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Uvod: V neonatalnem obdobju je zlatenica najpogostejše klinično stanje in hkrati najpogostejša težava novorojenčkov. Pri večini novorojenčkov je to le prehodno neškodljivo stanje, ki nastane zaradi povečanega nastajanja bilirubina. Bilirubin je endogeni antioksidant, ki novorojenčka v prvih dneh življenja ščiti pred prostimi radikali, vendar je v visokih koncentracijah nevrotoksičen in povzroča možganske poškodbe. Pomembno je hitro ugotavljanje in ocenjevanje stopnje zlatenice pri novorojenčku in spremljanje stanja. Namen: Namen diplomskega dela je opisati zlatenico pri novorojenčku in z raziskavo ugotoviti podobnost vizualne ocene ter meritev koncentracij transkutanega in serumskega bilirubina pri novorojenčkih. Metode dela: Pregledali smo literaturo, zbrali in analizirali podatke. Literaturo smo zbirali v znanih internetnih iskalnih bazah, kot so CINAHL, COBISS, DiKUL, MEDLINE, ScienceDirect. V diplomskem delu je bila izvedena prospektivna, kohortna raziskava V analizo je bilo vključenih 50 zdravih novorojenčkov. Vsi novorojenčki so imeli gestacijsko starost nad 36 tednov in bili težji od 2.500 gramov. Analizirali smo novorojenčke pri katerih je prisotna vidna zlatenica, ki zahteva opazovanje. Pri vsakem novorojenčku smo opravili vizualni pregled in na podlagi videnega po Kramarjevi lestvici določili stopnjo zlatenice. Poleg kapilarnega odvzema krvi smo izvedli tudi transkutano meritev bilirubina na treh različnih predelih, in sicer na čelu, prsnem košu in med lopaticama. Ugotavljali smo korelacijo med vizualno oceno zlatenice in meritvami koncentracij transkutanega in serumskega bilirubina pri novorojenčkih. Rezultati: Raziskovalni tim je ob ocenjevanju novorojenčkov po Kramarjevi lestvici v kar 52 % napačno vizualno ocenil koncentracijo bilirubina v krvi. Ugotovili smo, da se odstopanja izmerjene koncentracije bilirubina v serumu od transkutanih meritev razlikujejo glede na predel telesa, kjer smo izvedli meritev s transkutanim bilirubinmetrom. Rezultati so pokazali, da je najbolj ustrezno mesto oz. mesto, kjer je odstopanje najmanjše, v predelu med lopaticama. Razprava in zaključek: Neonatalna zlatenica je ena najpogostejših težav, s katerimi se srečujejo pediatri in patronažne medicinske sestre. Področje ocenjevanja in določanja zlatenice pri novorojenčkih je potrebno še bolj podrobno raziskati, ugotovitve vpeljati v klinično prakso ter tako omogočiti še boljšo oskrbo in obravnavo zlateničnih novorojenčkov. Jaundice is the most common clinical condition in the neonatal period and the most common problem of the new-borns. This is a passing condition for most new-borns and it is not harmful. It happens due to a higher level of bilirubin. Bilirubin is an endogenic antioxidant which protects the baby from the free radicals in the first days of life. However, it can be neurotoxic in higher quantities and can cause brain damage. Therefore, it is important to determine and evaluate the level of jaundice with the new-born baby and to closely follow the situation. Purpose: The purpose of this thesis is to describe the jaundice of new-born babies and with the conducted survey find out similarities of the clinical assessment and the measurements of the concentrations of transcutaneous and serum bilirubin of new-borns. Methods: We reviewed the literature, collected and analyzed data. Literature was collected in well-known Internet search databases such as CINAHL, COBISS, DiKUL, MEDLINE, ScienceDirect. We conducted a prospective and coherent analysis. 50 healthy newborns were included in the analysis. All of them were over 36 weeks and weighed more than 2500 grams. We analyzed neonates in whom visual jaundice is present, which requires observation. A visual examination was performed on each newborn and the degree of jaundice was determined based on what was seen according to the Kramar scale. In addition to capillary blood sampling, we also performed transcutaneous measurement of bilirubin in three different areas, namely on the forehead, chest and between the shoulder blades. We correlated the visual assessment of jaundice with measurements of transcutaneous and serum bilirubin concentrations in neonates. Results: The research team falsely (according to the Kramar scale) visually evaluated the level of bilirubin in the blood of new-born babies (in 52% of all cases). We found out that the deviations and differences of measured level of bilirubin concentration in the serum and from transcutaneous measurements are caused according to the body part where these measurements were conducted. The results showed that the best and most common place was between the shoulder blades where these deviations were the lowest. Discussion and conclusion: Neonatal jaundice is one of the most common problems faced by pediatricians and community nurses. The field of assessment and determination of jaundice in new-borns needs to be further investigated, the findings introduced into clinical practice and thus enable even better care and treatment of jaundiced new-borns.

