Pediat. Res. 2: 287-324 (1968)

ABSTRACTS Meeting of The American Pediatric Society and The Society for Pediatric Research

Atlantic City, New Jersey, May 4, 1968

SPECIAL SECTIONS (APS) Paper submitted to The American Pediatric Society (SPR) Paper submitted to The Society for Pediatric Research

1 The Effects on Fluid and Electrolyte Balance of Angio- FRANgois R. LAMARRE*, Dept. of Pediatrics, cardiography. AARON R. LEVIN*, HERMAN GROSS- Albert Einstein College of Medicine, Bronx, MAN*, EDWARD T. SCHUBERT* and ANGELA C. N.Y. (introduced by Henry L.Barnett). GILLADOGA*, N.Y. Hosp., Cornell Univ. Med- Abnormal hemodynamics in congenital heart dis- ical College, New York, N.Y. (introduced by ease may be responsible for growth retardation. Cel- Mary Allen Engle). lular hypoxia, metabolic alterations and dietary factors Forty-seven studies in 27 patients aged 1 month to are some important factors which have been incrimin- 18 years were performed to determine the acute effects ated in the pathogenesis of this syndrome. We recently of angiocardiography on fluid and electrolyte balance demonstrated that infants in congestive heart failure in infants and children with congenital heart disease. had significantly higher plasma glucose levels at %, 1 Studies were carried out during diagnostic cardiac cath- and 2 hours than normals following an oral glucose eterization. Twelve patients had cyanotic congenital load. Accompanying this impaired glucose tolerance heart disease. Seventy-five per cent Hypaque® (1 ml/ was a significant suppression of insulin release. In the kg body weight) was utilized, the bolus being delivered present study, we investigated glucose metabolism and within one second. Serum control values for sodium, insulin release in children with cyanotic heart disease chloride, potassium, BUN, bicarbonate, osmolality, associated with pulmonary stenosis. Oral glucose toler- pH, hemoglobin and hematocrit were obtained im- ance tests were performed on 34 infants and children mediately prior to the first angiocardiogram and then ranging from 1 month to 16 years of age. Three patient within 5 minutes and 15, 30 and 180 minutes there- groups were studied: 11 normal children, 7 with cyan- after. No fixed pattern was noted in sodium or chloride otic heart disease, and 8 with noncyanotic heart dis- values in the initial period. Osmolality showed a rise at ease. The glucose tolerance tests in the three groups 5 minutes, returning to normal by 30 minutes. BUN, were normal; however, insulin levels of the cyanotic serum potassium, pH, bicarbonate, hematocrit and children were significantly higher (p<0.01) at 1 and hemoglobin all tended to fall dramatically immediately 2 hours than normals and higher at %, 1 and 2 hours after injection; however, these parameters returned to than the noncyanotic children. near normal by 15 or 30 minutes. Patients having re- Since pancreatic secretory activities were reported peat angiocardiograms prior to return of all parameters to be directly related to blood flow, the increased in- to normal showed more pronounced and progressive sulin release in cyanotic cnildren with pulmonary sten- changes. Analysis of data suggests a marked dilutional osis may be due to hyperactivity of the Islets of Langer- and acidotic effect occurring in the first 5 minutes after hans resulting from an increase in systemic blood flow injection of 75 % Hypaque® with normality often being in these children. Abnormal insulin release in children established by 15 minutes and usually present by 30 with cyanotic heart disease may also explain the hypo- minutes after angiocardiography. Hence, repeat angio- glycemic episodes observed occasionally following com- cardiography at shorter intervals than these is to be plete surgical correction. (SPR) avoided, especially in infants in cardiac failure, on digi- talis, and in cyanotic patients, to prevent the possible 3 Relationship Between pH, PQOZ andPoz in the Pul- effects of severe acidosis, hemodilution and hypokal- monary Vascular Bed of the Cat. PETER H. VILES*, emia and to allow recovery from the acute biochemical JOHN T. SHEPHERD* and WILLIAM H. WEIDMAN, insult produced by Hypaque® on fluid and electrolyte Mayo Clinic and Mayo Foundation, Rochester, balance. (SPR) Minn. To study relationships between pH, PcO2 and P02on 2 Abnormal Insulin Release in Cyanotic Heart Disease.pulmonary vessels, isolated cat lungs were perfused GERSHON HAIT*, MARINA A. CORPUS*, and with blood at constant flow and ventilated with 20, 10, 5 and 2.5 % oxygen. Airway and left atrial pressures remained constant. Lactic acid (0.37V) or sodium bi- * By invitation carbonate (0.9M) were infused to alter pH. Pcogwas 288 Abstracts zero or 60 mm Hg (0 or 10 % CO2 in ventilating gases). The diagnosis of viral infection was based on: (1) In six lung preparations with PcO2 °f 0 and pHof7.6, positive cultures for adenovirus in 7 patients (type 3-6, pressor responses to hypoxia were attenuated or absent. type 5-1); (2) positive culture plus significant com- Lowering pH to 7.0 with oxygen tension normal caused plement fixing (C.F.) antibodies in 4 patients (type a mean increase in perfusion pressure (Pp) from 17 to 3-2; type 1 and 5-1); (3) significant change in titre of 25 mm Hg and augmented pressor responses to hypoxia. C.F. antibody in acute and convalescent sera in 16; In six lung preparations with PcO2 of 60 mmHgand pH (4) significant change in C.F. antibody for both adeno- of 7.6, Pp increased from 14 to 26 mm Hg with severe virus and respiratory syncytial virus (RSV) in 2; (5) hypoxia (P02 = 20 mm Hg); lowering pH to 7.0 with significant change in C.F. antibody for RSV in 5. Thus, oxygen tension normal caused Pp to increase from 14 29 had adenoviral disease while 5 had RSV infection. to 16 mm Hg, and near maximal increases in Pp (11 The acute stage was a typical picture of bronchiolitis mm Hg) occurred with Po2 of 40 mm Hg. Assuming with radiological changes in lungs. that an element of pulmonary vasoconstriction, which Nineteen out of 26 survivors of acute bronchiolitis may be caused in part by acidosis and hypoxia, exists in have recurrent episodes of coughing and wheezing re- infants with respiratory distress syndrome, this study quiring 94 hospital admissions and 437 out-patient supports the rationale of treatment directed toward visits. Seven have been placed in foster homes and one repair of acidosis, hypercapnia and hypoxia. is in hospital 12 months after admission because of (Supported in part by USPHS Grants HE-5883 and chronic respiratory failure. Nearly all have barrel- HE-5515.) (SPR) shaped chests and abnormal physical findings in the lungs. Only one has clubbing. Chest x-rays have shown 4 Abnormal Cardiac Rhythms Associated with Con- hyperinflation in 14 and stable, but chronic changes genital Anomalies of the Venae Cavae. KAZUO MOM-in all 19. Three have partial atelectasis of lobe and 4 MA* and LEONARD M. LINDE, UCLA School of have proven bronchiactesis. Medicine, Department of Pediatrics, Division of It is suggested that severe bronchiolitis caused by Cardiology, Los Angeles, Cal. either adenovirus or RSV can lead to chronic disease Electrocardiograms of 43 patients with congenital of the lung. (APS) heart diseases (CHD) and anomalies of the venae cavae were studied. In 26 patients with persistent left superior 6 Hypoxic Constriction of Pulmonary Artery and Vein vena cava draining into the coronary sinus, left axis of in Intact Dogs. BEVERLY C. MORGAN and WARREN frontal P waves between +15 and —30 degrees was G. GUNTHEROTH, Univ. of Washington School found in 35 %. Isorhythmic A-V dissociation with inter- of Medicine, Seattle, Wash. ference was observed in two patients. In nine patients There is general agreement that hypoxia produces with persistent left superior vena cava draining into the pulmonary vasoconstriction. From pressure-flow data, left atrium, there were eight instances of abnormal it is not clear whether the vasoconstriction is pre- or atrial activation. These included a vertical P wave axis postcapillary. The purpose of this study was to estab- between +75 and + 90 degrees in three, extreme left P lish, by direct measurement of pulmonary vein dia- wave axis between —40 and —80 degrees in three, meter, whether pulmonary venous constriction occurs and left atrial rhythm in two patients. In electro- in intact dogs breathing an hypoxic gas mixture. cardiograms of patients with absence of the inferior Eighteen animals were studied following recovery from vena cava and azygos continuation, eight of eleven implantation of dimension transducers (miniature showed left axis of the P wave (between —10 and —80 mutual inductance coils) on a pulmonary artery and degrees). Wandering or shifting atrial pacemaker was pulmonary vein, ultrasonic flowmeters on aorta and observed in six cases. In five control groups of cardiac pulmonary vein, and pressure cannulae in pulmonary patients with presumably normal caval drainage, fron- artery, pulmonary vein, pleural space and femoral tal P wave axis usually fell between +20 and +70 de- artery. Breathing hypoxic mixtures for 10 minutes pro- grees. Therefore, abnormal left or vertical axis of the duced an increase in depth and rate of respiration, frontal P wave, left atrial rhythm, wandering or shift- respiratory alkalosis, a rise in cardiac output, and a rise ing pacemaker and A-V dissociation in patients with in pulmonary and systemic arterial pressure. Pulmon- CHD suggests the presence of either persistent left ary vein pressure and mean intrapleural pressure de- superior vena cava or absence of the inferior vena cava. creased, but distending pressure (intraluminal minus (SPR) intrapleural) in the pulmonary vein rose during hy- poxia due to a greater fall in intrapleural pressure. Vein 5 Chronic Obstructive Lung Disease Following Viraldiameter either decreased or was unchanged in the Bronchopneumonia. P.K.ADHIKARI*, N.V.RAO*, presence of increased distending pressure; thus pul- C.A.FERGUSON*, Department of Paediatrics, monary venous constriction was demonstrated in 15 of University of Manitoba and Children's Hos- 18 experiments. Pulmonary artery diameter and pres- pital, Winnipeg, Canada (introduced by H. Me- sure increased simultaneously in most animals; how- dovy). ever, in one-third, pulmonary artery diameter re- Pathological changes inTadenoviral bronchopneu- mained unchanged despite significant increase in pul- monia is well documented. Histological study of mate- monary artery pressure, demonstrating arterial con- rial from our hospital led us to the study of survivors of striction. These data support the hypothesis that both severe bronchiolitis. pre- and postcapillary pulmonary vessels constrict dur- Thirty-four patients with proven virus bronchiolitis ing hypoxia. For the first time in an intact animal, ac- were studied between 1959 and 1967. Twenty-seven tive constriction of the pulmonary vein is documented were American Indians. Fourteen out of the 34 came by direct measurement. (SPR) from the city. The median age at diagnosis was 10 months (range 4—70). Twenty-six survived the acute 7 Pulmonary Valvular Dysplasia: A New Form of Pul- disease. Nineteen of them are being followed regularly. monary Stenosis. JAKES H. MOLLER*, MICHAEL E. Their presen t median age is 34 months (range 12-100). KORNS*, COLIN H.SCHWARTZ* and JESSE E. Abstracts 289 EDWARDS*, Univ. of Minnesota Med. School., arterial saturation but a smaller decrease in saturation Dept. of Ped. and Path., Minneapolis, Minn, on crying while on the drug compared with pre-drug (introduced by Russel V. Lucas, Jr.). control in three of the five patients. No undesirable side We have observed an unusual and previously un- effects were observed. It is concluded that propranolol described type of pulmonary valvular stenosis in six may be useful as adjunctive treatment in selected pa- children. The pulmonary valve has three cusps, a nor- tients with cyanotic congenital heart disease. (APS) mal sized pulmonary annulus and no commissural fu- sion. The valve leaflets, however, are thickened, re-, 9 Beta Receptor Activity in the Fetal Lamb. CYNTHIA dundant and immobile. Histologic examination of the T.BARRETT*, MICHAEL A.HEYMANN* and leaflets revealed complete cellular disorganization and ABRAHAM M.RUDOLPH. Cardiovascular Re- excessive amounts of myxomatous connective tissue. search Institute and Department of Pediatrics, The right ventricular outflow tract obstruction present University of California Medical Center, San is related not to commissural fusion but to the immob- Francisco, Cal. ility of the leaflets. Beta receptor activity has not been well studied in At operation, the absence of commissural fusion and the fetus, and it is not known when these receptors de- the normal sized annulus implied normal valve func- velop or whether fetal responses to beta stimuli differ tion; infundibular resection was therefore carried out. from those occurring postnatally. We examined physio- Each patient died in the postoperative period. logic responses to both stimulation and blockade of beta Preoperative recognition of this anomaly is possible. receptors in lamb fetuses at varying gestational ages. Auscultatory findings are those of pulmonary valvular Isoproterenol infusions produced a significant rise in stenosis, except a systolic ejection click is absent. All six heart rate in each of 15 animals studied (61-145 days' children were of small stature. Two had peculiar facies gestation) with return to control values upon cessation (hyperteleorism, low set ears and ptosis). The electro- of the infusion. Umbilical blood flow was measured and cardiogram revealed a marked right axis deviation cardiac output did not change, but redistribution of (+150° to +270°) and right ventricular hypertrophy. flow occurred with more of the cardiac output going to Right ventricular pressures varied from 97/0 to 190/0 the placenta and heart and less to the carcass. Arterial mm Hg. Right ventriculography is diagnostic. The pressure and blood gases did not change. Propranalol thickened leaflets are clearly visualized. The leaflets are caused a significant decrease in heart rate in 3 fetuses immobile; thus the valve does not 'dome' in systole. and effectively blocked the effects of isoproterenol on The 'jet' of radio-opaque dye seen in classic pulmon- heart rate in 5. No gestational differences were ob- ary valvular stenosis is absent. served in response either to isoproterenol or to pro- We have no experience in successful operative ther- pranalol. We conclude from the increases in heart rate apy. Pulmonary valvular replacement appears to be caused by isoproterenol that beta receptors are present the ideal operative approach. The surgeon recognizing in the heart and that they are active normally even at a this lesion at operation might try radical resection of very early gestational age since the heart rate fell after one or more leaflets. (SPR) propranalol. Although postnatally beta stimulation alters myocardial contractility to produce an increase 8 The Effect of Long- Term Propranolol Administration in cardiac output, our evidence suggests that although on Patients with Cyanotic Congenital Heart Disease. some redistribution of blood flow occurs in the fetus, RICHARD A.GREENE*, EMMANUEL MESEL*, and cardiac output does not change. NORMAN J.SISSMAN*, Stanford University Med- (Supported by USPHS Grant HE-06285.) (SPR) ical School, Palo Alto, Cal. (introduced by Her- bert G.Schwartz). 10 Effect of Respiratory Rate and Airway Pressure on The efficacy of long-term administration of pro- Arterial Oxygen Tension During Artificial Ventila- pranolol in ameliorating the clinical course of patients tion. PENELOPE CAVE*, WILLIAM J. DAILY*, with congenital heart disease of the Tetrad of Fallot GRANT FLETCHER* and PHILIP SUNSHINE, Stan- type was evaluated. Propranolol has been shown to im- ford Univ. School of Med., Palo Alto, Cal. prove the manifestations of 'hypoxic spells' when The purpose of this study was to investigate the effect given intravenously but has not been studied when of varying patterns of mechanical ventilation on arter- given orally chronically. Patients were selected on the ial oxygen tension in infants with severe respiratory basis of clinical criteria of a young age (when surgery distress syndrome (RDS). Ventilation was begun only is attended by a relatively high risk) and comparative after treatment with O2 and NaHCOs had failed and well-being except for the occurrence of 'hypoxic spells'. Five patients were studied. Four had Tetrad of Score 0 1 Fallot and one had a single ventricle with transposition and subvalvular pulmonic stenosis. Ages at onset of PaO2 (100% Os) >70 50-70 treatment varied from 6 to 30 months. Initial dose, pHa > 7.3 7.20-7.30 given in divided doses 3 times daily, was 2 mg/kg/day PaCO2 <60 60-70 but this was increased in all up to 5 mg/kg/day. Results Score 2 3 4 showed that one patient had no improvement and re- PaO2(100%Oa) 40-49 <40 quired a systemic-pulmonary anastomosis 3 weeks after pHa 7.0-7.19 < 7.0 Apnea onset of treatment. The other four had marked decrease PaCO 71-80 >80 in the frequency and severity of their hypoxic spells. 2 Two patients developed increasing dyspnea on exer- the infant scored 3 or more (see above). Twenty-seven tion and polycythemia despite improvement in spells; studies were done with six infants. Each infant was they underwent successful anastomoses 8 and 9 months studied 4-6 times in the first 120 hours of controlled after starting propranolol. The other two patients are ventilation. A study consisted of 4-8 randomized doing well 8 and 10 months after initiation of treat- changes of respiratory rate and airway pressure select- ment. Ear oximetry showed little change in resting ed to approximate similar levels of ventilation. Arter- 290 Abstracts ial samples were drawn 25 minutes after each new pat- student who is asked to formulate a diagnosis(es) for tern ofventilatio n wasstarted. The studies were grouped the problem represented by each card deck. The se- according to age after initiation of ventilation. Corre- quence in which the cards are selected is recorded by lations were made between change in rate and pressure the student. Scoring is achieved by use of a computer and corresponding change in arterial pH and gas ten- which is programmed to compare the process used by sions. In every group of studies, PaO2 varied directly the student in solving the clinical problem with that with airway pressure and inversely with rate whether used by a group of'experts'. calculated as a change from the original settings or The reliability of this instrument was evaluated by from the immediately preceding settings. No correla- comparing the scores of 19 students who solved two tion was found between pH or PaCO2 and rate, pres- clinical problems (r = 0.66; p < 0.05). Concurrent sure or PaO2, suggesting that the selected rate-pressure validity was evaluated by comparing the DMP scores combinations approximated similar levels of alveolar of 42 students with their grades in Pediatrics and of ventilation. The data show that oxygenation of infants 19 students with their performance on a Patient Man- with severe RDS can be significantly influenced by agement Problem supplied by the University of Illinois variation of specific parameters of mechanical venti- (r = 0.50 and 0.60 respectively; p < 0.05). lation independent of changes of arterial carbon di- Eighteen students who had completed an unstruc- oxide tension. (SPR) tured student-centered Pediatric clerkship solved the clinical problems presented to them in the DMP by a process which was more like that used by the 'experts' 11 A Pediatric Reporting System Generated from Com- than did 18 students in a control group who concur- puter-Stored Narrative Medical Documents. MAR- rently participated in the common-place, highly struc- GARET LYMAN*, JULIUS KOREIN* and LEO J. tured clerkship. This difference was significant at the TICK*, New York University, New York, N.Y. 0.05 level. Both groups were comparable by all other (introduced by Saul Krugman). measures (National Board scores, Pediatric clerkship Quarterly reporting of progress in delivery of com- grades, and grade point average). These findings pro- prehensive health services under recent Children and vide additional support for the validity (construct) of Youth grants by the Children's Bureau is a requirement the instrument. (SPR) for continued support. The Bellevue Pediatric (C and Y) Project will be greatly assisted in its delivery of com- prehensive health care to a large population by a com- 13 Factors Related to Patients' Failure to Follow Long- puterized medical record. Such a system will be used to Term Medical Recommendations. LEON GORDIS* assist in assembling records of the several health facili- and MILTON MARKOWITZ, Departments of Ped- ties commonly used by indigent populations into an iatrics, Johns Hopkins School of Medicine and orderly, complete and readily available compilation. Sinai Hospital, Baltimore, Md. In effect, the various health facilities used by the popu- Quantitative methods have been applied to studying lation served will be 'subcontractors' for comprehen- a factor important in health care evaluation—patient sive care—each contributing casefinding, treatment or compliance with physicians' instructions. The extent to supervision to the child's health with full knowledge of which patients fail to comply with medical recommen- the medical information accumulated by the others. dations and the reasons why they do not follow them The reporting system includes demographic data, acute are of particular importance in maintaining chronically episodic visits, diagnostic categories and the stages of ill children on long-term medical care. In order to study comprehensive care reached at any given time. For the compliance in such a population, 136 children who had Bellevue Project, data for the reports are derived ex- a history of rheumatic fever and who were on oral pen- clusively from those documents which serve as the icillin prophylaxis were selected for study. Compliance patient's medical record: i.e., there are no additional was determined using the sarcinea lulea method for de- or separate notations made just for the reporting sys- tecting penicillin in urine, adapted for mail-in testing tem. The documents are formatted, and narrative con- (Pediatrics 41: 151 [1968]). Mothers were interviewed tent is entered into computer storage. Medical criteria and medical records abstracted to identify medical, have been established which classify categories of pa- sociologic and cultural variables which might relate to tients in accord with those definitions given for the re- noncompliance. Weekly random urine specimens were porting system, and appropriate computer programs obtained at school during a 20-week period. Patients written to effect analysis of the documents for auto- were classified as compilers (75 % or more urine tests matic production of the required report. Examples of positive) or noncompliers (25 % or less tests positive). the documents used and results of this approach to Of the study group, 36 % were noncompliers and 32 % analysis of medical records will be presented. (APS) compliers. Compliance status could be predicted quite well using a 3-test sequence as a screening method. Compliance status on days of clinic visits did not differ 12 Assaying the Process of Reaching a Clinical Diagnosis. significantly from that determined from random school RAY E.HELFER* and CARL H. SLATER*, Univ. specimens. Statements from child or mother about of Colorado, School of Medicine, Denver, Colo. whether he had taken penicillin differed significantly (introduced by Arthur McEIfresh). from objective findings of urine tests. Relationships of This paper describes a reliable and valid instrument compliance to age, sex, race, socioeconomic status and for assaying the process by which a clinical diagnosis is other variables were examined. The data indicate that reached. 'The Diagnostic Management Problem' the critical variable affecting compliance in this pop- (DMP) is made up of 96 consecutively numbered cards ulation is the degree to which mother and child sense on which is recorded certain historical information, a he is personally vulnerable to effects of the disease. physical finding, or a laboratory result which pertain These results are important for long-term care of to a specific clinical problem. An index which specifies chronically ill children and have major methodological the type of information on each card is provided to the implications for health care research. (APS) Abstracts 291 14 Videotape Sampling of the Child's Day in the Hospital. the physician can save valuable time for other more JEROME L.SCHULMAN and JOSEPH C.KASPAR*, acutely ill patients. (APS) Department of Pediatrics, Northwestern Uni- 16 Environmental Influences on Drug Effect. CHARLOTTE versity Medical School, Chicago, 111. S.CATZ* and SUMNER J.YAFFE. Dept. of Ped- A videotape recorder was installed in a viewing cor- iatrics, School of Med., State Univ. of New York ridor, separated from a patient room by a one-way mir- at Buffalo, N.Y. ror. This facility is located in the Clinical Research Cen- We reported previously that in mice, strain varia- ter. The recorder was coupled to an automatic pro- tions in hexobarbital response (reflected as sleeping gramming device which obtained records for twenty time—ST) occur and that this response is under genetic seconds of each five minutes during the daylight hours. control. A corresponding increase in hexobarbital oxi- Each segment was rated as to whether the child was out dase activity was obtained in vitro. At this age (21 of bed, sleeping or awake. In addition, when awake, days) in the normal developing mouse, weaning occurs. his mood was rated on a seven point scale. Each time Therefore, the influence of this environmental event on someone was present in the room, the occupation and hexobarbital response was investigated. Littermates interaction were noted. Data was separately tabulated (weaned and nonweaned) were compared at three dif- for the afternoon of admission, the morning before ferent weaning schedules: early (15 days), normal (21 surgery, the postoperative afternoon and the day after days), and late (28 days). Half the litter remained with surgery. The population consisted of nineteen children the nursing mother; the other half was separated and admitted for repair of inguinal hernias. The results started on regular laboratory pellets. In the early should be assessed in view of the high nurse to patient weaned group, hexobarbital response was measured at ratio on this ward. Physicians were present only on the 18 and 21 days of age (3 and 7 days after weaning re- day of admission in relation to performing the admis- spectively). At 18 days of age the weaned group had a sion physical examination. Nurses were present in the significant decrease in ST when compared to their non- room 15 per cent of the time on the afternoon following weaned littermates (31 min versus 62 min). This dif- surgery, but less at other times. The staff was sig- ference between groups was no longer present when nificantly less likely to enter the room if the mother is tested 7 days postweaning. Animals were used only present, although the reasons for this are not clear. The once experimentally. A significant difference in hexo- pattern of activity varied significantly during different barbital response was noted between littermates on the periods of hospitalization, with, for example, only two normal or late weaning schedules. ST was 29 min versus children sleeping at all on the afternoon of admission. 