Hereditary Tyrosinemia Type 1 Mice under Continuous Nitisinone Treatment Display Remnants of an Uncorrected Liver Disease Phenotype.

Hereditary tyrosinemia type 1 (HT1) is a genetic disorder of the tyrosine degradation pathway (TIMD) with unmet therapeutic needs. HT1 patients are unable to fully break down the amino acid tyrosine due to a deficient fumarylacetoacetate hydrolase (FAH) enzyme and, therefore, accumulate toxic tyrosine intermediates. If left untreated, they experience hepatic failure with comorbidities involving the renal and neurological system and the development of hepatocellular carcinoma (HCC). Nitisinone (NTBC), a potent inhibitor of the 4-hydroxyphenylpyruvate dioxygenase (HPD) enzyme, rescues HT1 patients from severe illness and death. However, despite its demonstrated benefits, HT1 patients under continuous NTBC therapy are at risk to develop HCC and adverse reactions in the eye, blood and lymphatic system, the mechanism of which is poorly understood. Moreover, NTBC does not restore the enzymatic defects inflicted by the disease nor does it cure HT1. Here, the changes in molecular pathways associated to the development and progression of HT1-driven liver disease that remains uncorrected under NTBC therapy were investigated using whole transcriptome analyses on the livers of Fah- and Hgd-deficient mice under continuous NTBC therapy and after seven days of NTBC therapy discontinuation. Alkaptonuria (AKU) was used as a tyrosine-inherited metabolic disorder reference disease with non-hepatic manifestations. The differentially expressed genes were enriched in toxicological gene classes related to liver disease, liver damage, liver regeneration and liver cancer, in particular HCC. Most importantly, a set of 25 genes related to liver disease and HCC development was identified that was differentially regulated in HT1 vs. AKU mouse livers under NTBC therapy. Some of those were further modulated upon NTBC therapy discontinuation in HT1 but not in AKU livers. Altogether, our data indicate that NTBC therapy does not completely resolves HT1-driven liver disease and supports the sustained risk to develop HCC over time as different HCC markers, including Moxd1, Saa, Mt, Dbp and Cxcl1, were significantly increased under NTBC.

Neurocognitive outcome and mental health in children with tyrosinemia type 1 and phenylketonuria: A comparison between two genetic disorders affecting the same metabolic pathway.

Tyrosinemia type 1 (TT1) and phenylketonuria (PKU) are both inborn errors of phenylalanine-tyrosine metabolism. Neurocognitive and behavioral outcomes have always featured in PKU research but received less attention in TT1 research. This study aimed to investigate and compare neurocognitive, behavioral, and social outcomes of treated TT1 and PKU patients. We included 33 TT1 patients (mean age 11.24 years; 16 male), 31 PKU patients (mean age 10.84; 14 male), and 58 age- and gender-matched healthy controls (mean age 10.82 years; 29 male). IQ (Wechsler-subtests), executive functioning (the Behavioral Rating Inventory of Executive Functioning), mental health (the Achenbach-scales), and social functioning (the Social Skills Rating System) were assessed. Results of TT1 patients, PKU patients, and healthy controls were compared using Kruskal-Wallis tests with post-hoc Mann-Whitney U tests. TT1 patients showed a lower IQ and poorer executive functioning, mental health, and social functioning compared to healthy controls and PKU patients. PKU patients did not differ from healthy controls regarding these outcome measures. Relatively poor outcomes for TT1 patients were particularly evident for verbal IQ, BRIEF dimensions "working memory", "plan and organize" and "monitor", ASEBA dimensions "social problems" and "attention problems", and for the SSRS "assertiveness" scale (all p values <0.001). To conclude, TT1 patients showed cognitive impairments on all domains studied, and appeared to be significantly more affected than PKU patients. More attention should be paid to investigating and monitoring neurocognitive outcome in TT1 and research should focus on explaining the underlying pathophysiological mechanism.

Geographic differences in the distribution of parasitic infections in children of Bolivia.

