Minutes Of Life Research Articles

Antecedents of Neonatal Encephalopathy in the Vermont Oxford Network Encephalopathy Registry

Neonatal encephalopathy (NE) is a major predictor of death and long-term neurologic disability, but there are few studies of antecedents of NE. To identify antecedents in a large registry of infants who had NE. This was a maternal and infant record review of 4165 singleton neonates, gestational age of ≥ 36 weeks, meeting criteria for inclusion in the Vermont Oxford Network Neonatal Encephalopathy Registry. Clinically recognized seizures were the most prevalent condition (60%); 49% had a 5-minute Apgar score of ≤ 3 and 18% had a reduced level of consciousness. An abnormal maternal or fetal condition predated labor in 46%; maternal hypertension (16%) or small for gestational age (16%) were the most frequent risk factors. In 8%, birth defects were identified. The most prevalent birth complication was elevated maternal temperature in labor of ≥ 37.5 °C in 27% of mothers with documented temperatures compared with 2% to 3.2% in controls in population-based studies. Clinical chorioamnionitis, prolonged membrane rupture, and maternal hypothyroidism exceeded rates in published controls. Acute asphyxial indicators were reported in 15% (in 35% if fetal bradycardia included) and inflammatory indicators in 24%. Almost one-half had neither asphyxial nor inflammatory indicators. Although most infants with NE were observably ill since the first minutes of life, only 54% of placentas were submitted for examination. Clinically recognized asphyxial birth events, indicators of intrauterine exposure to inflammation, fetal growth restriction, and birth defects were each observed in term infants with NE, but much of NE in this large registry remained unexplained.

1805 Oxygen Saturation Monitoring at Birth: Feasibility of the 2010 Neonatal Resuscitation Guidelines

BackgroundThe 2010 Neonatal Resuscitation Guidelines recommend preductal transcutaneous oxygen saturation (SpO2) monitoring at birth.ObjectiveTo verify the feasibility of SpO2 monitoring at birth by determining the time to get the first...

WS7-5 - To Clarify the Difference between the Treatment by Oncologist and Palliative Physicians: A Multicenter Retrospective Study, HOME1202

ABSTRACT Background It has been reported that early palliative care for patients with lung cancer has optimized the final timing of chemotherapy and has led to improvements in both of quality of life, mood and survival of patients with lung cancer in the United States. On the other hand under Japanese health care system, the effect of introducing palliative care early after diagnosis for patients with cancer has not been clear. First of all, it is necessary to elucidate the difference of medical care for cancer between oncologist and palliative physicians. Objective To research precise picture of Medical care for cancer on oncologist retrospectively and compare to concurrent research on palliative physicians. Methods We examined medical records of 244 cases died of cancer from January to December 2010 at the facilities participating Hokkaido Team Oncology Meeting (HOME) of which consisted oncologists, palliative physicians, nurses and pharmacist belonging our center hospital and cooperating facilities. Then we compared these records to 230 cases concurrently investigated introducing palliative care by the palliative physicians. Results The median time to death from date of last treatment was 39.5 days; this time was short in breast and colorectal cancer, long in liver and lung cancer. Chemotherapy within 14 days of death was carried out in 32 patients (23%), and in 14 patients with lung cancer (18%) was similar to the case of lung cancer in the US Cases of sedation with opioids alone carried out by oncologist was higher than that carried out by palliative physicians significantly (P Conclusion Termination time of chemotherapy for patients varies depending on what type of cancer. But Oncologist did not tend to select the chemotherapy until the last minute of life in this study. Sedation method was clearly different between oncologist and palliative physicians. Early sedative intervention by palliative physicians suggested to be able to provide high-quality end-of-life care. In future we examine the influence of cancer species and health care system, evaluation of QOL and method of intervention, and then we will plan a prospective clinical trial.

