Glutamate optimizes enzymatic activity under high hydrostatic pressure in Desulfovibrio species: effects on the ubiquitous thioredoxin system.

In piezophilic microorganisms, enzymes are optimized to perform under high hydrostatic pressure. The two major reported mechanisms responsible for such adaptation in bacterial species are changes in amino acids in the protein structure, favoring their activity and stability under high-pressure conditions, and the possible accumulation of micromolecular co-solutes in the cytoplasm. Recently, the accumulation of glutamate in the cytoplasm of piezophilic Desulfovibrio species has been reported under high-pressure growth conditions. In this study, analysis of the effect of glutamate on the enzymatic activity of the thioredoxin reductase/thioredoxin enzymatic complex of either a piezosensitive or a piezophilic microorganism confirms its role as a protective co-solute. Analysis of the thioredoxin structures suggests an adaptation both to the presence of glutamate and to high hydrostatic pressure in the enzyme from the piezophilic strain. Indeed, the presence of large surface pockets could counterbalance the overall compression that occurs at high hydrostatic pressure to maintain enzymatic activity. A lower isoelectric point and a greater dipolar moment than that of thioredoxin from the piezosensitive strain would allow the protein from the piezophilic strain to compensate for the presence of the charged amino acid glutamate to interact with its partner.

Delivery room management of extremely preterm infants: the EPIPAGE-2 study.

OBJECTIVE: To analyse the delivery room management of babies born between 22 and 26 weeks of completed gestational age and to identify the factors associated with the withholding or withdrawal of intensive care. STUDY DESIGN: Population-based cohort study. PATIENTS AND METHODS: Our study population comprised 2145 births between 22 and 26 completed weeks enrolled in the EPIPAGE-2 study, a French cohort of very preterm infants born in 2011. The primary outcome measure was withholding or withdrawal of intensive care in the delivery room. RESULTS: Among infants born alive at 22-23 weeks, intensive care was withheld or withdrawn for >90%. At 24 weeks, resuscitative measures were withheld or withdrawn for 38%, at 25 weeks for 8% and at 26 weeks for 3%. Other factors besides gestational age at birth associated with this withholding or withdrawal for infants born at 24-26 weeks were birth weight <600 g, emergency delivery (within 24 h of the mother's admission) and singleton pregnancy. Although rates of withholding or withdrawal of intensive care varied substantially between maternity units (from 0% to 100%), the variability was primarily explained by differences in distributions of gestational age at birth. CONCLUSIONS: Although gestational age is only one factor predicting survival of preterm infants, practices in France appear to be based primarily on this factor, which thus has direct effects on the survival of extremely preterm infants. The ethical implications of basing life and death decisions only on gestational age before 25 weeks require further examination.

[Experience of parents after the loss of a newborn twin in the NICU: a qualitative study 3 years after the death]. / Vécu de parents ayant perdu un jumeau en réanimation néonatale : étude qualitative, 3 ans après le décès.

INTRODUCTION: The mortality rate both before and after birth is higher in twins. Parents face a particularly difficult mourning experience when confronted with the loss of 1 of their newborn twins. The aim of this article is to describe how parents experience and cope with this situation over the long term, how they describe the loss at the time of the death in a neonatal intensive care unit (NICU), the way they are able to become attached to the surviving twin, and the role that NICU caregivers can play to help them. METHOD AND POPULATION: This study is part of a larger qualitative study on parental mourning after the loss of a newborn in 4 NICUs in France. Semi-structured research interviews were conducted 3years after the death. The interviews were recorded, transcribed, and anonymized. Discourse analysis was used to extract the data on different themes. Among the 166 participating parents, 26 had lost a newborn twin. RESULTS: The parents reported their difficulties when faced with simultaneous contradictory events at the time of the death of a twin child in the NICU. Mourning appeared to be more difficult in this particular case: to combine the loss of a deceased child with the care of the surviving newborn was very complicated. The existence of the "co-twin" was described as an essential support for the parents; however, over the long term, this child could not fulfill the feelings of emptiness. The relation with this surviving child was sometimes disturbed by parental anxiety that the accident could recur. Fathers and mothers showed repression of their sadness and despair. The representations of the 2 children in their parents' mind were sometimes very close or even overlapping and some parents were confused with regards to the place each of them could have. In the NICU, the caregivers should be able to listen to the parents expressing their contradictory feelings, to sustain the acknowledgement of the loss of 1 child, and in becoming attached to the surviving child. Parents need to be reassured about their living child's health. CONCLUSION: When faced with the loss of a newborn twin, parents are overwhelmed by the coexistence of contradictory feelings. The role of the medical staff is essential in building separate stories and having different memories for each child.