BACKGROUND: A high percentage of the population in Latin America lives with intestinal parasitic infections, a neglected tropical disease frequently not treated. Intestinal parasitism is associated with other disorders, but information about the epidemiological situation in countries like Bolivia is scarce. Environmental conditions play a role in the prevalence of certain parasites. The main objective was to know the current situation of parasitic infections among children under 12 years old from different geographical areas of Cochabamba - Bolivia. METHODS: We analysed the laboratory reports of four second-line hospitals in different areas and the Tertiary Care Hospital. Results of stool examinations performed between 2011 and 2015 in children under 12 years of age were collected. RESULTS: We gathered the results of 23,221 examinations. The 89% of children were less than five years old. Pathogenic parasites were found in 31%. Entamoeba histolytica and Giardia lamblia were the two most prevalent parasites in all areas. Helminths were 19% of positive samples and Ascaris lumbricoides was the most prevalent. Parasitic infections are more frequent in tropical areas where helminths are highly concentrated. Pre-school age children (OR: 5.296; 95% CI: 4.81-5.83) and semi-tropical area (OR: 3.26; 95% CI: 2.90-3.66) were strongly associated to the presence of pathogenic parasites. CONCLUSIONS: Parasitic infections in children are still very prevalent in Bolivia. Protozoan infections are a major problem, while the prevalence of helminths seems to be decreasing. The most vulnerable population is still concentrated in semi-tropical and tropical areas, where the risk of parasitic infection is probably increased due to poor environmental conditions. Our results could allow reconsideration of more effective parasitic disease control policies, taking into account regional characteristics.

Oxidative Stress, Glutathione Metabolism, and Liver Regeneration Pathways Are Activated in Hereditary Tyrosinemia Type 1 Mice upon Short-Term Nitisinone Discontinuation.

Hereditary tyrosinemia type 1 (HT1) is an inherited condition in which the body is unable to break down the amino acid tyrosine due to mutations in the fumarylacetoacetate hydrolase (FAH) gene, coding for the final enzyme of the tyrosine degradation pathway. As a consequence, HT1 patients accumulate toxic tyrosine derivatives causing severe liver damage. Since its introduction, the drug nitisinone (NTBC) has offered a life-saving treatment that inhibits the upstream enzyme 4-hydroxyphenylpyruvate dioxygenase (HPD), thereby preventing production of downstream toxic metabolites. However, HT1 patients under NTBC therapy remain unable to degrade tyrosine. To control the disease and side-effects of the drug, HT1 patients need to take NTBC as an adjunct to a lifelong tyrosine and phenylalanine restricted diet. As a consequence of this strict therapeutic regime, drug compliance issues can arise with significant influence on patient health. In this study, we investigated the molecular impact of short-term NTBC therapy discontinuation on liver tissue of Fah-deficient mice. We found that after seven days of NTBC withdrawal, molecular pathways related to oxidative stress, glutathione metabolism, and liver regeneration were mostly affected. More specifically, NRF2-mediated oxidative stress response and several toxicological gene classes related to reactive oxygen species metabolism were significantly modulated. We observed that the expression of several key glutathione metabolism related genes including Slc7a11 and Ggt1 was highly increased after short-term NTBC therapy deprivation. This stress response was associated with the transcriptional activation of several markers of liver progenitor cells including Atf3, Cyr61, Ddr1, Epcam, Elovl7, and Glis3, indicating a concreted activation of liver regeneration early after NTBC withdrawal.

Is a semi-elemental diet better than a polymeric diet after congenital heart surgery?

