ABSTRACTS

LINKING COMPOSITION OF A HOUSE DUST MITE EXTRACT WITH THE IGE-SENSITIZATION PROFILE IN A PREVENTIVE SUBLINGUAL IMMUNOTHERAPY TRIAL IN PRESCHOOL CHILDREN

Bannert Christina¹, Hassler Michaela¹, Schmidthaler Klara¹, Debiasi Markus¹, Ronceray Leila¹, Mayer Elisabeth¹, Wissmann Eva¹, Dehlink Eleonora¹, Eiwegger Thomas¹, Lupinek Christian², Valenta Rudolf², Szepfalusi Zolt¹

¹Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Austria

²Department of Pathophysiology and Allergy Research, Medical University Vienna, Austria

Background: Allergen specific immunotherapy (AIT) is successfully used in treating IgE-mediated allergies. However, extracts used for AIT dot not always cover the individual sensitization profile. Thus, some sensitizations may not be covered or new sensitizations may evolve during AIT.

We analyzed the molecular IgE-, IgG-, and IgG4-pattern changes along preventive sublingual immunotherapy in 2-5 year old children and correlated it with the allergen distribution in the extract applied.

Methods: In a pilot study for testing the preventive effects of sublingual specific immunotherapy 24 house dust mite sensitized preschool children were randomized in a treatment or placebo group. Patients were treated for 2 years with either sublingual allergen specific immunotherapy extract (n=12) or placebo (n=12). Patients´ sera was collected at time of inclusion, after 12 and 24 months of treatment as well as 2 years post treatment. The allergen content of the extract was analyzed using mass spectrometry and ELISA. Reactivity of patients´ sera against the extract was assessed by western blotting. Array technology (MEDALL) was used to measure allergen specific IgE, IgG and IgG4.

Results: The immunotherapy extract contained 122.38 µg/ml protein. Apart from the major mite species (Dermatophagoides pteronyssinus and farinae) proteins of other mites and ticks were detected in the extract. A wide range of mite allergens was present in the extract. Amino acids of Der p 14 were detected most frequently by mass spectrometry, whereas Der p 7 was completely absent. Group 2 allergens (2.14 µg/ml) and Der p 1 (2.07 µg/ml) were present at equal concentrations, the allergen content of Der f 1 (1.03 µg/ml) and Der p 10 (0.37 µg/ml) was considerably less.

The major allergen components Der p 1, Der f 1, Der p 2 and Der f 2 induced allergen specific IgG and IgG4, but not IgE in the SLIT treated group. The minor allergens Der p 14 or Der p 7 did neither trigger relevant allergen specific IgE nor IgG/IgG4 production in microarray. However, most patients had IgG antibodies to group 7 allergens in the immunoblot. House dust mite components, which were not included in the microarray detection system, showed no immunoblot reactivity as well.

Conclusion: Major mite allergen components present in an immunotherapy extract induce readily allergen specific IgG and IgG4 antibodies, but no new IgE sensitizations. Minor allergens do not show relevant IgE-, IgG- or IgG4 immunoreactivity.

THE DUCTUS VENOSUS AND HEMODYNAMIC ASSOCIATIONS WITH OTHER FETAL SHUNTS IN PRETERM INFANTS

Sigrid Baumgartner¹, Lisa Pitterle², Angelika Berger¹, Georg Fischer³, Ulrike Salzer-Muhar²

¹Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna, Austria

²Department of Pediatrics and Adolescent Medicine, Division of Pediatric Cardiology, Medical University of Vienna, Austria

³Section for Medical Information Management and Imaging, Medical University of Vienna, Austria

Background and aim: Aim was to assess time of patent ductus venosus (PDV) closure and associated hemodynamics between PDV, patent ductus arteriosus (PDA) and foramen ovale (PFO).

Methods: Retrospective analysis of electronic report forms of functional echocardiographic studies with documented status of the PDV. Inclusion criteria: preterm infant, gestational age (GA) 23+0 to 36+6 weeks+days, examination in the first eight weeks of life, absence of cardiac malformation.

Results: 249 report forms of 162 preterm infants were recruited. The PDV was closed in infants with GA ≥28+0 (n=73) vs. GA ≤27+6 (n=89) as follows: days of life 1–3: 87% vs. 92%; 4–6: 58% vs. 78%; 7–9: 33% vs. 42%; 16–18: 0% vs. 22%. The associations between the presence of a PDV and a PDA (p=0.005) or PFO (p=0.040) were significant. A PDV was significantly higher associated with a PDA//PFO with bidirectional or right-to-left shunt than with left-to right shunt (p<0.001 respectively). Infants with pulmonary hypertension had higher PDV-rates (90%) than stable infants (41%). PDA flow patterns indicating left-to-right shunt and high pulmonary resistance were associated with higher PDV-rates than PDA flow patterns indicating a hemodynamically significant PDA.

Conclusions: Preterm infants with GA ≤27+6 exhibited a delayed PDV-closure compared to infants with GA ≥28+0. The association of high pulmonary resistance with a PDV could be seen as a coincidence within the pathophysiology of cardiovascular transition. It remains to be studied if the PDV, as a portosystemic shunt, has also a role in maintaining pulmonary hypertension.

CHANGES IN NUTRITIONAL STATE AND CARDIOVASCULAR PARAMETERS IN ALIMENTARY OBESE CHILDREN AFTER A MONTH-LONG STAY IN CHILDREN´S TREATMENT CENTRE

Ksenia Budinskaya¹, Aleš Dvořák¹, Zuzana Kubecová¹, Nikola Kosová¹, Hana Hrstková², Olga Nádeníčková³, Kateřina Bednaříková³, Zuzana Nováková¹

¹Department of Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic;

²Department of Pediatrics, Faculty Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic

³Children‘s Treatment Centre Křetín, Czech Republic

Background: As a result of an imbalance between energy intake and expenditure in the population, obesity is currently a problem in the developed countries. The increasing incidence is observed both in adults and children.

Aim of this study: to evaluate the changes in nutritional state and cardiovascular system parameters during a stay in Children´s Treatment Centre.

Methods: Children were observed for one month (n=49; age 8–17 years; 27 girls). All the measurements were made at the beginning of the stay (in) and its end (ex) and include nutritional state parameters (weight, height, body mass index-BMI, waist to hip ratio – WHR, overall fat ratio – % fat, basic metabolic expenditure – BME; Inbody system, USA) and cardiovascular system parameters (systolic and diastolic blood pressures-SBP, DBP, pulse interval – PI). Cardiovascular parameters were obtained from 5 minute continuous BP measurement using non-invasive Penaz method (Finometr, FMS, Netherlands). Then, spectral analysis was employed for estimation of baroreflex sensitivity (BRS) as a parameter of short-term BP regulation. The Wilcoxon paired test was used for statistical analysis.

Results: During the stay, nutritional state parameters decreased significantly (p≤0.01); in versus ex: weight 77.6±16.3 vs. 72.7±15.4 kg; BMI 29.2±4.0 vs. 27.2±3.6 kg/m²; % of fat 38.2±7.2 vs. 35.4±7.7%; WHR 0.94±0.1 vs. 0.92±0.1; BME 1415.1±243.7 vs. 1392.4 ±233.6 kcal. In cardiovascular parameters, statistically significant (p≤0.05) increase in PI (743.0±120.8 vs. 813.0 ± 126.6 ms) and BRS (8.5±3.6 vs. 10.5±4.7 ms/mmHg) were observed.