[Ethical problems of extreme prematurity: results of a qualitative study with obstetricians and midwives]. / Problèmes éthiques posés par l'extrême prématurité: résultats d'une étude qualitative auprès des obstétriciens et des sages-femmes.

OBJECTIVE: Our objective was to explore the practices, attitudes and feelings of obstetricians and midwives in case of extreme prematurity. POPULATION AND METHODS: A qualitative study was conducted as part of a European Concerted Action (EUROBS) in 1999 and 2000 in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France respectively. Semi-structured, tape-recorded interviews were conducted and were independently analysed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated. RESULTS: Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the foetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as more inclined than the obstetrical team to initiate intensive care. If the child was born alive, intensive care was started, knowing that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, less frequently at birth or after birth. DISCUSSION AND CONCLUSION: Compared with obstetricians, midwives tended to have a less favourable perception of the neonatologists' practices, and to deplore the lack of parental information and involvement in decision-making. Decisions about the obstetrical management and resuscitation of extremely preterm infants are essentially always made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

French midwives' practice of termination of pregnancy for fetal abnormality. At what psychological and ethical cost?

OBJECTIVES: To study the clinical, emotional and moral difficulties that French midwives encounter in the labor ward while performing termination of pregnancy (TOP) for fetal abnormality. SETTING: Six public maternity hospitals located in the Ile de France region, two of which were referral centers for prenatal diagnosis (PND) and TOP. METHOD: Questionnaire survey RESULTS: Ninety-two of 115 midwives responded. Sixty-five percent of the midwives reported that their role in the labor ward during TOP was difficult. Aspects contributing substantially to the perceived difficulties were the midwives' responsibility to provide psychological support to patients and the emotional distress of the midwives themselves. Seventy-five percent reported that they were concerned about the child being alive in cases of late TOP. Twenty-five percent of the midwives reported moral conflicts due to personal, cultural or religious background, mainly for particular indications. There was a consensus about the clinical management of TOP. Overall, midwives with professional experience, training, and those who worked in a referral center reported fewer difficulties. CONCLUSION: It is necessary to improve institutional support available within maternity units to alleviate the difficulties midwives face in their roles. The need for training/updating midwives about psychological and ethical aspects of TOP should also be considered.

Mothers' psychological distress 1 year after very preterm childbirth. Results of the EPIPAGE qualitative study.

BACKGROUND: The objectives of this study were to assess qualitatively mothers' physical and psychological health, their perception of their child's health and development, and their difficulties with childcare from 2 months post discharge to 1 year after a very preterm delivery. METHODS: The study population included all mothers who delivered before 33 weeks of amenorrhea between November 1998 and November 1999 in a Parisian maternity unit and between February 2000 and February 2001 in a maternity unit located in Rouen (France). Twenty-one of the 38 mothers contacted agreed to participate (55%). Semi-structured interviews were conducted by a clinical psychologist at the woman's home. They were taped, fully transcribed and subjected to content analysis. RESULTS: The main difficulties reported by mothers at 1 year were fatigue, depressive mood, anxiety and physical symptoms. Depressive mood was associated with social isolation, post-traumatic symptoms, withdrawal and feelings of guilt. Most mothers also described their child as being difficult and tiring. Mothers' reports about their own health and difficult behaviour of their child were more negative at 1 year than at 2 months post discharge. CONCLUSIONS: The mothers' psychological distress following a very preterm birth did not improve between 2 months post discharge and 1 year after delivery. Comprehensive follow-up care programmes should take into account this consequence of a very preterm birth and provide access to adequate psychological support, care or treatment.

[Psychological consequences of multiple births]. / Conséquences psychologiques des naissances multiples.

Since the mid 1970s, the number of multiple births has dramatically increased in our country and most European countries. This paper summarizes the psychological consequences of multiple births based on a review of the literature and on our clinical experience. During pregnancy mothers experience great physical problems linked with increased medical risks for themselves and for the children. These risks cause psychological difficulties: hospitalisation and separation from the family, fear of a premature delivery and anxiety for the children. After delivery the children are often hospitalized, which makes the attachment process difficult. The mortality of multiple children is high and mourning for one child creates particular problems for parents who simultaneously face grieving and attachment processes. After hospital discharge, the overload of work mothers experience leads to physical and nervous fatigue, which does not make easier individual relationship with the children. Mothers have a high level of psychological vulnerability and an increased risk of depression. The satisfactory development of each twin or triplet child requires individualized relationship with his/her mother and his/her father. That is how he/she will be able to build his/her identity and future autonomy. It is important to be aware of the problems experienced by the families and to improve the way material help and psychological support are provided to them.

Women's interpretation of an abnormal result on measurement of fetal nuchal translucency and maternal serum screening for prenatal testing of Down syndrome.