69 min at 24 days and 17 min versus 45 min at 28. The child's mood did not vary in relation to who was days. The concentration of hexobarbital in blood present. (APS) obtained upon awakening was similar, indicating that end-organ sensitivity is equivalent in all 15 A Project Progress Report of a Coordinated Pediatricgroups. The significance of the reported observations Home Care Program in a Children's Hospital. in the rodent for infants and children is unknown but F.B.BECKER* and A.M.BONGIOVANNI, Chil- merits investigation and consideration. (SPR) dren's Hosp. of Philadelphia and Univ. of Penn- sylvania, Pa. 17 The Long-Term Effects of Embryonic and Fetal Ir- This report covers 27 months of a Coordinated Ped- radiation. ROBERT L. BRENT, Jefferson Med. Coll., iatric Home Care Program based in a children's hos- Philadelphia, Pa. pital. It is current philosophy that hospital-based home Human epidemiology studies indicate that relatively care programs meet chronic illness needs, high costs of high doses of irradiation can increase the incidence of hospitalization, geriatric needs and shortage of pro- certain malignancies in irradiated populations. In fessional personnel. A pilot study was begun into meth- 1958, STEWART reported that the mothers of leukemic ods of extending and coordinating medical and para- children had twice the frequency of diagnostic irradia- medical facilities into homes of pediatric patients. Need tion to the abdomen during the relevant pregnancy as was determined by surveys of in-patient and out- did mothers of nonleukemic children. The studies from patient population. Approximately 30 % of in-patients the Atomic Bomb Casualty Commission have not sub- on any given day and 85 out-patients per week were stantiated an association between preconception ir- potential candidates strictly on medical grounds with- radiation, in utero irradiation and malignancy in the out social or economic factors. Two basic categories offspring. This area of interest is unique in that although emerged. The home care category included 206 pa- there are scores of clinical studies, few animal studies tients which represented 1650 hospital days saved; the have been concerned with the long-term effects of in community health category, 444 patients with no utero irradiation. Ten years ago our laboratory initiated saving. Ancillary hospital services, nursing, social ser- such a study in mice. Over 6000 embryos have been ir- vice, drugs, medications, medical supplies, equipment, radiated and allowed to live out their normal life span. oxygen, inhalation therapy, speech therapy and med- Preimplantation, differentiating and fetal stages were ically indicated transportation are available to all irradiated with 0, 30, 60 or 90R. The animals were categories regardless of ability to pay, type of illness or weighed throughout their life and a complete gross and services needed. Admission to the program is based on microscopic examination was performed at the time medical and nursing needs, the parents' attitude and of death. The results dealing with the length of life and home facilities. Our program has demonstrated that incidence of tumors indicate that low dosage irradia- home care will work for children. Planning, evaluation tion to mouse embryos at the stages of gestation that and parent education in health supervision can be ac- were studied did not decrease life expectancy or in- complished. Physician-directed nursing, social and re- crease the incidence of tumors. In fact, the embryo lated services at home can be achieved. Early discharge demonstrated no life-shortening effects following 90R, from hospital and/or prevention of hospitalization is although this same dose of irradiation in the adult safe and feasible. Continued care at home can be pro- mouse produces a substantial life-shortening effect. vided and coordinated for the pediatric patient, and These and other animal data do not support the con- 292 Abstracts cept that diagnostic irradiation during pregnancy is an of this group received some type of pulmonary therapy indication for therapeutic abortion. This controversy in addition to the medical measures used in Group II. has become important since some physicians have uti- Life expectancy for this group was 49 % to 10 years and lized the occurrence of diagnostic x-ray exposure dur- 14% to 25 years of age. Group III was divided into ing pregnancy as an indication for therapeutic abor- male and female cohorts. The life expectancy curve for tion. This latter approach is confusing and will even- males was better than for females after the age of 3 tually result in an increase in litigation. years. Group IV: 379 patients with 1801 patient years (Supported by Grant AEC NYO 2071-41.) (APS) of observation who received prophylactic pulmonary therapy. Life expectancy for this group was 85 % to 18 Effect of Early Underfeeding on the Growth of the 10 years and 61 % to 21 years. Conclusion: (1) The earlier White Carneau Pigeon. JEROME LIEBMAN and in life treatment is started and the more intensive the AARON LEASH*, Case Western Reserve Univer- treatment, the better the prognosis. (2) Life table sur- sity School of Medicine. Department of Ped- vival analysis may permit discovery of minor factors, iatrics and Animal Facilities, University Hos- other than sex, which have significant but minimal in- pitals, Cleveland, Ohio. fluences on survival. The summation of these factors, The white carneau pigeon spontaneously develops however, may provide further improvement in the out- severe aortic and coronary atherosclerosis grossly and look for children with cystic fibrosis.(SPR ) microscopically similar to that of humans. Aortic fatty streaks develop after 12 weeks; 50% have significant 20 A Rapid Screening Psychometric Testing for Pediatri- atherosclerosis by one year, and all have disease at cians. FERNANDO J.DE CASTRO*, KENNETH L. three years. Long-term experiments are under way to VAUGHN* and RALPH M.GIBSON*, University determine whether underfeeding from birth to wean- of Michigan, Department of Pediatrics, Ann ing (28 days) will be protective to the adult. MCCANCE Arbor, Mich, (introduced by James L. Wilson). and WIDDOWSON in various animals have shown that The Kent Emergency Scale (KES) is a screening early underfeeding followed by ad lib feeding after test for mental age which can be performed by a phy- weaning markedly suppresses eventual adult size. After sician in approximately ten minutes. To determine the attempting multiple methods, the most satisfactory validity of this test in a pediatric out-patient unit, a type of underfeeding has been determined to be that of sample of forty patients (ages 6 to 17 years) requiring giving the parents (both of whom feed the squabs) one- psychological testing was selected. These patients were third of their normal diet. There was marked under- tested (a) by one of two pediatricians using the KES, growth with a 30 % attrition rate compared to a 15 % and (b) by one of four psychologists using a Weschler, death rate in the controls. All weights are in grams. a Stanford-Binet or a Leiter test. The mean IQ_ ob- tained by pediatricians was 82 and by the psycholo- Number Hatch 1 week 2 weeks 3 weeks gists 83. The differences between pediatricians' results Controls 160 22.2 187.8 389.3 493.9 and psychologists' results were 0 to 4 IO_ units in 42 % Underfed 103 21.9 134.2 212.8 271.0 of the cases; 5 to 9 IQ, units in 22 %; 10 to 14 IQ. units in 25 %; 15 to 19 IQunits in 5 %; and 20 to 21 IQunits in 5 % of the patients. The standard error of the esti- Number 4 weeks 5 weeks 6 weeks 6 mos. mate was 11.4 IO_units and the correlation coefficiency Controls 160 520.2 528.1 526.6 579.1 was +0.78 (significant a < 0.01). These results confirm Underfed 103 387.9 470.0 478.3 568.7 the usefulness of the KES as a screening device for pediatricians confronted with children presenting be- The weights are the same at hatch and at 6 months, havioral and educational problems. (APS) but are significantly different in between, maximally so at 3 weeks, when the squabs begin to feed themselves. 21 Intestinal Manifestations in Immune Deficiencies. Thus, though there was tremendous undergrowth dur- R.S.DUBOIS*, C.C.ROY*, D.MERRILL*, V. ing the underfeeding period, the deprived squabs rapid- FULGINITI* and K.DRUMMOND*. University ly caught up to the controls after weaning and on ad lib of Colorado Medical Center, Denver, and Mon- feedings. Therefore, underfeeding and undergrowing treal Children's Hosp., Montreal, Canada (in- during the preweaning period apparently do not affect troduced by D.O'Brien). adult size in the white carneau pigeon. (SPR) Five congenital hypogammaglobulinemics (Bruton type), three cases of isolated IgA deficiency, four of 19 Life Table Analysis of the Changing Prognosis for idiopathic acquired hypogammaglobulinemia (IAH), Children with Cystic Fibrosis. WARREN J. WARWICK five with thymic dysplasia and one thymic alympho- and RICHARD G. POGUE*, Dept. of Ped. and Bio- plasia were studied and shown to have a high incidence med. Data Proc. Unit, Medical School, Univ. of disaccharidase deficiency, a finding not previously of Minnesota, Minneapolis, Minn. reported. All these patients except one with isolated Life table analysis of age-specific mortality rates per- IgA deficiency had intermittent diarrhea; however, in mits the formation of life expectancy curves. Such only four could steatorrhea be documented, one Bruton tables and curves were prepared for four groups of pa- type, one IgA deficiency and two IAH. Both duodenal tients. Group I: patients diagnosed prior to 1940 who juice and stool cultures have been negative for ova, received no known effective treatment. Of this group, parasites and pathogenic bacteria. Light microscopy 72 % died by 1 year of age and 96 % died by 5 years. studies of the jejunal mucosa have been uniformly nor- Group II: patients who received antibiotic and other mal except for one case of IgA deficiency and two with medical treatments but did not receive pulmonary IAH. All three had steatorrhea and presented with therapy. They were analyzed by data obtained from various degrees of villous atrophy; in addition, one had six sources. The best results from these showed 42 % features of lymphoid nodular hyperplasia. Lactose and survival to 5 years and 23 % to 10 years of age. Group sucrose tolerance tests were done in 14 and 13 patients III: 4040 patients seen at 43 of the 60 CF Centers. All respectively. Five of the LTT's were abnormal and yet Abstracts 293 jejunal lactase was deficient in 12-14 while five STT's transport inhibitory effect. Similarly, addition of hep- were flat with 8-14 showing sucrase deficiency. In all arin to the viscous and turbid saliva from patients with patients, serum levels of IgG agreed with duodenal cystic fibrosis eliminated its Na transport inhibitory juice measurements. There was a perfect correlation effect, decreased its turbidity, and made it qualitatively between salivary and duodenal juice. However, in one less viscous. We concluded that the Na transport in- patient with IgA deficiency, a normal level of 1 IS IgA hibitory factor of cystic fibrosis may be a positively was found in both saliva and duodenal juice. The di- charged macromolecule that interacts with the mem- saccharidase deficiencies found could not be correlated brane of transporting cells of exocrine glands causing with histological changes or with the type of immune defective sodium reabsorption. The same factor could defect except in thymic dysplasia where all five cases be responsible for the abnormality of mucus in cystic had sucrase deficiency. (APS) fibrosis. (SPR)

22 Lithocholic Acid in Meconium. HARVEY SHARP*, 24 Studies on Infant Diarrhea. IV. Composition of Jejunal JAMES CAREY*, JANET PEIXER* and WILLIAM KRIVIT, Univ. of Minnesota Medical School, Fluid after a Single Feeding. R. TORRES-PINEDO* Minneapolis, Minn. and H.RODRIGUEZ*, Dept. of Pediatrics, Univ. Lithocholic acid increases the mitotic indices of bile of Puerto Rico School of Medicine, San Juan duct epithelium and eventually causes cirrhosis in all (introduced by A. Ortiz). the animals tested (J.Lab.clin.Med. 69: 737 [1967]). Studies of the change in the volume and composition Because of an observation of improved liver function of ingested milk-like mixtures containing glucose, lac- concomitant with reduction of serum bile acids (J. Ped- tose or maltose, during the digestive-absorptive pro- iat. 71: 723 [1967]) an investigation of the development cess were performed in infants with acute diarrhea and of bile acid metabolism was undertaken in fetuses and shortly after recovery. The Iuminal fluid was sampled newborns. One hundred grams of meconium pooled at two points of the jejunum, 25 cm apart, hourly dur- from normal newborns in 15 to 20 g batches were ing 5 hours. Since transmucosal sugar transfer is essen- analyzed. Following separation by silicic acid columns, tially unidirectional, maximal jejunal absorptive and fatty acids comprise approximately 3 % g weight, chol- hydrolytic abilities may be assessed by comparing esterol 0.1 % g weight and bile acids 0.5 % g weight. original to sampled concentration ratios of sugar with The bile acid fractions were then separated on a celite those of polyethylene glycol (S out/in + PEG out/in) column. The predominant bile acids were chenode- because variations in gastric emptying volumes apply oxycholic and cholic acid. Lithocholic and deoxycholic to both terms and cancel out. The following average acids were isolated in half of the meconiums pecimens. ratios were obtained at proximal collecting points These secondary bile acids were verified by both thin (diarrhea versus recovery): Glucose, 54 h (0.70-0.45); layer and gas chromatographic techniques. The meco- 1 h (0.59-0.34); 2 h (0.52-0.33); 3 h (0.52-0.10); 4 h nium has been examined for bacteria and found to be (0.50-0); 5 h (0.20-0). Lactose (hydrolysis index), sterile. Analysis of fetal gallbladder bile demonstrated 1 h (0.79-0.48); 2 h (0.84-0.23); 3 h (0.77-0.05); 4 h (0.38-0); 5 h (0.25-0). Maltose (hydrolysis index), 1 h predominantly chenodeoxycholic acid, with cholic acid 1 1 1 1 (0.38- ); 2 h (0.36- ); 3 h (0.28- ); 4 h (0.32- ); 5 h the only other bile acid isolated. Limitations in sample 1 size and strong alkaline hydrolysis might fail to detect (0.45- ). The results revealed impairment of absorp- lithocholic acid but not deoxycholic acid. Lithocholic tion and prolongation of transit times for all three acid has never been detected before adulthood and de- sugars during diarrhea, lactose being maximally oxycholic acid has not been isolated under one year of impaired. At equal molar loads, absorption of age. Serum lithocholic acid concentrations in healthy monosaccharides provided by hydrolysis was lower adults may reach 0.1 JJ, g/ml. These findings suggest that than when ingested free. Close correlations for volume, secondary bile acids traverse the placental barrier. Na+ and sugar were observed with preponderance of Since lithocholic acid can be present in the gastroin- high Na+ (low vol, low sugar points in recovery), and testinal tract in utero, a possible relation to infantile low Na+ (high vol, high sugar points in diarrhea). (APS) obstructive jaundice must be considered. (SPR) 1 Maltose recovery data still incomplete. 23 Studies on the Mechanism of Sodium Transport In- hibition in Cystic Fibrosis of the Pancreas. JOHN A.25 Postnatal Development of 24-Hour Rhythms in Pineal MANGOS* and NONA R. MCSHERRY*, Univ. of Hydroxyindole-O-Methyltransferase (HIOMT) and Wisconsin Medical School, Madison Wis. (in- Salivary Gland Norepinephrine (NE). ROBERT Y. troduced by G.C.Lobeck). MOORE, RUTH ANN SMITH*, JEAN A. WEAVER* We have demonstrated that the sweat and saliva of and NICHOLAS A. VICK*, Dept. of Ped. and Med., patients with cystic fibrosis contain a macromolecular Univ. of Chicago School of Med., Chicago, 111. substance that inhibits sodium (Na) reabsorption in the The pineal gland contains NE and a unique enzyme, rat parotid gland by 60-80 %. Similar inhibition of HIOMT, which forms melatonin. Levels of NE and transductal Na transport was observed when the lum- activity of HIOMT show a 24-hour rhythm; they are inal side of the cells of the duct system of the rat parotid high at the end of a dark period (8 a.m.) and lowfollow- was exposed for 90 seconds to solutions containing one ing a light period (7 p.m.). Maintenance of the nor- of several strongly positively charged macromolecular epinephrine rhythm appears to be critical for main- compounds (protamine, histones, polyethylene imine, tenance of the HlOMT rhythm. Unlike some 24-hour poly-L-lysine, poly-ornithine) in concentrations as low rhythms, the NE and HIOMT rhythms are dependent as 10-7 M. Our results demonstrate that interaction of upon information about environmental lighting car- these compounds with the membrane of the transport- ried to the pineal by sympathetic nerves arising in the ing cells affects transport of Na. Addition of the nega- superior cervical ganglion. Other tissues innervated by tively charged substances heparin or polyglutamic acid superior cervical ganglion, i.e., the salivary glands, also to the above solutions resulted in elimination of their show a 24-hour rhythm in NE content. The time course 294 Abstracts of the postnatal development of these rhythms is not Diaphorase (2,6-dichloroindophenol) activity was known and was investigated. Pregnant rats were placed similar for NADPH and NADH. Activity fell from day in diurnal lighting (lights on 8 a.m. to 7 p.m.). Infants 1 to 3, as with NADH reductase, and increased to a were killed on postnatal days 1, 3, 6, 8, 10, 16,21 and 35 maximum at 30 days. In summary, all enzymes studied at 8 a.m. and 7 p.m. Salivary glands from each were as- reached maximum activity by 30-45 days of age, with sayed for NE content and pineals for HIOMT activity. decline thereafter. Sex differences did not follow a Salivary glands showed a normal adult NE level and regular pattern, but were found by 45 days in some a clear rhythm by day 10. The pineal HIOMT levels (M>F demethylation, F>M NADH reductase) but did not approach adult activity until day 21, when a not in all. The results demonstrate that the activity of significant rhythm appeared. This provides further enzymes localized in the same membrane and partici- evidence that pineal rhythms and function are initiated pating in a chain of oxidative reactions exhibit different and maintained by the sympathetic nervous system. developmental patterns. (SPR) (Supported by USPHS Grant 7 R01-03063.) (SPR)

26 Reticuloendothelial Galactosida.se and Glucuronidase28 A Sequential Analysis Demonstrating Increased Mor- in the Neonatal and Germ-Free Rat. JOHN R. ESTER- tality Following Gastrostomy in Low Birth Weight LY*, ALFRED C. STANDEN* and BJARNE PEAR- Infants. SHAKUNTHALA VENGUSAMY*, JOHN F. SON*, Fort Detrick, Frederick, Md. (introduced RAFFENSPERGER*, ROSITA PILDES*, HARRY D. by Gerard B.Odell). LEVINE* and MARVIN CORNBLATH, Univ. of The histochemical demonstration and localization Illinois Col. of Med. and Cook County Hospital, of beta-D-galactosidase (GAL) and beta-D-glucuroni- Chicago, 111. dase (GLCR) were compared to the morphologic dif- A sequential controlled study was conducted to com- ferentiation of several lymphoid tissues in prenatal, pare the effects of gastrostomy feedings with routine developing neonatal, and germ-free rats. The thymus oral feedings on survival to 21 days in infants between had a relatively mature histologic structure by 7-10 750-1250 g birth weight. A reduction in mortality of days of age, and maturation of the neonatal spleen and 20 % was used to test for a significant difference be- intestinal lymphoid tissue had occurred by the third tween the two groups. One hundred and twenty-two week. Differentiation in peripheral lymph nodes was infants were randomly placed in a control or gastro- subsequently found between one and six months of age. stomy group at 48 to 72 hours of age. Each gastrostomy These organs were markedly underdeveloped in adult infant was paired with a control infant of similar weight germ-free rats, whereas their appearance was more group (1 = 750-1000 g, 11 = 1001-1250 g) and of the nearly mature in the 'conventionalized' animals. The same sex. All infants were given I.V. fluids on admis- GAL activity of the thymus was absent or minimal in sion to the premature nursery and similar graduated the fetal and newborn rat. Its appearance paralleled feedings at comparable ages (12 hours after gastro- the histologic development. GLCR was present at stomy). Clinical characteristics were similar in both birth, but decreased during the next few days and re- groups. Of 54 pairs that were matched when the study appeared coincident with the GAL. In contrast, GAL was concluded, 34 were identical in outcome and did and GLCR reactivity in intestinal mononuclear cells not contribute to the analysis, whereas 20 were dis- preceded the morphologic changes. In the spleen and cordant with only one of the pair surviving (table). peripheral lymph nodes, increases in both enzymes paralleled histologic maturation in the neonatal, adult, Group Similar pairs Discordant Survivors Total germ-free and conventionalized animals. These find- Lived Died pairs - Control ings indicate that morphologic appearance may be a Gastrostomy useful index of the relative activity of these lysosomal enzymes in developing lymphoid tissues. (SPR) I 6 3 2 6 17 II 25 0 5 7 37 Total 31 3 7 13 54 27 Patterns of Enzyme Development in the Hepatic Endo- plasmic Reticulum. L. F. SOYKA*, Department of From these data, it was concluded that survival was Pediatrics, Stanford University School of Med- significantly higher in the control group. Specific icine, Palo Alto, Cal. (introduced by G. M. causes of death including hemorrhage and infection McKhann). were more frequent in the gastrostomy group than in Two microsomal drug metabolizing systems and the control group. (APS) four electron transport enzymes in 9,000 g supernates from fetal to 90-day-old rats have been studied to ex- 29 Effect of Colchicine on Cellular Turnover and Enzy- plore the biochemical correlates of the impared ability matic Activity of Intestinal Mucosa. JOHN J. of newborns to metabolize drugs. Activity per kg body HERBST*, RUTH HURWITZ*, PHILIP SUNSHINE weight was employed to express results since drugs are and NORMAN KRETCHMER, Stanford Univ. often administered on this basis. This denominator also School of Medicine, Palo Alto, Cal. incorporates changes occurring in liver weight per unit Diarrhea is a well-recognized toxic manifestation of body mass and protein content per unit of liver. Rela- prolonged colchicine administration. This investiga- tive liver weight decreased after birth, reaching a nadir tion was designed to study the effects of this drug on at ten days after birth and increasing 2 X by 45 days. specific aspects of intestinal physiology, e.g., enzymatic Hydroxylase activity was absent in the fetus, reached activities and cellular proliferation. Forty hours after a a peak by 30 days, and declined. Demethylase was de- single injection of colchicine (1 mg/kg) into rats 30 days tectable in the fetus and increased > 10 X by 45 days. of age there was an 85 % decrease in the activity of in- NADPH cytochrome c reductase was found in the 3 g testinal invertase, which returned to normal within fetus and showed little increase until day 30. NADH 72 hours. cytochrome c reductase activity fell after birth but then When colchicine (4 mg/kg/day) was administered in increased 60 X, achieving maximum activity at 45 days. drinking water there was a 50 % decrease in activity of Abstracts 295 intestinal invertase after 3 days of imbibition. The anemia (PA) or asscociated with other forms of vita- animals had mild diarrhea, but their body weights were min B12 deficiency. OBERHOLZER et al. (Arch.Dis. comparable to those of normal controls. Histologically, Childh. 42: 492 [1967]) reported two cases of methyl- slight broadening of the villi and an increase in the num- malonic aciduria associated with chronic metabolic ber of goblet cells were noted. Within 72 hours after acidosis. The metabolic defect is in the conversion of cessation of colchicine administration, activity of in- MMA to succinate. testinal invertase returned to normal. There was a We have studied three patients with massive excre- slight decrease in the activity of aspartate transcarb- tion of MMA without vitamin B12 deficiency who de- amylase in the villi and crypts, but the activity of uri- monstrated abnormal urinary glycine excretion pat- dine kinase was unchanged from control animals. Two terns in addition to periods of intermittent hyper- hours after a pulse of H8-thymidine, 36.2 % of the cells glycinemia (3-5 mg% as compared to greater than were labeled in the crypts as compared to 35.8 % in the 5 mg % in classic glycinemia). One of OBERHOLZER'S controls. patients also demonstrated an abnormal glycine spot These data indicate that the change in activity of in- in the urine. In our patients, MMA excretion ranged testinal disaccharidase following colchicine cannot be from 3 to 6 g/day. Two of the three patients developed merely a reflection of arrested cellular proliferation but neutropenia and thrombocytopenia during their acid- must also affect cellular differentiation. These experi- otic episodes. Ketoacidosis by itself, as seen in diabetic ments can serve as useful models to study the environ- children, does not increase MMA excretion. The urines mental acquisition of deficiencies in digestive enzymes. of three children with documented classic glycinemia (Supported by USPHS grants HD-02147 and 5T01- were tested and MMA excretions were normal. The HD-49.) (SPR) association of abnormal amounts of MMA in the urine with intermittent plasma glycine elevations differen- 30 Unusual Insulin Secretion Characteristic of Cystictiate this variant of hyperglycinemia from the classical Fibrosis of the Pancreas. S.HANDWERGER*, form and perhaps also from the disorder reported by J.ROTH*, P. GORDEN* and P.A.DI SANT'AG- OBERHOLZER et al. These findings may constitute a new NESE, National Institutes of Health, Bethesda, syndrome. Md. (Supported in part by USPHS grants AM-02231, Cystic fibrosis, with or without impaired glucose FR-240, HD-2870 and FR-75.) (SPR) tolerance, was characterized by insulinopenia follow- ing oral glucose but normal insulin release following other stimuli. In 31 patients, oral GTT was normal or 32 A Metabolic Defect in Glucose Utilization by slightly impaired in 64 %, moderately impaired in 26 %, Achondroplastic Cartilage. THOMAS H. SHEPARD, and severely impaired in 10 %. Following oral glucose, BENJAMIN C,MOFFETT* and Louis R.FRY*, insulin secretory patterns (immunoassay) revealed that Univ. of Washington School of Med., Seattle, (1) patients with normal or slightly impaired tolerance Wash. had a prompt but subnormal rise in insulin; (2) patients In spite of many animal models, no metabolic lesion with moderately impaired tolerance had a delayed as has been demonstrated previously in achondroplasia. well as subnormal response; and (3) patients with se- The affected newborn rabbits (ac/ac) resemble human vere intolerance had a negligible rise. When glucagon achondroplastics by their shortened long bones, en- or tolbutamide was infused at the height of the insulin larged skulls and brains, and the histologic appearance response to oral glucose, serum insulin promptly in- of the metaphyses, but differ in that the mode of in- creased 100 % or more in all cases, irrespective of blood heritance is recessive. glucose changes. Other studies showed (1) much less Heterozygote (Ac/ac) animals were bred; approxi- impaired glucose and insulin responses to intravenous mately 25 % of the offspring were easily identified as glucose as compared to oral glucose; (2) normal in- achondroplastic (ac/ac). Cartilage with bone from sulin tolerance; (3) normal HGH responses to hypo- newborn dwarfs and normal littermates was carefully glycemia; and (4) no effect of phentolamine on insulin cleaned and placed in organ culture with one of the 8 36 secretion. The glucose intolerance is not classical dia- following isotopes: (1) H thymidine (2) SO4; and betes ; family history, characteristic complications and (3) uniformally labelled 14C-glucose. After 24-hour ex- postmortem signs of diabetes were absent. In contrast posure, the explants were counted in liquid scintilla- to the cystics, young patients with diabetes mellitus and tion or fixed for tissue radioautographs. hypoinsulinemia failed to secrete further insulin when The isotope incorporation from the 14C-glucose was glucagon, tolbutamide, or arginine was infused at the significantly higher in the ac/ac cartilage than in the height of the insulin response to oral glucose. We con- controls (ac/ac = 222 ± 26, normal = 139 ± 34, df clude that the glucose intolerance in cystic fibrosis is due 33, t = 3.02, p<0.01). No differences in ^S or 3H to a defect in the mechanism whereby oral glucose incorporation have been found. stimulates insulin release. (SPR) From tissue radioautographs, the achondroplastic cartilage incorporated more 14C activity than controls, 31 Intermittent Glycinemia and Methylmalonic Aciduriabut the striking difference was that the achondro- —A New Syndrome? GRANT MORROW III*, plastic cells located in the central part of the cartilage LEWIS A.BARNESS, VICTOR H.AUERBACH and were more heavily labelled than the similarly located 36 ANOELO M.DIGEORGE, Dept. of Ped., Hosp. cells in the control. The distribution of grains S and Univ. of Pennsylvania, Univ. of Pennsylvania 3H was not qualitatively different. School of Med., Children's Hosp. of Philadel- One possible interpretation of these findings is that phia and St. Christopher's Hosp. for Children a defect in energy metabolism requiring greater glu- and Temple Univ. School of Med., Philadelphia, cose supply may become manifest in the central avas- Pa. cular areas of cartilage. As this same area is the source Until recently, excessive urinary excretion of methyl- of cells for linear growth, the result could be the marked malonic acid (MMA) was found only in pernicious shortening of the achondroplastic long bone. (SPR) 296 Abstracts

