key: cord-0004822-rgun9d7k authors: nan title: ADOLESCENT MEDICINE date: 1982 journal: Pediatr Res DOI: 10.1203/00006450-198204001-00017 sha: 6ea23e73343ea737ee5241eeba3c8856133b64d0 doc_id: 4822 cord_uid: rgun9d7k nan • 3 rHE EFFECTS OF TEENAGE PREGNANCY ON NEONATAL BEHAVIOR . Cynthia Garcia Coll. (Sponsor William Oh). Brown Univ. Women & Infants Hosp., Dept. of Ped., Providence, RI This study assessed the impact of adolescent pregnancy on newi orn behavior in 2 cultural settings. The Brazelton Scale was administered during the first 3 days to 148 term newborns born in Florida (38 of mothers yrs.) and 155 born in Puerto Rico (42 of mothers <17 yrs). stepwise Mul tiplc Regression was used to analyze the-additive effects of maternal age and obstetric factors on 7 clusters of neonatal behavior. Puerto Rican infants of older, married mothers with higher gestation and Pondera! Index had higher habituation scores (p< .001). Higher scores for regulation of state were found for infants of older mothers, higher 9Pstation and less obstetric risk (p··.009). Infants of older mothers with lower obstetric risk and drug score and higher Ponderal Index had higher scores on autonomic regulation (p< .02). In Florida, infants of older mothers with a lower druq 3core and higher Ponderal Index had higher motor scores (p<.03). Higher range of state scores were found in infants of older mothers with lower drug score and higher gestation (p<.001). Higher regulation of state scores were related to older mothers, lower drug score and higher apgar scores (p<.02). Infants older mothers with lower drug scores, lower obs7".etric risk and Ponderal Index had higher autonomic regulation scores (p<.02). These data suggest that teenage pregnancy and obstetric factors have an additive adverse effect on newborn behavior. Furthermore, teenage pregnancy and other high risk factors affect the Brazelton clusters differently in the two cultures, suggesting an additional roJe of ethnicity on the effects on neonatal behavior. A double blind, placebo (P) controlled study of a 6 day course of steroid {S) therapy for IM was undertaken to ascertain (1) the clinical response to S and (2) the effect of S on the antibody response to Epstein-Barr virus (EBV). College students with IM caused by EBV, who did not have tonsillar obstruction, were evaluated clinically and serologically IIgG and IgM anti-VCA, anti-EA(D/R), anti-EBNAJ at 0, 1,2,4,12, and 24 wks. Thus far, 14 pts have been followed at least 4 wks (mean 14 wks): 7 on P and 7 on S. There was no difference in the resolution of (a) clinical symptoms (dysphagia, fatigue, anorexia), (b) physical signs (fever, adenopathy, pharyngitis) or (c) days of school missed. On the Beck depression test, 0/14 pts were initially depressed, but 3/7 S were post steroid. 2/7 S pts had complications: a peritonsillar abscess and diabetes mellitus. IgG anti-VCA decreased in 3/5 Sand 5/6 P pts. 4/7 Sand 3/6 P pts had anti-EA (D). This persisted in 4/7 S pts at 4 wks, 2/4 at 12 wks and 1/5 at 24 wks. Only 1/7 P pts had anti-D titers at 4 wks and 0/7 thereafter. 3/7 S and 2/7 P pts have not yet developed anti-EBNA. Comparing the geometric mean titers ( Table) , the fall of IgG anti-VCA and .CT'ti-EA(D) may be slower in S pts. In these pts, S had no short term benefit. Macro-orchidism is a clinical predictor of the "fragile-X"syn-X-linked disorder of Dental retardation with an identifiable structural"fragile"site, fra (X)(q27),on the X-chromosome. Testicular volumes were determined at an adolescent clinic on a random sample of 348 normal healthy boys 12-18 yrs. of age Jf whom 221 were black & 127 were white. Measurements of the greatest width & length of each testicle with the subject standing were made by one of the investigators using a transparent straightedged ruler. Volumes were calculated with the formula for an elipsoid,-n-i,•L•w2. Race, wt., ht., age & sex maturity ratings (SMR) were recorded for each subject. Least squares analysis showed that combined volume of the testes (t.v.) is more correlated with pubic hair or genital maturity ratings than with race, age, ht. ,wt. ,or any combination thereof; p < .0001 for correlation with the SMR for pubic hair or for genitalia. There was no significant statistical difference in the mean volumes between the races at any SMR. Though the genital rating correlated slightly better than the pubic hair rating with the t.v.,the difference was not significant & mean SMR's were used for graphic purposes. Mean combined testicular volumes in cm3 with ±one standard deviation were: SMR I. 10.05 ± 6.44; SMR II. 13.49 :!: 6.79; SMR III. 29 ± 11.17; SMR IV. 40.25 ± 11.53; SMR V. 58.56 ± 17.15 . A representative sample of adolescent boys in special education classes at school were also measured & there was no significant statistical difference in t.v. 's when compared with those of normal boys. u;o1 CAT lCJNS FOR FLEX !RLE F lhLRUPTIC IN the survey and those who did not. Among subjects followed, 38% used tampons prior to publicity on TSS. After publicity there was a significant decrease in tampon use: 27% were using tampons (p<.005). At follow up, 32% were using tampons(ns). Subjects using tampons at follow up reported feeling significantly more susceptible to TSS than napkin users(t=2.88,p=.005). Although 59% of the tampon users believed their suceptibility to TSS would decrease if they used napkins, 87% said they would not change their product. Among napkin users, 75% believed their susceptibility to TSS would increase if they used tampons;75% would not change methods. Tampon use in adolescents has not returned to its pre-publicity levels. Although media coverage on TSS has decreased, the publicity may have had long term effects on catamenial product use in fcraalf-:S. TO BROMOCRIPTINE (BR). Ronald I. Jacobson, Myron Genel and Bruce Bower, Dept. Ped. Yale U. Sch. Med. New Haven and Hartford Hosp., Dept. Med., Hartford, CT. Prolactin (Pr) secreting pituitary ademonas are associated with infertility, impotence and • testosterone(T) in adult males. Onset during adolescence would thus be expected to impair sexual development either via direct mass effect of a prolactinorna or from action of t Pr per se. We have encountered arrested puberty in 2 males with t Pr and observed hormonal and clinical improvement during therapy with the dopamine agonist Br. At age 15 Case 1 remained Tanner II with declining height velocity of 3.5 cm/yr. Pr (normal <20 ng/ml) was 128-176 ng/ml and T 83 ng% (adult male >350 ng%). Tomograms showed small sellar erosion. After surgery was refused, Br (2.4 mg/day) reduced Pr to <10 ng/ml with rise in T to 640 ng%. Height velocity doubled to 8 cm/yr and maturation resumed. Case 2 presented at 17 with Pr 420 ng/ml, T 24 ng%, and a pituitary mass. After resection of a chromophobe adenoma plus radiation, t Pr (500-1020 ng/ ml) persisted with panhypopituitarism. Hypogonadism with • T of 70 ng% and • sperm count of 2.2 million/cc resolved with 5 mg/day Br which reduced Pr to <10 ng/ml while T rose to 683 ng% and sperm count to 18.5 million/cc. In both, withdrawal of Br led to t Pr and • T. Puberty began normally at 12-13 yrs in both and cessation of maturation indicated underlying pathology, not physiologic delay. Poor compliance with contraceptive regimens has been shown to be an important antecedent of adolescent pregnancy. The purpose of this study was to prospectively test the effect of a peer versus nurse counseling program on adolescent compliance with oral contraceptives. Fifty six females aged 14 to 19 from a lower socioeconomic background were predicted to be compliant or noncompliant based on a compliance index (Litt et al). The noncompliant subjects were then randomly assigned to a peer (n=25) or nurse (n=25) group. At the initial visit and at I, 2, and 4 month follow-up visits all subjects received Ortho-Novum 1/35 combined with a tablet marker and were counseled by a nurse or peer. Compliance was measured using a Guttman scale consisting of: I) avoidance of pregnancy 2) appointment adherence 3) pill count and 4) urinary fluorescence for riboflavin. At the first follow-up the adolescents counseled by a peer had a significantly (p<0.02) higher mean compliance level than the nurse group. At the remaining follow-up visits the peer group continued to have higher mean compliance levels although the differences were not statistically significant. Moreover, the subjects who were originally predicted to be compliant (n=6) and counseled by a nurse demonstrated lower (p<0.02) compliance and higher attrition (p<0.05) than the peer group. These results suggest that incorporating a peer counselor into the health care team may be an effective method of increasing adolescent compliance. Evaluating adolescent mother-infant interactive behaviors from 10 min. videotapes necessitated the development of a counting method with particular emphasis on adolescent behaviors not yet described in studies of older mothers. Based on previous methods developed for counting adult mother-infant behaviors, our method consisted of 37 individual maternal items and 5 infant items. The maternal items were included under the 5 traditional categories of gentle touch, caretaking behaviors, proximity to mother, visual behavior, vocal/verbal beiJ,,vior, and 2 additional categories: assertive touch and personal behavior, both thought to be unique to adolescents. Infant items were vocalization, general state, and activity, including eyes open or closed. Coders were trained, using a training videotape, to count the number of behaviors in 15-secnnd sequences for the entire 1 O minutes of the tape. Scores for each i tern were recorded on a score sheet and totaled. Coders practiced on 10 nonstudy tapes until they reached at least 80% agreement with an established coder. Pearson correlations confirmed interceder re 1iabi1 i ty. Neither the i ntercoder agreement scores no;· the Pearson correlations fell below .86 for any item on the scoring of 130 additional videotapes. mrthr·d for measurinci adolescent mother-infant interactive behaviors is, therefore, reliable. • 14 CIRCADIAN RHYTHMS OF BLOOD MINERALS IN ADOLESCENTS. Morri E. John F. Rosen, Mark Mizrachi. Dept. Peds., CRC, Computer Ctr., Albert Einstein :allege of Medicine, Montefiore Hdsp., Bronx, N.Y. We have previously described normal circadian rhythms of •load ionized calcium (ca++), serum total calcium (CaT) and •hosphate (Pi) in healthy adult men (Science l.ll.:672, 1981) . To letermine if these mineral patterns vary in teen-agers, during ieriods of rapid skeletal growth, we studied 6 normal males :Tanner 4-5) who were 13-17 years old. Blood was sampled every 10 min. for 24 hours via an indwelling venous catheter. Based 1pon analyses of data averaged across the 48 time points, 3 model :urves were derived mathematically to describe all but minor :luctuations in the raw data. These curves are described ns ·allows: a U shaped ca++ curve with a peak at AM and trough >etween PM; the Pi curve revealed 2 peaks: the smaller one >ccurred at '\-0 PM and the larger peak at AM; the CaT curve ·evealed 2 troughs: the larger trough occurred at PM and the ;maller one at AM. The diurnal ranges of variation were: :a++= 0.31 mg/dl, Car= 0.43 mg/dl, Pi = 2.5 mg/dl. Intermodel :orrelations were: ca++/caT = .325*; ca++/Pi = .137; CaT/Pi = . -750** (* = p <.05, ** = p <.01). Comparison of these circalian rhythms to adult patterns revealed high correlation coeffi-:ients; however, the diurnal variation in Pi was significantly (>2x). Conclusions: 1) Circadian rhythms in blood minconcentrations are present in adolescent males. 2) The wide jiurnal range in Pi appears to be characteristic of teen-agers. 3) Deviations from these patterns may provide a sensitive diag-1ostic for therapeutic intervention in disease states. ADOLESCENT COITAL ACTIVITY AND INFANT PREMATURITY. Kogut, Mary G. Silvennan, Howard P. Iker. Univ. of ioches ter, Strong Memorial Hosp., Dept. of Ped., Rochester, N. Y. It is unclear whether there is a relationship between maternal lrd trimester coital activity and infant prematurity. To learn 1bout adolescents' 3rd trimester coital activity and the birthand gestational ages of their infants, 75 young mothers :onsecutively enrolled in an adolescent maternity project were ;tudied. Methods consisted of chart reviews and also semi-structured interviews conducted by the adolescents' primary nurses juring the postpartum hospitalization. riean maternal age at delivery was 17.3 yrs. (15.7-19 yrs.); 60% were black, 40% were non-black; the majority were of lower socioeconomic status. Thirteen(l7%) reported no coitus during pregnancy. Sixty-two (83%) reported coitus during pregnancy; of these, 45(73%) reported 3rd trimester coitus. The mean birthweight of infants of mothers reporting 3rd trimester coitus was 2911 gms (850-4960 gms) and that of infants of mothers reporting no 3rd trimester coitus was 3412 gms (2430-4000 gms) (p < .001). Mean gestational ages (GAs) were 37.7 wks. (27-42) and 39.3 wks. (31-43) respectively. Eleven(l4.7%) of the 75 infants weighed .£2500 gms. Seven of these 11 had GAs .£ 37 wks. Six of the 7 mothers of infants with both a birthweightL2500 gms and a GA.1;37 wks. reported 3rd trimester coitus. The influence of maternal age, race, parity, smoking, substance use, height and weight were also considered. As a group, infants of mothers reporting 3rd trimester coitus had significantly lower birthweights than those whose mothers reportr,d no 3rd trimester coitus. ADOLESCENT SUICIDE GESTURES -A LONG TERM 16 FOLLOW UP. Matilda S. Mcintire, Thomas P. O'Brien, Carol R.Angle. University of Nebraska Medical Center, Department of Pediatrics, Omaha, NE 68105. Self-poisoning with a low lethality of intent is estimated to occur at an annual rate of 30/1000 in the age group 10-24 years yet little is known concerning its long term significance. Pediatricians are frequently the primary medical contacts for the evaluation of both suicidal risk and overall perturbation of these adolescents, and their training is relevant to the observation of the effects of maturation on behavior. A nine year follow-up of 15 of 47 adolescents hospitalized at ages 12-18 years in a psychiatric facility because of severe perturbation associated with a suicidal behavior disclosed recurrent suicidal gestures in 47%. The overall incidence of 47 gestures by the 15 subjects peaked at ages 14-15. A sharp decline after age 18 supports the concept that suicidal behavior of low lethality is an age related response. Despite residual mild depressive symptoms in almost half, functional adaptation was good in the majority and was independent of the number of events or of the initial diagnostic category. All subjects considered themselves better adjusted, with greater life satisfaction and improved interpersonal relationships; 80% had completed high school and 93% were capable of stable employment. All subjects attributed benefits to multiple support systems, particularly a strong relationship with at least one emotionally mature person, a more favorable environment-usually accomplished by moving out of the house, achievement of education and employment skills, and economic independence. TilE ivers1ty o ntreal. a1nte-ust1ne osp1ta Adolesccntdicine -Department of Pediatrics. Montreal -Quebec -Canada. This study was designed to describe the way adolescents with a chronic disease experience their hospitalization. Seventy-seven subjects, aged 11 to 20 answered a self-administered questionnaire upon discharge from hospital. Their feelings were measured on a four-point scale. The distribution of feelings along this scale was wide, but tended more toward the positive than toward the negative pole. Those whose feelings were more negative had been hospitalized more frequently and were more preoccupied with disease-related problems; they more often described the aonosphere at home as bad and more often reported difficulties with their parents; finally, they said they were less involved in social activities on the ward. Preoccupations about disease-related problems were assessed using a four-point scale; most conceTI1S were expressed toward their medical prognosis and professional future. Medical patients reported more preoccupations than surgical ones • The majority of the subjects reported that they would have liked greater opportunities to discuss their disease with doctors and nurses. With respect to social life, preferred activities were receiving visits and chatting with other patients and staff. The results suggest that there is a considerable variation in the way adolescents with a chronic disease experience hospitalization. They underline the importance of social life on the ward and stress the educative and supportive role of the staff. Most AN patients reached subnormal maximal HR, BP, power output, VO and serum NE levels at peak exercise. These data suggest sympathetic activity and an abnormal reflex response to the stimulus of exercise with AN; AN patients may also have a myocardial insult. To identify if adolescent health concerns are related to ethnicity, 525, 7-12 grade students in a Southern California school district were surveyed; 62% were Anglo, 11% Hispanic, 8% Asian and 19% others. Hispanics considered themselves as healthy as others, however, they had times more unanswered health questions and problems (p( .001). While all ethnic groups had multiple health concerns, more Anglos were concerned about drugs, acne, alcohol use, obesity, contraception, and abuse. More Anglos felt that Adolescent Clinics should provide information and services about these areas (p< .001) compared to others. Suicide and saddness were concerns of equal numbers of Anglos and Hispanics. Perceived vulnerability to illness varried by ethnicity. More Hispanics felt susceptible to tuberculosis. However, they less frequently could identify its cause and considered it to be less serious (p( . 01). While 14% of each group felt they would contract a STD, Hispanics would more often leave it untreated and could not identify its cause. While all groups utilized organized health services, Hispanics would more often suggest folk or home treatme11t for common illnesses (herbs, teas, curanderos, over the counter drugs) (p(.01). Expectations about services and treatments vary by ethnicity. Those providing health services to adolescents of varied ethnic groups must be aware of the subtle differences. ADOLESCENT RISK-TAKING BEHAVIORS IN A RURAL UPSTATE NEW YORK COUNTY. Kathilleen C. Perkins, Andrew A. Sorenson, Elizabeth R. McAnarney, Univ. of Roch., Dept. of Ped. and Prev. Med., Rochester, N.Y.(Spon.-R. Hoekelman) Public concern involving adolescent teen pregnancies is mounting while other social problems remain unchecked. These adolescent behaviors may be related. This study examines the correlations of various risk-taking behaviors among adolescents in a rural county in upstate N.Y. For 22 towns and 2 cities in this county, demographic information and data were gathered over a 3 yr. period for the following variables: drivers in motor vehicle accidents (MVA) by sex and age group; pregnancies by age group; arrests for felonies by age group; youth leaving school before completing 12th grade by sex; and placement on probation by age and sex. All of these risk-taking behaviors among adolescents living in the entire county are positively correlated. For those417 yrs. of age the rate of pregnancies is significantly related to the rate of male drivers yrs. in MVA's (p4.03), rate of yrs. arrested for felonies (p 4.001) and the rate of males placed on probation (p 4.0001) and the rate of 16 and 17 yr. old females who drop out of school{p L.05). It is interesting to note that the larger of the two cities (with 9000 teens) has consistently lower rates of adolescent risk taking behaviors than does the smaller city (3000 teens), except for male school drop-outs. Perhaps the most surprising finding is that the rate of teen pregnancies is negatively correlated with the proportion of adult females who have no high school education. This study points out the desirability of replacing the categorical approach to adolescent problems with an holistic one. RENIN Criteria by which adolescents can be cateqorized as havinq hypertension(HBP) associated with suppressed, normal, hiqh or hyperresponsive plasma renin activity(PRA) have been established in a clinical research center settinq. Confidence bands(95%) for the four-hour upriqht PRA 4.5±2.l(S.D.) nq/Mg/hr in relation to the 24 hour urinary sodium excretion(renin-sodium index)were established in 30 nonnotensive adolescents. An oral Lasix(l ml/ko) stimulation test to induce acute volume depletion was used to establish criteria for suppressed(increase<40\)and hyperresponsive On the basis of the renin sodium index a high PRA was documented in 16' of 43 children with essential and 84% of 25 children with renal related HBP. Following Lasix stimulation PRA was suppressed in 11% and hyperresponsive in 14% of the children with essential HBP. Although the fractional increase in PRA in children with high PRA associated with either essential or renal related HBP was similar, it was less than (p<0.05) that observed in either normotensives or in those with normoreninemic essential HBP. These two tests permit PRA to be critically defined in hypertensive adolescents. The availability of such data has permitted us to make rational decisions concerning the nature of additional studies, as well as enabling cardiovascular risk factors to be identified and followed. Also, such studies can be easily performed in an outpatient milieu. One million adolescents become pregnant each year. several authors have noted that pregnant teenagers are at hiqh risk of illness and emotional disruption both pre and postpartum. A comprehensive pregnancy program was established to determine if such complications to adolescents and their babies could be reduced by providing multidisciplinary care for teenagers through pregnancy and with their infants for 12 mos. subsequent to delivery. The program was based at a municipal hospital within a medically underserved and economically depressed urban environment. Prenatal, obstetrical, postpartum and infant care were delivered by a team of a nurse coordinator, obstetrician, pediatrician, social worker, visiting nurse and psychiatrist. There were 306 adolescents (ages 12-16) and 229 infants cared for over a period of 2 yrs. Muternal complications included preeclampsia 2.9%, anemia 13.7%, Cesarean section 5.5%, premature birth postpartum endometritis 2.6t, and postpartum depression 1.3% of the 229 infants followed for 12 mos., 4 had congenital anomalies, 3 were abused; and 17 required hospitalization for various illnesses. 133 (58\) completed their immunizations. There were two neonatal deaths. These results demonstrate a far lower incidence of complications in these adolescents and their infants than has been previously reported. It would appear that a comprehensive multidisciplinary pregnancy program can contribute markedly to the reduction of morbidity and mortality in the high risk adolescent and her infant. The computerized records of 950 consecutive new patients seen in a free adolescent clinic over a 3 year period were reviewed for compliance with initially scheduled follow-up visits. Follow-up visit.s were scheduled in the clinic for 248 new p.ltients. Patients returning within two weeks of their scheduled date were considered to have complied. Using these criteria 134 (54%) appointments were kept. The following factors were analyzed as predictors of compliance: agP, race, school and employment status, living arrangements, location of residence, number of parents at home, whether sexually active, taking any medication, use of cigarettes, alcohol or marijuana, and contraception usage. In addition the number of patient identified presenting problems and the nature of patient and physician identifi<.>d problems analyzed. None of the demographic data showed a significant correlation with compliance. A significant association (p <: .01) was shown between compliance and the number of problems initially identified by the patient. Patients presenting for routine examinations without identified problems had significantly poorer compliance (34%) than those with one (50%) or two or more (64%) problems. One patient identified problem, possible pregnancy, was found to be a significant (p<:; .05) negative predictor of compliance. These data identify specific adolescent patient groups where poor compliance can be expected. Additional reinforcement in these groups may be useful. • 24 ADOLESCENT CLINIC POPULATION. George C. Rodgers, Jr., George H.W. Christie, Vernon R. Hink (Span. by Billy F. Andrews), Univ. of Lou. Sch. of Med., Dept. of Ped., Lou., KY, and the Onondaga Cty. Dept. of Hlth., Fam. Plan., Syracuse, NY. The computerized records from 950 first visits ton free health department sponsored adolescent cljnic were reviewed. The records covered a three year period. Patient .1ges were 12-21 yrs (mean 16.5 yrs). There were 608 females and 342 males. The population was predominantly white 1ower middle class with 26% being racial minorities. A routine hemoglobin was obtained on 724 patients. Based on age and sex related normal" 7.2% of patients (7.7% females and 6.4% of males) were at1emic. A routine dipstick urinalysis was done on 696 patients and showed one or more abnormalities in 21%. Proteinuria was found in 15.7% of patients (16.8% of females and 14.1% ol males). Glucosuria was detected in 2% of paticntg aiod hemoglobinuria in I .4% of patients. More than one urine abnormality was found in 1.7% of pat·ients. Routine PAP done on 106 patients yielded 12.3% ahnormals (twelve Class 2 and one Class 3). gonorrh£>a cultures done un 1)2 patients yielded only two positives, hoth in suspected cases. Throat cultures for group A beta lwnolytic streptococci were positive in 12 of 68 cultures submitted, while only 2 of '•0 urine were considered positive. Monospot tests were done in 11 patients with 2 positives. A routine VDRL was done in 715 patients with only one positive test. These confirm tl1at routine blood counts and urinalyses in adolescent patientg identify Rignificant nul'lhers of abnormalities. The use of a routine VDRL does not seem ADOLESCENT MEDICINE 83A RELATIONSHIP OF ENDOCERVICAL CHLAMYDIA INFECTION, AB-NORMAL PAP SMEARS, AND CONTRACEPTIVE USE JN ADOLESCENT rEMALES. Mary-Ann B.Shafer, Janet C.Shalwitz, Julius ;chachter and Richard L.Sweet (Spon. by Melvin M. Grumbach) Univ. 1f Cal., San Francisco, Dept. of Pediatrics, San Francisco. Chlamydia infections are becoming recognized as important sex-1ally transmitted diseases in adolescent females and are assoc-.ated with abnormal Pap smears. 75 sexually active subjects :x=l5.8 yrs. ,r=l3-20 yrs) and 9 never sexually active subjects :X=l6.S yrs,r=l3-20 yrs), undergoing pelvic exams in a general •outh clinic of an ambulatory pediatric setting, had Chlamydia :rachomatis cultures and endocervical Pap smears done. All preg-1ant girls and girls with menses were excluded. Contraceptive 1se in the sexually active group included: 35% oral contraception; !4% barriers; 41% no method; 1 subject used an IUD. All 9 never ;exually active subjects had normal Pap smears and negative :hlamydia cultures. In contrast, 44%(15) of sexually active subiects had abnormal Pap smears. Of these 34%(11) used oral contra-:eption; 19%(6) used barriers; 47%(15) used no method; (1 used an lUD) . A large proportion of sexually active subjects had positive :hlamydia cultures: 17%(13). More chlamydia positive subjects iad abnormal Pap smears: 54%(7). Contraceptive use in chlamydia >ositive subjects included: 64%(7) oral contraception; 18%(2) >arriers; 36% (4) We have demonstrated that over 50% of anorexic patients have :erebral atrophy on CT Scans. In order to assess the psychologi-:al and cognitive implications of these changes evaluation was )erformed on 11 anorexic patients (9 females, 2 males, ages 12 to 20 years, mean age 15.9 years) to ascertain cognitive, memory, perceptual-motor and personality status. Avera£e to superior scores were obtained by nine patients (82%) on the cognitive, 11emory and perceptual-motor mcasures:Wechsler Intelligence Scales, •ISC-R or WAIS, Ravens Progressive Matrices, Trails A & B,Benton Test of Visual Retention, Berry-Buktenica Test of Visual Motor Integration, and Wide Range Achievement Test. Seven of these nine high functioning patients had moderate to severe cerebral atrophy on CT Scans (78%). Two additional patients with markedly abnormal CT Scans scored in very impaired ranges, but both had learning problems and school failure antedating the onset of anorexia by years. On tests of personality status 8 patients (73%) tested as mi Idly to severely depressed on the Beck Depression Inventory (Scores 11 to 43, Mean=23.8). Six of 10 patients showed markedly elevated MMPI scores consistent with personality pathology including depression. Five exhibited peak elevation (T-Scores 74-103, Mean=88) on the schizophrenia scale. Overall most patients remained cognitively intact, but the majority had significant depression and personality aberrations. Because of pediatricians' concern for pregnant adolescents, a group of 497 very young mothers age 13-15 years were compared to mothers 16 to 19 and 20 to 40 years by analyzing 22 factors for neonatal outcome, parturitional performance, obstetrical risk and physical characteristics. The data were derived from 6282 primiparous births over the past four years. Among factors studied were birthweight, gestational age, Apgar score, morbidity, mortality, presentation, length of labor, instrumentation, C-section, preeclampsia, cephalopelvic disproportion, premature rupture of membranes, maternal height, prepregnancy weight and weight gain during pregnancy. Analysis of variance tests showed no differences by age in maternal height and weight gain. Mean prepregnancy weight was higher in the 20 to 40 year age group. x2 analyses were used to test the significance of associations among the remaining variables and maternal age. For the very young mothers, the observed values were not significantly different from the expected values for any of these 19 variables. Pregnant adolescents and their offspring are not, according to these data, at a biological disadvantage. Literature suggesting that adolescent gravidae are at high risk may be based on data uncontrolled for parity. 28 FETAL OUTCOME -IS ADOLESCENT PREGNANCY A RISK FACTOR? Barry Zuckerman, Joel J. Alpert, Elizabeth Dooling, Edgar Oppenheimer, Ralph Hingson, Suzette Morelock, and Herb Kayne (spon. by Jeffrey B. Gould). Boston Univ. Sch. Med., Boston City Hosp., Depts. of Ped., Soc. Med. Sci.Boston A study of maternal health and fetal development in a low SES population at Boston City Hospital rrovided an opportunity to explore whether(l)infants born to primiparous adolescents exhibit poorer outcome at birth than infants born to primiparous nonadolescents; and(2) if the outcome is poorer, whether the cause is adolescent status or other heal th habits or life situations. Four study pediatricians performed all physical and Dubowitz examinations without knowledge of the mothers' age. The birth weight, length, head circumference, length of gestation, Apgar scores and birth trauma of 275 infants of adolescent mothers (3-18 yrs) were compared at birth to 423 infants of nonadolescent mothers (19-30 yrs) . The only difference noted was that infants of adolescents •1<:ighed 94 grams less (p.S,. .03) than the infants of nonadolescents. Since the adolescents and nonadolescents differed on many characteristics which might affect fetal outcome, 23 factors were entered into a multiple regression analysis as variables. Health factors such as prepregnancy weight and weight gain, use of x-rays during pregnancy and marijuana use were independently and significantly (p_s.01) associated with birthweight. Adolescent status was not independently associated with birthweight or any other growth or clinical risk parameter. Some of the health factors are amenable to clinical intervention and represent a greater risk to pregnancy outcomes than whether or not the mother is adolescent. This study documents the of non-fatal crash and noncrash events during a 16 mth data collection effort in 9 hospital emergency rooms located in one California county. Data were obtained from a standardized protocol and medical records (n=621). The Abbreviated Injury Scale (AIS) was used to grade injuries and the Injury Severity Score (ISS) was calculated. Comparisons of the mechanisms and severity of injuries between crash and noncrash events are described. Subsequent analysis indicates that approximately 12% of the children presenting to emergency rooms with motor vehicle related injuries were involved in non-crash events. Age-related differences between crash and non-crash children were significant in that younger children were primarily involved in the non-crash event. The mechanism producing the injury also differed between crash and non-crash children: while interior impact was the primary injury producing mechanism in both events, a much higher percentage of ejections occurred in the non-crash event (41% vs. 5%). ISS did not differ significantly between non-fatal crash and non-crash children, [x2 (p) = 0.11]. Severe injuries are incurred in both crash and non-crash events, especially when a child is ejected from the vehicle. This severe mechanism of injury could be avoided by use of child restraint systems and/or by improved door lock mechanisms. Mandatory child restraint use legislation, if enforced, would be an effective preventive measure. mothers recognized the significance of visiting to the child regardless of the severity of their medical problem and stayed longer if they felt this helped their child cope with hospitalization (p <.OS). Mothers who reported problem behavior prior to hospitalization in their children visited less (p<.Ol) and should be identified for appropriate intervention. 111PACT OF CYSTIC FIBROSIS ON FAMILY LIFE WE Bohannon, SA Phillips, WF Gayton, and SB Friedman, University of Maryland School of Medicine, University of t1aryland Hospital, Department of Pediatrics, Baltimore A comprehensive assessment of the impact of cystic fibrosis (CF) was conducted with 43 CF families. A semistructured interview with parents (43 mothers and 29 fathers) focused upon family parent-child interactions, sibling and peer relationships, and medical issues related to CF. Parents' responses were coded by two independent raters to identify "major problems," "minor or "no problems." Out of the 62 questions assessing areas of potential problems, only 8 were viewed by parents as posing "major problems" for themselves and/or their children. Areas thus identified will be presented in detail to indicate the nature of the problems. The impact of hospitalization was the most prevalent concern: 60% of mothers and 58% of fathers identified this as a "major problem." Issues included uncertainty regarding the outcome (34%), separation from the child (25%), and other pressing family responsibilities (16%). Communication between the parents was considered a "major problem" by 28% of mothers, but only 3% of fathers. Ten to 15% of parents described problems regarding their marital relationship, accepting the illness, feeling they should do more for their CF child, feeling their other children had been deprived or complained about inattention, or their relationship with the ill child's grandoarents. These data indicate that most CF families are coping successfully with the impact of a serious chronic illness, but that health-care professionals should be alert to areas of The relationship between inadequate nutrition in early infancy and subsequent brain growth and development has been reported. To determine the extent of this relationship, we studied 19 high risk, very low birthweight, premature infants (mean :!: SD birth wt •• 97 :!: .19 kg, gest. age 29 :!: 2 wks) requiring intensive care management during the neonatal period and followed them up to 12 mos. adjusted age (AA). Nutritional status during the neonatal period was correlated with subsequent growth and development at 12 mos. AA using standard growth parameters and the Bayley Scales of Infant Development. Follow-up measurements were: wt. = 8.3 :!: 1.2 kg; length = 72.3 :!: 2.7 cm; head circumference = 45.3 :!: 1.6 cm; Mental Developmental Index (MDI) = 71.3 :!: 18.7; Psychomotor Index (PD!) = 78.4 :!: 18.1. There was an inverse correlation between the number of weeks in the neonatal period in which the caloric intake was lower than 80 cal/kg/day (r=.61, p<..Ol) and protein intake was less than 2 gm/kg/day (r=.52, p < .05) with the PD! scores. Neonatal nutrition was only weakly related to growth parameters and MDI at 12 mos. AA. The low correlation with MDI may be due to the fact that abnormalities in motor development can be identified earlier than those in mental development and therefore this correlation should be retested at older ages. This study indicates that early inadequate protein and caloric intake is associated with lower PD! scores in premature infants at 12 mos. AA and emphasizes the need for close nutritional monitoring during the critical neonatal period. The utility of primitive reflex assessment in the motormpaired child has been hindered by lack of a quantitative escription of normal reflex maturation. The Primitive Reflex rofile is a quantitative examination technique used to evaluate rimitive reflexes. Standardization data was obtained on a ohort of 381 normal infants examined serially at each well aby visit between birth and two years of age. Reflex activity enerally decreased with increasing age, although distinctive atterns of maturation were noted for individual reflexes. he Asyrrrnetric Tonic Neck Reflex was present in the majority f subjects at birth, peaked at two months, then declined teadily throughout the first year. The Tonic Labyrinthine eflex in Prone was most pronounced at four-to-six months and eclined more slowly. The Synvnetric Tonic Neck Reflex was een only in a minority of subjects between four and six months. he Moro Reflex was uniformly present at birth and was suppressed y six months. Nonsegmental Rolling ("log rolling"), both ead-on-body and body-on-body, was replaced by segmental rolling fter six months. Obligatory responses, seen frequently in erebral palsy children, were not seen in any reflex at any ge in this normal population. This standardized examination echnique allows primitive reflexes to be objectively assessed. . 