OBJECTIVE: To assess the effects of sociodemographic and health-provider factors on women's understanding of abnormal results on measurement of nuchal translucency (NT) and maternal serum screening (MSS), 18 months after the implementation of a policy aimed at increasing women's awareness regarding MSS. METHODS: A representative sample of women (n = 734) who gave birth in Parisian maternity units in 1999 were asked about their understanding of an abnormal result on MSS and NT. We assessed the effects of sociodemographic and health-provider factors on the probability of women interpreting an abnormal result correctly, misinterpreting it as a definitive diagnosis, or declaring that they did not know how to interpret the result. Response rate was 92% and the analyses included multinomial models. RESULTS: For both MSS and NT measurement, the majority of women interpreted an abnormal result correctly. However, there were substantial sociodemographic differences in the probability of women interpreting an abnormal result correctly, and more so in the probability of their declaring not to know how to interpret the result. The probability of correct interpretations was substantially higher, and that of declaring not to know how to interpret the result substantially lower, for MSS than NT measurement. However, for several sociodemographic groups, the proportion of women who misinterpreted an abnormal result on screening as indicative of a definitive diagnosis was also higher for MSS as compared with NT measurement. CONCLUSIONS: These findings underscore the need for additional efforts, along with alternative strategies, to inform women about the implications of prenatal screening, particularly in the case of measurement of NT.

[Difficulties with the follow-up of a cohort of very preterm infants: The EPIPAGE Paris-Petite-Couronne population]. / Difficultés de suivi d'une cohorte d'enfants nés grands prématurés : EPIPAGE Paris-Petite-Couronne.

OBJECTIVES: To describe the characteristics of the children of parents who did not respond to a follow-up questionnaire in a cohort of very preterm infants (EPIPAGE study) and to explore the reasons why they did not complete the questionnaires. METHODS: The non-respondents (N = 176) were the parents who did not return the questionnaires at 1 and 2 years. Contacts were organised by telephone calls and at home visits. RESULTS: The families of the non-respondents presented more socioeconomic difficulties and their children were born more preterm than those followed up without difficulties. The efforts made to contact the non-respondents revealed that their families were often confronted with major adverse socioeconomic difficulties, had severe illnesses and psychological troubles. Half of the children of the non-respondents were finally examined at the 5-year assessment. They showed lower performances at the cognitive development test and a poorer health status than the children of the respondents. CONCLUSION: When the follow-up does not include the initial population in its totality, the socioeconomic difficulties are underestimated and probably also the rate of sequelae associated with very preterm delivery.

[Consequences for the family of a very preterm birth two months after discharge. Results of the EPIPAGE qualitative study]. / Conséquences pour la famille d'une naissance très prématurée deux mois après le retour à la maison. Résultats de l'enquête qualitative d'EPIPAGE.

OBJECTIVES: To assess mothers' and fathers' psychological health 2 months after discharge of a very preterm infant. To describe the problems encountered with the child, the quality of the marital relationship, the organization of the family and to compare the answers made by mothers and fathers. POPULATION: Mothers having delivered before 33 weeks in two maternity units in Paris and in Rouen were contacted. Among the 38 mothers who were eligible, 21 accepted to participate. Their children were born between 26 weeks and 32 weeks and weighted from 630 to 2100 g. METHOD: A semi-structured interview was conducted at home by a psychologist with each member of the couple. It lasted approximately 1 h. Each interview was tape-recorded and fully transcribed. The analysis allowed to discover the main themes emerging from the interviews and to search for the role of factors. RESULTS: Two months after discharge, mothers expressed anxiety and feelings of depression. Fathers noted considerable fatigue and both parents expressed concerns about the child's health and development. Marital dissatisfaction and behavioural symptoms in siblings were also noted. Mothers' difficulties were not linked to the degree of prematurity or length of stay in neonatal unit but with the baby's present health state, his rehospitalizations and maternal characteristics such as isolation, lack of support and previous perinatal loss. The mother's psychological organisation modifies the role of objective factors. Fathers seemed more able to cope with and overcome the traumatic event caused by the very preterm birth. They insisted on their role of support for the mother and the mother-child relationship. CONCLUSION: The consequences of a very preterm birth are important and concern the whole family. After hospital discharge, the follow-up care of the very preterm baby should take the family social and psychological situation into account.

Ethical decision-making for extremely preterm deliveries: results of a qualitative survey among obstetricians and midwives.

