Copper to Zinc Ratio as Disease Biomarker in Neonates with Early-Onset Congenital Infections

Copper (Cu) and zinc (Zn) are essential trace elements for regular development. Acute infections alter their metabolism, while deficiencies increase infection risks. A prospective observational case-control study was conducted with infected (n = 21) and control (n = 23) term and preterm newborns. We analyzed trace element concentrations by X-ray fluorescence, and ceruloplasmin (CP) by Western blot. Median concentration of Cu at birth (day 1) was 522.8 [387.1–679.7] μg/L, and Zn was 1642.4 ± 438.1 μg/L. Cu and Zn correlated positively with gestational age in control newborns. Cu increased in infected newborns from day 1 to day 3. CP correlated positively to Cu levels at birth in both groups and on day 3 in the group of infected neonates. The Cu/Zn ratio was relatively high in infected newborns. Interleukin (IL)-6 concentrations on day 1 were unrelated to Cu, Zn, or the Cu/Zn ratio, whereas C-reactive protein (CRP) levels on day 3 correlated positively to the Cu/Zn -ratio at both day 1 and day 3. We conclude that infections affect the trace element homeostasis in newborns: serum Zn is reduced, while Cu and CP are increased. The Cu/Zn ratio combines both alterations, independent of gestational age. It may, thus, constitute a meaningful diagnostic biomarker for early-onset infections. View Full-Tex

Neutrophil “plucking” on megakaryocytes drives platelet production and boosts cardiovascular disease

Intravascular neutrophils and platelets collaborate in maintaining host integrity, but their interaction can also trigger thrombotic complications. We report here that cooperation between neutrophil and platelet lineages extends to the earliest stages of platelet formation by megakaryocytes in the bone marrow. Using intravital microscopy, we show that neutrophils "plucked" intravascular megakaryocyte extensions, termed proplatelets, to control platelet production. Following CXCR4-CXCL12-dependent migration towards perisinusoidal megakaryocytes, plucking neutrophils actively pulled on proplatelets and triggered myosin light chain and extracellular-signal-regulated kinase activation through reactive oxygen species. By these mechanisms, neutrophils accelerate proplatelet growth and facilitate continuous release of platelets in steady state. Following myocardial infarction, plucking neutrophils drove excessive release of young, reticulated platelets and boosted the risk of recurrent ischemia. Ablation of neutrophil plucking normalized thrombopoiesis and reduced recurrent thrombosis after myocardial infarction and thrombus burden in venous thrombosis. We establish neutrophil plucking as a target to reduce thromboischemic events

PEDIA: prioritization of exome data by image analysis.

PURPOSE: Phenotype information is crucial for the interpretation of genomic variants. So far it has only been accessible for bioinformatics workflows after encoding into clinical terms by expert dysmorphologists. METHODS: Here, we introduce an approach driven by artificial intelligence that uses portrait photographs for the interpretation of clinical exome data. We measured the value added by computer-assisted image analysis to the diagnostic yield on a cohort consisting of 679 individuals with 105 different monogenic disorders. For each case in the cohort we compiled frontal photos, clinical features, and the disease-causing variants, and simulated multiple exomes of different ethnic backgrounds. RESULTS: The additional use of similarity scores from computer-assisted analysis of frontal photos improved the top 1 accuracy rate by more than 20-89% and the top 10 accuracy rate by more than 5-99% for the disease-causing gene. CONCLUSION: Image analysis by deep-learning algorithms can be used to quantify the phenotypic similarity (PP4 criterion of the American College of Medical Genetics and Genomics guidelines) and to advance the performance of bioinformatics pipelines for exome analysis

Thrombocytopenia, Immature platelet fraction, nucleated red blood cells and reticulocyte cell indices in the blood count of neonates