14 children whose families constituted the exeriment;il group were from 2 to 5 years old, had been n the dietary regimen since prior to two months of ge, were of normal intelligence, and had no siblings ith PKU. Control group parents were matched for soial class, child age, birth order, and number of chidren in family; none had children with handicaps. arents of PKU children were significantly more retrictive of their children's independent functioning han were the parents of the NON-PKU Fathers nd mothers of PKU children differed in the types of estrictions they expressed. More restrictions diffrentiated the PKU fathers from the NON-PKU control roup fathers than differentiated the PKU mothers from he NON-PKU mothers. Social class, child age, and bith order were found to be significant intervening vaiables. Strong, internalized controls related to fad restrictions were noted in the PKU children in the tudy, seemingly developed as a result of parental trining strategics. Parents relied on these child conrols to enhance dietary compliance in a manner that ermitted the child more social independence. In the first phase of a multi-dimensional study of the effects of weaning from the breast on infant behavior, a maternal interview and questionnaire were developed and administered to 100 middle-class American mothers who weaned their infants during the first year of life. The major objectives of the interview and questionnaire were to provide detailed descriptive data about the human weaning process and to identify and assess the behavioral responses of infants to weaning in the first year. Preliminary results indicate that some infants exhibit increased fussiness and/or a change in sleep patterns irranediately following the onset of weaning, and that these effects are more likely to occur with infants whose mothers initiate weaning during the second half of the first year. One explanation for this apparent age-related differentiated response may be that breastfeeding becomes an increasingly important means of emotional assuagement for infants as they reach higher levels of cognitive and emotional development. The mean and median age for the initiation of weaning was six months. The mean and median age for the completion of weaning was seven months. Many inf ants were reported to have weaned themselves, but most were receiving significant nutritional supplementation during this period of self-weaning. The most corranon reason given by mothers for weaning was that their milk dlone was not adequately assual..Jing their infants' hunQer. The need exists for a well-validated language screening ins1rument covering the first 3 years of life, since this is when most language skills emerge. To examine the relationship between language milestones and development during the first 3yr. of life, and to devise a brief language screening test suitable for physician use, an early language milestone scale (ELM Scale) was written, normed and validated. Fortyone items written by one of us (JC) were normed on 191 children age 0-36 months compromising a chronologic, racial, and socioeconomic cross section of the qer.eral population.Percentile values for the emerqence aoe of each item were obtained;pass/fail criteria for the ELM Scale as a whole were developed based upon these values. The ELM Scale was then given to 119 children referred to us for evaluation of possible developmental disability.Each child was also formally tested by a psychr.logist and speech pathologist who were unaware of the child's performance on the ELM Scale,with the followinq results: Formal Scale Norm 5 50+4 We conclude that language milestones from 0-3 yr correlate clcse· ly with devplopmental status. The sensitivity and specificity of the ELM Scale justify its use as a screening instrument among children at risk for developrrental disability. Although auditory brain stem responses(ABR)are widely recommended for assessment of neonatal auditory function, infants so tested have had little long term follow up. To assess the prognostic validity of neonatal ABR, we tested 50 VLBW(2 SD of normal). At 4 months only 1 of these infants and 2 others were abnormal. Thus of the 9 infants initially classified as abnormal only 1(11%) had abnormal responses at all 3 tests with permanent hearing loss at 20 months whereas of 41 infants initially classified as normal, 6(12%)were subsequently abnormal (4 with middle ear [M. E.] disease and 2 central defects). Abnormalities which disappeared after the neonatal period correlated best with birth wt., RDS, Neonatal risk score(p<.OS)and therapy (p<. 001). At 20 months 9(18%) infants were abn. only 3 of whom had been abn. as neonates(! pennanently impaired and 2 who had become S 1 tention. We believe that infants who 8 deviate from this pattern should be fol-Frequency (Hz) lowed for potential dysfunction. HEAD CIRCUMFERENCE (HC) GROWTH AND DEVELOPMENTAL "() OUTCOME AT TWO YEARS IN VERY LOW BIRTHWEIGHT (VLBW) INFANTS. Steven J. Gross and Carol 0. Eckerman (Spon. by Samuel L. Katz). Duke Univ. Med. Ctr .• Ped., Durham. The predictive role of early HC growth for subsequent development was evaluated in all 85 survivors with birthweight <1500 gm. born from 1/1/78 to 3/31/79. Infants were divided into 4 groups based on HC at birth (<10% or >10%) and HC growth at six weeks (<3.5 cm or >3.5 cm). The VLBW infants and 95 full-term infants matched in social background were evaluated at 6, 15 and 24 months with neuromotor (NM) examinations and the Bayley Scales of Infant Development. The percent of POOR OUTCOME (major NM defect and/or DI <80) was significantly related to HC growth. HC AT BIRTH: <10% >10% HC AT 6 WKS: < 3. 5 cm ?3. 5 cm <3. 5 cm . The incidence of poor outcome for infants with HC at birth >10% and HC growth cm was low and similar at each age to that for full-term infants. At 6 months, the other 3 groups of VLBW infant; had poorer outcome. At 15 and 24 months, the two groups with less postnatal HC growth continued to show poorer outcome; however, the group with HC at birth <10% but greater postnatal HC growth demonstrated catch-up, such that outcome was now similar to that for full-term infants. The group with poorer HC growth at both periods showed uniformly poor outcome at all ages. and developmental outcome of VLBW infants. To determine the potential and correlates of catch-up growth, we prospectively followed 182 VLBW (3% at 40 25(17%) 16(46%) Thus potential for catch up in SGA VLBW infants is limited to infancy and the failure to catch up in 46%.may relate to the timinr, and severity of the growth deficit in utero. In contrast AGA infants may grow poorly during the neonatal period yet catch up as late as the 2nd year. Significant correlates of impaired P,rowth at 21 months were head circ. <3% at 40 wks (p<. 0001), social class (p<.001), marital status (p<.003), BW (p<.005), neonatal risk score (p<.05), low developmental quotient (p<.05) and neurological abnormality or chronic disease (p<.04). 7/15(47%) of infants with neurologic abnormality were small, whereas32/157(20%) of the neurologically intact infants were undergrown at 21 months. Thus there appears to be a critical period for catch up growth in VLBW infants when intervention may be possible. SERVICE. Joan E. Hodgman, Nancy Edwards, George A. Halterman, Division of Neonatology, Dept. of Pediatrics, USC School of Medicine and Womens Hospital, LAC/USC Med. Ctr., Los Angeles, Ca., USA. On July 1, 1981 we began the initial year of a one year postgraduate training program for physician assistants (PAs) in the specialty of Neonatology. The program was established, l)to provide primary care to high-risk newborns in a highly technological environment; 2)to provide PAs an opportunity for postgraduate training in a specialty area. Three PAs were selected on the basis of academic performance, completion of an accredited PA Program, national board scores, interviews, and prior experience. They were assigned to specific teams composed of a Fellow, a pediatric resident, and an intern. The PA follows the team schedule, including night call, and is responsible for admission work-ups Ii rotation with the intern, and for performing a variety of diagno&tic and therapeutic procedures. The PA also has primary responsibility for follow-upmanagement of the baby, always under appropriate physician supervision. PA "residents" are utilized in all areas of the service, i.e. the Normal Nursery, NICU, Special and Intermediate Care Nurseries, Delivery Room Resuscitation Team, and the High Risk Preemie Follow-up Clinic. Evaluations by supervising physicians reveal that the PAs are demonstrating a high level of clinical performance, and have been well received across the entire Newborn Service. We believe that utilization of PAs may be a viable solution to the problem of decreasing involvement In an effort to better characterize the behavioral changes .hat accompany iron deficiency in infancy a "Solemnity Score" SS) was developed and utilized in conjunction with the Bayley lental Development Index (MDI). Both tests were administered •rior to, and one week after, treatment with IM iron. Infants, •ges 9 to 12 months, were stratified into 4 groups based on . Iron deficient >11 <12 ng/ml >30 µg/dl <72 fl Solemnity was scored as follows: 0, wreathed in smiles, with .parkling eyes, laughter; 1, quite smiley; 2, occasional smile; 1, one or two smiles/hr.; 4, no smiles/hr. After iron therapy •Oth scores on the Bayley MDI and the SS changed significantly in he iron deficient infants. In groups 3 and 4 the mean increase .n the MDI was 21.9; for groups 1 and 2 it was 5,4 (p <.01). The :s score fell from 2.72 to 0.61 in the iron deficient infants; in :roups l and 2 the SS score changed from 1.5 to 0.85. Ten of 18 .nf ants in groups 3 and 4 became less solemn and 6 remained un-:olemn. In contrast only 3 of 20 inf ants in groups 1 and 2 be-:ame less solemn; 14 remained unsolemn. These results suggest .hat even non-anemic, iron deficient infants have a characterisic demeanor that should alert physicians to the presence of this :ommon nutritional deficiency. A PSYCHOLOGICAL EVALUATION OF PRE-ADOLESCENTS WITH RECURRENT ABDOMINAL PAIN (RAP). Susan Jakob, Louis Najarian, Fred Daum, Harvey Aiges, Jim ,nd Mervin $1 lverberT. Yeshiva Un1vers1ty, Department of 'sychology and Corne 1 University Medical College, North Shore lniv. Hosp., Departments of Psychiatry and Pediatrics, New York. To determine the specific psychological characteristics of ire-adolescent girls with RAP, three variables (1) dependency 1eeds, (2) conflict about sexual identity, and (3) pre-disposi-:ion to somatization were evaluated in 7 pre-adolescent girls 1ges 10-13 with RAP, 7 with inflammatory bowel disease, and 7 1ithout illness. All were matched for age and IQ by the W. I.S.C.i. Each individual was given a standard psychological battery :onsisting of the Draw-A-Person, Thematic Aperception Test T.A.T.), and Rorschach tests. Additionally, their parents •nswered questions regarding medical, psycho-social, and behaviol"' 11 issues. All tests were administered by a researcher "bl ind" :o the specific diagnoses and were scored independently by 2 1sychologists. Several items in the questionnaire reveal :ignificant differences related to dependency needs and prelisposition to somatization (p<0.05) between those girls with iAP and the 2 other study groups. These results are confirmed 1y items in the T.A.T. and the Rorschach tests which also lemonstrate significant differences in dependency needs, conflict 1bout sexual identity, and pre-disposition to somatization. n summary, the psychological evaluation of pre-adolescents lith RAP by questionnaire, T.A.T. and the Rorschach test indi-:ate that pre-adolescent girls may have specific psychological :haracteristics which predispose them to recurrent abdominal pain. A longitudinal investigation is being conducted to evaluate .he developmental status of 50 inf ants born to drug dependent 1omen enrolled in Family Center, a comprehensive treatment pro-;ram providing psychosocial and medical services as well as 1ethadone maintenance for opiate abusing women. Infants were 1ssessed at 6 and 12 months of age with the Bayley Scale of Men-:al Development. At six months of age, the mean mental develop-1ent index (MDI) was well within the normal range (mean MDI = .05). However, males had significantly higher scores than fe-1ales, mean MDI's were 109 and 102 respectively. Twenty-four .nf ants have reached 12 months of age and their average perform-1nce continued to be within the normal range of development (mean !DI= 103). The repeated assessments at 6 and 12 months of age ·evealed a significant decline in Bayley Scores for male infants :6 month mean MDI = 114; 12 month mean MDI = 103). There were 10 differences in scores between male and female infants at 12 ionths of age. The sex differences found at 6 months of age are .nconsistent with the literature and suggest the need for further ·esearch to determine if drug dependent women are more responsive :o male infants during the first few months of life. Overall, :hese data indicate that infants born to drug dependent women lo not suffer any demonstrable developmental sequelae during :he first year of life. Outcome of children born to drug dependent women has been an area of concern for health professionals. Previous research has been directed primarily toward identifying the medical risk factors associated with prenatal exposure to narcotic agents. This has resulted in little information regarding environmental risk factors concomitant to this population. In order to investigate the specific characteristics of these drug dependent women that are related to child rearing practices, a Knowledge of Child Development questionnaire was administered. Subjects where opiate abusing women enrolled in a comprehensive treatment program providing psychosocial and medical services as well as methadone maintenance. All of the women (N = 30) tested had a history of at least 2 years of drug abuse, an average of 11 years of education and an average age of 28 years. Of 33 test items, 14 were answered incorrectly by over 1/3 of the mothers and 6 questions were answered incorrectly by more than half. The most frequently missed questions pertained to basic developmental milestones. Mothers consistently underestimated the age by which a child should be able to walk, talk, and have the physiological maturity for toilet training. As a practical application of this information, parenting classes, within comprehensive treatment programs, should stress basic infant development in order to avoid unrealistic and inappropriate expectations that may damage mother-infant interaction. NEONATAL PERCEPTIONS OF DRUG DEPENDENT MOTHERS, 5:3 Karole Kaltenbach, Betty Leifer, Loretta P. Finnegan, Thomas Jefferson University, Department of Pediatrics, Philadelphia, Pennsylvania A mother's perception of her newborn has been found to be an important factor in the psychological and social development of her child. In order to more fully understand the risk factors for infants born to drug dependent women, this study investigated how these women perceive their infants. Sixty drug dependent women and 21 non-drug dependent women of comparable socioeconomic and medical backgrounds were administered the Broussard Neonatal Perception Inventory 24 hours post partum. Drug dependent mothers had significantly more negative perceptions of their newborns than non-drug dependent mothers ( .,..:"" = 4 .17, p < . 05). In addition, differences in maternal perceptions within the drug dependent group were found to be a function of severity of withdrawal. Mothers of infants who subsequently required pharmacotherapy for abstinence had significantly more negative perceptions than mothers of infants who did not require therapy ('J'-'-= 7.38, p < .01). Although drug dependent mothers may have more negative perceptions because they expect their infants to undergo abstinence, studies with normal infants have found that mother's perceptions are often unrelated to the physical condition of the child. These findings suggest that infants born to drug dependent women may be at risk for maladaptive mother-infant relationships and that maternal characteristics specific to this p0pulation must be better understood. In order to study the prevalence of psychiatric symptomatology in childhood cancer patients the Beck Depression Inventory (BDI), Children's Depression Inventory (CD!), the State-Trait Anxiety Inventory (STAI), the State-Trait Anxiety Inventory for Children and a Life Events Inventory developed for this population were administered to 34 children with cancer between the ages of 8-18 years. Illness variables such as length of time since diagnosis and number of remissions were considered in the data analysis. Eight of the 17 adolescents studied obtained a cutoff score on the BDI indicative of mild depression and of the 17 children studied, five achieved a cut-off score on the CDI indicative of mild depression. In both children and adolescents there were significant differences between the depressed and nondepressed children on the other instruments administered. There were less positive life events (p< .01), more negative life events (p< . 05) and more trait anxiety (p < . 01) in the depressed than the nondepressed groups. Illness variables were not significantly related to life events and the other measures of psychiatric symptomatology. Thus, half of the adolescents studied and one third of the children studied demonstrated evidence of psychologic disturbance on all of the instruments administered. INTRAVENTRICULAR HEMORRHAGE (IVH) VENTRICULAR DILATATION AND OUTCOME. Anne Koons, Sh an Sun, Richard Koenigsberger, Mathias Hagovsky, Carol Bechtold. Spon. F. Behrle) New Jersey Med. School, Div. Neonatology, Newark, N.J. From 1980 thru Sept. 1981 infants with IVH were followed. Papile's classification with a modification in Stage I II was used to categorize these neonates. Stage II la was used for posterior horn dilatation alone and/or minimal dilatation of the lateral ventricles, lllb for moderate dilatation of entire ventricular system. Outcome was assessed quarterly by Bayley testing and neurologic exam. 4 of 7 patients with Grade I I lb IVH failed to demonstrate complete resolution of ventricular dilatation. Three infants (12, 9 & 5 months) had normal developmental assessment and neurologic exam, although head circumferences followed the 90th percentiles. A fourth infant with early reduction of Since maternal psychological factors may affect infant feeding and thus "confound" the relationship between feeding and subsequent obesity, we have developed and tested two instruments to Body Habitus (IBH) consists of 4 drawings of 9-month-olds exhibiting a range of body habiti from quite lean to very chubby; new mothers are asked to rank the 4 in order of preference for their new baby. The Maternal Feeding Attitudes (MFA) is a 10-item questionnaire addressing the new mother's food "pushiness". were tested (and retested) prospectively in a sample of 50 consecutive women giving birth to normal full-term healthy newborns. Both the IBH and the MFA produced high test-retest intraclass correlation coefficients (RI's): ,92 and .95, respectively. Significant inverse correlations were found between the IBH and both age (r=-.38; P=.004) and the Green SES index (r=-.28; P=.025), indicating that older, higher-SES mothers prefer leaner infants. Breast-feeding mothers had significantly lower mean IBH scores than did formula-feeding mothers (P=.029). The MFA, by contrast, was not associated with any of these variables. We conclude that maternal adiposity preference and feeding attitudes can be reliably measured. Owing to their possible associations with infant obesity and its determinants, we urge that these factors be included in future studies in this domain. Bruch has called behavior modification to induce weight gain in AN "perilous". report key findings of a successful behavioral regimen that combined treatment and metabolic studies for 8 patients with AN (none with vomiting) in a CRC. All patients adjusted satisfactorily to the protocol and met the discharge weight goal in 26 to 64 days. The research-care team consisted of a pediatrician, a psychiatrist and the CRC staff, each with clearly defined roles. Each patient received a prescribed, constant diet for 6-day periods, during which metabolic balance studies were performed. Intake was increased by 300 Cal/day at the end of each period if weight gain was not at least 0.2 kg/day. The bathroom door was locked; complete bed rest was enforced for 24 hrs. if any day's food was not eaten; and staff accompanied the patient to other areas of the hospital. He were encouraged to find that: l) patients perceived the controlled, consistent research protocol as supportive; 2) patients were minimally "manipulative", due to the finely regulated environment of the CRC, which contrasted beneficially with their adverse home environments; 3) the on-site metabolic kitchen added flexibility and palatability to the diet, 4) the dietitian's professional advice aided in the acceptance of the diet; and 5) a nurturant research team could initiate therapeutic changes in the patients and families while conducting clinical studies. These findings suggest important treatment principles for p•tients with AN in other settings. A CONTROLLED STUDY OF PRE-SURGERY PREPARATION FOR 58 CHILDREN. I. Frankl in Kuhn, Jr., Samuel LeBaron, and Lonnie Zeltzer. (spor1. by Charles Grose) . The Univ. of Tex. Hlth. Sci. Ctr., Dept. of Pediatrics, San Antonio, Texas. Standard preparation programs to reduce anxiety of children about to undergo surgery are assumed to benefit children and parents. To test that assumption, 60 children (3-11 years), admitted to a county hospital for nonemergency surgery, were randomly assigned to l of 4 experimental groups: (l) child preparation, (2) parent preparation, (3) both child and parent preparation, and (4) no preparation. Preparation techniques included videotapes, coloring books, structured parent interviews, and written guidelines for parents. Dependent measures of children included: (1) self-reports of anxiety {"fear thermometer" rating fear of 15 aspects of hospitalization and surgery), (2) behavioral observations made by 2 independent raters on children's anxiety and cooperation during hospitalization (88% perfect agreement between the 2 raters), (3) physiological measures of anxiety (including pulse, respiratory rate, blood pressure, nausea, vomiting, medication needs), (4) length of hospital stay, and (5) problem behaviors pre-, during, and post-hospitalization (rated by parents). Parents also rated their own anxiety during their child's hospitalization and their satisfaction following discharge. Analysis of variance and covariance indicated no differences between the 4 groups for any of the dependent measures. The data indicate that standard pre-surgery preparation does not necessarily reduce either children's or parents' anxieties or increase parental satisfaction. We conclude that such preparation should be individualized rather than standardized. The purpose of this study was to determine whether prematurity tnd/or young maternal age arc important risk factors for child abuse. Previous studies, most of which have used a case-control lesign, have provided contradictory evidence about the relation-;hip of these factors to abuse because of the failure to use com->arable controls, to clearly define abuse, and to take account of lifferences in clinicians' likelihood of detecting abuse. To investigate these risk factors, a case-control design was tsed. Cases were 106 children who: (1) had been reported to the 'NHH child abuse registry from 1/75 to 12/79, (2) had evidence of lefinite or probable physical abuse based on an independent re-1iew of the incident, and (3) had been born at the same hospital. each case, a control who had no evidence of abuse was chosen 'rom a log of births and matched according to birthdate, sex, :ace, method of payment for the hospitalization, and provider of iealth care (to minimize detection bias). Perinatal data were ab-;tracted from the hospital charts. Analysis showed that the rates >f prematurity (gestational age < 37 weeks) were no different in :ases and controls: odds ratio (w)=l.43, x2=0.53, p>.5. The rate >f teenage mothers (age <20) at the birth of the abused child was iigher in the cases than the controls ( .. =1.86, x 2 =3.60, p=.058). rhus, prematurity is not a risk factor and young maternal age at >irth is likely a risk factor for abuse. These results emphasize :he need for careful research design in such studies. THE MATCHING FACES ATTENTION TASK, Craig B. Liden, 62 (Span. by Thomas K. Oliver), School of Medicine, Univ. of Pittsburgh, Dept. of Ped., Children's Hos. of Pgh. The Matching Faces Attention Task (MFAT) provides o structured 1eans to obtain quantitative and qualitative data regarding seec'i.ve attention in school age children. MFAT requires children o selectively attend and problem solve in performing a distinct-.Ve feature analysis on each of 24 test items. Response time and orrectness of match is recorded for each test item. Total cor-·ect (TC) and total response time (TRT) scores are broken down to .nfvrmation regarding cognitive tempo, vigilance, distractibility nd problem solving efficiency. The task takes 5-10 min to com-·lete and requires test booklet-Form A or B, and a stopwatch. Selective attention as measured by TC improved with age in a ormative population (N=350). TRT decreased with age. TC strongy correlates with measures of other developmental functions: ine motor (.305), auditory sequential memory (.410), visual seq-Jential memory ( .391), receptive comprehension ( .491), syntax com-•rehension (.349), and expressive vocabulary (.491). MFAT successul ly discriminated between groups (N=l35) of high, moderate and ow ochievers (p<.01) and correlated with reading (.466), math .546), and total achievement (.533). In clinical trials (N>500) the MFAT has been documented to be JSeful in: discriminating types of inattention; contributing to selection of candidates for drug therapy; generating cognitive .ntervention strategies; and longitudinally monitoring attention-.I status. On the basis of initial studies, MFAT would appear to cost effective and efficient clinical and research tool for attention in school age children. An association of fetal growth retardation with maternal heroin use is well known. Studies of growth patterns of infants born to methadone mothers yield inconsistent information. This study reports longitudinal growth in infants born to 3 groups of uomen: 22 heroin users (II), 21 methadone-maintained (M), and 28 controls (C) matched for maternal age, race, marital status and prenatal :are, in a community hospital serving a low S. E. population. psychoactive drug usage was prevalent among both drug Birthweight, length, and head circumference (adjusted for gest. age) of drug groups (H,M) were significantly smaller than controls (plx/month,<2x/week) (87.); part night at least twice a week (187.) ; all night at least twice a week (19%) . Children who slept with parents only in an extraordinary circumstance were not considered co-sleepers. Recent co-sleeping occurred in 737. of black and 337. of white families. Regardless of race, a co-sleeping child was significantly more likely to be over two years old, not living with the father, and tended to have a less-educated mother. Co-sleeping seemed to reflect a parental approach to sleep management of adult presence and body contact, i.e.,co-sleeping children were significantly more likely to have their bed in the parent's room, to have adult company when falling asleep, to be given body contact other than co-sleeping in response to night waking, and less likely to be put in their own sleeping place to fall asleep or to be given a bottle to hold. Night waking was more common in children who slept with parents (p=0.03), regardless of co-sleeping pattern. Few families had discussed their practices with their pediatricians. These results demonstrate that co-sleeping is common, though generally against pediatric recommendations and without pediatrician awareness. Thumbsucking and transitional object attachment have been considered normal and important aspects of young children's developing independence. To test an alternate hypothesis, that they are a function of falling asleep without adult company, a representative sample of 99 mothers of healthy children between 6 monthsand 4 years of age were interviewed. 50% of the children fell asleep with adult company, almost always the mother 1 s. The prevalence of falling asleep withcut an adult present increased only slightly over this age range, from 43% to 56%. Regardless of age, these children were significantly more likely to suck their thumbs (p=0.04) and to use a transitional object (p=0.001). Other c.nmmon behaviors when falling asleep, such as drinking a bottle or sucking a pacifier, and uncommon ones, such as crying, self-rocking, or grinding teeth, did differ in the two groups. Children who fell asleep with parental company were more likely to be rocked (p=0.02) less likely to require any special object or behavior (p=0.04). There was no difference in the prevalence of bedtime struggles or night waking. The association between falling asleep while breastfeeding and thumbsucking or transitional object use could not be determined, because only 5 children were still being nursed to sleep. The results indicate that thumbsucking and transitional object attachment are not simply normal aspects of a child's increasing independence. Rather, they may be the product of pediatric recommendations that young children fall asleep alone, advice which deviates from the practice in most human societies and our own past. The extent to which the developmental outcome of very low birthweight (VLBW) infants can be predicted from neonatal assessments has been an unresolved question. In our study, 61 consecutive infants weighing less than 1500 gms at birth were examined at 40 weeks post-con,:eptiona] age (PCA) with CT scans and the Einstein Neonatal Neurobehavioral Assessment Scale (ENNAS). Subsequent ueurobehavioral development was assessed at 7,12 and 18 months using the MDI and PDI scores of the Bayley Scales.CT scans were called abnormal if they showed diffuse periventricular low densities and/or other specific lesions (e.g., intracranial hemorrhage or ventricular enlargement). The ENNAS is a 22 item exam; the sum of abnormal items gave a score for each infant. A multiple linear regression was performed the CT data and ENNAS scores at liO weeks PCA with later assessments of neurobehavioral development (Bayley scores). Both the CT scan findings and the ENNAS scores were significantly related to MDI and PDI scores at 7, 12 and 18 months. In summary, either C'I' scan datn. o,. ENNAS scores at 40 weeks PCA are statistically reliable predictors of neurobehavioral development in VLBW infants over the first 18 months of life. Therefore, the availability of these two clinical assessments, both with predictive re..:..iabili ty, offers an important opportunity to determine w:1ich VLBW infants may need early intervention. Social support and stress are modifiers of a person's health status. In a chronic disease such as asthma, they have been implicated in the disease outcome. We examined prospectively the effect of a mother's social support and stress on her child's morbidity fran asthma. Over a 9 month period mothers of asthmatic children, ages 3-11 years, were evaluated 3 times by means of a mailed self-administered questionnaire designed to assess their social support and stressful life events. Concurrently, their children's morbidity from astlma was assessed monthly by monitoring the days of disability from the asthma, the ntmlber of unscheduled physician visits for the asthma and hospitalization resulting from the asthma. An initial group of 39 mothers completed and returned the first questionnaire, while 28 and 22 completed and returned the second and third questiormaires at 4 and 9 months respectively. The data showed that the social support of responding mothers was fairly stable over the study period, as was the ntmlber of stressful life events. However, there was no correlation between the mothers' social support and stress and their children's morbidity from asthma. These results contrast with our previous retrospective study and suggest that a mother's social support and stress may have more of an effect on her perception of severity of the asthma than the actual morbidity. 48 children under 4 years hospitalized for child abuse,97 for accidents, 41 for failure to thrive, and 23 for ingestions were matched individually with controls suffering from comparably acute medical conditions on age, social class, and race. A structured maternal and paternal interview yielded 63 significant single-variable comparisons in thesP. domains: child health and development, past and present family disruption and conflict, parental physical and emotional health, and environmental setting. function analysis suggested interrelationships among the case groups and an additive mode of pathogenesis, with more severe stresses associated with more severe childhood symptoms. Cluster analysis on a random half-sample identified three cohesive groups, characterized as ecologic equilibrium, adversit:Y!._ and crisis. This reformulation subsumed respectively increasing proportions of severe symptoms and replicated successfully on the other half-sample. Its elaboration gives a convenient matrix for organizing data from practice and a value free alternative to the present manifestational classification system, which adds insult to injury. Parent questionnaires eliciting data on sleeping-feeding-crying patterns in 75 3 and 6 month old babies were scored for "intrinsic traits", 11 level of parental conern 11 , and "family adustment". There were significant associations with subsequent ratings by teachers on a kindergarten performance profile. These were strongest for the 3 month old "intrinsic traits": "Trouble getting to sleep" at 3 months correlated negatively with teachers' assessments of "leadership" (.37), "peer interaction" (.41), 11 class participation" (.41), "communication" (.42), and "overall social" (. 4 7). "Excessive cry and "poor consolability" had the next most negative association (.30-.41 ). Feeding problems correlated at .23-.36. The infant sleeping-feeding-crying measures did not relate to kindergarten teachers' assessments of "mastery" (e.g., "persistence", and .. use of time", "conformity of routine", and "following directions"). Parental overconcern during infancy and poor family adjustment to the new baby were not nearly as predictive of kindergarten social dysfunction as were "intrinsic traits 11 • Follow-up of the 17 subjects with the greatest number of problems in infancy showed a consistently high proportion with social-emotional concerns at 30-42 months kindergarten entry. The data suggest that for a subgroup of children infantile functional disorders may be antecedents of poor social transition to school but are not predictive of difficulty with classroom competence and task mastery in kindergarten. Lack of maternal involvement in the early neonatal period is thought to be associated with later problems in the maternal-infant relationship. In order to increase a mother's interest in her transported sick newborn we developed a VP system between our ICN and one of our referring hospitals. We used a digital slow scan VP to show hospitalized mothers their infants during their phone calls. To determine how effective this device was in increasing a mother's interest in her infant, we monitored the frequency of phone calls made from the mother to the hospital staff. We compared the frequency of phone calls between mothers who were offered VP (N=7) and those who had regular telephone service (N= 7). All mothers delivered at the same referring hospital and were similar in maternal age and parity, cultural and socioeconomic background, marital status, and length of hospital stay after de-Their infants were similar in gestational age, birth-we1ght, sex, admitting diagnosis and length of stay in hospital. We found that the mean number of phone calls made per day by the study mothers (l.O±o.3 calls/day/mother, ! SE) was significantly greater than the number made by the control mothers (0.2:0.1, p<.025). In addit\on, after the left the hospital, the study mothers concinued to call more frequently about their infants (0.91:!:0.17 vs 0.35:!:0.15 calls/day/mother, p<0.05). Use of VP during separation immediately after ivery increases the mother's interesL in her sick infant. and Sharyn Brown. UCLA School of Medicine, Cedars-Sinai edicol Center (CSMC>; Deportment of Pediatrics, Los Angeles. In the 1980 fiscal year at CSMC (4/ I /80 -3/31 /8 I), 29 infants weighing 100 grams or less at birth received neonatal intensive core. $I 08,000 The cost increases over and above inflation can be attributed to new chnology which in turn is reflected in improved neonatal outcome. The 1proved survival "efficiency" con best be appreciated when one comres the 1976/ 1980 approximate costs of producing one survivor: $62,000 d $I 08,000 respectively, on increase of "only" 74% despite on increase average hospital charges of 86%. However, the average cost per< 1000 om infant admitted, rose from $25,000 in 1976 to $67,000 in 1980. -Con society afford the high cost of survivors? The 1980 group of fonts cost society over $1.9 million. Inflation tends to blur the true in cost, however, evidence suggests that additional infants ore rviving at costs less than predicted by the rote of inflation. The rote of flotion, on the other hand, may drive our society to the untenable sition of allowing solvagoble infants to die. Inter-hospital cost comparisons may be inaccurate as services provid, and patient course and outcome differ between hospitals. To ercome this difficulty, all billed hospital goods and services provided to jroup of infants cared for at CSMC were itemized and tallied. By then Jlying hospital-specific charges for every item on the bill of each ant, inter-hospital charge comparisons could be mode. In the 1980 fiscal year at CSMC (4/1/80-3/31/81), 29 infants (62% ·vivol) weighing < 1000 grams at birth were admitted to our Neonatal ensive Care UnitcNICU). To dote, hospital charges of 15 of 29 infants survivors, 9 deaths) hove been compared with the charges that would ,e been generated at 7 other tertiary NICUs across the notion. lnter-;pitol comparisons appear in the following 30-72 Percentage breakdown of the total charges at CSMC is as fol lows: >m chorges-31 %; respiratory therapy (ventilators, oxygen, tronscutone-; monitoring, blood goses)-38%; pharmacy-I I%; laboratory-I 0%; central >ply-5.7%; radiology-2.2%; miscelloneous-2.0%. Likely, the wide variation in charges reflects regional differences in ;pitol costs of supplying goods and services, patient population, percen-Je of charges recovered, ns well as hospital billing practices. Caesarean section (CS) hos been associated with poor maternal-infant attachment. As the immediate postpartum period hos been identified as a critical time for establishing o maternal-infant bond, the objective of this study was to determine if extra visuol ond tocti le contact at birth between mothers and infants delivered by CS mode any difference in their attachment three months after birth. Accordingly, 40 middle-class women scheduled for repeat CS with epidural anesthesia were divided into two groups: Control group: routine hospital care during delivery (infant removed from delivery room 3-10 minutes after birth); Experimental group: 45-75 minutes additional visual and tactile contact during ond following surgery. Three months later, the behavior of 33 of the 40 mothers were recorded by a blinded observer during a 10 minute mother-infant play period. In oddition, a questionnoire was administered to each mother concerning the effect that a CS delivery hod on her personal life and on her altitude toward her infant. From a preliminary analysis of the data collected, it appears that extra contact under the given circumstances, does not influence maternal-infant attachment. It should be emphasized, however, that no untoward effects of extended maternal-infant contact were observed, and all mothers enjoyed the experience. This, in itself, may justify extended contact when it is medically safe. Further studies need lo be conducted with women from different socio-economic bockgrounds and with women undergoing unscheduled primory CS. Dept. of Pediatrics. To further define the influence of methylphenidatc on the growth hormone-somatomedin axis and prolactin secretion, scrum growth hormone and prolactin concentrations were measured in samples collected by continuous withdrawal and in response to provocative stimuli. Somatomedin C levels were measurec in fasting samples only. The nine hyperactive subjects were all studied during methylphenidate therapy{on)and after drug discon·· tinuation(off). Serum growth hormone concentration showed the ex· pected pattern of variability from hour to hour in subjects both on and off drug. The usual sleep associated peak in growth hormone concentration was observed in both groups. Comparison of mean 24 hour growth hormone concentrations on =3.82±0. 