A retrospective observational study has been set up in order to compare feeding tolerance and energy delivery in children fed with a semi-elemental diet or a polymeric diet after congenital heart surgery. The study took place in the intensive care unit of a tertiary children's hospital. One hundred children were included: 56 received a semi-elemental diet and 44 received a polymeric diet. Patients were aged between 2 days and 6 years. Data from patients were obtained from medical files between February 2014 and May 2016. The feeding protocol was changed in March 2015 when a semi-elemental diet was substituted for the polymeric diet. Primary outcome was the feeding tolerance. Feeding intolerance occurs if the patient has more than two episodes of emesis or more than four liquid stools per day. Feeding tolerance in the semi-elemental and polymeric diet groups was comparable: emesis occurred in 14.3% versus 6.8% of patients, respectively (p = 0.338); diarrhea occurred in 3.6% versus 4.5% (p = 1000); post-pyloric feeding was necessary in 14% versus 9% (p = 0.542). Energy delivery was also comparable in the two groups: on postoperative day 2, the semi-elemental diet group reached 50% of the caloric target versus 52% in the polymeric diet group (p = 0.283); on day 5, 76% versus 85% (p = 0.429); and on day 10, 105% versus 125% (p = 0.397). Energy delivery was insufficient on postoperative days 2 and 5, but nutritional goals were achieved by day 10. No patient developed necrotizing enterocolitis in our population.Conclusion: the present study suggests that the feeding tolerance to a semi-elemental or a polymeric diet is similar after CHS.What is Known:•Nutrition can modify prognosis in PICU•Different types of diet have been tested in children with intestinal disorders or with congenital heart disease. None of these diets have shown to be superior in terms of feeding tolerance.What is New:•Semi elemental and polymeric diets seem to have the same feeding tolerance in PICU after cardiac surgery for congenital heart disease.

Emotional and behavioral problems, quality of life and metabolic control in NTBC-treated Tyrosinemia type 1 patients.

BACKGROUND: Treatment with 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC) and dietary phenylalanine and tyrosine restriction improves physical health and life expectancy in Tyrosinemia type 1 (TT1). However, neurocognitive outcome is suboptimal. This study aimed to investigate behavior problems and health-related quality of life (HR-QoL) in NTBC-dietary-treated TT1 and to relate this to phenylalanine and tyrosine concentrations. RESULTS: Thirty-one TT1 patients (19 males; mean age 13.9 ± 5.3 years) were included in this study. Emotional and behavioral problems, as measured by the Achenbach System of Empirically Based Assessment, were present in almost all domains. Attention and thought problems were particularly evident. HR-QoL was assessed by the TNO AZL Children's and Adults QoL questionnaires. Poorer HR-QoL as compared to reference populations was observed for the domains: independent daily functioning, cognitive functioning and school performance, social contacts, motor functioning, and vitality. Both internalizing and externalizing behavior problems were associated with low phenylalanine (and associated lower tyrosine) concentrations during the first year of life. In contrast, high tyrosine (and associated higher phenylalanine) concentrations during life and specifically the last year before testing were associated with more internalizing behavior and/or HR-QoL problems. CONCLUSIONS: TT1 patients showed several behavior problems and a lower HR-QoL. Associations with metabolic control differed for different age periods. This suggests the need for continuous fine-tuning and monitoring of dietary treatment to keep phenylalanine and tyrosine concentrations within target ranges in NTBC-treated TT1 patients.

Evaluation of nutritional care of hospitalized children in a tertiary pediatric hospital.

BACKGROUND AND AIMS: Hospitalized children are at risk of malnutrition. The aim of the present study was to evaluate a clinical practice in a tertiary hospital. The nutritional team developed a specific software for screening of malnutrition and risk of malnutrition (Evalnut) that provides also recommendations for the nutritional management of the patient. The data recorded into this program and the tool itself were analyzed and optimizations are highlighted. METHODS: A retrospective study analyzed the data collected in 2015 during 4931 consecutive hospitalizations (3984 children) at the University Children's Hospital Queen Fabiola. Pivot tables analysis (Excel) of the database of the screening tool was compared with the clinical practice of the dietitians. First data processing excluded records with abnormal or missing values. Impact of nutritional care analysis needs at least 2 evaluations and a positive patient's height trend. In case of height equality, only length of hospital stays less than 2 weeks were kept. RESULTS: This study highlighted inaccurate database records related to imperfections of the computer program, missing or erroneous measures and incomplete encoding. First analysis on 3219 valid hospitalizations showed statistical correlations. Prevalence of malnutrition on admission was 33%, split into 14,5% acute malnutrition, 15% chronic malnutrition and 3,5% mixed malnutrition. Overall, 30,3% of the children were categorized at risk of developing malnutrition during their stay. Positive impact of nutritional management on the resulting nutritional status was demonstrated on the second data selection (352 hospitalizations): WFH median (interquartile range) increased from 96,1% (87,1-106,4) on admission to 96,9% (89,1-106,1) (p < 0,01) on discharge. An optimization of the existing software was finally proposed. CONCLUSION: In our hospital, the dietitians are the most aware on the importance of nutritional assessment and management during hospitalization. Encouraging results are obtained. Inclusion of a nutritional program in the medical file is useful to raise interest amongst caregivers and is particularly valuable for the nutritional follow up of the patients by the nutrition team.