Cilj istraživanja: Cilj ovog istraživanja bio je istražiti hiperbilirubinemiju kao pouzdanog laboratorijskog pretkazatelja perforacije akutnog apendicitisa u djece. Ispitanici i metode: U prospektivnu kohortnu studiju uključena su ukupno 284 ispitanika koji su imali patohistološki potvrđen akutni apendicitis. Anamneza, demografski i klinički podatci zabilježeni su u protokolu studije. Prije operacije uzeti su uzorci krvi za određivanje akutnih upalnih parametara i vrijednosti bilirubina. S ozbirom na intraoperacijske nalaze bolesnici su podijeljeni u dvije skupine, perforirani akutni apendicitis (n=64; 22,5%) i neperforirani akutni apendicitis (n=220; 77,5%). Primarni ishod bila je dijagnostička točnost razine bilirubina u razlikovanju jednostavnog od perforiranog akutnog apendicitisa. Rezultati: Medijan bilirubina u bolesnika s perforiranim akutnim apendicitisom bio je značajno viši u odnosu na bolesnike s neperforiranim akutnim apendicitisom (27 µmol/L nasuprot 10 µmol/L, P

amil ija en zi ma u ridin -dif osfat -glu kuronoziltransferaza (U GT ) kat a lizuj e glukuronidaciju širokog spektra endobiotika i ksenobiotika. UGT1 familija je kodirana genskim kompleksom UGT1, koji se sastoji od 13 proksimalnih varijabilnih egzona i od 4 zajednička distalna egzona. Alternativnom obradom nastaje više transkripata, među kojima je posebno značajan onaj čiji je produkt UGT1A1 enzim, koji učestvuje u metabolizmu bilirubina i mnogih lekova. Više od 60 varijanti je detektovano u UGT1A1 genu, koje su povezane sa patološkim stanjima. Varijante u TATA boksu promotora UGT1A gena se razlikuje po broju TA ponovaka. Wild type UGT1A1*1 sadrži 6 TA ponovaka (TA6), dok su varijante koje sadrže 5, 7 ili 8 TA ponovaka označene kao UGT1A1*36 (TA5), UGT1A1*28 (TA7) i UGT1A1*37 (TA8). Transkripciona aktivnost promotora je manja što je veći broj ponovaka u odnosu na TA6. Žilberov sindrom (ŽS) je često kliničko stanje koje karakteriše hiperbilirubinemija i ikterus. Uzrokovan je smanjenom aktivnošću UGT1A1 enzima. Najčešće detektovana varijanta koja se nalazi u osnovi ŽS je UGT1A1*28. Njena učestalost varira u različitim populacijama, a kod belaca je prisutna sa 26% do 31%. ŽS je blago oboljenje, ali kao komorbiditet može dovesti do pogrešne dijagnoze bolesti jetre ili hemolitičkih procesa. U tim slučajevima je neophodno potvrditi ili isključiti dijagnozu ŽS molekularnom analizom UGT1A1 gena. Malo se zna o uticaju varijanti promotora UGT1A1 gena na scenario kod oboljenja jetre. Samo u nekoliko slučajeva je kod pacijenata sa hepatitisom C sprovedeno genetičko testiranje na UGT1A1*28, i pošto je dokazana pozitivnost objasnila detektovan nivo bilirubina, pacijenti su lečeni po standardnom protokolu i postigli su kontinuiran virusološki odgovor. Kod hemolitičkih anemija, kao što je talasemija, takođe je pokazano da je nivo bilirubina povezan sa pojavom komplikacija. Stoga se varijante u UGT1A1 genu tretiraju kao tercijarni modifikatori kod beta- talasemijskih sindroma... The uridine-diphosphate-glucuronosyltransferase enzyme family (UGT) catalyse the glucuronidation of a wide range of endobiotics and xenobiotics. The UGT1 family is encoded by the UGT1 gene complex consisting of 13 proximal variable exons and 4 common distal exons. Alternative splicing gives multiple transcripts, among which the UGT1A1 enzyme product, which is involved in the metabolism of bilirubin and many drugs, is particularly important. More than 60 variantshave been detected in the UGT1A1 gene, which are associated with pathological conditions. Variants in the TATA box of the UGT1A gene promoter differ in the number of TA repeats. Wild type UGT1A1 contains 6 TA repeats (TA6), while variants with 5, 7 or 8 TA repeats are designated UGT 1A1*36 (TA5), UGT1A1*28 (TA7) and UGT1A1*37 (TA8). The transcription activity of the promoter decreased accordingly to higher number of repeats compared to TA6. Gilbert's syndrome (GS) is often a clinical condition characterized by hyperbilirubinaemia and icterus. It is caused by a reduced activity of UGT1A1 enzymes. The most commonly detected variant found in the basis of GS is UGT1A1*28. Its frequency varies in different populations, and whites are present from 26% to 31%. GS is a mild illness, but as a comorbidity it can lead to a wrong diagnosis of liver disease or hemolytic processes. In these cases, it is necessary to confirm or exclude the diagnosis of GS by molecular analysis of the UGT1A1 gene. The effect of variants of UGT1A1 gene on the development in liver disease is poorly known. In only a few cases, genetic testing for UGT1A1*28 was performed in patients with hepatitis C, and since the confirmed positivity explained the detected level of bilirubin, patients were treated by standard protocol and achieved a continious viral response. In hemolytic anemia, such as thalassemia, it has also been shown that the level of bilirubin is associated with the numerous of complications. Therefore, the TA promoter variants in the UGT1A1 gene are treated as tertiary modifiers in beta-talasemia syndromes...