Biomarkers of Brain Injury in Neonatal Encephalopathy Treated with Hypothermia

To determine if early serum S100B and neuron-specific enolase (NSE) levels are associated with neuroradiographic and clinical evidence of brain injury in newborns with encephalopathy. Patients who received therapeutic whole-body hypothermia were prospectively enrolled in this observational study. Serum specimens were collected at 0, 12, 24, and 72 hours of cooling. S100B and NSE levels were measured by enzyme linked immunosorbent assay. Magnetic resonance imaging was performed in surviving infants at 7-10 days of life. Standardized neurologic examination was performed by a child neurologist at 14 days of life. Multiple linear regression analyses were performed to evaluate the association between S100B and NSE levels and unfavorable outcome (death or severe magnetic resonance imaging injury/significant neurologic deficit). Cutoff values were determined by receiver operating curve analysis. Newborns with moderate to severe encephalopathy were enrolled (n = 75). Median pH at presentation was 6.9 (range, 6.5-7.35), and median Apgar scores of 1 at 1 minute, 3 at 5 minutes, and 5 at 10 minutes. NSEand S100B levels were higher in patients with unfavorable outcomes across all time points. These results remained statistically significant after controlling for covariables, including encephalopathy grade at presentation, Apgar score at 5 minutes of life, initial pH, and clinical seizures. Elevated serum S100B and NSE levels measured during hypothermia were associated with neuroradiographic and clinical evidence of brain injury in encephalopathic newborns. These brain-specific proteins may be useful immediate biomarkers of cerebral injury severity.

Apgar score of zero at one minute: Perinatal factors and early neonatal outcomes

Aims: To assess the perinatal results of newborns with a zero Apgar score at the first minute of life. Methods: Case-control study conducted over a period of 10 years. We assessed maternal, fetal, and neonatal variables. Data were analyzed using SPSS 19.0. Results: Of the 15,616 births occurring during the study period, 29 (0.2%) had a zero Apgar score at the first minute of life (Group I). A control group comprised three newborns with Apgar scores greater than zero for each case (Group II). Comparing cases (Group I) and controls (Group II) showed a higher rate of cesarean deliveries (69% vs. 46.7%; p < 0.05), younger gestational age (34.8 ± 5.5 years vs. 38.5 ± 2.5 years; p < 0.0001), higher incidence of hemorrhagic amniotic fluid (27.6% vs. 17.2%; p < 0.0001), lower fetal weight (2,307 ± 958 g vs. 3,069 ± 609 g; p < 0.0001), lower fifth-minute Apgar score (2.5 ± 2.0 vs. 8.9 ± 0.7; p < 0.0001), lower pH of the umbilical artery (7.01 ± 0.21 vs. 7.21 ± 0.08; p < 0.0001), need for neonatal intensive care unit (100% vs. 20.7%; p < 0.0001), and early neonatal mortality rate (n = 12, 41.4% vs. n = 0). Conclusion: The perinatal assessment of newborns with zero Apgar score in the first minute of life showed a higher rate of operative deliveries and preterm fetuses with low birth weight than in control infants. The higher need for neonatal intensive care therapy is associated with more significant fetal acidosis and apparent death.

Cystic Hygroma Co-existing with Congenital Subglottic Stenosis

Respiratory distress is one of the commonest cause of admission into a Neonatal Intensive Care Unit, be it surgical or medical in nature. Adequate and prompt resuscitation as well as intubation can be life saving. Emergency or early tracheostomy may be necessary if airway intervention is needed. The authors present the case of a term neonate who was born with a large cervical cystic hygroma causing compression of the airway, together with a concurrent grade III subglottic stenosis, in respiratory distress within few minutes of life. Nine months post tracheostomy and sclero-therapy treatment twice, the child shows marked improvement. The succesful management of this unusual case of severe extrinsic compression with concurrent internal airway obstruction is presented.

The First Minute of Life: How Does Real Life Compare to Algorithms?

Background: Within 30 seconds of birth ILCOR recommends that newborns should be warmed, have their airways opened and breathing and heart rate (HR) assessed. By 60 seconds, respiratory support given if appropriate and oximetry considered.

Should be Oxygenation of Extremely Premature Infants (EPI) Guided by FIO2 Adjustment during the First Five Minutes of Life?

Background: The adequate management of FiO2 adjustment depends on the feedback evaluation of heart rate (HR) and saturation of oxygen (SO2) values.