Conclusion: This study shows the positive effect of the stay of children with diagnosed alimentary obesity in Children´s Treatment Centre both on the cardiovascular system function (improved control by parasympathetic nervous system) and on nutritional parameters.

Acknowledgment: This study was established at Masaryk University as part of the project „Kardiovaskulární systém: od modelu přes terapii k prevenci“ number MUNI/A/1365/2015 with the support of the Specific University Research Grant, as provided by the Ministry of Education, Youth and Sports of the Czech Republic in the year 2016.

SUPLEMENTATION OF VITAMIN D IN CHILDREN WITH INFLAMMATORY BOWEL DISEASE

Copova I., Hradsky O., Sumnik Z., Soucek O., Matyskova J., Maratova K., Zarubova K., Dedic T., Bronsky J.

Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic

Background: The high prevalence of low 25-hydroxyvitamin D (25OHD) serum levels in pediatric patients with inflammatory bowel disease (IBD) has been confirmed in several studies. According to the recommendations of the Institute of Medicine (IOM) the adequate level of 25OHD is 50 nmol/L (20 ng/mL), while for patients with chronic disease, it is up to 80 nmol/L (32 ng/mL). So far there is no clear consensus about the substitution of vitamin D to achieve and maintain adequate levels of 25OHD in pediatric patients with IBD. The aim of the study was to determine the percentage of pediatric patients with IBD that reached adequate levels of serum 25OHD after the substitution of 2000 IU of vitamin D per day.

Methods: Totally 76 patients (57 patients with Crohn‘s disease (CD), 19 patients with ulcerative colitis (UC)) were included in the longitudinal study. At the time of screening the medication or food supplements containing calcium or vitamin D were excluded. After three months the level of 25OHD was measured and substitution of cholecalciferol was started at dose of 2000 IU per day in the form of four oral drops. Throughout the study, patients were checked at three-month intervals and followed up for one year.

Results: In the total number of measurements (n=109) before the vitamin D supplementation the serum level of 25OHD was lower than 80 nmol/L in 91 cases (83%) and in 51 cases (47%) levels were lower than 50 nmol/L. 25OHD. Levels prior to substitution were not significantly different among patients with CD and UC. Levels lower than 80 nmol/L were measured in 90%/68% (CD/UC) and lower than 50 nmol/L in 47%/45% (CD/UC) of all cases. After the initiation of substitution with vitamin D the serum level of 25OHD had increased over 80 nmol/L in 95 of 186 cases (51%), and over 50 nmol/L in 158 of 186 cases (85%). The favorable levels of 25OHD were reached after three months of substitution therapy and maintained throughout the study. The effect of other factors such as disease activity, erythrocyte sedimentation rate (ESR), serum albumin levels, has not been demonstrated to influence the levels of 25OHD. There was an independent association between vitamin D status and the substitution of vitamin D, and parathyroid hormone (PTH).

Conclusion: Vitamin D substitution at a dose of 2000 IU per day is sufficient to achieve 25OHD levels over 50 nmol/L in majority of patients, however 80 nmol/L only in half of the patients.

TTV LOAD IN KIDNEY TRANSPLANTED CHILDREN

Heilos A., Uhl P., Arbeiter K., Aufricht C., Müller--Sacherer T., Heindl-Rusai K.

N790 POeT Program for Organfailure, -replacement and Transplantation Medical University Vienna, Austria, Department of Paediatrics and Adolescent Medicine, Division of Paediatric Nephrology and Gastroenterology Medical University Vienna, Austria, Department of Paediatrics and Adolescent Medicine, Division of Paediatric Nephrology and Gastroenterology

Chronic deterioration of graft function is mainly caused by antibody-mediated rejection, medication side effects and infectious complications all linked to either under- or over-immunosuppression (IS). In the paediatric population, the individual status of IS is of high relevance since (I) children are at higher risk of over-IS than adults and (II) adolescents are more prone to under-IS because of non-adherence. Today, the IS is monitored by measurement of calcineurin inhibitor or mTOR inhibitor blood levels.

Assessment of Torque teno virus (TTV) viral load could be an alternative and easy method to assess the quality of IS in transplanted patients. TTV is a non-enveloped, single-stranded, circular DNA virus belonging to the family anelloviridae. It is present in the plasma of >90% of individuals and can even be detected in 90% of children by the age of 3.5 years. Since TTV has no known disease inducing capacity, detectable changes do not have direct therapeutic consequences and could, therefore serve as a diagnostic and prognostic marker in transplanted patients.

Data from adult studies prove that TTV load increases shortly after lung transplantation and is significantly influenced by the IS regime in liver transplanted adults and children.

Experimental procedure: The first aim of this study was to determine the TTV load in kidney transplanted children before and after transplantation in order to detect changes due to the IS. The second objective was to cross-sectionally monitor the TTV load for a period of one year and analyse standard deviation, coefficient of variation and their association with age, gender, post-transplant time and IS-regime.

In this study, 45 kidney transplanted children were involved.

The next step will be to analyse correlations between TTV load and IS medication trough levels and signs of under- or over-IS caused by non-adherence or as a consequence of infectious episodes in the individual patients, respectively.

COLONISATION OF ANTIBIOTIC RESISTANT E. COLI BACTERIA IN HEALTHY INFANTS‘ GUT DURING THE FIRST YEAR OF LIFE – PREVALENCE AND RISK FACTORS

Benjamin Hetzer¹, Dorothea Orth-Höller², Reinhard Würzner², Martina Prelog³, Thomas Müller¹, Peninnah Oberdorfer⁴

¹Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria

²Division of Hygiene and Medical Microbiology, Medical University of Innsbruck, Innsbruck, Austria

³University Children’s Hospital, University of Würzburg, Würzburg, Germany

⁴Department of Pediatrics, Chiang Mai University, Chiang Mai, Thailand

Background: Increasing resistance against antibiotics is a serious emerging problem worldwide. Especially in neonates infections with resistant E. coli bacteria are a life- threatening hazard. The aim of this study, conducted in the region of Northern Thailand, was to record the development and prevalence of antibiotic resistant E. coli as well as the evaluation of several risk factors of bacterial colonization in healthy infants’ gut during the period from birth until one year of life. Furthermore we investigated the role of parental colonization as well as adhesion and virulence factors concerning the colonization of infants’ gut.

Methods: Stool samples were collected during the first 48 hours after birth, after two weeks, two months, four to six months and after one year and screened for resistant E. coli bacteria against seventeen different antibiotics. Furthermore prevalence of antibiotic resistant E. coli was evaluated in parents. Persistent bacterial strains in infants were compared to the parental strains by PFGE (Pulsed field gel electrophoresis). In addition these strains were typed by MLST (Multilocus sequence typing) and investigated for the presence of genes linked with extra-intestinal and intestinal pathogenicity as well as adhesion factors by multiplex and single PCRs. Known risk factors of colonization with antibiotic resistant bacteria (e.g. feeding, antibiotic usage…) were evaluated by a questionnaire that had to be filled out each time of sample collection.