Misuse of antenatal care and its association with adverse outcomes of pregnancy in a Southern rural area of Vietnam.

Researchers in Vietnam reported a high percentage of pregnant women attending ANC at least once, but an insufficient utilization of ANC services remains. The evidence demonstrating how the utilization of these services affect pregnancy outcome is not documented in Vietnam. We investigated the association between the misuse of ANC services and pregnancy outcome, and assessed other determinants associated with ANC services utilization. We conducted a prospective community-based study in Trang Bom district, Dong Nai, during 12 consecutive months. Data were collected using a structured questionnaire and medical records. Women were followed up to delivery. Misuse of ANC services, related factors and its association with adverse events were assessed using logistic regression. Out of 3301 pregnant women, 91% initiated an ANC visit within first trimester, 95% attended at least three ANC visits, but a low percentage of pregnant women underwent blood and urine tests at least once (20% and 39%, respectively). Factors significantly associated with a higher risk of adverse outcomes were lack of blood test and urine test, parity ≥ 3, ANC visits < 3, history of an adverse outcome, and having a clinical condition. Blood and urine tests were less frequently used by young women, women from ethnic minorities, women using only private facilities for ANC attendance, and women with a low number of ANC visits. Despite a high percentage of early entry into ANC and of at least three ANC visits, misuse of ANC services still exists and contributes to adverse outcomes. There is a need to increase the awareness of women on the benefits of ANC services by educating young women as well as women with several children. Health workers should be encouraged to propose suitable ANC services to pregnant women.

Interest of Anorectal Manometry During Long-term Follow-up of Patients Operated on for Hirschsprung's Disease.

BACKGROUND/AIMS: Although many advances in the management of Hirschsprung's disease have recently been achieved, postoperative outcomes of these patients remain difficult in a non-negligible number of cases. Therefore, this study aims at investigating characteristics of anorectal manometry and its relationship with postoperative outcomes during long-term follow-up in Hirschsprung patients. METHODS: Patients over 4 years of age operated on for Hirschsprung's disease were interviewed to complete detailed questionnaires on bowel function. The patients who consented to undergo an anorectal manometry during follow-up were enrolled in this study. We investigated their clinical characteristics, manometric findings, and their postoperative bowel function. RESULTS: Nineteen patients out of 53 patients (35.8%) were enrolled, 68.4% who were male. Mean age of patients at manometry was 11.3 ± 6.3 years. Twelve out of 19 patients (63.2%) were incontinent. The mean anal resting pressures of incontinent patients were significantly lower than continent patients (47 ± 12 mmHg versus 63 ± 11 mmHg, P < 0.05, t test). Due to neurological impairment, only 11 patients (57.9%) were able to perform a complete manometry. A dyssynergic defecation was found in 4 patients during strain tests. Maximum tolerated volume of the incontinent patients was significantly lower than that of the continent patients (97 ± 67 mL versus 181 ± 74 mL, P < 0.05, t test). CONCLUSION: Anorectal manometry is an objective method providing useful information that could guide a more adapted management in patients with defecation disorders after Hirschsprung's disease operation.

Long-Term Outcomes and Quality of Life in Patients after Soave Pull-Through Operation for Hirschsprung's Disease: An Observational Retrospective Study.