Preductal Oxygen Saturation Trends Immediately after Birth and Feasibility of Implementation of NRP 2010

Background: The concept of normoxia is still not well defined. We definitely want a trend toward using “appropriate” oxygen concentrations for neonatal resuscitation. The goal is to keep the baby's oxygen saturation in the targeted levels. But is this feasible during initial phase of resuscitation? Objective: To define the preductal oxygen saturations (SpO2) trends and to find feasibility of maintaining targeted SPO2 immediately after birth. Methods: All newborns delivered by NVD &LSCS were included. SpO2 was measured with sensor placed on the right hand. Preductal oximetry data was downloaded and analyzed. Based on this data the percentile curves were drawn for normal vaginal and caesarian births. Results: Data from 118 infants were analyzed. 70 newborns were caesarean babies & 48 were normal vaginal deliveries. Figure Potential limitation: Total study population 215,Areas of data dropout 14.8% Areas of rapid changes in saturation 12.09%Sensor misplacement 13.48% Need for supplemental O2 6.5% Remaining sample size 118 i.e. 54.88%. Conclusion: Our results suggest that early oximetry readings, particularly in the first 60 seconds, must be interpreted with caution. Pulse oximetry could potentially play a role in adjusting the oxygen concentration beyond 2 minutes of life. The simplicity & feasibility of this tool may be deceptive and there is still no substitute for clinical acumen.

The First Minute of Life: How Does Real Life Compare to Algorithms?

Background: Within 30 seconds of birth ILCOR recommends that newborns should be warmed, have their airways opened and breathing and heart rate (HR) assessed. By 60 seconds, respiratory support given if appropriate and oximetry considered. Objectives: To determine time taken to perform DR interventions recommended by ILCOR; and the proportion with the recommended interventions performed within the allotted time. Methods: Using video recordings we measured the time taken to warm, assess HR, attach an oximeter and give respiratory support; and determined which infants had the recommended interventions completed by 30 and 60 seconds. Results: We reviewed recordings of 23 infants [mean(SD) gestational age & birth weight 29(3) weeks & 1312(594)g]. All interventions took longer than recommended (Table1). Four infants were not on the trolley within 30 seconds. By 60 seconds, 10/21 infants were in polyethylene-bags, 3/23 had their HR determined and 12/23 had an oximeter on. No infant had all tasks completed within 30 or 60 seconds of birth Conclusion: Our newborns were not managed within the time-frame recommended by ILCOR. The 30-second intervals recommended may be too short.

Brain oxygenation monitoring during neonatal resuscitation of very low birth weight infants

To explore if regional cerebral tissue oxygen saturation monitoring by near-infrared spectroscopy (NIRS) is feasible during neonatal resuscitation of very low birth weight (VLBW) infants after birth. Cerebral tissue oxygen saturation was measured by NIRS in 51 VLBW infants (mean gestational age: 27.8 weeks) during the first 10 min after delivery. A regional cerebral tissue oxygen saturation signal was available after a median (interquartile range) age of 52 (44 to 68) s. In three infants the signal was obtained after 10 min of age. After delivery cerebral tissue oxygen saturation rose continuously from 37 (31 to 49) % at 1 minute of age and reached a steady state in the range of 61 to 84% ∼7 min after birth. Percentiles of cerebral tissue oxygen saturation of this cohort of preterm infants are given. Cerebral tissue oxygen saturation monitoring is feasible during neonatal resuscitation of VLBW infants within the first minutes of life.

322 Oropharyngeal Suctioning in Newborn Infants Impairs Cerebral Oxygenation During Transition After Birth

Background: Oropharyngeal suctioning during transition after birth can induce bradycardia and/ or apnoea. These are reasons for restrictive approach. Objectives: Aim of the study was to investigate the influence of oropharyngeal suctioning on cerebral and peripheral oxygen saturation during transition after birth. Methods: In a prospective randomized study term newborn infants were measured during the first ten minutes after elective caesarean section. In the suctioning group oropharyngeal suctioning was done for five seconds in the first minute of life. In the control group no suctioning was done. Regional tissue oxygenation (rSO2) was measured of the brain, preductal peripheral tissue (right forearm) and postductal (left calf) peripheral tissue using near-infrared-spectroscopy (INVOS 5100, Somanetics). Heart rate and arterial oxygen saturation (SaO2) were measured preductal (right hand) and postductal (left foot) with pulseoxymetry. Results: 20 newborn infants were included in each group. All showed normal adaptation. Five minutes after birth in the suctioning group cerebral rSO2 (58±23% vs. 70±13%) and postductal SaO2 (70±19% vs. 82±11%) were significantly lower compared to the control group rSo2 of preductal (44±22% vs. 51±17%) and postductal peripheral tissue (36±19% vs. 39± 13%), as well as preductal SaO2 (80±13% vs 84±8%) tended to be lower in the suctioning group compared to the control group, but without reaching significance. Ten minutes after birth, there were no significant differences. Heart rate did not show significant differences between both groups. Conclusion: This study demonstrated that oropharyngeal suctioning impairs cerebral tissue oxygenation (rSO2) and postductal SaO2 during transition after birth.