Results: 35.2% (50 out of 142) neonates’ meconium samples already contained resistant E. coli in meconium. The highest frequency of resistant E. coli was shown against tetracycline (32.2%) followed by ampicillin (28.7%), trimethoprim (21%) and cefazolin (8.4%). Increasing prevalence of antibiotic-resistant E. coli was found at every point of sample collection. During the study period all infants showed resistance to at least one of the antibiotics tested. Prevalence of resistance in infants after one year of life (tetracycline 81.3%, ampicillin 73.4%, trimethoprim 66.2% and cefazolin 34.5%) almost matched the prevalence of resistant E. coli in parents (tetracycline 86.4%, ampicillin 82.1%, trimethoprim 63.1% and cefazolin 32.3%). Only in 12 families (8.45%) identical E. coli strains could be found in parents and persistent in infants’ stool. A high diversity of persistent E. coli strains could be observed between the families. Two identical strains could only be found twice in observed families (ST10, ST1193). There was no significance of influence on persistence or transmission from parents to infants by analyzed genes linked to pathogenicity or adhesion factors nor by risk factors evaluated by the questionnaires.

Conclusion: In populations with high prevalence and diversity of antibiotic resistant bacteria, influence of single risk factors in colonizing infants’ gut seems to be low. This fact complicates the fight against the spread of resistance. In the course of progressive globalization, solutions cannot be only national. Global awareness concerning this problem and the sensitizing of primary providers of public health care worldwide is needed.

REPORT ON BIRTH ASPHYXIA – FIRST EXPERIENCES WITH A NOVEL ONLINE REGISTRY AT THE 1ST DEPARTMENT OF PAEDIATRICS, SEMMELWEIS UNIVERSITY

Kata Kovács¹, Márton Kolossváry¹, Enikő Szakmár¹, Ünőke Méder¹, Zsuzsanna Élö¹, Lilla Lamboy¹, Attila Szabó¹, Miklós Szabó¹, Ágnes Jermendy¹

¹1st Department of Paediatrics, Semmelweis University, Budapest, Hungary

²MTA-SE “Lendület” Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary

Background: The incidence of perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) is around 150–200 cases per year in Hungary. One third of the asphyxiated newborns are treated in the NICU of the 1st Department of Paediatrics. Due to the large patient load, we aimed to build a new online database system to facilitate scientific research and guide clinical decision-making.

Methods: The Asphyxia registry, called “Biobankok”, is an online database and structured reporting tool, developed with bioinformatics assistance. As a first test of the system, we conducted a retrospective cohort study of asphyxiated newborns with standard hypothermia treatment, who were born between 2013 and 2015.

Results: Currently, a total of 84 patients (gestational age 38.6±1.9 weeks, 56% males) are registered in the database. Our preliminary results show that the asphyxiated neonates were born with 3208±522 g, with average Apgar scores of 2.4/4.5/5.7 at the 1st/5th/10th minutes of life. The average age of the mothers was 32.6±5.9 years, 60.7% of the newborns were born with cesarean section, and in 21.4% of the cases a prolonged fetal expulsion occurred. After establishing HIE criteria (within the first 6 hours of life), hypothermia treatment was started during neonatal transportation, in 57.1% of cases with active cooling, in 35.7% with passive cooling, and only 7.1% of newborns started the cooling treatment in the NICU. The median time spent with intensive care was 11.8 days [IQR 9;19]. Asphyxia is often associated with multiorgan failure, it was present in 86% of the patients, and in 31% of patients further hospital treatment was required after intensive therapy.

Conclusion: Automatic collection of descriptive data is feasible using our in-house developed structured reporting-registry tool. Critical analysis of patient outcomes of recent years could help to optimize clinical care. In addition, our results may provide guidance to other perinatal centers on treating asphyxiated newborns.

CONGENITAL PULMONARY AIRWAY MALFORMA-TIONS: POSTNATALLY VANISHING LUNG LESIONS

List J. H., Urbanek R., Meinicke H., Hentschel R., Stenzel M., Müller C. B., Heinzmann A., Bode S. F.

University Medical Center Freiburg, Center for Pediatrics and Adolescent Medicine, Freiburg, Germany

Background: Congenital pulmonary airway malformations (CPAM) are intrapulmonary lesions containing various types of epithelial linings, they maintain communication with the normal tracheo-bronchial tree and preserve a normal blood supply. Mostly a unilateral and unilobar occurrence is discovered. Because of the wide-spread use of obstetric ultrasound and in selected cases fetal magnetic resonance imaging CPAM are increasingly detected antenatally. When CPAM is associated with symptoms, there is an accepted agreement that resection is appropriate. There is a controversy related to the risks of surgery and possible late functional impairment on the one hand and malignant transformation on the other.

Methods: Pre- and postnatal ultrasound and MRI, thoracic X-Ray.

Results: We report on 3 children with antenatally diagnosed CPAM lesions. In all cases, prenatal sonography revealed no further malformation. Postnatal adaption and respiration were sufficient. Thus, surgical intervention was not required. In the course of the first year of life, subtotal regression in two and a complete disappearance of the lesion in one child was observed.

Conclusion: The optimal management of asymptomatic CPAM is controversial. According to the prevailing opinion the treatment of CPAM depends on location and neonatal condition. In the case of respiratory compromise, resection must be taken into consideration and is supposed to be curative. Prognosis of antenatally detected cystic lung lesions depends mainly on the specific histology of the lesion. However, serial ultrasound monitoring postnatally may facilitate our recommendation on conservative approach.

ISOLATED ELEVATION OF THYROID STIMULATING HORMONE IN OBESE CHILDREN

Lobotková Denisa, Tichá Ľubica, Staníková Daniela, Staník Juraj, Podracká Ľudmila

1st Department of Paediatrics, Faculty of Medicine, Comenius University and Children’s University Hospital, Bratislava, Slovakia

Background: In recent years, thyroid function has been studied extensively in obese children. An elevation of serum thyroid stimulating hormone (TSH) level is a frequent finding, but its relation with peripheral hormone metabolism is not fully understood. There is a controversy concerning whether the altered thyroid function is the cause or the consequence of fat excess. The aim of this study was to investigate the association of TSH with thyroid hormones in a cohort of obese children compared to normal-weight controls and to study changes in thyroid hormones in relation to changes in BMI in the obese children.

Patients and Methods: Thyroid function (serum TSH, free thyroxine (fT4) and free triiodothyronine (fT3) levels) was evaluated in a cohort of 150 obese children (mean age 12±3.1 years) and 50 normal-weight controls (mean age 12.2±3.3 years), all with negative thyroid antibodies. Moreover, serum reverse triiodothyronine (rT3) levels were also measured in a subgroup of 51 obese children and 15 controls. In 80 obese patients thyroid function was also measured after 1 year follow-up.

Results: An elevated serum TSH level (≥4 mIU/L) was found in 19.3 % of obese children. Serum TSH level was significantly higher in obese children compared to controls (2.67 vs. 1.99 mIU/L, p<0.0001), while no difference was observed in fT4, fT3, rT3 levels and in fT3/fT4 and fT3/rT3 ratio, respectively. Significant positive correlation has been found between TSH and BMI-SDS (r=0.306, p<0.00001). However, in obese subjects no association between TSH levels and thyroid hormones was noted, while fT3 correlated positively with fT4 (r=0.255, p<0.003) and inversely with rT3 (r=-0.322, p<0.03). After 1 year follow-up of obese children the changes in BMI SDS correlated positively with the changes in TSH levels (r=0.376, p<0.001), but no significant changes in peripheral thyroid hormones were observed.

