[Abnormal antioxidant system in inborn errors of intermediary metabolism]. / Alteraciones del sistema antioxidante en errores cong nitos del metabolismo intermediario.

INTRODUCTION: Oxidative stress may be implied in the pathogenic mechanisms of inborn errors of intermediary metabolism (IEIM). OBJECTIVE: The evaluation of the antioxidant status in IEIM by the measurement of erythrocyte antioxidant enzyme activities, superoxide dismutase (SOD), glutathione peroxidase (GPx), glutathione reductase and catalase. PATIENTS AND METHODS: 34 patients with IEIM: 1) eleven with organic acidurias on protein restricted diet; 2) nine without special diet; 3) five patients with aminoacidopathies on protein restriction; 4) three patients with galactosemia and six with aminoacidopathies on protein free diet. Erythrocyte antioxidant enzymes were measured by spectrometric procedures adapted to the Cobas Fara II analyser. RESULTS: SOD activity was significantly higher in groups 2 and 4 (p= 0.009, p= 0.001, respectively), and significantly lower in group 3 (p= 0.001) compared with age matched controls. SOD activity was significantly higher in the patients with IEIM on protein free diet (groups 2 and 4) compared with those on protein restricted diet (groups 1 and 3; p= 0.002) or with controls (p= 0.003). GPx activity was found significantly lower in group 1 patients (p= 0.004), and higher in group 2 (p= 0.029) compared with controls. CONCLUSIONS: 35% of the patients with IEIM had SOD activity above the control range, most of them with organic acidurias or homocystinuria, suggesting an induction of enzyme protein synthesis owing to an excess of free radical generation. The lower activities observed in patients on natural protein restriction may likely be due to a deficient bioavailability of antioxidant cofactors.

The economic burden of stroke in Italy. The EcLIPSE Study: Economic Longitudinal Incidence-based Project for Stroke Evaluation.

Stroke is the second most common cause of death in the world. The aim of this study is to estimate stroke's direct costs and productivity losses in Italy from a societal perspective and to explain cost variability. A prospective observational multicentre cost of illness study was designed. Four hundred and forty-nine consecutive patients admitted because of acute first-ever stroke in 11 Italian hospitals were enrolled. Costs and outcomes were assessed at patients' enrollment, and at 3, 6 and 12 months after discharge. Overall, social costs in the first six months following the attack were euros 11,600 per patient; 53% of this was health care costs, 39% non-health care costs and the remaining 8% productivity losses. Age, level of disability and type of hospital ward were the most significant predictors of six-month social costs. The acute phase counted for more than 50% of total health care costs, leaving the remaining 50% to the post-acute phase, indicating that follow-up should be on the agenda of policy makers also.

[Ornithine transcarbamylase deficiency. Biochemical studies in the diagnosis of 4 cases and the identification of carriers]. / Deficiencia de ornitina carbamil transferasa. Estudios bioquímicos realizados para el diagnóstico de cuatro casos y la identificación de portadores.

The biochemical studies for the diagnosis of four cases of OCT deficiency are described: two male sibs, with total enzymatic deficiency and neonatal death, and two symptomatic heterozygous females. The enzymatic activity was determined in hepatic necropsy or duodenal biopsy from these patients and carriers were identified among their relatives. The usefulness of the enzymatic analysis compared with the protein loading test followed by the determination of ammonia and orotic acid for the female carrier detection is discussed, and the interest of their identification to prevent the risk of hyperammonemic crisis with possible neurologic sequels is stressed.

[Proposed protocol for the study of cerebrovascular disease in childhood]. / Propuesta de protocolo de estudio de las enfermedades cerebrovasculares de la infancia.

AIM: The etiology of cerebrovascular disease in the paediatric population, remains unknown in up to 40% of the cases ("idiopathic"), but recent advances could improve this percentage. We devised a comprehensive study protocol for such investigation aimed at the identification of potentially modifiable risk factors for paediatric stroke. PATIENTS AND METHODS: From the 141 patients initially registered in our data base for stroke population (from January 1984 until December 1995), we invited all the patients with idiopathic cerebrovascular disease to complete the study protocol. New cases appeared from January 1996 until July 1999 were also included. RESULTS: A total of 68 cases were identified. We found an etiology in 38% and in 76% of the cases we found at least one risk factor for stroke. Mild hyperhomocysteinemia was the most frequent risk factor identified (36% of patients versus 5% of controls), one of them an infant with fatal haemorrhagic infarct with classic homocystinuria. 31% of the patients had thrombotic risk factors (protein S, protein C, antithrombine III deficiency, factor V Leiden, etc). 17.6% had unspecific febrile illness at the time of the cerebral infarction and 11.6% had minor head injuries before the stroke. CONCLUSIONS: The use of the protocol improves the identification of potentially modifiable risk factors for stroke in childhood and may serve as a practical guideline for clinicians. The stroke protocol is as important as management strategies for acute stroke or for recurrence prevention, currently under consideration in the adult population.

