, the development of multiple large reddish-pink areas of ecchymosis with bullae on her lower extremities, flanks, and groin were noted (Figure 1). Patient expired before surgery could be performed and the time from presentation to the time of death was 14 hours. The blood and bullae fluid cultures grew Streptococcus dysgalactiae equisimilis (SDE). Postmortem pathology determined cause of death was SDE sepsis with loculated pericarditis but no necrotizing fasciitis was seen.DISCUSSION: SDE is a rare cause of STSS which typically affects elderly or immunocompromised patients and only a few cases have been described in the literature (Table 1). Our patient met criteria for STSS which caused rapid shock and MODS (renal dysfunction, coagulopathy, liver involvement, and a generalized erythematous macular rash).CONCLUSIONS: Group G Streptococci is an unrecognized but lethal cause of Streptococcal TSSReference #1: Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition. The Working Group on Severe Streptococcal Infections. JAMA 1993; 269:390-391DISCLOSURE: The following authors have nothing to disclose: Katie Young, Faraz Khan Luni, Youngsook YoonNo Product/Research Disclosure Information.
- Transcutaneous Bilirubin After Phototherapy in Term and Preterm Infants. [JOURNAL ARTICLE]
- Pediatrics 2014 Oct 20.
To compare transcutaneous bilirubin (TcB) readings with total serum bilirubin (TSB) after phototherapy, estimating the range of TcB where confirmation through blood sampling can be avoided.Preterm and term neonates receiving in-hospital phototherapy underwent TcB measurements (device JM-103, TcB) alongside routine TSB before and after treatment. We calculated time-dependent safety margins for transcutaneous readings to correctly assign 99% of infants not to receive phototherapy.Between August 2011 and December 2012, 86 newborn infants (47 preterm, 39 term) underwent a total of 189 parallel measurements. Mean difference (TcB - TSB) before treatment was -0.6 mg/dL (SD, 1.9 mg/dL). Within the first 8 hours after phototherapy, TcB levels were -2.4 mg/dL (SD, 2.1 mg/dL) below TSB. Thereafter the difference gradually returned to pretreatment values (-1.8 mg/dL in 8-16 hours, -1.1 mg/dL in 16-24 hours, and -0.8 mg/dL after 24 hours), while variations remained stable over time (SD, 1.4-1.8 mg/dL). In the first 8 hours after treatment, TcB levels of -7.3 mg/dL below the individual phototherapy threshold allowed safe rejection of confirmatory blood sampling. After 8 hours, that safety margin was reduced to approximately -5.0 mg/dL.TcB measurements remain a valuable tool after phototherapy when time-dependent underestimation of TcB is being accounted for.
- Direct Antiglobulin Titer Strength and Hyperbilirubinemia. [JOURNAL ARTICLE]
- Pediatrics 2014 Oct 20.
We recently demonstrated that direct antiglobulin titer (DAT) positive, blood group A or B newborns born to group O mothers had a high incidence of hyperbilirubinemia, attributable to increased hemolysis. We reanalyzed our data asking whether increasing DAT strength plays a modulating role in the pathophysiology of the hemolysis and hyperbilirubinemia.Data from previously published DAT-positive, ABO-heterospecific neonates were analyzed for hyperbilirubinemia and hemolysis according to strength of DAT. DAT was measured by using a gel agglutination technique and reported as values ranging from DAT ± to DAT ++++. Hemolysis was evaluated by blood carboxyhemoglobin corrected for inspired, ambient CO (COHbc), and expressed as percent total hemoglobin (tHb). Hyperbilirubinemia was defined as any plasma total bilirubin value >95th percentile on the hour-specific nomogram.Hyperbilirubinemia was more prevalent in those with DAT ++ readings (16 of 20, 80%) than those both DAT ± (37 of 87 [42.5%], relative risk: 1.88, 95% confidence interval: 1.35-2.61) and DAT + (32 of 56 [57.1%], relative risk: 1.40, 95% confidence interval: 1.02-1.92). COHbc values were higher for those with DAT ++ (1.45 ± 0.49% tHb [mean ± SD]) than those DAT ± (1.20 ± 0.37% tHb, P = .01) or DAT + (1.22 ± 0.37% tHb, P = .02).DAT ++ readings were associated with a higher incidence of hyperbilirubinemia and higher COHbc values than DAT ± or DAT + counterparts. Increasing DAT strength may be a modulator of hemolysis and hyperbilirubinemia in ABO-heterospecific neonates. DAT strength, and not merely DAT presence or absence, should be taken into consideration in the management of ABO-heterospecific newborns.
- Serum Bilirubin and Bilirubin/Albumin Ratio as Predictors of Bilirubin Encephalopathy. [JOURNAL ARTICLE]
- Pediatrics 2014 Oct 20.
Bilirubin/albumin ratio (B/A) may provide a better estimate of free bilirubin than total serum bilirubin (TSB), thus improving identification of newborns at risk for bilirubin encephalopathy. The objective of the study was to identify thresholds and compare specificities of TSB and B/A in detecting patients with acute and posttreatment auditory and neurologic impairment.A total of 193 term/near-term infants, admitted for severe jaundice to Cairo University Children's Hospital, were evaluated for neurologic status and auditory impairment (automated auditory brainstem response), both at admission and posttreatment by investigators blinded to laboratory results. The relationships of TSB and B/A to advancing stages of neurotoxicity were compared by using receiver operating characteristic curves.TSB and B/A ranged from 17 to 61 mg/dL and 5.4 to 21.0 mg/g, respectively; 58 (30%) of 193 subjects developed acute bilirubin encephalopathy, leading to kernicterus in 35 infants (13 lethal). Auditory impairment was identified in 86 (49%) of 173 infants at admission and in 22 of 128 at follow-up. In the absence of clinical risk factors, no residual neurologic or hearing impairment occurred unless TSB exceeded 31 mg/dl. However, transient auditory impairment occurred at lower TSB and B/A (22.9 mg/dL and 5.7 mg/g, respectively). Intervention values of TSB and B/A set at high sensitivity to detect different stages of neurotoxicity had nearly the same specificity.Both TSB and B/A are strong predictors of neurotoxicity, but B/A does not improve prediction over TSB alone. Threshold values detecting all affected patients (100% sensitivity) increase with advancing severity of neurotoxicity.