Thrombocytopenia and Adverse Bleeding Events in Neonatal Lumbar Punctures in the Emergency Department.

OBJECTIVE: Lumbar punctures are performed as part of a routine evaluation of neonates with fever in the emergency department. Current recommendations regarding performing a lumbar puncture in the presence of thrombocytopenia exist for children with leukemia and other cancers; however, there are no such recommendations for the general neonatal population. This study assesses the frequency of thrombocytopenia and adverse bleeding events in neonates who undergo a lumbar puncture to determine whether a complete blood count, and specifically the platelet count, should be reviewed before performing the lumbar puncture. METHODS: This is a retrospective chart review of neonates 30 days or younger presenting to a single freestanding pediatric emergency department who received a lumbar puncture over the course of 11 years. The complete blood count was reviewed for thrombocytopenia, determined to be platelet count of less than 150,000/µL. The chart was reviewed for any documented adverse bleeding events associated with the lumbar puncture. RESULTS: A total population of 2145 was studied with 56 patients determined to be thrombocytopenic. Seven total bleeding events were identified: 1 in the thrombocytopenic group and 6 in the nonthrombocytopenic group. All bleeding events were deemed to be clinically significant, either resulting in prolonged hospital stay or required further workup and medical intervention. The percentage of clinically adverse bleeding events that were related to the lumbar puncture was 0 (0.0%; 95% confidence interval, 0.0%-6.4%) and 2 (0.1%; 95% confidence interval, 0.0%-0.3%) ( P = 1.0) in the thrombocytopenic and nonthrombocytopenic groups, respectively. CONCLUSIONS: Our results demonstrated a very low risk of bleeding events associated with lumbar punctures in neonates, with no increased risk in the thrombocytopenic group. As such, we conclude that waiting for the results of a complete blood count before performing the lumbar puncture in neonates without a known bleeding disorder is unnecessary.

Impact of pregnancy planning and preconceptual dietary training on metabolic control and offspring's outcome in phenylketonuria.

To prevent maternal phenylketonuria (PKU) syndrome low phenylalanine concentrations (target range, 120-360 µmol/L) during pregnancy are recommended for women with PKU. We evaluated the feasibility and effectiveness of current recommendations and identified factors influencing maternal metabolic control and children's outcome. Retrospective study of first successfully completed pregnancies of 85 women with PKU from 12 German centers using historical data and interviews with the women. Children's outcome was evaluated by standardized IQ tests and parental rating of child behavior. Seventy-four percent (63/85) of women started treatment before conception, 64% (54/85) reached the phenylalanine target range before conception. Pregnancy planning resulted in earlier achievement of the phenylalanine target (18 weeks before conception planned vs. 11 weeks of gestation unplanned, p < 0.001) and lower plasma phenylalanine concentrations during pregnancy, particularly in the first trimester (0-7 weeks of gestation: 247 µmol/L planned vs. 467 µmol/L unplanned, p < 0.0001; 8-12 weeks of gestation: 235 µmol/L planned vs. 414 µmol/L unplanned, p < 0.001). Preconceptual dietary training increased the success rate of achieving the phenylalanine target before conception compared to women without training (19 weeks before conception vs. 9 weeks of gestation, p < 0.001). The majority (93%) of children had normal IQ (mean 103, median age 7.3 years); however, IQ decreased with increasing phenylalanine concentration during pregnancy. Good metabolic control during pregnancy is the prerequisite to prevent maternal PKU syndrome in the offspring. This can be achieved by timely provision of detailed information, preconceptual dietary training, and careful planning of pregnancy.

Preventing maternal phenylketonuria (PKU) syndrome: important factors to achieve good metabolic control throughout pregnancy.

BACKGROUND: Insufficient metabolic control during pregnancy of mothers with phenylketonuria (PKU) leads to maternal PKU syndrome, a severe embryo-/fetopathy. Since maintaining or reintroducing the strict phenylalanine (Phe) limited diet in adults with PKU is challenging, we evaluated the most important dietary and psychosocial factors to gain and sustain good metabolic control in phenylketonuric women throughout pregnancy by a questionnaire survey with 38 questions concerning therapy feasibility. Among them, the key questions covered 5 essential items of PKU care as follows: General information about maternal PKU, PKU training, diet implementation, individual metabolic care, personal support. In addition, all participating PKU mothers were asked to estimate the quality of their personal metabolic control of the concluded pregnancies. 54 PKU mothers with 81 pregnancies were approached at 12 metabolic centers in Germany and Austria were included. According to metabolic control, pregnancies of PKU women were divided in two groups: group "ideal" (not more than 5% of all blood Phe concentrations during pregnancy > 360 µmol/l; n = 23) and group "suboptimal" (all others; n = 51). RESULTS: The demand for support was equally distributed among groups, concerning both amount and content. Personal support by the direct social environment (partner, family and friends) ("suboptimal" 71% vs "ideal" 78%) as well as individual metabolic care by the specialized metabolic center (both groups around 60%) were rated as most important factors. The groups differed significantly with respect to the estimation of the quality of their metabolic situation (p < 0.001). Group "ideal" presented a 100% realistic self-assessment. In contrast, group "suboptimal" overestimated their metabolic control in 53% of the pregnancies. Offspring of group "suboptimal" showed clinical signs of maternal PKU-syndrome in 27%. CONCLUSION: The development of training programs by specialized metabolic centers for females with PKU in child bearing age is crucial, especially since those mothers at risk of giving birth to a child with maternal PKU syndrome are not aware of their suboptimal metabolic control. Such programs should provide specific awareness training for the own metabolic situation and should include partners and families.