Conclusions: A moderate elevation of serum TSH level is frequently found in obese children, but this finding is not linked to changes in the peripheral activity of thyroid hormones. Further studies are required to examine the relationship between TSH, fT4 and fT3 levels as well as body weight and thyroid function.

A BABY – BOY WITH BRITTLE BONES, OSTEOGENESIS IMPERFECTA

Lochmanova J.

Department of Pediatrics, Hospital of Ceske Budejovice, Czech Republic

Introduction:Osteogenesis imperfecta is a variable and rare disorder. It is caused by a mutation of a gene which negatively impacts building of the connective tissue. It affects both males and females equally and it occurs all around the world with the prevalence 1:10–30 000 births.

Case study: Preterm infant (34 weeks of gestation), low birth weight (1520 g), gemellus A (biamniati-bichoriati, in vitro fertilization), achieved through Cesarean section. First days after the birth were without any complication; he was on nCPAP support for 5 days and started full enteral feeding from the day 7. Dismissal was at the age of 25 days. Suddenly, 3 weeks after, mum has founded a painful swollen left tight during a routine diaper changing. The baby-boy was admitted to our Department of Pediatrics. Orthopedic examination showed a fracture of the diaphysis of left femoral bone. Conservative treatment using the Bryant‘s traction was applied. Due to the rare occurrence of long bones fractures at this age various laboratory tests were run, including the tests for inherited metabolic disorders and gene mutations. Missense mutation of gene COL1A2 was founded. Whole body X-rays revealed multiple fractures, compressive vertebral fractures and the skeleton with diffuse decalcination. Results of these examinations and clinical appearance were significant for type III osteogenesis imperfecta. The treatment of this patient with the bisphosphonates has been initiated.

Conclusion:There is no causal therapy for this genetic bone disorder. Patient care involves a multidisciplinary team who strives to lessen the impact of the brittle bone disease on the quality of life and life expectancy.

MUSCULOSKELETAL SYSTEM IN ADOLESCENTS WITH TYPE 1 DIABETES

Maratova K., Matyskova J., Obermannova B., Pruhova S., Petruzelkova L., Kolouskova S., Soucek O., Sumnik Z.

Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic

Background: Sarcopenia and osteoporosis belong to the late complications of type 1 diabetes (T1D) in adults. The exact ethiopathogenesis of these complications is not completely elucidated, but a negative effect of chronic hyperglycemia on the bone metabolism and muscle proteins has been proposed in the literature. Whether and to what extend is musculoskeletal impairment present in childhood and adolescence is yet to be determined. The aim of the study was to assess bone mineral density (BMD) and dynamic muscle function parameters in adolescents with T1D and to test the association between these parameters and HbA1c serum level and T1D duration.

Methods: Ninety-five patients (59 boys and 36 girls, mean age 16.2±1.2) with T1D were included in the cross-sectional study. The patients were divided into two groups according to the duration of the disease (less than 6 years and more than 9 years, respectively). The BMD of the non-dominant tibia was assessed using the peripheral quantitative computed tomography (pQCT). Dynamic muscle functions were evaluated using the jumping mechanography. Gender and age specific Z-scores were calculated using published reference data. HbA1c was evaluated retrospectively as an average of the last 5 years.

Results: Trabecular BMD and the Strength-Strain Index were significantly lower in subjects with T1D (Z-scores -0.78±1.3 and -0.49±0.84, respectively, both p<0.001). Cortical BMD was significantly increased, when compared to controls (Z-scores 1.2±0.90, p<0.001). Relative muscle power (Pmax/BM) and force (Fmax/BW) were significantly decreased in T1D subjects (Z-score -0.4±1.0; p<0.001, and -0.3±1.1; p<0.01, respectively). Duration of T1D negatively affected Pmax/BM (p<0.01), but not Pmax/BW (p=0.54). The serum Hb1Ac levels did not differ between the two disease duration groups. No association between the HbA1c serum levels and bone or muscle parameters was observed.

Conclusion: T1D influences the musculoskeletal system already in the adolescence. Whether longer duration of more severe decompensation of the disease is causing the increased fracture risk in T1D remains to be elucidated.

NOVEL THERAPEUTIC APPROACHES TO ACHONDROPLASIA AND SETTING UP CZECH REGISTRY OF ACHONDROPLASI REACH

Pesl Martin, Linda Skutkova, Jana Strenkova, Hana Hrstkova, Pavel Krejci

Department of Biology, Faculty of Medicine, Masaryk University, Brno, Czech Republic

St. Anne’s University Hospital, ICRC, Brno, Czech Republic

Department of Pediatrics, University Hospital Brno, Czech Republic

Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic

Background: Achondroplasia (ACH) occurs in between 1:15,000 to 1:40,000 live births, and represents the common genetic form of human dwarfism. There is anticipated about 80–100 living pediatric individuals with ACH in Czech Republic. ACH is caused by activating mutation in fibroblast growth factor receptor 3 (FGFR3) tyrosine kinase. FGFR3 activation in the growing bones negatively regulates endochondral growth through premature growth arrest and disturbed differentiation of chondrocytes (Krejci et al., 2014).

There is no treatment available for ACH at present, despite the fact it is considered a curable condition. Growth hormone is no more considered an indicated option, controversial remains limb-lengthening surgery, due to related orthopedic complications and questionable outcomes. Our previous research formed a basis for development of ACH therapeutic based on C-natriuretic peptide (CNP), as CNP signaling restores chondrocyte proliferation via inhibiting downstream FGFR3 signaling (Krejci et al., 2005; Pejchalova et al., 2007). A stable CNP analog BMN111 is currently evaluated in clinical trials as a treatment for ACH. The phase 3 will evaluate the drug efficacy and may take, to our opinion, at least 7 years from now to complete, due to the necessity of long-term term BMN111 administration in order to show improved growth in children with ACH. Since BMN111 can only affect the growth of children with existing epiphyseal growth plates (current BMN enrolment age is 5–14 years), it is therefore necessary to enroll the Czech ACH patients into the ongoing clinical testing.

Methods: Ethical committee as well as the Czech Data Protection Authority (The Office for Personal Data Protection – Urad na ochranu osobnich udaju) approved personal data gathering. For direct patient contact a basic online form was prepared. For pediatric evaluation we prepared complex sets of questions and check box answers, representing basic epidemiological data, but also exclusion criteria for possible clinical studies. On-line data collection was based on a TrialDB system (Yale University, Connecticut, USA). A unique ID is generated for each patient; data transfer is encrypted and the system is designed to prevent any unauthorized use during data transfer. Data are stored on the central server on Masaryk University in Brno in the Oracle 9i database. The records are nation-wide, with close link to clinical genetic centers in Brno and Prague. Registry was tested for functionality and prepared in Czech and English language.

Results: The online Registry resource was opened in late November 2015 and gathered more than 57 individual patient contacts during first 6 months. Most of patients provided link to local pediatrician and allowed local presentation of Informed Consent and detail information. Acquisition of Informed Consents and full scale data sets is ongoing.

Conclusion: We established contact with more than 60% of anticipated ACH patients in the age of interest. The full scale evaluation was already performed in approximately 30% of participants. The patient registry allows safe assessment of current level of diagnostics and care. It shall answer the questions concerning on epidemiological data and thus preparing the local participation in phase 3 evaluation of the proposed therapy.