33 Type II Hyperlipoproteinemia in a Family with lower concentration of 8 chain messenger RNA Hypercholesterolemia and Premature Coronary Artery (mRNA) is the major cause of the slower rate of 8 chain Disease. EVERETT W. LOVRIEN*, MANUEL R. synthesis. As presently understood, an operon of 8 and MALINOW* and ROBERT D. KOLER*, Univ. of /? chain genes would require that the synthesis of 8 Oregon Medical School, Crippled Children's mRNA be no less than that of/SS mRNA. Thus, these Division, O.R.P.R.C., Portland, Ore. data provide further evidence against the existence of Two siblings, at the ages of 5 and 9 years were eval- such an operon. (SPR) uated after their father suddenly expired at the age of 32 from acute coronary insufficiency. Pedigree analysis 35 MDH Isozymes in Ascaris—Biological and Diag- revealed 22 relatives had died of heart attacks before the nostic Significance. DAVID S.ZEE* and WILLIAM age of 45. Plasma cholesterol in the children was 472 H. ZINKHAM. The Johns Hopkins School of Med- and 486 mg% respectively. Triglycerides were 41 and icine, Baltimore, Md. 78 mg %. Electrophoresis of plasma proteins with sub- The demonstration of extraintestinal parasites in sequent oil-red-O stain for lipid revealed elevation of host tissues may be difficult and at times impossible; /?-lipoprotein. Using antiserum to human /?-lipoprotein, e.g., the detection of Toxocara canis larvae in tissues of agar immunoelectrophoresis was normal. The a-lipo- patients with visceral larval migrans. Other investiga- protein, pre-/? and chylomicron fractions were normal. tors have shown that the physical and chemical prop- This type of lipoprotein abnormality has been classi- erties of host and parasite enzymes are often different. fied as Type II by FREDRICKSON and LEES (New Engl. Using Ascaris suum ("pig Ascaris") as an experimental J.Med. 276: 34 [1967]). model, the properties of malate dehydrogenase (MDH) One-hundred-and-thirty members of the family were studied and compared with those of the host. were examined; 24 individuals had elevation of chol- Starch gel electrophoresis revealed four bands of MDH esterol and /9-lipoprotein. The earliest age detected was activity in Ascaris; one mitochondrial and three super- 6 months; 10 individuals were less than 16 years of age. natant forms. Thermostability and pH optimum curves The earliest death from heart attack was age 27 years. of the three supernatant isozymes differed, the middle The 9-year-old propositus had arcus juvenilis; some isozyme exhibiting intermediate properties. Observa- individuals had tendinous xanthomas, abnormal tions on the ontogeny and tissue distribution of the EKGs and calcified abdominal aortas. Males and fe- supernatant isozymes, dissociation and recombination males were equally affected. The pattern of inheritance experiments and the detection of an electrophoretic was an autosomal dominant. Of 67 individuals at risk, variant suggests that the supernatant isozymes are 32 were affected. dimers composed of subunits under separate genetic By correlating plasma cholesterol levels and lipo- control. Electrophoretic differences exist between the protein patterns, affected members can be identified MDH isozymes of pig tissues and Ascaris suum as well as early in the pediatric age group before they develop between human tissues and Toxocara canis. When a signs of coronary disease. Treatment has been started 1:20,000 dilution of Ascaris homogenate was added to in this family with low cholesterol diet and cholestyra- an equal volume of pig liver homogenate, the MDH mine. (SPR) isozymes of the parasite were still observed on the starch gel pattern. Studies are in progress to determine the 34 Regulation of Beta and Delta Chain Synthesis in minimum number of larvae that can be detected in tis- Sickle Cell Anemia. HAIG H. KAZAZIAN, JR.* and sues of guinea pigs experimentally infected with Ascaris HARVEY A. ITANO*, National Institutes of suum. (SPR) Health, Bethesda, Md. (introduced by Barton Childs). 36 The Cytogenetic Effect of Exposure to LSD in utero. A normal human erythrocyte contains 40 times as MAIMON M. COHEN*, KURT HIRSCHHORN* and much p chain of hemoglobin A (ocz^s) as 8 chain of WILLIAM A. FROSCH*, State Univ. of New York, hemoglobin A3 (cc252). The basis of this difference was Buffalo, Mt. Sinai Hosp., New York, and Belle- investigated with the use of reticulocytes from indi- vue Hosp., New York, N.Y. (introduced by viduals with sickle cell anemia, whose erythrocytes con- Ronald G. Davidson) s s tain 30 times as much /3 chain of hemoglobin S (a2/S 2) The induction of chromosomal aberrations by the as 5 chain. Ribosomes and supernatant hemoglobins psychotomimetic hallucinogen, lysergic acid diethyl- were isolated from reticulocytes that had been incu- amide (LSD-25), has been demonstrated both in vitro bated with 14C-labeled amino acids. Peptides obtained and in vivo. Such damage could result in the induction from tryptic digests of incomplete, or nascent, poly- of neoplasia in the "user", in a teratogenic effect on the peptide chains attached to ribosomes and globin were developing fetus, and in a genetic effect through purified and assayed for radioactivity. Since the amino- chromosmal aberrations in gametes. In this study the terminal tryptic peptides, ST1 and ^ST1, respectively, chromosomes af 12 infants exposed to LSD at various of 8 chain and /Js chain are structurally different, they times during fetal life were investigated. Also included can be individually assayed. The nascent chains of the were their mothers and 7 other adult "users". The con- ribosomal preparations contain 0.01-0.02 as much ST1 trol group consisted of 6 children (matched for age and as /3STI. Polypeptide chain synthesis proceeds from the sex), their mothers and 4 other normal adults. The amino-terminal amino acid to the carboxyl-terminal mean chromosome breakage rate of the controls was amino acid. Hence, nearly all ribosomes making a poly- 1.26 % cells with breaks (range 0.00-2.40 %) as opposed peptide on a messenger RNA will contain the amino- to 8.72 % (range 1.30-20.30) among those exposed to terminal tryptic peptide. Thus, the number of active the drug. Comparing only the children "at risk", a 8-chain-associated ribosomes is assumed to be 0.01- similar difference was found—1.25% in the controls 0.02 that of |3s-chain-associated ribosomes. The label- compared to 7.74 in those exposed in utero. A total of ing of tryptic peptides from supernatant hemoglobins 8 structural rearrangements was observed among those A2 and S indicated that the rate of 8 chain synthesis is exposed to LSD (6 dicentrics and 2 quadriradials) while 0.005 that of the ffi chain. These data suggest that a none was seen in the controls. Although chromosomal Abstracts 297 anomalies have been observed in abortuses and con- on the right which showed no ova but possibly some genitally malformed infants, all of the children in this ovarian stroma on biopsy. Chromosome studies from study are apparently healthy with no obvious birth blood showed XYY/XY/XO mosaicism (XY>XO> defects. (SPR) XYY). These patients will be compared to others to demonstrate the phenotypic variability of the presence 37 A Novel Chromosomal Basis for Imperforate Anusof Y chromosomes in females. (APS) (The "Cat's Eye" Syndrome). PARK S.GERALD, CHARLES DAVIS*, BURHAN M. SAY* and JOHN 39 Autoradiographic Studies ofD Chromosomes. GERALD L. WILKINS*, Children's Hospital Medical Cen- E.BLOOM* and PARK S.GERALD, Children's ter, Boston, Mass. Hospital Medical Center, Boston, Mass. SCHAGHENMANN et al. described a possible new syn- Autoradiographic studies using tritiated thymidine drome which has colloquially been called the Cat's Eye have been done for 19 patients with D group (13-15) syndrome. In its complete form this syndrome consists chromosome abnormalities. The specific chromosomes of mental retardation, colobomata, preauricular fistu- affected in each case were identified to determine if lae, congenital heart disease, urinary tract malforma- members of the D group were randomly involved in the tion and imperforate anus associated with the presence various conditions studied. The results of these investi- of an extra, acrocentric chromosome slightly smaller gations were combined with those of 22 similarly than a G. Two new kindreds with this chromosomal studied patients from the literature. The results from disorder have now been studied and the identification the total of 41 patients are as follows. All six patients of this collection of malformations as a new syndrome with the Dx trisomy syndrome involved chromosome 13. has been confirmed. In family No. 1, the propositus is a The five D/D centric fusion translocations occur- mosaic although he exhibits the complete syndrome. red between chromosomes 13 and 14. Thirteen D/G The parents are chromosomally normal and no other centric fusion translocations, with one exception, in- immediate member of the family has any malforma- volved chromosome 14. A ring D chromosome was tions. In family No. 2, the propositus has mental retar- identified as number 13 in three patients and number dation, congenital heart disease and imperforate anus 14 in two. Reciprocal translocations between a D and a —over 90 % of his cells have the extra chromosome. chromosome in another group involved chromosomes Three other members of the kindred are mosaic for this 13 (three patients), 14 (one patient); and 15 (two pa- chromosome disorder; two of them have imperforate tients). Prominently satellited D chromosomes (two anus (and no other major defect) and the third is pheno- patients) were both found to be number 15. Short arm typically normal. This latter family emphasizes the un- deletions (two patients) occurred in chromosomes 13 usual' behavior of this chromosome, since a mosaic and 15. It is apparent that the specific D chromosomes grandparent has transmitted the abnormality to his involved in certain D chromosomes abnormalities (D1 mosaic grandchild through a daughter who is appar- trisomy, D/D and D/G centric fusion translocations) ently chromosomally normal. The occurrence of a are not randomly determined. Evidence for satellite single congenital malformation in association with a association as a cause of this nonrandomness was sought chromosome abnormality supports the contention that from autoradiographic studies of normal D chromo- microscopically invisible chromosome changes might somes but could not be found. The nonrandomness may be the basis for some 'isolated' congenital defects. result because the mechanism producing the abnor- (APS) mality affects only certain D chromosomes. Alternative- ly, but much less likely, all D chromosomes may be in- 38 The Role of the T Chromosome in Females with volved in the conditions studied, but only certain com- Mosakism. LILLIAN Y.HSU*, KURT HIRSCH- binations may persist because of selection. (SPR) HORN*, ARTHUR GOLDSTEIN* and RALPH E. MOLOSHOK, Departments of Pediatrics and Ob- 40 Karyotypes of Consecutive Newborns. HERBERT A. stetrics and Gynecology, Mount Sinai School of LUBS* and FRANK H.RUDDLE*, Depts. of Ped., Medicine, New York, N.Y. Med. and Biol., Yale University, New Haven, Individuals with XY/XO mosaicism present a wide Conn, (introduced by Charles D. Cook). range of phenotypic manifestations including Turner's The chromosomes of 4,500 infants born between syndrome, intersexes and so-called male Turner's syn- October 1967 and October 1968 and 1,000 of their drome. An XYY sex chromosome constitution has been mothers are being analysed. The primary purpose of shown to cause increased stature and mental defect. the study is to effect a quantitative, statistical and clin- Two cases of XYY/XY/XO mosaicism studied by us ical definition of chromosomal normality in man, but were found to have markedly different phenotypic a number of other types of information can be gained manifestations. The first patient is a 38-year-old 6' 3" from these data in the course of the study. Although 30 tall female, with primary amenorrhea, lack of secon- cells in each individual will be studied subsequently by dary sex characteristics, and a history of a previously quantitative technics, including a FIDAC scanner, two excised right gonadoblastoma. Chromosome studies conventional karyotypes are being prepared initially from blood, fibrous tissue from the region ofth e gonado- and form the basis for this report. The present study is blastoma, and from a streak gonad on the left showed addressed to the problem of assessing the clinical role XYY/XY/XO mosaicism with a predominance of XY of chromosomal studies in the neonatal period. Close in the blood and the fibrous tissue, but with mostly XO to 1 % of the infants have had a chromosomal abnor- from the streak. The second patient is a 13-year-old mality, but only one has been clinically abnormal, an in- child with short stature and underdeveloped secon- fant with D trisomy. Preliminary analysis of the clinical dary sex characteristics who has been raised as a fe- data, including birth weight, the presence of minor male. She was born with ambiguous external genitalia anomalies and the various factors in the parents felt to with an enlarged clitoris and a urogenital sinus. Laparo- predispose to chromosomal abnormalities has not tomy at 10 months revealed a uterus, tubes, a testis on yielded a set of criteria which would enable the identi- the left which was removed and an unidentified gonad fication of a group of newborn infants with a high prob-

20 Pediat. Res., Vol. 2, No. 4 (1968) 298 Abstracts ability of having a chromosomal abnormality. If this centrifugation; (2) disrupted by sonication. An aliquot group of disorders is to be diagnosed in infancy, there- of macrophages + CV was incubated in vitro and fluid fore, routine chromosomal studies on each infant ap- harvested at 18 hours for IF assay. Serum IF levels pear to be necessary. Twenty per per cent of the new- (U/ml) at 6—10 hours after inoculation are summarized: borns showed a 'normal variant' in their karyotypes. No. 1 No. 2 No. 3 These variants have been reported to be present in in- creased frequency in congenital heart disease and other Macrophages + CV 1200 2000 1900 groups of patients. Statistical analysis of the frequency Macrophages + CV (supernatant) 340 — — of congenital anomalies, abnormal pregnancies and Macrophages + CV (sonicate) 250 500 600 gross chromosomal abnormalities in these families is Macrophages + CV (main- currently in progress in the first thousand infants. The tained in tissue culture) < 100 240 460 relatively unbiased mode of ascertainment of this group of newborns with 'normal variants' should per- Three- to five-fold higher levels of IF were found in mit a final assessment of their significance. (SPR) the serum of mice receiving a transfusion of IF-pro- ducing macrophages. Maintenance of the observed levels of IF in serum (1200-2000 U/ml) is particularly 41 Alpha-1-Globulin Deficiency in Familial Infantile significant in view of the fact that the half-life of exo- Liver Disease. H. SHARP*, E. FREIER* and genous IF is only 5-8 minutes and the total production R. BRIDGES*, Univ. of Minnesota Medical of IF in vitro was < 100-450 U/ml in 6-8 ml. These data School, Minneapolis, Minn, (introduced by suggest: (1) macrophages may be a major site of pro- W.KRIVIT). duction of serum IF; (2) production of IF under in A deficiency of a-1-antitrypsin in two siblings with vitro conditions may not reflect the true in vivo inter- portal cirrhosis prompted the following investigation. feron-producing capacity of a cell. Studies are in pro- They were identified by a virtual absence of the a-\- gress to determine if the transfusion of IF-producing globulins by cellulose acetate electrophoresis. The macrophages may be utilized in the treatment of viral studies by Eriksson and his collaborators have shown infections. (SPR) that some 90 % of the a-1-globulins on electrophoresis are accounted for by the a-1-antitrypsin, a glycopro- 43 Proportion of Total Serum IgM-Immunoglobulins tein with a molecular weight of 60,000. This is the same that is Specific Antibody Following Typhoid Immuni- protein that is absent in these patients. Eriksson and zation of Children. WILLIAM A.ALTEMEIER, III*, others have previously described an autosomal reces- JOSEPH A. BELLANTI and EDWARD L. BUESCHER*, sive form of emphysema appearing in adults that is also Walter Reed Army Inst. Res. and Georgetown associated with a deficiency of this glycoprotein. We Univ. School of Med., Washington, D.C. have now studied a total of six families containing seven Following primary immunization with Salmonella children with this syndrome. Three other infants in vaccines, the majority of serum antibody activity is as- these kindred died of liver disease prior to this study. sociated with IgM-immunoglobulins. The amount of All the patients studied had an absence of the a-1- antibody protein produced and its contribution to total globulin, a level of antitrypsin inhibitor of less than serum IgM are unknown and form the basis for the 0.4 mg/ml of serum and an almost complete absence present studies. of the a-1-antitrypsin by immunoelectrophoresis using A total of 8 children received either 1 or 2 injections specific antisera. Six of the nine siblings of these patients of typhoid vaccine. Within 10 days, total serum IgM, so far examined have had levels of antitrypsin in the measured by quantitative precipitation, reached peak heterozygote range (0.40-0.80). The parents studied concentrations averaging 170% of preimmunization have all been in the heterozygote range. The other levels; IgG and IgA changed relatively little. By 28 days forms of cirrhosis that we have studied (secondary to IgM usually approximated initial levels. The quantity biliary atresia, cystic fibrosis, tyrosinemia, familial and specificity of IgM typhoid antibody were measured cystic disease of the liver and kidney, familial biliary by comparing serum IgM levels before and after ab- cirrhosis of unknown etiology, chronic active hepatitis) sorption with various types of Salmonella. Analysis of 6 have all had normal or increased levels of antitrypsin. sera obtained 7 to 14 days postimmunization revealed The biochemical and clinical data indicate an auto- 22 to 46 mg of IgM/100 ml serum could be absorbed somal recessive move of inheritance at the present time. by the vaccine strain of S. typhosa. This represented 18 to (APS) 33 % of all serum IgM and 45 to 86 % of the IgM in- crease induced by immunization. The specificity of this antibody to the O, H, and Vi antigens of S. typhosa was 42 Role of Macrophages in Interferon (IF) Production studied by absorbing with Salmonella of varying anti- in Vivo. A. LOWELL GLASGOW, Univ. of Roch- genic compositions. The vaccine strain possessing O, ester School of Med. and Dent., Rochester, H, and Vi antigens was most effective, S. typhosa H901 N.Y. with O and H was intermediate, and S. typhosa 0901 IF is an important factor in host resistance to virus with only O removed the least IgM. These data sug- infections. Clearance of virus from the blood by phago- gest that routine typhoid immunization increases cytic cells and demonstration of IF production by these serum IgM and that most of the increase is specific cells suggest that they may make a contribution to the antibody. (SPR) 'interferonemia' observed in many viral infections. Peritoneal macrophages were collected, exposed to 44 Characterization and Isolation of Reaginic Antibodies chickungunya virus (CV) in vitro, washed, counted, 6 to Wheat Gliadin in the Serum of a Wheat-Sensitive and 4-6 x 10 cells were inoculated IP into recipient Subject. DOUGLAS C.HEINER, GERALD B.GOLD- G3H mice. To control for IF production in recipients STEIN*, LAWRENCE GOODFRIEND* and BRAM by nonadsorbed virus in the inoculum, other groups of ROSE*, Div. of Immunochemistry and Allergy, mice received an inoculum with cells: (1) removed by Royal Victoria Hosp., Montreal, Canada. Abstracts 299 A subject with marked hypersensitivity to ingested versity School of Medicine, Depts. of Pediatrics, wheat had reaginic antibodies in high titre (1:10,000) Surgery and Pathology, Morgantown, W.Va. and a positive Prausnitz-Kustner test was elicited with (introduced by William G. Klingberg). either 2 X 10-8 mg of alpha gliadin intradermally or one A syndrome is described, characterized by the ab- slice of bread by mouth. Reagin, like IgG, was dis- sence of thymus-related lymphocytic functions in the persed throughout DEAE cellulose fractions including presence of a morphologically normal thymus and a the initial pH 8.0, 0.01 M phosphate eluate which con- heretofore unclassified type of dysgammaglobulinemia. tained only IgG, and not IgA, IgM or IgD. Gliadin A 3-year-old boy, with healthy parents and six healthy was copolymerized using either ethylene maleic an- siblings, was admitted with a history of marked growth hydride or ethyl chloroformate to produce immuno- retardation, recurrent bronchopneumonia, long- sorbents with retained antigenic activity. Serum was standing Candida infections, a chronic anemia, and exposed to three different gliadin immunosorbent pre- failure to respond to gamma globulin therapy. He parations and, after exhaustive washing, biologically failed to develop skin-responsiveness to dinitro-fluoro- active specific reagin was eluted from each immuno- benzene after repeated attempts of sensitization, lacked sorbent using 2M NaCl or 2M KI. No immuno- isoagglutinins, and had no typhoid antibodies after globulins could be detected by immunochemical an- repeat immunizations. His platelets were normal. He alysis of the eluates but injection of washed immuno- had normal IgG, markedly elevated IgA and decreased sorbent-reagin complexes into three separate rabbits IgM. Intraperitoneal implants of thymic tissue in mil- resulted in the production of antibodies to IgG in each. lipore chambers and intravenous infusions with fetal No antibodies to IgA, IgM, IgD, albumin, transferrin liver cells failed to restore his immunologic competence. or ceruloplasm were produced. Antibodies to IgE were He died suddenly. assayed by ISHIZAKA and were found to be absent. Autopsy revealed a grossly and histologically normal Antibodies to completement BiC) were produced in thymus, but hypoplasia of Peyer's patches and of ap- low titre. The findings indicate that reaginic antibodies pendiceal lymph follicles. The spleen showed few but can be selectively adsorbed to, and eluted from, im- normal malpighian corpuscles. Thyroid and para- munosorbents and suggest the possibility that some thyroid tissues were normal. Thymus and peripheral reagins to foods may not belong to the IgE class of im- lymph nodes showed PAS and pyronine positive re- munoglobulins. (SPR) ticulum cells and occasional plasma cells. The thymic implants were replaced by loose vascularized fibrocon- 45 The Implications of Specific Infectious Susceptibilitiesnective tissue with small aggregates of lymphocytic ele- in Immune Deficiency States. VINCENT A.FULGI- ments. Hypoplastic, nonfunctioning peripheral lym- NITI*, Univ. of Colorado Med. Center, Denver, phoid tissue in the presence of a morphologically nor- Colo, (introduced by C.Henry Kempe). mal thymus suggests cellular unresponsiveness as the Infections in children with deficient cellular im- basic mechanism for the immunologic defect. (APS) munity differ markedly from those encountered in children with deficient antibody production. Some in- sight into normal specific defense mechanisms may be 47 Cellular Immune Defect: Immunologic Reconstitution gained by consideration of these differences. Fifteen by Allogeneic Bone Marrow. REBECCA H. BUCK- children with deficient cellular immunity associated LEY*, ZOLTAN J. LUCAS*, BRACK G. HATTLER, with immature development of the thymus have been JR.*, CHESTER M. ZMIJEWSKI* and D.BERNARD studied. Eight of these had normal immunoglobulin AMOS*, Duke Univ. School of Med., Dept. of production (thymic dysplasia) and seven very low or Ped., Durham, N.C. (introduced by James B. absent immunoglobulins (thymic alymphoplasia). The Sidbury, Jr.). infectious disease patterns in the two groups was almost Defective cellular immunity was detected in a 10- identical; extreme susceptibility to gram-negative en- year-old girl with severe chronic mucocutaneous moni- teric bacilli (13/15), Candida albicans (12/15), viruses (9 liasis by demonstration of: (1) delayed cutaneous aner- of 13 adequately studied) and the protozoan, Pneumo- gy to a standard panel of antigens and to repeated ap- cystis carinii (tihree definite and three possible). In ad- plications of DNGB; (2) prolonged homograftsurvival; and (3) failure of cultured peripheral lymphocytes to dition, three of the children had peculiar micro- 3 abscesses in the liver and GI tract; two in association incorporate H-uridine normally when stimulated by with a presumed sporozooan. Where applicable, de- phytohemagglutinin. Intravenous amphotericin B had layed dermal hypersensitivity and in vitro lymphocyte been given every 5-12 months since the age of 4 years, stimulation with specific antigens were tested and found but skin lesions would return within approximately 2 absent in this group of children despite intensive ex- months of discontinuing therapy. Following a 16-day posure to the corresponding infectious agents. In con- course of intravenous amphotericin B, we attempted immunologic reconstitution of the patient by the intra- trast, among five patients with congenital or aquired 9 hypogammaglobulinemia (HGG), infections were venous infusion of 3.42 X 10 white (predominantly predominantly due to pyogenic organisms, principally bone marrow) cells from her antigenically similar the pneumococcus and hemophilus infiuenzae. All of the father (determined by histocompatibility testing). Six children with HGG had intact cellular immunity and months following the marrow infusion, the patient's underwent viral infections without incident and did skin remained free of monilial lesions except at the nail- not become infected with Candida albicans. These ob- beds; minimal oral thrush was present on the buccal servations suggest that cellular immunity functions in mucosa; positive delayed hypersensitivity reactions defense against Candida albicans and some viruses and could be demonstrated to C. albicans and to two other may play a role in gram-negative enteric and Pneumo- antigens; and her peripheral lymphocytes demon- tystis carinii infections. (APS) strated normal blastogenesis in vitro. Delayed hyper- sensitivity was still intact when last tested at 11 months 46 Lymphasthenia; Normo-Thymic Lymphoid Dysfunc- following the marrow transfusion. The patient has re- tion. HEINZ J.WITTIG*, JOSEPH R.LANCASTER, mained free of significant moniliasis for 17 months and JR.