The neurological and neuropsychiatric spectrum of adults with late-treated phenylketonuria.

INTRODUCTION: Phenylketonuria (PKU) is a rare, treatable inborn error of metabolism with frequent neurological and neuropsychiatric complications, especially in undiagnosed or insufficiently treated individuals. Given the wide range of clinical presentations and the importance of treatment implications, we here delineate the neurological and neuropsychiatric symptom spectrum in a large cohort of previously unreported adults with late-treated PKU. METHODS: We consecutively evaluated late-treated PKU cases and pooled clinical and paraclinical data, including video-material, from three centers with expertise in complex movement disorders, inborn errors of metabolism and pediatrics. RESULTS: 26 individuals were included (10 females, median age 52 years). Developmental delay and intellectual disability were omnipresent with severe impairment of expressive communication noted in 50% of cases. Movement disorders were prevalent (77%), including tremor (38%, mostly postural), stereotypies (38%), and tics (19%). One case had neurodegenerative levodopa-responsive parkinsonism. Mild ataxia was noted in 54% of cases and 31% had a history of seizures. Neuropsychiatric characteristics included obsessive-compulsive (35%) and self-injurious behaviors (31%), anxiety (27%), depression (19%) and features compatible with those observed in individuals with autism spectrum disorder (19%). Neuroimaging revealed mild white matter changes. Adherence to dietary treatment was inconsistent in the majority of cases, particularly throughout adolescence. CONCLUSION: A history of movement disorders, particularly tremor, stereotypies and tics, in the presence of developmental delay, intellectual disability and neuropsychiatric features, such as obsessive-compulsive and self-injurious behaviors in adults should prompt the diagnostic consideration of PKU. Initiation and adherence to (dietary) treatment can ameliorate the severity of these symptoms.

Development of a practical dietitian road map for the nutritional management of phenylketonuria (PKU) patients on pegvaliase.

Background: The metabolic dietitian/nutritionist (hereafter 'dietitian') plays an essential role in the nutritional management of patients with phenylketonuria (PKU), including those on pegvaliase. Currently, more educational support and clinical experience is needed to ensure that dietitians are prepared to provide optimal nutritional management and counselling of pegvaliase-treated patients. Methods: Via a face-to-face data-review meeting, followed by a virtual consolidation meeting, a group of expert dietitians and one paediatrician discussed and developed a series of recommendations on the nutritional evaluation and management of patients receiving pegvaliase. The consensus group consisted of 10 PKU experts: six dietitians and one paediatrician from Europe and three dietitians from the US. One European and three US dietitians had experience with pegvaliase-treated patients. Results: The consensus group recommended that a physician, dietitian and nurse are part of the pegvaliase treatment team. Additionally, a psychologist/counsellor should be included if available. Practical proposals for the nutritional evaluation of pegvaliase-treated patients at baseline, during the induction and titration phases and for long-term maintenance were developed. The consensus group suggested assessment of blood Phe at least monthly or every 2 weeks in the event of low blood Phe (i.e., blood Phe <30 µmol/L). It may be appropriate to increase blood Phe monitoring when adjusting protein intake and/or pegvaliase dose. It was recommended that natural protein intake is increased by 10-20 g increments if blood Phe concentrations decrease to <240 µmol/L in patients who are not meeting the dietary reference intake for natural protein of 0.8 g/kg. It was proposed that with pegvaliase treatment blood Phe levels could be maintained <240 µmol/L but more evidence on the safety of achieving physiological blood Phe levels is necessary before any recommendation on the lower blood Phe target can be given. Finally, both patients and dietitians should have access to educational resources to optimally support patients receiving pegvaliase. Conclusion: This practical road map aims to provide initial recommendations for dietitians monitoring patients with PKU prescribed pegvaliase. Given that practical experience with pegvaliase is still limited, nutritional recommendations will require regular updating once more evidence is available and clinical experience evolves.