Zlatenica novorojenčka je najpogostejše klinično stanje, s katerim se srečujemo v neonatologiji, saj jo zaznamo pri 60 % novorojenčkov. Čeprav je pojav najpogosteje posledica fizioloških sprememb po rojstvu, je opredelitev drugih možnih razlogov za zlatenico zelo pomembna, saj v primeru hemolize, ki je pogost razlog patološke zlatenice, pričakujemo visoke vrednosti bilirubina in anemijo. Visoke vrednosti bilirubina so za novorojenčka zaradi toksičnega delovanja bilirubina na živčne celice potencialno nevarne. Iz ne povsem pojasnjenih razlogov je nevrotoksičen učinek bilirubina v prisotnosti hemolize povečan, zato hemolizo uvrščamo med rizične dejavnike za razvoj akutne in kronične bilirubinske encefalopatije. Dokazovanje hemolitičnega dogajanja je pri novorojenčku zato pomembno tako z vidika pojasnjevanja etiologije zlatenice kot njene obravnave. Potrditev hemolize je pri novorojenčkih lahko težavna. Uvedba zanesljivega in enostavnega diagnostičnega testa za dokaz hemolize bi bila zato dobrodošla pridobitev v obravnavi zlateničnega novorojenčka. Pri razgradnji hema nastaja ogljikov monoksid (CO), ki se veže na hemoglobin in tvori karboksihemoglobin (COHb). Vrednost COHb v krvi je zato indeks endogeno nastalega CO in hemolize. Določitev COHb z oksimetrijo je hitra, enostavna in široko dostopna laboratorijska metoda, ki za analizo potrebuje majhno količino krvi. Meritve COHb z oksimetrijo pri novorojenčkih še niso bile ustrezno preučene. Opredelitev pomena določanja COHb z oksimetrijo pri novorojenčku za dokazovanje hemolize je zato zanimiv raziskovalni izziv, h kateremu je bila usmerjena tudi raziskava, predstavljena v doktorskem delu. V uvodnem delu so predstavljeni etiologija fiziološke zlatenice in najpogostejši razlogi za patološko zlatenico ter etiologija in mehanizmi hemolize pri hemolitični bolezni novorojenčka. Poleg tega so povzeti izsledki raziskav, ki pojasnjujejo mehanizem nevrotoksičnega delovanja bilirubina in potrjujejo vlogo hemolize na pojavnost bilirubinske encefalopatije. Pri dokazovanju hemolize se poslužujemo posrednih hematoloških kazalcev hemolize in transfuzijskih testov. V nadaljevanju so pojasnjene klinične dileme ob uporabi hematoloških in specialnih laboratorijskih testov za potrditev hemolize pri novorojenčku. Natančneje je predstavljen proces razgradnje hema in rezultati kliničnih raziskav, ki potrjujejo, da je pri hemolizi tvorba CO povečana, kar lahko dokažemo z merjenjem COHb v krvi ali CO v izdihanem zraku. COHb v kliničnih laboratorijih določamo sprektrofotometrično z oksimetri, v raziskovalne namene pa je bila do sedaj pogosteje uporabljena plinska kromatografija. Hem oksigenaza (HO) je encim, ki katalizira razgradnjo hema. HO-1 izoforma encima je inducibilna, zato uvodoma opredeljujemo teoretične klinične dejavnike, ki lahko povzročijo indukcijo encima in s tem vplivajo na nastajanje CO v telesu in vrednosti COHb. V drugem delu so predstavljene metode in rezultati raziskave, ki je bila sestavljena iz dveh delov. V prvem, prospektivnem delu smo primerjali vrednosti COHb, določene z oksimetrijo, med 18 zaporedno hospitaliziranimi donošenimi novorojenčki s hemolitično boleznijo ploda in novorojenčka zaradi neskladja v sistemu krvnih skupin ABO med materjo in otrokom, 21 donošenimi novorojenčki z zlatenico brez hemolize, ki so potrebovali fototerapijo, ter 47 zdravimi donošenimi novorojenčki. Vrednosti COHb so se med skupinami statistično značilno razlikovale in so bile v skupini novorojenčkov s hemolizo bistveno višje kot v skupini novorojenčkov z zlatenico in v skupini zdravih novorojenčkov (mediana COHb 2,4 % (IQR 1,3) vs. 1,3 % (IQR 0,8) in 1,3 % (IQR 0,2)). Rezultati multivariantne analize so pokazali, da je vpliv hemolize na vrednost COHb pri novorojenčkih od vseh v model vključenih spremenljivk največji in statistično značilen. Diagnostično zanesljivost meritve COHb z oksimetrijo za dokaz hemolize smo ocenili s površino pod ROC-krivuljo (angl. receiver operating characteristic area under the curve, ROC AUC). Rezultati ROC-analize dokazujejo, da je meritev COHb dobra diagnostična metoda za potrditev hemolize pri novorojenčku, saj je bila ROC AUC >0,9, občutljivost in specifičnost v raziskavi določene optimalne razmejitvene vrednosti COHb, ki je bila &#8805 1,7 %, pa sta bili visoki. V drugem, retrospektivnem delu raziskave smo primerjali vrednosti COHb, določene z oksimetrijo, med 8 novorojenčki s sepso, 37 novorojenčki z dihalno stisko, 16 novorojenčki s hemolizo in 76 zdravimi novorojenčki. Vsi vključeni novorojenčki so bili donošeni. Tudi analiza retrospektivnih podatkov je pokazala, da je COHb statistično značilno višji pri novorojenčkih s hemolizo (mediana COHb otrok s hemolizo je bila 2,4 % (IQR 1,3)), medtem ko razlike v sicer nekoliko višjih vrednostih COHb pri novorojenčkih s sepso in dihalno stisko (mediana COHb 1,45 % (IQR 0,5) in 1,4 % (IQR 0,4)) ter zdravimi novorojenčki (COHb 1,3 % (IQR 0,3)) niso bile statistično značilne. Vrednotenje diagnostične zanesljivosti meritve COHb z oksimetrijo kot testa za potrditev hemolize z ROC-krivuljo retrospektivnih podatkov je potrdilo ugotovitve prospektivnega dela raziskave. Tudi ROC AUC retrospektivnih podatkov je bila visoka (>0,9), optimalna razmejitvena vrednost COHb enaka (&#8805 1,7 %), občutljivost in specifičnost testa pa visoki, kljub vključitvi otrok s sepso in dihalno stisko v analizo. Odvisnost COHb od postnatalne starosti je bila negativna, saj so vrednosti COHb prve dni po rojstvu pri zdravih novorojenčkih višje. 