39UlEM) and off =4.38±0.35 ng/ml methylphenidate revealed no significant difference{p>.J). Subjects on methylphenidate responded to arginine stimulation with significantly greater hormone concentrations than subjects off methylphenidate at 45 minutes (p=.05)and 60 minutes (p<.05)after initiation of the arginine infusion. Mea1 prolactin concentrations on =13.7±1.8 nff 13.0±1.7 mg/ml wer• not significantly different (p>.J). MP2n fasting somatomedin concentration on methylphenidate =0.76!.03 U/ml and off =0.88± .03 U/ml were not significantly different {p>.J) and were within the range of normal for children. Growth deficits in hyperactiv• children treated with methylphenidate do not appear to be relate' t;1 clysfuncti·.n1 uf uypothalamic-pituitary-somatomedin axis. l'"SYCllDLOG1CJ\l, STARIU1"Y lN PKU DIET TERMINATION AT AGE 83 THREE. Edward Schwartz, Debra llufstetlcr, Richard .J. Allen, Univ. Mich. llosp., Dept. of Ped., Ann Arbor Ml. 156 demographically unselected Michigan hypcrphenylalanincmic infants were diagnosed between 1965-77. Of these 94 were divided into 3 groups based on dietary phenylalanine tolerances measured between the age of 6-!Rmos. Severe PKU were those with dietary phenylalanine restricted to 190-450mg/24hrs to maintain blood phenylalanine levels of 5-lOmg''· A diet of 4SJ-1000mg/24hrs was defined as mild while 11 hyperphe" were those on an unrest ricte 139) and low IQ (IQ< 139) groups indicated no differences in motor and language scales but significant differences in early state, activity, attention, impulsivity and organization, each favoring the low IQ G. There was no difference between the two G in achievement tests except that the high IQ G was superior in mathematics. Comparison of high IQ G to LD indicated no significant differences in behavior, although G continued to score better on intelligence and achievement tests. Our data suggests that highly G children may exhibit behavioral qualities that not only differ from the normal but may resemble behaviors usually associated with children at risk for learning disabilities and that the G represent a heterogeneous population -the lower IQ reflecting a continuum of the normal population, the higher IQ G representing a distinct group with superior academic and achievement functioning but behavior more representative of that usually associated with LD children. Pediatricians should recognize that disorders of attention and activity may not only be associated with LD and suggest that a diagnosis of highly G be added to the differential diagnosis of activity and attention difficulties. Med., Depts. Ped., Lab. Med., Neurol., and the Yale Child Study Ctr., New Haven, CT 06510. While large numbers of children are treated with methylphenidate (MPH) for attention deficit disorder (ADD), its pharmacokinetics and mode of action have not been clarified. We conducted a double-blind drug-placebo study in which each subject served as his own control. Subjects were 13 boys (7.1 to 12.8 years, mean 10.6) satisfying rigorous criteria for ADD; 9 had hyperactivity (H) and 4 did not (no H). Each of 3 doses of MPH (0.3 mg/kg 0.D., 0.3 mg/kg B.l.D., and 0.6 mg/kg 0.D.) or placebo (B.l.D.) was administered for 3 weeks. MPH terminal half life averaged 2.5 hours, and MPH levels in a child given the same 0.3 mg/kg dose on two occasions were highly replicable, averaging 10.3 vs 10.0 ng/ ml ( 2 hours) , 8. 2 vs 8. 2 ng/ml ( 3 hours) and 12. 2 vs 13. 4 ng/ml (peak). Hyperactivity and attention improved on all doses better than placebo with the 0.3 mg/kg B.l.D. and 0.6 mg/kg daily doses producing the best response. Plasma concentrations of MPH were significantly related to clinical response, and children with ADD (H) responded better than those with ADD (no H). Plasma concentrations of MPH may be useful in assessing clinical response. Higher doses (0.3 B.I.D., or 0.6 mg/kg) are superior to lower for behavior and blood levels may be useful in explaining apparent non-response or individual differences. THE IMPACT OF NEONATAL LOSS. R. Siegel, A. Glicken, S. Henneberry, C. Cleveland, L.J. Butterfield, and R. Harmon. The Children's Hospital, Denver, Colorado. This paper will describe a research study which was designed to evaluate the impact of neonatal loss on families. An interview questionnaire was developed which allowed for assessment of how families were coping with the loss of their infant, and inquired about events surrounding their infant's death. This permitted the study of maternal grieving, as well as the effects of staff interventions on this process. A total of 38 married women were interviewed at 3 and 9 months following the loss of their infant. The findings supported the observations of other researchers who describe a heightened potential for long-term ill effects on families suffering a neonatal loss. Findings showed that most families did describe their neonatal loss as having had a major impact on their functioning. It was also shown that although neonatal loss h3s significant effects on family functioning and maternal grieving, in general these effects are qreatest immediatly after loss and at 3 months and begin to lessen at 9 months following the loss. 89% of mothers reported sadn:?ss or depression at 3 months; the data showed similar differences at 3 and 9 months, respectively with 80% vs. 74% reporting their life was significantly different as a result of the loss, 29% vs. 10% reported severe marital difficulties, 47% vs. 48% financial problems, 58% vs. 28% difficulty sleeping, and 49% vs. 26% eating problems. Many mothers described the period from 2-4 months as most difficult since often family and friends became less emotionally available and expectprl them to be "back to normal". To determine the proportion of visits during the first years of life which were accounted for by either acute otitis media (AOM) or middle ear effusion (MEE), we studied 2568 children prospectively from birth. AOM was defined as middle ear fluid in an ill child and MEE as asymptomatic middle ear fluid. AOM or MEE was diagnosed at 17.5%, 24.0%, and 24.1% of all visits during years 1,2, and 3 of life respectively. After excluding well-baby visits, AOM or MEE was diagnosed at 32.3%, 32.1%, and 30.3% of visits during years 1,2, and 3. Of all visits made to follow-up any prior illness, visits to follow-up AOM or MEE accounted for 64.3%, 71.0, and 70.0% respectively. Prevention and better management of ADM and MEE could produce significant reductions in demand on the health-care system. A brain sparing type of head growth pattern has been described in small-for-gestational-age (SGA) neonates born of hypertensive mothers (Group A), as opposed to a low profile head growth pattern in SGA neonates born of no:rmotensive mothers (Group B). Based on this finding, 20 SGA children in Group A were compared with 35 SGA children in Group B at the age of 4-7 years. Children were compared for growth, neurological function, and intellectual development. Results: 1. No differences were found in growth characteris-A&B. 2. Group A showed better scores on intellectual testing, especially verbal IQ (P < .OS). 3. Group A showed a larger number of major neurological deficits. 4. Jn verbal and full scale IQ scores, Group A showed a negative correlation with gestational age and birth weight (P < .OS), while Group B showed a positive correlation (P < .01). Conclusion: 1. SGA neonates in Group A score better on intellectual testing than those in Group B, possibly due to a brain sparing effect. 2. Neurological injuries seen more conunonly in Group A reflect intrapartum hypoxia and indicate careful intrapartum fetal monitoring. 3. In Group A, delivery should be effected as soon as lung maturity is established, as prolongation of pregnancy after this is detrimental. In Group B, provided fetal function tests are adequate, mothers may be allowed to go into spontaneous labor. The Fairfax Hospital, F,al ls Church, Va., Sponsored by P. A. Jose To examine the breastfeeding experiences of mothers of preterms (PT), questionnaires were sent to all mothers of PT infants hospitalized at Fairfax Hospital from April 1980 -April 1981 and to 480 mothers of full term (FT) delivering vaginally during the same period. Data were obtained from 112 PT (mean GA=3lwks.) and 202FT mothers. Of those intending to breastfeed, fewer PT then FT mothers were nursing at 2 (65% vs B5%, p<.005) and 6 months (38% vs 56%, p<.05). Nonetheless, most PT mothers intending to breastfeed were doing so at 2 months. These mothers were compared to PT mothers intending to nurse who were not successful. Infant hospitalization was shorter in the successful group (p<.006) despite no differences in GA or BW. Among the most interesting findings, infants of successful mothers generally sucked or during first nursing attempts whereas infants of unsuccessful pairs often cried {p<.005). Success or failure in nursing PT infants was influenced by support from fathers and friends {p<.005) but not by hospital physicians, nurses or private OBs and Peds. Establishing lactation with hospitalized premies is difficult. Yet mothers who find proper support can be successful. Nursery policies and attitudes should be reviewed to determine how to support their efforts. The presence of multiple minor anomalies at birth has been correlated with subsequent hyperactive behavior (Science 199:563, 197·C: and mental deficiency (J Pediatr 65:189,1964) . We examined 7,157 newborn infants for 101 minor physical features. 10% had 3 or more minor anomalies (MA), defined as having no medical/surgical importance and occurring in less than 4% of infants of the same race. 98 children with 3 or more MA were reevaluated at ages 4 to 6 years with the following: WPPSI or WISC-R, VMl, the Auditory Association and Grammatic Closure subtests from the ITPA, the Draw-aperson and a hearing screening test. The parent accompanying the child was administered the Vineland Social Maturity Scale. Each child also was observed through a one-way mirror for a five minute play period. The room was divided into four quadrants, each of which had a toy in it. The number of quadrants entered, the number of quadrants changed and the longest number of seconds spent on an activity were recorded. A 5-pt. clinical rating of activity level was assigned to each child based on times out of seat, general dis tractibility and overall attention span. Three point ratings of emotional stability were assigned each child based on his responses and verbalized concerns during the administration of the Wechesler scale and the Draw-a-person. There were no significant differences on any of the above measurements between inf ants subdivided by the number of minor anomalies. None of the infants was mentally retarded. Thus, an increase in minor anomalies was not felt to have a strong relationship to learning disabilities or increased activity DEVELOPMENTAL "CATCH UP" PHENOMENON IN PRETERM (PT) SMALL FOR GESTATIONAL AGE (SGA) INFANTS. Betty R. Vohr, William Oh. Brown Univ., Women & Infants Hosp. Dept. of Ped., Providence, RI pattern, neurological & developmental performance of 21 PT SGA & 20 PT appropriate for gestational age (AGA)infants matched for birth weight, socio-economic status and date of birth were prospectively studied. 19/21 SGA (90%) & 15/20 AGA (75%) of infants born in 1975 and 1 76 were followed yearly for 5 yrs. SGA mean b.wt. (M±SD) was 1220•195g and AGA 1195±190g. At 5 yrs. of age, mean wt. and length of SGA infants remained at the 3rd-10th% compared to 2Sth-50th \ for AGA. Mean head circumferences, however,were comparable for both groups and were at the 25th-50th \. Neurological assessments showed 2 SGA cases with mild spastic diplegia(l0%)and l AGA infant with spastic diplegia. The ns ns SGA infants have significantly lower DQ scores than AGA controls at 1-3 yr.; however, both SGA and AGA infants gradually make developmental gains. Developmental 11 catch up" for AGA infants occurs by 12 mo. in contrast to 4-5 yrs. for SGA. Overall neurodevelopmental outcome was good despite the fact that these data reveal early developmental delay of PT SGA infants with late "catch up" by 4-5 yrs., stressing the importance of long term follow up to accurately assess outcome. Physicians' social and moral values are important to the extent they influence decisions in patient care. This study compares pediatricians• and non-pediatricians• attitudes and behavior in medical practice. A sample of 178 USF School of Medicine physicians (13 pediatric: 45 non-pediatric residents; 20 pediatric: 100 non-pediatric faculty) were surveyed concerning patients' rights to free choice, patients' rights to refuse treatment, national health care, equity in allocating medical care, abortion, and treatnoent of handicapped children. Siqnificant differences {p<.05) were found between pediatricians 0 and non-pediatricians' attitudes toward suicide, abortion, belief in an afterlife, and equity in allocating medical resources. Pediatric residents and faculty did not support patients' rights to choose suicide or abortion. Pediatric residents would perform life-saving surgery on a Uown's syndrome infant, while nonpediatric residents would not. Pediatric residents and faculty were more likely to encourage continuance of an unwanted pregnancy than were non-pediatricians. Pediatricians showed a greater tendency to employ religious values in making decisions than non-pediatricians. These findings suggest that for this sample pediatricians differ from other specialists in their ethical beliefs and that their decisions involving patient care reflect these differences. To examine the emotional impact of the death of a twin on 1others and fathers, a study was conducted comparing the reponses of eight sets of parents who lost a twin with eight sets 1f parents who lost a singleton newborn. In each group the 1abies had a mean gestational age of 31 weeks and the mean length 1f time between the death and survey completion was 15 months. "he mean age at death was 2.8 days for the twins and 10.5 days 'or the singletons. The parents completed a questionnaire which :overed their emotional reactions and social interactions during :he first six weeks fo 11 owing the loss and their present .ponse. Analyses of variance indicated that although mothers ex->erienced more depressive symptoms than fathers (p .001) and :hat symptoms diminished over time (p = .032), there was no siglificant difference between the responses of parents who lost a :win and those who lost a singleton. All of the mothers and 80% Jf the fathers of twins report being told by others to feel Fortunate for having a living twin, yet 60% of these parents re-Jort experiencing a physical longing to be with their baby Following his/her death and continue to frequently think of their Jead twin. No parent of a surviving twin reported prefering no!_ :o discuss their baby's death. These findings indicate that the !xistence of a living twin does not lessen parental grief and :hose care for these families should be aware of this fact is they counsel parents in their bereavement. The purpose of this study was to determine whether cigarette >making during pregnancy affected neurobehavioral function of infants. Subjects were healthy, full-term infants, 173 born to mothers who smoked 10 or more cigarettes daily (S) and 173 to non-smoking mothers (NS). They were assessed at 3 days on the Neonatal Behavior Assessment Scale (NBAS). 96 Sand 115 NS returned at l month to be examined neurologically and on theNBAS. On the initial NBAS, S showed decreased orienting behavior on 3 items (Table) and differed on 2 items related to state control (more rapid onset of irritability and increased utilization of hand-to-mouth activity). On the 1 month exam, these behavioral differences had resolved but NS were found to smile more frequently. Also, a significantly greater number of S (25) than NS (10) had abnormal or suspicious neurologic findings (p<.05). Combinations of increased muscle tone, hyperreflexia and excessive irritability (insulated crying state) were the most common findings. These data suggest the need for further follow-up to determine the implications these early differences have for ultimate neurodevelopmental and behavioral outcome. NBAS This study describes the interaction of fathers w:ilth preterm infants, and compares it to mothers' interactions with preterm infants and the interactions of lx>th parents with fullterm infants. Parent-child interactions at 5 months are related to perinatal complications and to developmental outcome at 18 months. Ten preterm and ten fullterm infants were recruited as newborns with their parents, and followed lonqitudinally until they were 18 months post-term conceptual aqe. At 5 months post term, all infants were videotaped durinq 3-minute en-face interactions with each parent. Episodes of play defined as "games 11 were subsequently coded. While mothers and fathers did not differ significantly in overall number of games played with fullterm infants, with preterm infants fathers played significantly fewer games than did mothers (P<0.02). In particular, fathers played significantly fewer non-arousinq (verbal/visual vs. tactile/limb-movement) games (p<0.05). The data suggest that fathers adapted to the stress of the preterm infant by decreasing the number of games they play. Cross-time correlations showed different patterns of relationships for preterm infants' interaction with mothers and fathers. Healthier premature infants played fewer arousinq games with mothers (r=.75), but not with fathers. Althouqh fathers qenerally played a more indirect role, nevertheless the number of nonarousinq games both parents played was more highly correlated with 18-rnonth Bayley psychornotor scores (r=.67) than that of either parent alone. The study demonstrates fathers' adaptations in facilitating the preterm infant's development. Cross-sect lon exertcse studies rn our laboratory have shown lmpatrments ln maximum values of blood pressure (BP), heart rate (HR), and working capacity (KgM/min/kg) (WC) in children with sickle cell anemia (SS). Also, lschemla (I) was noted on the exercise E2mm depression) with ME. MME in 12 of the 15 pts one month-13yrs PO demonstrated LV enlargement in 6 (50%), abnormal septa! motion in 6 (50%) and LV free wall and/or septal thickness >2 SD above expected normals in 11 (92%), The LV systolic time intervals and percent shortening (%5) were abnormal in 7 pts. Children with predominant AI had the worst LV recovery rate. All 4 had persistently dilated, thick LV's on MME and abnormal %S. Persistent LV dysfunction is noted in the majority of the children after prosthetic AoV implantation. Early intervention, particularly in children with AI may improve the long-term outcome. CHARACTERIZATION OF SINGLE VENTRICLE WITH COMBINED PULSED DOPPLER ANO TWO-DIMENSIONAL ECHOCARDIOGRAPHY George S. Bisset. Ill, Stephen S Hirschfeld, Tulane Jniv. Sch. of Med., Dept. of Ped., Tulane Med Center, New Orleans Pulsed Doppler (PD) and 2-dimensional ecbocardiograpby 1ere utilized to assess the anatomic and hemodynamic status of iatients (pts) with single ventricle (SV). Of 13 children, 11 bad ;v of left ventricular type, 1 bad SV of right ventricular type ind 1 bad SV of the undifferentiated variety. Evaluation of atrio-1entricular (AV) valve morphology revealed 5 pts with 2 AV valves :each had a small tricuspid valve (TV)), 4 with common AV valves, l with a single TV and 3 with single mitral valves. AV valve in-;ufficiency was demonstrated by PD in 3 of the 4 pts with common IV valves and 1 additional pt with a small, straddling TV. The ireat vessel positions were identified as ct-transposed in 4, 1-:ransposed in 4 and normal in 5. PD examination with the Doppler ;ample volume (DSV) positioned in the main pulmonary artery revealed 2 pts with ductal-dependent pulmonary blood flow. Two pts had 1ormal pulmonic valves (PV's) with typical PD continuous flow patterns indicating patent ductus arteriosus. Four others had tur-Julent systolic flow patterns consistent with antegrade flow thr-Jugh stenotic PV's. With the DSV positioned distal to the aortic 1alve no pt demonstrated disturbed flow, indicating an absence of iortic or sub-aortic obstruction. The atrial septum was intact in ? pts and absent in 1. A patent foramen ovale versus secundum itrial septal defect was demonstrated in 5 pts. In conclusion, ?-DE-PD provides an accurate non-invasive assessment of SV morvh-Jlogy and hemodynamics. Catheterization may be obviated in many of these pts particularly when palliative surgery is comtemplated. Since developmental differences in the effect of ca++ on myo-:ardial contractility(MC)have been described, we hypothesized that :he calcium antagonists, verapamil(V),nifedipine(N)and diltiazem (D)may also exhibit age-related differences on MC.Thus, we evalua-:ed the dose-response relationship of V,N and Don indices of MC, leveloped pressure(DP)and maximal rate of pressure development(dP/ lt)in the isolated blood-perfused immature(I;n=6)and adult(A;n=S) rabbit heart. The table below shows the for the con-:entration(;.M)found to inhibit by 20% and 50% the DP and dP/dt at •constant pacing rate. (*p < 0.01, I vs A). The results show that V and N are 10 times more potent in depressing MC in I than A hearts and that D exhibits significantly less age-related effects on MC than V or N.The data sug.;est age-r(:lated differences either in affinity for the calcium antagonists or a greater dependence on extracellular ca++ influx in the I heart. shortened by the seventh postoperative day (P <.OS) in comparsion to the preoperative PR interval. 228/292 (78%) were only observed to be in sinus rhythm. 9/292 (3%) had a preoperative dysrhythmia. 64/292 (22%) had a postoperative dysrhythmia. 22 (8% of total) of these patients were symptomatic. 16/65 (5% of total) had a tachydysrhythmia. 6/292 (2%) currently have a pacemaker (5% of our pediatric patients with pacemakers). In 17/292 patients (6% of total and 26% of those with dysrhythmias) dysrhythmias were noted in the first three days postoperatively. 22/292 (7% of total, 34% of dysrhythmias) presented with dysrhythmias between the fourth and fourteenth day after surgery. 7/292 (2% of total, 11% of dysrhythmias) presented from two weeks to three months postoperatively. 4/292 (1.4% of total, 6% of dysrhythmias) presented from three months to one year postoperatively. 3/292 (1% of total, 5% of dysrhythmias) presented from one to three years postoperatively. 7/292 (2% of total and 10% of dysrhythmias) presented at from three to eight years postop. 4/292 (1.4% of total and 6% of dysrhythmias) presented at greater than eight years postoperatively. The The effect of left atrial (LA) stimulation on refractory periods (RP) and A-V nodal conduction (A-H) have not been previously reported in children (C). Indirect measurements from coronary sinus stimulation have been obtained in adults with dysrhythmias (D). Ten C (8 preoperative and 2 postoperative) with congenital heart defects and with no evidence of D were evaluated electrophysiologically by atrial extrastimulation at the same cycle length (CL) (500 msec) from both the right atrium (RA) and LA. The LA was stimulated directly through an interatrial conununication. Rapid RA pacing was also performed. The effective RP of the RA and LA ranged between 130-240 msec; and 100-250 msec respectively. The functional RP of the RA and LA ranged between 210-320 msec; and 140-280 msec respectively. There was no significant difference between the RP for RA and LA by thP. paired "t" test. Atrial refractoriness was reached first preventing evaluation of A-V nodal RP in 7 C. The A-H intervals measured from RA and LA stimulation at a CL of 500 msec ranged between 70-120 msec; and 55-105 msec respectively. The A-H interval was significantly shortened by LA stimulation (p<0.05). Our findings indicate that in C the site of atrial stimulation has no significant effect on atrial RP and A-V nodal conduction is significantly shortened when evaluated by LA stimulation. Shortened A-H intervals on LA stimulation can be explained by earlier entry into the lower A-V node from the LA with retrograde conduction to the low RA. Conduction disturbances are common in children with Marfan's syndrome, but the occurrence of serious ventricular arrhythmia has not been stressed. An 18 yr male with mild mitral regurgitation (MR) had cardiac arrest and was successfully resuscitated. He was found to have ventricular tachycardia (VT) and frequent premature ventricular contractions (PVCs) . This prompted us to review our group of 24 children with Marfan 1 s syndrome. They were first seen at the mean age of 7.4 yr (4 mo-16 yr) and were followed for a mean of 5.7 yr (1-22 yr) . Six died and 6 were lost to follow-up. Four had no significant heart disease. E.K.G.s were available in 22 patients (pts) and 19 were abnormal. PVCs were noted in 8 pts: 2 had severe MR, 4 had mild MR, 1 had mild aortic dilatation (AO dil.), 1 had no mitral or AO abnormalities. Three pts were asymptomatic but the other 5 were symptomatic. The 2 with severe MR had congestive heart failure and underwent mitral valve (MV) replacement. Three had VT in addition to PVCs: 1 had syncope and arrest, 2 had chest pain with fatigability; 2 of these had MV prolapse and AO dil. with left ventricular enlarge- • Little information is available on the hemodynamic changes during morphogenesis of the heart. We measured heart rate, mean dorsal aortic blood flow !O'J and mean arterial blood pressure (15') in 160 white Leghorn chick embryos on day 3 (stage 18), day 3. 5 (stage 21 I, day 4 (stage 24) and day 5 (stage 27) of incubation. Dorsal aortic blood velocity was measured with a 20 MHz pulsed-doppler flow meter using a 1 mm piezoelectric crystal positioned at a 45° angle to the dorsal aorta. Dorsal aortic diameter was measured with a micrometer eyepiece and blood flow was calculated. In-vitro correlation, the velocity meter was linear (y=.85x+1.19, r=.99) over a range of 1 to 20 mm/sec. Mean arterial blood pressure was measured with a servonull pressure system from a 5 micrometer tip diameter cannula inserted in the right vitelline artery. In-vitro correlation of the pressure system was linear (y=lx-.24, r=.99) Rhesus hemolytic anemia, although observed less frequently since the introduction of Rhogam, still presents a diagnostic and therapeutic challenge to the clinician. In severely affectea pregnancies, unless intrauterine (JUT) is initiated, fetal hydrops can develop with ensuing death. From an ongoing study of 250 high risk pregnancies, the pericardia! space of 13 Rh-sensitized fetuses was imaged witl1 two-dimensional-directed M-moae echocardiography (20-MM)and evaluated for evioence of a PE. When present, the PE occurreo as early as 20 weeks of gestation and its presence preceded the appearance of ascites, soft tissue edema, or pleural effusion as manifest by ultrasound. In three fetuses the PE resolved following !UT. One fetus, in which the PE was diagnosed 4B hours prior to birth, was noted to have the PE on neonatal echocardiographic examination following birth. In conclusion, the pericardia! sac, due to its limited potential space, to (1) be the site of the earliest manifestation of fluid accumulation in fetuses destined to develop hydrops ano (2) Morphine (MS), benedryl (B), and chloral hydrate (CH) are wide· ly used as sedatives in patients with cardiac C.isease; i1owever, no datc:=i P.xistrcaanljnq the effect of these drugs on the sinus nodE early post-op. To examine the effect of these agents, as well as baseline day-to-day variation (V) and effect of supine (P) position, we measured the total sinoatrial conduction time (SACT) (n=33) and the maximal corrected sinus node recovery time (CSNRT) s 1 -rated no significant difference between the means of the paired observations or among the means between the 6 groups. we conclude that 1) MS, B, CH, and MS with B do not predictably alter the sinus node when employed in this clinical setting. 2) There is no significant variation in SACT or CSNRT related to day-to-day change or the supine position. years).Procainamide (P) (10 mg/kg IV; 4-:-9 mcg/ml serum level),Ou,.. bain (0) (0.01 mg/kg IV not exceeding .5 mg), or Quinidine (Q) (20 mg/kg/day po X4d; mcg/ml serum was administered and EPDS was repeated. Response to drugs was evaluated by inhibition of sustained AVRT and by measuring the effective refractory period (ERP) of the atrium, AV node and accessory connection (AC). Ouabain demonstrated variable effect on the atrial ERP and no effect on AVRT.P and Q prolonged the atrial ERP (4/4 tested) and AC retrograde ERP (2/4) was abolished in each patient tested acutely with P or Q, and also by chronic oral Q (follow-up T:s mos) .We conclude that acute EPDS is a valuable technique to assess drug response in patients with refractory AVRT and that acute P response corresponds to chronic Q response. SVC obstruction is a well-recognized complication of the Mustard operation for transposition of the great vessels. We describe 3 patients who imderwent Mustard repair at a mean age of 9 months and developed increasing head circumference (HC), facial edema, and cerebral edema or documented hydrocephalus postoperatively. Cardiae catheteri zation (CC) showed severe SVC obstruction with a mean SVC pressure of 27 nrnHg and a mean pressure gradient of 19 nm Hg between the SVC and systemic venous atrium. The azygous vein was widely patent in all 3 patients. The first patient died at 27 months of age and was found to have diffuse cerebral congestion and mild right uncal herniation. Computerized axial tomographic (CAT) scans in the remaining 2 patients revealed cerebral ventricular dilatation with widening of the cortieal sulci ccxnpatible with conrnunicating hydrocephalus. The second patient tmderwent surgical revision of the SVC obstruction after which the HC and CAT scan reverted to normal and the mean SVC pressure at repeat po stop CC fell to 11 mm Hg. The third patient underwent surgical revision only recently, but already has shown resolution of the facial edema and normalization of HC. In conclusion, severe SVC obstruction following the Mustard operation may result in chronie cerebral congestion and hydrocephalus despite azygous deccxnpression. The CNS abnormalities are reversible with surgical relief of the SVC obstruction. Seven infants (mean age 2.5 months and mean weight 3.5 kg) with severe intractable congestive heart failure secondary to large left to right shunts and pulmonary hypertension underwent pulmonary artery (PA) banding. The series included 4 patients with single ventricle, 2 with complete AV canal without AV valve incompetence, and 1 with interrupted aortic arch (IA) and ventricular septal defect (VSD). The initial patient with IA and VSD underwent contrast injection in the inferior vena cava and had marked right to left shunting across the VSD, consistent with excessive banding. The remaining 6 patients underwent suprasternal notch echocardiography--5 in the immediate postoperative period and 1 one year postoperatively. In these 6 patients the entire circumference of the PA band was visualized. The mean cross sectional area (CSA) at the band was 1.57(±0.40) cm /M in to the pre-operative mean CSA of the PA of 5.91U 1.60) cm /M 2 • The mean CSA of the ascending aorta was 2.50( ±0.77) cm 2 tw. The pntient evaluated 1 year postoperatively was also noted on echo to have encroachment by the band on the right PA and this was confirrncd angiographically. Two of these 6 patients underwent postoperative cardiac catheterization and were found to have systolic pressure gradients of ·ro and 100 mm Hg across the band. In conclusion, 2-Dimensional echocardiography allows immediate and long-term evaluation of the efficacy and complications of PA banding. MDIFICATION re.,.bom larbs ha:! catheters place:I in the pulm:>nary artery (PAP), a:irta (SAP), left atriun (LAP) and inferior vena cava; the ductus 1oBS tie:I and a flow transducer place:I arrurd the nein PA. After recC>Tery, larbs (l'F4, age 5-15 days) were studie:I on tloTer the dose range with no change in QP. A tendency for higher PVR/SVR occurre:I at both me:liun and high D doses plus T than with D alone ( In 1974 we reported a high incidence of dysrhythmias (dys) after the classical Mustard operation (Group A), but a lower incidence in patients (pts) in whom the operation was modified to lessen the chance of damage to the sinus node (Group B). We report here 7 years (yrs) additional follow-up on these pts. Group A (37 pts) was followed from 6 weeks to 14 yrs (mean=8.9 yrs). Group 8 (44 pts) was followed from 6 weeks to 9 yrs (mean=4,7 yrs). All ECGs on these pts were reviewed. The dys were classified as sinus (SR), passive dys (sinus bradycardia), active dys (atrial flutter), or conduction disturbance. Results were expressed as the incidence per number of different rhythms during follow-up intervals. The incidence of SR in Group B (80%) was greater than Group A (27%) during the first 2 yrs. However, after 7 yrs, the incidence of SR in Group B had fallen to 58%. This was coupled with an increase in passive dys. The incidence of active dys (Group A 4-18%, Group 8 4-9%), and conduction disturbance (Group A 4-20%, Group B 3-13%) remained relatively unchanged in both groups during the study. These data suggest that late occurring dys remain a problem after the Mustard procedure even if sinus node trauma at the time of surgery is minimized. Progressive scarring along baffle suture lines may be an explanation. The metabolic and hemodynamic effects of acute propranolol (P) administration (I mg/kg IV) prior ta ischemia were studied in dogs subjected to 20 min of normothermic global ischemia on cardiopulmonary bypass (CPB). Pre CPB ATP levels in P dogs were similar to levels in control (C) dogs (4.95+0.14 umoles/g wet wt). On CPB during reperfusion ATP levels were better preserved with P treatment (table). P treatment did not alter heart rate (HR), mean aortic pressure (AO, data not shown), myocardial oxygen consumption (MV0 2 ) or left ventricular blood flow (BF Post CPB ATP levels in P dogs recovered better and reached 80% of preischemic levels. AO pressure was similar in the two groups and P dogs came off CPB more smoothly with fewer arrhythmias. P treatment, however, decreased HR, Cl and MV0 2 • Therefore, P treatment was clearly beneficial for the myocardium subjected to ischemia as ATP levels were higher and MV02 was decreased. P use for myocardial protection may require catecholamine stimulation to augment Cl following CPB. We testetd the ability of a pulsed Doppler velocity meter ( PDVM) to quanti tate myocardial performance noninvasi vel y. Studies were performed in 7 adult dogs under general anesthesia by controlled ventilation. Peak ascending aortic blood flow velocity (VAO' cm/sec) its first derivative, blood flow acceleration (dVA 0 /dt, cm/sec ), were measured noninvasively and compared to mean aortic (A ,mmHg) and left ventricular (LV ,mmHg) pressures, the rate oP LV pressure development (LV dp/dt ,mmHg/sec) and the pre-ejection period (PEP) to left ventricular ejection time (LVET) ratio (PEP/LVET). Mean values prior to interventions were: VAo=45.5, dVAD/dt:1003, Ao=88, LV=115/8, LVdp/dt 2150 and PEP/LVET 0.320. inotropfc stimulation with dobutamine, LVdp/dt rose to 4400, PEP/LVET fell to 0.256, and both VAO and dVA /dt increased to 62.4 and 1432 respectively. Propranolol ad-(.2mg/kg, IV) and preload elevation (30ml/kg saline) caused parallel changes in noninvasive and invasive performance indices. Programmed pacing trains also caused similar changes in V AO' dV AO/dt and LVdp/dt. After load elevation by methoxamine infusion, nowever, affected LVdp/dt little (-6$), caused a small elevation in PEP/LVET (+la), but depressed both VAfl_ and dVA 0 /dt substantially (-47$ and -43$ respectively). The -l'DVM provides useful noninvasive information about LV function which in some, but not all circumstances, parallels changes in LVdp/dt. Eighty cases of KD were reviewed. The diagnosis was based on Kawasaki's criteria. Tne aim was to determine whether patients at high risk of developing coronary aneurysms (CA) could be identified noninvasively using the ASAI scoring system, electrocardiograms (ECGs), and two dimensional echocardiograms (2Ds). Most (87%) were 100 mm/hr; platelet counts >500,000; anemia; and pyuria in about half the patients. Bacterial and vir·al cultures were positive in only 14%. Ten variables were scored using a modified ASAI system. Thirty-two percent of patients scoreo >__6. ECGs were abnormal (rhythm disturbance, chamber enlargement, or pathological Q waves) in 35J. 2D echoes were positive (pathological or frank aneurysm) in 24%. Fifty-eight aortograms were done. Recause of possible cardiac surgical in.jury to tlie sinus node, the integrity and function of subsidiary atrial pacemakers has taken on increased importance.The automaticity(auto)c1f in other mammalian cardiac tissue is strongly influenced by membrane potential (MP) .We studied human atrial fibers (!!AF) from children undergoing open heart surgery to determine the relationship of auto to MP and to determine the effects of pharmacologic agents on auto.Standard microelcctrode techniques were used to record action potential (AP)characteristics;and current injection was used to modify MP.Control AP characteristics 0f±SE):maximum diastolic potential 7±1.SmV;AP aniplitude =t6.3±2.3mV; automatic rate=49.5 beats/min (n=l2).llypcrpolarizntion of MP by 10-20 rnV induced cessation of auto.Dcpolari?.ation of Mi' by 10-20 mV increased automatic rate by 10-40 beats/min. HAF were supC'rfused with tetrodotoxin (TIX) l mg/I., which deprt·sses inward sodium current; and verapamil(V) 1 mg/L,whicl1 slow inward calcium current.Both significantly decreased automatic rate at the control MDP and cnl1anced the hyper1>olarizntio11 induced atrial quiescence.However,the depolarization induced increase in auto was unaffected by TTX but was inhibited by V. In summary,the automatic rate of HAF is sensitive to MP, increasing ilS MP decreases.Automatic fibers are sensitive ta tl1e of V over a wide of MP,but their sensitivity to TTX decreases e,horh ciutl,m.:tic ,·dtc ;ind phc1n·1:11:.iJ0.