CSD-Grown Y1-xGdxBa2Cu3O7-δ-BaHfO3 Nanocomposite Films on Ni5W and IBAD Technical Substrates.

Chemical solution deposition (CSD) was used to grow Y1-xGdxBa2Cu3O7-δ-BaHfO3 (YGBCO-BHO) nanocomposite films containing 12 mol% BHO nanoparticles and various amounts of Gd, x, on two kinds of buffered metallic tapes: Ni5W and IBAD. The influence of the rare-earth stoichiometry on structure, morphology and superconducting properties of these films was studied. The growth process was carefully studied in order to find the most appropriate growth conditions for each composition and substrate. This led to a clear improvement in film quality, probably due to the reduction of BaCeO3 formation. In general, the superconducting properties of the films on Ni5W are significantly better. For x > 0.5, epitaxial ~270 nm thick YGBCO-BHO films with Tc > 93 K and self-field Jc at 77 K ~2 MA/cm² were obtained on Ni5W. These results highlight the potential of this approach for the fabrication of high-quality coated conductors.

Two-step chromosome segregation in the stalked budding bacterium Hyphomonas neptunium.

Chromosome segregation typically occurs after replication has finished in eukaryotes but during replication in bacteria. Here, we show that the alphaproteobacterium Hyphomonas neptunium, which proliferates by bud formation at the tip of a stalk-like cellular extension, segregates its chromosomes in a unique two-step process. First, the two sister origin regions are targeted to opposite poles of the mother cell, driven by the ParABS partitioning system. Subsequently, once the bulk of chromosomal DNA has been replicated and the bud exceeds a certain threshold size, the cell initiates a second segregation step during which it transfers the stalk-proximal origin region through the stalk into the nascent bud compartment. Thus, while chromosome replication and segregation usually proceed concurrently in bacteria, the two processes are largely uncoupled in H. neptunium, reminiscent of eukaryotic mitosis. These results indicate that stalked budding bacteria have evolved specific mechanisms to adjust chromosome segregation to their unusual life cycle.

Chemical solution deposition of Y1-x Gd x Ba2Cu3O7-δ -BaHfO3 nanocomposite films: combined influence of nanoparticles and rare-earth mixing on growth conditions and transport properties.

Y1-x Gd x Ba2Cu3O7-δ -BaHfO3 (YGBCO-BHO) nanocomposite films containing 12 mol% BHO nanoparticles and different amounts of Gd were prepared by chemical solution deposition following the trifluoroacetic route on SrTiO3 single crystals in order to study the influence of the rare earth stoichiometry on structure, morphology and superconducting properties of these films. We optimized the growth process for each of several Gd contents of the 220 nm thick YGBCO-BHO films by varying crystallization temperature and oxygen partial pressure. This optimization process led to the conclusion that mixing the rare earths in YGBCO-BHO films leads to wider growth parameter windows compared to YBCO-BHO and GdBCO-BHO films giving larger freedom for selecting the most convenient processing parameters in order to adapt to different substrates or applications which is very important for the industrial production of coated conductors. The optimized films show a continuous increase of T c with Gd content x from ∼90 K for the YBCO-BHO films to ∼94 K for the GdBCO-BHO films. Consequently, an increase of the 77 K self-field J c with Gd content is observed reaching values > 7 MA cm-2 for Gd contents x > 0.5. The transport properties of these films under applied magnetic fields are significantly improved with respect to the pristine YBCO films. All YGBCO-BHO nanocomposite films grew epitaxially with c-axis orientation and excellent out-of-plane and in-plane texture. The films are dense with a low amount of pores and only superficial indentations.

Molecular toolbox for genetic manipulation of the stalked budding bacterium Hyphomonas neptunium.

The alphaproteobacterium Hyphomonas neptunium proliferates by a unique budding mechanism in which daughter cells emerge from the end of a stalk-like extension emanating from the mother cell body. Studies of this species so far have been hampered by the lack of a genetic system and of molecular tools allowing the regulated expression of target genes. Based on microarray analyses, this work identifies two H. neptunium promoters that are activated specifically by copper and zinc. Functional analyses show that they have low basal activity and a high dynamic range, meeting the requirements for use as a multipurpose expression system. To facilitate their application, the two promoters were incorporated into a set of integrative plasmids, featuring a choice of two different selection markers and various fluorescent protein genes. These constructs enable the straightforward generation and heavy metal-inducible synthesis of fluorescent protein fusions in H. neptunium, thereby opening the door to an in-depth analysis of polar growth and development in this species.