1. dan po rojstvu je bila povprečna vrednost COHb zdravih novorojenčkov 1,35 %, 7. dan 1,26 % in 14. dan 1,01 %. V razpravi so izsledki doktorske raziskave primerjani z do sedaj znanimi podatki o nastajanju CO in vrednostih COHb, določenih z drugimi laboratorijskimi metodami, pri različnih skupinah novorojenčkov. Vrednosti COHb, določene z oksimetrijo, so pri bolnikih s hemolizo v enakem območju ali nekoliko višje od vrednosti, določenih s plinsko kromatografijo. Tudi primerjava vrednosti COHb pri zdravih novorojenčkih in novorojenčkih s fiziološko zlatenico, določenimi z oksimetrijo ali plinsko kromatografijo, je pokazala podobne ugotovitve, najverjeteje zaradi odsotnosti korekcije COHb za CO v vdihanem zraku pri oksimetrični metodi. Odsotnost korekcije vrednosti COHb za CO v vdihanem zraku zato lahko predstavlja pomembno slabost meritve COHb z oksimetrijo. Kljub temu rezultati raziskave dokazujejo, da je meritev COHb z oksimetrijo dober diagnostični test za potrditev hemolize, saj zelo dobro razlikuje novorojenčke s hemolizo od novorojenčkov, ki hemolize nimajo. Izsledki opravljane raziskave so izhodišče za nadaljnje delo, kot je raziskovanje pomena COHb, določenega z oksimetrijo, pri nedonošenčkih, in vloge COHb v napovedovanju razvoja zlatenice in stopnje hemolize. Rezultati pričujoče raziskave dokazujejo, da je določitev COHb z oksimetrijo dober diagnostični test za potrditev hemolize pri donošenih novorojenčkih in da sta specifičnost in občutljivost testa pri razmejitveni vrednosti COHb &#8805 1,7 % visoka. Vpliv kliničnih dejavnikov, ki lahko inducirajo HO-1 in s tem vplivajo na vrednosti COHb, je majhen in statistično nepomemben, zato je diskriminativnost testa visoka tudi ob prisotnosti kliničnih dejavnikov, kot sta sepsa in dihalna stiska novorojenčka. Izsledki raziskave predstavljajo izhodišče za uporabo meritve COHb kot diagnostičnega testa za potrditev hemolize pri novorojenčkih. Neonatal jaundice is the most common clinical condition detected in neonatology, as it is present in more than 60 % of neonates. Even though it commonly results from physiologic changes after the birth, the identification of other possible pathologic reasons for icterus is very important. In case of haemolysis, which is a common pathologic factor for neonatal jaundice, high levels of bilirubin and anaemia can be expected. High level of unbound bilirubin can be potentially dangerous for the neonate, since it can cause bilirubin-induced neuronal damage. Haemolysis augments the risk of bilirubin neurotoxicity, but the mechanism of this intensifying effect is uncertain. Consequently, haemolysis represents an important risk factor for development of acute and chronic bilirubin encephalopathy. Confirmation of haemolysis in neonate is therefore very important in terms of explaining the aetiology of the jaundice as well as for its management. Confirming haemolysis in neonates can be very challenging. Introduction of a reliable and simple diagnostic test for the confirmation of haemolysis would therefore be very appreciated in the management of neonatal jaundice. During haeme degradation process carbon monoxide (CO) is produced and bound to haemoglobin, forming carboxyhaemoglobin (COHb). The COHb level in blood can serve as an index of endogenous produced CO and haemolysis. Determination of COHb with CO-oximetry is fast, simple and widely available laboratory method, needing small amount of blood. Determination of COHb with CO-oximeters in neonates hasn’t been adequately studied. Defining the role of COHb measured with CO-oximetry in neonates in evaluation of haemolysis is therefore an interesting research challenge to which the present study was aimed. In the introduction, pathophysiology of physiologic icterus, the commonest reasons for the pathologic icterus and the aetiology and mechanisms of haemolytic process in haemolytic disease of the newborn are presented. Furthermore, the mechanisms of bilirubin induced neurologic damage are discussed and studies confirming the role of haemolysis in the development of bilirubin encephalopathy are presented. In neonates, haemolysis is detected with indirect haematological and specific transfusion laboratory tests. Clinical dilemmas when using these tests in neonates are discussed. Haeme degradation process and the results of clinical studies demonstrating increased formation of CO during haemolysis detected with elevated COHb levels in blood or elevated CO in exhaled breath air are presented. In clinical laboratories COHb is determined spectrophotometrically with CO-oximetry, while for research purposes COHb has been more often determined with gas chromatography. Degradation of haeme is catalysed by haeme oxygenase (HO). The HO-1 isoform is an inducible enzyme clinical factors potentiality