•,;c 1·e-· of HAF are modulated by MP. LEH VE:HRICUL/\R EJECT!Otl FRl\CTIOll 1:1 TRICUSPliJ 133 ATRESIA: /\SSESS'1EilT BY RllDI'lrrncuDE AtlG!OCARfllrJ1:l/\PllY __ I lur!:_i_t_z_, 11_1_..,_;_ n_ _C_h_i_n_, Q_o_"2__1_d _ _'i_j_rpj_, aldwell, :1arlene !labinovitch (snon. bv '1orris Green), Indiana ·n-fre-rfftv -:fe·d-fra-,--Sc_h_o-ol,--D-e-partment of Pediatrics; Harvard niversity :1edical School and Children's llospital, Oenartments f Radioloqv and Pediatric Cardioloq1, Boston. Left ventricular ejection fraction (LVEF) has been considered mportant selecting patients ·.:ith tricuspid atresia (TA) or a Fontan nrocedure (Fontan). To assess incidence and ossible aoe relationsl1in of almormal LVEF, radionuclide entriculoqranhv was nerformed in 24 unselected natients 1·1ith A (aqe ranqe 1-month to 24 years, median years). Paliative suroery had been done is 23, and 5 of these also had a ontan. LVEF measured durinq supine rest in all, and luring supine isometric exercise (EX) in HJ. '1ean group LVEF 1as .56 (range .39-.75); LVEF 11as similar in the post-Fontan 'atients. 10 patients (2 with 1irior Fontan) had an abnormal ·estinq LVEF {<.5'J). 5 studied durinq EX demonstrated , siqnificant Jecrease in LVEF of >.'J5; l of these 5 had a 1ormal restinq LVEF. 11as not a statistical relationship 1etween aqe and LVEF for the group without Fontan. llowever, 1ean aqe of the ratients with normal LVEF was n.2 years, and 1f those 1·1ith abnormal LVEF, 12.2 years. 13oth patients with 1rior Fontan anu abnormal LVEF under11ent surgery 1·1hen >1·1 vears. ilmost half the ratients l'lith Tl\ have an abnormal LVEF; further ?valuation of the sionificance of this abnormality is necessary. tadionuclide ventriculoqraphy can provide a relatively noninvasive method to assess LVEF and its imr>nrtance. This study was designed to determine a range of normal for ·ight and left ventricular ejection fraction (RVEF and LVEF) in 1ediatric patients. First-pass radionuclide angiocardiography 1as performed on 74 supine, resting, unsedated patients (age l to 20 years) undergoing bone scans or investigation for 1astrointestinal bleeding. Cardiac imaging was performed in the ·ight anterior-oblique projection. Regions of interest were lrawn from stroke volume images; ejection fraction was analyzed 'rom time-activity curves. Mean RVEF was .53+.06 (range .43-.73). "wo patients, both under 2 years of age, had anrfRVEfc .45. 3/5 1nder l year of had .50. Mean LVEF was .68+.09 :range .49-.86). One patient had an LVEF< .50, and only 2/42 iatients over 10 years of age had LVEFc.55. Despite these :endencies, group means for different age ranges were similar. ro evaluate discriminatory ability, clinical utility of this :echnique was tested: 10 patients hith chronic lung disease, :or pulmonale, and "possible con9estive heart failure" had !VEF=.41+.09 .01 vs. normals); 8 patients with cardiomyopathy ind "left-sided congestive heart failure" had LVEF=.30+.09 [p,-.001 vs. normals). This relatively noninvasive radio-1uclide procedure can thus be used to help identify and follow patients with abnormal pump function. Olley, John E. Gillan, Dept. of Pediatrics, Div. of Cardiology, and Dept. of Pathology, Hospital for Sick Children, Toronto. Clinical data from 12 fulltenn newborns referred to the Hospital for Sick Children because of severe CHF, and found to have CAVM were reviewed. The mean age of presentation was 40 hrs. Electrocardiographic evidence of MI was found in 11 of 12 patients (pts) studied. Moderate to severe ischemic were found in 9 pts and electrocardiograms (ECG) showed T wave changes in more than one lead associated with ST changes and/or abnormal O waves. Mild ischemic changes were found in 2 pts and consisted of T wave flattening or inversion in more than one lead. The ECG showed right ventricular hypertrophy in 5 pts, combined ventricular hypertrophy in 5, right atrial enlargement in 5, and combined atrial enlargement in 4 pts. Post-mortem histologic evidence of MI and infarction was found in available from 7 out of 9 pts. The above evidence suggests that the neonate with a CAVM has a severely jeopardized and altered myocardium. EXPERIMENTAL BASIS FOR BALLOON VALVULOPLASTY OF CON-GENITAL PULMONARY VALVULAR STENOSIS. Jean S, Kan, John I!. Anderson, Robert I. White, Jr. The Johns Hopkins University, Baltimore, Maryland 21205 Balloon angioplasty has successfully been used to open stenotic blood vessels, The feasibility of applying this technique to congenital pulmonary valvular stenosis has not been previously assessed. In an effort to assess the hemodynamic response of the hypertrophied right ventricle (RV) to temporary balloon occlusion, 6 dogs were prepared by banding of the pulmonary artery. Hemodynamic responses to acute balloon occlusion of the pulmonary artery were studied in the 6 banded dogs 3 months after banding, and in 5 control dogs. The following hemodynamic parameters were measured during incremental periods of balloon occlusion of the pulmonary artery: RV systolic pressure (RVSP), RV end diastolic pressure (RVEDP), femoral artery pressure (FAP), cardiac output <(CO) by dye dilution, and electrocardiogram, MEAN PRESSURE VALUES MEASURED DURING BALLOON OCCLUSION (m."11Hg) CONTROL BANDED RVSP (initial) RVSP (peak) 68 116 RVEDP (max) 21 23 RVSP in both groups peaked at 10 sec after occlusion while RVEDP rose gradually during the occlusion. At occlusion intervals of less than 120 sec, predominately reversible supraventricular arrhythmias were noted. These results suggest that temporary complete occlusion of the pulmonary artery, as would occur during balloon valvuloplasty, is well tolerated by the hypertrophied right ventricle. (1.94, 1.81) . RV and LV ejection fract\ons were normal. At surgery (19 Gp A, 11 Gp B), ASD size was comparable in NI vs Ab!. However, mean age of NI was less than Abl (3.3 vs 7.4, p < 0.02). Abl SN-AYN was found in 0/10 at age 0.6-2.2, in 7/11 at age 2.5-5, and 6/9 at> 6 yrs. Our study strongly suggests age-related dysfunction of SN-AVN, starting to appear after age 2 yrs. This has obvious therapeutic implications. The effect in hypoxemic newborn dogs (Pa02<38 torr) of an acute infusion (over 5') of NaHC03 or NaCl (2meq/kg diluted 1:1 with D5W) were studied on cardiac output (C.O.) and its distribution using radioactive microspheres • Control animals received an infusion of equal volume of D5W. There was no difference between the groups prior to the infusion in any of the parameters measured. There was no change in heart rate, BP, systemic vascular resistance or distribution of C.O. following any of the infusions. Cardiac output and stroke volume increased in animals receiving NaHC03 but not in those receiving an equiosmolar load of NaCl. NaHC03 in the hypoxic newborn has an inotropic effect which is not explained by hyperosmolarity and plasma expansion. Torsades de pointes (TP)-multiform ventricular tachycardia-has not been reported in children or adolescents and only rarely has it been described in adults. During intracardiac electrophysiologic studies (EPS) to evaluate suspected or documented ventricular (V) tachycardia (T), TP was induced in 3 pts who had normal QT intervals and no evidence of metabolic disorders. EPS included single (S1 ), double (S2S3) and bursts (B) of V stimuli. Pt l (16 yrs old) had nonsustained (NS) multiform VT-cycle length (Cl) 300 msec-on Holter (H) without symptoms (sx) but had sustained (S) TP (Cl 220) induced by B. After procaineamide (PA), NS TP occurred and Cl • to 200. Because of • LV function (probably 2° to myocarditis) digoxin was given and no VT recurred. Pt 2 (13 yrs old) had Rastelli repair of V inversion, pulmonary stenosis/VSD at age 7. Couplets were found on H; S TP (Cl 185) was induced by B. During serial EPS, S TP was induced after quinidine (Cl 200), NS TP after propranolol (Cl 260), and none after phenytoin. Pt 3 (17 yrs old) with normal heart had bidirectional VT on H (Cl 350) unaccompanied by sx. TP (Cl 200) was induced by B which converted to V fibrillation. NS TP were induced during serial EPS after PA (Cl 250), quinidine (Cl 300, 150), and phenytoin, but propranolol prevented TP. We conclude that inducible TP during EPS in the young has variable characteristics regarding pt population, underlying heart disea>e. and response to therapy. Serial drug EPS are useful to document therapeutic effect. EFFECT ----vasoactive intestinal peptide (VIP) and Suhstance P(SP) may be neurotransmitters in the "pept i dergi c 11 nervous system. They occur in the lung, but their effects on newborn pulmonary vascular resistance(PVR) are unknown. Flow probes were placed around the L and R pulmonary arteries(PA) of 3-18 day old lamhs; catheters were placed in the aorta(Ac) and either LorRPA5-12days later. Bolus injections of 0.1-µg/kgofV!Pand SP were made into either PA of unsedated lambs in normoxia(N) and hypoxia(ll). Land RPA flows, Ao and PA pressures (AoP, PAP in mmllg) were recorded continuol!sly. A direct effect on l'VR of VII' or SP results in a change in the ratio of flow into the injected lung over total pulmonary flow (Qinj/Q·1). VIP(n=8) is a direct pulmonary vasodilator COinj/Qr increasing from 0.49 to 0.52*) at a very low dose(O.lµg/kg). VIP also lowers AoP(84 to 77*) and increases cardiac output (CO: 1.17 to I .42 L/min*) at the same dose, indicating systemic vasodilation. Similarcffc•:ts were seen with II and propranolol (!mg/kg). In contrast, SP(n=6) had variable effects: it increased CO and AoP at l.Oµg/kg, hut increased Oinj/QTonly in II, only transiently, and only at low dose (0.3µg/kg). At IO µg/kg, SI' caused marked agitation. Ncith<'r agent showed selectivity as a PA (as opposed to a systemic) vasodilator. We conclude that VIP is as potent a pulmonary vasodi la tor as any known, but SP's effects on PVR arc weak and variable. Although the non-pulmonary effects of VIP and SP would appear to preclude thci r use as ncon:1t:1l PA they may well contr·ihutc to tl1c maintenance of pulmonary vascular homcosta:;is. (*p . J 0). Microscopic examination of the heart revealed non-specific changes while no cirrhosis was evident in the liver. The physiologic, morphologic, and biochemical findings of this study are comparable to that found in man with alcoholic cardiomyopathy and suggests that the moderate ingestion of ETOH has significant effects on cardiac function in the preadult heart. We are investigating the Li-Na CT measurement as a screening test for genetically determined hypertensive disease using the method of Canessa et al. (NEJM,1980:302, 772-6) . CT was studied in RBCs of children with primary (1°) HPT and secondary (2°) HPT with comparison to age-weight-sex-and race-matched normotensive controls. Results show a significant increase in the Li-Na CT flux in children with HPT compared with controls, The mean CT(±S.D.) for each group is shown below in mMLi/liter RBCs/hr. Between 1977 and 1981, 23 patients (pts) with complete atrioventricular canal (C.A.V.C.) had total repair. Five pts died (21. 7%). At autopsy, 4 had a small right ventricle (RV) and 1 had a small left ventricle (LV). Three pts with C.A.V.C. and a small RV have not been submitted for operation (op). In these 7 pts with a small RV (Group S) the RV/LV diastolic ratio (Rd) byM-mode echocardiography (echo) was 0.25-0.35 (mean 0.29 ± 0.03SD), while the Rd in 18 op survivors with adequate echoes was 0.42-1.2 (mean 0.74 ± 0.21SD). Two-dimensional echo in Group S was suggestive of a small RV in 5 pts, equivocal in 1, and inadequate in the 7th. Angiography (Ang) in Group S was distinct from that in balanced C.A.V.C., showing hypoplasia of the trabecular portion of the RV with a normal outflow tract and a normal or large pulmonary artery (PA). In contrast, the 18 survivors had a large LV and a normal or large RV and PA. The pt with the small LV had an echo Rd of 2.3 and by Ang a large RV and PA, small LV, and sub-aortic narrowing. Age, systemic/pulmonary flow ratio, systemic/pulmonary resistance ratio, and RV/LV systolic pressure (RVP/LVP) ratio were similar in the survivors and non-survivors. In both groups RVP/ LVP showed a significant and similar reduction immediately after repair. These data show a higher incidence of hypoplastic RV (27%) in C.A.V.C. than in most reported series. In C.A.V.C., RV or LV hypoplasia can be diagnosed by M-mode echo and Ang. In these pts the mortality of complete repair is prohibitive. A HIGH FREQUENCY REAL TIME ULTRASOUND SCANNER Soraya Nouri, Michael Wolverson (Sponsored by Thomas Aceto, Jr.) Observation of spontaneously arising echoes in the lumen of blood vessels at real time ultrasound has not been satisfactorily explained. They are seen most often in large caliber vessels in which flow is relatively slow such as the I.V.C., portal and internal jugular veins, but are seldom seen in the heart or arteries. An invitro model of a blood containing vessel was devised by placing blood in thin rubber tubing immersed in a water bath. Flow in the system was generated by means of an attached syringe and the tubing scanned with an 8 mHz small part instrument. The experiment was repeated using various mixtures consisting of (1) washed red cells suspended in .85% saline in the same concentration as in whole blood. (2) Dilutions of the washed red cell suspension (used in [1] above) with .85% saline of 1:1, 1:4, 1:100, and 1:1,000. (3) Hemoglobin solution of the same concentration as in (1) and (2) above. (4) Particle free plasma. Numerous low level echoes were noted in static and flowing blood and red cell suspensions, but not in plasma or hemoglobin. Formed elements of blood are, thus, the responsible scattering agent. Changing number and amplitude of with changing flow ratP, observed clinically, is probably related to red cell aggregation in stasis. Further improvements in ultrasound technology may allow spontaneous echogenicity of blood to be observed more consistently and used to better advantage. There was a significant fall in ventricular wall thickness during both systole (p<0.025) and diastole (p<0.05) in the first 2 wk. Mean weight loss was 5.11:':1.0 kg at 2 wk and 14. 7:'.5.3 kg at 12 wk. No elcctrocardiographic abnormalities or were seen. We were unable to demonstrate any loss of body protein in the first 2 wk by nitrogen balance. There was however a significant naturesis and diuresis in the first 2 wk which may have resulted in a reduced blood volume, which in turn may account for the observed reduction in ventricular wall thickness. Amiodarone is a new antiarrhythmic agent that has been shown to be effective in treating a variety of arrhythmias in both children and adults. We report our experience utilizing amiodaronc in the treatment of three children, ages 11-13 years, diagnosed as having anatomically normal hearts and ventricular arrhythmias (2 ventricular tachycardia, 1 multifocal PVC's). All 3 pts were initially treated with standard antiarrhythmic drugs (quinidine, propranolol, procainamide) and either did not respond (2/3 pts) or experienced drug toxicity (quinidine -1 pt). Amiodarone was administered in a single oral daily dose of 10 mg/kg/day x 1 week, followed by a daily maintenance dose of 5-11 mg/kg/day. All pts have shown a significant clinical response to oral amiodarone with either complete suppression of ventricular tachycardia (1 pt), abolition of multifocal PVC's (1 pt) and near complete suppression of ventricular tachycardia in the third pt (1 short run of ventricular tachycardia in 24 hr ECG). One pt has had corneal microdeposits detected by slit lamp examination and is receiving methylcellulose eye drops; no other adverse reactions have been encountered during the followup of 4 months to 3 years. ventricular arrhythmias in children are often resistant to standard drug therapy. Amiodarone may be an effective agent in those pediatric pts with primary ventricular arrhythmias in whom pharmacologic suppression is desired. Rapid injection of ionic contrast material versus non-ionic ompounds during cardiac catheterization (CC) is known to produce n t osmotic load. However, little information is available oncerning the effects of contrast on LV myocardial wall stress LVWS). Using double blind technique 20 pts. < 3 yrs. of aqe ndergoing cardiac catheterization were divided equally into roup I receivinq Diatrizoate t1eqlumine, Renoqrafin-76 (R) and roup II a non-ionic radiopaque compound Metrizamide (M). Followng baseline LV pressure (P) and echo measurement of LV interval iameter and posterior LVW in systole and diastole an LV injection as performed: Group I receiving l. 41 + . 12 cc/kg, I I l. 53 + . 18 c/kg. At one minute intervals the previous indices were recorded nd wall stress calculated for systole and diastole: (GM/CM2) p < 0. In order to assess echo criteria in defining hsPDA and correlating these criteria to risk for poor outcome, 51 VLBW infants (750-lSOOg, 27-34 wks gestational age [GA]) underwent prospective sequential clinical and echo examinations during the first month of life. Echoes were performed on days 1,2,3,5 and 7 and then once/wk. hsPDA was defined as 1) t left ventricular (LV) dimension or t left atrial dimension (LAD) or LAD/ Aorta 1.4 and 2) typical ductal murmur or t shortening fraction or°"' LV systolic time interval ratio. 32/51 (63%) infants had hsPDA during the first wk of life (early) and did not differ from those without hsPOA in BW or GA. However, infants with early hsPDA had lower Apgar scores (p<0.05) and were more likely to require ventilator support for RDS (p<0.05). A murmur was not audible in 21/32 (66%) infants with early hsPDA. These infants with silent ducts did not differ from infants with murmurs in BW, GA, 5 min Apgar or outcome (duration of ventilation, incidence of BPD). Infants who required ventilator support for RDS with early hsPDA needed ventilation for a mean of 13.8±9.4 days, whereas those without early hsPDA needed ventilation for 3.3±2.6 days (p<.001). Infants with early hsPDA had a higher incidence of BPD and/or death than infants without early hsPDA -17/32 vs 4/19 respectively, p<0.03. Therefore, the above criteria for hsPDA are useful in identifying the·VLBW infant at risk for poor outcome. Early differentiation of sick newborns (NB) with critical congenital heart disease (CHO) from those with non-cardiac illness is essential to the appropriate management of these patients. Linear array two-dimensional echocardiography (LA2DE) provides a technically simple, portable method for assessing cardiac anatomy in NB. Resolution is excellent. LA2DE characteristics of the great arteries were evaluated in 51 consecutive sick NB referred for possible CHO. The median age was one day (0-7) and median weight was 3.2 kg (2.5-4.1). The ratio of the diameters of the large-to-small great vessels was calculated. 24 NB with a ratio greater than 1.4 had CHO with a large shunt in either direction. Of the 27 NB in whom the ratio was less than 1.2, 10 had parallel great arteries (transposition of great arteries), and 17 had normally related great arteries. Of the 17 with normally related great arteries, 6 had a thickened and poorly mobile semilunar valve, and 11 had no evidence of cardiac abnormality. LA2DE findings were confirmed by subsequent cardiac catheterization in all 40 patients with CHO and by clinical course or autopsy in the 11 with no evidence of CHO. Thus, LA2DE is an excellent tool for physicians caring for sick NB to use in non-invasive assessment to distinguish cardiac from non-cardiac disease. Left heart anatomy in 22 heart specimens from infants with TAPVD was compared to normal specimens matched by age, crown-heel length and brain weight. Thicknesses were measured with a Fowler micrometer; lengths and circumferences with needlepoint dividers; diameters with a graduated cone; and atrial surface areas (estimate of volume) with a tablet digitizer after pressing endocardial surfaces against plate glass. Two observers independently graded the left contour of the ventricular septum as 2+ or 1+ concave (normal) and flat or l+ convex (indicating mild to moderate displacement into left ventricular cavity). Sets of observations were 90% reliable by linear regression (least squares method). Differences between normal and TAPVD specimens were determined by the Student's T test. The left ventricle in TAPVD was longer (p= .OS) and wider (p=.001) than normal. The septum was displaced into the left ventricular cavity in 18 specimens (including newborns, p=.001); this suggests that right ventricular preponderance and compression of LV cavity is not always due to increased pulmonary flow after birth. Length of left atrium was decreased from normal (p=.05) and surface area diminished (p=.001). We conclude that left ventricular cavity in TAPVD may be abnormal in shape. Since left atrium is smaller than normal, appropriate efforts should be made to maximize its effective size at time of surgical correction. In order to evaluate the role of 2D echo for identifying complex MV and TV anatomy, we studied 22 patients who had an overriding atriovcntricular valve identified on angiography. Eleven had anatomic verification at autopsy (n=S), or at surgery (n=6). Of 13 with inlet VSD, TVO was subclassified by 2D echo as TVO without straddling in 7, (4 confirmed anatomically), and TVO wiLh straddling in 6, 1 confirmed anatomically. TVO was best evaluated on 4 chamber views. Ventricular inversion in 4 p:1tients or criss-cross heart in 2 did not preclude diagnosis. Three patients had MVO and 2, 1 with and l without straddling, were verified anatomically. Short axis views best delineated MV relationsl1ips Lo a more anterior subarterial VSO. Six patients had single ventricle of right ventricular type and a portion of a common AV valve which overrode and straddled into an inferior-posterior blind trabecular pouch, a relationship verified in 4 anatomically. Our study relates the angiographic and echocardiographic views used for evaluation of valve overriding and suggests that angiography and 20 echo arc complementary techniques for diagnosing overriding atrioventriclJlar valves. In addition, 21> echo can identify chordal attachments to the septum or those crossing the ventricular septal defect and associated with straddling. Valdes-Cruz, Theron W. Ovitt, Stanley J. Goldberg, Hugh D. Allen, Jack G. Copeland, Robert B. Mammana, Univ. of Az., Depts. of Pediatrics, Surgery and Radiology, Tucson This st11dy combined the use of 2D echo and DVSA in 3 patients with double aortic arcl1 and 4 patients with aortic coarctation who subsequently underwent s11rgical correction without cardiac caLheterization. In the 3 children with double aortic arch (ages 4 months to 7 years), the 20 echo corroborated the absence of associated cardiac abnormalities. Additionally, a subcostal left ventricular outflow tract view could be developed which showed the aortic bifurcation high above the aortic valve and the proximal portion of both limbs of the double aortic arch. In the 4 patients with coarctation of tl1e aorta (age 6-11 yrs), clinical examination and 2D echo confirmed nonstenotic bicuspid aortic valve in all 4, and a small v0ntricular septnl defect associated with a ventricular septa] aneurysm in 1. Suprasternal nc>tcl1 ecl10 viPws imaged discrete coarctation distal to the left subclavian '1rtery. DVSA was accomplished with injection of l cc/kg of 6Qt. Renovist into a peripheral vein, allowing imaging of Ll1e double aortic arch in all 3 patients and diagnosis of atresia of the left itrch between Lhe carotid and subclavian in 2. DVSA also confirmt->d thL' anatomy of the coarctations prior to surgery. For simple lesions, as in this study, 20 ecl10 and DVSA can provide complete presurgical diagnosis without cardiac cathcterization. Conventional diagnosis of left to right persistent ductus arteriosus (PDA) shunting relies on clinicaJ, radiographic, and echocardiographic findings. As these methods err to underdiagnosis, we studied the value of radionuclide angiography in 42 neonates clinically suspected of a PDA. A mobile gamma scintillation camera was used, and injections of 2 mCi of sodium 99m pertechnetate in 0.2 -0.3ml volume was injected as a bolus through a peripheral IV. Birthweights ranged from 640 to 2640 grams; nearly were _:_ 1000 grams, and only 2 were > 2000 grams. Postnatal ages ranged from I to 22 days, with nearly 3/4 2 7 days when initially studied. Twenty-five infants had a Qp/Qs 2.2, 21 of whom needed surgery. Only four of thirteen infants with a Qp/Qs < 2.2 required surgery. Three infants who required surgery had no clinical evidence of a shunt and LA/Ao's were 0.8 to 1 There were no differences between the two groups in duration of ESRD or HD, anemia, hypertension, or bilateral ncphrectomy. After HD no consistent changes were found for: LV shortening fraction, electromechanical systole (QS2), pre-ejection period (LPEP) or its ratio to ejection time (LPEP/LVET) in the group as a whole. Group II had significant decrease of QS2 (p < 0.002). All patients had left atrial dimension decreased after HD (x: 11 ± 7%). Patients with no weight loss had significant improvement in LPEP (p < 0.03) and LPEP/LVET (p < 0.001). Patients with > 2% wei6ht loss had significant prolongation of QS2 (p < 0.001) and LPEP (p < 0.045), and deterioration of LPEP/LVET (p < 0.025). We conclude that children on chronic HD have acute improvement in LV function after HD only when no significant weight loss occurs. This finding suggests that high filling pressures are needed to maintain normal LV performance in patients on chronic HD. Several vasoconstrictors stimulate production c>f prostacyclin, which attenuates their vasoconstriction.We determined if endogenous prostaglandins modify tl1e vascular response to digoxin.Effects of Indomethacin(I)on changes in systemic vascular resisLance(SVR) and coronary vascular resistance induced by digoxin were examined in rabbits.Isolated hearts were perfused at constant flow witl1 blood from donor rabbits so that changes in coronary J..IL·rfusion pressure(CPP)were proportional to changes in cor0nary vascular resistance.Effects on SVR were determined in intact rahbits.Digoxin was given IV to donor or intact rabbits in tl1e absence or presence of l(!Omg/kg IV).Baseline variables did not diffpr between groups and I alone did not alter coronary vascular resistance or SVR or change contractility produced by digoxin.The Mean EF, chamber size, and %60-were not statistically different between the 2 groups, and no significant change in mean EF or %60 could be detected at l yr post op for either qroup. However, 5 of 16 VE pts. showed a -t in EF post op (me0.93 in 45 of 49 studies. To assess contractile serve. studies were performed at rest (R) and during isoproterenol infusion (!) (O. l µg/kg/min). Resting contractility was maximal at 1 and 3 weeks. and fell markedly at 4 weeks (31%). Contractility was not affected by isoproterenol at l and 3 weeks, but increased at 2 (25%) and '• (47%) weeks. Maximal contractility was similar at all ages. These studies demonstrate that the newborn myocardium is operating at maximal performance with no inotropic reserve. Similar findings at 3 weeks may be secondary to the known physiologic anemia. Proiatrics and Phannacology, University of Iowa, College of Medicine, Iowa City, IA 52242. An altered ventilation-perfusion (V/Q) relationship is a !l'ajor functional abnonnality noted in infants with chronic lung di!,ease. To examine the possibility that this V/Q aboormality is due to alterro lung vascular developnent due to hyperoxia, we exposro newborn rats to Fi0 2 of 0.21, 0.4, 0.8 and >0.95 for the first 6 days of life. Evaluation of the vascular bed was performro after the 6 days of exposure and following 7 and 14 days of air re·· covery. Structural analysis included capillary counts by light microscopy, barium PA angiography, and methylmethacrylate oorrosion casts by scanning electron microscopy (SEM) • Functional changes were assessro by Aa00 2 in Fi0 2 1.0. After 6 days there was a rrouction of capillary number/area in the animals exposro to >0.95 02. Capillary number/area returned to control values after 1 week and 2 weeks recovery in air. The pattern of PA branching was similar in l::oth hyperoxic and control animals. SEM casts of the lung vascular bed revealed differences in the microvasculature between control and hyperoxic lungs. Maximal Pa02 in Fi02 1.0 showe::l a dose-related re::luction in the hyperoxic exposro animals. After 1 week recovery in air, the dose response relationship reverse::l. With 2 weeks of recovery there were no differences between the groups. We conclude that hyperoxia alters pulmonary vascular developnent in the newborn rat. This !l'aY serve as a m:x:lel for the V/Q abnormality noted in prerrature infants with chronic lung disease. Supported by NIH Grants GM12675 and HL07413. To detect early hemodynamic changes in children with head trauma of varying severity, we undertook a prospective, noninvasive echocardiographic study of children following isolated closed head trauma. Echocardiographic detennination included shortening fraction and ventricular time intervals (PEP: preejection period and ET: ejection time) for both left and right ventricles. Glasgow coma scores, degree of intrapulmonary shunting, respiratory status and outcome were determined for all patients. Sixteen patients were studied on admission to the PICU and followed serially until discharge or death. Our findings include a significant difference (p in the ratio of RVPEP/RVET in survivors ( .24 + .015) versus nonsurvivors (.44 + .095). No statistically significant difference was demonstrated for LVPEP/LVET or SF between groups. Furthermore in the survivors, over time, RVPEP/RVET fell significantly (p< .01) (.24 ± .015 to .17 ± .006). In contrast, this ratio increased in non-survivors ( 44 ± .095 to .543 ± .12, p <. 02). We also found significant correlation between the RVPEP/RVET and the degree of intrapulmonary shunting (R = .69) and severity of injury (R = .69), as determined by the GCS. We conclude that echocardiography demonstrates significant hemodynamic alterations in children with isolated head injury. Further, that in children with head injury there is early elevation in pulmonary vascular resistance and that patients in whom this is most severe, have a poor prognosis. This study was designed to evaluate the effects of hypoxia (Nz) and reoxygenation (re-Oz) on mitochondrial respiration and mitochondrial Ca uptake in isolated, arterially perfused newborn (NB) and adult (A) rabbit heart, After perfusion, mitochondria were isolated, and mitochondrial function and Ca uptake were determined by polarograhic and Millipore filtration techniques, respectively. In the control muscle, rate of State 3 respiration (QOZ), ATP-dependent and respiration-dependent Ca uptake in NB were greater than in A. After 60 min Nz,State 3 QOz decreased significantly in both NB (64 + 4% of control, n=8) and A (60 + 7%, After re-Oz following Nz, State 3 QOz recovered to control in NB (96 + 6%, n=8), but not in A (56 + 3%, n=lZ). In A, ATP-dependent Ca uptake was not affected by 60 Nz but decreased significantly (P<0.01) after re-Oz (6Z 3%, n=6). ATP-dependent Ca uptake in NB was unchanged during Nz and re-Oz. Respiration-dependent Ca uptake was significantly (Pc.t role in the pathogenesis of reflux during infancy. SHOs are a recently-defined class of enzymes that catalyze the net synthesis of disulfide bonds using Oz and producing UzOz; such bonds are essential for the structure, function and transport of proteins. Human milk SHO oxidizes the low-molecular thiols cysteine and dithiothreitol but not glutathionine; bovine milk SHO oxidizes all three. SHO activity in human milk is greater early in lactation. Other human secretions, including saliva, sweat and semen, also have SHO activity. A survey of adult rat tissues shows SHO activity to be present in kidney and skin, but not in liver and-brain. SHO activity was not present in the kidney of suckling rats until 18 days of age. Weaning occurs at 21 days, and SHO activity remained at a low level until 23 days of age at which time there was a 3-fold increase in kidney SHO above the 18 day level. SHO in rat skin was initially detected at 23 days of age. The results indicate that SHO in rat kidney and skin are induced following weaning and that this enzyme follows a developmental pattern similar to that of rat kidney ornithine aminotransferase and alkaline phosphatase. The metabolic roles of SHU in milk and other secretions, iLs induction at weaning and their relevance to human development and nutrition will be discussed. Previous studies have shown that excess insulin secretion in vivo and high physiologic concentrations in vitro inhibit formation of surfactant by the fetal lung. To determine which cell is primarily responbive tu insulin action type II pneumocytes and fibroblasts were grown from organotypic cultures obtained f rum fetal rabbits at 27 days of gestation. Cells growing in mo11ulayers that were over 80% type II pneumocytes or fibroblasts were exposed to 1-125 insulin in a buffered medium and specific binding of insulin was measured. Optimum binding conditions were established (incubation at 20°C, pH 7.4 for I hour). Analysis of the binding data showed Scatchard plots that were curvilinear, consistent with negative cooperativity or at least two pPpuLit;_,llls of binding sites. Under optimum conditions type II cells have about 30,000 high affinity and about 230,000 low affinity sites per cell. Kd of the high affinity sites was approximately 2 nM and of the low affinity sites was approximately 150 nM. Fibrt)blasts had many fewer high aff ir.ity sites never exceeding 5000 per cell. The large number of high affinity receptors in tl1e type 11 pneumocytes indicates that this is the primary cell through which insulin inhibits surfactant production in infants of poorly controlled diabeLic mothers. Mouse teratocarcinoma cell cultures share many characteristics with the early mouse embryo and are a suitable model for studying aggregation and compaction during preimplantation development. H6 cells form uniform, grape-like clusters of adhering cells when rotated in medium (MEM) with 10% fetal calf serum. These aggregates are induced to compact within 1 hour when additional calcium (5mM) is supplied, resulting in a tight mass of cells with obscure cell boundaries and a smooth outer surface. Compaction can be reversed by removal of calcium and inhibited by cytoskeletal poisons and by the lectins concanavalin A and wheat germ agglutinin. This behavior is similar to compaction in the 8 cell morula. Mutants of H6 with altered aggregation or compaction will be useful for studying the molecular nature of these processes. We have isolated 3 aggregation-deficient variants which have lost the ability to form intercellular adhesions. Since cell surface glycoproteins are implicated in cell adhesiox, agglutination by eight lectins was tested. Only peanut agJlutL1in (PNA) had a significantly reduced effect on all 3 variants compared to parental cells. Measurement of fluoresceinated-PNA bound to the cell surface confirmed this deficiency; the mean fluorescence va 1 ue for parenta 1 cells was reduced to 1 /3 in the variant lines, suggesting that a galactose-rich glycoprotein is defective or missing in the variants and is associated with aggregation. ( Basal (B) and norepinephrine (NE, lo-•M) stimulated BAT respiration (QO,) were measured ± ouabain (lmM) using cells from fetal rabbit litters at 24 (Group I, n=4) and 31 (Group II, n=4) days gestation and at 10 days postnatal age (Group Ill, n=4). Cell volume also was determined. Mean (±SEM) B Q0 2 {µl 0 2 /10• cells-hr) increased from 12.9!1.6 (Group I) to 47.2+5.5 (Group II) and 89.0±6.8 (Group Ill). Volume increased from 4.6±0.5 picoliters {pl) {Group I) to 34.7±4.0 pl {Group III). After volume adjustment, B Q0 2 in Group III >Groups I and II, Group I =Group II. Ouabain did not suppress basal respiration. NE Q0 2 increased from 41.7<6.6 in Group I to 845±142 in Group II with no further increase in Group Ill (836±78). Ouabain suppression of NE Q0 2 increased from 42.8±4.4% (Group I) to 61 .9±2.9% (Group II) with no further change in Group III (69.9±1.6%). Sodium transport dependent NE Q0 2 increased from 17.8!3.6 (Group I) to 533± 104 (Group II) with no further increase in Group III (561±51). Non-transport dependent NE QO, (ouabain suppressed) increased from 24. 