An English Admiral and an American Aviator: Advanced Trauma Life Support and Two Historical Military Casualties

This article considers two historical military casualties in the context of present day Advanced Trauma Life Support (ATLS) teaching. The death of Admiral Lord Nelson, Royal Navy, at the Battle of Trafalgar in 1805 has been well documented while that of Lieutenant Luke, an American aviator, U.S. Army Air Service, in France in 1918 has been almost disregarded. Both suffered a gunshot wound to the chest with the responsible weapon similarly sited. Nelson's dying was witnessed and recorded in detail by his surgeon. Luke's death was unwitnessed and has been the subject of considerable speculation. A recent monograph removes much of this speculation but cannot describe his last few minutes of life. This article describes both events and considers the mechanism of injury. It presents speculative radiological reconstructions and an outline of emergency management according to ATLS for both and further clinical speculation on Luke's demise.

PP-99. Relationship between oxygen saturation and umbilical cord pH immediately after birth

Background: The aim of this study is to determine the relationship between oxygen saturation (SpO2) by pulse oximetry levels and umbilical cord arterial pH values in healthy newborns during the first 15 minutes of life. Methods: The study was performed with healthy term, appropriate-for-gestational-age newborn infants. The infants were divided in two groups: umbilical cord arterial blood pH value �7.19 (group 1)and>7.19(group2);SpO2levelsduringthefirst15minutesoflifewerecomparedbetweengroups.

Psychotropes, grossesse et adaptation néonatale du nouveau-né. Étude exploratoire (Unité Mère-Enfant, Bordeaux : 2001–2007)

Background Knowledge about the impact of psychotropic drugs intake during pregnancy on newborns and infant health is limited. The present preliminary study compares neonatal adaptation of babies whose mothers took psychotropic drugs during pregnancy to adaptation of babies whose mothers didn’t, for dyads hospitalized in the Mother-Baby Unit of Bordeaux (UMB- Société Marcé Francophone – Database). Method Intake of psychotropic drugs during pregnancy was retrospectively evaluated in a sample of 187 women hospitalized with their baby. Neonatal adaptation of the newborns was evaluated through the APGAR score at 5 minutes of life. Univariate analyses were used for this exploratory study. Results APGAR scores of exposed newborns (87) were significantly lower, and specifically for newborns exposed to mood stabilizers and/or antipsychotics. Exposed children were more frequently hospitalized for neonatal cares. The duration of pregnancy was shorter for mothers treated with mood stabilizers and/or antipsychotics and/or benzodiazepines. Conclusion This preliminary exploratory study suggests, in spite of its limitations, that newborns whose mothers were hospitalized in post-partum and who used psychotropic medications during pregnancy presented with more neonatal health difficulties than those of untreated mothers.

Indução do trabalho de parto em primíparas com gestação de baixo risco

A indução do parto objetiva promover o nascimento antecipado por parto vaginal quando sua continuidade promove maior risco materno-fetal que sua interrupção. Este estudo tem como objetivo identificar fatores relacionados à indicação de indução do trabalho de parto em primíparas e seu desfecho em uma maternidade-escola. Trata-se de um estudo descritivo retrospectivo, realizado na MATER – Maternidade do Complexo Aeroporto em Ribeirão Preto-SP. O estudo incluiu 119 primigestas com registro em prontuário de indicação e submetidas à indução do trabalho de parto que deram a luz nessa maternidade de janeiro a junho de 2007. A indicação mais frequente de indução do trabalho de parto foram a corioamniorrexe prematura (58,8%), oligoâmnio (21%) e pós-datismo (16,8%). O misoprostol foi o fármaco mais indicado, 37% isoladamente e 61,3% associado à ocitocina. A via de parto foi 63% vaginal. O sofrimento fetal agudo foi a principal indicação para cesárea (38,5%). A infecção materno-fetal foi a complicação identificada com índice de apenas 7,6%. Dos recém-nascidos, 68% obteve Apgar entre 8 e 10 no primeiro minuto de vida e 118 deles alcançaram esses índices no quinto minuto. Os resultados confirmam a tendência de que esse procedimento é uma importante estratégia para reduzir os índices de cesárea.Descritores: Trabalho de parto induzido; Trabalho de parto; Colo do útero; Ocitocina; Misoprostol.