influencing the enzyme transcription and consequently influencing the CO formation and COHb levels in the body are discussed. In the second part, methods and results of the study, consisting of two parts, are presented. In the prospective part of the study, the COHb values measured with CO-oximetry in 18 successively hospitalized term neonates with ABO haemolytic disease of newborn, 21 term neonates with jaundice without haemolysis needing phototherapy, and 47 term healthy neonates were compared. The COHb levels were higher in the group of neonates with ABO haemolytic disease of newborn compared to the COHb levels in jaundiced neonates without haemolysis and healthy neonates (median COHb 2.4 % (IQR 1.3) vs. 1.3 % (IQR 0.8) and 1.3 % (IQR 0.2), respectively) and the differences were statistically significant. The results of multivariate analysis showed that haemolysis had the biggest, statistically significant effect on the COHb values compared to other variables included in the model. Receiver operating characteristic (ROC) curve analysis was performed to evaluate a diagnostic value of COHb measured with CO-oximetry as a test for detecting haemolysis in neonates. According to the receiver operating characteristic area under the curve (ROC AUC), the COHb measured with CO-oximetry is a good diagnostic test for confirming haemolysis in neonates, since ROC AUC was more than 0.9, and the sensitivity and specificity of the optimal cut off COHb value, which was in our study set as &#8805 1.7 %, was very high. In the second, retrospective part of the study, COHb values measured with CO-oximetry in 8 term neonates with neonatal sepsis, 37 term neonates with respiratory distress, 16 term neonates with haemolytic disease of newborn, and 76 healthy neonates were compared. Also, the retrospective analysis of the COHb values measured with CO-oximetry showed statistically significantly higher COHb values in neonates with haemolysis (median COHb was 2.4 % (IQR 1.3)), while the values of COHb between neonates with sepsis and respiratory distress (median COHb 1.4 % (IQR 0.5) and 1.4 % (IQR 0.4), respectively) and healthy neonates (median COHb 1.3 % (IQR 0.3)) were not statistically different, although the median COHb values were slightly higher in neonates with sepsis and respiratory distress compared to healthy neonates. Furthermore, the value of COHb measured with CO-oximetry as a diagnostic test for detecting haemolysis in neonates was evaluated with ROC curve analysis of retrospective obtained data. The ROC curve analysis confirmed the result of the prospective study, since the ROC AUC of retrospective data was high (>0.9), and the specificity and sensitivity of the optimal cut off COHb value, which was the same as in prospective study (&#8805 1.7 %), were high, even though the neonates with sepsis and respiratory distress were included in the analysis. The correlation between the COHb values and postnatal age was negative, since COHb values are declining in the first days after the birth. The mean COHb value in healthy neonates was 1.35 % on the 1st day after the birth, 1.26 % on the 7th day after the birth, and 1.01 % on the 14th day after the birth. In the discussion, the results of the research are compared with the results of other studies which evaluated the production of CO and COHb values, determined with other laboratory methods, in different groups of neonates. The COHb values measured with CO-oximetry in neonates with haemolysis are similar or slightly higher than the COHb values measured with gas chromatography. The comparison of the COHb values measured with oximetry or gas chromatography in healthy neonates and neonates with jaundice without haemolysis showed similar trend, probably because the oximetry method doesn't correct the COHb value for inhaled air CO. Absence of the correction of COHb value according to the environmental levels of CO seems to be the most important limitation of CO-oximetry, as well as of this study. Nevertheless, the results of the research show that COHb measured with CO-oximetry is a good diagnostic test for detecting haemolysis in neonates, since it performs well in discriminating neonates with and without haemolysis. The results of this research open new possibilities for further work, such as an evaluation of the COHb values measured with CO-oximetry in preterm neonates and an evaluation of the COHb values measured with CO-oximetry in the prediction of icterus and its severity. The results of the study confirm that COHb measured with CO-oximetry is a good diagnostic test for detecting haemolysis in term neonates, and the specificity and the sensitivity of the cut off COHb value of &#8805 1.7 % are very high. The influence of other clinical factors that may induce HO-1 and influence the COHb values is small and statistically insignificant, therefore the discrimination of the test is high despite the presence of sepsis or respiratory distress, factors that may induce HO-1. The results of the study represent the base for clinical use of COHb measured with CO-oximetry as a diagnostic test for detecting haemolysis in term neonates.