* and ENID F. GILBERT*, West Virginia Uni- her height has advanced from the 3rd to greater than 300 Abstracts the 10th percentile for age. The clinical improvement possible explanations for the reaction could not be ex- observed following allogeneic marrow transfusion in cluded: (1) antigen-antibody interaction involving this chronically ill child indicates the potential useful- IgG aggregates found in commercial gamma globulin ness of the approach in the treatment of immunologic preparations and the IgG antiaggregate antibody found deficiency disease in the future. (SPR) in the patient's serum; (2) inadvertent intravascular administration of aggregate containing commercial 48 Alteration of the C'lq Component of Complement (C) gamma globulin with the biologically active aggre- in Agammaglobulinemia (AGG) Syndromes: An In-gates being responsible for the reaction. (SPR) born Error Reflected in the C System. H. GEWURZ*, R.J.PICKERING*, C.L.CHRISTIAN*, G.NAFF*, 50 The Wiskott-Aldrich (W-A) Syndrome, A Defect in R. SNYDERMAN*, S. E. MERGENHAGEN* and Antigen Processing or Recognition? R.MICHAEL R. A. GOOD, Univ. of Minnesota, School of Med- BLAESE*, WARREN STROBER* and THOMAS A. icine, Minneapolis, Minn. WALDMANN*, National Institutes of Health, Nat. Recent studies of the C system in diseases associated Cancer Inst., Bethesda, Md. (introduced by with repeated infections have revealed a selective de- Paul A. di Sant'Agnese). ficiency of the C'l component in AGG syndromes. C'l Immunological studies were carried out in 11 pa- is a macromolecule which consists of three subcom- tients with the W-A syndrome (thrombocytopenia, ec- ponents. The first subcomponent to interact with anti- zema and recurrent infection). Delayed hypersensitiv- body—C'lq—is itself a gamma globulin which, like ity responses were absent when tested with PPD, rheumatoid factor, can agglutinate IGG-sensitized mumps, SKSD, Tricophyton and Candidaskin tests, and latex particles. Hence, the serum concentration of C'lq DNCB sensitization despite the fact that the patients g-globulin was determined in the several AGG syn- had mean circulating lymphocyte levels of 2300/mm3 dromes. C'lq was assayed by both the immunopreci- and normal in vitro lymphocyte transformation to phy- pitin assay of HANAUER and CHRISTIAN and by adapta- tohemagglutinin. Measurement of serum immuno- tion of the agglutination assay of EWALD and SCHUBART. globulins generally showed normal yG, high yA and In both series, mean C'lq titers were greatly depressed yD, and low yM levels. Turnover studies with I131 yM in lymphopenic AGG of the Swiss type (27 % and showed that the low yM levels were due to decreased < 10 % normal, respectively) and moderately depressed synthesis. Natural antibodies to blood group antigens or normal in other forms of AGG (77 % and 46 % nor- and five serotypes of E. coli were strikingly diminished. mal, respectively). 'Properdin' titers also showed the In addition, antibody responses to the polysaccharide pattern of marked deficiency in Swiss-type AGG with antigens, pneumococcal polysaccharide types I and II, normal or near-normal values in other forms of AGG. blood group substances, and Vi antigen were markedly Normal titers of C4 and C'2, and normal or elevated depressed. It is, therefore, likely that the low yM level C1 q titers in six other diseases associated with repeated is secondary to diminished responses to polysaccharide infections, suggested this represented a deficit of C'lq antigens which normally sustain the yM levels. Poor synthesis. Whether this apparent synthesis deficit is pri- antibody responses compared to controls were also ob- mary with the lymphoid tissues, or follows a regularly- tained with a variety of bacterial, viral and protein occurring secondary damage to an alternate site such antigens including polio, diphtheria toxoid, brucella as the intestine, is not yet clear. Our finding normal and tularemia vaccines. Both yG and yM antibodies C'lq levels in the DiGeorge syndrome suggests the lat- were produced when there was a detectable response. ter possibility. In either case, we conclude that the We conclude that the W-A patients have a broad im- marked reduction of C'lq and 'properdin'can aid in munological defect involving both humoral and cellu- the early detection of Swiss-type AGG. (APS) lar responses. A broad defect of this type, in association with near normal levels of functional lymphocytes and 49 Anaphylaxis and Antibody to Aggregated Gamma Gadequate immunoglobulin levels, suggests a disorder in Globulin in an Individual With Acquired Hypogamma-antigen processing or recognition; i.e. a disorder of the globulinemia. ELLIOT F. ELLIS* and CHRISTOPHER afferent limb of immunity. (SPR) S.HENNEY*, Univ. of Colorado School of Med. Denver, Col. (introduced by William Hatha- 51 Beta Adrenergic Blockade and Diabetes: Acute Studies way). and Long-Term Therapeutic Trial. LESTER BAKER*, Anaphylaxis after intramuscular gamma globulin is ROBERT KAYE, AVNER BARCAI* and NASIR a rare occurrence. We have investigated such an epi- HAQJUE*, Children's Hospital of Philadelphia, sode in a 17-year-old male with acquired hypogamma- Pa. globulinemia. A unique finding was the presence of an Previous studies demonstrated an increased ketone antibody which precipitated with immunological iden- sensitivity to epinephrine (E) infusion in juvenile dia- tity to rheumatoid factor (RF) on Ouchterlony analy- betics. There did not appear to be a good correlation sis using aggregated human gamma globulin (HGG) as between the rate of FFA rise and the ketone elevation. antigen. This antibody, however, differed from 'clas- To explore these relationships further, acute beta adren- sical' RF in a number of important respects. It reacted ergic blockade was induced in seven diabetic children neither with native HGG nor with gamma globulins of by I.V. MJ 1999, a sulfonamidophenethanolamine other species when studied by antigen binding tech- compound. MJ 1999 prevented any rise in glucose, FFA niques. The majority of the antibody was shown to be and ketones during E challenge. of the G species, further distinguishing it from classical Two diabetic girls who required hospitalization RF. No anti-Gm antibodies were demonstrable in the every 3-4 weeks for ketoacidosis were further studied. patient's serum. IgE was not detectable by gel diffusion Loss of control appeared to be correlated with emo- precipitin analysis nor did the patient's serum block an tional upset. Stress interview resulted in a rise of glucose induced Prausnitz-Kustner reaction. The mechanism at three times the rate seen in a control interview, and of anaphylaxis, therefore, did not appear to involve a 10-fold increase in the rate of FFA rise. Urinary E ex- anaphylactic antibody of the IgE species. Two other cretion increased 3-fold. Beta adrenergic blockade Abstracts 301 prior to stress interview resulted in no rise of glucose or zer connected to an umbilical catheter in the piglet FFA, although urinary E doubled. Trial of long-term through pickup tubing mounted in walls of the isolators. oral MJ 1999 in these children has thus far resulted Blood glucose (glucose oxidase), osmolar, and electro- in no hospitalizations for almost 3 months. These lyte values were determined routinely. In general, results suggest: (1) E may be an important humoral tolerance curves for germfree piglets were of the pre- mediator affecting diabetic control during emotional diabetic type. Osmolality and electrolyte data paral- arousal; (2) blockade of the rise in glucose and FFA leled total reducing and not glucose oxidase values. Al- is possible with MJ 1999, and is effective when though both types were effective, live organisms were challenged by exogenous E or by emotional stress; (3) more efficacious than killed organisms for inducing a long-term beta adrenergic blockade therapy of the shift from abnormal to normal patterns of absorption diabetic who is prone to frequent acidosis shows great and utilization. Both the rate and magnitude of the 'in- promise, and further evaluation is warranted. (SPR) ductive shift' were dependent upon the genus and num- ber of organisms introduced, the test substance em- 52 Studies in Insulin Secretion: A Comparison of Normalployed, and the age of the animal. Among 10 genera of Newborns andInfants of Gestational Diabetic Mothers.bacteria tested, Escherichia, LactobacUlus and Candida ROSITA S.PILDES*, ROBERT HART*, RICHARD were the most efficient in favorably modifying absorp- WARRNER* and MARVIN GORNBLATH, Univ. of tive phenomena. Studies are in progress to evaluate Illinois Coll. of Med. and Cook County Hosp., the influence of selected microorganisms on carbo- Chicago, 111. hydrate absorption and utilization in premature in- Infants of gestational diabetic mothers (IGDM) as- fants. similate intravenous glucose more rapidly than normal (Supported by USPHS grant 5-R01-HD-01609-03.) newborns; this has been attributed to hyperinsulinism. (SPR) In the adult, ingested glucose is a more potent stimulus to insulin secretion than intravenous glucose. There- 54 Evidence that Acrodermatitis Enteropathica (AE) is a fore, islet cell function was examined in 11 normal and Disease of Fatty Acid Metabolism. RALPH CASH* 8 IGDM by means of oral glucose tolerance tests and C.K.BERGER*, Children's Hospital of (2 g/kg). All newborns were less than 24 hours old and Michigan and Sinai Hospital, Detroit, Mich, were fasted for at least 4 hours prior to the test. Changes (introduced by Charles F.Whitten). in peripheral venous blood glucose, plasma immuno- AE is a rare disease of infancy of undetermined etiol- reactive insulin (IRI), growth hormone (GH) and free ogy with distinctive epidermal lesions, malabsorption fatty acids (FFA) were measured at 30-minute inter- and growth failure. Because the clinical state resembles vals for 2 hours. In both groups, fasting blood glucose that of fat-deficient puppies, serum fatty acids were an- (63 versus 60 mg/100 ml) and GH (68 versus 64 m,ug/ alyzed in a critically ill 3-month-old male with AE ml) were the same. In the IGDM, corresponding IRI Arachidonic, an essential fatty acid (EFA) was defi- levels were high (14 ±2 versus 7± 1 uU/ml, p=<0.05) cient, 1.4 % of the TFA (N:5-12), while its precursor, and FFA, low (1.27±0.04 versus 1.62±0.15 mEq/1, linoleic, was present in excess, 19.1 %. The serum also p=<0.05). At % hour, IRI levels were significantly contained saturated and unsaturated fatty acids (ten- higher and glucose, lower in the IGDM. Blood glucose tatively identified) of chain length 18, 20, 22 and 24, values remained significantly higher in the normals not normally found in human serum. Oral arachido- throughout the test In contrast, IRI values were ident- nate, while raising the level of serum arachidonate, ical at 1 hour and higher in the normal at 1 % and 2 hours. failed to elicit a clinical or biochemical change. I.V. Total 2-hour increments of IRI were 103 ± 23 in nor- fat elicited a dramatic clinical response (suggesting an mal and 63 ± 14,uU/ml in IGDM. These observations absorptive defect), with the disappearance of the 'ab- suggest that the improved glucose tolerance character- normal' fatty acids, with the exception of a C20 with izing IGDM may be attributed to an augmented basal five double bonds, an acid capable of correcting the insulin secretion and a brisk response to a glycemic dermal lesions of EFA-deficiency in animals. The fatty stimulus, whereas the diminished tolerance in the nor- acid derangement has been confirmed in an adult with mal newborns is associated with a delayed insulin re- AE, in whom clinically successful Diodoquin therapy lease similar to that of the adult onset diabetic. The caused lessening or disappearance of the 'abnormal' fall (20 %) in FFA was similar in both and changes in fatty acids. These observations suggest an explanation GH were variable. (SPR) for the efficacy of human milk in AE, in that certain fatty acids found in cow's milk inhibit the synthesis of 53 The Influence of Microorganisms upon Intestinal Ab-arachidonic acid. Our data indicates that AE is asso- sorption of Carbohydrates in Premature Germfreeciated with distinctive alterations of the serum fatty Swine. JACK W.LUKEMEYER* and JAMES J. acids, particularly the EFA. This is the first time that SCHAFFER*, Dept. of Ped., Indiana Univ. defective interconversion of the polyunsaturated fatty School of Med., Indianapolis, Ind. (introduced acids has been demonstrated in humans. (SPR) by Morris Green). Over 150 germfree piglets derived by hysterotomy 55 Maternal Phenylketonuria: Implications on Growth from specific-pathogen-free Minnesota 3 sows, 3 to 5days and Development. WILLIAM K. FRANKENBURG* prior to term, have been studied. Littermates were ran- and BURRIS DUNCAN*, University of Colorado domly distributed among several 24" X 24" X 60" plastic Medical Center, Denver Col. (introduced by isolators maintained in the same room regulated at93F. Henry K.. Silver). Tolerance tests, involving mono- and disaccharides, Eight non-PKU offspring of phenylketonuric moth- cow's milk, or infant formulae, were conducted in pig- ers are presented. All of the offspring were mentally lets of various ages which had received: (1) no organ- subnormal and had DQ_(IO_ scores lower than their isms, (2) selected genera of viable organisms, or (3) non- mothers. A review of reported 'normal' offspring of viable organisms. Animals were monitored for reduc- phenylketonuric mothers reveals that of 63 non-PKU ing substances in the blood by means of an autoanaly- offspring of phenylketonuric mothers (i.e., children 302 Abstracts born to women having documented phenylalanine Markedly elevated levels of methionine in blood levels above 20 mg/100 ml with urine specimens giving have been observed in homocystinuria and in various a positive ferric chloride reaction), only one had a forms of hepatic disease such as that seen in tyrosinosis, measured IQ_ score above 90. Of the eight non-PKU galactosemia or neonatal hepatitis. These methionine offspring (who are assumed to be heterozygous for elevations are relatively constant, are present with nor- PKU) given an oral phenylalanine loading test, five mal protein intake and cannot be permanently abro- had phenylalanine-tyrosine ratios in the normal non- gated by only a reduction in dietary methionine. In the heterozygous range. It therefore appears that the one- course of blood amino acid screening of large numbers hour phenylalanine-tyrosine ratio fails to discriminate of young infants, marked methionine elevations have between the normal nonheterozygote and the indi- been detected in 18, aged 5-9 weeks, each of whom was vidual heterozygous for PKU. Growth data from the ingesting at least 7 grams of protein per kilogram per above cases and 13 additional non-PKU offspring de- day. In each instance there was no evidence of either monstrated uniform intrauterine and postnatal growth liver disease or of an inborn error of metabolism. Plas- retardation. The cases reported to date emphasize the ma methionine as measured by ion exchange chroma- importance of ruling out maternal phenylketonuria in tography ranged from 4.7 to 18 mg % (upper limit of all families with 'familial mental retardation' or 'fam- normal 0.6 mg %), while most of the other free amino ilial microcephaly'. (APS) acid levels were elevated to at least twice the normal values. Of the latter, tyrosine was frequently the most strikingly elevated. Blood urea nitrogen levels ranged 56 K.K.: A New Red Cell Membrane Defect. WILLIAM from 22 to 32 mg % (upper limit of normal 21 mg %) KRIVIT and JAMES T.LOWMAN*, University of Minnesota, Minneapolis, Minn. and serum alkaline phosphatase levels ranged from Red cell membrane defects are present in acantho- 19.5 to 28.2 Bodansky units (upper limit of normal 14 cytosis, paroxysmal nocturnal hemoglobinuria and BU). The urine amino acid pattern was that of a moder- spherocytosis. Our patient, K.K. a 5-year-old Cauca- ate generalized aminoaciduria. In each subject, reduc- sian lad, has a different type of membrane defect. Se- tion of protein intake to approximately 3 g/kg/day vere hemolysis and splenomegaly noted in first month resulted in a return of all values to normal. Several of life has required 40 admissionsfortransfusionsdespite mothers reported lessened vomiting and reduced irrita- multiple therapy and splenectomy. Marked peripheral bility in the infants. In one subject, reinstitution of the blood (7-10/100 white cells) and marrow normoblast- high protein intake reproduced the amino acid ab- osis (70 %) continues with minimal reticulocytosis. The normalities which again reverted to normal upon the following were all within normal limits: osmotic fra- ingestion of lower amounts of protein. (APS) gility, acid hemolysin, hemoglobin determination on cellulose acetate, paper and starch gel, nonhemoglobin 58 Glycogen Metabolism in Erythrocytes of Glycogen protein electrophoresis on starch gel, complete glyco- Storage Disease. SHIMON W.MOSES*, REUBEN lytic and hexose monophosphate shunt enzymes, glu- 14 CHAYOTH*, STANLEY LEVIN*, ELA LAZARO- cose consumption and glucose 2-C utilization and in- VITZ* and DAVID RUBINSTEIN*. Dept. of Ped. termediate carbohydrate metabolites, urinary and bone Research, Kaplan Hosp. Rehovath and Central marrow porphyrin studies, Coombs tests direct and in- Negev Hosp., Beer-Sheva, Israel (introduced direct. The intracorpuscular defect was clearly indi- 51 by Norman Kretchmer). cated by Cr half-life survival of 6 days of his cells in Evidence of active glycogen metabolism is being pre- normal recipient and converse time of 18 days. Abnor- sented in both normal and glycogen-rich erythrocytes mal autohemolysis (10-15%) was corrected by glu- taken from patients with type III glycogen storage dis- cose, ATP, inosine but not heparin. In aerobic condi- ease. Activity of all enzymes catalyzing the reactions tion, this correction was not equivalent to anaerobic required for glycogen synthesis and degradation have tests. Mechanical fragility was twice normal. The phos- been demonstrated in mature erythrocytes. Using cells pholipid percentage partition of red cell membrane was from patients with type III glycogen storage disease, it abnormal as follows: was demonstrated that the glucosyl units are first incor- porated in the outer tiers, then transferred to the core Phospho- Choline Ethanol- Serine Sphingo- where they tend to accumulate due to the absence of glyceride amine myelin amylo-l,6-glucosidase. The glycogen-rich cells have a (PE) higher rate of glucose utilization which is not reflected by an increased lactate production. The rate of 14CO Normal 29.2±1.5 27.5±1.5 14.8±1.7 25.4±1.4 14 K.K. 35.1-37.8 23.6-24.6 9.2-10.7 23.9-25.2 production from glucose-1- C during incubation was After increased in the abnormal cells when methylene blue incubation 37.8-39.4 12.7-17.2 4.6- 6.0 30.9-36.0 was added. (Supported by USPHS grant AM-09-302-03.) The marked loss of PE on incubation indicates an in- (SPR) crease in susceptibility to oxidation. Conceptually, a lack of appropriate antioxident or inherent suscepti- 55 Studies of the Control of Renal Gluconeogenesis. JU- bility of lipids to normal peroxidation may be the LIAN IRIAS* and ROBERT E.GREENBERO, Dept. mechanism involved in this new entity. (APS) of Pediatrics, Stanford Univ. School of Medi- cine, Palo Alto, Cal. 57 Hypermethioninemia and Elevation of Other Free Renal gluconeogenesis has recently been related to Amino Acids in Infants on High Protein Intakes. HAR- certain aspects of renal function. Several approaches VEY L. LEVY*, PHYLLIS M. MADIGAN*, ROBERT have been used in the present study to elucidate control A. MACCREADY* and JOHN D. CRAWFORD, Mas- mechanisms. Rates of gluconeogenesis in rat renal cor- sachusetts General Hosp. and Harvard Med. tex slices were determined by measuring glucose re- School, Boston, Mass. lease into incubation media under aerobic conditions. Abstracts 303 Role of calcium ion: Gluconeogenic rates are increased phalopathy and hepatic dysfunction, a syndrome con- 2-3 times by Ca++ (initially reported by KREBS et al.: sistent with that described by REYE et al. in 1963. All Biochem.J. 86: 22 [1963]). Glucose production in- presented in winter months; ages ranged from 3 % creases linearly with [Ga++] until a maximum is months to 12 years. All had a history of recent mild ill- reached at 5 mEq/1, decreasing at higher [Ca++]. ness; two had chicken pox and six had mild upper re- At a normal serum concentration of ionized Ca++, spiratory infections. They began to have recurrent 2.5 mEq/1, an intermediate rate is observed, suggesting vomiting followed by rapid neurological deterioration that the calcium effect may represent a regulatory with delirium progresing to coma, rigidity and decere- mechanism. If slices are incubated in a calcium-free brate posturing. None had icterus but hepatic enlarge- medium for 30 min and calcium is then added to a con- ment was noted in seven. Five were noted to have ab- centration of 5 mEq/1, a maximal gluconeogenic rate is normalities in respiration and a respiratory alkalosis obtained without lag. The calcium effect is demon- was demonstrated in the three patients who had blood strable when either pyruvate of dihydroxyacetone is gas determinations. Spinal fluid cell and protein deter- used as substrate, implying a site of effect above the minations were normal. All eight patients had labor- level of triose phosphate. atory evidence of hepatic damage with elevated serum Developmental analysis: With pyruvate as substrate, glutamic oxaloacetic transaminase levels. Only two minimal glucose was produced by slices from newborn had blood glucose levels under 40 mg%. Blood am- animals; by four days of age, the rate was half that of monia levels were obtained in the last three patients and slices from adult rats. By contrast, dihydroxyacetone were markedly elevated with values as high as 1022 /xg % supported gluconeogenesis equally well in renal cortex (normal 50-150). Prothrombin time was done in six from newborn and adult rats, suggesting that the step patients and was 50 % or less in five. One child had limiting development of gluconeogenesis is below the rising antibody titers to influenza A2. There were three level of triose phosphate. The activity of phosphoenol- deaths and one living child is severely neurologically pyruvate carboxykinase increases at a much faster rate damaged. The remaining children have recovered ful- than that of other gluconeogenic enzymes in kidney ly. The last three patients, two of whom died, were during the first four days after birth. (SPR) treated with cleansing enemas, neomycin sulfate orally and by enema, steroids and repeated exchange trans- 60 Salicylate Intoxication—Treatment with Potassium fusions. These cases demonstrate that severe hepatic Citrate. WILLIAM T.DOBBINS*, Children's Hos- failure may occur in Reye's syndrome and they sug- pital, Denver, Col. (introduced by Alan K. gest that ammonia intoxication may contribute to the Done). neurologic impairment. However, irreversible cere- The primary treatment ofsalicylat e intoxication con- bral injury occurs very rapidly and it is as yet unknown sists of the rapid removal of salicylate from the body. whether vigorous treatment of the hepatic failure can This is best accomplished by the diuresis of an alkaline improve the survival. (APS) urine. Use of sodium bicarbonate as advocated by OLIVER, WHITTEN and others has not been entirely suc- 62 Spongy Degeneration of the Brain (Von Bogaert- cessful since many patients with severe acute and chron- Bertrand Type)—Probable Generalized Metabolic ic salicylate intoxication have shown a resistance to al- Disorder. W. MELLMAN, A. TENENHOUSE* and kalization of the urine. In addition, the administration P. GIAMBETTI*, Depts. of Pediatrics, Biochem- of large amounts of sodium bicarbonate has produced istry and Neurology, Univ. of Pennsylvania complications of hypernatremia, alkalosis, tetany and School of Med., Philadelphia, Pa. hypokalemia. Based on the premise that the resistance Two siblings have been diagnosed as having spongi- to alkalization was due to a relative potassium defi- form degeneration of the brain. One is a 7-year-old boy ciency, a study was undertaken to determine the effec- with spastic quadriplegia, macrocephaly and optic tiveness of large amounts of oral potassium citrate in atrophy. His brain and muscle biopsies were examined promoting the production of an alkaline urine in chil- by both light and electron microscopy. The brain re- dren with salicylate intoxication. Children ranging in veals the atypical astrocytic mitochondria described in age from 3 months to 8 years with severe acute, and this disease. The muscle shows atrophy of a neurogenic chronic salicylate intoxication were treated with var- type. ious fluid regimens, with and without potassium ci- The younger sibling now 13 months has had a pre- trate. The combination of: (1) I.V. fluids (44 mEq sumptive diagnosis of this disorder. At 10 weeks she NaHCO3, 35 mEq KC1 in 1000 ml 5 % glucose) 2000 a lacked head control and was hypotonic. A muscle ml/M /8 h; (2) NaHCOs-3 mEq/kg by push and biopsy at this time, while on a 300 mg calcium intake, 1.5 mEq/kg ql5 min X 3 if needed to obtain an alka- contained 4-5 X control levels of calcium (960 ^g/g). At line urine; and (3) potassium citrate, orally or by naso- 2 5 months she still lacked head control and she was gastric drip, 200 mEq/M /8 h produced the best re- placed on a 40 mg calcium intake. Two weeks later she sults, namely: (1) All patients had a rapid diuresis of an had head control, improved muscle tone, and social alkaline urine. (2) Blood levels of salicylate decreased responsiveness. This clinical improvement lasted for an average of 70 % in 8 h. (3) Salicylate clearance aver- only about 3 weeks, despite continuation of the diet. aged 20 mg/kg/h. (4) None of the patients developed She then lost head control and has made no progress complications. (SPR) since then; she has neither spasticity nor macrocephaly at 13 months. 61 Hepatic Failure in 8 Cases ofReye's Syndrome. ALLEN The calcium content of her muscle 3 weeks after D.SCHWARTZ*, PETER R.HUTTENLOCHER* and starting the low calcium intake was 296 fig/g, at 8 GERALD KLATSKIN*, Depts. of Ped. and Med., months was 191, and at 12 months was 93. The serum Yale-New Haven Hospital, New Haven, Conn, calcium was always within the normal range. At one (introduced by Charles D. Cook). year she showed bone demineralization and low serum Between December 1965 and January 1968, the phosphate. At this she was returned to a normal calcium authors have observed eight patients with acute ence- intake, and 2 weeks later her muscle calcium was 763. 