Resuscitation of the term and preterm infant

Resuscitation is one of the most frequently performed procedures in the neonatal period. Since the most recent guidelines from the International Liaison Committee on Resuscitation (ILCOR) appeared in 2005, experimental and clinical research has introduced changes regarding the different components of the procedure, with the common denominator being the least aggressive to the baby. Babies should be kept warm, avoiding suctioning as a general rule, adjusting pressure, volume and oxygen to the minimum to achieve stabilisation without causing harm to the airways or oxidative stress, and applying all the available technology in the delivery room before transportation to the neonatal intensive care unit. The response to ventilation should primarily be assessed by the heart rate. Babies of gestational age >or=32 weeks should be ventilated initially with 21% oxygen and if <32 weeks with 21-30% oxygen. Intubation, chest compressions, use of drugs or volume therapy are rarely needed in term or near term babies in need of resuscitation. The first minutes of life are decisive, and what we do during these minutes will have unequivocal influence later on.

Fatores de risco para óbito em unidade de terapia intensiva neonatal, utilizando a técnica de análise de sobrevida

To identify risk factors associated with death of infants admitted to neonatal intensive care unit of Taubaté University Hospital. It is a longitudinal study with information obtained from medical records of newborns admitted to the neonatal intensive care unit of Taubaté University Hospital. Type of outcome, discharge or death, was dependent variable. The independent variables were maternal and gestational variables: maternal age, hypertension, diabetes, corticosteroid therapy and delivery; variables of the newborn: birth weight, gestation length, Apgar score in the first and fifth minutes of life, multiple birth, congenital malformations and sex; hospitalar variables: report of mechanical ventilation, positive pressure ventilation, reports of prolonged parenteral nutrition, sepsis, intubation, cardiac massage, phototherapy, hyaline membrane disease, oxygen and fraction of inspired oxygen. It was built a model in three hierarchical levels for the survival analysis by the Cox model; it was used the software Stata v9 and the final model contained variables with p <0.05. The risks were estimated by measure effect known as hazard ratio (HR) with confidence intervals of 95%. The newborns transferred during hospitalization to another service were excluded from the study. There were admitted during the study period 495 newborns, with 129 deaths (26.1%). In the final model, only the variables of steroid use (HR 1.64, 95% CI 1.02-2.70), malformation (HR 1.93, CI 95% 1,05-2,88), very low birth weight (HR 4.28, 95% CI 2,79-6,57) and Apgar scores lower than seven of no1 min (HR 1.87, 95% CI 1,19-2,93) and 5 min (HR 1.74, 95% CI 1,05-2,88) and the variables phototherapy (HR 0.34; 95% CI 0,22-0,53) and endotracheal intubation (HR 2.28, 95% CI 1 .41-3, 70). Factors related primarily to the newborn and the hospitalar internment (except therapy with corticosteroids) were identified as associated to mortality highlighting a possible protective factor of phototherapy and the risk of infants with very low birth weight.

Titrating oxygen needs in the very preterm newborn in the delivery room

Fetal to neonatal transition is characterized by an abrupt increase in the arterial partial pressure of oxygen and oxygen delivery to the tissue both causing a physiologic pro-oxidant status. Under normal circumstances arterial oxygen saturation measured by preductal pulse oximetry in term babies does not reach consistent values (85-90%) until four to five minutes a fter cord clamping, and 7 to 10 minutes in preterm infants. Of note, the time needed to stabilize saturation inversely correla tes with gestational age. Oxygen in excess causes oxidative stress and inflammation in preterm infants. In order to avoid the se negative consequences the inspiratory fraction of oxygen should be titrated until achievement of stable and safe oxygen saturation. Remarkably, the availability of an oxygen saturation nomogram could be of great help for the care givers. Supplementing the newborn with high inspiratory fractions of oxygen pursuing to rapidly achieve high oxygen saturation should be avoided. Instead, a proposal consisting in initiating resuscitation with lowe r oxygen inspiratory fractions and titrating according to t argeted saturations is proposed. Multicenter international prospective randomized clinical trials powered to evaluate oxygen administration in the first minutes of life and neurodevelopment at two years are be ing launched at present and hopefully will clarify many of our doubts.