Bilirubin je katabolni produkt hema, ki je sestavni del hemoglobina, mioglobina, citokromov, katalaze in peroksidaze. V celicah se hem s hem oksigenazami pretvarja v biliverdin in slednji z biliverdin reduktazo v bilirubin. Pri zdravih ljudeh je vrednost celokupnega bilirubina v krvi med 5 in 17 µM. Bilirubin je lipofilna molekula, ki se ob prihodu v kri nekovalentno veže na serumsko beljakovino albumin. Nastane vodotopen kompleks albumin-bilirubin, ki potuje po krvi. Nevezanega oz. prostega bilirubina je v serumu zelo malo, pri zdravih ljudeh okoli 10 nM, vendar je v ravnovesju z bilirubinom, vezanim na albumin. Prevelike koncentracije bilirubina delujejo nevrotoksično in lahko povzročijo okvaro osrednjega živčevja pri novorojenčkih (kernikterus) ali pri odraslih z odpovedjo jeter (bilirubinska encefalopatija). Nekatere zdravilne učinkovine lahko prek kompetitivne interakcije z bilirubinom na vezavnih mestih na albuminu povzročijo sproščanje bilirubina. Tako se lahko poveča koncentracija prostega bilirubina v krvi. V nalogi nam je s štirimi metodami uspelo dokazati, da med bilirubinom in ibuprofenom prihaja do kompeticije za vezavo na albumin in da ibuprofen izpodriva bilirubin z vezavnega mesta. Ugotovili smo, da ima podoben učinek izpodrivanja bilirubina z vezavnega mesta na albuminu tudi ketoprofen, ki je strukturno sorodna molekula. Zasnovali smo ogrodje modela, s katerim bi lahko v prihodnosti izvajali visokozmogljive metode rešetanja spojin (angl. high-throughput screening) in identificirali zdravilne učinkovine, ki vplivajo na vezavo bilirubina na albumin. Zaenkrat namreč nimamo popolnega znanja o tem, katere zdravilne učinkovine lahko povzročijo interakcijo z bilirubinom na vezavnem mestu na albuminu. Bilirubin is a catabolic product of hem, which is an integral part of haemoglobin, myoglobin, cytochrome, catalase and peroxidase. Hem is catalysed to biliverdin through heme-oxygenase, which in turn is reduced to bilirubin by biliverdin reductase, in the cells. In healthy people the total amount of bilirubin in serum is normally between 5 and 17 µM. Bilirubin is a lipophilic molecule which, in blood, is non-covalently bound to the serum protein albumin. Polar complex albumin-bilirubin is made and transported through the blood. In healthy people, approximately 10 nM of unbound or free bilirubin exists in serum this is, however, in equlibrium with bilirubin bound to albumin. Higher concentrations of bilirubin have a neurotoxic effect in newborns (kernicterus) or in adults with serious liver failure (bilirubin encephalopathy). Some drugs can cause the release of bilirubin through competitive interaction with bilirubin on the albumin binding sites. This can increase the free bilirubin concentration. This thesis demonstrates competition between bilirubin and ibuprofen for the binding site of albumin by employing four different experimental methods. Moreover, we also show that ibuprofen displaced bilirubin from the albumin binding site. We found that ketoprofen (a drug similar to ibuprofen), has the same ability to displace bilirubin from the binding site, as ibuprofen. We designed a model with the potential to implement high-throughput screening for the identification of drugs that interact with bilirubin-albumin binding mechanism. Presently, there is a gap of knowledge in interaction of different drugs to albumin binding sites.

Zatajenje jetre, bez obzira na uzrok, sa sobom nosi visoki rizik morbiditeta i mortaliteta. Brojni toksini koji se nakupljaju tijekom zatajenja jetre slabo su topljivi u vodi i stoga se transportiraju u cirkulaciju vezani za albumine. Bubrežna nadomjesna terapija ne utječe značajnije na koncentraciju bilirubina i drugih toksina koji se vežu na albumine u serumu. U bolesnika s jetrenim zatajenjem potrebne su dodatne detoksikacijske metode. Postoji nekoliko umjetnih izvantjelesnih sustava za potporu jetri zasnovanih na albuminskom principu, ali je njihova dostupnost ograničena zbog visokih troškova i potrebe za posebnom edukacijom osoblja koje izvodi postupak. Do sada je opisano nekoliko slučajeva primjene SPAD-a (engl. single pass albumin dialysis) kao učinkovita alternativa. Glavna prednost ove metoda je što se može provesti koristeći uređaj za konvencionalno nadomještanje bubrežne funkcije. U ovom prikazu, autori opisuju primjenu SPAD-a za liječenje teškog zatajenja jetre u bolesnika s Weilovom bolešću.