4. 3 (Group I) to 312 . • 41 (Group I I) with no further change in Group III (250•24). Adjustment for cell size did not change the pattern of development of NE QO,. Conclusions: The increase in fetal B Q0 2 is dependent on increased volume and not on changes in transport dependent Q0 2 . In contrast, maturation of NE Q0 2 is independent of volume and dependent on chanqes in both sodium transport dependent and independent respiration. Basal {B), norepinephrine {NE) and dibutyryl cAMP (dBCAMP) stimulated oxygen consumption (Q0 2 ) were measured in isolated BAT cells from fetal sheep at 121-124 days gestational age (GA) {Group!, n=4), 136-140 days GA (Group II, n=5) and 2-4 days after birth (Group III, n=4). BAT cell volume also was determined. Mean (±SEM) B QO, (in µl 0 2 /10 6 cells-hr) increased from 10.5±1.0 in Group I to 31.4±2.1 in Group II and 38.5±2.8 in Group 111. Cell volume increased from 9.0±0.74 picoliters (pl) in Group I to 13.4±2.0 pl in Group II and 18.4±2.3 pl in Group III. B Q0 2 (adjusted for cell volume) for Group II was qreater than for Group I (p<0.005) and equal to Group III. Maximal NE (10-•M) Q0 2 increased from 74.4±16 in Group I to 294±47 in Group II. Maximal NE Q0 2 in Group III (111±27) was < Groun II and = Grouo I. dBCAMP stimulated Q0 2 increased from 51.3±12 in r,roup I to 175±22 in Group II and 172±29 in Group III. Summary: 1) Basal BAT QD 2 (adjusted for chanqes in cell size) increases between 120 and 140 days GA but not after delivery. 2) Maximum NE Q0 2 occurs at 140 days GA and decreases after delivery. 3) Post-receptor stimulated BAT QO, (dBCAMP) increases between 120 and 140 days GA but does not decrease after delivery. Conclusions: l) Full maturation of BAT thermogenesis occurs prior to delivery near term in the ovine fetus. 2) In the neonatal lamb a decrease in BAT sensitivity to NE occurs at the receptor-adenyl cyclase level. FASTING NEONATAL CANINE OXIDATIVE METABOLISM FOLLOW-ING MATERNAL STARVATION. R.Kliegman, E.Miettinen, G.Campbell, M.Patel (Spon.by A.Fanaroff) . Case Western Reserve Univ., Depts. Pediatrics & Biochem., Cleveland, OH Maternal canine starvation(MCS) produces diminished fetal(F) growth and neonatal(NEO) hypoglycemia. To investigate the effects of MCS, 11 pregnant dogs were starved for 72 h prior to term delivery while 9 controls were fasted overnight. Circulating substrates and GLU, palmitate(PAL) and alanine(AL) turnover plus AL appearance in GLU were determined as was V02 and RQ in pups fasted for 3,6,9 or 24 h. MCS + F growth (251±7 vs 271±7 g) ·* MCS + maternal(M) (2.3±0.4 vs 5.3±0.3mM), F (2.2±0.5 vs 4.5±0.2) and NEO GLU at 3,6 and 9 h. MCS t Mand F levels of ketones(K), while K was + after 24 h of fasting in MCS pups. FFA was t after MCS in the M (10.3±0.9 vs 3.3±0.4) and F (0.8±0.1 vs 0.3±0.1). FFA levels in MCS pups were similar to controls at 3 and 6 h but ? at 9 and 24 h when they became lower than control values. MCS or 24 h of NEO fasting had no effect on AL levels or turnover. GLU production was + in MCS pups at 3 (Zl.2±1.8 vs 26.0±l.6µmol/ kg/min), 6 (24.0±2.0 vs 29.5±1.8) and 9 (26.6±1.l vs 34.7±2.8) h, AL incorporation into GLU t during 24 h of fasting in both groups but was + at 3,6 and 9 h after MCS. PAL turnover was unaffected by MCS between 3-9 h but + in both groups at 24 h. VOz was unaffected by MCS and t in both groups between 3 and 9 h. However, at 24 h VOz + in both groups. Control RQ t from 3-Z4 h (0.79±0.0Z-0.87±0.0Z). MCS RQ was t only at 3 h (0.84±0.0Z). Conclusion: NEO canine fasting results in + V02 due to + FFA oxidation; MCS produces fasting NEO + GLU due partly to + GLU pro- ar"tery to superior sagittal sinus(A-V) differences were determined for glucose(GLU), lactate(LAC), FFA, 6-hydroxybutyrate (BHBA), acetoacetate(AC) and oxygen(Oz) content after 3,6,9 and Z4 h of neonatal fasting. GLU A-V diff were always positive and were unaltered by MCS or neonatal fasting (range O.Z31-0.527mM). LAC was released by the brain in all pups at each time. However, the cerebral LAC A-V diff was less in MCS pups at 3(-0.07±0.05 vs -0.20±0.05),*6(-0.04±0.0l vs-0.13±0.06) and 9(-0.01±0.01 vs -O.lZ±0.08) h. A negative A-V diff for BHBA was noted only at 3 h whereas the e:.;traction of BHBA and AC were small and not affected by MCS. FFA A-V diff were small but positive at each time. At 6 h however, FFA A-V diff was t after MCS (0.34±0.14 vs 0.09± 0.03). At Z4 h FFA A-V diff + (0.016±0.011 MCS vs 0.036±0.013). The cerebral GLU/Oz ratio was between 0.78 and 1.08 and was not affected by MCS or fasting. Conclusion: 1) In the presence of low circulating GLU levels, cerebral GLU A-V diff are unaffected and suggest enhanced GLU clearance by the neonatal canine brain; 2) Uptake of GLU may account for 78-100% of cerebral Oz consumption. Additionally, less GLU was released as LAC suggesting more complete cerebral GLU oxidation in MCS pups. Except in MCS pups at 6 h, alternate fuel uptake accounts for a small fraction of Oz uptake, emphasizing the central role of GLU for cerebral energy production. * ErXlogenous cpiates are widely clistribJ.ted in the autoronic nervous system. To assess their potential role in influeocing the maturing circulation, we studied the effects of rrethionineenkephalin ( 15 nananole/kg, lVl on heart rate and mean aortic blood pressure (MAP) in 20 chronically instrumented fetal (120-130 d.gest.l, 5 newborn (2-4 wks/oldl, arrl 15 adult sheep. Methionineenkei:;halin caused a 40% decrease in heart rate cp<0.002, n=5) and a 30% decrease in MAP Cp! age fetal rabbits was rwintaincd for up to 7 days in organ culture in the absence or presence of cortisol (F, 10-7 M). The rate of (PC) was assayed by the incorporation of [ 11) chol inc into PC after 1, 3, 5 and 7 days of culture. \"ihcn lung tissue fror1 19-day fetuses was used, F increased choline' incorporiSt<>d 1, days 5 and 7. /\ similar effect occurred when lung tissue fror-i 24-d >> phenylethylamine. Similar elution profiles were noted during sephadex chromatographic purification but not cullulose ion-exchange chromatography. Polyacrylamide gel chromatography of the purified lung PNMT showed partial but not complete homology with the adrenal enzyme. Pharmacologic inhibitors of adrenal PNMT did not inhibit the purified lung enzyme. Lung PNMT was measured in 5-100 day (d), 4-120 d, and 4-140 d fetuses and in 7 newborn sheep at 3.6±0.8 d. Activity increased from 132±18 at 100 d to 326±26 in NB. The correlation with advancing age (r;.570) was significant (p<.05). Conclusions: 1) PNMT is present in ovine fetal and newborn lung; 2) Chromatographic and pharmacologic properties of lung PNMT are different from the adrenal enzyme. Speculation: 1) Local production of E by lung PNMT may be important in regulation of surfactant metabolism. There was no change in the sensitivity of the various organisms to chloramphenicol at the end of the study period in the dark or in fluorescent light. It was concluded that under in vitro conditions, light of the type used for phototherapy of hyperbilirubinemia does not cause antibiotic resistance to develop. • 226 ACTIVITY IN DEVELOPING RAT LUNG. Ward Rice, Jeffrey Whitsett, University of Cincinnati College of Medicine, Department of Pediatrics Surfactant release and smooth muscle tone in the lung are regulated by increases in intracellular c-AMP and shifts in intracellular calcium (Ca). Calmodulin (CDR) is known to regulate both c-AMP and Ca levels in certain cell types by interacting with c-AMP phosphodiesterase (PDE) and by stimulating Ca transport. Inhibition of c-AMP-PDE by treatment of the fetus with PDE inhibitors increases c-AMP and lung compliance and decreases the incidence of RDS in premature neonates. To understand the role of c-AMP and CDR in the regulation of pulmonary maturation and surfactant release, characteristics of c-AMP-PDE and CDR activity were determined in developing rat lung. Cytosolic PDE activity was 1.28±0.24 nmoles c-AMP hydrolyzed/min/mg protein (±SEM, n;5) at 18 days gestation, before surfactant production begins. PDE activity decreased to 0.48±0.09 at 20 days gestation, reached a nadir in the newborn animal of 0.17± 0.04 and increased to 0.41±0.12 in the adult. At 18 days gestation c-AMP-PDE was inhibited by Ca-CDR, an effect not apparent in older animals. While lung PDE changed during development, CDR activity remained constant: 293±42 ng of CDR actvity/mg protein (±SEM, n;6) at 18 days gestation, 262±35 at 20 days, 229±36 in the newborn, and 203±28 in the adult. A significant (p<0.05} fall in PDE activity is associated with perinatal lung maturation. Although total CDR activity did not change with age, functional changes in Ca-CDR interactions with c-AMP-PDE were demonstrated during perinatal lung maturation. Adenosine has been demonstrated to be a mediator in the increase in cerebral blood flow (CBF) in hypoxic states. 'Iheophylline can inhibit the prcxluction of adenosine. studied seven unanesthetized lambs aged 3-10 d. to ascertain theophylline effect during hypoxia. Catheters >A?re placed under pentobarbital anesthesia into the left ventricle, brachiocephalic artery, sagittal sinus, atxlominal aorta, and inferior vena cava. Animals >A?re studied on the first r-ostoperative day. CBF was measured with radioactive microspheres. Cerebral oxygen consumption (CMR02) was obtained from the product of CBF and cerebral arteriovenous difference in 02· Each animal had measurements made in rcx:xn air and moderate hypoxia before and after the onset of an infusion of theophylline. Animals had theophylline levels of 10-20mg/dl. Baseline CBF was depressed by theophylline (106.3 ± 5.60 ml·lOOg-l•min-1( ± SEM) to 87 i 5.Slfp<.01)]. However, CMR0 2 was unchan::ied (6.55 ± .63 ml•lOOg-•min-± SF.M to 6.10 ± .48). The hypoxic resr-onse was not altered by theophylline (CBF ; 920/caoz + 39; r = .95 (control) and CBF = 980/caOz + 22; r ; .95 (theophylline) (p>.05). 'Ihus, theophylline depresses baseline CBF, but does not alter the resr-onse to hyr-oxia. '!he imr-ortance of adenosine as a mediator for the increase in CBF with hypoxia cannot be determined from these data. Exchange transfusion with adult blood produces an acute rightward shift in the oxyhenlCXJlobin dissociation curve in the fetus. he studied six fetal sheep at 125-130 days of gestation. catheters >A?re placed under halothane anesthesia, and the animals studied on the third post-operative day. Baseline measurements of respiratory gases, cerebral blood flow (CBF) and cardiac output (microsphere technique), cerebral 02 delivery (CBF x carotid arterial 02 content), cerebral 02 const.nnption (CMROz) and the cerebral fractional Oz extraction (carotid-sagittal sinus arteriovenous 02 content difference " carotid 02 content) were made. Exchange transfusion with adult blood was performed and the measurements repeated. In four animals the P50 changed from 16. 7 ± • 78 ( ± SEM)lllTl!lg to 35.4 ± 2.2nulllg. In animals intermediate P50 values (23 and 27rmlllg) ..:!re chosen to investigate non-specific effects of exchange; none ..:!re found. The P50 shift had no effect on CMROz (3.86 ± 0.28 ml/lOOg/min), but produced a significant (P<.02) fall in 02 delivery (ml/lOOg /min; y = -0.31P50 + 19.43; r; -0.77) and a consequent rise (P<.01) in cerebral fractional 02 extraction (y ; 0.01P 5 o + 0.08; r = 0.96). A rise in cardiac output was not significant. Fetuses have higher cerebral 02 delivery than adults (Science-in press); sare of this difference may be due to a difference in P50· (NIH Grants llD 13830, llL 10342). Cytosolic SOD preparations were compared by their electrophoretic mobility and inununological reactivity. The following primate species were compared: chimpanzee (Pan), baboon (Papio), Rh<·sus (Macaca), African green monkey (C'ercopi thecus), Patas monkey (Cercopithecus), owl monkey (Aotus), squirrel monkey (Saimiri) and spider monkey (Ateles). Human SOD was purified and monosp0ci-:;·) (! :·.!.ntiserum was rai scd in rabbi ts. Using double gel diffusion, an antieenic identity was revealed between human, chimpanzee and spider monkey SOD preparations. M:F·ked antieenic dissimilarities were detected between human SOD and the other primate SOD preparations. The degree of structural divergence between the different species was determined by comparing the ratio of the antigenically cross-reacting material (as determined by sinele radial immunodiffusion) to the enzymatic SOD activity. This index of divergence was shown to be: human 1. Studies in our laboratory using the Swiss-Webster (SW) mouse have shown 1) the SMG NGF tissue concentrations have a logarithmic increase between 17-18 days of postnatal life, and 2) that this increase can be accelerated by injections of thyroxine for the first twelve days of postnatal life. These results verify a responsivity of NGF tissue concentrations to exogenous thyroid hormones but do not demonstrate dependency. Thus using a newly developed genetically conditioned congenitally hypothyroid mouse model (hyt/hyt), we are examining the use of NGF as a marker of thyroid hormone effect and the interrelationship of NGF and thyroid hormones on normal development. In preliminary studies, examination of both euthyroid (E) and hypothyroid (H) pups at 21 days of postnatal life reveals low tissue concentrations of NGF in the SMG (<.081 ng/mg tissue) relative to mean values (10 ng/mg) in SW mice. At 30 days H mice had low SMG NGF values (<.081 ng/mg) relative to E (l.89tl.59 ng/mg) or SW (200±20 ng/mg) values. The early biological effect of thyroid hormones on SMG was reflected in a decrease in the SMG/body weight ratio in H (.64±X10-2 ) relative to E (.87!Xlo-2 ) mice. Conclusions: 1) The increase in SMG NGF tissue concentrations in SW is delayed in (E) controls of the hyt/hyt mutant; 2) This species difference is further obtunded in association with decreased SMG mass in the hyt/hyt mouse; 3) SMG NGF serves as a marker for hypothyroidism in this species. GCM acts as a protective barrier for the gastrointestinal tract_ Many of the pl•ysiologic properties attributed to GCM are due to the complex carbohydrate coat. Recently, lectin studies have shown maturational differences in the rat intestinc1l cell surface components. To further investigate these differences small intestine GCM was isolated from NB (<24 hrs) and adult (Ad) rats using reported techniques. GCM purity was documented by carbohydrate and amino acid analysis. In SDS-agarose-acrylamide slab gel electrophoresis both mucins appear as a single broad band with the NB GCM moving ahead of the Ad GCM. After electrophoresis, lectin binding to GCM was done by incubating 125I-lecwith the gel. Gel slices were counted for radioactivity and the degree of each lectin bound was calculated hy integration of the total cpm bound to tl1e gels. In comparing the lectin binding to Ad and NB GCM (5µg of protein/gel), 3 different patterns were observed: 1) Dolichos biflorus bound only to Ad GCM and not to NB GCM, 2) Wheat germ agglutinin bound 6 times more avidly to NB GCM and 3) Ulex europeus I and Lotus tetragonolobus had the same degree of binding to both ml1 .. .. These preliminary t·esl1lts suggest that the carbohydrate coat may be different in Ad and NB GCM, due to either incomplete glycosylation or a different glycosylation pathway in the NB. These alterations may affect adequate protection of the mucosa! barrier in the developing intestine. We have shown that acute hypoxemia causes an increase in heart rate(HR) and cardiac output(CO), a fall in Oz consumption(VOz), and decreased subendocardial perfusion suggestive of left ventricular(LV) ischemia. To assess the role of beta adrenergic stimulation in these responses, we studied the effects of propranolol (P)(lmg/kg) during acute stable hypoxemia in the chronically-instrumented lamb (l-14 days of age). Acute hypoxemia alone caused the expected responses as tabulated below. LV work, calculated from the product of HR and peak aortic systolic preJsure (rate-pressure product), and LV-V02 increased markedly, in association with a decrease in subendocardial:sttepicardial flow ratio to 1.03:1 (radionuclide-labelled microsphere method). With propranolol, there was an abolition of the tachycardia and a fall in CO, with a subsequent further fall in systemic 02 transport(SOT). However, LV-V02 and LV work decreased markedly and LV endo-epi flow ratio returned to normoxic values (l.Z6:1). Acidbase status remained normal and mixed venous Oz Induction seen in this epithelial-fibroblast bilayer system is in contrast to many organ culture systems, where marked disruption of the villus mesenchymal core is observed. It suggests that, as in another foregut derivative, the lung (Science 204: 1094, 1979) , glucocorticoid effect on duodenal epithelium may be mediated by mesenchyme. Pneumonectomy and nephrectomy result in organ specific compensatory growth of the contralateral organ. Somatomedins may play a role in this.phenomenon (Am. Rev. Resp. Dis. 121,701,1980) . To explore whether serum Somatomedin C (Sm-C) levels are related to organ growth, left nephrectomy or sham chest surgeries were performed on 11, 11, and 10 rats respectively. Serum was collected on post-op days 3 and 5 and at sacrifice on day 7 and Sm-C levels were determined by radioimmunoassay. Sm-C appeared to fall in all groups durinq first 5 postop days, presumably due to the stress of surgery. From days 5 to 7, sham rats continued to show a fall in Srn-C levels; Sm-C levels were risinq significantly (p<0.05) in both pneumonectorny and nephrectomy rats (paired t-tPst). At no time did pneumonPctorny or nephrectomy rats have serum Sm-C levelg significantly elevated over shum rats. These findinqs sugqest that serum Sm-C does not reflect ongoing organ qrowth and that any influence on compensatory organ qrowth exerted by Sm-C probably occurs via a paracrine (i.e. local secretion, diffusion and action) rather than an endocrine mechanism. Lactate oxygen quotients have suggested the nutritional importance of lactate in the unstressed fetal lamb. The present study compared the net fetal LUU with the simultaneously measured fetal LUR. We studied fourteen late gestation sheep with catheters maintained chronically in the maternal artery and uterine vein, and the fetal artery and umbilical vein. Uterine and umbilical blood flows were measured using antipyrine, and net uterine and umbilical lactate uptakes were calculated by the Fick principle. Placental lactate production averaged 11.8 ! 0.7 mg/min (mean + SEM). Placental lactate distributed preferentially towards the fetus, with the net fetal LUU averaging 1.95 ! 0.16 mg/kg/min. Using primed, continuous infusion of l4C-(U)-Lactate in 6 animals, simultaneously measured fetal lactate turnover averaged 6.5 ! 0.8 mg/kg/min. Correcting lactate turnover for non-metabolic umbilical diffusional tracer loss, the fetal LUR averaged 5.9 ! 0.7 mg/kg/min. Fetal lactate production rate (LPR), calculated as the difference between LUU and LUR, averaged 4.5 ! 0.7 mg/kg/min. Infusion of 3H-glucose into the fetus demonstrated that approximately 3 mg/kg/min of the fetal LPR was derived ultimately from glucose and 1.5 mg/kg/min from non-glucose precursors. We conclude that under unstressed conditions, I) lactate is quantitatively a major exogenous nutrient for the fetal lamb, and 2) fetal lactate utilization is the result of a large exogenous lactate umbilical uptake from the placenta plus an even larger endogenous fetal lactate production. Previous studies have suggested that newborn infants are unable to oxidize free fatty acids for hepatic ketogenesis during the first 8 hours after birth. In vitro studies in newborn guinea pig have shown a similar delay in development of hepatic fatty acid oxidation postnatally. To assess the onset of total body fatty acid oxidation, the utilization of labelled palmitate was measured in vivo in groups of newborn guinea pig pups and compared to fed and fasted adult animals. (l_l4c) palmitate was injected intracardiac. The time course of label excretion as I 4co2 was followed for 2 hours. Results are expressed as percent dose recovered (M ! SEM): Age of Animal 60 minutes 120 minutes 1-4 hr (n=5l 7. 27.9 ! 2.7 39.3 ! 2.9 *p < .001 -compared to 16-24 and 24-72 hour old animals. Conclusion: The in vivo oxidation of plasma fatty acids in the newborn guinea pig is significantly reduced during the first 4 hrs of life, with rate approximating that of fed adult guinea pigs. After 16 hrs of age, there is an increase in rate to levels similar to that of fasted adult animals. These in vivo results are consistent with our previous in vitro studies suggesting that ability to utilize free fatty acids is not developed in the guinea pig until several hours after birth. Since insulin mediates many fetal growth processes which may also be affected by HYPO and GC, we invectigated the characterictics of the insulin receptor (IR) of liver plasma membranes (LPM) during maturation and the effect of HYPO and GC rabbits. In control fetuses (n=6), specific binding of !insulin per 50 11g of LPM protein increased progressively from d22 to a peak of 27 + 4% at birth (3ld). Administration of propylthiour.:icil (PTU) -plus thyroxine (Tll) to maternal drinking water from d23 onwards induced fetal but not maternal HYPO (fetal free T4 undetectable; maternal free T4 normal) since PTU but not crosses the placenta. Normal fetal IR number of 7 + 0. 9 x 10 M/L was reduced by SO't (p<0.01). was for the first 6d of life, specific binding of I-insulin was 30\ less than control (p 12). Pregnancies were al lowed to progress to 21 days gestational age when fetuses were removed by Caesarian delivery. Fetal serum glucose levels were 375 ± 31 mg/di in streptozotocin-treated animals (FS) compared to 39 ± 2 mg/di in control pregnancies (FC). However, insulin concentrations in both groups of fetuses were (2.5 ± .2 ng/ml in FS vs. 2.7 ± .3 ng/ml in FC>. 2 I-insulin binding to lung membrane preparations of FS was significantly reduced (220 ± 50 frroles insulin bound/mg DNA) when compared to FC (580 ± 80 fmoles insulin bound/mg DNA). The data do not support the hypothesis that hyperinsulinemia causes reduced synthesis of DPC and PG. On the contrary, the down-regulation of insulin receptor binding in the face of normal circulating insulin levels is noteworthy and suggests an impairment of insulin effects on fetal lungs in diabetic rat pregnancies. Chronic hyperglycemia was induced by continuous intravenous infusion of glucose {14±2 mg/Kg/min, M±SE) into 4 chronically catheterised fetal lambs from which tracheal fluid was collected from 112 through 133, 135, 143 and 145 days gestation respectively. Serum glucose levels (32±2 mg/dl) and serum insulin levels (48±12 µU/ml) in these fetuses were higher than serum glucose levels (18±2 mg/dl, p <0.001) and serum insulin levels (12!3 µU/ml, p < 0.001) in 4 chronically catheterised control fetuses of the same gestational age. Glucose infusion to the fetuses did not alter the maternal serum glucose (60±3 mg/dl) or serum insulin levels (35±4 µU/ml). Surface active material (SAM) measured on a surface balance, began to appear in tracheal fluid of control fetuses at 120 days and was present in all 4 controls at 12g days ge>stdtion. SAM did not appear at all in tracheal fluid of 3 glucose treated fetuses and appeared in the fourth fetus at 142 days ge>station. 5AM flux was significantly reduced in the tracheal fluid of the glucose treated fetuses (M < 1 11g/Kg /Hr) in comparison with the control fetuses (60'7 µg/Kg/Hr, p < 0.001). I conclude that chronic hyperglycemia reduces SAM flux in tracheal fluid of fetal lambs. A similar mechanism may operate in utero to cause respiratory distress in infants of diabetic mothers whose glucose homeostasis is poorly controlled. Pregnant ral:tiits were dosed with betamethasone (B} or saline (S} I.M., on days 26 and 27 of gestation. Pups were delivererl on day 29 via C-section airl killerl prior to breathing, or allCMed to live 6, 24, or 48 oours. B-treated pups exhibited reducerl body weights, dry lung weights, airl lung protein. Maxim.lm lung volume/gm dry lung weight was not altered with B treatment. Pressures at 30%, 80%, airl 30% rraximum lung volume on inflation (i} and deflation (d}, derived fran air pressure/volume (P/V} =ves shewed lCMer P 3 .at 6 hours, airl higher P 3 0dat 0 hours in the B pups. No other p% measurancnt was affectea-!5y B treatment. lavage ptvspholipid (PL) phosphorus was greater in B pups at 6, 24, 4e hours with a 57% increase in PL/body weight by 48 hours, Re.iative percent lavage PL carponents were altered with B at t:une 0, but only phosphatidylglycerol ranainerl lCMer than with S treatment after the onset of breathing. Light and electron microscopic evaluation of lungs indicated B-associated increase in nunber airl size of lamellar bodies in Type II alveolar cells at6 hours, which was less evident by 24 hours. This study shCMS that ;> treatment increases alveolar surfactant PL levels which are maintained through 48 hours of life in the pranature ral:tiit. 'It.is increase in PL correlaterl with rrorphologic changes in Type II cells, but was not associated with corresponding alterations in P/V curves. These observations would support the conclusion that factors in addition to B-inducerl elevaterl PL levels are irrportant in determining P/V relationships. Supporterl by NIH Predoctoral traineeship #GM07069. .7 Time to first feed, gestational age and class, birth weight, sex, race, neonatal weight loss at 3 days, method of delivery, maternal oxytocin, analgesia and anesthesia, history of "pill" contraception, parity, and ethnic background were not different between groups. No mothers received phenobarbital or steroids. Conclusion: Suppositories resulted in early evacuation of meconium in both breast and bottle fed neonates. No significant effect was noted in peak bilirubin levels in the first 5 days of life. Routine use of suppositories to decrease peak serum bilirubin cannot be recommended for term healthy neonates. Beckerman, Children's Hospital, Cincinnati Catecholamines regulate smooth muscle tone and surfactant release by the stimulation of c-AMP synthesis in pulmonary cells. The effects of c-AMP on the cell are thought to be mediated by protein kinases {PK) activated when c-AMP binds to its regulatory subunit releasing the catalytic subunit. The catalytic subunit phosphorylates regulatory proteins within the cell altering their function. The present study describes the ontogenic changes of c-AMP-protein kinase activity, c-AMP binding proteins, and phosphoprotein substrates in the rat lung fran day 17 of gestation to adulthood. c-AMP dependent protein kinase was demonstrated at all ages studied. Phosphorylation activity was present in both cytoso l and merrbrane of the lung and was enhanced by c-AMP, c-GMP and Ca. c-AMP protein kinase activity in the presence of histone was 5.5±.87 nmole·mg-1 on day 18 of gestation and decreased postnatally to 2.75±.57 nmoles·mg-1, p<.01 in the adult. Phosphatase activity did not with age. The regulatory subunit of c-AMP-PK was identified with [ H] c-AMP which bound to a single class of sites in lung cytosol, Ko 3.3±0.3rM. [3H] c-AMP binding capacity was also highest in the prenatal period, postnatal ly fran 4.6±1.2 on day 18 of gestation to 2.62±.4 pmoles mg-in the adult, p<0.01. Marked developmental changes in the phosphoprotei n substrates of c-AMP-PK were also identified by audoradiography after polyacrylamide gel electrophoresis. The high c-AMP-protein kinase activity observed during late gestation is associated with increased lung a-adrenergic receptor density and the activity of other aspects of the c-AMP dependent response system. These regulate surfactant release, glycogen mobolization and smooth muscle relaxation in the lung. T 20°c Ringer's lactate to reduce environmental temperature and then rewarmed the embryo to baseline. 38°C Ringer's lactate was applied to control embryos which were similarly studied. We observed no change in heart rate, dorsal aortic blood flow or diameter among control embryos. Heart rate and dorsal aortic flow are directly related to temperature in experimental embryos. Stroke volume remains constant. These data indicate temperature effects pacemaker rate but not myocardial function. This is a protective cardiovascular mechanism. . Pregnancy is associated with changes in both the volume and composition of fluid in body water compartments. In order to study the forces which regulate fluid flux, colloid osmotic pressure (COP), hematocrit (HCT), serum total solids (STS), mean blood pressure (MBP) and MBP-COP gradient (M-C) were measured in 184 women with normal uncomplicated pregnancy. COP fell gradually during the first and second trimesters, and reached its nadir at 30-34 weeks, thereafter it rose. These changes were p <.0001. The relationship of COP and gestational age (GA) was best described by the quadratic equation. The pattern of chanqes of HCT and STS during pregnancy were similar to COP. MBP and M-C were linearly correlated to GA. COP correlated directly with STS (r=0.71). Stepwise multiple regression analysis of COP on GA, STS, HCT, MBP and M-C showed that STS was the most significant variable, with GA, M-C and MBP followed in order. With the exclusion of HCT, the variables explained 100% of the variations of COP in normal pregnancy. In 90 pregnant women with diabetes mellitus, the COP and STS were lower, and M-C was higher than in women with normal pregnancy. COP in 9 women with toxemia of pregnancy was lower than both the above groups. The increase in M-C with advancing GA would promote fluid flux from the intra to extra vascular space in normal pregnancy and this process is further aggravated in pregnancy with diabetes mellitus and toxemia. The effect of HV on the MBF response to feeding was examined in term <2 Jay old (n=7) and 2-4 weeks old (n=lO) piglets. Phasic blood flow was measured using the experimental preparation previously described*. Temperature, EKG, and aortic pressure (AP) were monitored. Mesenteric vascular resistance (MVR) was calculated from mean AP and MBF. HV was induced by 15% reduction in estimated blood volume by blood withdrawal .,;a jugular and/or femoral catheter. MBF in the younger group showed a significant increase from control value 15-45 minutes after feeding (23.6 ml/ kg of sow's milk or commercial formula) which was not sustained through the 2 hour measurement period. MVR showed no significant change. In contrast, the older group, fed 26.5 ml/kg, showed a significant decrease in MVR. These findings differed from responses of normovolemic pigs of comparable ages where feeding under controlled conditions in the younger group showed a significant increase in MBF usually accompanied by a decrease in MVR, while the older group showed a significant postprandial MBF increase with an insignificant decrease in MVR. These results suggest an immaturity of the cardiovascular regulatory system in the younger pi9s with induced HV and feeding. Dailv enerp;v eiroenditure is difficult to estirrate in infants during onp:oinp: nursery care unless continuous 02 consUJTll'ltion (V02) and C02 production (VC02) can be measured. In this studv, V02 and VC02 were measured continuously for 24 hrs. usinp: indirect calorimetrv. The dailv enerp:y exnenditure was derived from daily V02 and vco 2 ; both were calculated from the area under the 02 and C02 concentration-t:trne curve of the expired mixed r:ases. The accuracy of the method was tested in vitro bv burninp: 100% ethvl alcohol and the averap:e error between measured and the theoretical values for 'V02 was 4. 9% and for VC02 was 4. 7%. 3-5ml of IPAL (mistaken for saline) were injected IV during a venous cut down procedure. We review the acute toxicities and suggest a management plan. An llOOgm, 30wk black female convalescent from HMD received the IPAL on eighth day of life. Within minutes she manifested acute hypoventilation, hypotension and bradycardia. She was areflexic and nonresponsive. Cardiopulmonary resuscitation including atropine and adrenalin and placement on assisted ventilation while vasopressors and alkallnization were begun. A double volume exchange transfusion (DVET) for removal of IPAL was done after the initial level exceeded the toxic range levels of 50-100. The following To detennine rtEchanism(s) underlying the efficacy of c in apnea, we further evaluated the effect of C on breathing pattern and the Hering-Breuer inspiratory inhibitory reflex in 12 infants (ages 12d -6 mo, gest age 30-41 wks, bt wgt 1.04 -4.8 kg) with apneic spells consistent with near-miss crib death. VentilatLon (VE) was rrEasured using a face mask attached to a pnellllOtachorreter to rrEasure fla.v and integrated to give tidal voll.llTE (VT) before and after C (10 mg/kg IV). Airway pressure was also rrEasured in 8 infants with a strain gauge pressure transducer during airway occlusions at end-expiration (FRC) before and after the drug. Inspiratory and expiratory tines during non-occluded breathing (T 1 c , TEc ) and during occluded breathing (Tro , 'IE°) were obtained directly from these recordings. Results sha.o.r that VE significantly increased with C (from 350.3.>42.7 to 444.2± 39.3 rnI/kg/rnin p1t; i;lte ce1:eptor concentrations are quite similar to those found in liver supernatant fractions among various inbred strains of Ah-responsive mice and rats. These data lend furthersupport to the hypothesis that system is present in the human. Humaine, Univ. de Nancy, and LERS Synthelabo, Paris, France. Twenty-nine hypertensive rrothers were given Acebutolol (A), a cardio selective beta blocker, 200 to 800 mg/d. A and its main active rretabolite, N-acetyl acebutolol (N-AA) plasma concentrations were rreasured by HPIC. Clinical status, physiologic and biochemical data were collected in the 31 neonates ( 19 term, 12 preterm, 4 twins) for at. least 72 hours. At birth, plasma A and N-AA concentration were fotmd in the sarre range, in cord and in maternal vein plasma. In all neonates, but one, early or late hypertension was observed. A close correlation was fo\IDd between blood pressure values and A (r = 4.63, p<0.01) on the first day. Continuous physiologic recording showed deceleration of basal heart rate below 120 bpn in 12 cases. In these infants, rrean A plasma concentrations were 2-fold higher than in 19 wit.'1out bradycardia. One infant died from cardiogenic shock on day 3. Six newborns suffered from transient tachypnea associated with x-ray pattern of wet lungs a11d had rrean (±SE) A plasma concentration higher than without respiratory (260 124 vs 87 ± 23 ng/ml, p<0.05) similar to the effect observed in newborn lambs treated with propranolol*. These data indicate an effective and hazardous beta blockade in infants born to ,; treated hypertensive !!Others. *Walters, R.V., Olver, R.E. : Pediatl: Res 12:239-242, (1978). '!l-.e placental transfer of acebutolol (A) and its main active rretal::olite N-acetyl acebutolol (N-AA) was studied in 14 hypertensive rrothers receiving a daily dose of 200 to 800 ITl'I of A chronically and in their 14 newborns. 'Ihe delay between last dosing and birth varied from 5.0 to 26.5 hours. A and N-AA plasma concentrations ¥.ere rreasured in rrothers' veins, umbilical vein and umbilical artery by HPLC. N-AA concentrations ¥.ere always higher than those of A, both in rrothers and in newborns. In one case, A was not detected (below 9 ng/ml) but N-AA was present. r-Ean (±SE) plasll'd. concentrations were: ACEBU'IDIDL (ng/ml) N-AAA (ng/ml) Micernal vein (n = 13) 157.2 34.6 526.7 ± 97.8 Umbilical vein (n = 15) 93.0 ± 18.8 344.5 ± 92.6 Urrbilical artery (n -11) 78.6 ± 10.3 361.0 ±114.9 Ratios betwe<>n umbilical/maternal vein concentrations ranged from 0.1 to 1.1 (x ±SE= 0.7 ± 0.3 for A) and 0.1to1.4 (0.6 ± 0.3 for N-AA) . Ratios between umbilical artery and vein concentration ranged from 0. Follow up at 24 months corrected age was perfonned on 20 pretenn infants with ISX exposure within 24 hours of delivery, 20 gestational age and weight-matched controls, and 20 term infants matched for social and environmental factors, to ascertain possible sequellae to maternal beta-mimetic tocolytic therapy. ISX exposed infants were subdivided into high and low drug groups according to their cord drug concentration and drug-free interval before delivery. All groups had similar mean maternal age, parity, education, and racial distribution. Groups were assessed for growth, physical and neurologic abnormalities and development by the Bayley Mental and Motor Scales of Infant Development. Growth failure, microcephaly, and major neurologic abnonnalities were seen only in preterm infants and did not differ between preterm groups. HIGH ISX (n=l2) MENTAL INDEX (MDI) x(SD) 79(16) PSYCHOMOTOR INDEX (PD!) )(SD) 91.5(11) LOW ISX PRETERM TERM (n=8) CONTROL 85.5(9) 85.6(17) 91.1(14) 99 (7) 96.9(21) 109.8(14) Pretenn infants born after tocolytic failure but with low cord 1eve1 s have outcomes comparab 1 e to preterm infants without to co lyti c exposure. Further studies are needed to assess the possible risk of high drug levels at the time of birth to future development. ON MANAGEMENT OF THE 2()1 NEONATAL NARCOTIC WITHDRAWAL SYNDROME. Imelda Carin, Leonard Glass, Aruna Parekh, Nathan Solomon, Joseph Steigman, Depts. of Pediatrics and Radiology, Downstate Medical Center, Brooklyn, NY. 31 neonates exposed to methadone in-utero requiring treatment for withdrawal symptoms were randomly assigned to a paregoric (PG) or phenobarbital (P) treatment group. Maternal drug intake, birth weights, gestational ages and time of institution of therapy were similar in both groups. C is a third generation cephalosporin with excellent in vitro activity against H. influenzae (HIB), S. pneumoniae meningitidis (M).