ENDOSCOPIC RECURRENCE WITHIN 8 MONTHS AFTER ILEOCECAL RESECTION IN CHILDREN WITH CROHN´S DISEASE, AN OBSERVATIONAL STUDY

Kristyna Potuznikova, Kristyna Zarubova, Ondrej Hradsky, Jiri Bronsky

Gastroenterology and Nutrition Unit, Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic

Background: Within Crohn’s disease (CD) patients approximately 7% to 20% are diagnosed at the age of 0–19 years. Seventeen to 34% of pediatric CD patients undergo intestinal surgery. The aim of our study is to evaluate the endoscopic recurrence in children within 8 months after ileocecal resection (ICR). No study evaluating the endoscopic recurrence in children has been previously published.

Methods: Our study includes pediatric CD patients, who underwent ICR between October 2011 and June 2015 at our hospital and were followed-up for at least 8 months afterwards. We observed the endoscopic recurrence (Rutgeerts score) in all patients not later than 8 months after ICR.

Results: Fifteen of 34 patients (44%) included in our research had endoscopic recurrence (Rutgeerts score >i1) within 3–8 months after ICR. At the time of surgery average patient age was 15.9 years (range 9.7–18.6). Median time from diagnosis to surgery was 14 months (range 1–77 months). Twenty-three (68%) of observed patients were treated with azathioprine (AZA) after the surgery, 10 patients (29%) were administered AZA in combination with anti-tumor necrosis factor alfa (anti-TNF) therapy and 1 patient was treated with anti-TNF in monotherapy.

Conclusion: In our patients approx. 44% had endoscopic recurrence within 8 months after ICR which appears to be slightly higher compared to a randomized controlled trial focused on adult patients (approx. 39% at 6 months after ICR).

THE ROLE OF MATERNAL CARE BEHAVIOR IN THE EFFECTS OF MATERNAL IMMUNE ACTIVATION ON DEPRESSION-LIKE BEHAVIOR IN THE MOUSE

Marianne Ronovsky¹, Claudia Lindtner², Stefanie Berger², Angelika Berger², Daniela Pollak¹

¹Department of Neurophysiology and Neuropharmacology, Medical University, Vienna, Austria

²Department of Pediatrics and Adolescent Medicine, Medical University, Vienna, Austria

Background: In a mouse model of gestational infection we have previously reported that maternal immune activation (MIA) is associated with depression-like behavior in the adult male and female offspring and correlated with long-lasting cellular and molecular deficits in the brain. Enduring behavioral and neural adaptations can be modulated by specific elements of the perinatal environment, most prominently by maternal care behavior (MB). These life-long influences of MB on offspring behavior are thought to be engrained in the brain through epigenetic mechanisms, which confer long-lasting changes in gene expression without alterations in DNA sequence.

Methods: MIA was induced by administration of Poly(I:C) at embryonic day 12.5 (E12.5) to pregnant C57BL/6N mice and maternal behavior was recorded on the postnatal days 1 to 6. mRNA levels of glucocorticoid and mineralocorticoid receptors (GR and MR), confirmed targets of regulation by MB and implicated in the pathophysiology of depression, were evaluated by quantitative real-time PCR (qRT-PCR) in hippocampal tissue of adult female offspring.

Results: MIA significantly reduced the percentage of time mothers engaged in licking-grooming behavior, the main form of physical contact experienced by the newborn pups, which is known to modulate behavioral, autonomous and endocrine functions later in life. A significant enhancement in hippocampal mRNA expression of GR and MR were observed in MIA as compared to control female offspring.

Conclusion: We here firstly describe the significantly dampening effect of Poly(I:C)-induced MIA on maternal licking and grooming behavior in the mouse and provide evidence that the expression of prime targets of epigenetic regulation is also altered in the adult female offspring brain. It is conceivable to speculate that MIA may, through hitherto undefined mechanisms, impact MB which in turn epigenetically regulates corticosteroid receptor expression in the offspring brain, potentially leading to or causing emotional disturbances later in life. The present study could be of significant translational value, as it may elucidate the specific relevance of physical contact in the postnatal environment as relevant determining factor for susceptibility or resilience to the impact of prenatal infection on the regulation of emotional function later in life.

GENETIC AND CLINICAL CHARACTERISTICS OF CHILDREN WITH PRIMARY VESICOURETERAL REFLUX AND RENAL HYPODYSPLASIA

Lea Solman¹, Boris Zagradisnik², Nadja Kokalj Vokac³, Natasa Marcun Varda⁴

¹Department of Paediatric Dermatology, Great Ormond Street Hospital, London, UK

²Laboratory of Medical Genetics, University Medical Centre Maribor, Maribor, Slovenia

³Laboratory of Medical Genetics, University Medical Centre Maribor, Maribor, Slovenia and University of Maribor, Faculty of Medicine, Maribor, Slovenia

⁴Department of Paediatrics, University Medical Centre Maribor, Maribor, Slovenia and University of Maribor, Faculty of Medicine, Maribor, Slovenia

Background: Vesicoureteral reflux is the most common urinary tract anomaly in children, and it is associated with recurrent urinary tract infections. Every acute pyelonephritis can cause permanent kidney damage, with the development of reflux nephropathy (RN), high blood pressure and end-stage renal disease in the most severe cases. Several candidate genes have been proposed in the genetic studies of VUR and scarr development. We wanted to confirm whether changes in copy number variations (CNV) in candidate genes affect the development of the VUR, renal scarring and RN in children. We have chosen twelve candidate genes because of their involvement in the kidney development as well as previous reports of mutations in these genes causing VUR and RN (ROBO2, EYA1, ZFP37, GATA3, MYH9, WT1, KLK1, ACE, GFRA1, AGTR1, CABN10, VIPR2).

Methods: We included 94 children, diagnosed with VUR and the control group of healthy individuals. Our genetic analysis was performed with Multiplex Ligation-dependent Probe Amplification technique (MLPA). We also compared patients diagnosed with VUR only to patients with VUR and RN. We analyzed their clinical history, VUR grade, biochemical investigations and need for surgical treatment.

Results: There was no statistically significant difference in the copy number variations of the candidate genes noted between groups of patients with VUR and healthy control patients. We could not show statistically significant difference in the copy number variations of the candidate genes between groups of patients with VUR and patients with VUR and RN. The group of patients with VUR was statistically significantly different from the group of patients with VUR and RN for gender, VUR grade and surgical treatment.

Conclusion: We did not find an association between copy number variations of the candidate genes and development of VUR and RN. Our search for a specific mutation could have influenced such a result. Further studies, using the new generation sequencing and array comparative genomic hybridisation will be required to fully understand the pathogenesis of VUR and associated risks for renal scarring.

PHENOTYPE AND GENOTYPE CHARACTERIZATION IN TWO PATIENTS WITH MEHMO SYNDROME

Staníková D.^2,1, Škopková M.¹, Staník J.^2,1,3, Ukropec J.¹, Daniš D.¹, Kurdiová T.¹, Ukropcová B.¹, Tichá Ľ.², Klimeš I.¹, Gašperíková D.¹

¹DIABGENE & Diabetes Laboratory, Institute of Experimental Endocrinology, Slovak Academy of Sciences, Bratislava, Slovakia

²First Department of Pediatrics, Medical Faculty at Comenius University, Bratislava, Slovakia

³Center for Pediatric Research Leipzig, Hospital for Children & Adolescents, University of Leipzig, Germany

Background: MEHMO (microcephaly, epilepsy, hypogenitalism, mental retardation, obesity) is a rare disorder with X-linked inheritance. Only three families with this disorder were described previously, with the linkage to a region on X chromosome. No specific gene has been identified so far.