304 Abstracts This disease appears to be associated with altered not be differentiated by parameters studied. SN was evels on nonionized intracellular calcium. (SPR) not associated with above possible antecedents. (Supported by USPHS grant PH 43-68-4.) (APS) 63 The Neuropathy of Krabbe's Diffuse Sclerosis (Glo- boid Cell Leukodystrophy). H.G.DUNN*, B.D. 65 The Effect of Nerve Growth Factor (NGF) on the LAKE*, C.L.DOLMAN* and J.WILSON* Depart- Synthesis of a Neuronal Lipid. MICHAEL GRAVES* ment of Paediatrics, University of British Colum- and GUY M. MCKHANN, Department of Pedia- bia, Canada, and Hospital for Sick Children, trics, Stanford University School of Medicine, Great Ormond Street, London, England Palo Alto, Cal. (introduced by S.Israels). Nerve growth factor (NGF) is a protein which pro- In contrast to metachromatic leukodystrophy (sul- motes growth and differentiation of two immature fatide lipidosis), the Krabbe type of diffuse sclerosis has nerve cell types, sensory and sympathetic nerve cells. not been generally recognized as being associated with Previous studies have emphasized that the effect of a peripheral neuropathy. In the present study, six in- NGF is to increase anabolic processes, with a stimula- fants with Krabbe's disease were examined in this re- tion of RNA synthesis the primary event. In the present spect. Tendon reflexes were depressed in five of these study, we have focused on the effect of NGF on the syn- six cases and gradually lost in two. Nerve conduction thesis of gangliosides, a group of glycolipids which are studies in three children repeatedly showed marked re- components of neurones, particularly of synaptic mem- duction of conduction velocity in motor fibres of large branes. limb nerves; conduction in sensory fibres was also tested The assay system is the incorporation of l-C14-glu- in two patients and found to be impaired. Biopsy of a coseamine into gangliosides in vitro by the dorsal root sural nerve in two children and of a scalp nerve in ganglion of the 8-day chicken embryo. A concentra- another demonstrated demyelination when myelin tion of NGF is used which promotes nerve fiber out- stains, acid phosphatase preparations or electron micro- growth by this tissue in vitro. Gangliosides are separated scopy were used. At autopsy, all six cases showed evi- by solvent partitioning, with final identification by thin dence of demyelination in peripheral nerves, and teased layer chromatography. Over an 8-hour incubation nerve preparations in two cases demonstrated that this period, NGF promotes a 50 % increase of incorporation demyelination was segmental in type. It is concluded of C14-glucoseamine into gangliosides. In contrast, in- that a peripheral neuropathy is usually present in sulin has anabolic effects on hexose and nucleotide Krabbe's disease. Peripheral nerve biopsy, usefully pre- metabolism by ganglia but promotes neither nerve fiber ceded by nerve conduction studies, may be of value in outgrowth nor ganglioside synthesis. the diagnosis of this leukodystrophy. (APS) This experimental system may be useful for the study of the relation between a growth-promoting substance 64 Spasmus Nutans and Congenital Nystagmus: Noso- with tissue specificity and the metabolism of a mem- logically Separate? P.JAYALAKSHMI*, T. F. MC- brane lipid localized within that same tissue. (SPR) NAIR SCOTT, S.H. TUCKER* and D.SCHAFFER*, Children's Hospital of Philadelphia, School of 66 Abnormal Phospholipid Composition and Synthesis in Med. Univ. of Pennsylvania, Philadelphia, Pa. PMN Leucocytes in Downs' Syndrome. E. E. MCCOY Infantile nystagmus (NYS) of unknown etiology may and J. L. NANCE, Department of Pediatrics, Uni- be variously diagnosed as spasmus nutans (SN), con- versity of Virginia School of Medicine, Char- genital nystagmus (CN), or of unknown type (NUK). lottesville, Va. To test the nosological validity of this distinction, pro- A shortened half-life and increased activity of mul- spective data were reviewed from birth to 8 years on a tiple enzymes has been noted in PMN leucocytes of total (T) of 52 infants with NYS and 56 controls (C), Downs' syndrome (DS). As phospholipids are impor- from within NIH Collaborative C.P. Project (Phil- tant in cell structure, lipid composition and synthesis adelphia population—7,000 [POP]), regardless of pre- was studied in isolated PMN leucocytes from male DS vious diagnoses. Of these, 30 were SN [sub group (SGr) patients, age 14 to 25 years, and normal young men, of 28 studied in greater detail], 4CN and 18 NUK. Re- age 20 to 25 years. Isolated PMNs were incubated in sults. I. Incidence of NYS higher (p = 0.01) in (a) Ne- acetate-C14, lipid extracted then separated into classes groes (96 %T; 97.5 % SGr; 87 %POP); (b) multigravida and phospholipids into 5 fractions by thin layer chroma- 3, (75 %T; 71 %SGr; 5.5%POP). II. The following tography. The total lipid content determined chemical- were higher (p = 0.01) in T and SGr than C (1) family ly was similar and the amount of cholesterol and tri- history (FH) of (a) NYS (10/44T; 7/25SGr; 1/56 C), glycerides was similar in the two groups. The total (b) neuropsychiatric disease (NPD), (23/46T; 14/ amount of cholesterol ester and of phospholipid was 25SGr; 15/56C); (2) presence in child of (a) strabis- significantly less in DS subjects (p<0.025). There was mus (S), (25/52T; ll/28SGr; 3/56C), (b) otherneuro- significantly less phosphatidyl choline (PC), lysoleci- logical abnormality (NA), (17/52T; 9/28SGr; 1/56 C). thin (LPC) and sphingomyelin (Sph) in DS PMN but III. Prognosis as to persistance of NYS 5 years of age in similar amount of phosphatidyl serine (PS) and of both T and SGr not significantly altered (p = 0.1) in phosphatidyl ethanolamine (PE). The incorporation regard to FH of NYS, FH of NPD, presence of S or NA, of acetate-C14 into total lipid, cholesterol and chol- onset at birth or later. IV. In SGr, the following pre- esterol ester was similar. Incorporation by DS was cipitating events were insignificant (p = 0.1). (1) Pre- markedly greater into triglycerides (p<0.001) but sig- vious or present obstetrical complications; (2) neo- nificantly less into the phospholipid fraction (p <0.005). natal course; (3) prematurity; (4) illnesses; (5) heat Acetate-C14 incorporation into PS was less (p<0.005), trauma. In addition, disturbed maternal child rela- and into PE greater (p <0.025) by DS, but similar for tionship (psychologist reported 4/28SGr; 7/48C; p = PC, LPC and Sph for both groups. The results show 0.1) and poor lighting (judged adequate on inspection that lipid composition and synthesis in PMN of male for 23 of 28 children) were not operative. Conclusion. Re- DS patients differs from that of normal men. As phos- gardless of initial diagnosis, SN, CN and NUK could pholipids have important roles in cell function and Abstracts 305 structure, the abnormalities of PC, LPC, PS, PE and 69 Dwarfism and Mental Retardation: the Serum Growth Sph metabolism in DS may provide an explanation for Hormone Response to Hypoglycemia. S. DOUGLAS a shortened half-life and increases of multi-enzyme ac- FRASIER* and FRED G. SMITH, JR., Pacific State tivities previously noted in PMN leucocytes of these Hosp., Pomona, Cal., Univ. of South Calif. patients. (SPR) School of Med., Los Angeles County General Hosp. and Univ. of Calif. School of Med., Los 67 Fatty Add Synthesis in the Developing Brain. ER- Angeles, Cal. NESTO AEBERHARDT* and JOHN H.MENKES, An association between mental deficiency and UCLA School of Medicine, Los Angeles, Cal. growth retardation is well recognized. In order to Mitochondria and microsomes prepared from ma- evaluate the possible role of abnormalities in growth ture rat brain incorporated malonyl-Co A and acetyl- hormone (GH) secretion in dwarfism associated with Co A in a variety of saturated and unsaturated fatty mental retardation, we have investigated the serum acids by a chain elongation mechanism. Malonyl-Co A GH response to hypoglycemia in mentally retarded was the precursor for fatty acid biosynthesis in the mi- children. Thirty-one institutionalized test patients crosomal system, while both malonyl- and acetyl-Co A (height 2-6 SD below the mean for age), 15 institution- were active in mitochondria. Microsomes incorporated alized control subjects (height ± 2 SD from the mean malonyl-Co A into saturated fatty acids (18:0), and for age) and a noninstitutionalized control group of 20 polyunsaturated fatty acids (22:4, 22:6). The mito- endocrinologically and intellectually normal children chondrial acetyl-Co A system synthesized mainly were studied. Serum samples were obtained 0,15,30,60, monounsaturated fatty acids (20:1), with lesser 90 and 120 min after the i.v. administration of crystalline amounts of saturated and polyunsaturated fatty acids. insulin (0.05-0.1 units/kg). Serum GH was measured by In the developing rat the total amount of fatty acid radioimmunoassay. The mean peak serum GH concen- synthesis by either system was maximal at 13 to 15 days, tration after the induction of hypoglycemia was 26.6 a time of rapid myelination. Synthesis of saturated fatty m^g/ml (95 %CL 1.8-70.7 ny«g/ml) in institutionalized acids, mainly 18:0, by the microsomal system followed and 18.9 m^ig/ml (95%CL 4.5-38.3 nyjg/ml) in non- a similar development pattern, while mono- and poly- institutionalized controls. The mean peak serum GH unsaturated fatty acid synthesis in the microsomal and concentration was not significantly different in these mitochondrial system did not change with maturation. two groups. The data were pooled, giving a mean peak The effects of estrogens on fatty acid synthesis in serum GH concentration of 22.2 m/tg/ml (95 % CL 3.1- mature and immature rat brain will also be presented. 52.9 m/tg/ml) for control subjects. The mean peak (SPR) serum GH concentration in test patients was 18.5 xn/ig/ ml (95 %CL 1.0-50.0 nyjg/ml) and did not differ sig- 68 Postnatal Alterations in Brain Protein Metabolism. nificantly from that of control subjects. However, the RICHARD J. SCHAIN, MICHAEL J. CARVER* and peak serum GH concentration was <5 m^g/ml in 7 test JOHN H. COPENHAVER*, UCLA School of Med., patients (22.5 %) while the peak serum GH concentra- tion exceeded this level in all control subjects. This dif- Dept. of Ped., Los Angeles, Cal., and Univ. of 2 Nebraska Coll. of Med., Dept. of Neurol. and ference is significant (x =6.75; p=<0.01). These Psychiat., Omaha, Neb. results indicate that abnormalities in GH secretion oc- Protein turnover, as determined by incorporation of cur commonly in dwarfism associated with mental re- labelled amino acids into protein fractions, is more tardation and may contribute to the growth failure ob- rapid in the immature nervous system than in the adult served in these patients. (SPR) male. The present studies were undertaken to investi- gate these changes in the newborn miniature pig. The 70 A longitudinal Study of EEG and Auditory Evoked piglets were procured by hysterectomy at differing Responses During Sleep in Low Birth Weight Infants. gestational ages or following spontaneous delivery. ELLIOT D.WEITZMAN* and LEONARD J.GRA- Tracer doses of L-(U14C) phenylalanine were adminis- ZIANI*, Depts. of Neurol. and Ped. and Rose F. tered intraperitoneally during the first few days of life. Kennedy Center, Albert Einstein Coll. of Med., Animals were sacrificed one hour after administration New York, N. Y. (introduced by Harry H. Gor- of the isotope. TCA insoluble (protein) and soluble don). (free amino acid) fractions were prepared from liver, Brain maturation was evaluated by a study of EEG cerebral cortex, pons-medulla and cerebellum. The patterns, auditory evoked responses and activity be- relative order of activity in the areas examined was havior during sleep in 25 low-birth-weight infants with constant regardless of age. The activity in liver protein gestational ages of 23 to 39 weeks. Algebraic summed was 4-5 fold greater than in brain areas. Incorporation evoked responses to clicks were recorded from the scalp of the labelled amino acid into brain protein fell 50 % EEG by a computer technique. Sequential recordings or more within the first 24 hours in the spontaneously and behavioral observations were obtained at 2-week delivered piglets. Expression of the radioactivity in intervals until discharge from nursery and then one brain protein as a fraction of activity in liver protein month later. The less mature infants spent more time revealed, while there was some decrease in incorpora- in an active sleep state. As the infants matured, periods tion into liver protein postnatally, there was a con- of quiet sleep occurred for longer durations and inter- siderably greater decrease in the various brain regional rupted the active sleep phase more frequently. The EEG areas. Premature delivery of the piglets resulted in a pattern of infants 23 to 26 weeks post conception age similar but more abrupt decrease in labelling of protein consisted almost entirely of an 'intermittent' pattern. in all regional brain areas. These data suggest that a As maturation progressed, this 'intermittent' pattern rapid decrease in brain protein turnover occurs shortly became more closely associated with periods of quiet after birth unrelated to gestational age. The occurrence sleep. A 'continuous' EEG pattern, appearing at ap- of a similar phenomenon in prematurely born human proximately 29 to 31 weeks post conception, was in- infants might be expected to significantly affect CNS creasingly associated with an active sleep phase. By 34 development. (SPR) to 35 weeks the correspondence between EEG pattern 306 Abstracts and sleep state was more constant. The first negative lacking either thymidine kinase or inosinic acid pyro- and the second positive wave of the evoked response phosphorylase. In five experiments, almost all of the had a significantly longer latency during the 'inter- hybrid cells contained an intermediate reductase mittent' (quiet sleep) compared to the 'continuous' activity. Therefore, the variant cells may represent (active sleep) EEG pattern in infants 34 to 44 weeks of 'operator-constitutive' mutants; alternatively the syn- age post conception. Wave latencies decreased with thesis of reductase may not be controlled by a diffusible maturity of the infant and the evoked response com- repressor in mammalian cells. (SPR) plexity was related to both age post conception and the scalp electrode placement site. (SPR) 73 A Bacterial Model System for Study of a New Mech- anism for Mutation. CHARLES R. ROE*, Duke 71 Experimental Congenital Adrenal Cortical Hyper- Univ., Durham, N.C (introduced by James B. plasia: Existence of Vulnerable Primordium of 3fS- Sidbury, Jr.). Hydroxysteroid Dehydrogenase in the Rat Blastula. An incisive test for genetic relatedness in micro- ALLEN S.GOLDMAN, Children's Hosp. of Phil- organisms is the guaninecytosine (GC) content of DNA adelphia, Pa. and hybridization of single-stranded DNA from differ- Most teratogens are ineffective when given to the ent species. An irrefutable law of kinship in micro- pregnant rat before the eighth day of gestation, during organisms is that the DNA GC content is constant for the development of the three germ layers. The produc- each species. A mutational event has been witnessed tion of a model of congenital adrenal hyperplasia due to that conflicts with the hypothesis requiring a fixed GC a genetic deficiency of 3/S-hydroxysteroid dehydro- content. A mutant organism obtained from a culture genase by a C-19 substrate analog (2a-cyano, 4,4,17a- of Pseudomonas testosteroni has been studied which has a trimethyl-17/?-hydroxyandrost-5-en-3-one) is due to higher GC content than its wild-type. Electrophoretic its selective inhibition of this fetal enzyme. At term, studies of numerous enzymes as well as the total protein fetuses of rats injected with analog on days 5, 6 (time reveal all to be more acidic. Amino acid analyses reveal of implantation of the early blastula), 7 and 8 have a remarkable changes in per cent composition of many highly significant degree of adrenal hyperplasia, clit- amino acids but no deletions. This organism grown oral hypertrophy, and hypospadias, and virtually no under certain conditions reverts back to organisms histochemical activity of the dehydrogenase in the fetal which in all categories fall into the P. testosteroni group. adrenal or Leydig cells. Adrenal weight per g fetal A mechanism based on a defective DNA polymerase weight was significantly larger in fetuses of mothers having altered base selectivity has fulfilled all criteria treated prior to mating, since their birth weights were of change in the mutant organism. Reports of tran- reduced. These fetuses also had a slight but significant sitions and transversions in protein synthesis are be- degree of hypospadias and reduced activity of de- coming more frequent. These reports are related to hydrogenase. These observations indicate that analog single proteins while the present hypothesis suggests produces the same syndrome and defect of dehydro- ordered nucleotide substitution throughout the DNA. genase when administered considerably before either An extensive mutation of this nature would result in development of activity of dehydrogenase, or of differ- three categories of organisms all having GC content entiation of cells containing enzyme. Since it is un- displaced from the normal species value: (1) potentially likely that these effects can be explained by persistence lethal mutations in which several amino acids could of free analog in mother or fetus, evidence is provided not be utilized in protein synthesis; (2) 'normal'indi- for the existence and vulnerability of a molecular pri- viduals in which all proteins would be normal in amino mordium of an enzyme in a mammalian egg or blastula. acid content and sequence; and (3) individuals in (SPR) which all proteinswould be affected and marked pheno- typic changes would be present. The latter category 72 Hybridization of Cultured Cells with Normal and In- may well have application in developmental abbera- creased. Folate Reductase. JOHN W. LITTLEFIELD, tions involving overwhelming phenotypic changes. Ped. Genetics Unit, Massachusetts General (SPR) Hospital, Boston, Mass. Extending earlier work by FISCHER and by HAKALA, 74 Inhibition of 3^-Hydroxysteroid Dehydrogenase {3fi- we have selected in a step-wise clonal fashion a number HSD): Changes in Adrenal Mitochondrial Protein of presumably pre-existing variant hamster cells with Synthesis which are not Effects ofACTH. SALVADOR 100- to 10,000-fold increased resistance to aminopterin CASTELLS* and EDWIN D.BRANSOME, JR.*, Unit due to 10- to 100-fold increased folate reductase activ- of Experimental Medicine, Dept. of Nutrition ity. The latter probably reflects an increased amount and Food Science, Massachusetts Inst. of Tech- of enzyme, judging from the experience of HAKALA nology, Cambridge, Mass, (introduced by Ira with another cell line, since there is no evidence for an K.Brandt). inhibitor or activator nor any change in the sensitivity Guinea pigs were treated for 4 days with a synthetic of the enzyme to heat or aminopterin. The increased steroid inhibitor of 3/J-HSD, 2a-cyano-4,4,17a-tri- amount fo enzyme is probably due to accelerated syn- methyl-androst-5-en-17/3-ol-3-one (CK), or depot thesis because there is essentially no change in the ACTH for 4 days to 2 weeks. There were a number of stability of the enzyme in vitro or in vivo. differences in effect on adrenal protein metabolism. In bacteria increased enzyme synthesis can be ex- Mitochondrial proteins were of particular interest be- plained by loss ofarepressor ('regulator-constitutive' cause they include steroidogenic enzymes remote from mutants) or the ability to be repressed ('operator- the microsomal locus of the inhibition by CK of 3/5- constitutive' mutants). Since the former should be re- HSD action. The adrenals were exposed to L-leucine- cessive and the latter codominant, several of the variant 3H for 4 hours in vivo. Crude mitochondrial pellets were cells have been hybridized with others containing a obtained by centrifugation at 15,000 g for 10 minutes of normal amount of reductase. For this purpose, the an 800 g cytoplasmic supernatant. Adrenal hyper- high reductase marker was introduced into sublines trophy, as measured by adrenal weight, was more pro- Abstracts 307 nounced in the CK-treated animals than in ACTH- opment. Two enzymes of the pathway, aspartate trans- treated. The specific radioactivity of mitochondrial carbamylase (ATCase) and dihydroorotase (DHOase) protein was greater in the inhibited animals than in were assayed at intervals of 3 days in the liver, heart, either chronic AGTH-treated or normals. When mito- brain and intestine of the chick embryo from the 7th chondrial proteins were fractionated by acrylamide gel to the 19th day of embryogenesis. The most elevated electrophoresis, it was evident that the inhibition of enzymatic activities were observed in the earliest stages. 3/S-HSD led to increased labeling of some proteins and These values decreased with increasing embryonic age, not of others. ACTH failed to reproduce such effects. apparently in relation to the relative rate of growth of In another series of experiments, endogenous ACTH each organ. High activities were detected in liver and production and the effect of CK on adrenal enlarge- intestine while lower activities were encountered in ment were suppressed by administration of dexametha- brain and heart. Preliminary work indicates the pres- sone, but many of the effects of CK on protein metab- ence of dihydroorotate dehydrogenase and carbamyl olism remained. These results suggest that inhibition phosphate synthetase in these embryonic tissues. The of one of the enzymes involved in steroidogenesis may developmental patterns of activities and the magnitude by itself cause changes in protein synthesis which cannot of these activities for ATCase and DHOase are distinc- be completely explained by the stimulatory effect of tive for each organ, although within the individual or- ACTH. Thus, in adrenogenital syndromes, not only gan these characteristics are strikingly similar for both increased ACTH production, but intracellular controls enzymes. In unicellular organisms this pathway has of enzyme protein synthesis may also play a role in been shown to be regulated allosterically. Similar phe- adrenocortical growth and steroidogenesis. (SPR) nomena may exist during development. (Supported by USPHS Grant HD 02147-02 and the. 75 Changes in Bilirubin UDP-Glucuronyl TransferaseW.K. Kellogg Foundation.) (SPR) During Postnatal Development. JOSEPH KRASNER* and SUMNER J.YAFFE, Dept. of Ped., School of 77 Effect of Caloric Restriction on Regional Growth of Rat Med., State Univ. of New York at Buffalo, N.Y. Brain. IRVING FISH* and MYRON WINICK, Dept. Activity of the enzyme, bilirubin UDP-glucuronyl of Pediatrics, Cornell Univ. Med. School, New transferase, is low at birth and reaches a peak (2 to York, N.Y. 3 times greater than adult values) at 14 days of age. In We have previously reported that caloric restriction vitro assays were carried out using hepatic microsomal during the first 21 days of life decreases the rate of cell preparations derived from mice of different ages. Kine- division in rat brain. However, neither normal cellular tic studies under the same assay conditions showed growth in specific brain regions nor the effects of caloric marked differences between microsomes derived from restriction on this growth have been studied: DNA con- adult and 14-day-old animals. Michaelis-Menten con- tent reaches a maximum in brain stem by 13 days and stants (Km), a characteristic of enzyme-substrate affin- cerebellum by 17 days. In cerebral cortex, DNA con- ity, were ~ 6 X 1 (HM and ~2x 10"3M respectively at tent is still increasing at 21 days. In hippocampus, a these two ages. Preparations derived from adult females discrete rise in DNA content occurs between 14 and 17 had enzymic activity twice that of the male, but the days. Protein content increases more rapidly than Km values were the same. After dialysis of the micro- DNA in cerebrum and brain stem and more slowly in somal pellet against EDTA and addition of deoxy- cerebellum. Thus protein/DNA increases in cortex and cholate, separation of the solubilized enzyme was car- brain stem and decreases in cerebellum. These data ried out on a Sephadex G-200 column. This treatment demonstrate that cell number reaches a maximum in resulted in 60-70 % solubilization of the activity con- different areas at different times and protein/cell in- tained in the original microsomal pellet. Striking chan- creases in certain areas and decreases in others. Caloric ges were noted in the relative substrate affinity of the restriction from birth results in a marked decrease in solubilized enzyme, derived from adult animals, with cerebellar DNA by eight days of age, whereas no effect Km increasing to ~ 2 X 10"sM. In contrast, solubiliza- can be demonstrated on cerebral cortex until 14 days. tion did not modify the Km value in preparations from The major early effect on brain stem is a reduction of 14-day-old animals. These findings indicate that differ- total protein and hence the protein/DNA ratio. Thus ent forms of the enzyme exist at the several stages of caloric restriction effects the various regions of brain development studied. Alterations produced by solubili- differently. Cell division is interfered with first in cere- zation procedures suggest a common structural form bellum and only later in cortex and brain stem. Pro- which changes its conformation during maturation. tein/cell is reduced most markedly in brain stem. These (SPR) data highlight the importance in future studies of divid- ing the brain into component regions. (SPR) 76 Synchronous Changes in Activity of Pyrimidine Bio- synthetic Enzymes During Embryogenesis. ALBERT78O Development of Ornithine-Ketoadd Aminotransferase GALOFRE* and NORMAN KRETCHMER, Stanford Activity in Mammalian Liver. NIELS C.R.RAIHA* Univ. Medical School, Palo Alto, Cal. and M.KEKOMAKI*, Dept. of Med. Chem. and The relevance of the de novo pathway for pyrimidine Children's Hosp., Univ. of Helsinki, Finland biosynthesis to the formation of nucleic acids and conse- (introduced by Norman Kretchmer). quently to the phenomenon of growth stimulated this Ornithine functions as an obligatory substrate for investigation. Previous work from this laboratory urea synthesis in the liver and as a precursor of poly- showed that the activity of aspartate transcarbamylase amines. The first step in ornithine catabolism is cata- was elevated in the heart and liver of the fetal rat and it lyzed in mitochondria by ornithine-ketoacid amino- decreased progressively during development. The transferase (OKT; EC 2.6.1.13). This study was under- chick was chosen as the experimental animal in the taken in view of the marked changes which occur in present study because of the relative ease in determin- urea and polyamine synthesis during development. In ing the stage of embryogenesis and also because deter- human liver a high fetal level of IKT was followed by minations could be made at very early stages of devel- much lower activity postnatally. In the rat, on the other 308 Abstracts hand, the activity was low during fetal life, with a tran- tal defect with an overriding aorta, and double outlet sient peak around birth. After the 14th postnatal day, right ventricle. activity increased to adult level within a week. Five Current studies have shown that significant growth mg/100 g body weight of triamcinolone i.p. induced retardation is present in the embryos with heart de- OKT activity to adult level in 24 hours when given post- fects which is not seen in sham operated controls. In ad- natally before the natural increase of activity. Puro- dition, the growth retardation is more severe in speci- mycin inhibited completely this effect. Fetal or adult mens with double outlet right ventricle than in those animals did not respond to glucocorticoid. In adult with less severe abnormalities. Growth retardation is animals, the enzyme activity was markedly increased general, affecting linear measurements as well as by high protein, and depressed by lack of protein and/or weight, although weight seems slightly more retarded. arginine in the diet. It is suggested that the peak of OKT On the 20th day of incubation, the weight of 15 experi- activity around birth is a developmental increase mental animals was 79 % of that of 20 sham operated caused by some unknown factor and not influenced by controls. Crown-rump length of experimentals was exogenous glucocorticoids, the second increase an adap- 85 % of control values. tive one due to a change in the balance between intake The etiology of the growth retardation is undeter- and utilization of protein and amino acids. This can be mined. Since the defects are produced by purely me- altered by glucocorticoids (SPR) chanical means, it is the heart defect itself which in some way leads to interference with embryonic growth. Total 79 Biochemical Similarities of Childhood and Adult Cyst- egg weights during incubation indicate that experi- inosis. JERRY A. SCHNEIDER* and J. EDWIN SEEG- mental eggs lose more weight during incubation than MILLER*, National Institutes of Health, Bethes- do controls. This might suggest higher metabolic activ- da, Md. (introduced by R.Rodney Howell). ity since only water vapor and gases can be lost through Individuals with the adult form of cystinosis (AC) the shell. However, the differences are too small to ac- have corneal, conjunctival and bone marrow deposits count for more than a portion of the total growth retar- of cystine crystals which are indistinguishable from dation. (SPR) those observed in children with cystinosis (CC). Unlike CC, which is invariably fatal, AC is entirely benign, with no demonstrable renal defects. It is hoped that 81 Plasma Progesterone in the Perinatal and Neonatal studies of AC will increase our understanding of CC. Period. PATRICIA W.CONLY*, THEODORE MOR- RISON*, DOUGLAS H.SANDBERG* and WILLIAM The free-cystine content of both leukocytes and cul- W. CLEVELAND, Univ. of Miami School of Med., tured skin fibroblasts from three unrelated patients Miami, Fla. with AC was markedly greater than normal (NL, see This study was designed to investigate progesterone table). In all cases, the values fell between those for metabolism at delivery and in the neonatal period. Con- heterozygotes (HET) and homozygotes for CC. centrations of progesterone were measured in maternal, When either leukocytes or fibroblasts from AC pa- cord and infant's plasma. The competitive protein- tients were subjected to subcellular fractionation, three binding radioassay developed by MURPHY (J.clin. observations were made which had also been true for Endocr. 