Trotz der hohen Inzidenz der Thrombozytopenie auf einer Neugeborenen- Intensivstation sind Pathophysiologie, Blutungsrisiko sowie die Transfusionsgrenze nicht geklärt. Durch die Anwendung der fluoreszenz- durchflusszytometrischen IPF-Messung konnte sowohl bei der early- als auch bei der late-onset Thrombozytopenie gezeigt werden, dass die Produktionsrate gesteigert werden kann. Im Falle einer schweren Thrombozytopenie ist sie jedoch vermindert. Daher ist davon auszugehen, dass die Ursache ein Thrombozytenverbrauch ist, der durch eine Produktionsstörung verstärkt werden kann. Bei der meist mild verlaufenden early-onset Thrombozytopenie ist es anhand der IPF möglich, der einen Anstieg der Thrombozyten zu antizipieren. Bei der Untersuchung zur Lungenblutung lag die mediane Thrombozytenzahl zwar niedriger als bei der Kontrollgruppe, die Inzidenz der schweren Thrombozytopenie hingegen war gleich. Andere Faktoren hingegen waren mit der Lungenblutung assoziiert (verlängerte aPTT, FFP Transfusion, fehlende Lungenreifeinduktion, höherer Sauerstoffbedarf). Somit scheint auch bei dieser Krankheitsentität so zu sein, dass andere Faktoren als die Thrombozytenzahl das Blutungsrisiko determinieren. Im internationalen Vergleich zum Transfusionsverhalten bei neonataler Thrombozytopenie waren die angegebenen Transfusionsgrenzen sehr heterogen. In den US lag die mediane Transfusionsgrenze in den fast allen Fällen höher als im europäischen Vergleich (AUT/GER/SUI). Bei fehlender Evidenz, dass liberale Transfusionsgrenzen zu einem klinischen Benefit führen, ergibt dies eine geschätzt 1,8fach erhöhte Transfusionsrate bei klinisch stabilen Frühgeborenen ohne Blutung in den US. Als weitere fluoreszenz-durchflusszytometrischen Methode wurde die NRBC Messung bei VLBW Frühgeborenen in den ersten Lebenstagen und bei Patienten mit Sepsis/NEC durchgeführt. Mit Hilfe dieser Methode konnte gezeigt werden, dass Veränderungen im Verlauf der NRBC- Konzentration mit einem ungünstigen Outcome assoziiert sind. Die Messung der Retikulozyten-Indices, insbesondere das Delta-He, ist in der Neonatologie bisher nicht etabliert, könnte aber interessantes Werkzeug in der Anämiediagnostik in Zukunft werden. Insgesamt zeigten die Studien, dass mit Hilfe der modernen voll-automatisierten Blutbildanalyse rund um die Uhr zusätzliche Informationen gewonnen werden, die das ärztliche Verhalten beeinflussen können. Die Messung der IPF könnte zukünftig in Zusammenhang mit der Thrombozytenzahl und klinischen Risikofaktoren Einfluss auf die Transfusionsindikation haben.Despite the high incidence of thrombocytopenia in the neonatal intensive care unit, pathophysiology, risk of bleeding, as well as the transfusion limit are not clarified. By using fluorescence flow cytometric, the measurement of the immature platelet fraction (IPF) showed that the production rate can be increased, both in the early and late-onset thrombocytopenia. In the case of severe thrombocytopenia, however, IPF is reduced. Therefore, it can be assumed that the main cause of neonatal thrombocytopenia is platelet consumption, which can be aggravated by a production deficit. In early-onset thrombocytopenia, which is usually mild, it is possible to anticipate an increase in platelet count on the basis of the IPF. In the pulmonary hemorrhage study, the median platelet count was lower than that of the control group, but the incidence of severe thrombocytopenia was similar. Other factors, however, were associated with pulmonary bleeding (prolonged aPTT, FFP transfusion, lack of lung maturity induction, higher oxygen need). Thus, in this disease entity it also appears that factors other than the platelet count determine the risk of bleeding. An international survey to compare the transfusion behavior in neonatal thrombocytopenia revealed that the transfusion limits were very heterogeneous. In the US, the median transfusion limit was higher in nearly all cases than in the European comparison (AUT / GER / SUI). In the absence of evidence that liberal transfusion limits lead to a clinical benefit, higher transfusion limits result in an estimated 1.8-fold increased transfusion rate in clinically stable premature infants without bleeding in the US. As a further fluorescence flow cytometric method, the NRBC measurement was performed in VLBW preterm infants during the first days of life and in patients with sepsis / NEC. Using this method, it was shown that changes in the course of NRBC concentration are associated with an unfavorable outcome. The measurement of the reticulocyte indices, in particular the delta- He, has not been established in neonatology, but could become an interesting tool in anemia diagnosis in the future. Overall, the studies showed that additional information is obtained around the clock with the aid of the modern fully-automated blood count analysis, which can influence the medical behavior. The measurement of the IPF may have an influence on the transfusion indication in the future in connection with platelet counts and clinical risk factors

Fresh frozen plasma transfusion - a risk factor for pulmonary hemorrhage in extremely low birth weight infants?