INTRODUCTION: Patients after pull-through operation for Hirschsprung's disease (HD) are at high risk of defecation disorders. This study aimed at investigating their long-term outcomes and quality of life (QoL) in comparison with controls. PATIENTS AND METHODS: Patients older than 5 years operated on for HD were interviewed to complete detailed questionnaires on bowel function. Patients without neurologic impairment were enrolled in a QoL survey to compare with controls matched for sex and age and selected randomly from the general population using sampling set in a ratio of four controls to one case of HD. RESULTS: In total, 53 operated patients were enrolled. Mean age of the patients was 16 ± 8 years, with 68% boys. Rectosigmoid aganglionosis was the most seen form of HD in 38 (72%) cases. Open Soave was performed in 40 (75.5%) cases, and minimally invasive surgery Soave (MIS Soave) in 13 (24.5%) cases. At investigation, prevalence of fecal incontinence and constipation were 22.6 and 13.2%, respectively. Regarding QoL survey, 45 patients and 180 controls were enrolled, excluding 8 patients with neurologic impairment. Thirty-seven (82.2%) patients were classified as having a good QoL (score ≥ 9 points); whereas six had a fair QoL (5-8 points) and two had a poor QoL (< 5 points). QoL score in the cases and the controls were 10.2 ± 2.5 and 11.9 ± 0.4 points, respectively. Long aganglionosis form of HD was significantly associated with a low QoL (score < 8 points), adjusted odds ratio = 9, 95% confidence interval [1.3; 64.1] (p < 0.05). In subscales analyses, the prevalence of each dimension including fecal continence, school absenteeism, unhappiness or anxiety, food restriction, and peer rejection was significantly higher in operated patients than in controls (p <0.001). CONCLUSION: Although the QoL of patients operated on for HD in general was with good outcomes, fecal incontinence and constipation still are problematic issues and challenges in a high percentage of patients. Therefore, a long-term and multidisciplinary follow-up is essentially required for these patients.

Rectal suction biopsy with calretinin immunohistochemistry in patients suspected with residual aganglionosis after operation for Hirschsprung disease.

INTRODUCTION: This study investigates the use of rectal suction biopsy (RSB) with calretinin immunohistochemical staining (CIS) in patients suspected of having abnormally innervated bowel after pull through operation for Hirschsprung disease (HD). METHOD: This study was conducted in Children's Hospital 2, Ho Chi Minh City from January 2015 through June 2016. Patients suspected with abnormally innervated bowel after pull through operation for HD were submitted for a RSB with CIS. Following histological results, the patients underwent an appropriate treatment (redo pull through operation or non-operative medical management) and followed up at least 6 months to evaluate their outcomes. RESULTS: Ten patients were enrolled in our study. The median age was 5.6 (range 1.4-20) years. The diagnosis of normally innervated bowel was made in five patients by showing positive reactivity of CIS on RSB, whereas five others were diagnosed with abnormally innervated bowel. Final diagnosis of the five latter patients was confirmed by analyses of the resected bowel after a redo pull through operation (including 4 cases with residual aganglionosis and one case with transition zone bowel). CONCLUSIONS: RSB with CIS is a reliable and simple method for diagnosis of abnormally innervated bowel after pull through operation for HD. LEVEL OF EVIDENCE: III TYPE OF STUDY: Study of diagnostic test (evaluate the effectiveness of a diagnostic test or outcome assessment).

Diagnostic value of rectal suction biopsies using calretinin immunohistochemical staining in Hirschsprung's disease.