27: 1167 [1967]) was employed. The sensitivity these tissues in CC: (1) three-quarters of the free-cys- of the method allows measurements of m/zg/ml concen- tine was found in the granular (acid-phosphatase-rich) trations of 12 women at delivery ranged from 46 to 387 fraction; (2) almost twice as much cystine was re- with a mean of 158. By 2-3 days post partum the con- covered from the granular fraction if it was first treated centrations had dropped to 1-24 m/tg/ml. Cord plasma with Triton X-100; and (3) hypotonicity caused a from the same subjects had much higher concentrations greater release of cystine than acid phosphatase from ranging from 435-2000 m^g/ml with a mean of 1130. this fraction, suggesting the cystine is not trapped in In the infants, levels of progesterone declined rapidly. lysosomes. Thus, the principal difference between CC There were 4-32 (mean 17) on the first, 3-15 (mean 7) and AC was content of intracellular cystine, which was on the second, and 0-11 (mean 3) m^g/ml on the third 80-100 times normal in CC and 30-50 times normal in day of life. Concentrations of progesterone in 27 pre- AC. (SPR) matures varying in birth weight from 1350-2470 g ranged from 2-34 m^g/ml on the first day, 1-5 (mean2) Free-cystine (fxmole % cystine/gram protein) on the second day, and 2-4 on the third and fourth days. No. No. Concentrations in six infants with respiratory distress Leukocytes ofpa- Fibroblasts ofpa- syndrome were not different from other prematures. PL Mean (Range) tients Mean (Range) tients Maternal and cord levels of progesterone in one case of CC 6.44 (3.98-13.1) 9 8.40 (6.64-10.6) 6 abruptio placenta were remarkably low. The concen- HET 0.49 (0.01-0.89) 9 0.34 (0.12-0.72)4 tration in the mother's plasma at delivery was 28 m/zg/ NL 0.08 (0.01-0.17) 10 0.07 (0.01-0.15)9 ml and that in cord blood 88. These studies indicate AC 2.24 (0.96-3.60) 3 3.32 (1.54-5.09) 3 that blood from the placenta contains extremely high concentrations of progesterone. Lower levels in the peripheral venous blood from the mother may repre- 80 Embryonic Growth Retardation in the Chick Secondary sent dilution. In both mother and baby, levels of pro- to Mechanically Induced Heart Defects. IRAH. GESS- gesterone decline rapidly following delivery. (SPR) NER, Univ. of Florida Coll. of Med., Gainesville, Fla. An experimental method for producing a spectrum 82 Plasma FSH Levels in Normal Children and in of predictable congenital heart defects in the chick has Children with Various Pituitary or Gonadal Disorders. been described. This method utilizes temporary me- DON S. SCHALCH*, MICHAEL F. BRYSON* and chanical manipulation of the primitive heart tube as the LOUYSE A.LEE*, Univ. of Rochester School of etiologic agent. Defects produced include a small or Medicine and Dentistry, Rochester, N.Y. (intro- large ventricular septal defect, a large ventricular sep- duced by Gilbert B.Forbes). Abstracts 309 Plasma FSH levels have been determined by radio- hypogonadism indicate activity of the pituitary-gon- immunoassay in a number of normal children ranging adal axis in the prepubertal state. (APS) in age from birth to adolescence, and in children with various pituitary or gonadal disorders. At birth, the 84 Constitutional Male Sexual Precocity-Testosterone mean FSH level (32.9 m/tg/ml) in normal infants was Production Rates (TPR) and Therapy. ALVRO M. markedly elevated. Subsequently, plasma FSH con- CAMAGHO* and ROBERT L.TROUY*, Univ. of centrations dropped to low but readily detectable levels Tennessee Coll. of Med., Memphis, Tenn. (in- in both boys (2.6 m/*g/ml) and girls (1.5 mjug/ml), and troduced by James N.Etteldorf). showed a gradual but significant rise (p<.05) to the Urinary TPR's (mg/24 h) in 5 males (ages 2 to 7 time of adolescence. In menstruating girls, the mean years) with constitutional sexual precocity (CSP) FSH level during the follicular phase of the menstrual ranged from 25 to 100% of normal adult males (av. cycle (3.3 niyug/ml) was significantly higher (p<.001) 5.8). Biweekly injections of 150 to 250 mg of 17a- than the level during the luteal phase (1.4 m/tg/ml). hydroxy-6a-methylprogesterone acetate (6-MPA) All demonstrated a mid-cycle peak in FSH (8.6 m/ig/ were given for 10 to 80 weeks. TPR's were determined ml), while only half had a second peak (8.3 nijug/ml/ 4 to 6 days after the last injection. In patients C.V. and which occurred during the mid-follicular phase. Eight J.H., the TPR fell from 5.8 to 0.2 and from 1.0 to <0.1; children with various degrees of precocious sexual de- in C.V., twelve days after the last injection of 6-MPA, velopment had normal plasma FSH levels. In contrast, the TPR was similar to the control level; it was in- the mean FSH level in 7 patients with primary gonadal creased in both to greater than control levels with the failure (3 Turner's, 2 Khnefelter's, 1 testicular femini- simultaneous administration of chorionicgonadotropin zation, 1 anorchia) was markedly elevated (14.6 m/j,g/ and 6-MPA. C.V. was treated with 6-MPA for 80 ml), consistent with the absence of gonadal hormone weeks and there was a deceleration of linear growth suppression. Evidence that the negative feedback sys- and skeletal maturation; TPR was 1 % times the con- tem was still intact was provided by the finding that trol value 6 months after discontinuing 6-MPA. In plasma FSH dropped to normal levels in some of these R.G., M.M. and D.I., there was a definite decrease in subjects after testosterone or estrogen administration. the TPR while receiving 6-MPA (from 7.8 to 3.8,9.3 to No detectable plasma FSH was found in 2 subjects with 3.1,4.9 to 1.4) but not to the level attained in C.V. and hypopituitarism and 1 with a hypothalamic tumor. H. J. Six months of treatment in R.G. did not decelerate These studies reveal the dynamic nature of the pituit- linear growth and skeletal maturation; data are in- ary-gonadal axis and also the usefulness of this immuno- complete in M.M. and D.I. In C.V., H.J. and D.I., assay in the diagnosis of pituitary and gonadal dis- the percentage of injected testosterone excreted as free orders. (SPR) and glucuronide was altered by 6-MPA; there was a 53 %, 206 % and 650 % increase. Conclusions: (1) TPR is increased in males with CSP and is decreased by 83 The Relationship of Plasma Luteinizing Hormone 6.MPA. (2) Variable suppression of TPR by 6-MPA (LH) Concentration to Gonadal Function. indicates the importance of TPR's in monitoring the A.W.ROOT*, T.MOSHANG, JR.*, A.M.B0NG10- effect of the drug; urinary testosterone excretion may VANNI and W. R. EBERLEIN, Univ. of Pennsyl- not correlate with the production of testosterone in vania School of Med. and Children's Hospital, males receiving 6-MPA. (3) Increased dosages and/or Philadelphia, Pa. more frequent administration of 6-MPA should result Plasma LH concentrations were determined by in further lowering of TPR. (4) The data suggest that double antibody radioimmunoassay in 201 subjects. In 6-MPA may be effective in the treatment of boys with 34 normal males, 0.17-13 years, LH was <2.5 mlU/ml this disorder. (SPR) (2nd IRP-HMG) in 28 and 2.5-11 mlU/ml in 6. In 15 males, 13-18 years, LH was 2.8-11 mlU/ml in 7, 85 The Effects of the Administration of Beta-Hydroxy- and was not detectable in 8. LH was <2.5 mlU/ml in butyrate (BOHB) on the Levels of Insulin, Glucose 11/14 females less than 10 years, and 3-14.8 mlU/ml in and Glycerol. LILIANE LORIDAN* and BORIS SEN- 12/15 early pubertal premenarchal females (10-14 IOR*, Department of Pediatrics, New England years). LH was not measurable in the plasma of 24/33 Medical Center Hospitals, Boston, Mass, (intro- males (3-16 years) with constitutional delay in growth duced by S. S.Gellis). and development and ranged from 2.7-9.8 mIIJ/ml in Past studies have shown a reduction in levels of glu- the others. In 18/20 subjects with hypopituitarism, LH cose and free fatty acids (FFA) in response to ketones, was <2.5 mlU/ml. Of 22 children with true sexual pre- an effect generally attributed to stimulation of insulin cocity, premature pubarche or premature thelarche, secretion. Since increased insulin secretion as a normal the LH concentration was <2.5 mlU/ml in 18; in 2 response to starvation appears paradoxical, the effects children with sexual precocity and intracranial tumors, of ketone administration were reexamined. The sub- LH was 9.5 and 5.8 mlU/ml. LH was 15.8-22.5 mlU/ jects were six adults, four children with a history of ml in 4/8 children (0.08-12 years) with Turner's syn- hypoglycemia with ketosis and two control children. drome, while in 4/5 older patients (12-18 years) LF was After an overnight fast, BOHB 15 g/m2 was infused in- 9.5-47.3 mlU/ml. Plasma LH ranged from 7-63.4 travenously. The study was repeated in the children mlU/ml in 9 males (17-47 years) with Klinefelter's following induction of gluconeogenesis by 2 days of a syndrome and 4.5-36.3 mlU/ml in 4 males (11-16 low carbohydrate-low calorie diet and a 15-20-hour years) with anorchia. In 4 male pseudohermaphro- fast. Sequential samples of blood were assayed for glu- dites (0.25-15 years), LH was 6-11 mlU/ml. The in- cose, glycerol, FFA, immunoreactive insulin (IRI) and travenous administration of estrone depressed elevated BOHB. In response to BOHB: (a) Glucose levels fell in plasma LH levels in patients with Turner's and Kline- all, following the overnight fast, but to a greater degree felter's syndromes and maintained suppression for more in the children (decrement 29.7 mg per cent versus than 12 hours. The presence of circulating LH in some 5.5 mg per cent), (b) During induced gluconeogenesis, normal children and elevated levels in the child with glucose levels barely decreased (2.8 mg per cent), (c) 310 Abstracts Glycerol levels fell substantially in all. (d) No increase pituitary, insulin raises food intake, food efficiency and in levels of IRI was found, (e) The patients and control weight, but there is no growth of muscle or carcass, only children did not differ in their responses. The results growth of liver. Here RNA, protein, Zn, Mn and GDH indicate a direct reduction of lipolysis and lowering of per unit DNA are markedly increased (for size or age glucose levels by BOHB. Ketones appear physiologi- mate) (p<0.001). By contrast in pituitary insuffiency cally in response to carbohydrate deprivation at a time (untreated) liver RNA, GDH, Zn and Mn are markedly when the glucose level is maintained by gluconeogen- decreased per unit DNA (size mates) (p<0.001). GH esis. By providing fuel for muscles and brain they may does not increase enzymes, trace metal, protein, or actually spare glucose. Thus ketones appear to accom- RNA per unit DNA of liver. Calorie restriction pro- pany hypoglycemia and not cause it. (APS) duces a picture similar to that of a hypophysectomized insulin treated rat. (APS) 86 Diazoxide (D) and Hypoglycemic States of Infants. THEODORE W.AVRUSKIN*, JOHN F. CRIGLER, 88 Plasma Growth Hormone after a Single Intramuscular JR., and DENNIS SLONE*, Harvard Med. School Injection. S.DOUGLAS FRASIER*, GERTRUDE and Tufts Univ. School of Med., Boston, Mass. COSTIN*, SHUN M. LING* and SOLOMON A. KAP- The effect of D (15 nig/kg/day for 5-16 days) alone LAN, Los Angeles General Hosp., Children's or with ACTH-gel or Naturetin on multiple daily fast- Hosp. and Univ. of South Calif. School of Med., ing and postprandial blood sugars (BS-mg%), fasting Los Angeles, Cal. serum immunoreactive insulin (IRI-^U/ml) and Efficient utilization of human growth hormone growth hormone (IRGH-m^g/ml) and the response of (HGH) requires administration of the minimum dos- BS, IRI and IRGH to glucose, glucagon, tolbutamide age which will achieve an adequate clinical response. or 1-leucine has been studied in three infants with per- Dosage has not been based on the plasma concentra- sistent idiopathic hypoglycemia (IH) and an 18-month- tions achieved after HGH administration. We have old girl of a diabetic mother (IDM) with hypoglycemic followed the plasma HGH concentration, measured by seizures. Two of three infants with IH showed no signif- radioimmunoassay, over 48 hours after the initial IM icant changes in fasting BS and increased IRI and injection of 1 or 2 mg HGH (NPA lot No. S-4) in 5 IRGH or in BS and IRI responses to tolbutamide and hypopituitary children. Patients received 25-60 ^g 1-leucine (patient 1) or glucagon (patient 2) when D HGH/kg body weight. Detectable levels of HGH (5.2- was given. BS decreased and clinical symptoms in- 29 m,ag/ml) were observed at 15 minutes. The plasma creased when Naturetin was added (patient 1) and HGH concentration increased rapidly to a peak of 65- ACTH-gel dose reduced (patient 2). The third infant 158 m^g/ml at 2 or 4 hours and slowly fell over the next with IH (BS 30 ± 2.0, mean ± standard error) and ab- 8—lOhours. Twelve hours following injection, theHGH normal BS and IRI response to tolbutamide became concentration was 1-12 m,«g/ml. Plasma HGH was euglycemic (57 ± 1.9) during D and remained so after 3 m^g/ml or less in all patients at 24 hours. Between D was discontinued. Fasting IRI and IRGH increased 24 and 48 hours the plasma HGH concentration was to elevated levels in the post-D period (17 ± 3.8; 10 ± 1.6—3.5 m,«g/ml. The pattern of plasma HGH con- 2.5). The effect of D in patient 3 is uncertain. The IDM centration following an IM injection is clearly different showed a significant (p< 0.001) change in fasting BS from the pattern of physiologic diurnal variation in (63 ±2.5, 75 ±2.1, 65 ±1.9) and IRI (5.7 ±0.4, 2.9 plasma HGH. These observations suggest that present ± 0.7, 4.0 ± 0.7) with no change in IRGH on addition dosage schedules of HGH are pharmacologic and that and withdrawal of D, respectively. Repeated tests be- more efficient use of HGH may result from schedules fore and during D showed significant attenuation of 1- which better approximate physiologic growth hormone leucine and tolbutamide-induced hypoglycemia and secretion. (SPR) IRI release and a temporary decrease of glucose- induced IRI associated with an appropriate change in 89 Pituitary Hormone Concentration in the Stunted Head- BS. Hypoglycemic infants vary considerably in their Irradiated Rat. H.DAVID MOSIER, JR., and RE- responses to D, a fact of therapeutic as well as possibly GINA A.JANSONS*, University of California, Ir- etiologic importance. (SPR) vine; College of Medicine, Los Angeles, and Illinois State Pediatric Institute and the Depart- 87 Action of Insulin and Growth Hormone on Cell Growth. ment of Pediatrics, University of Illinois College DONALD B. CHEEK, and JOAN E. GRAYSTONE*, of Medicine, Chicago, 111. Department of Pediatrics, The Johns Hopkins The mechanism responsible for growth failure re- University School of Medicine, Baltimore, Md. sulting from irradiation of only the heads of two-day- This study was designed to show: (1) The action of old rats has been investigated. Previous studies have insulin on muscle mass, deoxyribonucleic acid (DNA), shown that the pituitary is reduced in size to a greater ribonucleic acid (RNA), protein, and skeletal collagen, extent than is the body weight in the stunted rat. Ad- and on liver, weight, protein, RNA, DNA, zinc (Zn), ministration of bovine growth hormone (Li), thyroxin manganese (Mn), and enzymes glutamic dehydroge- or both, fails to correct the growth impairment. In this nase (GDH) and glutamic oxalacetic transaminase experiment somatotropin, gonadotropin and thyro- (GOT) (transaminase) in the intact rat from 26 to 38 tropin were measured in the pituitaries of irradiated days postnatally. Controls were given an ad lib diet. and control rats at 23, 42 and 121 days of age using the (2) The action of insulin on hypophysectomized rats tibial epiphyseal width, the combined ovarian weight 38-49 days as contrasted with hypophysectomized rats and 24-hour thyroidal I131 uptake in young hypophys- receiving GH or no treatment. These hypophysecto- ectomized rats as indices. Controls were injected with mized groups received the same food/100 gram body saline. The results showed essentially that the concen- weight as did intact rats (calorie restricted). It was tration of these pituitary hormones are not reduced in found that insulin in presence of pituitary raises food the pituitaries of the irradiated rats. In fact, in 121-day- efficiency, increases muscle growth (more and bigger old females the pituitary concentration of gonadotropin cells) but total liver protein is the same. Without the was about twice that of controls. Thus, although there Abstracts 311 is a reduction of pituitary size, the findings suggest that kinetic abnormality was evident for adenosine diphos- mechanisms for pituitary hormonal production are in- phate. Differences in pH optimum and functional tact in the stunted irradiated animals. (SPR) stability of the isozymes were also evident. Leukocytes were unaffected. Family studies revealed paternal 90 Growth Hormone Responsiveness in Fetal Malnutri- heterozygosity for quantitative PK deficiency of the tion. DONALD A.HILLMAN, MARILYN M.LI* and usual type (PKX). Clinically normal maternal relatives ELEANOR COLLE, McGill Univ., Montreal and some siblings demonstrated intermediate deviations Children's Hosp. Research Inst., Montreal in PK kinetics. Phenotypic expression in the propositii Canada. required simultaneous inheritance of both the PKj and From a study of growth hormone responsiveness in PK2 genes. Both genetic defects were traced through 200 children admitted for the investigation of growth three generations and transmission conformed to auto- failure, the birth histories revealed that 15 % were sig- somal recessive modes in the propositii. (SPR) nificantly underweight for their gestational age-^-fetal malnutrition (FM). The HGH response following in- 92 Iron Supplementation: Effect on Iron Stores. sulin, lysine vasopressin and arginine in the FM babies W.K. SCHUBERT*, S. SEGER* and F. SCHNEE- was compared to a control group of children of similar MAN*, Children's Hospital Research Founda- age and sex whose growth rate was normal. The HGH tion, Clinical Research Center, Babies' Milk responses to insulin induced hypoglycemia were as Fund Association, Cincinnati, O. (introduced follows: by Edward L. Pratt). Iron supplementation for normal infants remains Fasting 20min 40 min controversial; studies of its effect on storage iron are FM 5.3 ,/g/ml 11.2 17.8 not available. Twenty-two newborn infants with no evi- Control 2.4 3.73 8.1 dence of hematologic disease by history or physical P< 0.02 0.01 0.005 examination and with hemoglobin concentrations of over 16 grams % were assigned at random to two Fasting 60 min 90 min 120 min groups, one fed an iron-supplemented prepared formula FM 5.3 /zg/ml 15.4 12.0 6.7 containing 12 mg of iron per quart and the other the Control 2.4 8.09 5.21 5.2 same formula without iron. These groups were part of P< 0.02 0.05 0.01 n s a larger study of 118 infants in whom identical studies, except for tissue iron evaluation, were done. Nutritional In addition, arginine stimulation of four FM and management, including introduction of strained foods four normal newborn infants in the first three days of and iron-fortified cereal at 6 weeks of age, and routine life, revealed in both groups high levels of HGH, irreg- well-baby care were performed by the same clinician. ular responses to arginine and no signicant difference Prepared formulas were fed for 12 months; thereafter, between the two small groups. In some FM children, homogenized milk was fed. Tissue iron was estimated plasma cortisol response to hypoglycemia and LVP by sideroblast counts of bone marrow smears obtained was exaggerated, and increases in plasma insulin in at 3-month intervals during the first 18 months of life. response to arginine were minimal. However these Sideroblast counts were lower in the non-supplemented changes were not regularly observed. It is concluded group beginning at 6 months of age, and were signi- that the growth failure observed in FM cannot be ficantly lower at 9, 12, and 15 months of age (p = 0.01, ascribed to HGH deficiency. The reason for the higher 0.01, 0.05); significance was not present at 18 months HGH levels is unexplained and is not related to differ- of age. Hemoglobin, hematocrit, MCV, MCH, ences in blood glucose in the two groups. (SPR) MGHC, TIBC and per cent saturation were signifi- cantly lower from the third month through 18 months 91 An Inherited Kinetically Aberrant Isozyme of Ery- of age in the non-supplemented group. Serum iron tkrocyte (RISC) Pyruvate Kinase (PK) Responsible was also lower in the non-supplemented groups and for Hereditary Hemolytic Anemia. DENIS R. MIL- significantly lower (p = 0.01) between the sixth and LER*, DONALD E.PAGLIA*, WILLIAM N.VALEN- fifteenth months. Between 6 and 18 months of age of TINE*, MARJORIE A.BAUGHAN*, CLAUDE F. the 60 patients in the non-supplemented group, 35 had REED* and O.Ross MCINTYRE. Univ. of Roch- hemoglobins below 10 grams %; 7 of these were below ester, N.Y., Univ. of California, Los Angeles, 8 grams %. In the iron-supplemented group, 8 had Cal., and Dartmouth, Hanover, N.H., Medical hemoglobins below 10 and none had hemoglobins Schools (introduced by Robert J.Haggerty). below 8 grams % (p = 0.01). These findingssugges t that Atypical cases of heritable hemolytic anemia have in hematologically normal children, supplemental iron been noted which conform clinically and biochemically in prepared formula prevents depletion of iron stores to anemia of PK deficiency except for apparently ade- and iron deficiency anemia. (APS) quate quantities of RBC PK activity. The reported pa- tients complied with all criteria for PK deficiency in- 93 Anticoagulant Properties of Stored Pooled Normal cluding Dacie type II autochemolysis patterns, dimin- Human Plasma. GEORGE R.HONIG*, C.F.ABILD- ished and unstable RBC ATP, increased 2,3-diphos- GAARD, A. LlNDLEY*, E. N. FoRMAN*, S. P. GOT- phoglycerate levels, the absence of spherocy tosis, hemo- OFF, J.WOLINSKY* and I.SCHULMAN. Univ. of globinopathies or other demonstrable enzyme defi- Illinois Coll. of Med., Chicago, 111. ciencies and a partial but significant response to splen- Recent observations in our laboratory reveal that ectpmy. Further investigation of fivesuc h anomalous stored plasma, widely used in treatment of shock, diar- cases in two unrelated families demonstrated a kinetical- rhea and burns, has potent anticoagulant activity. ly aberrant isozyme of PK (PK2) with remarkable ineffi- Hematologic studies on an infant admitted for shock ciency at lowered concentrations of its basic substrate, disclosed striking prolongation of a variety of coagula- phosphoenolpyruvate (PEP). Michaelis constants for tion tests which suggested heparin effect (prothrombin PEP were tenfold greater than control values but no time, partial thromboplastin time, thrombin time, in 312 Abstracts the face of normal levels of specific coagulation factors, tion of dietary or physiologic amounts of FA with nor- fibrinogen and fibrinolysin). Further history revealed mal absorption of glucose, xylose, fat and vitamin B12. that the child had received a large volume of stored, Barium studies of gastrointestinal tract and micro- pooled normal human plasma in the emergency room. scopy of the jejunal mucosal biopsy were normal. On The same plasma produced a marked anticoagulant regular diet without supplemental FA she develops effect on normal plasma, in vitro, with the results indi- anorexia, weight loss, buccal ulceration, anemia, leuko- cating inhibition of the thrombin-fibrinogen reaction. penia and thrombocytopenia, bone marrow megalo- Similar results were obtained with 16 different lots of blastosis, increased chromosomal breakage with struc- stored plasma from five different sources. Biochemical tural changes including dicentric chromosomes and and immunologic studies revealed that the plasma was quadriradial configurations, increased urinary FIGLU devoid of fibrinogen but contained large amounts of excretion, reduction in plasma, RBC and CSF folate_ fibrin degradation products. Treatment of the plasmas to Ong/ml (L. Casei method). FA 250 ,«g orally did not with rabbit IgG antihuman fibrinogen completely re- correct the anemia and she continued to deteriorate moved the anticoagulant activity. Infusion of stored hematologically whereas 250 /xg FA intramuscularly plasma into rabbits produced a defect identical to that resulted in a reticulocytosis within 7 days and return of found in the original patient. It has long been known the above parameters to normal. Reversal of normal that storage of purified fibrinogen results in degrada- plasma/CSF folate ratio with normal plasma folate tion of the protein into split products which have anti- levels indicated impaired folate transport into CSF. Re- coagulant activity. That this occurs on storage of whole turn and maintenance of normalcy could also be human plasma has not been appreciated. Therapeutic achieved by 40 mg FA orally daily. No FA antagonists use of the plasma may in some circumstances produce in serum were demonstrated. (APS) laboratory abnormalities suggesting severe coagulation disorders and may, in individuals being treated for 96 The Mechanism of Action of Chemotherapeutic Agents hemorrhagic shock, contribute to further bleeding. in Acute Lymphoblastic Leukemia. B. C. LAMPKIN*, (SPR) T. Nagao* and A. M. MAUER, Dept. of Pediat., Univ. of Cincinnati Coll. of Med., Cincinnati, O. 94 Studies on Fetal Hemoglobin Synthesis in the Newborn: The effect in vivo of chemotherapeutic agents in acute Its Application in Determining Gestational Age. AR-lymphoblastic leukemia is poorly understood. How- LISS H.TUTTLE, deceased, SERGIO A. DE LAME- ever, knowledge of their effects is essential to proper RENS* and DANIEL M. LANE*, Univ. of Tennes- use of these drugs for therapy. For this study three types see Coll. of Med., Memphis, Tenn. (introduced of chemotherapeutic agents, corticosteroids, vincristine by James N. Etteldorf). (VCR) and cytosine arabinoside (CA) were evaluated. A modification of the technique of KXEINHAUER et al., Their effect on marrow blast cells was followed by serial with reticulocyte staining previous to the acid elution, measurements of H3T labeling index (LI), mitotic in- was used to determine the relative concentrations of dex (MI), and volume of buffy coat (BC). Studies with adult and fetal hemoglobins within the mature erythro- prednisone were done in four children; hydrocortisone cyte and the reticulocyte of newborns. Calculation of in seven; VCR in seven and CA in three. A highly sig- these concentrations was determined by the method of nificant decrease in LI was seen in all patients after GARBY et al. Since reticulocytes are recently formed prednisone and in five of seven patients 24 hours after cells with a short half-life, concentrations of fetal hemo- hydrocortisone. In the latter group, a striking decrease globin within these cells should reflect its rate of syn- in BC was found 1 to 24 hours after therapy and a sig- thesis at the time of sampling. nificant decrease in the MI 24 to 48 hours after therapy. Ninety-six newborns (including 13 sets of twins), of After VCR, the MI increased 4 to 14 times at 12 to gestational ages varying from 27 to 40 weeks, were 24 hours. In five patients the MI was still increased at studied. In infants of less than 35 weeks' gestation, fetal 48 hours. The LI was decreased at 48 hours. After CA, hemoglobin concentrations in the mature erythrocytes the MI and LI were decreased markedly by 4 hours but and in the reticulocytes were similar. After 35-week after 24 hours the LI had returned to pretreatment gestation, there was an abrupt and progressive drop in levels. The MI was still decreased. From these results it the percentage of fetal hemoglobin in the reticulocytes. would appear that (1) corticosteroids inhibit DNA syn- This technique can be used in determining gesta- thesis and thereby secondarily decrease the number of tional age and could serve as a new parameter to in- cells in mitosis; (2) VCR arrests cells in mitosis and vestigate the maturity of the newly born. (SPR) thus removes cells for subsequent DNA synthesis; (3) CA inhibits both DNA synthesis and mitosis; and (4) 95 Isolated Defect of Gastrointestinal Absorption of Folkcorticosteroids lyse lymphoblasts. The time relation- Acid Resulting in Megaloblastic Anemia, Associatedship of these effects is important in designing treatment with Mental Retardation and Cerebral Calcification.regimens. (APS) PHILIP LANZKOWSKY*, MARION E.ERLANDSON and ALLAN I.BEZAN*, Cornell University Med- 97 Comparison of Exchange Transfusion and Deferox- _ ical College, New York City, N.Y. amine in the Treatment of Acute Iron Poisoning Folic acid deficiency associated with a generalized N. MOVASSAGHI*, G. G. PURUGGANAN* and malabsorption of other nutrients is a well recognized S. L. LEIKIN, Research Foundation, Children's entity. A syndrome consisting of isolated malabsorption Hosp. of the D.C. and Dept. of Ped., George of folic acid (FA) has been identified in a child who pre- Washington Univ. School of Med., Washington, sented at 3 months of age with megaloblastic anemia, D.C. diarrhea and mouth ulcers. She has been followed for Acute iron poisoning in children continues to be a 17 years and has shown normal physical development, serious problem but, because of the lack of an effective gross mental retardation and basal ganglia punctate therapy, severe cases of iron poisoning can be fatal. The calcification. The megaloblastic anemia has been efficacy of iron removal by deferoxamine (DF), ex- shown to be due to specific gastrointestinal malabsorp- change transfusion or a combination of DF and ex- Abstracts 313 change transfusion was studied in dogs with acute iron tactoid formation, i.e., bundles of parallel rods. Fresh poisoning. A lethal dose of ferrous sulfate was adminis- blood from two patients with HbSS, and one with tered by gastric tube to 3 groups of dogs. In group 1, HbSC were sickled by exposure to low O2 tension or two hours following iron administration, DF 200 mg/ sodium bisulfite, fixed initially in glutaraldehyde at kg was given intravenously over a one-hour period. 