AbstractAim: To evaluate risk factors for pulmonary hemorrhage (PH) in extremely low birth weight infants (ELBW) taking into consideration coagulation screens, platelet counts, transfusion of fresh frozen plasma (FFP), and platelet concentrates prior to PH. Patients and methods: A retrospective case-control study consisting of 20 ELBW infants with PH and 40 matched controls. Coagulation screens, platelet counts at birth and at onset of PH, and transfusion frequencies prior to PH were compared to case-controls at birth and 24-96 h after birth. Results: While the initial platelet counts, fibrinogen concentrations, and international normalized ratios were similar in PH infants and controls, the activated partial prothrombin time was prolonged (P=0.05). Compared to 28% of case controls (P<0.05), 55% of infants with later PH received FFP prior to PH. Platelet counts were significantly lower at onset of PH (median 81/nL; range: 37-236/nL) compared to controls (166/nL; 27-460/nL; P<0.005). Multivariate analysis indicated a lack of antenatal steroids, supplemental oxygen, and transfusion of FFP as independent risk factors for PH. Conclusion: Prolonged activated partial thromboplastin time (aPTT) might be associated with PH. PH does not primarily depend upon severe thrombocytopenia. A developmental mismatch in hemostasis by transfusion of adult donor plasma should be considered a risk factor for PH

Immature Platelet Counts and Thrombopoietin Plasma Concentrations in Thrombocytopenic and Non-thrombocytopenic Preterm Infants

Objective: Immature platelet counts (IPC) may prove useful in guiding platelet transfusion management in preterm neonates. However, the relationship between IPCs and thrombopoietin (Tpo) concentrations has not been evaluated in preterm neonates. Methods: Prospective cohort study in thrombocytopenic (n = 31) and non-thrombocytopenic very low birth weight (VLBW) infants (n = 38), and healthy term neonates (controls; n = 41). Absolute platelet counts (APCs), IPCs, and Tpo concentrations were assessed by a fully-automated hematological analyzer (IPC, APC) and by ELISA (Tpo concentrations) in parallel on day 1 of life (d1), d3, and d7. Results: In healthy term neonates, APCs remained stable between d1 and d3. In non-thrombocytopenic VLBW infants, APCs increased from d1 to d7, while in the thrombocytopenia group, APCs declined from d1 to d3, before they slightly increased again by d7. Median IPCs were similar in healthy term vs. non-thrombocytopenic VLBW infants and remained stable between d1 and d3 (p > 0.05). Notably, IPCs significantly increased between d3 and d7 in both non-thrombocytopenic and thrombocytopenic VLBW infants. However, in thrombocytopenic VLBW infants, IPC values were significantly lower at each time point as compared to non-thrombocytopenic VLBWs (p < 0.001). In each subgroup, Tpo concentrations increased from d1 to d3. The median Tpo concentrations were significantly higher in thrombocytopenic as compared to non-thrombocytopenic VLBW infants at d3 (p = 0.01) and d7 (p = 0.002). Discussion: Term infants, thrombocytopenic, and non-thrombocytopenic preterm infants display similar developmental changes in indices of megakaryopoietic activity. In thrombocytopenic preterm infants, however, the responsive increases in Tpo and immature platelets appear to be developmentally limited

Three Novel EPCAM Variants Causing Tufting Enteropathy in Three Families

Tufting enteropathy (TE) is caused by recessive EPCAM mutations, and is characterized by intractable diarrhea of congenital onset and disorganization of enterocytes. TE generally requires parenteral nutrition (PN) during childhood or intestinal bowel transplantation. We report three unrelated families with six children with TE. We highlight the high rate of disease-related mortality. We observe adequate weight gain with PN, but low to normal and stunted body length, supporting the recent notion that a short stature might be intrinsic to TE. The diagnosis of TE in the index patients from each family was delayed for months to years, even when clinical data, duodenal biopsies, or exome sequencing data were obtained early on. We identified three novel pathogenic EPCAM variants: a deletion of exon 1 that removes the ATG initiation codon, a missense variant c.326A &gt; G (p.Gln109Arg), and nonsense mutation c.429G &gt; A (p.Trp143*) in a compound heterozygous state with the Mediterranean splice site variant c.556-14A &gt; G (Tyr186Phefs*6). Homozygosity for p.Gln109Arg was associated with absent EPCAM staining, and compound heterozygosity for p.Trp143*/Tyr186Phefs*6 was associated with reduced EPCAM staining in duodenal biopsies; such observations might contribute to a genotype–phenotype correlation in larger cohorts of TE patients. This study extends the clinical and molecular spectrum of TE