BACKGROUND: The study investigates the diagnostic value of calretinin immunohistochemical staining (CIS) on rectal suction biopsies (RSB) in Hirschsprung's disease (HD). METHODS: A prospective study was conducted at Children's Hospital 2 in Ho Chi Minh City, Vietnam, from January through December 2015. Patients suspected of HD during this period underwent RSB and were followed in order to assess the accuracy of the diagnostic test with CIS compared with conventional histology (H&E). RESULTS: A total of 188 children with RSB were investigated. Median age was 7.1 (range 0.2-159) months with 65.4% boys. HD was confirmed in 80 (42.6%) children. There were 1 false positive and no false-negative cases. The sensitivity and specificity were 100% (80/80) and 99.1% (107/108) for CIS and 100% and 85.2% for H&E, respectively. Cohen's kappa coefficient was 0.9891 with a diagnostic accuracy of 99.5% for CIS, compared with 0.8303 and 91.5% for H&E, respectively. There were no serious complications related to the RSB. CONCLUSION: RSB with CIS is a useful diagnostic method for HD, with easy interpretation and no need for cryostat. CIS has a high diagnostic accuracy and should be considered as the primary method for the diagnosis of HD by RSB. LEVEL OF EVIDENCE: Diagnostic Studies - Level I.

Neurocognitive outcome in tyrosinemia type 1 patients compared to healthy controls.

BACKGROUND: Hereditary Tyrosinemia type 1 (HT1) is a rare metabolic disorder caused by a defect in the enzyme Fumarylacetoacetate Hydrolase. Due to this defect, toxic products accumulate which, in turn, cause liver and kidney dysfunction. Treatment with 2-(2-nitro-4-trifluoromethylbenoyl)-1,3-cyclohexanedione (NTBC) and diet has diminished these problems, but recent data indicate that HT1 patients have neurocognitive problems. However, the neuropsychological profile of these patients is unknown. Therefore, this study aimed to investigate this neuropsychological profile by comparing HT1 patients with healthy controls. METHODS: Neurocognitive testing was performed in a heterogeneous group of 19 NTBC and dietary treated HT1 patients (five female, fourteen male; mean age 12.9 ± 4.8 years; range 7.9-23.6 years) and 19 age and gender matched controls (five female, fourteen male; mean age 13.2 ± 4.6 years; range 8.1-24.8 years). IQ scores were estimated and all participants performed the Amsterdam Neuropsychological Tasks, measuring executive functions (inhibition, cognitive flexibility and working memory) and social cognition (face recognition and identification of facial emotions). RESULTS: HT1 patients showed poorer estimated IQ, executive functioning (working memory and cognitive flexibility), and social cognition compared to healthy controls. Lower IQ scores in HT1 patients were mostly unrelated to scores on executive function- and social cognition tasks and therefore did not account for group differences in these domains. Further analyses within the HT1 patient group (comparing different groups of patients based on the age at diagnosis and the clinical symptoms at diagnosis) did not reveal any significant results. The duration of NTBC treatment was negatively correlated with IQ. CONCLUSIONS: Despite the heterogeneity of the patient group, these data clearly show that IQ, executive functioning and social cognition are affected in HT1 patients, and that IQ screening is not sufficient for cognitive monitoring of these patients. Further research should focus on the underlying pathophysiological mechanisms of these impairments to consequently try to improve treatment strategies.

Effect of calcium and vitamin D on growth, rickets and Kashin-Beck disease in 0- to 5-year-old children in a rural area of central Tibet.

OBJECTIVE: To evaluate the effect of calcium (15 mmol/day) and vitamin D (625 µg/month), as single supplement or in combination, vs. no supplement on growth, clinical signs of rickets and Kashin-Beck disease (KBD) and dental health. METHODS: Prospective controlled trial involving children aged 0-5 years living in four groups of villages in a KBD-endemic rural area of central Tibet who received either calcium and/or vitamin D or no supplement. The cohort was followed over 3 years. Primary outcome was the impact of the different supplementation regimes on KBD, rickets and growth; secondary outcomes were impact on urinary levels of calcium and phosphorus, biomarkers of bone and cartilage turnover, and dental health. RESULTS: No difference was observed between the four groups with regard to anthropometric data, rickets, KBD, urinary levels of CrossLaps(®) and CartiLaps(®) . Weight for height or age, mid-upper arm circumference and skinfold thickness decreased in the four groups. Height for age increased and the prevalence of KBD fell in the four groups. Dental health was better in the group receiving calcium and vitamin D. Urinary calcium levels increased after 3 years of follow-up in all groups; the group receiving vitamin D had a higher increase (P-value: 0.044). The same global increase was observed for urinary phosphorus levels; the group receiving calcium had a higher increase (P-value: 0.01). CONCLUSIONS: Calcium and vitamin D failed to improve growth and bone metabolism of children living in a KBD-endemic rural area. Calcium and vitamin D supplementation improved dental health.