37° C and processed for study in the electron micro- Group 2 underwent exchange transfusion three hours scope. Thin sections of sickled cells revealed cy toplasmic after iron administration, and group 3 received DF and elements never observed in normal red cells. Mildly an exchange transfusion two and three hours, respec- distorted cells contained an irregular meshwork of tively, following iron administration. The amount of fibers varying from 65 A° filaments to 180 A° rods. iron removed was measured in the exchanged blood Crescentric sickle cells contained bundles of 180 A° rods and in the urine collected while the animal was alive or generally oriented in the long axis. Chilled sickled cells for a period of six hours. The mean quantity of iron re- were disc shaped and contained no filaments or rods. moved was 486 /«g, 12,755 fig and 12,641 //gin groups 1, Colchicine and vinca alkaloids inhibited sickling and 2 and 3 respectively. Two dogs survived in the group re- rod formation. Sickled erythrocytes were hemolyzed in ceiving exchange transfusion but none in the DF or a tissue homogenizer under conditions which did not combined treated group. Exchange transfusion appears destroy normal cells. The parallel bundles of rods broke to be a more effective and rapid method than DF alone down into an irregular meshwork of 65 A° filaments, for removal of iron in the treatment of severe iron poi- then dissolved as swelling increased. Crystals of hemo- soning. The addition of DF to exchange transfusion globin formed in normal blood cells did not resemble does not significantly increase the amount of iron the tactoids in sickled cells. These findingsindicat e that removal nor does it improve the survival. (SPR) sickling is due to a sol-gel transformation and not to in- tracellular crystallization of HbS. The degree of cell 98 Detecting Hemolytic States from Carboxyhemoglobindistortion is dependent upon the extent of rod forma- tion and association in parallel bundles. Rods appear Levels. ROLF R.ENGEL*, F.LEE RODKEY* and 0 CARL E. KRILL*, National Naval Medical Cen- to develop from 65 A filaments of HbS, and hemolysis ter, Bethesda, Md. (introduced by John A. An- reverses the process of rod formation. (SPR) derson) . During the catabolism of heme there is a molecule of 100 An Increase of Antihemophiliac Globulin (AHG) in a CO generated for each molecule of bilirubin formed. Hemophiliac with Acute Lymphoblastic Leukemia. In demonstrating increased endogenous CO formation JOHN D. BOUHASIN*, St. Louis Univ. School of from accelerated hemolysis, it is important to separate Med. and Cardinal Glennon Mem. Hosp., St. out the effect of variable exogenous exposure. The car- Louis, Mo. (introduced by Arthur E.McEl- boxyhemoglobin (COHgb) level in 229 normal chil- fresh). dren ranged from 0.6 to 3.9 % saturation with a mean of Elevations of AHG levels in patients with acute leu- 1.3% (SD 0.47%). Twenty children with hemolytic kemia have been reported previously, but a rise of AHG diseases had from 1.3 to 2.6 % of their circulating hemo- in a hemophiliac with leukemia has not been reported. globin saturated with CO. The 6-fold range observed A four-year-old male with AHG deficiency of moder- in normal children is largely due to variable ambient ate degree (5% AHG cone), presented with acute exposure, since 226 comparisons between nonsmoking lymphoblastic leukemia in April, 1966. Bleeding did adults who were breathing the same gas mixture for not occur after the bone marrow aspiration or from extended periods always gave COHgb values which injection sites. AHG assays initially showed 75 % and differed by less than 0.3 % saturation. By comparing 100 % of normal AHG concentration. the blood CO content of a suspect hemolytic patient AHG levels on two occasions during remission were with a normal sibling or other control individual who 20 % and 49 % of normal. During a recent relapse, the has been exposed to the same exogenous CO level for AHG concentration rose to 97.5 % of normal. Prelim- several hours, it is possible to obtain a qualitative index inary work with cultured lymphocytes reveals definite of increased endogenous CO production. Children with AHG activity in the cells. known hemolytic disease had COHgb levels which were In view of the previously reported elevation of AHG at least 0.5 % saturation higher than their matched con- nonhemophiliac patients with acute leukemia, the re- trols. Because fetal hemoglobin was found to have a cent splenic perfusion studies, and our findings, it is lower affinity for CO than adult hemoglobin, caution postulated that the lymphocyte is the site of production must be exercised in comparing a newborn or thalas- of AHG. (SPR) semia patient with an individual who has primarily adult hemoglobin or hemoglobin S. The assay for 101 Transmission of an Encephalitogenic Agent from Pa- COHgb can be done in 10 minutes by gas chromato- tients with Subacute Sclerosinq Panencephalitis graphy and requires only 0.1 ml of whole blood. Unlike (SSPE) to Ferrets. M.KATZ*, L.B.RORKE*, the reticulocyte count, abnormal results can be expect- W. S. MASLAND*, H.KOPROWSKI* and S.H. ed before the erythropoietic response. (SPR) TUCKER*, The Wistar Institute and Depts. of Pediatrics, Pathology and Neurology, Uni- 99 The Mechanism of Erythrocyte Sickling and Hemo- versity of Pennsylvania, Philadelphia, Pa. (in- lysis in Sickle Cell Anemia. JAMES G. WHITE, Univ. troduced by A. M. Bongiovanni). of Minnesota Medical School, Minneapolis, Ferrets were inoculated with brain material from Minn. two children with SSPE. After an incubation period of Despite precise definition of the molecular defect in five months, the ferrets exhibited ataxia, spastic gait sickle hemoglobin (HbS), the fundamental mechanism and weight loss. Histopathologic examination of their by which reduced HbS causes distortion of susceptible brains revealed cortical gliosis, structures suggestive erythrocytes has not been determined. One theory sug- of intranuclear eosinophilic inclusion bodies and gests that sickling is due to the intracellular crystalliza- mild meningitis. Secondary passage into new ferrets tion of HbS, and another that distortion may be due to reproduced the disease in three months and its form 21 Pediat.Res.,Vol.2,No.4(1968) 314 Abstracts was more intense and included myoclonic jerks. Histo- other attenuated preparations. HPV-77 derived vac- pathologic picture revealed an intense meningoence- cines were produced by our laboratory in chick em- phalitis of a characteristic viral type. White matter, bryo cells (CE) and in GMK; by Philips Roxane, Inc. brain stem and spinal cord were involved to a greater in dog kidney cells (DK) and by Merck, Inc. in duck extent than gray matter, and cerebellum was spared. embryo cells (DE). Merck, Inc. also produced Benoit There was no demyelination. Electroencephalograms strain vaccines at three passage levels. None of 112 per- showed patterns compatible with progressive ence- sons inoculated with the eight attenuated viruses ex- phalitis, culminating in slow wave configuration and perienced vaccine-associated illnesses and there was no burst-suppression activity resembling that seen in communicability to 90 contacts. HPV-77 vaccines in SSPE. Neither serologic analyses nor tissue culture in- GMK, DE and DK and Benoit C vaccine induced anti- oculation has yielded thus far any clue to the identity bodies in 91 to 100 % of participants. Benoit D, HPV-77 of this infectious agent. Its prolonged latency in the ex- propagated in CE and Benoit E seroconverted 83 %, perimental animals and the subacute course of their 75 % and 29 %, respectively. Antibody titers were 2- to disease suggest that this agent belongs among slow 8-fold lower in persons given the three less immuno- genic vaccines and antibody appearance was delayed. Virus excretion was generally characteristic of the vac- 102 Studies of the Altered Reactivity to Measles Virus in cines. Even with the less immunogenic vaccines pro- Killed Vaccine Recipients. VINCENT A.FULGINITI, duced from 'over-attenuated' strains, virus was shed JAMES H. ARTHUR* and C. HENRY KEMPE, Univ. in 59 % of persons developing antibody. Pharyngeal Colorado Med. Center, Denver, Colo. tissue appears to be a preferred site for attenuated ru- Children who have previously received killed measles bella virus multiplication. While data presented here virus vaccine (KMV) may demonstrate an altered re- indicate that some virus shedding may be expected activity to subsequent live virus exposure. The exact with any effective live rubella vaccine, communicabil- mechanism is unclear. To clarify the immunologic re- ity appears unlikely. Fully immunogenic HPV-77 de- activity of such vaccines, 145 children who received rived vaccines have been administered to 553 persons KMV in 1961-1962 were evaluated for serum antibody without infection of any of their 537 intimate contacts. and delayed hypersensitivity and compared to children (SPR) who experienced only natural measles or only live virus immunization in the past. The following data were ob- 104 Fluorescent Antibody Test for Cytomegalovirus Macro- tained globulin. JAMES B.HANSHAW, HARVEY J.STEIN- FELD* and CHERIE J. WHITE*, Univ. of Roch- Serum Skin induration ester School of Med. and Dentistry, Strong HIA = 1.0 cm Memorial Hosp., Dept. of Ped., Rochester, N.Y. Group Number < 1:8 Killed virus Live virus REMINGTON [1967] demonstrated toxoplasma macro- Measles globulin in the serum of infants with congenital toxo- only 10 0 0 0 plasmosis by an indirect fluorescent antibody test. The Live vac- application of this method to the detection of cyto- cine only 10 0 0 0 megalovirus (CMV) macroglobulin could provide a KMV 145 95 (66 %) 142 (98 %) 119 (82 %) rapid and practical test for active infection in early in- fancy. A drop of the test serum is placed on an encircled In a second experiment, nine of the seronegative smear of trypsinized CMV infected WI-38 cells. (Un- KMV children were bled six weeks later and given infected cells on the same slide act as serum controls.) 0.5 ml of live measles virus vaccine. All nine had de- Following a 30 min incubation period at 20° C, the slide veloped serum HIA titers of 64—512 after the skin test is washed and a drop of fluorescein-conjugated goat and prior to the vaccine administration. None reacted antihuman }>M antiserum is added to each cell area. adversely to the vaccine nor changed their serum titer. The smear is again incubated for 30 min, washed, and By comparison, 15 children studied in 1967 who de- mounted. Positive smears, characterized by fine-lined, veloped severe atypical measles 5-6 years after KMV brilliant, blue-green fluorescence in the perinuclear administration had serum HIA titers less than 1:8 at area, were found in all of 26 virus-positive infants (0—6 the onset of their disease. These collective data suggest mos.). Cytomegalovirus macroglobulin could be de- that KMV recipients develop delayed hypersensitivity monstrated in infected infants irrespective of the yM. or which may be responsible for their altered reactivity, CF antibody level. In contrast, infants with rubella, but the latter is only manifest if serum antibody titer toxoplasmosis were negative, as were uninfected in- is low or absent. It appears as if intradermal virus in- fants with maternally acquired CMV antibody or ele- oculation may boost antibody titer without severe vated yM levels. These data suggest that the cytome- sequelae. (SPR) galovirus macroglobulin test is a specific and sensitive indication of active CMV infection in early infancy. 103 Clinical Comparison of Highly Modified and Conven- (SPR) tional Strains of Attenuated Rubella Viruses. HARRY M. MEYER, JR., PAUL D. PARKMAN, THOMAS E. 105 Echo Virus Type 9 Infection and Tuberculin Sensi- HOBBINS*, H.ELLIOTT LARSON* and HOPE E. tivity. S.BERKOVICH, E. M. SMITHWICK* and HOPPS*, National Institutes of Health, Bethes- M. STEINER*, Dept. of Ped., State Univ. of N.Y., da, Md. Downstate Med. Center, Brooklyn, N.Y. Successful clinical trials with attenuated rubella A number of viral infections can depress delayed skin virus (HPV-77) led to further efforts at virus modifica- sensitivity to tuberculin. Among these agents, measles tion to determine whether one could develop a strain is most consistently effective. Following attenuation, which would not be shed in the nasopharynx. This re- however, this effectiveness is largely lost. During port describes a clinical comparison of HPV-77 vac- measles, the altered skin reaction is associated with a cine grown in green monkey kidney (GMK) with seven significant decrease in the in vitro lymphocyte response Abstracts 315 to tuberculin. In addition, sensitive lymphocytes in- Children with sickle cell disease (SS disease) appear fected in vitro with wild measles fail to respond as ex- to be far more susceptible to severe pneumococcal pected to tuberculin stimulation. Both effects may be disease, such as meningitis, than are those with normal due to changes induced in the lymphocyte by the hemoglobin. Their often fulminant course is reminis- measles virus. The question arises whether other viral cent of pneumococcal infections in splenectomized agents that proliferate in cultures ofperiphera l lvmpho- children. The parallel is consistent with the known cytes also depress skin and lymphocyte reactivity to pathologic changes in SS disease which markedly af- tuberculin. Answer to this query was provided by study fect the spleen. Serum opsonizing activity for the pneu- of an outbreak of Echo 9 disease that occurred in our mococcus in SS disease was measured with a phago- tuberculosis ward during August, 1966. The skin tests cytic test using peripheral leukocytes from normal in- of 14 children with virologic and/or serologic evidence dividuals incubated in test and control sera. The per- of infection remained strongly positive. The virus strain cent phagocytosis in SS disease serum was 6.8 % ± 3.2 recovered has been tested in peripheral lymphocyte (SD), while for control children it was 37.6 % ± 14.4. cultures obtained from eight other tuberculous chil- Activity disappeared from both control and test sera dren and has not significantly depressed the reactivity of when heated. Total hemolytic complement activity of their lymphocytes to tuberculin. In contrast to the SS disease sera was comparable to that of normal in- measles virus, therefore, Echo 9 does not exert a detect- dividuals. Leukocytes from patients with SS disease able effect on tuberculin sensitivity in vivo or in vitro. were indistinguishable from those of normal controls Apparently, the ability to proliferate in peripheral when incubated in normal serum. The deficiency of leucocytes, a property shared by both agents, is not the opsonizing activity may account for the impaired viral factor responsible for changes in skin and lympho- clearance of blood-borne pneumococci in SS disease. cyte reactivity to tuberculin. (SPR) (SPR)

106 Antibiotic Therapy in Chronic Granulomatous Disease108 Corynebacterium Diphtheriae Skin Infections and the of Childhood (CGDC). HAROLD W. LISCHNER* Epidemiology of Diphtheria in the South. MARK A. and THEODORE R.LAMMOT III*, Temple Univ. BELSEY*, MICHAEL SINCLAIR*, RUTH RODER* School of Med. and St. Christopher's Hosp. for and DOROTHY LEBLANC*, Tulane Univ. School Children, Philadelphia, Pa. (introduced by Vic- of Public Health and Tropical Medicine, New tor C. Vaughan III). Orleans, La., and the National Communicable Recurrent purulent infections in CGDC are due to Disease Center, Atlanta, Ga. (introduced by an inborn defect in intracellular lysis of bacteria after Margaret H. D. Smith). their phagocytosis (HOLMES et al.: Lancet 1: 1225 C. diphtheriae infections of skin lesions (SL), though [1966]). There is no satisfactory therapy. The failure of not as frequent as nasopharyngeal and throat (NPT) usual treatments is understandable, since the granulo- infections, may be as important as the latter in the epi- cytes of children with CGDC can protect phagocy- demiology of diphtheria. NPT and SL carrier pre- tized bacteria from the action of a wide variety of anti- valence of 7.8% and 2.8% were found among 1070 microbial agents even after the granulocytes are no healthy individuals, 263 of whom had skin lesions, in longer viable (J.Reticuloendothelial Soc. 4: 431 six population groups. SL carrier levels ranged from [1967]). A rational approach to palliative therapy may 0.7 % in nonendemic areas to 18.9 % among case con- however be possible. In vitro data suggest that phagocy- tacts. The total and NPT C. diphtheriae carrier pre- tic vacuoles may protect bacteria after disruption of valences were higher in 11 households with SL carriers the cell, and may sometimes undergo rephagocytosis. compared to 22 NPT carrier households; infection per- Resting-state bacteria maintain their antimicrobial sisted longer in SL carrier households. Twenty-one of sensitivity in such vacuoles and, in vitro at least, are sus- the 38 individuals with SL C. diphtheriae infections had ceptible to antimicrobial action upon final rupture of NPT infection, the strains being identical at both sites. the vacuole. If bactericidal antibiotics were present at C. diphtheriae in skin lesions probably represents a skin the site and time of phagosomal rupture in the body, equivalent of the respiratory carrier state; they have reinfection might be prevented. This approach, using been found at every stage in a wide variety of lesions, continuous therapy, appears to have been successful at and appear not to influence the spontaneous healing of least temporarily in two brothers with classic GGDC. lesions. Autogenous SL to NPT transmission was sus- One boy had severe osteomyelitis and multiple cuta- pected as being causally related to several diphtheria neous ulcers, the other a huge deep tissue abscess and 1$1 cases. All other patterns of transmission were also noted. liver abscesses or scars demonstrated by I rose bengal However, SL to SL, and SL to NPT transmission, is scan. The acute lesions, due to coagulase negative more consistent than NPT to NPT transmission with Staphylococcus aureus, responded slowly to vigorous ther- the seasonal incidence of diphtheria in the South. apy. Subsequently pencillin has been administered con- Artificially acquired immunity, determined by his- tinuously for nine months. For the first time since early tory or antitoxin assay by the hemagglutination tech- infancy the boys have appeared healthy and had no nique, was unrelated to either SL or NPT C. diphtheriae recurrences or new lesions, in spite of the fact that the infection. Age was inversely related to NPT and SL in- same penicillin-sensitive organism still hibernates in fection (reflecting natural immunity); (SPR) the protective environment of at least one boy's phago- cytic cells. 109 Nursery Routines and Staphylococcal Colonization. (Supported by USPHS grant FR-5624.) (SPR) C. P. S. WILLIAMS* and T. K. OLIVER, JR., Dept. of Pediatrics, Univ. of Washington, Seattle, 107 Impaired Pneumococcal Phagocytosis in Sickle Cell Wash. Disease. ROBERT H. DRACHMAN* and JERRY A. Nurseries were opened at the University of Washing- WINKELSTEIN*, Johns Hopkins Univ. School of ton in September 1961, providing an opportunity to Med. Baltimore, Md. (introduced by David study coagulase-positive staphylococcal (staph) coloni- H. Carver). zation for an extended period of time. The number of 316 Abstracts infants admitted per year to the newborn nursery has perpetuated by officials. Recommendations were for risen from 814 in 1962 to 1374 in 1967. Average stay is more flexibility of design to facilitate future changes, four days. The anterior nares are cultured at discharge, but meanwhile to redistribute bassinet space on a new as a monitor of staph colonization. For the first 20 basis, computed as to number of infants per given size months, care included caps and gowns for all person- of room, compartmentalization of nursery area specifi- nel, masks for all except full-time nursery nurses, hair- cally into close observation, intensive care, convales- nets for female personnel, hand scrubbing with brushes cence and standard full-term newborn care. Juxtaposi- using hexachlorophene on entering nursery, and tion of labor and delivery room area, as well as ped- handwashing with hexachlorophene between handling iatric services, was recommended. Attention was drawn of infants. Infants were bathed with hexachlorophene to the possible advantages of movable walls, and to in the delivery room and daily thereafter. The coloni- changes in air flow management designed to reduce zation rate for first 20 months in the newborn nursery cross-colonization and perhaps reduce the need for in- was 4.2 %. After that time, sequential changes in rou- cubators. Functional changes included charting within tine were made: caps, masks, hairnets were discon- each nursery, and use of the same special care nursery tinued, initial bathing deferred until infants achieved for postoperative management. Additional aspects will thermal stability, medical students and parents given be presented to illustrate agreement as to the need for free access to the nursery, brushes in handwashing dis- flexibility experiment in design and function, use of continued, and finally, gowns discontinued except 'warehouse' space rather than oblong outside walls, when actually handling infants outside an incubator, and repeated reevaluation of the effects of future all with no rise in colonization and virtually no disease. innovation. Adjacent to the newborn nursery is a 16-unit intensive (Sponsored by NICHD-NIH) (APS) care nursery for low birth weight or other ill newborns, two-thirds of whom are outborn. Low colonization 112 Development of a Practical Neonatal Monitoring Sys- rates have also occurred here, despite a more extended tem for Systolic and Diastolic Blood Pressure, Heart stay and the occasional admission of outborn infants Rate, Respiratory Rate and Temperature. PAUL A. infected with staph. This study demonstrates that low BYRNE* and JOHN W.BELD*, St. Louis Univ. staph colonization and disease levels can be maintained School of Med., Cardinal Glennon Mem. Hosp., in nurseries for an extended period of time using careful St. Louis, Mo., and Conductron Corp., St. handwashing and infant bathing with hexachloro- Charles, Mo. (introduced by Arthur E.Mc- phene. Furthermore, certain traditional elements of Elfresh). nursery routine may be eliminated, as long as surveil- Blood pressure is measured by an automatic system lance is maintained so that rises in colonization may be for auscultation of Karotkow sounds detected by a crys- detected promptly. (APS) tal microphone placed over the brachial, radial or tibial artery. A circuit activated by the Karotkow sounds 110 Epidemiology of Enteropathogenic E. Coli (EEC) In-controls a servo-system to inflate or deflate a cuff at the fections. MARGARET H. D. SMITH, KENNETH W. diastolic and systolic pressures. Electrical gating at a NEWELL* and JULIE SULIANTI*, Depts. of Ped- precise time interval controlled by the QRS complex iatrics and Epidemiology, Tulane Univ., WHO, eliminates many artifacts. Correlations between direct- Geneva, Maternal and Child Welfare Service, ly measured intraarterial blood pressures and those Ministry of Health, Djakarta, Indonesia. measured as described yield an almost perfect cor- A prospective longitudinal study was undertaken in relation. 57 households in Louisiana from June 1963 through Direct aorta Indirect brachial June 1965, to describe characteristics of EEC-infected (mm Hg) (mm Hg) persons, duration of excreter state and factors influenc- ing incidence and prevalence of infection. 8.2 % of Infant 1 (systolic) 64 62 8,483 fecal specimens contained EEC serogroups. EEC Infant 1 (diastolic) 38 40 was a total household rather than a childhood infec- Infant 2 (systolic) 95 105 tion. However, more children than adults were in- Infant 2 (diastolic) 48 50 fected; risk of secondary infection was higher if a child, Impedance pneumography is utilized in measure- 1-2 years of age, was the primary case. Findings suggest ment of rate and patterns of respiration. EEC introduction into households by foods, probably Heart rate, respiratory rate, temperature and blood from zoonotic reservoir. (APS) pressure are read on meters calibrated appropriately and may be recorded. 