-We administered C to 12 children receivingstandard therapy for bacterial meningitis (10 HIB mean C MIC = .014 ug/ml; 2 Sp mean C MIC= .15 ug/ml). C was infused over 20 minutes on days 2 and 10 of illness. Two patients were studied after single doses; the remainder received 3 doses at 6 or 8 hour intervals. Serum was obtained at peak (end of infusion) and trough and at 15, 30, 60, 90, 120, 180, 240, 300 and 480 minutes after infusion. Spinal fluid was obtained 1.5-2.0 hrs after the infusion. C concentrations were detennined by HPLC and bioactivity confinned by CSF killing assay. Phannacokinetic data was analyzed by a NONLIN computer program. The best fit a two compartment model although some patients exhibited one compartment characteristics. No adverse effects were seen. These data suggest that C may be effective in treating bacterial meningitis and should be further evaluated. There is currently little information concerning the use of pentazocine during pregnancy and its effect on the neonate. Three groups of women enrolled in a comprehensive perinatal addiction program were studied: Group A (N=27) were drug-free controls, Group B (N=38) were low-dose methadone-maintained women, and Group C (N=lO) were women addicted to pentazocine and pyribenzamine ("T's and Blue's") throughout pregnancy. No differences were seen in maternal age, gravidity, obstetrical complications, gestational age or neonatal Apgar scores. Significant differences were observed in the following physical parameters: An evaluation of neonatal status using the Brazelton Neonatal Behavioral Assessment Scale revealed that infants of mothers who used "T's and Blue's 11 were more irritable, less consolable and showed reduced orientation and motor maturity than control infants and greater impairment than the methadone-addicted infants in all these parameters. These data suggest that infants delivered to 11 T's and Blue's" addicted women are at as great a risk for neonatal difficulties as methadone-addicted newborns. Placing the pregnant pentazocine addict on low-dose methadone maintenance may improve the prognosis of the newborn. Two groups of infants born to drug-addicted mothers were evaluated in a prospective controlled study and compared to a third control group of normals. Group I inf ants (N=39) were delivered to mothers on well-controlled low-dose methadone maintenance, Group II infants (N=l9) were delivered to polydrug-(nonnarcotic) abusing mothers and Group III infants (N=27) were delivered to control mothers who had no history or evidence of drug abuse. All three groups were similar in maternal age, gravidity and socioeconomic class and neonatal gestational age and Apgar scores. Significant differences in mean weight, length and head circumference at birth are detailed in the In follow-up there was evidence of long periods of annea which was documented by an abnormal pneumogram. Blood and urine levels on the infant at birth, 2 weeks and 1 month of age were negative for amphetamines. Due to the history of high levels of amphetamine exposure in utero, a1, a2 and 8 receptor sites were evaluated in the placenta and on the peripheral blood platelets at birth and 1 month of age. The resulta of these findings and their significance in terms of the withdrawal patterns and apnea of the newborn will be discussed. The effect of PD on serum concentrations (cone.) of Phenobarbital (Ph), Amikacin (Ak), Cefazolin (Cf) were studied in 2 pediatric patients. In patient 1 (5 days of age, 4.5 kg), intravenous (IV) Ph was administered (7.5-10 mg/kg/day) for seizure control. He received PD for management of hyperammonemia secondary to argininosuccinate deficiency. Ph clearance by PD was 6.36-8.22 ml/min/l.73m2. In patient 2 (16M, 7.5 kg), Ak (10 mg IV q 24°) and Cf (45 mg IV q 8°) were administered for presumptive sepsis post A-V canal repairment and cardiac pacemaker implantation. PD was instituted because of progressive renal function deterioration of renal function post-operatively. PD clearance of Ak and Cf were 2.34-3.72 ml/min/l .73m2 and 1.72-4.44 ml/min/l.73m2 respectively. Serum concentrations (cone.) of all three drugs decreased substantially during PD. Additional amount of Ph was required to maintain therapeutic serum cone. to assure seizure control. PD clearance of Cf was found to correlate with cardiovascular function integrity. OJr experiences demonstrated that substantial amount of the drugs can be removed during PD to result in sub-therapeutic serum cone. Serum drug cone. should therefore be obtained to determine the amount of drug necessary to maintain adequate therapy. Plasrra elimination of INOO in the newlxlm infant with patent ductus arteriosus is prolonged 2 to 10 tirres relative to the adult. We studied the in vitro oxidative rreta.tolism of INIXJ to desrrethylindo (DMI) by hepatic microsort\31 preparations in 1,8,14,30 and 60 (adult) day old rats. Microsorres 1'ere incubated for 15 minutes with 5 increasing concentrations of INIXJ (5x10-5 to l0-3 M) and the formation of DMI was rreasured by HPI.C after extraction. Michaelis-r-Enten constant (Km) and maxirral velocity(Vm) 1'ere calculated and their developrrent =rrpared to the changes in enzymatic activity at a concentration of INOO of 2.5 x lo-4 M (V). AGE ( Table) show that from 8 days of age on, the increase in V inversely correlated (r -0.97) with Km, with no significant change in Vm. '!his suggests that the age-related increase in specific activity is due to progressive increase in affinity with no changes in total enzyne concentrations. We conclude that deficient INOO microsomal rretabolism postnatally could be due to presence of enzymatic c:orrpetitive inhibitors and/or low substrate-enzyne affinity. The oxidative rreta.tolisrn of Indo into desrrethylindo (!:MI) in the NR is decreased coopared to adult. We studied the possibility of increasing this rretabolism with two inducers. Zero-day-old rats 1'ere injected IP for 3 days with either phenobarbital (PB)in saline (40 rrg/kg/d) or B naphthoflavone (NF) in corn oil (20 rrg/ kg/d) and corrpared to a control group receiving either saline or corn oil. At 3 days, hepatic microsorres 1'ere incubated for 15 min with 5 increasing concentrations of Indo (SxlQ-5 to 10-3 M). Michaelis oonstant (Km), maxirral velocity (Vm) and activity at an Inda concentration of 2.5x1Q-4 M (V) 1'ere calculated. Cytochrorre P-450 (Cyt P-450) and NADPH cytochrorre C reductase (Cyt C red) were rreasured spectrophotorretrically. There was no difference in the rontrol group between saline and com oil. Infants exposed in-utero to Isoxsuprine (ISX). a B-sympathometric tocolytic agent have been reported to have increased birth weights and to have increased ventricular septal thickness when examined with echocardiography (ECHO). Ritodrine (RIT), a newlyapproved B-sympathomimetic tocolytic agent is now being used for premature labor. Infants exposed in-utero to RIT had similarly increased birth weights and thickened septums. Studies were performed on 27 control infants, 23 ISX and 11 RIT infants. Normal septal thickness is 3-4 nm. lpecific drug demanded a second agent. Results were as follows: 'hese results suggest that paregoric treated infants require a econd drug infrequently in comparison to phenobarbital or diazeam treated infants. The above data should also alert the cliniian to the possible necessity of utilizing more than one pharmaologic agent in the detoxification procedure. • Drug specific waveforms (ref), termed drug evoked potentials, were identified by an electronystagnometer (ENG) in a group of newborn infants exposed to the following medications: caffeine, (N=l2) theophylline (N=l2), dopamine, (N=l) meperidine (N=7), phenobarbital, (N=2)diazepam, (N=l) and fluphenazine (N=l). Electrodes were applied to the outer canthus of the eyes and to forehead of each infant and potentials were recorded in four head positions (straight, right, left, and neck arched). Group I consisted of 20 control infants with no drug exposure in whom no discernible DEP pattern was noted. Group II consisted of 35 newborns exposed to drugs by direct administration (n=27), passive placental transfer (N=7) and passive breast milk transfer (N=l). Specific and reproducible DEP waveforms were obtained in each group of infants exposed to the same drug. Results of these observations reveal that these drugs can be identified by evaluation of the frequency, amplitude, and slope of the DEP waveform. non-invasive procedure provides an accurate alternative method to blood and urine analysis for inmediate identification and continuous monitoring of a large variety of therapeutic agents. Reference: Westerman and Gilbert. Thiopental (T) may be clinically useful in protecting the neonate against asphyxia] brain damage. As yet there are no phannacokinetic data for this age group. We studied T properties in 4 asphyxiated neonates (x ± SE; BW=3345±360 gm; GA=40.3±0.25 wks) as part of a randomized trial. Twas begun by 2 hours of age in all and was given as a constant IV infusion in the following sequential dosages: 1)10 mg/kg over 30 min; 2)5 mg/kg over 30 min; 3)5 mg/kg/hr x 3; 4)3 mg/kg/hr x B; 5)1.5 mg/kg/hr x 6 and 6)0.75 mg/kg/hr x 6. This regimen was modified to ensure sedation and seizure control. T levels were obtained just prior to the next dose, before any modification in dosage and for 4-6 days after the infusion was stopped. The steady state (10 to 18 µg/ml) was obtained within 1 hour of starting the infusion, was maintained during the infusion and for about 48 hrs after the infusion was stopped. Mean elimination half-life, plasma clearance and volume of distribution for T were 45 hrs (range 26-70); 60 ml/(hr x kg) (range 43-74); and 3.7 L/kg (range 2.4 to 5.9), respectively. The variation was probably secondary to variability in the volume of distribution. No adverse effects were noted other than a drop in mean arterial blood pressure of 7 nmHg (range 4-11). We conclude from these preliminary data that it is feasible to give T at these infusion rates and that its pharmacokinetic properties are significantly different from those of the adult. Supported by NIH Grant lROl HD/NS 14940 -01. All subjects had a 3 point kinetic study and subsequent daily monitoring of STC. Each STC was compared with the predicted STC derived from data used in the following drug monitoring strategies: I, individual patient kinetic study; II, 2 peak STC's; III, no STC monitoring (assuming that the patient conforms to mean population kinetics). Mean first order kinetic constants for the group were: Vd, .30±.16 L/kg; .98±.45 h. All strategies were similar in accuracy: STC's were slightly higher than those predicted by each of the three strategies, presumably reflecting the well described deep compartment accumulation of aminoglycosides. However, the precision of methods I and II was not better than III and they actually tended to be less precise (See Table) . RATIO Ethanol is a teratogen in experimental animals and humans and the effects are variable but correlate best with maternal blood ethanol concentration(BEC). The purpose of this study was to measure BEC in mother, fetus and newborn monkeys to define the pharmacokinetics at different gestational ages and doses. Rhesus and cynomolgus monkeys from 106-156 days gestation were prepared with indwelling catheters in both maternal and fetal arteries. Dilute ethanol was infused in a maternal vein for 30 min. at doses of l.5,1.0 or 0.8 g/kg. Simultaneous blood samples were drawn from mother and fetus and for 4-6 hours after the infusion. Three neonates were sampled for 120 min. after delivery to obtain elimination kinetics. Maternal and fetal BE elimination rates(ER) were nearly identical during the four hours following infusion. Maternal and fetal BEC correlated highly (r=0.98) during the elimination phase. After delivery of the fetus, the maternal ER of 14.9±1.6 mg%/hr was 4 times that of the neonatal ER (3.6±0.2 mg%/hr). We conclude that the maternal BEC in monkeys is highly predictive of the fetal BEC. The capacity of the neonate to eliminate ethanol is limited, probably due to a low level of alcohol dehydrogenase in the newborn. Therefore, fetal exposure to this teratogenic agent is determined primarily by maternal elimination capacity. The simultaneous clearances of amikacin (ACl) and inulin (!Cl) were studied in 9 hospitalized children with normal renal function aged 5-18 yrs. The children were hydrated for 5-6 hrs prior to study with 100cc/M2/hr of Nl saline. During the study the rate was increased to 125cc/M2/hr. ACl was calculated as D/AUC from 10 serum levels of amikacin obtained throughout 4 hours time. The AUC was estimated beyond 4 hours. Urine flow rates were calulated from spontaneously voided timed urine specimens obtained during the same period. A linear relationship was demonstrated between ACl and urine flow as ml/min/M2 (p<.001; r=.81) !Cl was obtained using a loading dose followed by a constant infusion of inulin. !Cl calculated as D/AUC had a linear relationship to urine flow (p<.001; r=.79). Both !Cl and ACl calculated using UV/P correlated well with the results obtained using D/AUC indicating urine loss was not a problem. Two children not receiving amikacin were hydrated for lY,-3 hrs with Nl saline at a rate of 62cc/M2/hr and had fractional sodium excretion rate FENa and !Cl measured. The IV rate was then increased to 125cc/M2/hr for hrs and the studies repeated. In one child the GFR (D/AUC) changed from 92 ml/min to 136 ml/min while the FENa changed from 0.36% to 1.11%. In the other the GFR changed from 132 ml/min to 207 ml/min while the FENa was 1.3% and 1.15% respectively. These data suggest a responsiveness of GFR and drug clearance to alterations in the hydration rate in children who have a normal sodium ba 1 ance. The aim of this study was to develop a noninvasive, safe, sensitive clinical test capable of detecting xenobiotic-induced alteration of the cytochrome P1450-.02) were: tremors (disturbed), increased muscle tone,fever,excoriation,nasal stuffiness,high pitched cry, and hyperactive Moro reflex. Using these symptoms,and their degrees of severity,as a revised system,125 random matched scores were obtained and a comparison made. Correlation between the two systems was r=.85(p<.0001). A regression was calculated to establish a critical point on the revised system with the results that a 5 on the new system corresponds to an 8 on the current one (an 8 being the point at which treatment is iflitiated). The matched piirs of scores were then divided according to these critical points with the result that 112 pairs corresponded exactly for treatment/nontreatment status. Of the 13 scores which did not "match",8 infants would have been treated earlier on the revised system than on the current one, while 4 had local peaks and therefore would not have been treated on either system. This abbreviated scoring system, consisting of 7 pertinent symptoms of neonatal abstinence, may be a more efficient tool in the management of these infants. Aminoglycoside antibiotics potentiate muscle weakness in patients with presynaptic (botulism) or post synaptic (myasthenia, competitive blockade) neuromuscular transmission defects. Because two patients whose clinical course of muscle weakness due to hypermagnesernia worsened after aminoglycosides, and the similarity of action of Mg++ ion to botulinal toxin on the neuromuscular junction, we investigated the ability of tob and amk to potentiate MgS04 induced lethality in Swiss-Webster mice. Six week old male mice were given MgS04 in saline, or MgS04 was given after tob or amk so that peak levels of each drug (aminoglycosides and MgS04) would coincide. MgS04 alone produced death in 4 of 30 mice (13%). MgS0 4 plus three concentrations of tab (90 mice in each group) resulted in a significantly (p< 0.001) greater number of deaths when compared to matched groups given MgS04 alone (MgS04 + tab 25 mg/kg -63% deaths, Mgso 4 + tab 50 mg/kg -57% deaths, MgS04 + tob 100 mg/kg -70% MgSD4 plus three doses of amk also resulted in a significantly (p< 0.001) greater number of deaths, when compared to matched groups given MgS04 alone. (MgS04 + amk 50 mg/kg -50%, MgS0 4 + amk 100 mg/kg -70%, MgS0 4 + amk 200 mg/kg -80%). Tab or amk alone did not generate symptoms associated with neuromuscular blockade or death. Aminoglycoside antibiotics potentiate neuromuscular block by further decreasing acetylcholine release. 18 20 0.52 0.66* AM is a direct PA dilator, lowering Qinj/QT (threshold=0.3mg/kg). At higher doses, AM is a systemic dilator, lowering SVR*(l mg/kg) and Ao pressure(3mg/kg). At every dose, AM lowers Rinj/SVR; the decrease is significant* i.n H at 0.3 and l mg/kg. AM did not LA pressures; propranolol did not alter PA or Ao vasodilation. Human cytochrome P-450 monooxy9enase can be induced by polycyclic aromatic hydrocarbons (PAH). Enhanced activity is implicated in certain solid tissue cancers; nonresponse has been associated with leukemia Placenta contains a P-450 system whose activity increases in response to smoking, presumably due to PAH exposure. This system can be identified by activity toward benzo"1)pyrene (BP) and 7-ethoxyresorufin (ER) and is specifically inhibited in vitro by 7,8-benzofl avone (BF). 1-Je measured BP ancVor ER act i vity°'Tn p 1 acentas obtained at the delivery of 29 malformed neonates. Abnormalities included:neural tube defects(l2), GI and GU anomalies (5), cleft lip and palate (4), congenital heart disease (3), amniotic band syndrome (2), and multiple malformations (3). Ei9hteen mothers smoked as determined by postpartum interview and cord blood thiocyanate Placentas from 8 of these cases failed to respond to smokinq (5 anencephaly, 1 cleft, 1 GI, 1 multiple anomalies). Applying these same criteria to concurrently determined placental activities from 54 normal pregnancies in smokers identified 3 nonresponses (p<0.01, Fisher's exact testi Inhibition of ER activity by BF indicates the expected cytochrome P-450 is probably present in nonresponsive placentas, but does not increase to anticipated levels. Althouqh decreased estrogen in anencephaly could influence response to smoking, nonresponse was not limited to this defect and the findinqs may indicate increased risk for malformation in association with lack of response to PAH exposure. This study was designed to test whether the Theophylline (Th) induced decrease in cerebral bloodflow demonstrated in adult humans and animals affects cerebral tissue pH (CtpH). The effect of Th on cerebral tissue-arterial H+ concentration gradient (l'lH+) was studied in 3 anesthetized newborn piglets (I) during hyperventilation (HV) (2) after a JO mg/kg i.v. injection of Th and (3) during HV after Th therapy. CtpH was continuously measured with a tissue pH electrode (Roche Bioelectronics) implanted in the cererbral cortex. Arterial blood pH was measured intermittently. Baseline CtpH was lower than arterial blood pH (7.07-7.18* vs 7.39-7.42*). After liV, there was a slight decrease in l' l H+ (-I 0%, -17%, -20% respectively). Th did not affect baseline II H+. However, in Th pretreated animals, HV was associated with a dramatic increase in l'lH+ (+ 48%, + 77%, + 126% respectively). Indeed, after Th, HV resulted in a transient increase in C.tpH followed by a decrease from pre HV values (6.98-7.24*) to (6.96-7.lu*), although blood pH remained in the range of 7.6 to 7.8. This phenomenon was never observed during HV before Th. It is suggested that the decrease of cerebral blood flow induced by HV in Th pretreated animals results in an impaired tissue oxygen supply and in subsequent tissue acidosis. It is concluded that Th induces cerebral acidosis during HV. *RANGE. PB dissociation and distribution are related to pH, and tissue release is observed with alkalosis. To study brain PB release 9 anesthesized piglets (<10 days, 1060-2900 g) were studied 12 to 24 hrs after an intra peritoneal injection of 10 rng.kg-1 of PB. Arterial blood pH, arterial and venous PB levels and brain PB content were measured before and during respiratory alkalosis (pH range: 7.55 to 7.65). Brain tissue was sampled from the left hemisphere before and during alkalosis ; samples were obtained either before 10 minutes or after 10 minutes of hyperventilation. Brain PB content changes show a biphasic pattern : early (lOrnn) after the onset of respiratory alkalosis, brain PB rises unexpectedly (+24±14\*) and decreases later on (-16±18\*). A negative correlation between fiPB (\) and alkalosis duration at sampling was observed (r=-0.8, p<0.01). Arterial blood levels of PB increase early after the onset of alkalosis (+20.6±14\*) while venous levels were not significantly modified (-1.8±15.6\*). These data show 1) Brain PB changes significantly with pH. 2) Changes are dependent on the duration of alkalosis and PB release only occur after 10 mn. 3) The early rise of brain PB might be related to the rise in arterial PB; PB distribution changes might differ with organs and further studies are needed to explore these multicompartimental changes. a-Adrenergic stimulation of placenta suppresses placental lactogen secretion and increases glycogenolysis, estrogen synthesis and HCG secretion. In this laboratory, a1 adrenergic receptors coupled to catecholillline-stimulated adenylate cyclase have been previously danonstrated in hlllldn placenta. c.AMP generated by adenylate cyclase preslllldbly exerts its major intracellular effect by binding with cAMP-PK i.tiich in turn phosphorylates cell proteins. c.AMP binding and c.AMP-PK have not been previously identified in placenta. [3H]c.AMP binding to crude cytosol fractions of tenn placenta was rapid, saturable and reversible. Scatchard analysis was linear suggesting a single class of c.AMP binding sites, KD=l.13±0.llxlO-S,.,, n=5, with a binding capacity of l.27t0.18 ixooles/mg protein. Canpetition for the [3H]c.AMP binding site showed the potency order c.AMP»cG'-lP» N6o2 dibutyryl c.AMP, anal agous to c.AMP binding to c.AMP-PK in other tissues. ADP, ATP and adenosine did not canpete for the binding. c.AMP-PK activity was danonstrated in the S3fo crude fri!Ctions of placental cytosol by its ability to incorporate P fran [lS'32p]ATP into added histone protein (1.80±.15 fold stimulation, p<.05). Phosphorylation of endogenous placental proteins in both crude membrane and cytosol was also stimulated by c.AMP (p<.05). DEAE-cellulose colum chranatography perfonned to identify placental c.AMP-PK isoenzymes showed two peaks of [3H] c.AMP binding and coincident c.AMP-PK activity coresponding to classical Type I (31'.t) and Type II (69'.t) c.AMP-PK. Regulation of placental function by catecholamines and other honnones knoWTl to mediate c.AMP levels may be accanplished through phosphorylation of eel l proteins by these c.AM? dependent protein kinases. Moxalactam, a new 1-oxa-beta lactam is a mixture of R and S epimers. Although R moxalactam has been shown to be twice as active as S moxalactam against many microorganisms, their pharmacokinetics have not been reported. We studied the pharmacokineti cs of R and S moxa l actam in 12 pa ti en ts (age B-45 mo). Nine patients had periorbital cellulitis, 2 had epiglottitis and 1 had facial cellulitis. Patients received a single dose of moxalactam, 50 mg/kg intravenously over 20 min. Blood samples were obtained just prior to the infusion and at 0.5,1,2,4,6 and 8 hr after stopping the infusion. An HPLC method was used to measure the serum concentrations of R and S moxalactam. Total body clearance of R, S and R + S moxalactam from 29.01 to 183.7, 19.00 to 79.95 and 23.34 to 113.6 ml/min/m , respectively. The respective apparent volumes of distribution of R, S and R+S moxalactam ranged from 6.68 to 25.3, 4.06 to 10.8 and 5.14 to 14.7 L/m 2 . Total body clearance and apparent volume of distribution of R moxalactam were higher than S moxalactam (p < 0.DD4). Mean elimination half-lives of R, Sand R + S moxalactam were 2.04, 2.26 and 2.24 hr, respectively. A five-fold interpatient variation and difference in clearance of the epimers may indicate the need for monitoring serum or CSF moxalactam concentration in patients with severe unresponsive CNS infections. Dis position of the prod rug, CS, affects the bi oava i1abi1 ity and kinetics of C. An incomplete bioavailability of C has been reported in fullterm infants and children, no data are available for premature infants. We studied the bioavailability and kinetics of C in 5 patients with CNS infections (gestational age: 28 wk-37 wk; chronologic age: 5 wk-13 wk; weight: 1.8-2.6 kg). CS,12-28 mg/kg was given IV every 12 hover 0.5-1.0 h. At steady state, blood samples were obtained at 0, 0.5,l,2,4,6,8 and 13 h after starting infusion. Total timed urine output was collected over the same dosing interval. Both C and CS were analyzed by HPLC. Peak serum cone. of C and CS ranged from 10.11-59.86 and 2.62-40.98 µg/ml, respectively. Bioavailability of C ranged from 0.79-0.99 and total, renal, and nonrenal clearance from 0.88-3.17, 0.15-0.B4 and 0.66-2.33 ml/kg/min; the respective clearances of CS ranged from 4.39-15.2, 0.17-2.7, 4.15-15.19 ml/kg/min. Urinary recovery of C was 10.1%-29.4% and that of CS was 0.5%-20.8%. Mean apparent volumes of distribution were 1.55 L/kg for C and 0.79 L/kg for CS and elimination half-lives were 10.l and 0.9 hr, respectively. Incomplete bioavailability of C and 4-fold variability in clearance of both C and CS explain the need for individualizing doses to achieve therapeutic effect and minimize toxicity. 294 TIME. C. Nahata, Dwight A. Powell, by Milo D. Hilty). Colleges of Phannacy and Medicine, Ohio State University, Children's Hospital, Department of Pediatrics, Columbus, Ohio. Bioavailability and kinetics of chloramphenicol (C) depend on the disposition of its prodrug, CS. Although an incomplete hydrolysis of CS to C has been shown, little is known about the change in CS kinetics during hospitalization. We studied CS kinetics on two occasions at steady state in 10 patients . The kinetic studies were separated by 2-17d (7.3 ± 4.3d). Doses of CS were, 19.7-26 mg/kg q 6 hr and 19-25.4 mg/kg q 6 hr IV over 0.5-1.0 hr, resnectively. Blood samples were obtained at 0,0.5,1,2,4 and 6 hr after starting infusion and analyzed by HPLC. Peak serum concentration ranges of CS after first and second studies were 22.9-181.6 and 18.7-57.9 µg/ml, while that of C were 16.9-46.3 and 12.5-37.6 µg/ml, respectively. Trough serum concentration rahges of C also decreased with time from 1.77-27.0 to 0.88-6.10 µg/ml. Total body clearance of CS after the first study, 9.32 ± 3.64 increased to 19.36 ± 7.32 ml/ kg/min after the second study (p < 0.005). Apparent volume of distribution and elimination half-life of CS did not change considerably with time. An increase in CS clearance and decrease in C concentration may be due to an autoinduction of CS and C metabolism and/or increased renal elimination of unhydrolyzed CS with time. Serum concentration of C should be monitored frequently to detect changes in its formation from CS, particularly in children receiving CS for longer than 5 days. Serum and urine concentrations of furosemide(F)were measured using gas chromatography in 2 groups of preterm infants. One group(S.D.)received a single bolus I.V.,dose of F(lmgm/kgm/day); the second group(M.D.)received 4 bolus I.V. doses of F(lmgm/kgm/ 6hrs.).Both groups were treated with F because of their persistent lung disease and the treatment period in both groups lasted 4 to 7 days.The mean gestational age of S.D. group was 29 weeks, and mean birth weight was 1013grams.For the M.D.group mean gestational age was 30 weeks and mean birth weight 1097grams. Postnatal age was similar for the 2 groups:6-17 days.At 6 hours after a dose, serum F concentrations(Se F),urine F clearance(R Cl)and diuresis during the 6 hour period(output)were calculated on initial(Dl)and final ( We studied postnatal ontogeny and thyroid regulation of a1AR with specific a 1 -adrenergic radioligand 3 H-prazosin on purified rat liver plasma membrane(LM) obtained from euthyroid control and PTU treated(l7 day of 22 day gestation onwards) newborn rats. 3 H-Prazo sin binding to LM was rapid, saturable and reversible. Its competition with various non-labelled adrenergic agonists and antagonists for a 1 AR sites showed stereoselectivity and potency order of inhibition:Prazosin=WB410l>Epi=Norepi>yohimbine>Isop, characteristic of a 1 AR. The LM from all the rats had 7-8 fold enrichment of plasma membrane marker enzyme 5'-nucleotidase from crude homogenates. Postnatal changes of a1AR were as follows: • In a sanple of 47 nonnal nuddte class infants, we carpared 24 infants whose I!Others received no rredication with 23 infants whose =thers received a single intramuscular injection (50 rrg) of pethedine (the =st widely used analgesic in Europe). They were assessed on the Brazelton scale on day 1 and 3, while the attitudes of I!Others to pregnancy, labor and deli very and child rearing, and the extent of scx:ial support, were coded fran in-,terviews on day 3. At 1 =nth the Broussard Neonatal Perception and the Bates Infant Questionnaire were administered. 12 I!Onths.the Bayley Scales, Carey Tenperament Scale, and hler Maternal Attitude Scale were administered. found no fferences in inf ant behavior due to drugs on the 7 clusters of the Brazelton scale but rredication was related to maternal i:>erception of infant behavior and terrperament at 1 nnnth, as .measured by the Broussard and the Bates. The findings at 1 year suggest that the carbination of obstetric and socioural variables explains =re of infant behavior at 1 year do the single effects of either class of variables alone. influence of obstetric factors and neonatal behavior on later develornental out= !l'ay be potcntiated or attenuated by sociocultural (maternal perception, scx:ial support systerrs, child rearing practices, etc.) dillensions. Pharmacol. and Ped. Oncol., Depts. Peds and Pharmacol., Univ. of Minn., Minneapolis, MN 55455. inquiries regarding the role of PCM in tumor growth and differentiation. A tissue culture line derived from MNB has been used to characterize the subcellular distribution and kinetic behavior of PCM. The activity of PCM was determined in subcellular fractions of MNB cells after differential centrifugation. In the presence of exogenous substrate (+gelatin), 51% of the PCM activitywas present in the 100,000 x g supernatant and 28.8% in the 800 x g particulate fraction. Endogenous (-gelatin) activity, which reflects the relative amount of PCM and its methyl acceptor proteins, was low amounting to less than 2.6% and 0.5% of the total PCM activity present in the 800 x g particulate and 100,000 x g soluble fragtions, respectively. The enzyme has an apparent Km of 13.9x10-M and a Vmax of 33 pmols/min/mg prot. Cytoplasmic PCM was competitively inhibited by adenosyl homocysteine (Ki=2.6uM), sinefungin (Ki=l. 5JJM) and A9145C (Ki=O. 2JJM). These data demonstrate that the PCM activity of cultured MNB The placenta is not just an inert barrier to the transfer of drugs between the maternal and fetal bloodstream but is actively involved in drug detoxification or biotransformation. It is important to determine whether alterations in placental drug metabolism is induced by chronic maternal addiction since the effects on the fetus could be far-reaching. We therefore studied 3 aspects of drug metabolism in the placentas of 4 drug dependent (heroin/methadone or alcohol) women and in 3 normal controls, namely: (I) reduction (neoprontosil), (2) conjugation (bilirubin) and (3) oxidation, type II (aniline). Since VPA is extensively bound to plasma proteins, determination of free drug pharmacokinetic variables may be of therapeutic importance. In view of the paucity of such information, we present the follONing data from 6 children. Regression analysis of % free VPA vs. total VPA demonstrated the following relationship:% free= total VPA -I3.9 (r = 0.836) 5.39 These results show that 1)%free drug concentration may vary fourfold over the total serum concentration range of 40-120 mcg/ml thus emphasizing the need for the establishment of a therapeutic range for free drug 2) the clearance of VPA is restrictive and therefore independent of liver blood flow but dependent on the free fraction of the drug. This study was sponsored by the White Cross Guild, MMSFI and CHRF. Although many infants with bronchiolitis receive theophylline (T), little is known about T pharmacokinetics in this age group. We studied T kinetics in 12 patients (age 3 weeks-6.5 mo) with normal liver, renal and cardiac function. Nine of the 12 patients received a single dose of aminophylline (5.0-8.5 mg/kg) whereas the remainder were at steady-state receiving multiple doses (2.5-5.0 mg/kg) of aminophylline. The dose was administered IV over 0.5-1.0 hr. Blood samples were obtained at 0,0.5,l,2, 4 and 6 hr after the start of drug infusion. In 6 patients, urine output was collected over the same dosing interval. Peak serum concentrations of T measured by HPLC ranged from 8.48-21.6 µg/ml. Total, renal and nonren;l clea2ance of T ranged from 4.66-19.3, 1.07-5.76 and 3.59-16.8 ml/min/m, respectively; renal clearance accounted for 15-50% of total clearance. Apparent volume of and elimination half-life of T varied from 7.04-12.0 L/m and 5.77-29.0 hr. Although no significant correlation was observed between age and theophylline kinetic pararreters, clearance appeared to increase and half-life tended to decrease with age. Our patients had a substantially lower clearance and longer half-life as compared to published data in children > l yr of age. A five-fold variation in T clearance demonstrates the need for monitoring T serum concentration to individualize therapy. Although Ac is one of the most widely used pediatric drugs, data are lacking to define optimal doses for fever control in young children. As part of a study comparing the efficacy and safety of SS-Ac (12-15mg/kg q 4hr) vs OS-Ac (24-30mg/kg q 8hr), kinetics of Ac were studied in 9 children ages 6 mo-6 yr randomly assigned to one of these regimens for a maximum of 3 days. Blood samples were obtained at 0,0.5,l,2,4,6 and 8 hr after the first and last dose. No other antipyretics were given for 6 hr prior to or during the study period. Serum cone. of Ac were rreasured by HPLC. All calculations were made assuming complete Ac bioavailability. Based on peak and trough Ac cone. after the first and last dose, no drug accumulation was noted over the study period. Respective peak Ac cone. (mcg/ml) after first and last dose were: SS-Ac (N=5) 15.57 ± 2.87 vs 18.10 ± 7.43; OS-Ac (N=4) 23.94 :!: 12.42 vs 24.14 :!: 12.28. Trough Ac cone. (mcg/ml) after first and last dose were: SS-Ac (at 4 hr) 5.22 + 3.44 vs 6.34 + 5.89; OS-Ac (at 8 hr) 5.76 ± 3.20 vs 4.87 + 3.54. Ac kineticvalues for the 9 pts after first and last dose were: clearance (ml/kg/min) 5.51 ± 2.81 vs 5.12 ± 3.28; Vd (L/kg) 0. The PK of M were assessed following the 1st dose and again during steady·state (ss) conditions in 18 cl•ildren (O.l-26 Y•Ht•). All patients received 150 mg/kg/day IV in 3 divided doses. Multiple serum samples obtained during the 8 hour dosage interval were analyzed using a sensitive specific HPLC technique. First one-compartment PK analysis revealed x(±SD) hr (0.4), Vd-12.19 L/l.73m2(6.4), ClToT107.8 ml/min/l.73m2 (36), and Cpmax 146.5 mg/L (48.5). No differences in these parameters were observer when compared to ss values. Two-compartment PK analysis could be performed in 9 of 18 patients; no significant differences existed between 1 and 2 compartment PK analysis. Statistically significant (p<0.05) were observed between age and both and ClToT· Comparison of these parameters to those obtained in adults revealed a shorter (p<0.001) and smaller Vd (p<0.001). In children <10 years of age, the was decreased (p<0.05) and Cl increased (p<0.05) from values obtained in older children. In addition, a significant (p<0.05) inverse relation- Paraldehyde is a drug of ten used to treat refractory seizures in children. It is commonly used in patients who have previously received other anticonvalsants, some of which are known to alter hepatic drug metabolism. As paraldehyde is thought to be primarily cleared by the liver, the present study was undertaken to assess the effect of phenobarbital pretreatment on the rate of paraldehyde elimination. Three male mongrel dogs were given paraldehyde, 0.25ml of a 4% solution/kg by intravenous infusion over 15 minutes. Multiple serum samples were obtained over a 8 hour period and analyzed for paraldehyde. Animals were then dosed for seven days with phenobarbital (5mg/kg/d). Following a two day drug free rest periocl the paraldehyde kinetic study was repeated. The serum half-life of paraldehyde was 2.1 hours (S.D=0.7) prior to phenobarbital treatment and 0.4 hours (S.D=0.24) post treatment (p(0.05). No significant differences in VD were observed. Two dogs showed a small secondary peak at 4-6 hours after the dose, suggestive of enterohepatic recycling. We conclude that the clearance of paraldehyde is significantly increased by pretreatment with phenobarbital, a known hepatic enzyme inducer. Patients who have received prior treatment with enzyme inducing drugs may require higher doses of paraldehyde than patients who have not received such drugs. Tove S. Rosen and Helen L. Johnson, Spon. by L.S. James This report presents findings from an ongoing follow-up study of children born to methadone-maintained mothers(M) and a matched comparison group(C) at three years of age (NM=28,Nc=l5). A physical evaluation and of clinical course, a neurological assessment, and behavioral evaluation including the Merrill-Palmer Scale of Mental Tests(MP), were performed on all subjects. There was no significant difference between groups on height, weight or rate of infections. However, there were significantly more head circumferences(HC) below the 3%ile in M vs. C (p<.01). Suspect or abnormal neurological findings, including eye findings and abnormalities in tone, coordination and language, were also more frequent in M vs. C (p<.05). The eye findings, which were strabismus and/or nystagmus, occurred in 34% of M, but in none of C. Although the groups did not differ in overall performance on the MP (XM=Sl.67±27.27; Xc=56.73±22.61), low scores were significantly more frequent in M (31%) than C(7%) (p<. 