Current status and actual need for pediatric liver transplantation in Southern Vietnam.

Liver transplantation (LT) has considerably improved the outcome of patients with end-stage liver disease, especially in children. The first pediatric LT in Vietnam was performed in 2004. To assess the current need for pediatric LT in Southern Vietnam, a total of 280 patients with chronic liver disease followed at Children's Hospital 2 (Ho Chi Minh City), the only pediatric LT center in this region, were evaluated from January 2009 to June 2014. Sixty-seven patients satisfied criteria for LT but only one transplant surgery occurred since 2009. Parental consent for LT was obtained only in 28.4% of patients. The main reasons for the small number of LTs were financial costs, far distance from home, lifelong follow-up and treatment, and shortage of organ donors. We conclude that the current need for pediatric LT in Southern Vietnam is high. Efforts should be made to develop the liver transplant program in this developing country.

Key features and clinical variability of COG6-CDG.

The conserved oligomeric Golgi (COG) complex consists of eight subunits and plays a crucial role in Golgi trafficking and positioning of glycosylation enzymes. Mutations in all COG subunits, except subunit 3, have been detected in patients with congenital disorders of glycosylation (CDG) of variable severity. So far, 3 families with a total of 10 individuals with biallelic COG6 mutations have been described, showing a broad clinical spectrum. Here we present 7 additional patients with 4 novel COG6 mutations. In spite of clinical variability, we delineate the core features of COG6-CDG i.e. liver involvement (9/10), microcephaly (8/10), developmental disability (8/10), recurrent infections (7/10), early lethality (6/10), and hypohidrosis predisposing for hyperthermia (6/10) and hyperkeratosis (4/10) as ectodermal signs. Regarding all COG6-related disorders a genotype-phenotype correlation can be discerned ranging from deep intronic mutations found in Shaheen syndrome as the mildest form to loss-of-function mutations leading to early lethal CDG phenotypes. A comparison with other COG deficiencies suggests ectodermal changes to be a hallmark of COG6-related disorders. Our findings aid clinical differentiation of this complex group of disorders and imply subtle functional differences between the COG complex subunits.

Effects of thirty elements on bone metabolism.

The human skeleton, made of 206 bones, plays vital roles including supporting the body, protecting organs, enabling movement, and storing minerals. Bones are made of organic structures, intimately connected with an inorganic matrix produced by bone cells. Many elements are ubiquitous in our environment, and many impact bone metabolism. Most elements have antagonistic actions depending on concentration. Indeed, some elements are essential, others are deleterious, and many can be both. Several pathways mediate effects of element deficiencies or excesses on bone metabolism. This paper aims to identify all elements that impact bone health and explore the mechanisms by which they act. To date, this is the first time that the effects of thirty minerals on bone metabolism have been summarized.

More training and awareness are needed to improve the recognition of undernutrition in hospitalised children.

AIM: Reports suggest that 10% of hospitalised children in Europe are undernourished. We investigated whether nutritional screening tools (NST) were used in Belgian secondary-level hospitals, examined strategies for detecting undernutrition and identified barriers preventing the systematic management of undernutrition. METHODS: A nationwide questionnaire-based survey of paediatric departments in Belgian secondary-level hospitals was carried out from September 2013 to February 2014. Respondents were dived into French-speaking (Walloon + Brussels) and Dutch-speaking (Flemish) departments. RESULTS: We received replies from 71 of the 97 (73.2%) departments. Half of the departments - 39.5% Flemish speaking and 71.4% Walloon speaking - carried out nutritional screening. Undernutrition was identified by measuring weight and length or height (92.7% of cases), clinical appraisal (74.7%), mid-upper arm circumference and/or skin fold thickness (19.7%). There was no protocol for undernutrition in many Flemish (60.5%)- and Walloon (28.6%)-speaking departments. Reasons given for not screening were as follows: lack of training (46.9%), ignorance of NST (42.2%) and lack of time (29.7%). CONCLUSION: Half of the paediatric departments in Belgian secondary-level hospitals did not carry out nutritional screening, and differences in current practices and attitudes may be due to cultural and/or educational differences.