[Evolution of a case of tyrosinemia type I treated with NTBC]. / Evolución de un caso de tirosinemia crónica tipo I tratado con NTBC.

Tyrosinemia type I is an autosomal recessive inherited disorder caused by deficient fumarylacetoacetase activity. Treatment with 2-(2-nitro-4-trifluoro-methylbenzoyl)-1,3-cyclohexanedione (NTBC), an inhibitor of 4-hydroxyphenylpyruvate dioxygenase, has successfully been applied for the last few years. Our aim was to evaluate the clinical and biochemical response to treatment with NTBC of a 18-year-old patient with a chronic form of tyrosinemia type I, whose main clinical feature was vitamin D-resistant rickets leading to severe osteoporosis with multiple bone fractures and skeletal deformities. After treatment, toxic metabolites became undetectable and porphobilinogen synthase activity returned to normal. Renal function improved, blood hemoglobin returned to normal and alfa-fetoprotein decreased. The patient's general condition greatly improved. However, the alfa-fetoprotein concentration slowly increased during the second year of NTBC treatment and hepatocellular carcinoma developed. NTBC treatment should be considered even in advanced cases of tyrosinemia type I, although only as a palliative therapy.

[Argininosuccinic aciduria. Comparative studies and detection of carriers in 3 affected families]. / Aciduria argininsuccínica. Estudios comparativos y detección de portadores en tres familias afectas.

Three patients with argininosuccinic aciduria are described. One of them is a neonatal form, with typical acute course and severe hyperammonemia who died on the sixth day of life. Postmortem analysis showed a marked plasmatic accumulation of argininosuccinic acid. Later on, red blood cell ASA-lyase levels demonstrated the heterozygosity of her parents and sisters. The two other patients are late onset forms and were diagnosed after detection of ASA and its anhydrides in plasma and urine. Levels of these metabolites did not correlate with levels of residual ASA-lyase in erythrocytes. Treatment with a hypoproteic diet supplemented with arginine has improved their clinical state. Carriers have been detected in both families. Importance of rapid diagnosis and treatment of hyperammonemic patients in order to prevent neurologic damage is emphasised.

[The neonatal form of propionic acidemia]. / Forma neonatal de acidemia propiónica.

A neonatal form of propionic acidemia is reported. Diagnosis was made by gas chromatography, mass spectrometry and urine excretion of 3-hydroxy-propionate and methylcitrate. Fibroblast cultures demonstrated an extremely low incorporation of C14-propionate, 6.5% range of normal values. Activity of propionyl-CoA-carboxylase was reduced. Intensive measures, including exchange-transfusion and ventilatory support, allowed life maintenance through neonatal period. Management of infant at three-month-old is based upon special diet with restriction of nocive amino acids, L-carnitine administration and infectious prophylaxis.

[Embryonic pathology caused by maternal phenylketonuria. A cause of underdiagnosed mental retardation. A report of 8 cases]. / Embriopatía por fenilcetonuria materna. Una causa de retardo mental poco diagnosticada. Revisión de ocho observaciones.

OBJECTIVE: Maternal phenylketonuria (MPKU) is characterized by intrauterine growth retardation, microcephaly, congenital malformations (mainly cardiac defects), dysmorphic facial features and mental retardation. There are women of child-bearing age that do not know that they are affected by phenylketonuria (PKU) and their pregnancies could result in damage to the fetus expressed as different neurological and congenital abnormalities. PATIENTS AND METHODS: We report 8 patients from 4 families. The first family had two offspring with intrauterine growth retardation, microcephaly and psychomotor retardation. The second family consisted of a daughter with mental retardation (without further data), a second baby which died during the first day of life, and a third child which died at 7 months of age with cardiac defects, microcephaly and dysmorphic features. Another child had intrauterine growth retardation, microcephaly psychomotor retardation, dysmorphic features and cardiac defects (coarctation of the aorta and subaortic stenosis). The third family had a son with microcephaly and mental retardation. The fourth family had a boy that died at 3 weeks of age with microcephaly, dysmorphic facial features, congenital heart disease (mitral atresia and septal defects) and Meckel diverticulum and a girl 5 years of age with intrauterine growth retardation, microcephaly and mental retardation. In all cases the mothers were unaware that they were affected by PKU and had mild intellectual defects. Two of them had PKU phenotypes. CONCLUSIONS: The offspring of PKU mothers untreated during pregnancy are affected by characteristic embriopathies related to the level of phenylalanine during pregnancy. In Spain, massive routine newborn screening was introduced around 1980-1985 and at present there are women of child-bearing age and are unaware that they are affected by the disease and that their pregnancies may result in fetal damage, as we demonstrate in these 8 patients. When faced with women with mental handicap or with antecedents of offspring with mental retardation, cardiac defects, microcephaly or intrauterine growth retardation, the determination of maternal phenylalanine concentrations is recommended. These teratogenic pathologies tend to disappear, but for the moment it is necessary to prevent this teratogenicity. The diagnosis is easy, avoids complementary exams, may help family studies and allows the implementation of dietary restriction during the subsequent pregnancy that would prevent fetal damage.