003). While MP scores were not correlated with eye findings or neurological assessments, they were significantly related to HC at birth (r=.40, p<.02) and at 36 months of age (r=.52, p<.01). Our studies show that a positive correlation between HC at birth and neurobehavioral ot1tcome in infancy persists through early childhood. The data presented here indicate that maternal methadone maintenance is associated with impaired development; specifically, smaller HC, eye findings, developmental delays and lower IQ scores. Little is known concerning interactions between Pb, trace metals and bone, the primary site of Pb storage and the major source of chelatable Pb. To understand further the metabolism of Pb and essential these elements were studied within the strictly defined chemical conditions of bone organ culture. Fetal rat bones, dissected free from cartilage, were cultured for 120H in plain BGJ medium (control = C) or BGJ + CaNa2EDTA (treated bones = T). At 120H, bo,nes were ashed, solubilized in HN03, and 25 µl were mounted on a mylar target. Elemental characteristic x-rays, excited by a 2.5 Mev proton beam, were observed with a Si(Li) spectrometer. X-rays for the metals analyzed from blanks, standards, and solubilized control and School of Med., Depts. of Physiology and Pediatrics, Phila., PA. fusion of isolated organs with cyclic AMP produce a similar rise in mitochondrial RR. The present study investigates the role of_,,6 receptor stimulation as a mediator of mitochondrial adaptation to hypoxia. 10 guinea pigs, of which 6 received .5 mg/kg/IV propranolol, breathed 8% o 2 . 3 guinea pigs received propranolol while breathing room air. Brain and heart subsarcolemmal mitochondria were isolated and state 3, state 4 RR (nmol Oz min-1 nmo1-1 cytochrome oxidase ± SEM) assayed. Heart mitochondria of propranololtreated normoxic animals had 23% higher state 3 than controls (342 ±23 vs. 419±12, p<.05). Hypoxia produced an 8% increase in heart state 3 RR in propranolol-treated animals. Hypoxia without)lbloci20 sec. in an 8 hr, period or 6 in a 24 hr. period. The infants were divided into two groups. Group A (17 infants) received a 7 day course of A with a loading dose of 6.8mg/kg and a maintainence dose of 2.0 mg/kg q8h. Mean serum level of A was 7.1+2.2 mg% on the 2nd to 3rd day of therapy. Group B (14 infants) were controls, and did not receive any A. Results: In Group A, 5 infants had increased apnea and developed respiratory failure requiring ventilation. In 1 infant the apneic spells remained unchanged on A. The GA BW for these 6 infants were 26-30 wks, and 690-1130g respectively. Two of these infants died. In Group B, 5 infants developed respiratory failure. The GA and BW for these infants were 27-29 wks, and 820-1040 g respectively. There were 2 deaths in this group. For the non-respirator infants the decline in apnea in Group A was 3-4 times greater than in Group B. The data indicate that in preterm infants with apnea: 1) A was effective in the frequency of apnea in infants whose GA> 30 wks and BW>ll30 g, but ineffective in those with lower GA and BW.2) A did not decrecse the need for assisted ventilation 3) A did not alter morta.l i ty. Bailie To test the hypothesis that the fetal hydantoin syndrome is due to metabolic activation of phenytoin to a toxic metabolite, pregnant mice were given phenytoin with or without pretreatment by an inducer, phenobarbital (Pb), or an inhibitor, piperonyl butoxide (Pip) of drug metabolism. Phenytoin treatment alone produced a 42% incidence of teratogenic injury (cleft palate and resorptions); controls had a 3.0% incidence. Pb pretreatment increased the incidence of teratogenic injury to 100%. Pip pretreatment decreased the incidence of teratogenic injury to 36%. In another group of experiments young adult male mice were given phenytoin in a single i .p. dose. Liver glutathio11e (GSH) was determined 4 hours after the dose. Pretreatment with Pb lowered liver GSH content from 82% of control non-pretreated to 53% of control. Pretreatment with Pip entirely prevented the decrease in liver GSH by phenytoin. Pretreatment with butylated hydroxytoluene (BHT), an inducer of epoxide hydrolase, prevented phenytoin-induced GSH depletion. These data demonstrate that: 1. phenytoin teratogenic injury in this mouse animal model is increased or decreased by inducers and inhibitors of drug metabolism, respectively; 2. phenytoin produces liver GSH depletion; 3. this GSH depletion is increased or decreased by inducers and inhibitors of drug metabolism, respectively. The conclusions from these data are: 1. phenytoin teratogenic injury may occur via a reactive metabolite; 2. this reactive metabolite possibly may be an epoxide. We havt: previously dt:monstratt:d in thl: rat that prenatal phenobarbital exposure: results in tivc in tht: otfspring (Scit:ncc 208:508,1980). Therefore, we 1:::xamint:!d the possibilitt of whetht::rPhenytoin (P) 1 a known tt:ratogen and a structurally relatc:d anticonvulsant, is also capabll: of causing dysfunctions. Timtd-prt.!gnant rats (CD strain) wee" injected (SC) with a sing!" daily dose of Na ph .. nytoin 05mg/kg body wt) dissolved in O.IN NaOH on 17 thru 20 days of gestation. Control mothers were given vehicle. Pregnancy was uneventful and P treated motht!rS dt::livered litters which appt.!arcd normal, t!XCept for body weight which was significantly decreased. P trt!ated offspring (16 wk old), when matt:.d with normal adult stud malt!S, had a higher incidcnce of infertility, dt::spite the presence of sperm in the vagina (P-30% vs C-16. 7%). In addition, the mean number of implantation site-;-per animal was markedly reduced (P-11.0 vs C-15.8). The mean rate of resorption was higher (38.2%) in P .;ffspring than in control (6.1%). As a consequence, P offspring had a fewer number of live fetust::s (P-8.0 Thesto findings suggest that pn·natal Stephen P. Spielberg, Hospital for Sick Children, Div. Clin. Pharm., Toronto Glutathione(GSH) serves as a major cell defense against toxicity from metabolites of drugs such as acetaminophen(APAP). Patients heterozygous for GSH synthetase deficiency(GSH-SH) are phenotypically normal in the absence of drug-induced stress, and have normal baseline intracellular GSH content. We have studied the response of GSH-SH lymphocytes to APAP metabolites generated by a murine hepatic microsomal system. Cells were incubated with microsomes and APAP for 2 hrs, collected by centrifugation, suspend ed in drug and microsome-free medium for 16 hrs, and toxicity assessed by trypan blue dye exclusion. GSH-SH cells had normal baseline viability. However, the cells showed significant damage at low APAP concentrations which were non-toxic for normal cells, and had an increased percent of dead cells at high concentrations (normal:l8.3+0.5% dead cells at 1.5mg/ml APAP; patients:29.9+0.5% and 29.7+1.5%). N-Acetylcysteine added to the medium after the 2 hr drug challenge decreased toxicitv in normal cells(3.9±0.5%), but did not alter GSH-SH cell toxicity. GSH-SH cell GSH content not recover as much as in normal cells when incubated with N-acetylcysteine after APAP exposure. N-Acetylcysteine may protect cells in part by providing cysteine for synthesis of GSH which, in turn, may be involved in repair processes after APAP-induced damage. GSH-SH patients(prevalence approx. 10-4) may be at increased risk for APAP toxicity, and may not be protected by N-acetylcysteine because of decreased ability to regenerateGSH after APAP challenge secondary to normal enzyme activity. S.P. Spielberg, W.T. Gerson, D.G. Fine, Johns Hopkins Sehl. Med., Oepts. of Pediat. and Pharmacol., Baltimore, a,nd Hospital for Sick Children, Oiv. Clin. Pharm., Toronto. A patient sequentiallv developed aplastic anemia from phenytoin and c8rbarnazepine. Both compounds undergo metabolism to potentially toxic arene oxide metabolites(Ao>1). We tested the hypothesis that the patient's adverse reactions were due to decreased ability to detoxify AOM by challenging his peripheral lymphocytes with metabolites generated by a murine hepatic microsomal system. The patient's cell viability was normal in the absence of drugs. Phenytoin metabolites produced dose-dependent(31-125ut1) toxicity from 10.6 to 22.6% dead cells; normal cells from 20 control subjects showed no toxicity above baseline(approx. 5%). Carbamazepine metabolites also produced greater toxicity to patient cells than to controls. Toxicity was dependent on microsomes and was enhanced in normal cells by inhibiting epoxide hydrolase, and was blocked by adding purified epoxide hydrolase to the medium. Cells from another patient with phenytoin toxicity who tolerated carbamazepine without sequelae showed increased toxicity from phenytoin hut not from metabolites. While no relatives of the first patient were available for study, the defect in detoxification in the second patient was expressed in relatives' cells as an autosomal recessive trait. The results provide the first evidence for the role of AOlf in the pathogenesis of aplastic anemia in humans. Individual differences in cell response to potentially toxic AOH mav be due to genetically heterogeneous defects in detoxification of these metabolites. PLASMA GLUCOSE CHANGES DUR I NG THEOPHYLL I NE THERAPY. G. Srinivasan, J. Singh R.S. Pildes, T.F. Yeh, Cook County Hospital, Depart. of Pediat. ChicagO,lll. Changes in daily plasma glucose after oral theophylline (T) therapy were studied in 13 apneic or respirator dependent preterm infants. Glucose was measured 1-2 hrs after each morning dose of T. All infants were on nasogastric drip feedings and/or intravenous fluids. Serum T levels ranged from tional age (mean:tSEM) was 31±.0.67 wks and postnatal age at the time of study was 14.7±.J0.4 days. Total duration of treatment was 8.8:t0.8 days. Glucose ( ''**p<0.01 (two tail), '"'p<0.05 (two tail), ''p<0.05 (one tail) There was a significant increase in plasma glucose during Day through 6; the values then decreased and glucose values were not different from those at base line after 7 days of T and after therapy was discontinued. The increase in plasma glucose could not be attributed to caloric intake or l.V. glucose and was probably mediated through cyclic AMP. Hyperglycemia (plasma glucose >150mg%)was not noted during the study period. Cimetidine, an H2 receptor antagonist, blocks histamine induced acid secretion. Cimetidine has been successfully used in the management of reflux esophagitis in newborns 1 although little is known about the pharmacokinetic characteristics of this drug. We administered cimetidine 10 mg/Kg intravenously to one term infant with a gastrointestinal bleed and orally to a second infant with reflux esophagitis. Venous blood samples were drawn at 0.5, 1,2,4 and 8 hours after the initial dose. Concentration of drug in plasma was assayed by high pressure liquid chromatography. After I.V. administration the serum half life was 1.8 hours and the clearance rate was 730 ml/kg/hr. The half-life and clearance rate was 2.2 hours and 500 ml/Kg/hr respectively after oral administration. Maximum serum levels observed were 5.0ug/ml (IV) and 4.2 ug/mL (PO) at 30 minutes, and minimum levels of 0.3ug/ml (IV)and 0.6ug/mL (PO) at 8 hours. A serum level of 0.5ug/mL is necessary to achieve 80% suppression of acid secretion. The higher level attained after oral adm1nistration may be due to delayed absorption of cimetidine. Our preliminary results indicate that the elimination of cimetidine in infants is similar to that in adults. Oral and intravenous administration appears to result in equivalent elimination patterns. Current dosing guidelines suggesting the administration of 5-10 mg/kg of c1metidine every twelve hours may not be applicable to infants. Our data implies that a lower dose and decreased dosing interval may be necessary in order to avoid potential adverse CNS, renal, and hepatic reactiu.1s. The use of intravenous (IV) morphine in combination with muscle relaxants, nitrous oxide and oxygen in balanced anaesthesia is of growing importance in children, but optimal dosage and rate of morphine administration is controversial due to limited available pharmacokinetic information. We have studied 12 children from birth to 5 yr of age receiving IV morphine as part of balanced anaesthesia regimens at varied dosages including bolus injections of 11 and 50 µg/kg and maintenance infusions of 1 and 2 µg/kg/min. In order to determine morphine serum concentrations we developed a sensitive and specific assay by reverse phase paired-ion high performance liquid chromatography with electrochemical detection. Only 100 µl scrum or plasma is required for analysis permitting quantitation at multiple points. Total body clearance (TBC) of morphine was 21.1 ± 2.4 ml/kg/min (X ± SD, n= 11), a value significantly greater than the TBC of 6.2 ml/kg/min reported by et al. (Clin. Pharmacol. Ther. 26:354-365, 1979 ) for children aged 1-7 yr after a single dose. From our data it appears that a loading dose of 50 µg/kg over 5 min followed by a maintenance infusion of 2 will provide a steady state serum morphine concentration between 80 and 100 i1g/L. The minimum serum concentration for analgesia during surgery in children approximates 65 µg/L according to Dahlstrom (see above). Calculation of parenteral morphine dosage for children must take into account a TBC three times greater than previously realized if subanalgesic serum concentrations arc to be avoided. TZ has been administered to newborns to lower PVR since the first description of persistent fetal circulation (PFC). Right to left cardiovascular shunts in PFC prevent accurate measurement of vascular resistances in newborns. surgery on the day of study, nor correlated with plasma TZ concentrations ([TZ]). order to achieve steady state [TZ] (coefficient of variation <15%) rapidly. Lambs were prepared for study by peripheral insertion of catheters 16+ hours before study. After a control period, a series of increasing [TZ] (similar to those observed in neonates) were achieved (2-5/experiment) and confirmed by chemical analyses. Cardiovascular resistances and heart rate were determined 3-5 times at each concentration, averaged and compared to control. The relationship between cardiovascular parameters and log [TZ] from 0.30 to 11.71 mcg/ml (N=24) were analyzed. Increasing [TZ] produced a concentration-related increase in cardiac index (p<0.05), decrease in svn (p<0.01, slope= -15.8), and decrease in PVR (p<0.001, slope= -28.2). Thus, increasing [TZ] decreases PVR twice as rapidly as SVR. VITAMIN Rabbit pups delivered via Caesarian-section at 31 days gestation (tenn) were housed in temperature, humidity and bacterially controlled chambers and exposed to 95+% oxygen or air for 48 hours. 100 mg/kg vitamin E or placebo was administered S.Q. at 1 and 24 hours of life. On sacrifice, the pups' tracheas were cannulated for pressure-volume determinations and lavage collection, or for glutaraldehyde fixation and morphanetric analysis. Oxygen exposure resulted in 25% less total lavage phospholipid content, smaller relative concentration of lavage phosphatidylglycerol (2.3 vs 3.6% total phospholipid), smaller maxi.mum lung volumes and a higher pressure to inf late the lungs to 30% maximum volume (19.2 vs 15.5 an H 2 0). Additionally, reduced air: tissue ratios were detennined f ran lung sections in oxygenexposed pups as canpared to air-treated littermates. Treatment with vitamin E was shown to canpletely abolish all these effects of hyperoxia, with values for oxygen-exposed +vitamin E-treated pups unchanged fran those for air-exposed controls. Vitamin E treated air-exposed animals were found to be the same as placebotreated, air-exposed littermates. These data indicate that hyperoxia exposure in the newb:>rn rabbit affects the lun:i b:iochanically, functionally, and morphologically. Vitamin E treatment restores these changes to control values without exerting any additional effect of its own in the control, air-exposed situation. Thus, vitamin E treatment rray act as a protectant in the lung challenge:l with hyperoxia, possibly through its action as an antioxidant. Supported by NIH pre:loctoral Traineeship #GM07069. !lept. of r'ed., Iowa City. Gentamicin tissue distribution and uptake were studied in chronically-catheterized lambs {n=28) in relation to their possible role in postnatal age-and hypoxemia-related effects on serum gentamicin concentration (SGentl. Gentamicin was administered intravenously in a dosage of 2.5 mg/kgBW(n=l8) or 10 mg/kgBW(n= 10). Lambs were grouped as young (less tr.an l week of age, n=l3) and older (2-5 weeks of age, n=l5) and were studied during normoxemia or hypoxemia (mean p02 36±7 torr). Tissue blood flow (TBF) to liver, spleen, ileum, jejunum, skeletal muscle, heart, adrenal and kidney was determined by radiolabelled microspheres. Gentamicin delivery to these organ tissues (DGent• calculated as product of TBF and SGentl• tissue gentamicin content (TGentl and SGent (determined by radioimmunoassay) were dose-dependent. SGent {µgm/ml) per unit (mg per kgBl·J) dose was significantly higher (p<0.05) in older (2.40±0.58) relative to (l. 16± D.43) normoxemic lambs. Hypoxemic lambs had significantly higher SGent than normoxemic lambs in both young (2.44±0.48 to 1.16± 0.43) and older (3.48±0.79 to 2.40±0.58) groups. DGent (µgm/min• gm) per unit dose was also significantly higher in hypoxemic relative to normoxemic lambs to liver (0.79±0.41 to 0.19±0.22), heart (16.89±7.47 to 6.12±3.08) and adrenal (15.48±9.13 to 4.62± 3.13) tissues. TGent (µg/gm) responded similarly: liver (0.44± 0.2 to 0.27±0.09), heart (0.34±0.41 to 0. 15±0.09) and adrenal (0.66±0.44 to 0.24±0.14). Hypoxemia-and age-related effects on SGent were not explained by differences in TGent in these lambs. e 326 Jeffrey A. Whitsett, Jeffrey A. Burdsall, Akihiko Noguchi, Children's Hospital Medical Center, Cincinnati Catecholamines mediate lung function by interacting with a-and a-adrenergic receptors (a-AR, a-AR). a Adrenergic stimulation of the lung results in pulmonary vascular and bronchiolar constriction contrasting with the smooth muscle relaxant effects of a-adrenergic agonists. Because of the possible role in the regulation of pulmonary blood flow and airway resistance during develoi:ment, the ontogeny of lung al-and a-AR's were compared. The binding of the al-adrenergic ligand [3H] prazosin was demonstrated in membranes of rat lung from day 18 of gestation to adulthood. Specific binding was present at all ages, was reversible and inhibition by agonists followed the order: (-)epi=(-)norepi»(-)iso>(+)norepi; antagonist potencies were: prazo-sin>WB4101, »yohimbine. Binding capacity increased progressively during the neonatal period from 52±9 on day 18 of gestation to 105±4 fmoles·mg-1 protein (mean±SE) by postnatal day 15 then dycreased reaching adult levels by 28 days of age, 62±3 fmoles·mg-• The pattern of al-AR's contrasted with that of a-AR's assessed with [3H]dihydroalprenolol ([3H] DHA). [3H]DHA binding increased during this same time period fran 46±4 on day 18 of gestation to 496±44 fmoles·mg-1 in the adult lung. Affinity for [3H]prazosin and [3H]DHA did not change with age. a-AR density is high in the neonatal period, decreasing thereafter. The timing of the changes in al-AR's correlates with the timing of increased sympathetic innervation of the developing rat lung and is distinct fran that of a-AR's sites. School, Chical':o, Ill. There are conflictinl': reports on the effect of Indomethacin (I) therapy on PDA in tinv premature infants. To determine possible factors associated with this variable response, an analysis of clinical, biochemical and pharmacokinetic data of 17 premature ini'ants with SYTTV'tomatic PDA (echo LA/Ao >l. 3) was undertaken. 0.3mP"../kg,IV I was l':iven q 24 hrs, for a rraximum of 3 doses if needed. The infants were divided into two i':rOUPs: Gr I: 7 infants with BW lOOOl':ffiS (1191+190Piiis, GA )2.l+l.1wks). Therewas no difference between Gr I and-Gr II before study in Postn. al':C (11.4+9.l vs 9.9+3.5 days), postconcept. al':e (31.1+3.l vs l.4wks) or in cfilrjiopulmonary status. "Successful-response" required clinical and echo and disapnE>e>rance of murrrn.ir. Gr I (7) Gr II (10) AVD (L/kF,) 0 Pildes. Cook County Hosp. Dept. of Ped. , 'Uni'v, of Ill. and Chicago "Mi!dical School, Chicap:o, Ill. In a d011ble.-blind study of I therapy 1n premature ini'ants with synptomatic PDA, G was -meaSt!I'ed 1n 47 infants (22 control, C; 25 I} llefOl"e and at 24, 48, 72 hrs after -iredication, All ini'ants had failed to Tespond to 24 l'n>s fluid Testriction and fu:rosemide. I or saline placebo was !Oven q 24 hrs for amax:lmum of 3 doses, as needed, Plasma I was -ireasured in 15 infants of the I group by gas chr-omatography, Prior to the study; the C and I groups -were cooparable in BW Gnean+SD U-30!-420 vs 135D+401!1J11S) GA 00.5+2,2 vs Jl,'4+2.3wksl, C8".'"'9+4,8 'VS 9.0t5,4dys). Total fluid and caloric intake were s:bnilar, -Plasma glucose <1n!".s%) TV F,luc. (Jng/kg/min) 94.2+"35.9 70.i3+19.6** 2,7+2.2 3.8+2.9 C48hrs) 90.'4'+19.0 70.'<)+29.5* 2,6+2.2 3.6+2.6 (72hrs) 8o.'4+13.] 70.5+18.3 2.7+2.o 3.2+1.8 While there was no si171. aifference between the gr6ups in Iv p;lucose intake, infants in I group had a sif'Tl. lower (*p<.05; **p< .01) glucose than that of the control group at 24 and 48 hrs after -rredication. A sif111. neg, correlation was seen between G and I concentration (p<.05] and between G and corresponding I concen-tTation-t:lme integl"al CP<.01]. 'l'his study sup-.,gests that I therapy decreases G and that endo@:enous PGs may play a role in glucose homeostasis in premature infants. Inhaled beta adrenergic agonists are the most effective inhaled bronchoailators used for the management of bronchial asthma. In adult patients, fenoterol, a specific B bronchodilator produces maximal bronchodilation in the range of 0.8 -1.3 mg. 11lere are no dose response curves in children for this class of bronchodilators. The object of the present study, was to define a safe bronchodilator dose in childhood asthma. 1be study was carried out as a 4 way crossover, doubleblind, randomized study. 20 children took part in the study, 8 of whom were 5-9 years of age and 12 were 10-14 years of age. Each group had a separate randomization 0£ treatment using the following doses: 1) placebo, 2) 100 mcg, 3) 300 mcg, 4) 1,000 mcg. The After 3 hours, there was still significant bronchodilatation when compared to the placebo. There was no statistical difference between a 100 mcg Vs. 300 mcg, but a comparison of the area under the curve between the high and low dose showed a significant increase for 1,000 mcg p <::-03. We conclude that inhaled fenoterol is a very adequate bronchodilator in asthmatic children and the dose required to produce maximum bronchodilation is in the range of 100 -300 mcg. Outerbridge. McGill University-MJntreal Children's Hospital ResearCh Institute, Quebec, Canada. 'lb assess the accuracy of initial drug use in neonatal pharmarotherapy, the degree of indication at onset of therapy was a:impared to that at discharge or completion of therapy. Nine indications (see Table) were assigned to 6616 drug regi.Jrens given for the first tirre to 495 neonates in an intensive care unit in 1977-78. 135 dzugs were used and indications were based on arbitrarily set criteria:l)evidencc for definite existence of disease process, based on laboratory and clinical criteria, 2)evidence for efficacy and appropriateness of a drug for the disease process based on available pharmacologic data.Results sho.-1 a good roncordance of the initial and the final degree of indication except for the non-inidcated drugs and those given on a presUI1ptive basis. INDICATIOO Hypothalamic pituitary function in the primary empty se!la syndrome (ESS) has been studied extensively in the adult population, but few pediatric patients have been evaluated. We report on the pituitary function in 5 female children-I black, 4 white-with ESS having a mean age at the time of diagnosis of 8 8/12 yrs. and a range of 2 9/12 -12 8/12 yrs. The diagnosis of empty sella was established by CT scan with and without metrizamide cisternography. Pituitary TSH, ACTH, GH and prolactin reserve were assessed in response to provocative stimulation. Oxytocin (OT) is essential for milk removal in most animals but in sheep and goats normal milk yields have been obtained during hand milking without measurable release of oxytocin using bioassay techniques. To examine the influence of nonnal suckling on plasma OT, we have measured plasma OT by RIA in 4 sheep on days 1 to 15 of lactation. Each ewe nursed one lamb 2 to 3 times daily. Samples were taken through an indwelling catheter before the lamb was brought near the ewe, and before contact was allowed with the lamb, at active suckling, and at l, 5, 10, 15, 30, and 60 min aftE'r suckling began. Basal OT was 10+4.5 pg/ml, rising significantly to 21.8+5.7 pg/ml after the lamb was returned but before tactile contact was established. A further rise occurred in all instances during suckling, maximum levels varying from 14 to 210 pg/ml. Mean plasma OT was raised over basal levels throughout the suckling periods which lasted 2.9+0.38 min on average. After suckling stopped, OT levels remained elevated in most instances for considerable lengths of time, returning to baseline in about 60 min. Thus, during each suckling episode, the lamb induced secretion of oxytocin in the ewe. Moreover, the reflex becomes conditioned very rapidly as indicated b:; the rise in maternal p 1 as ma OT at the sight of the 1 amb from day 2 onwards. (Spon by Ron Gold) Hosp. Sick Child., llept. Peds., Toronto. other testicular anomalies. We determined the ['I) before and 72 hours after a single HCG injection (1500 IU/m2) in 28 boys aged .02 to 15.2 years. The groups included 17 with cryptorchid- Prader-Willi Synd., 2 with small testes and 1 with anorchia. Twenty-five of the 28 patients (89%) demonstrated a >3 fold increase in (T) over baseline and/or a peak [r) >100 ng/dl. Statistical analyses of the (T) response of these patients hy paired t test are shown. normal term infants. Following chromatography in 0.25M formic acid to remove somatomedin binding protein, samples were assayed for SMPC by radioreceptor assay using placental membrane. IGF-I was measured by radioimmunoassay using antibody provided by the NIH. 125-I JGF-I was used as radioligand in both assays. IC.F-II was measured by radioimmunoassay using rabbit antibody generated against the C peptide region of IGF-II. 125-1 tyrosylated C peptide of IGF-II was used as radioligand. SMPC levels in cord blood averaged 0.49 ± 0.13 (SD) unit/ml (normal adult males 1.30 ± 0.25). IGF-I levels averaged 113 ± 35 ng/ml, significantly lower than normal adult levels (184 ± 32). IGF-II levels averaged 282 ± 84 ng/ml, also significantly lower than normal adult values (687 ± 169). IGF-II levels showed a strong correlation with birth weight (p < 0.005), while IGF-1 levels correlated weakly with birth weight (p = 0.05). Thus, IGF-II levels are relatively low in cord blood like SMPC Baseline PVP-I (n=9) 6.3±1.9 6.7±1.5 7.5±5.1 6.1±1.3 H (n=9) 6.0±1.8 6.1±1.5 4.6±2.1 5.9±1.4 TSH was <20 mcU/ml in all babies. Another 37 PNs were evaluated of whom 24 received PVP-I (1-7 exposures)and 13 received H.Values were not obtained at all time points. There was no difference in mean T4 and TSH concentrations between groups. Blood T4 ccmcentration fell by >50% in 6 very ill PNs who received PVP-I.TSH remained <20 mcU/ml in five, and rose slightly in one,strongly suggesting that iodine-induced hypothyroidism was not present antus is believPd to be the principal source of cholesterol utilized hy the fetal adrenal gland. Thus, accurate mP;isurements of cholesterol formed de nova in various fetal tissues are of siqnal importilnCP in UnderstilnCJii'iQ the requlation of Cholesterol metabolism in the fetus and more specifically in the fetal adrenal ciland. We determined thf' rates of cholesterol formed de nova in short term in vitro incubations of various fetal tissues;-ootalned from human -aoortuses at gestational acies from 8-22 weeks by measuring the rate of incorporation of tritium from [ 3H !water into cholesterol. The hiqhest r11tes of cholesterol synthesis were found in adrenal and liver tissues ( 47±? and 32±2 ng atoms tritium incorporated x mg-I protein x h-1, respectively; mean±SE), whereas intermediate rates were observed in testicular tissue (21±3 nq atoms x mg protein x h-1) and lower riltes (<6 ng atoms x mg-1 x h-1 ) in all other tissues studied. Modest variations in rates of cholesterol synthesis were observed with respect to gestational age in liver and adrenal tissues. In testicular tissue, peak rates of cholesterol synthesis were noted at 14 weeks qestation, ;mci declining values therp;ifter. Considerinci the r<'lpid qrowth of the fetal liver and the high rate of cholesterol synthesis in this organ, it appears that cholesterol utilized for steroidogencsis by the fetal adrenal gland could he derived primarily hy de nova synthesis in the fetal liver and adrenal qland. We have shown that gitui §ary desensitization with the long acting LHRH analog D-Trp -Pro -NEt-LHRH (LHRHa) produces a significant reduction in the concentrations of serum gonadotropins and gonadal sex steroids in children with IPP. We have now investigated the effects of LHRHa treatment on ulnar growth in patients with this condition. Ulnar growth is a sensitive index of short term growth in children and correlates well with linear growth. Seven girls and one boy (ages 4 to 8 years), with Tanner II-IV development, advanced bone age, and pubertal levels of gonadotropins and gonadal sex steroids, were studied. Three week ulnar growth rates (TIJG) were measured 2 months before, and for several months after institution of treatment with 4 of LHRH •• TIJG Basal 1-2 mo 3-4 mo 5-6 mo 7-8 mo 9-10 mo (mm/3wk) ( p T pathway with a single incubation and a simple, rapid chromatographic system. To determine the mechanism for this, we assessed plasma Sm-C, GH release, and Sm-C responses to exogenous GH in 8 children and adults with primary hypothyroidism. Basal Sm-C concentrations were below age and sex related norms in all subjects, and rose an average of 3-fold after thyroid hormone replacement. Of 6 subjects tested, 3 had normal Gii release to provocative stimuli, whereas 3 had subnormal responses ( < 7 ng/ml). Sm-C increased in all 6 in response to a single injection of Gil (0.1 U/kg) and rose to >4 times the basal level after 0.8 U/kg. GH secretion did not correlate with basal or GU-stimulated Sm-C. In a companion study, the mean Sm-C in thyroidectomized (Tx) male rats was O. 71 ± 0.25 U/ml (controls=2.16 ± 0.38). Treatment with T4 or hGH raised the Sm-C to l. 55 ± O. 41 and 1.44 ± O. 27 U/ml, respectively. Binding of 125I-hGH to "somatogenic" sites in crude membrane-rich homogenates from livers of Tx and GH-treated Tx rats was nearly twice that in euthyroid rats, and was due to increased binding Conclusion: Hypothyroidism is associated with low circulating Sm-C which is not due to an obvious decrease in CH secretion or responsiveness. It is possible that the growth failure of hypothyroidism is related to the lowered Sm-C. The possibility that C,often used in neonatal apnea, nay produce acute or chronic changes in thyroxine(T4J, thyrotropin (TSH) and growth horrrone(GH} was studied in the NR. Five day old rats were randomly ilivided into 3 groups(n=50/grp}. Control group received saline; lc:w-dose caffeine(UX:) group, received 5 mg/kg IP and high-dose caffeine(HOC} group, received 50 mg/kg IP. In each group, rats were sacrificed 2,4 or 24 h after a single injection (acute effects) or 24 h after 10 days of daily injection (chronic effects]. Gl, T4 and TSH were rreasured by RIA, C by HPLC. After acute C, Gl significantly increased 2h after HOC (rrean ±SEM} (75.4 ±15.5 vs 27.7±6.3 ng/ml,p<.05); 24h after UX: (97.1±11.3 vs 40.9± 7.0, p<.05) and HOC (169.8±36.2 vs 40.9±7.0 ng/ml, p<.001). After chronic C the increase in Gl was small suggesting depletion of pituitary reserve. After acute HOC, T4 response was bi.phasic with an increase at 4h (3.8±0.l vs 3.3±0.2 µg/dl, p<.05) and decrease at 24h (4.1±0.2 vs 4.8±0.2 µg/dl, p<.001). Thyrotropin-releasing honrone (TRH}-stimulated TSH at 24h was not influenced by C. Chronic C increased T4 and TSH, but decreased TRH stimulated TSH, suggesting bl1.mted TSH response after chronic C. C D:>se (mg/kg/dxl.Od) 0 (CONTROL) 5 (ILC} 50 (HOC} T4 (µg/dl} 4.1± 0.3 5.1± 0.3(p<.001) 6.0± 0.2(p<.001) TSH (µg/dl) 10.6± 1.4 17.9± 2.6(p<.05) 25.1± 6.9(p<.05) TRH-induced TSH 216.8±45.5 101.9±19.5(p<.05) 153.6±31.7(p<.05) We conclude that doses of C currently used for neonatal apnea may produce acute and chronic changes in horrronal status in the NR. Horrronal effects of C in ne\ooborn infants require further studies. Case had no mass on MC, but high levels of LHRH by RIA in his CSF ( l40pg/ml; controls-undetectable), implicating a suprasellar mechanism in the etiology of his precocity. Case 4 had an eroded sella and presumed prolactinoma (ame11orrhea, galactorrhea, hyperprolactinemia). After 1 yr therapy with bromocriptinc, transsphenoidal exploration revealed ESS confirmed by AEG, suggesting that tumor regression may predispose to arachnoid herniation. We conclude that in children (a) the spectrum of ESS is heterogeneous with both primary and secondary causes, and (b) endocrine abnormalities may be more common than in adults with the syndrome. The role of elevated CSF hormone levels in patients with abnormal CSF circulation warrants further investigation. typical hyperparathyroid bone changes, suggesting renal non-responsiveness but bone responsiveness to PTH. However, PHP presenting as rickets is not generally recognized. We report a 13-year-old healthy white female who presented with bilateral bowing of the legs and varus deformities typical of rickets. She was appropriate for age by height, weight and intelligence and had no brachydactyly. Both parents and 6 siblings were normal. Radiology showed advanced subperiosteal resorption in the fingers, slipped capital femoral epiphyses bilaterally and rachitic changes in all the epiphyses. Iliac bone biopsy revealed changes compatible with hyperparathyroidism. After treatment with I µg l,25(0H)2D daily, there was symptomatic relief and improvencnt in her serum chemistries. In conclusion, rickets could be a manifestation of renal non-responsive, bone-responsive PHP with normal vitamin D metabolism. The role of the B-adrenergic system in fetal response to hypoxia was studied in 7 chronically instrumented fetal lambs given 1 mg/kg propranolol IV (Exp.) and 7 control (C). Hypoxia (H) was induced by administration of 10% Oz to the ewe for 30 minutes. Propranolol alone caused a 20bpm fall in fetal HR but no change in blood composition. The change in BP, HR and acidbase indices following H were similar in both groups; however, during 30 minutes of recovery (R), no tachycardia was observed in (Exp.) and PHa fell significantly. Valle, Cali, Colombia. The study was designed to determine whether LHRH administered to the mother during labor resulted in increased bioactive (B)LH concentrations in the neonates. With their informed consent, 7 women with uncomplicated (39 to 41 wks) pregnancies were followed during spontaneous labor. During the last stage of vaginal delivery 100 ucg of LHRH was administered intravenously to the mother. Approximately 10 minutes after delivery, blood was obtained from the cord and at 15,30,45,60,90 and 120 minutes from an umbilical catheter in the neonate. Concentrations of BLH were determined in the serum by means of the in vitro RICT assay utilizing 2nd IRP-hMG as the standard. Of the 7 neonates 4 were niale and 3 female. All had normal birth weights and Apgar scores. The BLH concentrations in the cord blood of boys and girls were 165± 112 and 158±17 mIU/ml (mean±lSD). These values were not significantly different from values in the cord blood of 7 neonatal boys and 7 girls whose mother did not receive LHRH. In boys and girls of LHRH injected mothers the maximum BLH was achieved between 30 and 45 minutes. The increase in boys varied from 168 to 1586%, whereas in the girls it was lower 1 hetwcen 125 and 336%. It is therefore concluded that: 1) LHRH administered to the mother during the last of labor does not significantly alter BLH co!1centrations In cord blood but may contribute to postnatal BLH elevations and 2) the rise in newborn boys exceeds that of girls. The of this study were to a) determine the concentrations of b1oactive (B)Lll in the blood of both boys and girls during the first 7 days of life and b) evaluate the pattern of B-LH secretion on day 7. Blood was obtained daily for the first 7 days of life in 7 full-term neonatal boys and 4 girls. The BLH was determined in the serum by means of the in vitro RICT assay utilizing 2nd IRP-hMG as the standard mIU/ml To determine the pattern of BLH secretion on day 7, 4 girls and boys had blood withdrawn Q 20 min for a period of 2 h. The % CV in 4/5 boys (17.9,14.0,52.4,15 .2) and 3/4 girls (24. 4,17.3,19. 