Nutritional status of children hospitalized for parapneumonic effusion.

BACKGROUND & AIMS: Among children hospitalized for pneumonia, those with parapneumonic effusion (PPE) are at particular risk for nutritional deterioration. This study aimed to 1) investigate the evolution of the nutritional status during hospitalization and at outpatient follow-up; 2) determine clinical risk factors for weight loss during hospitalization; 3) describe the nutritional interventions for these children. METHODS: Retrospective chart review (January '07 - September '12) of 56 children with pneumonia, complicated by PPE in two Belgian hospitals for data on body weight and height at admission (t0) and discharge (t1), and two weeks (t2) and one month (t3) after discharge. Length of hospitalization (LoS), length of stay in paediatric intensive care (LoSPICU) and maximal in-hospital weight loss (tmax) were calculated and nutritional interventions were recorded. RESULTS: The median (range) age was 3.5 (1.0-14.8) years. Weight or height was lacking in five (8.9%) children at t0 and in 28 (50%) at t1; 21.4% was weighed only once during hospitalization. At tmax, respectively 17/44 and 5/44 children lost ≥ 5% and ≥ 10% of their weight. Median (range) LoS and LoSPICU were 18.0 (10-41) and 4.0 (0-23) days. One-fourth received a nutritional intervention. Weight for height at admission (WFH(t0)) significantly predicted maximal weight loss (ß (95% CI) = -0.34 (-2.0--0.1); p = 0.03). At t2 and t3, 13/32 and 5/22 of the children with available follow-up data did not reach WFH(t0), whilst in 4/35 and 5/26 body weight remained ≥ 5% under the weight(t0). CONCLUSIONS: One-third of children with pneumonia complicated by PPE and monitored for weight and height, lost ≥ 5% of their body weight during hospitalization. One-fourth did not reach initial WFH one month after discharge. Those with a higher WFH at admission were at higher risk of weight loss. More attention for monitoring of weight loss and the nutritional policy during and after hospitalization is warranted.

Early treatment of a child with NAGS deficiency using N-carbamyl glutamate results in a normal neurological outcome.

Acute hyperammonemia has a variety of etiologies and clinical manifestations. If not treated early in neonates, it leads to irreversible brain damage or death. We present a 7-day-old female patient who was brought to the emergency department with drownsiness and vomiting. Metabolic work-up revealed a blood ammonia level of 290 µmol/L (normal <100 µmol/L in neonates) with a compensated respiratory alkalosis, normal glycaemia and lactate and absence of urinary ketones. Oral feeding was stopped, an infusion of 20 % glucose was started, and sodium benzoate and arginine hydrochloride were given. After a drop of ammonemia within 12 h of treatment, it started rising again. N-carbamylglutamate (NCG) was added resulting in a rapid normalisation of ammonemia. Feedings were progressively reintroduced, the ammonia levels remained low. The results of the metabolic work-up were compatible with carbamyl phosphate synthase 1 (CPS1) or N-acetyl glutamate synthase (NAGS) deficiency. Genetic analysis confirmed the latter diagnosis with a homozygous mutation c. 1450T > C (p.W484R) in exon 6 of the NAGS gene in the patient and a carrier state in both parents. At the age of 9 months, the child is growing well with normal neurological development, under treatment with NCG 100 mg/kg/day and a normal diet. Conclusion: This case highlights the importance of keeping a high index of suspicion and early testing for ammonia levels in neonates/children with unexplained encephalopathy. In neonates with congenital hyperammonemia, NCG should always be started together with the standard management of hyperammonemia until all laboratory investigations are complete or indicate another disease.