Background & Aims Congenital diarrheal disorders are rare inherited intestinal disorders characterized by intractable, sometimes life-threatening, diarrhea and nutrient malabsorption; some have been associated with mutations in diacylglycerol-acyltransferase 1 (DGAT1), which catalyzes formation of triacylglycerol from diacylglycerol and acyl-CoA. We investigated the mechanisms by which DGAT1 deficiency contributes to intestinal failure using patient-derived organoids. Methods We collected blood samples from 10 patients, from 6 unrelated pedigrees, who presented with early-onset severe diarrhea and/or vomiting, hypoalbuminemia, and/or (fatal) protein-losing enteropathy with intestinal failure; we performed next-generation sequencing analysis of DNA from 8 patients. Organoids were generated from duodenal biopsies from 3 patients and 3 healthy individuals (controls). Caco-2 cells and patient-derived dermal fibroblasts were transfected or transduced with vectors that express full-length or mutant forms of DGAT1 or full-length DGAT2. We performed CRISPR/Cas9-guided disruption of DGAT1 in control intestinal organoids. Cells and organoids were analyzed by immunoblot, immunofluorescence, flow cytometry, chromatography, quantitative real-time polymerase chain reaction, and for the activity of caspases 3 and 7. Results In the 10 patients, we identified 5 bi-allelic loss-of-function mutations in DGAT1. In patient-derived fibroblasts and organoids, the mutations reduced expression of DGAT1 protein and altered triacylglycerol metabolism, resulting in decreased lipid droplet formation after oleic acid addition. Expression of full-length DGAT2 in patient-derived fibroblasts restored formation of lipid droplets. Organoids derived from patients with DGAT1 mutations were more susceptible to lipid-induced cell death than control organoids. Conclusions We identified a large cohort of patients with congenital diarrheal disorders with mutations in DGAT1 that reduced expression of its product; dermal fibroblasts and intestinal organoids derived from these patients had altered lipid metabolism and were susceptible to lipid-induced cell death. Expression of full-length wildtype DGAT1 or DGAT2 restored normal lipid metabolism in these cells. These findings indicate the importance of DGAT1 in fat metabolism and lipotoxicity in the intestinal epithelium. A fat-free diet might serve as the first line of therapy for patients with reduced DGAT1 expression. It is important to identify genetic variants associated with congenital diarrheal disorders for proper diagnosis and selection of treatment strategies.

The present paper aims to provide experts' consensus on diagnosis and management of cow's milk protein allergy (CMPA) among infants and children in Turkey, based on review of available evidence-based guidelines, publications and experts' clinical experience. The experts agreed that CMPA diagnosis should be based on symptomatic evaluation and diagnostic elimination diet as followed by implementation of an open challenge test after disappearance of symptoms and confirmation of CMPA diagnosis in re-appearance of symptoms. For breastfed infants, differential diagnosis involves withdrawal of cow's milk-containing products from the mother's diet, while calcium supplements and appropriate dietary advice are given to mothers to prevent nutritional deficiency. For infants not breastfed exclusively, cow's milk-based formula and any complementary food containing cow's milk protein (CMP) should be avoided. The first line treatment should be extensively hydrolyzed formula (eHF) with use of amino acid-based formula (AAF) in severe cases such as anaphylaxis, enteropathy, eosinophilic esophagitis and food protein induced enterocolitis along with cases of multiple system involvement, multiple food allergies and intolerance to eHF. Introduction of supplementary foods should not be delayed in CMPA, while should be made one by one in small amounts and only after the infant is at least 17 weeks of age. Infants who are at-risk can be identified by family history of atopic disease. Exclusive breastfeeding for 4-6 months (17-27 weeks) is recommended as the best method of infant allergy prevention. There is no evidence that modifying the mother's diet during pregnancy and/or breast-feeding and delaying solid or even potentially allergic foods beyond 4-6 months in infants may be protective against allergy among at-risk infants. When exclusive breastfeeding is not possible, at-risk infants should get a partially or extensively hydrolyzed formula (pHF or eHF) to prevent allergy until risk evaluation by a health professional. In conclusion, the present consensus statement provides recommendations regarding diagnosis, prevention and management of CMPA in infants and children in Turkey, and thus expected to guide physicians to optimize their approach to CMPA and decrease burden of the disease on infants and their caregivers.