Uticaj različitih antepartalnih, intrapartalnih i ranih neonatalnih faktora rizika, značajan je za tok i ishod trudnoće, za rani neonatalni period i za kasniji rast i razvoj deteta. Oštećen plod u trudnoći i/ili porođaju nije samo problem akušera i neonatologa već i izuzetan (veliki) problem sociologa, porodice i društva. Sve ovo nameće potrebu za ranim prepoznavanjem problema ploda sa rizikom u cilju smanjivanja perinatalnog (antenatalnog) morbiditeta i mortaliteta i omogućavanja normalnog rasta i razvoja deteta. Aloimunizacija označava postojanje cirkulišućih antitela majke protiv eritrocita fetusa, koja nastaju kao odgovor na postojanje stranog antigena na membrani eritrocita fetusa. O problemu aloimunizacije u svetu je dosta pisano i rađeno, a ima i zemalja, posebno onih sa razvijenom zdravstvenom zaštitom gde aloimunizacije više nema. U Srbiji, međutim, slično kao i okolnim Balkanskim državama, aloimunizacija je i dalje prisutna i predstavlja jedan od gorućih problema perinatalne kontrole. Hemolitička bolest definisana Rh(D) aloimunizacijom zauzima značajno mesto u perinatalnom morbiditetu i mortalitetu), ona predestavlja oboljenje sa genetskom predispozicijom. Hemolitička bolest fetusa/neonatusa (HBFN), je proces stvaranja IgG anti-D antitela u krvi Rh(D) negativne trudnice koja prelaze u cirkulaciju Rh(D) pozitivnog ploda, apsorbuju se na D pozitivne eritrocite ili ostaju slobodna u fetalnom serumu. Ovako apsorbovana antitela predstavljaju hemolizine koji razaraju eritrocite. Izvesni klinički aspekti Rh(D) aloimunizacije bili su poznati stotinama godina, ali etiologija oboljenja otkrivena je sredinom prošlog veka, što je uslovilo veliki napredak u razumevanju, dijagnostici i terapiji ovog problema. Rh faktor otkrilli su Landsteiner i Weiner 1940. godine, kada su utvrdili da se u serumu eksperimentalnih zečeva, prethodno imunizovanih eritrocitima Rhesus majmuna, stvara antitelo koje aglutiniše ne samo eritrocite majmuna već i eritrocite 85% ljudi bele rase; imunizujući antigen je dobio ime Rhesus antigen. Levine i sar. 1941. godine, pokazali su da je imuni odgovor Rh-negativne trudnice na prisustvo Rh-pozitivnih fetalnih eritrocita uzrok nastanka HBFN, koja je tada nazvana erytroblastosis fetalis (EBF). Landsteiner i Levin daju odgovore na etiologiju i imunohematologiju Rh(D) aloimunizacije, 1940. godine. Pažnja se usmerila ka prevenciji (saznanju da se pojava Rh(D) aloimunizacjie majke na Rh(D) antigen fetusa može sprečiti primenom odgovarajuće količine hiperimunog anti- D imunoglobulina), antenatalnoj dijagnostici i terapiji intrauterusna intravaskularna transfuzija (IUIVT). Napredak medicine tokom poslednjih 20 godina i usavršavanje dijagnostičkih i terapijskih procedura i tehnika izmenio je prognozu života ove dece. Razvoj dijagnostike u trudnoćama sa Rh imunizacijom i terapije HBFN-a obeležilo je pet dostignuća u literaturi poznatih kao "pet velikih skokova unapred": eksangvinotransfuzija (EST), prevremeni porođaj, spektrofotometrija plodove vode, ultrazvučna dijagnostika, pristup fetalnoj cirkulaciji-kordocenteza... The impact of different antepartal, intrapartal and early neonatal risk factors is significant for the course and outcome of a pregnancy, for an early neonatal period and for later growth and development of a child. The case of fetal damage during pregnancy and/or childbirth is a significant problem not only for obstetricians and neonatologists but also for sociologists, family and society as a whole. This calls for an early problem identification of fetus with a risk in order to decrease perinatal (antenatal) morbidity and mortality, and enable normal growth and development of a child. Allo-immunization indicates the existence of maternal circulating antibodies against fetal erythrocytes, that emerge in response to the existence of extraneous antigen on the fetal erythrocyte membrane. Around the world, a great deal of scientific and practical work has been dedicated to the problem of allo-immunization, and there are countries, especially those with developed health care systems, where alloimmunization is no more existent. However, in Serbia and its neughboring Balkan countries allo-immunization is still present and represents one of the vital problems of perinatal contol. Тhe hemolytic disease defined by Rh(D) allo-immunization contributes significantly to perinatal morbidity and mortality. The hemolytic disease of fetus/neonate is the disease (HDFN) with genetic predisposition and it represents a process of production of IgG anti-D antibodies in blood of a Rh(D) negative pregnant woman that go over into the circulation of Rh(D) positive fetus, get absorbed on D positive erythrocytes or stay free in fetal serum. Antibodies absorbed in this way represent hemolysins that destroy erythrocytes. Certain clinical aspects of Rh(D) allo-immunization have been known for hundreds of years, but the disease etiology was discovered in the middle of 20th centuary, and that greatly improved understanding of the problem, and its diagnostics and treatment. Rh factor was discovered by Landsteiner and Weiner in 1940, when in the serum of experimental rabbits, previously immunized by Rhesus monkey erythrocytes, they determined procreation of an antibody which agglutinates not only monkey erythrocytes but also erythrocytes of 85% of Caucasians; the immunizing antigen was called the Rhesus antigen. In 1941, Levine et al. showed that the immune response of Rh negative pregnant woman to the presence of Rh positive fetal erythrocytes is the cause of the hemolytic disease of fetus/neonate, that has since been called erytroblastosis fetalis (EBF). In 1940, Landsteiner and Levine gave answers regarding etiology and immunohematology of Rh(D) allo-immunization. The focus has then turned to the prevention (knowledge that Rh(D) allo-immunization of a mother to Rh(D) fetal antigen can be prevented by application of sufficient quantity of hyperimmune anti-D immunoglobulin), to antenatal diagnostics and to intrauterine intravascular transfusion (IUIVT) treatment...