Morphological Parameters of Blood Platelets in Small for Gestational Age Newborns.

Abstract 4466Platelets demonstrate many activities, e.g. hemostasis, integrity of blood vessels and phagocytosis. Hemostasis in newborns is characterized by a low efficiency in comparison to adults. The regulation of fetal growth is multifactorial and complex. Intrauterine fetal conditions, as well as maternal and environmental factors can lead to intrauterine growth restriction (IUGR). In small for gestational age (SGA) newborns, platelet dysfunction may be more expressed. On the other hand, there are some data indicating that blood platelet functions have some relation to their morphology. We have concentrated our attention on the determination of the count and morphological parameters of blood platelets in SGA newborns. Sixty-one SGA newborns: 31 girls and 30 boys were introduced to our study. They fulfilled all the criteria for SGA newborns, including clinical state and laboratory findings. The newborns were divided into two groups: < 5th centile – 35, and < 10th centile – 26 newborns. The birth weight for females ranged from 1850 to 2780 g and for male newborns from 2000 to 2900 g, at 37-41 weeks gestation. The Apgar score ranged from 8 to 10 points at 1-5 minutes of life. 22 full term newborns (FTN) were introduced to our study. Blood samples were collected from the umbilical artery within 5 minutes of cutting the umbilical cord. The first 0.5 ml of blood was discarded prior to collecting the blood sample for analysis. Within 10 minutes, the blood was transferred to the laboratory, and the platelet count and morphological parameters were determined using a hematologic analyzer, Advia TM 120 System. The platelet count in SGA newborns was lower than in FTN 238 × 103 /μL vs. 282 × 103 /μL, females demonstrated a higher number of platelets than males, SGA 243 × 103 /μL vss 231 × 103 /μL, FTN 311 × 103 /μL vss 258 × 103 /μL. In SGA, newborns < 5th centile 218 × 103 /μL, < 10th centile 263 × 103 /μL. MPV (mean platelet volume) was nearly the same in both groups SGA 8.1 fl, FTN 7.8 fl, gender did not exhibit any effect on MPV in the tested newborns: SGA female 7.9 fl, male 8.4 fl, FTN: female 7.9 fl, male 7.8 fl. The IUGR index did not affect MPV: < 5th centile 8.2 fl, < 10th centile 8.0 fl. PCT (platelet hematocrit) in SGA 0.19 %, in FTN 0.22%. Practically no difference was noted in SGA between female 0.19 %, male 0,18 %; whereas, in FTN female 0.24 %, male 0.21 %. SGA newborns < 5th centile 0.18 %, < 10th centile 0.20 %. PDW (platelet anisocytosis) index was the same in SGA 47 % and FTN 46 %. Higher values were observed in female 48 %, male 45 % SGA newborns, in FTN female 49 %, male 44 %. An evident decrease of PDW was found in SGA newborns < 5th centile 43 %, < 10th centile 52 %. The large platelets (LP) are significantly lower in SGA newborns (4.75 %), in comparison to FTN (6.23 %). Male newborns demonstrated a decrease in the percentage of LP, in SGA: male 4.2 %, female 5.3 %, in FTN: male 4.5 %, female 8.3 %. In SGA newborns < 5th centile 4.9 %, < 10th centile 4.3 %. Some authors suggest that platelet count is related to birth weight, and the degree of placental dysfunction corresponds to our findings in SGA newborns. One can suggest megakaryocytes are not able to produce a satisfactory platelet count. Small differences in the platelet count in relation to gender may result from restricted maturity of the thrombopoietic system. Therefore, it may predispose to a higher risk of bleeding tendency. A low number of LP may increase this risk. An increase of MPV in SGA newborns may indicate platelet consumption and activation. Lower PCT in SGA newborns results from a decreased platelet count. PDW may be used as a marker for bacteriaemia, schistocytosis, or platelet consumption. Evidently, a lower percentage of LP may be considered a symptom of thrombopoiesis immaturity. Our results in the SGA newborns may indicate incomplete development of thrombopoiesis. Disclosures:No relevant conflicts of interest to declare.