The aim was to identify the genetic etiology in two unrelated Slovak male probands (5 and 2 years old, respectively) with the clinical diagnosis of MEHMO and describe the genotype-phenotype correlation.

Methods: Blood samples of both probands and their parents were obtained. DNA analysis by the whole exome sequencing (WES) approach was performed. Subsequent analyses of identified variants were focused on the chromosome X. Candidate sequence variants were verified by direct sequencing by Sanger.

Results: Analysis of exome in proband 1 has identified 18 variants on chromosome X. Haplotype analysis showed that only 3 of them were found also in the mother and the mother‘s mother of the proband 1, and only one variant - in the gene EIF2S3 – was located in the previously described region of the chromosome X associated with MEHMO. The variant is a frame-shift mutation with premature stop codon influencing 8 last amino acids of the protein. The same mutation was found also in the proband 2 and his mother. The in vitro analyses confirmed the pathogenicity of the novel variant. The phenotype of the probands had several common features, i.e. microcephaly, mental retardation, epilepsy, growth retardation, obesity, and diabetes. Nevertheless, the phenotype was more severe in the older proband 1 including panhypopituitarism and frequent respiratory infections.

Conclusion: This is the first identification of a gene (EIF2S3) causing MEHMO syndrome. EIF2S3 encodes the γ subunit of the eukaryotic translation initiation factor 2 (eIF2), which is involved in protein synthesis. Point mutations in this gene have been previously identified in several families with microcephaly and impaired intellect (i.e. milder phenotype than MEHMO).

This work was supported by the Slovak Research and Development Agency (APVV 0187-12).

SKIN MICROCIRCULATION IN HEALTHY TERM NEWBORNS ASSESSED BY SIDESTREAM DARK FIELD IMAGINS

Marketa Stanclova, Zdenek Kokstein, Christian Lehmann, Vladimir Cerny

Charles University in Prague, Faculty of Medicine in Hradec Kralove, Department of Pediatrics University Hospital Hradec Kralove, Czech Republic

Background: The microcirculation is an important part of circulatory system and plays a crucial role in the exchange of oxygen and waste products between blood and tissues. Sidestream dark field (SDF) imaging is a noninvasive technique allowing visualisation of microcirculation at the bedside. Only a few papers showing data in term newborns are available. The aim of our study was to examine the reliability and reproducibility of SDF imaging of the skin microcirculation in healthy term newborns.

Methods: SDF imaging was used to obtain the data in healthy term neonates during the 3rd day of life. The probe with a sterile disposable cap was applied to the inner upper arm. Images of skin perfusion were stored on a hard-drive and analysed off-line using AVA 3.0 software (MicroVision Medical, Amsterdam, The Netherlands). Total number of analysable videosequences from 18 neonates was 88. We calculated following microcirculatory indices: vessel density of total and perfused vessels, proportion of perfused vessels, De Backer’s score and microvascular flow index.

Results: The total all and small vessel density (in mm//mm²) were 19.79 (2.78) and 19.64 (2.815), respectively. The perfused all and small vessel density (in mm/ mm²) was 17.24 (14.28–20.55) and 17.12 (14.24–20.53). Proportion of perfused vessels all and small was 88.83 (83.15–95.93) and 88.82 (81.95–95.59). De Backer’s score (n/mm) was 12.98 (2.08). The microvascular flow index was 3.0–3.0 points.

Conclusion: We were able to obtain reproducible data from the skin microcirculation in healthy term newborns. Future studies might use our data as baseline database for microcirculatory investigations.

HYPOXIC-ISCHEMIC ENCEPHALOPATHY THERAPY OPTIMIZATION IN NEONATES FOR BETTER NEUROPROTECTION WITH INHALATIVE CO₂ (HENRIC)

Enikő Szakmár, Ágnes Jermendy, Kata Kovács, Ünőke Méder, Csilla Andorka, Miklós Szabó

1st Department of Paediatrics, Semmelweis University, Budapest, Hungary

Background: In a retrospective cohort study, we showed asphyxiated infants treated with early therapeutic hypothermia had a higher risk to develop hypocapnia after adjusting for other clinically important parameters (OR [95% CI] 6.9 [2.4; 19.9]). In this patient population hypocapnia is likely to develop due to spontaneous hyperventilation driven by metabolic acidosis, and therapeutic hypothermia, which decreases metabolic rate. Current literature reported a strong association between hypocapnia and adverse outcomes at 18 months of age. The aim of the present study is to achieve and maintain a desired range of pCO₂ of 40-60 mmHg in asphyxiated, cooled, mechanically ventilated newborns with low concentration inhalative CO₂ gas mixture (5% CO₂ + 95% air). Here we report the methods of the proposed feasibility and safety study.

Methods: Term aphyxiated infants (≥ 36 weeks of gestation), fulfilling the criteria of hypothermia treatment, with a temperature corrected pCO₂ ≤40 mmHg at any time within six hours of life will be enrolled into the study. Hypothermia is induced within 6 hours of life and maintained for 72 hours using a water filled thermo blanket placed underneath the patients, targeting a rectal temperature of 33 to 34 °C. The gas mixture will be administered through patient circuits in conventional ventilators. The end point of inhalation when base excess increases above -5 mmol/L in the arterial blood gas sample and/or the maximum duration of inhalation is 12 hours. Arterial blood gas samples will be taken hourly to ensure targeted and tolerable pCO₂ levels. In addition, continuous amplitude-integrated electroencephalography will be registered and doppler ultrasound measurements of cerebral blood flow in the anterior and medial cerebral artery will be performed before and during and CO₂ inhalation. In addition, blood samples for routine clinical laboratory testing will be taken according to standard protocol. To test feasibility and safety of the low concentration CO₂ gas mixture a total number of 10 patients are planned to be recruited over 1-year period. The HENRIC protocol has been approved by the Hungarian Scientific and Research Ethics Committee.

Results: Preliminary results of the first three enrolled patients will be presented as part of data safety monitoring. The primary outcome of the HENRIC study will be the percentage of time spent in the desired pCO₂ range (40–60 mmHg) during CO₂ inhalation. Seizures, pH recovery time, severe hypotension and mortality will be monitored as secondary outcome. The study would be considered successful, if in the intent-to-treat analysis the combined time spent in desired pCO₂ range reached 70%, and no serious adverse events were noted.

Conclusion: Inhalative low concentration CO₂ administration is a physiologically plausible intervention for hypocapnia avoidance. If safety and feasibility are proven, inhalative CO₂ may be used to optimize neuroprotection in asphyxiated newborns.

HEALTH RELATED QUALITY OF LIFE ASSESSMENT IN PEDIATRIC HYPERTENSION: A CROSS-SECTIONAL STUDY

Tadej Petek¹, Tjaša Hertiš¹, Nataša Marčun Varda^1,2

¹Medical Faculty University of Maribor, Slovenia

²Department of Pediatrics, University Medical Centre Maribor, Slovenia

Background: Health related quality of life (HRQOL) assessment in the pediatric clinical practice is gaining increasing interest, as it fosters a patient-centered approach and can aid in clinical decision making. While a negative correlation between hypertension and HRQOL has been reported in adults, its influence in the pediatric population has not yet been finally determined.