Hepatobiliary scintigraphy (Cholescintigraphy) is a nuclear imaging procedure for morphological and functional investigation of hepatobiliary system. 99mTc-IDA derivatives are commonly used for hepatobiliary imaging. Biological properties of IDA analogues are determined by chemical structure. Corresponding molecular mass, lipophilicity, protein binding, as well as nature and position of substituents attached to the phenyl ring have major influence on biokinetics (the degree of hepatic uptake and the rate of excretion, as well as urinary elimination) of the 99mTc-IDA complexes. Since bilirubin competes with IDA derivatives, hyperbilirubinemia represents the limiting factor in the application of 99mTc-IDA analogues as hepatobiliary imaging agents. This paper's goal is to give a review of the most important data about physico-chemical and biological properties of numerous 99mTc-IDA analogues which are synthesized and evaluated as potential radiopharmaceuticals, and also those which are commercially used as diagnostics agents. Of all IDA derivatives, 99mTc-mebrofenin is the agents of choice for hepatobiliary imaging in hiperbilirubinemia conditions. Hepatobilijarna scintigrafija (HBS) predstavlja značajnu nuklearno-medicinsku metodu za morfološka i funkciona ispitivanja hepatobilijarnog sistema. Uobičajeno se za ova ispitivanja koriste 99mTc-IDA analozi. Biološke osobine IDA analoga određene su njihovom hemijskom strukturom. Odgovarajuća molekulska masa, lipofilnost, proteinsko vezivanje, kao i vrsta i položaj supstituenata u aromatičnom sistemu imaju presudan uticaj na biokinetiku (visoko nakupljanje i brz transport kroz hepatocite, visoku bilijarnu i minimalnu renalnu ekskreciju) 99mTc-IDA kompleksa. Pošto bilirubin ulazi u kompeticiju sa IDA analozima, hiperbilirubinemija može ograničavati primenu 99mTc-IDA analoga kao hepatobilijarnih agenasa. Ovaj rad ima za cilj da pruži pregled najvažnijih podataka o fizičko-hemijskim i biološkim osobinama brojnih 99mTc-IDA analoga koji su sintetisani i ispitani kao potencijalni radiofarmaceutici, kao i onih koji se komercijalno koriste kao dijagnostička sredstva. Od svih IDA analoga, 99mTc-mebrofenin predstavlja agens izbora za hepatobilijarna ispitivanja u uslovima hiperbilirubinemije.

Tyrimo tikslas – įvertinti veiksnius, turinčius įtakos bilirubino koncentracijai naujagimio kraujyje, ir nustatyti kriterijų, kuriuo remiantis galima prognozuoti naujagimių hiperbilirubinemiją esant ABO antigeniniam netapatumui. Tyrimo uždaviniai: įvertinti motinos ir naujagimio veiksnius, turinčius įtakos naujagimio bilirubino koncentracijai kraujo serume 6 gyvenimo valandą; ištirti veiksnius, turinčius įtakos bilirubino koncentracijos naujagimio kraujo serume pokyčiui pirmą–trečią gyvenimo parą bei pokyčio prognozinę vertę; nustatyti bilirubino koncentracijos kraujo serume, hematokrito, retikulocitų, sferocitų kiekių ir tiesioginės Kumbso reakcijos vertę prognozuojant naujagimių hiperbilirubinemiją, esant ABO antigenininiam netapatumui; palyginti invazinį ir neinvazinį bilirubino koncentracijos nustatymo metodus esant ABO antigeniniam netapatumui; įvertinti perkutaninės bilirubinometrijos vertę diagnozuojant naujagimių hiperbilirubinemiją esant ABO antigeniniam netapatumui. The aim of the study was to assess the factors influencing neonatal bilirubin level and to establish predictive criteria of neonatal hyperbilirubinemia in ABO antigenic incompatibility. The tasks to be carried out were as follows: to establish maternal and neonatal factors influencing neonatal total serum bilirubin at the age of 6 hoursTo establish the factors influencing the change of neonatal total serum bilirubin on days 1-3 of life and to identify the predictive value of this change. To establish the value of total serum bilirubin, hematocrit, reticulocyte, spherocyte and direct Coomb’s test in prognosing neonatal hyperbilirubinemia in ABO incompatibility, to compare non-invasive and invasive methods of total serum bilirubin assessment in the case of ABO incompatibility.