We assessed how the diagnosis of Celiac Disease (CD) is made and how the new ESPGHAN guidelines can be applied in children from countries with different resources. A real life prospective study was performed in 14 centres of 13 different Mediterranean countries. Participants were asked to apply the usual diagnostic work-up for CD according to their diagnostic facilities. There were 1974 patients enrolled in the study, mean age 4 years, 10 months; 865 male, 1109 female. CD was confirmed in 511 (25.9%) and was unconfirmed in 1391 (70.5%) patients; 14 patients were diagnosed as having CD according to the new ESPGHAN guidelines, 43 patients were classified as having potential CD. In all participating countries the diagnosis of CD relied on histology of duodenal biopsy; in 5 countries, HLA, and in one country endomysial antibodies (EMA) were not available. Symptoms did not add a significant increase to the pre-test probability of serological tests. The positive predictive value of tissue transglutaminase type 2 (tTG) antibodies performed with different kits but all corresponding to those recommended by ESPGHAN was 96.1% (95% CI 94–97.9%) in presence of tTG > 10xULN. In 135 patients with tTG >10xULN, HLA genotyping was performed and in all it was compatible with CD. The results of our study show that CD diagnosis still relies on intestinal biopsy in the Mediterranean area. New ESPGHAN criteria are not applicable in 5 countries due to lack of resources needed to perform HLA genotyping and, in one country, EMA assay. Further simplification of the new ESPGHAN guidelines might be made according to what preliminarily the present results suggest if confirmed by new prospective studies.

The World Gastroenterology Organization recommends developing national guidelines for the diagnosis of Celiac Disease (CD): hence a profile of the diagnosis of CD in each country is required. We aim to describe a cross-sectional picture of the clinical features and diagnostic facilities in 16 countries of the Mediterranean basin. Since a new ESPGHAN diagnostic protocol was recently published, our secondary aim is to estimate how many cases in the same area could be identified without a small intestinal biopsy.

Aim: To evaluate the efficacy of two regimens of combined interferon-α2a (IFN-α2a) and lamivudine (3TC) therapy in childhood chronic hepatitis B. Methods: A total of 177 patients received IFN-α2a, 9 million units (MU)/m ² for 6 months. In group I (112 patients, 8.7±3.5 years), 3TC (4 mg/kg/day, max 100 mg) was started simultaneously with IFN-α2a, in group II (65 patients, 9.6±3.8 years) 3TC was started 2 months prior to IFN-α2a. 3TC was continued for 6 months after antiHBe seroconversion or stopped at 24 months in non-responders. Results: Baseline alanine aminotransferase (ALT) was 134.2 ±34.1 and 147.0 ±45.3; histological activity index (HAI) was 7.4 ±2.7 and 7.1 ±2.3; and HBV DNA levels were above 2,000 pg/ml in 76% and 66% of patients in groups I and II, respectively ( P>0.005). Complete response was 55.3% and 27.6% in groups I and II, respectively ( P<0.01). AntiHBe seroconversion was higher and earlier, and HBV DNA clearance was earlier in group I ( P0.05). Breakthrough occurred in 17.9% and 24.6%; breakthrough times were 15.9 ±4.6 and 14.1 ±5.1 months; and relapse rates were 6.8% and none in groups I and II, respectively ( P>0.05, P>0.05, P>0.05). Responders had higher HAI (HAI>6) and higher pre-treatment ALT than non-responders. Conclusion: Simultaneous 3TC+IFN-α2a yields a higher response and earlier antiHBe seroconversion and viral clearance than consecutive combined therapy. Relapse rate is low. Predictors of response are high basal ALT and high HAI scores. 3TC can be administered for 24 months without any side effect and breakthrough rate is comparable with previous studies.