Methods: We administered the PedsQL 4.0 Generic Core Scales via postal survey to 69 children and adolescents, aged 5-18 years, diagnosed with arterial hypertension at a regional hospital department for pediatric hypertension and nephrology, and 70 parents. The control group consisted of 99 healthy children and adolescents, aged 6-15 years, and 100 parents from a local primary school. The Student’s t-test was used to compare hypertensive and control group mean PedsQL scores, and the Pearson’s r correlation index to obtain child-parent correlations.

Results: Hypertensive children and adolescents had a significantly lower overall HRQOL, together with lower physical, emotional and psychosocial functioning scores in both child self- and parent proxy-reports. Children also reported significantly lower school functioning scores. There were moderate (r>0.5) to high (r>0.7) correlations between self- and proxy reports.

Conclusion: Consistent with previous literature on HRQOL in the adult hypertensive population as also children with chronic diseases, our results suggest a lower HRQOL in the pediatric hypertensive population. Based on our findings, we suggest encompassing a broader view on the overall disease burden in hypertensive children and adolescents, giving special attention to physical, emotional and social functioning aspects, which may influence treatment outcomes.

THE FORENSIN EXAMINATION CENTER FOR CHILDREN AND ADOLESCENTS (FORENSICHE KINDER-UND JUGENDUNTERSUCHUNGSSTELLE - FOKUS) – PILOT PROJECT AT THE DEPARTMENT FOR PEDIATRICS AND ADOLESCENT MEDICINE, MEDICAL UNIVERSITY VIENNA

Eva Theuer¹, Martin Grassberger¹, Astrid Grundner¹, Daniela Thurn-Valsassina¹, Sabine Völkl-Kernstock², Katharina Leitner³, Wolfgang Novak⁴, Maria Kletecka-Pulker³, Susanne Greber-Platzer¹

¹Department for Pediatrics and Adolescent Medicine, Medical University Vienna, Austria

²Department for Child and Adolescent Psychiatry, Medical University Vienna, Austria

³Institute for Ethics and Law in Medicine, Medical University Vienna, Austria

⁴Department for Pediatrics and Adolescent Medicine, SMZ-Ost-Donauhospital, Vienna, Austria

Background: The Forensic Examination Center for Children and Adolescents (Forensische Kinder- und Jugenduntersuchungsstelle - FOKUS) was established in 2015 with the main goal to support and optimize the processes of examination, documentation and protection of children and adolescents with suspected physical, sexual and psychological abuse as well as neglect.

Methods: 59 cases of child maltreatment could be reported from July 2015 to March 2016.

It is a main part of FOKUS to create and provide documents and special checklists to optimize the early assessment and to give precise instructions for additional examinations and trace securing. Another main field of FOKUS are lectures about different aspects of child maltreatment and training courses for correct clinical and psychological examinations, securement of evidence, documentation. FOKUS can be contacted by the children hospitals of Vienna mainly by their child protection teams and collaborates with social services, law enforcement and state prosecution.

Results: 59 patients (aged 8 days to 17 years, mean age 7 years and 6 months, in 2 patients the exact date of birth was unknown, female sex 57.6%) were reported with suspected sexual abuse in 57.6%, physical maltreatment in 23.7%, Münchhausen Syndrome-by-proxy in 11.8%, abusive heads trauma in 5% and one suspected victim of neglect. The initiated interventions included physical and psychological diagnostics, photo documentation and securement of evidence as well as referrals to other medical specialties, e.g. Gynecology, Radiology, Dermatology, Ophthalmology, Pediatric Surgery, laboratory and blood coagulation diagnostics and Pediatric Psychiatry.

Conclusion: FOKUS is an overarching and coordinating facility for cases of child maltreatment, sexual abuse and neglect. The objective procedures, the methods of documentation and the interdisciplinary interventions initiated by FOKUS are an important instrument of support offered to all children hospitals in Vienna and should provide sufficient evidence for the conviction of the perpetrator at court.

EXECUTIVE FUNCTIONS IN ADOLESCENTS WITH TYPE 1 DIABETES MELLITUS

Tereza Vitvarova¹, David Neumann¹, Jan Kremlacek², Radka Simakova³

¹Dpt. of Paediatrics, Faculty of Medicine in Hradec Kralove, Charles University in Prague, and University Hospital Hradec Kralove, Czech Republic

²Department of Pathological Physiology, Faculty of Medicine in Hradec Kralove, Charles University in Prague, Czech Republic

³Philosophy Faculty, Palacky University Olomouc, Czech Republic

Background: Unfavorable metabolic control of type 1 diabetes mellitus (T1D) has a negative impact on the developing brain. Hyperglycemia and glycemic fluctuations disrupt mainly executive functions, which control the adaptive human behavior, activation of human motivation and persistence or change in the direction of acting. These functions coordinate various cognitive, emotional and behavioral happening with respect to achieving the target. While they are disrupted, patients may have difficulties to maintain the diet and the daily program.

Methods: Visual evoked potentials were examined in a cohort of twenty-two 13–19 years old T1D patients at euglycaemia and in nineteen 10-19 years old healthy controls. Responses were recorded using monocular stimulation. „Oddball“ stimulus pattern reflects the executive functions in the wave P300. Further reactions of the primary visual and the extrastriate area were evaluated.

Results: The results of T1D adolescents were physiological if compared to the general reference. When compared with the reuslts of the control group, T1D patients had a statistically significant prolongation of latency in the primary visual area, but the P300 wave did not differ.

Conclusions: T1D adolescents differ from the control group with prolonged latency of Reversal 20 in selected visual reactions. The study confirms the influence of the long-term metabolic control in T1D children and adolescents on executive functions, especially on inputs of primary visual area.

THE ROLE OF MYO5B AND SYNTAXIN 3 IN CARGO-SELECTIVE APICAL EXOCYTOSIS IN MICROVILLUS INCLUSION DISEASE

G. F. Vogel¹^,², K. M. C. Klee², A. R. Janecke¹, T. Müller¹, M. W. Hess³, L. A. Huber²

¹Department of Pediatrics I, Medical University Innsbruck, Austria

²Division of Cell Biology, Biocenter, Medical University Innsbruck, Austria

³Division of Histology and Embryology, Medical University Innsbruck, Austria

Objectives and Study: Microvillus inclusion disease (MVID) is a rare, fatal autosomal recessive enteropathy. This life-threatening, severe watery diarrhea is due to a disrupted brush border of enterocytes of the small intestine. The ultrastructure of patients’ enterocytes displays loss or immature formation of microvilli and the occurrence of so-called microvillus inclusions. Recently mutations in the MYO5B and STX3 gene, coding for the actin motor protein Myo5B and the apical target SNARE protein Syntaxin 3, respectively, have been shown to be causal for the observed clinical phenotype [1, 2, 3]. Myo5B is involved in important intracellular trafficking pathways. Myo5B, together with the small Rab GTPases Rab8a, Rab11a and Rab25, orchestrates recycling and transcytosis of membrane proteins and is crucial for correct polarization of epithelial cells (e.g. enterocytes).

Methods: Myo5B and Syntaxin 3 were deleted by genome-editing in polarized CaCo2 cells as enterocyte model, in order to analyze their role in the establishment of epithelial polarity and apical cargo transport.