111 Experiment in Updating Nursery Design Concepts. Practicality and simplicity have been stressed in this SYDNEY SEGAL and EILEEN G. HASSELMEYER*, system. It has been used to measure the blood pressure Department of Paediatrics, University of British and/or monitor 75 infants weighing between 820 g and Columbia, Vancouver, B.C., and PBIM, Na- 5600 g (SPR) tional Institute of Child Health and Human De- velopment, NIH, Bethesda, Md. 113 Oxygen Toxicity in Newborn Rats. J. CRAIG, LIVIA Structural and legal impediments to the application H. REV-KURY* and G. KURY*, Harvard Med- of modern techniques of special care and clinical in- ical School, Boston, Mass. vestigation were explored in an experiment in inter- Twenty-one litters of newborn rats with appropriate disciplinary communication and creativity. Partici- controls (8 litters) were exposed to concentrations of pants from pediatrics, obstetrics, surgery, anesthesia, 60 %, 80 % and 100 % oxygen for periods up to 9 days; nursing, hospital administration, public health, in- the lower concentrations were mixed with appropriate dustry, animal care, hospital architecture, as well as concentrations of nitrogen. At levels of 100 % oxygen, federal and state agencies, met for three days of inter- the mothers died within 3 days with massive pulmonary change. Bottlenecks created by building codes had been edema and pleural effusions. The mothers, therefore, imposed by clinical authorities of previous years and were removed from the 100% oxygen for 12.hours of Abstracts 317 each 24. The infant rats had growth retardation in ductus venous a mean of 49.3 hours; and in 115 in- comparison to the air-exposed controls. Incubation of stances in the UV below the DV a mean of 52.1 hours. the excised lungs of rats exposed to 100 % oxygen in Venous catheters were used for infusion of fluids; aortic tritated thymidine revealed 1/10 the frequency of catheters for pressures and sampling sites. All infants labeled cells in comparison to the controls. The histo- received a penicillin 100,000 U/kg/day and chloro- logic changes in the fixed expanded lungs were evident mycetin 20 mg/kg/day without complications for dura- only in the 80 % and 100 % oxygen animals after 6 and tion of catheterization + 72 hours. Heparin was not 4 days or more of exposure. These were qualitatively used. Two hundred and thirteen survivors had had at minimal. They consisted of overdistension of the al- least a six-month follow-up. One hundred and four died veolar spaces, irregular thickening of the alveolar walls with 92 autopsies. Two hundred and seven esophago- and failure of growth of alveolar segments. No mem- grams have been done on 155 survivors. Two survivors branes, edema or effusions occurred. It is evident that show residual complications. One has extrahepatic oc- the lung of the newborn rat is less susceptible to acute clusion of the portal vein with bleeding esophageal oxygen toxicity than the adult and that inhibition of varices, and one has asymptomatic occlusion of the lung and body growth may occur. right common iliac artery. One death was directly (Supported by grants USPHS HD 00144 and AEC related to embolization of the superior mesenteric [30-1] 3777.) (APS) artery. Four infants showed localized necrosis associated with infusion of 0.3 M THAM. Three 114 A Quantitative Assessment of Lung Injury from Oxygen showed thrombosis of U V, DV or hepatic veins alone. with and without Assisted Ventilation, and Air with Two had traumatic aortitis with adherent thrombi. Assisted Ventilation in Newborn Lambs. R.DE- One proven instance of sepsis occurred, not present at LEMOS*, J.WOLFSDORF*, R. NACHMAN*, catheterization. The primary risk associated with BLOCK*, G. LEIBY*, H. A. WILKINSON*, i: chronic aortic catheterization in this series appears to ALLEN*, W.MORGAN*, A.HALLER* and be embolization, while the risk of venous catheteriza- M. AVERY, The Johns Hopkins Medical School, tion is one of thrombosis and localized necrosis especial- Baltimore, Md. ly when the tip resides below the DV and when THAM The pathogenesis of the pulmonary injury reported is infused at that site. (SPR) in infants and older individuals after prolonged use of assisted ventilation with oxygen is unclear, since in the 116 Review of Experience with Umbilical Artery Catheter- clinical situation the respirator or the oxygen could con- izations in the Newborn. WILLIAM D. COCHRAN*, ceivably be injurious or synergistic in producing injury. HEATHER T.DAVIS* and CLEMENT A.SMITH: Fifteen lambs from 1-3 weeks of age were divided into Harvard Med. School, Boston, Mass. three groups, those receiving 80+ % oxygen alone In 387 infants over a 5 54-year period, umbilical through a tracheotomy, others ventilated with 80+ % artery catheterizations were done for diagnosis, ther- oxygen, and a third group ventilated with air from a apy or both. Two hundred and forty-nine of the in- volume-limited respirator. The following are a few of fants had respiratory distress syndrome; 92 were either the measurements made: infants of diabetic mothers or premature infants with transient respiratory distress; 18 were 'dysmature'; Oxygen 7 had severe erythroblastosis and 21 were classified as Oxygen and res- Air and miscellaneous. Two hundred and thirteen of the in- alone pirator respirator fants were 2500 grams or under in birth weight. In most Mean survival time (h) 36 55 86 instances the catheter was left in place for 22-39 hours; Range 10-56 20-72 70—>100 the longest such period was 92 hours; the earliest in- Lung wt/body wt 0.040 0.037 0.024 sertion was 13 minutes and the latest 96 hours of age. Mean peak vol at a static Complications (thrombosis, arteritis or perivascular pressure 45 cm H2O hemorrhage at autopsy, and blanching of one leg or (ml/glung) 1.91 2.24 3.14 bleeding in surviving babies) occurred in 8 % of all in- fants. However, in only 3 % of all cases were those com- Radiographic and histologic findings, as well as sur- plications found at autopsy in potentially hazardous face film balance studies, support the trend shown in the locations. Twenty-one per cent of the 86 total autop- table that no change was found with assisted ventila- sies (out of 93 deaths) had one or more of the autopsy tion with air for periods up to 100 hours; significant complications mentioned. No known subsequent ef- changes were associated with oxygen with or without fects have been observed following return of circulation a respirator, although they were of lesser severity in the in the group with blanched legs. (APS) caudal lobes, and tended to be patchy. (SPR) 117 Maturation of Chemical Thermogenesis in Premature 115 The Complications of Chronic Umbilical Vessel Cath- Infants. LEO STERN, ANGELES RAMOS* and JEAN eterization. VILDAN ERKAN*, WILLARD BLANKEN- LEDUC*, McGill University, Montreal Chil- SHIP* and MILDRED T.STAHLMAN, Vanderbilt dren's Hospital Research Institute, and Depart- Univ. School of Med., Nashville, Tenn. ment of Physiology, University of Montreal, Between October 1961 and June 1967, 317 newborn Canada. infants were subjected to umbilical vessel catheteriza- Noradrenaline is the mediator of chemical thermo- tion as part of a diagnostic and therapeutic regimen; genesis in the newborn. Nine premature infants below 202 had hyaline membrane disease, the remainder a 34 weeks gestational age at birth were studied sequen- wide variety of serious problems. Number 5 French tially to determine their ability to increase urinary nor- feeding tube catheters with platinum beads in the dead adrenaline excretion when changed from a 'neutral' space and luer adapters were used. In 284 instances, the (32-34°) to a 'cool' (25-27°) environment. On initial catheter lay in the abdominal aorta a mean of 48.8 study, six of nine increased noradrenaline excretion on hours; in 200 instances in the umbilical vein above the cold exposure with a mean increase of 0.350 nanog/kg/ 318 Abstracts min. Mean fall in rectal temperature for the group was Intravenous or intraperitoneal injection of H"3 or 2.4° with the three nonresponding infants showing the C"14 labelled leucine into animals of various ages result- largest fall (3-5°). When restudied two weeks later, all ed in the following percentages of total serum protein nine infants increased urinary noradrenaline excretion label precipitable by an immunoelectrophoretically in the 'cool' zone. The increases were quantitatively pure antiserum to porcine albumin: 2 % in three fetuses greater with a mean rise of 0.717 nanog/kg/min, and injected in utero and in their simultaneously injected, mean rectal temperature fall for the group was now delivered littermate; 7-13% in unsuckled newborns; only 0.9° not exceeding 2.2° in any ofthesubjects. These 19% in a 5-day-old animal; 25 % % in a 10-day-old findings suggest that the noradrenaline response is a animal; and 20 % in a 15-day-oldanimal. Preincubated major mechanism in the newborn's defence against slices from late fetal and unsuckled newborn animals cold and that its maturation in time parallels the de- showed only equivocal or no net synthesis of albumin, velopment of thermal stability in the premature infant. whereas slices from 10- and 14-day-old animals showed (SPR) substantial synthesis (means 60-80 ,ug/g liver wet weight). Radioactive labelling of immune-precipitable albumin by liver slices from 5-, 10- and 14-day-old 118 Phospholipids in Human and Monkey Amniotic Fluid.animals was 2-10 times greater than by slices from STANLEYN. GRAVEN, Hartford Neonatal Center, unsuckled newborns, using either tissue weight or pro- Univ. of Wisconsin and St. Mary's Hosp., Mad- tein as a basis. The percentage of total protein label as ison, Wis. albumin was 1 %-3 times greater in slices from older Phospholipids in amniotic fluid at different gesta- animals. Precipitations by antialbumin performed on tions were studied as a possible indicator of fetal pul- double-labelled slice incubation products confirmed monary development. Amniotic fluid was obtained that the results above did not result from artifacts in the from 40 mothers at gestations of 21-40 weeks. The precipitation step itself. (SPR) phospholipids were extracted and separated by TLC. The phospholipid phosphorous determinations were 120 Direct, Serial Blood Sugar Determinations in Infants performed. with Respiratory Distress Syndrome by Use of the All of the amniotic fluid samples from mothers with Autoanalyzer Technique. JAMES J. SCHAFFER* and uncomplicated pregnancies and healthy fetuses con- JACK W. LUKEMEYER*, Indiana Univ. School of tained significant concentrations of: (1) lecithin; (2) a Med., Indianapolis, Ind. (introduced by Morris fraction located below cephalin (probably a mixture of Green). phosphatidylmono and dimethylethanolamine); and Several investigators have demonstrated the favor- (3) a fraction that migrated with or near the solvent able effects of the early administration of glucose and front (probably phosphatidic acid). The amniotic fluids water in groups of high risk infants. Accordingly, a contained very low concentrations of cephalin, lysole- method was employed which permitted the use of an cithin and sphingomyelin. The lecithin extracted from autoanalyzer for the direct determination of blood glu- the amniotic fluid migrated as a narrow homogenous cose levels in a group of 12 infants with respiratory dis- band easily distinguished from the wide band observed tress syndrome. A sterile assembly connected to the for lecithins extracted from serum, egg yolk, or whole autoanalyzer pickup tube was attached to a No. 8 poly- lung. ethylene catheter inserted in the umbilical vein and No lecithin or fraction (2), but a low concentration samples of blood were withdrawn automatically. Bac- of fraction 3 (phosphatidic acid) was found in the teremia was not encountered. A solution of 10 % glu- amniotic fluid from a mother in labor at 34 weeks' ges- cose with sodium lactate was infused via scalp vein at a tation whose 1.77 kg infant developed RDS. A previous rate to maintain normal glycemia and urinary flow. 1.93-kg-34-week infant born to this mother and a Favorable clinical response was manifested by a de- 1.80-kg-33-week infant of the mother's sister both had crease in respiratory rate and cyanosis, an increase on severe RDS. muscular activity, and adequate urinary output (5- Data on amniotic fluid from 25 monkey pregnancies 10 ml hourly). Various degrees of hyperbilirubinemia at 75, 100, 125, 150 and 175 days' gestation also will be existed in the distressed infants; however, no exchange presented. transfusions were required. Preliminary data indicate It is proposed that phospholipids of fetal pulmonary that the infusion of a relatively small quantity of glu- origin appear in the amniotic fluid as early as 21-24 cose affords a rapid, significant rise in blood sugar, that weeks' gestation, but may be absent or in low concen- glycosuria is common, and that the effect of glycogeno- tration in amniotic fluid from pregnancies producing lytic agents, e.g., epinephrine and glucogon, is unpre- fetuses which appear to have a familial predisposition dictable. The advantages of the autoanalyzer technique to the development of the RDS. (SPR) include: (1) the use of a small blood volume for deter- mination; (2) reduced manipulation of the sick infants; 119 Synthesis of Serum Albumin by Perinatal Piglets. (3) immediate visualization of accurate blood sugar L. A. PAGE* and R.LARDINOIS*, Dept. of Ped- levels; and (4) regulation of the infusion at a rate to iatrics, Stanford Univ. School of Medicine, Palo insure normal glycemia and urinary flow. (SPR) Alto, Cal. (introduced by R. E. Greenberg). At birth the predominant serum proteins in the pig- 121 Clinical and Morphological Correlates in Acute Glom- let are postalbumin (a-fetoprotein) andaprealbumin(s) erulonephritis. JOHN E.LEWY*, LUIS SALINAS- recently described by this laboratory. Postnatally, MADRIGAL*, CONRAD PIRANI* and JACK MET- there is a sharp fall in these proteins and a rise in albu- COFF, Michael Reese Medical Center, Chicago, min. We have examined the synthesis of albumin by 111. perinatal piglets and slices of their livers, using im- Eighty-two biopsies and three autopsies were ob- munologic techniques. The studies indicate that at least tained on 49 patients with the clinical diagnosis of acute some of the rise in serum albumin reflects increased syn- glomerulonephritis and serologic evidence of a recent thesis. streptococcal infection. Two patients died during the Abstracts 319 acute stage of the disease and were autopsied. Forty- formation. We have extended these studies to include three biopsies were obtained during the acute phase 25 children with uremia secondary to a variety of renal (4-42 days after clinical onset). The severity of thehis- disorder. Sixty of 69 sera (87 %) from 20 of 25 patients tologic lesions were graded semiquantitatively from (80 %) uremic patients were positive for SPF; patients 0^i+ based on an assessment of a number of histo- with high blood urea nitrogen (BUN) had high levels of pathologic features in the glomeruli, tubules, vessels and SPF. Coagulation studies were normal without evi- interstitium, and compared with concurrently esti- dence of fibrinolysis. Infusion of urea into a patient mated levels of glomerular nitration rate (creatinine without renal disease resulted in a BUN of 90 mg/100 ml clearance), blood urea nitrogen (BUN), antistreptoly- but no SPF in the serum. Serial studies of SPF indicate sin O (ASO) and total hemolytic complement titers, that in certain illnesses, e.g., hemolytic-uremic syn- and semiquantitative urinalysis (Addis count). One or drome, anaphylactoid purpura, chronic nephritis, SPF more follow-up biopsies associated with clinical and are elevated during azotemic and disappear as the BUN laboratory reevaluations were obtained on 24 patients returns to normal, suggesting that uremia causes the for a period up to 5 years. In the acute phase, there was intravascular coagulation. In other illnesses, e.g., acute a statistically significant correlation between indices glomerulonephritis, lupus nephritis, SPF are elevated of histologic severity and impairment of creatinine after azotemia disappears or without azotemia and are clearance, and elevation of BUN. The morphologic correlated with the activity of the renal disease, suggest- changes did not correlate statistically with ASO or ing that intravascular coagulation is part of the patho- complement titers, or degree of hematuria, proteinuria, logic process affecting the kidney. Heparin did not af- pyuria or cyllindruria. Twenty-five children were fol- fect the SPF level in one uremic patient and may have lowed for two years or longer. One of these died from aggrevated a preexisting bleeding tendency. (SPR) progressive disease and was autopsied, two revealed persistent histologic and clinical changes, and 6 revaled 124 Anticoagulant Therapy of Progressive Renal Disease in only slight persistent clinical abnormalities with al- Children. ROGER C.HERDMAN*, JOHN R. EDSON* most complete resolution of their histopathology. Six- and ROBERT A. GOOD, Dept. of Pediatrics, Univ. teen appeared to have completely recovered clinically, of Minnesota Hospitals, Minneapolis, Minn. with morphologic resolution in all ten of these who Ten children with progressive renal disease including were rebiopsied. (APS) subacute nephritis, anaphylactoid purpura nephritis, chronic hypocomplementemic (CHN) and normo- 122 The Morphogenesis of Renal Parenchymal Malforma-complementemic nephritis and Wegener's granulo- tion. JAY BERNSTEIN, Dept. Pathology, Albert matosis were selected for treatment with several months Einstein Coll. of Med., New York, N.Y. of aqueous heparin (H) given subcutaneously every 8 In previous studies we have shown that abnormalities hours in doses sufficient to keep clotting time always of tubular development result from experiment hy- 2 % times normal; followed by long term warfarin (W) dronephrosis in immature animals. These alterations treatment in doses sufficient to double prothrombin in epithelial maturation mimic very closely the histo- time. In 5 cases an increase in renal function measured logic abnormalities seen in congenitally malformed kid- by inulin or creatinine clearance and in 4 cases a de- neys. An extremely frequent complication of theexperi- crease in daily urine protein output occurred although mental procedure, however, has been severe chronic it is not proven that this was due to therapy. Assays of pyelonephritis due to gram-negative bacilli. To estab- circulating coagulation factors were performed. In most lish that the developmental abnormalities are related instances these were abnormal initially and in some in- to urinary obstruction rather than to chronic inflam- stances were changed by therapy. Titers of hemolytic mation, similar studies were carried out in germ-free complement did not change except in 2 cases of CHN animals. Unilateral ureteral ligation in newborn rats where they rose from 30-40 % of normal to normal dur- resulted in a spectrum of histologic abnormality similar ing H. In such patients I1S6 BiC survival was studied. to that seen in conventional animals, except that in- Serial renal biopsies showed improvement in glomeru- flammatory lesions were not encountered. The initial lar morphology in 3 instances by routine microscopy alteration appeared to be marked dilatation of collect- with disappearance of glomerular deposits of fibrin ing ducts ana tubules, in which the epithelium retained and/or immunoglobulin in 2 instances by fluorescence or reverted to a primitive appearance. In the absence microscopy. The data firmly support the conclusions of tubular dilatation, even in severely hydronephrotic that H can return complement titers to normal in CHN kidneys, primitive epithelial changes were inconspic- and that in some instances quantitative abnormalities uous. These observations support the concept that of coagulation factors can be corrected. There is sug- urinary obstruction during nephrogenesis and renal gestive evidence that in some types of renal disease maturation is a major factor in the morphogenesis of anticoagulation may be worthwhile therapeutically. parenchymal abnormalities. (SPR) (Supported by USPHS grants HE-06314 and HE- 05662.) (SPR) 123 Split Products ofFibrinogen in Patients with Uremia. E.RICHARD STIEHM and CARL W.TRYGSTAD*, 125 Elevated Plasma Ketones, Free Fatty Acids and In- Dept. of Pediatrics, Univ. of Wisconsin Med. sulin Levels in Renal Glycosuria. P.W.HOUCK, School, Madison, Wis. A. M. GLASGOW and E. E. MCCOY, Department The presence of split products of fibrinogen (SPF) in of Pediatrics, University of Virginia School of the serum as measured by an immunologic technique Medicine, Charlottesville, Va. is a sensitive indicator of intravascular coagulation not Renal glycosuria is a disorder characterized by a low detectable by other coagulation studies. Our prior renal threshold for glucose and fasting plasma glucose studies (Midwest Soc. Ped. Research, 1967) indicated (PG) within the normal range. Normal and abnormal that serum from patients with several forms of renal glucose tolerance tests (GTT) have been reported in disease have positive tests for SPF, and that their meas- these patients. To explain the basis of abnormal GTT, urement provides useful diagnostic and prognostic in- the studies presented were undertaken. Simultaneous 320 Abstracts studies of plasma ketone (PK), free fatty acid (FFA) proteins of rat renal cortex in vivo and in vitro was used and plasma insulin (PI) levels in the fasting state, and to test this hypothesis. after glucose loading, were carried out in a three-year- Leucine-U-14C (10,MC/100 g body wt) was injected old girl who has had continuous glycosuria of at least I-P, either 24 h or 7 days after a single i.v. injection of one year's duration in the presence of normal fasting AMN (10 mg/100 g body wt) and 2 h prior to sacrifice PG values. During this time she has had two normal of rats. 14C incorporation into cytoplasmic protein was and two abnormal GTT's. In the fasting state and with not affected 24 h after AMN injection, but markedly normal PG values, markedly increased plasma levels increased after 7 days (cpm/mg protein, mean ± SE, of acetoacetate (PAA), /?-hydroxybuterate (PpOHB), AMN versus control: 352±29 versus 227±10, FFA, and PI were found. After glucose loading the p<0.01). In contrast, 14C incorporation into mitochon- PAA, PpOHB and FFA decreased to near normal, but drial protein was decreased within 24 h after AMN in- PI levels remained high. These studies demonstrate jection (106±6 versus 332 ± 35, p<0.01), but in- that some patients with renal glycosuria and abnormal creased after 7 days (256 ± 12 versus 147 ± 2, p<0.01). GTT have abnormalities of PAA, PpOHB and FAA When renal cortex slices of normal rats were incubated metabolism, plus elevated PI levels. It is postulated with glycine-2-14C in vitro, addition of a-oxoglutarate that these abnormalities are a compensatory mecha- (a-OG) to the medium increased 14C incorporation into nism secondary to large renal losses of glucose. Treat- whole tissue protein (no substrate versus a-OG: 732 ± ment with frequent glucose feeding partially corrects 20 versus 1728±64, p<0.001). 14C incorporation by these metabolic defects. (SPR) renal cortex slices of rats injected c AMN 24 h previous- ly also increased (943 ± 44), and addition of a-OG in- creased it further (1807 ± 46). However, the increment 126 Identification and Analysis of Multiple Glydne Trans- 14 port Systems in Isolated Mammalian Renal Tubules. of C incorporation due to addition of a-OG was much RICHARD E. HILLMAN*, ISIDORAALBRECHT* and less in AMN treated rats (145 ± 14 % versus 97 ± 15 %, LEON E. ROSENBERG*. Departments of Pediatrics p<0.05). Thus, AMN may interfere with protein syn- and Medicine, Yale University School of Medi- thesis by cells of rat renal cortex, perhaps by inhibition cine, New Haven, Conn, (introduced by of a-OG oxidation leading to impaired energy metab- C.D.Cook). olism. Studies in patients with hyperprolinemia and imino- (Supported by USPHS grant AM-08951.) (SPR) glycinuria have indicated that the renal transport sys- tem shared by glycine and the imino acids is not the 128 The Specific Nature of Glomerular Bound /SJC Globulin only mode of glycine transport in the kidney. In vivo and in Nephritis: Correlation with Immunofluorescent Stud- in vitro studies in rats have confirmed this impression ies and Evidence for an in vivo Immune Reaction. but have not delineated the number or nature of these R. E. SPITZER*, A. JAMES MCADAMS and transport systems. In the present experiments, isolated CD. WEST, Dept. of Ped., Univ. of Cincinnati rabbit renal tubules prepared by collagenase digestion Coll. of Med., and Children's Hosp. Research provided a suitable tissue preparation with which to Foundation, Cincinnati, O. analyze glycine transport and its relation to that of Immunofluorescent studies on renal biopsies have other neutral amino and imino acids. At low glycine often revealed the presence of $& globulin. The specific concentrations (0.01-1.0 mM), double reciprocal an- nature of the protein seen by this technique, however, alysis of kinetic data revealed a Kmof 0.7 mM and a has never been determined. Utilizing fluorescein- Vmaxof2.5mmoles/l/5 min. At higher concentrations labeled antibody directed against the three specific (1-100 mM), a sharp break in the double reciprocal antigens of/?JC, we have demonstrated the existence of plot indicated the presence of a second transport system only two (A,D) of the three (A,B,D) determinant (Km-67 mM; Vmax-100 mmoles/1/5 min). Both systems groupings normally found in native /JJC on the renal were inhibited equally by cyanide, dinitrophenol, and biopsy from a patient with chronic glomerulonephritis. by removing sodium from the incubation medium, but The absence of the B antigen indicated that this dep- studies using L-analine and L-proline as inhibitors of osited complement was not (I^Q per se as formerly glycine uptake provided evidence for a third transport thought. Elution with EDTA buffered saline at pH 7.7 process. Maximal inhibition of glycine uptake by pro- of a cortical-rich homogenate from the kidney of this line or alanine alone never exceeded 30^-0 %, whereas patient and immunoelectrophoretic analysis against the combination of the two resulted in 60-70 % inhibi- these same specific antisera showed not a single protein tion. About 30 % of glycine transport was not affected (native ftc) but, instead, two separate breakdown prod- by any competing amino acid. We conclude that gly- ucts of ^iC~PiG (containing the A and D determinants) cine is transported in the renal tubule by at least three and a2o (containing only the D determinant). Since distinct systems, one shared with the imino acids, one /Sx(j is the primary product of the reaction of ^c with shared with the neutral amino acids, and one which an immune complex, these findings are evidence of such may be specific for glycine. (SPR) a reaction occurring in vivo. Additional studies of biopsy specimens revealed that antibody to the D antigen of 127 Effect ofAminonucleoside (AMN) Injection on Amino/?!C most often yields the strongest fluorescence; occa- Acid Incorporation into Protein of Rat Kidney-Cortex.sionally, it gives the only fluorescence. This would sug- TAKASHI YOSHIDA*, YACOB Y.AL-UBAIDI* and gest that the use of labeled antibody directed against JACK METCOFF, Michael Reese Hospital, Dept. this determinant alone would be more specific and reli- of Ped., Chicago, 111. able than randomly tagged antisera. (SPR) Since mitochondria are the major sites of intracel- Iular bioenergetic processes, decreased oxidative phos- 129 Immunofluorescence of Cultured Kidney Cells Derived phorylation, oxidative enzyme activities and O2 uptake from Individuals with Renal Diseases. NESRIN BIN- by kidney of AMN nephrotic rats suggests impaired GOL* and EDWARD WASSERM AN*, Dept. of Ped., mitochondrial energy metabolism. The effects of AMN New York Med. Coll. N.Y. (introduced by on the incorporation of 14C labeled amino acids into Miriam Lending). Abstracts 321

Twelve percutaneous renal biopsies were performed WILLIAM J. FLANIGAN* and GEORGE L. ACKER in patients with acute, subacute and chronic glomer- MAN*, Clin. Study Center, University of Arkan- ulonephritis as well as lupus nephritis; biopsy speci- sas Medical Center, Little Rock, Ark. (intro- mens were processed simultaneously for light micro- duced by E.R.Hughes). scopy, immunohistology, electron microscopy and tis- Twenty-two patients (11 children and 11 adults) sue culture. with nephrotic syndrome were treated with azathio- A piece of cortex approximately 1 mm x 6 mm was prine (Az) for periods of 2 to 31 months (average 14). chopped, washed, subjected to Trypsin and EDTA ac- All had been unresponsive to prednisone, required un- tion for 20 minutes. Dissociated cells were cultured in due dosage, or could not tolerate the drug. Az was Leighton tubes with growth media containing 30 % given daily in a dose of 3 mg/kg; steroids were used con- fetal calf serum, incubated at 37° and 5 % CO2 in air. comitantly in a third of the cases. Serial renal biopsies One drop of cell suspension was stained with rabbit were obtained on each patient, the first before starting antihuman 7S gamma globulin and antihuman com- Az. Thirteen patients had proliferative glomerulo- plement ((Sic-fta) labelled with fluoresceinisothio- nephritis, six rapidly progressive nephritis (R.PN), two cyanate prior to culture. membranous changes, and one no histologic altera- Subcultures were prepared every week by 1:2 dilu- tions. tion and monolayers, grown on coverslips, stained with Twelve cases did well, achieving sustained clinical immune stains at weekly intervals. remission and complete or nearly complete chemical Specific peripheral staining for 7S gamma globulin remission. Two cases, both with proliferative disease, as well as for complement was observed on dispersed were partially improved. Eight (four proliferative; four cells prior to culture. RPN) manifested progressive disease. Six of the latter Staining for antihuman 7S gamma globulin con- failed to respond to Az. In each of these, irreversible tinued for several passages while staining with anti renal damage probably had occurred before Az ther- 2 (ftc-fta) disappeared rapidly. apy, as indicated by a CCr below 20 ml/min/1.73 m Six control biopsies from individuals with non- and/or vascular changes in the pre-Az biopsy. In one immunological renal diseases did not show any im- case, Az-induced pancytopenia led to fatal sepsis. In mune staining on the first day or when propagated in another patient, abrupt cessation of Az led to rapid the tissue culture under the same condition. (SPR) renal deterioration and death. In summary, sustained remissions followed the use of azathioprine in 12 of 15 130 The Use of Azathioprine in Nephrotic Syndrome notpatients treated before irreversible renal damage had Amenable to Steroid Therapy. WILLIAM T. KNIKER* , occurred. (SPR)

INDEX OF ABSTRACTS (Numbers following entries refer to abstract numbers)

ABILDGAARD, C.F. 93 - hemolytic56, 91, 98 BAUGHAN, M.A. 91 Abortion 17 - megaloblastic 95 BECKER, F.B. 15 Absorption, intestinal 53, 95 - nutritional 92 BELD, J.W. 112 Achondroplasia 32 - sickle cell 34 BELLANTI, J.A. 43 Acidosis, metabolic 31, 60 Angiocardiography 1 BELSEY, M.A. 108 ACKERMAN, G.L. 130 Antibody 44 BERGER, C. K. 54 Acrodermatitis enteropathica 54 Anticoagulant 93 BERKOVICH, S. 105 ACTH, effects 74 Anticoagulation therapy 124 BERNSTEIN, J. 122 Adenovirus 5 Antihemophiliac globulin 100 BEZAN, A. I. 95 ADHIKARI, P. K. 5 Anti trypsin 41 Bile acids 22 Adrenal cortex, hyperplasia 71 Anus, imperforate 37 Bilirubin 75 Adrenal gland 74 Arachidonic acid 54 BINGOL, N. 129 Adrenergic blockade 51 Artery BLAESE, R. M. 50 AEBERHARDT, E. 67 - pulmonary 6 BLANKENSHIP, W.J. 115 Agammaglobulinemia 48 - umbilical 116 BLOCK, J. 114 ALBRECHT, I. 126 ARTHUR, J.H. 102 Blood pressure 112 Albumin 119 Ascaris suum 35 BLOOM, G.E. 39 Alkalosis, respiratory 61 Aspartate transcarbamylase 76 Bone marrow 47 ALLEN, T. 114 Atherosclerosis 18 BONGIOVANNI, A.M. 15, 83 ALTEMEIER, W.A., III 43 AUERBACH, V.H. 31 BOUHASIN, J. D. 100 AL-UBAIDI, Y.Y. 127 AVERY, M.E. 114 Brain 67, 68, 77 Aminoaciduria 57, 126 AVRUSKIN, T.W. 86 BRANSOME, E.D.,Jr. 74 Aminogram 57 Azathioprine 130 BRENT, R.L. 17 Aminonucleoside 127 Azotemia 123 BRIDGES, R. 41 Aminopterin 72 Bruton's disease 21 Amniotic fluid 118 Bacteriolysis 106 BRYSON, M.F. 82 AMOS, D.B. 47 BAKER, L. 51 BUCKLEY, R.H. 47 Amphotericin B 47 BARCAI, A. 51 BUESCHER, E. L. 43 Anaphylaxis 49 BARNESS, L.A. 31 BYRNE, P. A. 112 Anemia BARRETT, C.T. 9