OBJECTIVE: To explore the practices, attitudes and feelings of obstetricians and midwives in cases of extreme prematurity. METHODS: A qualitative study was conducted as part of a European Concerted Action (EUROBS) in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France. Semi-structured interviews lasted an average of 60 min and were tape-recorded. They were independently analyzed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated. RESULTS: Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the fetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as being more inclined than the obstetric team to initiate intensive care. If the child was born alive, intensive care was started, in the knowledge that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, in particular when there was no emergency situation. Compared with obstetricians, midwives tended to have a less favorable perception of the neonatologists' practices, and to report less parental involvement in decision-making. CONCLUSIONS: Decisions about the obstetric management and resuscitation of extremely preterm infants are usually made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

The effects of a severe drought on mouflon lamb survival.

The mouflon population of Caroux-Espinouse, southern France, inhabits a highly seasonal area with dry summers. We monitored summer lamb survival during a severe drought in 2003, from early June to late August. The survival of 35 radio-tagged lambs over nine two-week periods was strongly affected by the timing of rainfall. Survival depended on the amount of rainfall recorded at a given 14 day period and in the previous 14-21 day period. Survival was not influenced by the exceptionally high mean daily temperature recorded during some periods. Male lamb survival (0.68) tended to be less than female survival (0.81), although not significantly, possibly because of a low sample size. The high lamb mortality (25.7%) recorded during a four-month period is much higher than previous estimates of first-year mortality (less than 10%). We recommend accounting for climatic variation in summer when studying the population dynamics of ungulates.

Ethical decision-making in prenatal diagnosis and termination of pregnancy: a qualitative survey among physicians and midwives.

OBJECTIVES: This study was aimed at exploring the conflicts and ethical problems experienced by professionals involved in prenatal diagnosis and termination of pregnancy (TOP) in order to improve the understanding of decision-making processes and medical practices in the field of prenatal diagnosis. METHODS: Qualitative study with in-depth tape-recorded interviews conducted in three tertiary care maternity units in France, between May 1999 and March 2000. All full-time obstetricians and half of the full-time midwives were contacted. Seventeen obstetricians and 30 midwives participated (three refusals, five missing). Interviews were transcribed and analysed successively by two different researchers. RESULTS: All respondents stated that prenatal diagnosis and TOP raised important ethical dilemmas, the most frequent being request for abortion in case of minor anomalies. They pointed out the inability of our society to appropriately care for disabled children and the risk of eugenic pressures. The decisions and practices in prenatal diagnosis should be debated throughout society. All respondents reported that their unit did not have protocols for deciding when a TOP was justifiable. The transmission of information to the women appeared to be a problematic area. Moral conflicts and emotional distress were frequently expressed, especially by midwives who mentioned the need for more discussions and support groups in their department. CONCLUSION: Health professionals involved in prenatal diagnosis face complex ethical dilemmas which raise important personal conflicts. A need for more resources for counselling women and for open debate about the consequences of the current practices clearly emerged.

Mothers' knowledge of screening for trisomy 21 in 1999: a survey in Paris maternity units.

OBJECTIVE: To assess mothers' knowledge of screening tests for trisomy 21. STUDY DESIGN: Interview of all women who had recently delivered a healthy child and were present in 15 Paris maternity units during one of the two non-consecutive days in June 1999 (N = 734). RESULTS: Two-third said that they had access to a nuchal translucency measurement (NTM) and to maternal serum screening (MSS), and 16% to amniocentesis. Thirty-eight percent of the women who had NTMs and 69% of those who had serum screening said that they had been informed of the need for amniocentesis if the results were abnormal. Among the women who had amniocentesis, 20% did not know the risk of miscarriage and 41% had not been informed about the possibility of terminating the pregnancy if trisomy 21 was diagnosed. CONCLUSIONS: Mothers' knowledge about the screening tests for trisomy 21 remains fragmentary. Providing comprehensive information about all these tests should be considered in early pregnancy so that women can make informed choices.

[Psychological consequences of twinship on the children and their parents]. / Impact psychologique de la gémellité sur les enfants et leurs parents.

This paper presents a synthesis about the psychological consequences of twinship based on a review of the literature and on our clinical experience. During pregnancy, delivery and the immediate post-partum, mothers experience physical and psychological difficulties linked with increased medical risks for themselves and for the children. The twins mortality is high before and after delivery. Grieving for one twin creates particular problems for parents. During first months after hospital discharge mothers encounter material and emotional stress. They are caused by overload of mothering tasks and the specificity of mother-twins relationship. The impossibility to establish a dyadic relationship with each child creates feelings of frustration and guilt. The risk of child abuse is increased in twins. The balanced psychoemotional development of twins requires parental attitudes enhancing their individualization as opposed to their "collectivization". The risk of prematurity is ten times increased in twins which increases the risks of developmental disabilities. Considering that the number of twin deliveries is rising in our country it is important to be aware of the problems experienced by the families and to improve the way material and psychological help is provided to them.