[Sudden death of a patient with 3-hydroxy-3-methylglutaryl coenzyme A lyase deficiency]. / Muerte súbita en un paciente con deficiencia de 3-hidroxi-3-metilglutaril-coenzima A liasa.

A new case of neonatal 3-hydroxy-3-methylglutaric aciduria is described. 3-hydroxy-3-methylglutaryl CoA lyase activities in leukocytes demonstrated the patient's homozygosity and the heterozygous character of the parents and two other members of the family. Dietetic management with low fat high carbohydrate diet together with protein restriction and carnitine resulted in a good control of the metabolic acidosis, the hypoglycemia, and the physical and neurological development. Nevertheless, sudden death occurred at the age thirteen months without any previous apparent trouble and the necropsia showed neither signs of infection nor hepatic or cardiac derangement.

[Hyperhomocystinemia and 677C T methylenetetrahydrofolate reductase polymorphism as a cardiovascular risk factor in childhood]. / Hiperhomocistinemia y polimorfismo 677C T de la 5,10-metilenotetrahidrofolato reductasa en hijos de pacientes con enfermedad coronaria prematura.

BACKGROUND: Factors related to hyperhomocystinemia in the pediatric population of our geographical area with a parental history of premature coronary disease (PCD) are not well known. OBJECTIVES: To evaluate the possible association between plasma total homocysteine (tHcy), the B vitamins involved in its metabolism (folate, vitamin B12 and B6), and 677C T polymorphism of methylenetetrahydrofolate reductase (MTHFR) in a group of children with a parental history of PCD. METHODS: A cross-sectional analytical study of 80 children (aged 5-18 years old) with a parental history of PCD was performed. Values found in these children were compared with reference values for similar age groups. Plasma tHcy and vitamin B6 were evaluated by high-performance liquid chromatography with fluorometric detection. Folate and vitamin B12 concentrations were determined by radioimmunoassay. Detection of 677C T polymorphism of MTHFR was performed using polymerase chain reaction amplification and Hinfl digestion. Statistical analysis was performed using the SPSS program, version 10.0. Concentrations of tHcy and vitamins were compared using the Mann-Whitney U-test and Spearman's correlation coefficient. The association between phenotype, hyperhomocystinemia and low vitamin concentrations was analyzed using the chi-squared test. ResultsPlasma tHcy values in the children aged more than 10 years with a parental history of PCD were significantly higher (p < 0.001) than the reference values. Vitamin B12 levels were significantly lower (p 0.015), but neither folate nor vitamin B6 levels differed from the reference values. A negative correlation (p < 0.0001) was observed between tHcy and folate (r 0.47) and between tHcy and vitamin B12 levels (r 0.51). Eighty percent of the children with the TT genotype of MTHFR showed hyperhomocystinemia. Suboptimal vitamin B levels were also associated with the TT genotype of MTHFR. CONCLUSIONS: Hyperhomocystinemia detected in children with a parental history of PCD is associated with the TT genotype of MTHFR and with low folate levels. Because hyperhomocystinemia can be corrected by vitamin B supplementation, tHcy determination is recommended in the offspring of patients with PCD.

Lactante con alteración del nivel de conciencia / Infant with lethargy

Introducción. Los lactantes afectos de intolerancia hereditaria a la fructosa (IHF) pueden desarrollar coma hipoglucémico durante el primer año de vida, al introducir la fructosa en su dieta. Observación clínica. Lactante de sexo femenino y cinco meses de vida que consulta por afectación progresiva del Lactant amb alteració del nivell de consciència nivel de conciencia después de su primera papilla de fruta. Se constata hipoglucemia severa y la niña se recupera con lactancia artificial. La detección de las mutaciones más frecuentes del gen de la aldolasa B en el cromosoma 9q facilitaron el diagnóstico. Comentarios. La IHF está causada por un déficit en la aldolasa B, es de herencia autosómica recesiva y tiene una incidencia estimada de 1:30000 neonatos vivos. Los niños afectos desarrollan sintomatología abdominal severa y sintomatología secundaria a la hipoglucemia al introducir en su dieta alimentos que contengan fructosa o azúcares compuestos. Si, a pesar de los síntomas iniciales, la ingesta de fructosa persiste, la enfermedad puede progresar a fallo hepático y disfunción tubular renal proximal. A partir de la edad escolar, el enfermo desarrolla aversión para los alimentos dulces de forma espontánea; a menudo, permanecerá sin diagnosticar. El diagnóstico inicial depende de un gran índice de sospecha; más tarde, estudios bioquímicos y genéticos establecerán el diagnóstico definitivo. Las pruebas de provocación están desaconsejadas. El tratamiento consiste en una dieta exenta en fructosa (AU)