Results: The loss of Myo5b or Syntaxin 3 disrupts enterocyte polarity, recapitulating the phenotype of MVID in-vitro. Biochemical analysis of SNARE couplings revealed a specific apical cargo trafficking route depending on Myo5B, Synaptotagmin-like protein 4a, Munc18-2, Vamp7 and Syntaxin 3. This route, furthermore, proofed to be cargo-specific as some apical cargo proteins (e.g. NHE3, GLUT5 and CFTR) mislocalised whereas others (e.g. DPPIV, SI and AminopeptidaseN) still properly localized at the apical plasma membrane [4].

Conclusion: Together, these findings outline the role of Myo5B and Syntaxin 3 in cargo-selective apical exocytosis and shed new light on the pathophysiology of MVID.

References

1. Mueller T, Hess MW, Schiefermeier N, et al. MYO5B mutations cause microvillus inclusions disease and disrupt epithelial cell polarity. Nat Genet 2008 Oct; 40 (10): 1163–1165.

2. Ruemmele FM, Mueller T, Schiefermeier N, et al. Loss-of-function of MYO5B is the main cause of microvillus inclusion disease: 15 novel mutations and a CaCo-2 RNAi cell model. Human Mutation 2010 May; 31 (5): 544–551.

3. Wiegerinck CL, Janecke AR, Schneeberger K, et al. Loss of syntaxin 3 causes variant microvillus inclusion disease. Gastroenterology 2014 Jul; 147 (1): 65–68.

Acknowledgements: The Austrian Research Funds (FWF) within the MCBO program supported this work.

PNEUMOTHORAX, PNEUMOMEDIASTINUM AND PNEUMOPERITONEUM IN A 10-YEAR-OLD GIRL FOLLOWING COLONOSCOPY

Eszter Vojcek, Barbara Vatai, Gabor Veres, Peter Vörös, Attila Szabó, Csaba Lódi

1st Department of Pediatrics of Semmelweis University, Budapest, Hungary

Background: Colonic perforation is a uncommon but severe complication of colonoscopy occurring in 0.2% to 0,5% of diagnostic colonoscopies and up to 2% of therapeutic colonoscopies. The most common sites of perforation are rectosigmoid junction and cecal area. This may be caused by direct procedures, use of electrocautery devices, or excessive intraluminal pressure of the colon. „Triple pneumo” is the combination of pneumothorax (PTX),pneumomediastinum and pneumoperitoneum following colonoscopy.

Methods: We present a case of a 10-year-old girl who was treated conservatively for irritable bowel disease (IBD) for 6 years. She underwent a diagnostic colonoscopy after which she developed acute respiratory failure. Urgent bedside imaging series revealed tension PTX, pneumomediastinum and pneumoperitoneum. She was immediately intubated and ventilated and laparotomy revealed a 1 cm wide perforation of the transverse colon. The rupture was closed and a terminal ileostomy was performed. Chest and abdominal tubes were inserted. Biopsy supported the diagnosis of severe ulcerative colitis. The patient remained intubated and mechanically ventilated for 1 day postoperatively. She was treated with combined antibiotic therapy (ceftriaxone and metronidazol) for 5 days The postoperative course was uneventful and we could extubate the patient one day after the operation. To best of our knowledge no other case of tension PTX, pneumomediastinum and pneumoperitoneum after colonoscopy in children has been reported so far in literature by extensive searching of the major databases.

Results: In our presentation we discuss the anatomic routes through which air may travel and cause PTX, pneumomediastinum and pneumoperitoneum. Risk factors for colonic perforation include therapeutic colonoscopies compared to diagnostic colonoscopies, comorbidities, endoscopic procedures and colonoscopies on patients over 75 years of age. There is evidence that approximately 85% of visceral perforations results in pneumoperitoneum, however pneumoperitoneum in about 5 to 15% can present without any visceral rupture. Therapeutic approaches include conservative management, endoscopic mana-gement or operative treatment of open or laparoscopic approach. 50 % of the perforations are diagnosed during colonoscopy, most cases are diagnosed within the first day however in certain cases they remain hidden and silent. Severe abdominal or chest discomfort, nausea or vomiting and fever or leukocytosis are alarming signs for perforation.

Conclusion: The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) also states that specific written and verbal information should be given to the parent or responsible adult following colonoscopy of the child. This information should include the signs and symptoms of possible side effects, steps to follow in case of an adverse event and a phone number which is available at a 24 hour coverage. Each endoscopy unit should have a written protocol to follow in accordance with the national guidelines for children after colonoscopy.

STATUS QUO IN PEDIATRIC AND NEONATAL SIMULATION IN THE EUROPEAN GERMAN--SPEAKING COUNTRIES: THE DACHI SURVEY

Wagner M.¹, Heimberg E.², Mileder L. P.³, Staffler A.⁴, Berger A.¹, Löllgen R. M.⁵

¹Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Austria

²Department for Pediatric Cardiology, Pulmonology, Intensive Care Medicine University Children’s Hospital Tübingen, Germany

³Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Austria

⁴Department of Neonatology, Central Teaching Hospital of Bolzano//Bozen, Bozen, South Tyrol, Italy

⁵Pediatric Emergency Department, Inselspital Bern, Switzerland

Background: Simulation has acquired wide acceptance as an important component of education in health care and as a patient safety tool. Successful recognition and resuscitation of critically ill or injured children requires proficient technical and non- technical skills [1, 2]. While the simulated practice of these competencies has been well established in most Anglo-Saxon countries [3], simulation training is still not established in many European countries.

Research question: The authors of this article and founding members of the Netzwerk Kindersimulation [4] (Pediatric Simulation Network) aimed to survey all pediatric and neonatal health care institutions and departments in Germany (D), Austria (A), Switzerland (CH) and the German-speaking part of Italy, South Tyrol (I) (DACHI) on their current status of pediatric and neonatal simulation-based training.

Methodology: We composed a comprehensive online survey including 26 questions on the distribution and organization, target groups, resources, instructor and participant education as well as research activities among all pediatric institutions and departments in DACHI. The questionnaire was validated according to established models [5] including a pre-test and distributed electronically by the online tool SurveyMonkey® [6].

Results: After dispatching a total of 474 surveys (n=359 in D, n=42 in A, n=66 in CH and n=7 in I) we achieved a 45.5% response rate, with 143 responders from D (39.8% in D), 35 from A (83.3% in A), 31 from CH (46.9% in CH) and seven from I (100% in I). In 62.7% of all surveyed institutions, simulation-based training is already performed, including standardized algorithm courses (87.3%), skill training (63.6%), and high fidelity simulation training (58.5%). Only 15.8% of all inquired institutions actively conduct research in the area of simulation, whereas 71.3% did express an interest. The most frequently stated impediments for establishing pediatric simulation-based training were lack of personnel (56.6%) and financial resources (63.2%).

Discussion and conclusion: The significant response rate of our survey underlines the presence of a previously unknown, but strong interest in pediatric and neonatal simulation in the DACHI region. The strength of this questionnaire lies in the identification of a large number of already existing simulation-based training programs in the DACHI region.

Our findings provide an initial position for the advocacy and expansion of simulation in pediatrics. The better knowledge of national and international resources, along with the recent foundation of the Netzwerk Kindersimulation [4] will support a more effective collaboration in education, training, quality improvement, research and resource management among all simulation enthusiasts in this region aiming to ultimately increase patient safety of children and neonates.

Abbreviations:

CRM – Crisis resource management; DACHI – Germany (D), Austria (A), Switzerland (CH), South Tyrol (I); GRASP – German-speaking Research Association for Simulation in Pediatrics