2) was at least 3 times greater than that of the assay (<5)suggesting the possibility of pulsatile secretion. These data demonstrate that a) BLH reaches a nadir on day 4 after birth in both boys and girls most probably corresponding to the disappearance of endogenous hCG activity; b) in boys BLH rises significantly by postnatal day 7, most probably the result of endogenous LH secretion; c) in girls BLH continues to decline and by postnatal day 7 is significantly lower than on day 4 and d) both boys and girls exhibit pulsatile secretion of BLH on postnatal day 7. IMPROVED METHOD TO ACHIEVE GOOD DIABETIC CONTROL. HbAlc (1> of total Hb) t Pre-CBI! Post 30 Days of CBI! Non-Diabetic Range 11.3±4.0 7.08±1.4 (N=7) 3.7 to 6.9 These data reveal insulin levels achieved with continuous basal insulin infusion (CBII) are similar to the non-diabetic. Moreover, glycemic control, with non-diabetic glycemic excursions and glycemic excursion times, is possible on CBI! without pre-meal boluses of insulin. This approach to the pump infusion of insulin is less complex than the variable bolus approach commonly used and is equally effective in producing good diabetic control. John A. Germak, Carlie H. White and Thomas P. Foley, Jr., Dept. of Ped., Univ. of Pgh., Pittsburgh In an attempt to elucidate the underlying mechanisms associated with the elevated threshold for TSH suppression in certain patients with CH. 12 infants with the apparent feedback defect (FBD) of 26 with CH were studied. FBD was defined as a serum TSH uU/ml beyond IO weeks of L-Thyroxine therap" with a total T4 (TT4) above the mean for age 9.0 normal free T4 (FT4), ng/dl and T3, 100 ng/dl. Of the 12 infants with FBD 8 had functional athyreosis (AT), 3 had ectopic or hypoplastic tissue (E/H) and 1 had dyshormonogenesis (DH). The mean bone age (BA) at diagnosis (dx) did not differ (p>O.l) between the 8 AT patients with (c) FBD, 32.4 ± 6 fetal wks (FW), and the 8 AT patients without (s) FBD, 35 + 8FW.BA at Dx in the 3 infants with E/H and I with DH was not delayed. Of the 12 infants c FBD, the TT4 was low in 9 (757.l, T3 low in 4 (33%) and FT4 low in 10 of 11 (91%) at Dx. The mean at Dx did not differ between the inf ants c FBD and infants s FBD (p>0.5). Serum prolactin (Pr) was elevated beyond 3 months of age in 3 of 4 AT c FBD infants compared to age-matched controls. The E/H and DH patl.ents c FBD-and 3 CH patients s FBD dc•monstrated normal Pr levels. In summary, FBD commonly occurs in CH. The duration of hypothyroidism a$ determined by BA at Dx and severity of hypot:1yroidism at Dx as determined by TT4, T3, or TSH do not differ in patients C.: or S l-1Bt:. A low FT4 at Dx was present in all but 1 infant c FBD. In AT patients c FBD there appears to be a persistent Pr elevation during infancy. Conventional growth hormone (CH) replacement often fails to induce growth rates that can restore stature to the normal range even in doses exceeding current recommendations. While dosage increments may alter the peak GH value, plasma GH levels are elevated for only hrs after intramuscular injection. Recently we showed that CSIGH could maintain sustained elevations in CH for 4 days. Because the natural secretory pattern of GH is pulsatile, the effectiveness of CSIGH in the stimulation of growth remained to be determined. 4 GHD boys (10.1±1.2 yrs) who had stable growth rates on conventional CH Rx (.3U/kg/wk in 3 doses) received CSIGH for 4 months in a dose which raised plasma CH to 9-11 ng/ml (.6-.9 U/kg/wk). During conventional Rx age adjusted growth velocity was normal (5.7+1.lcm/yr). CSIGH resulted in a striking acceleration to values iO excess of normal (11.3+ l.2cm/yr, P<.01). Growth acceleration was accompanied by signi= ficant rises in somatomedin C (.16+.08 to .95+.4 U/ml, P<.05) and the insulin response to oral glucose (area under curve 5.8+ .8 to 9.8±1.5(mU/ml)·min, P<.05). However, there was no impair= ment of glucose tolerance, cholesterol and triglycerides remained normal and CSIGH was well tolerated by patients. Most previous studies of the intellectual, academic and psychosocial functioning of children with short stature have focused on those with growth honrone deficiency, rather than the much larger group with m. To assess the effects of CD on learning and visual-rrotor functioning, we administered a battery of psychological tests to 24 affected children, aged 6-12 years. The results were cx:rrpared to those of 23 healthy children with rx>rmal stature matched for age, sex and socioeconanic status. The tests consisted of 8 subtests of the Wechsler Intelligence Scale for Children-Revised, the Peabody Individual Achievement Test and the Bender-Gestalt Test. School teachers conpleted the Child Behavior Checklist and the Conner's Teacher Rating Scale. There 1'.'ere rx> significant differences between the two groups for any of the 15 variables analyzed. About 1/3 of the parents in each group reported that their children had academic difficulties. Since we have previously demonstrated that the children with CD tend to have rrore sanatic conplaints, low self-esteem, and to be socially withdrawn, it may be that school teachers are 110re attuned to rx>tice acting out rather than internalizing sorts of behavior problans. In conclusion, children with CD are rx>t 110re likely to have school-related difficulties than their taller peers. they are apt to have increased behavioral difficulties, these &:> not seem to intrude significantly into the academic realm. In some patients with congenital adrenal hyperplasia (CAB) initiation of treatment with hydrocortisone (HC) when the bone age is 12 years or more results in changes of normal puberty regardless of the chronological age. -Two boys with non-salt losing CAH ages 3-6/12 and 4-8/12 with bone ages of 11 and 12 years respectively were assessed for serum bioactive LH (B-LH) and immunoreactive Lil (1-LH) response to gonadotropin releasing hormone (GnRH) injection (100 11g) prior to HC therapy, 8 days and 4 months later. Basal levels of J-LH were prepubertal in both boys before therapy but basal B-LH levels were elevated with a B/l ratio of 14.8 in the older patient and 4.7 in the younger one. The 1-LH response to GnRH was prepubcrtal in the untreated state whereas B-LH was not significantly responsive to GnR!I. Both B-LH and I-LH patterns were pubertal and similar 8 days after therapy in both patients and 4 months later in the younger patient hut the B-UI was much higher in the older patient. The disappearance rate of B-Lfl was different in that high levels persisted throughout the sampling period whereas 1-LH declined to baseline levels. The higher levels of B-I.11 seen in tl1c older child correlated with the physical signs of early puberty and a commensurate rise in serum testosterone. In summary, basal as well as stimulnted 8-Ul corresponded better than 1-LlJ to the hypothalamic maturation seen in children with CAH who arc exposed for prolonged periods to elevated ,.f sex steroid prior to therapy with HC. CURE OF SEXUAL PRECOCITY WITH REMOVAL OF LHRH-SECRET-ING HAMARTOMA. James P. Gutai, Leland A. CH was administered (0,2+.02 U/kg/wk) to 24 patients (18M, 6F) with CH deficiency, aged 7 to 25 years; 14 were idiopathic (IH) and 10 had CNS disorders (CNS). Fasting plasma was obtained at 0, 4,24 and 72 hr after a single injection of CH, and at 1 and 6 mos on chronic therapy. Increased growth velocity (6GR = 0.49+.05 cm/ mo) with CH therapy was significantly correlated with CH dosage (p <.005). IGF-I/SM-C was determined by RIA of unextracted plasma utilizing 125I-IGF-I (R. Humbel) and an antibody to SM-C (NPA). IGF-II and ILAs were determined by RRA following acid chromatography utilizing rat and human placental membranes respectively. All values were compared to the same normal adult male pool assigned a value of 1.0 U/ml. A variable but significant mean increase (p<.05) was seen in IGF-I/SM-C at 4 hr, and persisted at 1 and 6 mos (p <.01). A significant mean increase in ILAs seen at 24 and 72 hr (p <.005) was maintained at 1 and 6 mos (p <.005). A significant correlation (p <.001) between IGF-1/SM-C by RIA and ILAs by RRA was seen. There was no significant correlation between 6GR and either ILAs by RRA or IGF-I/SM-C by RIA, nor a difference in 6GR, 6ILAs or 6IGF-I/SM-C during puberty. IGF-II determined in 7 subjects (3 IH, 4 CNS) showed a significant mean increase at 1 mo (p <.05). Marked individual responses in IGF levels and lack of correlation with 6GR were evident. Our data indicate that both alkaline (IGF-I, SM-C) and neutral (I.CF-II, ILAs) IGF peptides are increased following CH therapy in hypopituitarism. • 360 CH SECRETION. Harvev J. Guyda & Barry I. Posner. Depts. Children's Hospital Research Institute, Montreal, Quebec. min in 57 male and 32 female subjects (Endocrine Society, 63rd Annual Program, 1981, p.101). Spontaneous GH secretory episodes (> 5 ng/ml) were evident in 40 short children (87%), 89% of 27 control children and adults, and were absent in 16 patients with hypothalamic-pituitary dysfunction (HPD). The number and amplitude GH episodes increased significantly with increased pubertal development. We have now ,tetermined IGF-I/SM-C levels q 2 h in unextracted plasma by a RIA employing 125I-IGF-l/SM-C (R. Humbel, Zurich) and an antibody to SM-C (NPA). The diurnal variation was <20% and a mean value of 4 determinations for each subject was obtained. A clear age-dependent increase in IGF-1/SM-C, correlated with Tanner staging, was evident. Adult subjects had significantly lower values than Tanner V adolescents. In HPD, low IGF-I/ Tanner I Gastrointestinal function in man is altered in hypopituitarism. Serum gastrin (G), an important trophic hormone in normal gastrointestinal function, is low in hypophysectomized animals. The low serum G can be restored to normal by GH therapy. We studied serum G in 24 children (mean age 9.7 yr, range 5.6-15.0 yr) with GH deficiency before and after acute and chronic GH therapy (Rx) to determine the effect of GH on G levels. Fasting (F) and one hr post-prandial (PP) G was determined before and after 5 d. GH (2 !. U./d), and again at 6 and 12 months during GH therapy 2 l.U. T.l.W. Gastrin 1 yr 18 SEM As observed in normal children PP G was greater than F G in the GH def. children before and after GH Rx (p< .05). GH Rx did not alter F or PP G levels compared to pre-Rx levels nor did the G response to a differ. There was no correlation between age and G response. Thus, it appears that GH Rx in GH deficient children does not increase basal or stimulated G secretion. Sponsored by NIH-RR-0188. Calif. Sch. of Med. and Childrens Hospital of Los Angeles, Dept. of Peds., Los Angeles, Calif. were <1.7 and 3.8 mIU/ml and peak levels during sleep were <1.7 and 2.1 mIU/ml, respectively (prepubertal levels <5 mIU/ml). Following luteinizing releasing hormone (LRH), FSH level did not rise above the basal value of ,1.7 and LH rose from 2.8 to 3.5 mIU/ml. Serum estradiol levels ranged from 189 to 1285 pg/ml, progesterone was 82 ng/ml and dehydroepiandosterone-S04 21 µg/dl. Multiple ovarian cysts up to 5 cm in diameter were present bilaterally on pelvic ultrasound. The normal T4 and T3 levels, normal TSH response to thyrotropin releasing hormone, as well as normal parathyroid hormone level, and normal cortisol response to ACTH stimulation and dexamethasone suppression ruled out hyperfunction of other endocrine glands. Following oral L-dopa,growth hormone rose to 23.7 ng/ml and prolactin decreased to 3.5 ng/ml. In our patient, the occurrence of sexual precocity, in the absence of elevated gonadotropins (Gn) and a prepubertal Gn ie£:.)onse to LRH suggests an autonomous hyperfunction of the ovaries not mediated through the hypothalamic-pituitary gonadal axis. We have studied the rate and character with which T-R and DHT-R complexes dissociate within, and after extraction from ['H]T or ['H]DHT-labelled genital skin fibroblasts (GSF) of a subject with Sa-R'ase deficiency. Within GSF the T-R and DHT-R complexes dissociate with tj of 30 and 90 min at 37°, respectively, but each type of comp ex dissociates with monophasic, first-order kinetics and is in the «activated» state as determined from an Arrhenius plot (27-40°). After extraction from GSF and partial purification through a G-75 column, DHT-R complexes still dissociate monophasically with the same tJ as above, but T-R exhibit biphasic kinetics -an initial «rapid» (preactivated) phase (k_ 2 , 40xlO-• min-1 ) followed by a «slow» (activated) one The relationship between perinatal changes in thyroid function and tissue respiration was evaluated by measuring hepatic and renal cortical oxygen consumption (Q0 2 ) with and without ouabain (lmM) in tissues from fetal lambs at 121-124 days gestational age (GA) (Group!, n=5), 136-140 days GA (Group II, n=5) and in newborn lambs between 1 and 7 days of age (Group Ill, n=8). Geometric mean triiodothyronine (T3) concentrations (±95% confidence levels) increased from 14.3 (<11.6-21.1) ng/dl in Group I to 40.7 (18.1-91.4) ng/dl in Group II and 504 (424-599) ng/dl in Group III. Serum T4 levels were similar in all 3 groups. Mean (±SEM) total hepatic Q0 2 values were similar in Groups I and II (34.7± 4.3 and 24.9±4.l 0 2 /100 mg.hr) and increased to 59.5±4.2 in Group Ill (p<0.01). Sodium transport dependent Q0 2 (total QO,ouabain suppressed Q0 2 ) was significantly greater in Group Ill (21.2+2.2) than in Groups I (11.4±2.7) or II (3.1±0.8), and was decreased in Group II compared to Group I. Non-transport dependent (ouabain suppressed) Q0 2 was similar in Groups I and II (23.3±2.4 and 21 .9±4.5) and increased in Group Ill (38.3±2.9, P< 0.01). Renal cortical total and ouabain suppressed Q0 2 values were similar in the three groups. Conclusions: 1) The increase in T3 concentrations observed in the newborn lamb correlates with an increase in hepatic but not renal cortical tissue respiration; 2) the increase in hepatic respiration is due to an increase in both sodium transport dependent and non-dependent respiration. The effect of T3 treatment on in vitro oxygen consumption (QO,) of isolated brown adipose tissue cells (BAT), liver, kidney cortex, brain and heart was studied in fetal sheep. Thyroidectomy and insertion of a constant infusion pump was performed at 119-121 days gestation followed by 8 days of infusion with either T3 (4 animals, Group I, 24 mcq/hr) or vehicle (4 animals, Group 11). After hysterotomy, animals were sacrificed with barbiturate and decapitation and the tissues were removed. Basal Q0 2 (±ouabain, lmM) was measured in all tissues; norepinephrine (NE, 10-'M) (±ouabain) stimulated respiration was measured on BAT only. Cord T3 serum concentrations at hysterotomy ranged between 160 and 502 nq/dl in Group I and were undetectable in Group II. There were no significant qroup differences for basal 00 2 (± ouabain, lmM) in any of the tissues studied. NE stimulated QO, significantly increased in Group I (123±18.5) (SEM) 02 /10 6 cells·hr) vs Group II (55±15.6) (p<0.05). Non-sodium transport dependent ME Q0 2 {ouabain suppressed) was increased in Group I (70!4.7 vs 27.3+7.8) (p<0.01) but transport dependent NE QO, (NE QO, -QO, with ouabain) was not different in the two qroups. Conclusions: Basal respiration in the ovine fetus at 120-130 days is not thyroid hormone dependent. In contrast stimulated BAT respiration increased two-fold suqqesting that thyroid hormones may play an important role in stimulated BAT thermooenesis in the ovine fetus. Three children aged 2, 11 1/2 and 15 years were shown to have variable degrees of thyroid hormone insensitivity. Prior to investigation all three received therapy with either thyroid blocking drugs or thyroid hormone due to wrong clinical diagnosis. Normalization of thyroid hormone levels resulted in hypothyroidism. The older two patients were first cousins. The youngest patient had signs of hypothyroidism including both developmental and skeletal delay which were possibly exaggerated with 8 months of propylthiouracil therapy. The older two patients had goiters and were clinically euthyroid. All subjects had increased levels of thyroxine 14. 4 -21.5 (nl 4.5 to 11.5), free thyroxine 2.7 -4.0 ng/dl (nl 0.8 to 2.3), triiodothyronine 243 -430 ng/dl (nl 100 to 200), and normal thyroxin binding proteins. Serum TSH was normal in 2 subjects and elevated in the 15 year old to 42 1i!U/ml (nl 1.9 to 5). All subjects developed a 30 minute peak response to TRH which was normal in 2 (10 and 16 µJU/ml} and exaggerated in the 15 year old (291 µJU/ml}. These observations indicate that the diagnosis of partial peripheral resistance to thyroid hormone may be missed in the clinically euthyroid child with a goiter and elevated thyroxine levels. The TRH test is an important step in differentiating this disorder and is indicated before therapy with antithyroid drugs. The underlying abnormality in these patients is unknown. Rapid gastric emptying of carbohydrate substances is thought to augment insulin secretion and result in the symptoms of reactive hypoglycemia. Seven children aged 1-12 years who had previous Nissen fundoplication alone or combined with pyloroplasty were studied. The rate of gastric emptying was measured by the .disappearance of Technicium 99 sulphur colloid in apple juice vehicle. Serial imaging was done at 15 minute intervals. Simultaneous measurements of blood glucose and insulin levels were obtained at 30 minute intervals. No subjects were symptomatic during the procedure. Gastric emptying in patients with fundoplication alone was 69 minutes (45-105 minute range) as compared to 129 minutes (35-288 minute range) in patients with fundoplication with pyloroplasty. There was no correlation between the rate of gastric emptying and the rise in blood glucose and insulin levels although three children had exaggerated insulin responses (50-72 µU/ml) with normal glucose levels at 30 minutes. This did not correlate with the type of surgery. From these observations it is concluded that gastric emptying is variable with either fundoplication alone or when combined with pyloroplasty. The glucose tolerance and the insulin response did not correlate with the rate of gastric emptying. Variation in linear growth rates with seasonal changes have been attributed to physical activity, sunlight exposure, or vitamin D influences. We compared the hGH-induced growth rates in 19 hypopituitary dwarfs aged 4 to 22 years during two 4 month periods. Subjects did not receive hGH 4 months before the study. Individual growth variation was analyzed. The growth rate during Spring -Summer (April -August) and Fall -(October -February} did not differ significantly (8.19 vs 8.12 cm/yr). Growth for these same periods was compared with all subjects while off of hGH therapy. The growth rates were significantly greater (p<0.05) in the Spring -Summer period. While rates of growth during therapy exceeded those during periods without therapy (p<0.005), no correlation was found between rates of growth and skeletal age or with the degree of skeletal age retardation. Our data support the concept that seasonal variations in growth rate persist in hypopituitary dwarfism, but do not influence growth rate during therapy with hGH. Durinq male sexual development, there are chanqes in the hypothalamic-pituitary-testicular axis which are modulated by alterations in 24 h secretory patterns of qonadotropins. In order to characterize the pattern in the absence of neqative feedback, we studied pulsatile LH/FSH secretion (q 15 min samples drawn without anesthesia in animals fitted with a vest and mobile tether) in castrated monkeys. Of the 18 monkeys, 4 were castrated at birth, and one each at l, 8, 10, 20, 26, 33, 42 and two at 25 months of aqe, and five were castrated as adults. Pulsatile secretion of LH/FSH occurred as: l) micro-pulses, havinq ampl itudes < 2X over baseline; 2) macro-pulses, where the increase in LH/FSH levels , 2X. The qreatest frequency and larqest amplitude of pulses occurred in adults. In early postnatal life, there were also larqe and frequent pulses but less than in adults. Pulsatile secretion was absent durinq prepubertal life and early puberty. In two animals, castrated at birth and studied at 33 months of aqe (midpuberty), markedly dichotomotous patterns were apparent. One animal had advanced into "puberty" and LH micro-and macro-pulses (up to 6Xl were seen with an t frequency and maqnitude of FSH pulses. The other animal retained a prepubertal secretory pattern, even when restudied 4 months later. These data indicate that chanqes in amplitude and frequency of LH/FSH pulsatile secretory patterns occur in the absence of the testis suqqesting pubertal maturation is independent of neqative qonadal feedback. We have previously measured urinary EGF in children using a human placental membrane radioreceptor assay which does not crossreact with insulin growth factor I (IGF I), somatomedin A, or other growth factors or peftide hormones. EGF excretion in normal children was 33.0 ± 2.8 µg/M /24 hr. EGF excretion was significantly (p <. .02) diminished in GH-deficient children before therapy and was similar to normal in a like group of children after prolonged GH therapy. In this study we have evaluated the relationship between EGF excretion and the length of GH therapy in order to determine whether EGF is a GH-dependent growth factor. Urinary EGF was measured in 5 GH-deficient children before and after .1 IU/kg of GH q 12 hr X 2. There was no significant rise in EGF excretion over 3 days. However, in 7 GH-deficient children treated for 1 month with .1 IU/kg of GH 3X/wk, excretion of EGF rose from 24.5 ± 3.4 J.Jg/M2/24 hr to 40.2 ± 4.8 1.1g/M2/24 hr (p <. .05). The rise persisted during treatment thereafter. Since EGF excretion is enhanced by prolonged (1 month) GH therapy, but not by short-term GH therapy, EGF is not a classic GH-dependent growth factor. Whether EGF represents a delayed intermediate in the mechanism of GH action or whether it is a product of the GH-induced growth effect remains to be elucidated. 5 girls with well-established central precocity were treated with 4-8 ug/kg/d of the LHRHa for 12 consecutive months. Pubertal development regressed one full Tanner stage in 4/5, menses ceased, maturation index scores returned to prepubertal levels, and E2 values fell to < 20 pg/ml in all. In all patients growth velocity decreased to normal and bone ages which had been rapidly accelerating pretherapy all advanced < 1 year during the 12 month treatment period. Parents remarked u?on the decrease in hyperkinesis and emotional labi lity which had been un·oelieved by previous therapy with medroxyprogesterone acetate in 2 patients. Conclusions: The LHRHa is capable of normalizing growth velocity and skeletal maturation in central precocity and thus appears to be unique among the agents which have been used to treat this condi tion. 1 = cm/yr, 2 = bone age, 3 = pg/ml, 4 = maturation index score. Blood ca++ concentration is regulated tightly, in part, by PTH and 1,25-D. Stimulation of the renal 1-hydroxylase enzyme by PTH produces an increase in 1,25-D biogenesis from its precursor, 25-hydroxy D. This has been demonstrated in normal and HP adults but not in patients with pseudo HP. The present study was designed to evaluate the enzyme 1 s responsiveness to bPTH in children with idiopathic HP. Four children (ages 4-10 years) received bPTH SU/kg parenterally at 0 and 2 hours. Blood samples were drawn sequentially to measure blood ca++(mg/dl), PTH(1il-equiv/ml), and 1,25-D (pg/ml A 12 yr. old girl was evaluated with a history of recurrent goiter and high TSI! after thyroidectomies. Clinically florid hyperthyroidism with goiter was diagnosed at age 5, and she had two thyroidectomies, four years apart, because of recurrent symptoms and dysphagia. Except for a maternal grandmother with hyperthyroidism, family history was negative for endocrinopathies. On examination she was clinically euthyroid with moderate thyromegaly; T4 8 .1 l•g%, TSH >40 µU/ml. Two months of thyroid hormone supplement slightly suppressed her elevated TSH (32 µU/ml), despite elevations in her T 4 (14.8 µg%), T 3 (353 ng%), and free T4 index (4.6 units). Growth hormone, cortisol, LH, FSH, and prolactin levels were normal and responded appropriately to provocative tests. Cranial CT scan, sellar polytomogram and visual fields were normal. The TSH response to TRI! was grossly exaggerated (peak level 676 µU/ml) and was only slightly suppressed by pre-treatment with dexamethasone. However, a dopamine infusion (4 11g/kg/min) resulted in a 65% suppression of both basal TSH level and the response to TRH. A five month trial of a dopamine agonist (bromocriptine), up to 7. 5 mg/day, was unsuccessful: basal TS?! levels persisted and there was no alteration in the TSH hyperresponsiveness to TRH. This study demonstrates the pituitary responsiveness of the non-neoplastic inappropriate TSH syndrome to dopamine hut not to bromocriptine. We have studied the prolactin response to TRH in 15 control children, 20 with idiopathic growth hormone deficiency (IGHD) and 15 with organic growth hormone deficiency (OGHD). Baseline prolactin concentration cm of 3 samples ± SEM) was 8.5 ± 1 ng/ml in control children, 15 .1 ± 3. 7 ng/ml in the IGHD children .:ind 64. 7 ± 43.9 ng/ml in the children with OGHD. Eight with IGHD had a history of perinatal insult. Baseline prolactin was significantly higher in these children (20.7 ± 5.5 ng/ml) than children with normal perinatal history (8.7 ± 1.6 ng/ml, p (-03). Mean peak prolactin conc0ntration after TRH was 45.8 ± 4.7 ng/ml in the control children, 46.9 ± 7.0 ng/ml in the children with IGHD and 95.0 ± 47.8 ng/ml in those with OGHD. Eighteen of the IGHD and ten of the OGHD children were restudied while being treated with GH (0.08 IU/kg t.i.w.). Intratreatment mean baseline and peak post TRH prolactin was not significantly different from pretreatment values. variability was found in the baseline values before and during GH Rx in the IGHD group. We In order to explore the possible role of E2 feedback at the pituitary level in the onset of puberty, the following experiments were performed. An in vitro perifusion system was developed to test the response of the isol.ateajmiiifary to E2 and pulsatile LHR H 1D1der physiological conditions. Five to six hemipituitaries from one month old (juvenile) female Sprague-Dawley rats were pl.aced in paired perifusi.on cells. One cell was perfused with Ml99 medium (A), while the other cell was simultaneously perfused with Ml99 + 10-9 M E2 (B). LHRH pulses (10-8 M) were given synchronously every 1.5-4.2 hr. The LH production rates in to each LHRH pulse were compared during 20 hours of perifusi.on at 38 C: Pulse Time ( The data-mdicate 1) an early iflhibifion (p< .05Tby EZ of Clf res'j5onse to LHR H and 2) a later gradual rise to persistently positively augmented LH surges in response to LHRH pulses (p < .025 between 12-18 hr). These results directly demonstrate for the first time that E2 has a biphasic effect upon pituitary LH responsiveness to LHRH. The initial effect (within 2 hr) is transient early inhibition. This is followed by prolonged augmentation, which commences by about 12 hr. Furthermore, these effects are discernible prepubertally. IE present the first report of primary tweraldosteronism in childhcxxl rue to unilateral IT'ilcronodular hyperplasia. A 10 yo l with dexim!thasore was noted excllXling dexilll!thasore sup-Pfl!Ssible t'rfperaldosteronism. Blood pressure ronnalized with spironolactore. m, iodochOlesterol scanning, ard adrenal veoograplff 1>ere not diagrostic of a discrete adrenal lesioo. Adrenal vein ronrone ScJ11Jling with JlCTH stinulatioo lateralized aldosterore secretiCJl uneq.iivocally to tte left adrenal 2land: 25.0 Although t"MJerplasia as a cause of i"rfperaldosteronism in childhcxxl is rrore camm than ill adeoora, a tllTIJr was predicte:l in this child since excessive aldosterooe appeared to criginate fran ere adrena 1. Hc:l.>ever, left adrena lectcey reveale:l macronodular hyperplasia, adrenal pathology coosistent with tte patient's young Post qieratively there has a runral izatioo of blood pressure, biochamcal, ard honronal parall!ters lefore and q2.l,h Nuloxone. We conclude that endogenous opiates do not mediate the day-night gonadotropin differences in early puberty. Moreover, the mechanisms of gonadotropin suppression in early puberty differ from that act- This study was undertaken to examine the physiology and effects if any, of administered thyroxine (T4) in the normal preterm infant. Group 1: 11 well, AGA, preterm infants weighing from ll80-1820gm (mean 1487 ± 198 gm) on day 3 or 4 of life were given 25 micrograms of L-thyroxine daily for 20 days. These were paired with 11 matched control infants. Weight, length, and head circumference (HC), as well as T4, T3 RIA and reverse T3 (RT3) were measured on days 1, 10, and 20. Group 2: In 5 similarly treated infant pairs, weight 1200-1580 gm (mean 1392 ± 153), T4 and free T4 were measured. Weight, length, and HC between matched pairs of both groups were not significantly different by the paired t-test on day 1, 10, or 20. In group 1, mean T4 and TJ were not significantly different in treated vs control patients on days 1, 10, and 20. Mean RT3 were similar on day 1: 1889 ± 566 vs 1970 ± 616 in treated vs control patients respectively, but significantly higher in treated patients on day 10: 1201.± 277 vs 830 .± 236 (p < D.005) and on day 20: 1048 .± 280 vs 736 ± 203 (p < 0.02). In group 2, mean serum T4 and free T4 were not significantly different in treated vs control patients on days 1, 10, and 20. These studies show that administration of thyroxine to the preterm infant does not affect serum levels of T4, T3, or free T4, and suggests that monodeiodination of T4 to RT3 plays a role in thyroid homeostasis in these infants. Hill, R. Tsanq, J. Elders. UAMS, Little Rock, AR., NCTR, Jefferson, AR., UCCM, Cincinnati, 0. Although pregnancy and lactation present a maximun to maternal mineral metabolism, little is known about endocrine factors maintaining mineral homeostasis during gestation. We have perfonned longitudinal studies in 22 pregnant Rhesus monkeys and 11 non-pregnant controls. All animals were kept protected against daylight and fed a standard Purina chow diet .. specimens for the measurement of 1,25-and 24,25-calcitriol (1,25 and 24 25) concentrations were obtained at monthly intervals during' pregnancy and for 3-5 months after delivery. Serum Dmetabolites were extracted, separated by standard HPLC procedures, and measured by chick intestinal radioreceptor assay. Mean serum 1,25 levels of 167 pg/ml during the first 50 days of pregnancy were not different from controls. However, levels increased significantly after 50 days (P<.001) reaching a peak between 80-120 days (481+42). 1,25 levels after termination of pregnancy dropped rapidly to values slightly above controls. and did not appear to be different in lactating and non-lactating mothers. Mean 24,25 concentrations of 3.3+0.6 ng/ml during the first 50 days of pregnancy were not different from controls. Although sterol levels increased in the majority of animals after 50 days, mean concentrations of 4.2±0.58 ng/ml between 80-120 days were not detennined different (P>.05) . .!.J1. conclusion: The marked changes in D-metabolism occurring in pregnant monkeys suggest that D-sterols play an important role in the control of gestational mineral homeostasis. wt. increments in the hospital (i\1.57cm&l.62kg)did not correlate with init. GH peaks. Normal GH responses (>7 ng/ml) were seen in 13/25 init. AITTs. N & GTT showed GH levels >7 ng/ml in 5/ll & 8/21, resp. Two pts. had normal GH levels on Nor GTT, but did not achieve adequate responses on AITT. Responses were persistently low in 5/20 subs. AITT; 2 of these 5, who underwent GTT or!', showed normal GH levels; 4 of these 5 had normal follow-up growth, & 1, w;.ose environment did not change, did not grow on GH therapy. There was no correlation between init. peak GH response & ht. ar:e (HA), wt. age (WA), or HA/WA. F response to ITT was >17µg/dl in 19/20 tests. T4,TSH, & 3TRH tests were normal. On the basis of subs. It has been proposed that the prevalence of mitral valve prolapse (MVP) is significantly increased in adults with hyperthyroidism (N Engl J Med 305:497, 1981) . To test this association in a pediatric population, we studied 20 patients (15 F, 5 Maged 8-20 yrs) treated for hyperthyroidism. At onset T4 was 21 ± 2 µg/dl and T3 480 ± 39 ng/dl; at the time of study T3 was 202 ± 15 ng/dl. Each patient had M-mode echocardiograms (ECHO) obtained and interpreted by two independent observers one of whom was unaware of the patients' condition. Auscultation was performed by a Cardiologist unaware of the ECHO findings. Only one child with Marfan's syndrome had clinical features of mitral valve disease, while another had a non-specific apical systolic murmur. ECHO findings in patients were compared to those of 53 age-and sexmatched controls. Using our published criteria, none of the controls had MVP although two (5%) had some ECHO features suggestive of MVP. In contrast, among the 20 patients, two had definite MVP (10%). An additional two (10%) had ECHO features suggestive of MVP. Thus, the overall prevalence of positive or suggestive ECHO findings was 20% (p < .05). There was no correlation between clinical or biochemical indices of thyrotoxicosis and presence of MVP. These results suggest the need for further study of larger numbers of hyperthyroid children to validate our findings. Further, this association may represent a spectrum with prevalence increasing over time necessitatinq longitudinal evaluation. OOLE OF C' AMP rn ANGiarENSIN MEDIATED AC'lll SfX:RETIOO 397 D.O.Sobel.Dept of Internal .Medicine an<.1 Pediatrics,National Naval Medical Center,Uniformed Services University, Bethesda, Maryland 20814 We recently dE!!!Dnstrated that angiotensin II(AII)directly stllnulates in vitro ACTH secretion in rat pituitary cells.To investigate the role of cyclic AMP as a ITEdiator of AII stimulated ACTH secretion,we studied !)the generation of extracellulag and intracellular C'.l\MP induced by AII(lOnM)& 2)the effect of Br C'AMP,and two phosphodiesterase inhibitors,isobutyl-3-methylxanthine(IBMX) and caffeine on AI! ITEdiated ACTH release.Minced anterior rat pituitaries were dispersed in trypsin/DNAase solution and placed in rronolayer cell culture.After 3 days.test ITEdia was incubated 3.5 hours and then stored for ACTH measurement RIA.AII(lOnM)stimulated a 150-180% increase of ACTH(l.3ng/3xl0 cells/3.5hours).AII (lOnM)did not stimulate an ijjcrease of intracellular or extracellular C'l\MP.IIlMX(0.25-2.5rrM), Br C'AMP(O.l-2rrM)and caffeine(5-50rrM) each stimulated dose dependently.AII+IeMX(50µM a non stimula-B?ry dose) stimulated a 170% increase of net ACTH over AI! alone. Br C' N-11' (2and20nM) Four hypopituitary patients were treated with hGH and thyroxine for 3 to 5 years. ACTH (ACTHAR gel 0.05mg/kg) was added for 6 months of each year. Growth rates were calculated as cm/year. In 9 of 14 comparisons, the rate was greater in the inunediately adjacent ACTH period. in 3 it was less and in 2 the rate with ACTH treatment was the same as without ACTH. These findings are significant by the Sign test (p< 0.019). The explanation for these results remains unclear because we previously found that hGH depressed endogenous ACTH secretion (Sobel, E.H. and B. Zumoff. Interactive effects of ACTH and growth hormone on adrenocortical hormone secretion. Ped. Res. 1..2.:514,1981) . The data, however, show that ACTH augments growth response to hGH in hypopituitarism. We have used the primate as an animal model to study the pubertal process and male sexual development. We report here cross-sectional and lonqitudinal studies characterizing chanqes in 24 h secretory patterns of LH and FSH in monkeys (Macaca mulatta and fascicularis) from 9 days of aqe through adult life. Monkeys (N=46) were fitted with a vest and mobile tether permitting chronic cannulation. Blood was drawn at 15 min intervals over 24 hours without anesthesia. LH, FSH and testosterone were measured by radi oimmunoassay. Pul sati le secretion of LH anc1 FSH occurred as: 1) micro-pulses, havinq amplitudes< 2 times over baseline; 2) macro-pulses where the increase ) 2 fold over baseline. Throughout, FSH secretion occurred mostly as a steady state undulatinq pattern with occasional micro-and macro-pulses at all aqes. On the other hand, the largest LH pulses (up to 15 times, from a baseline of< 0.9 to a maximum of> 15 of approximately 2 hours duration) occurred in the prepubertal animal and LH micro-pulses at all aqes. larqe testosterone macro-pulses occurred in the early postnatal period, late puberty and adult life. Gonadotropin secretory patterns associated with normal sexual development was hiqhly individual; uniformly the amplitude and frequency variec1. Jn this larqe series of animals, these data indicate that changes in frequency and amplitude of qonadotropin pulsatile secretion correlate with testicular maturation. Hypoxia is a potent stimulus to release of VP. We have shown up to 10% of plasma VP is cleared by the fetal kidney and excreted in urine. We propose that AF-VP may be a marker of fetal hypoxia in the fetal lamb. AF and plasma samples were obtained from 15 chronically catheterized fetal lambs (116 to 141 d gestation) (1) during steady state conditions (control), (2) following exposure of the ewe to 10% FI02 or partial umbilical cord occlusion x 30 min. (hypoxia), and (3) after exogenous VP infusion into AF. VP was reliably extracted from AF in acetone with an 80 ± 4% recovery. VP measured by RIA of AF has an interassay variability of 8% at 4 pg/ml and 10% at 25 pg/ml. Parallel biologic activity of AF VP was confirmed by bioassay. (1) In control state plasma VP (1.8 ± 1.4 pg/ml) did not correlate with AF-VP (1.7 ± 1.4, range 0.5 to 7.5 pg/ml) or change with gestational maturation. (2) With hypoxia (P02 25.5 ± 1.4 to 11.8 ± 1.6 mmllg) fetal plasma VP rose to 242 ± 266 pg/ml at 30 min. returning to control by l hr. Maternal levels did not change. AF-VP rose to 22 ± 20.4 pg/ml by 2 hrs. and remained significantly elevated (p<0.01) for at least 24 hours. Plasma VP following hypoxia was positively correlated with AF-VP at 24 hrs. (r = .87, p<.001). The actual iCa is influenced by momentary pH changes, which may be irrelevant for the calcium problem under study, but the standardized iCa at pH 7.4 can be misleading if the patient suffers from a persistent pH change. An instrument that measures both actual pH and iCa and calculates a standardized iCa at pH 7.4 will therefore be ideal. We report our experience with such an instrument, the ICAI Radiometer's Ionized Calcium Analyzer. The concentration of iCa was measured both in the whole blood and serum of 20 neonates. Specimens were collected at the same time and the determinations of blood and serum were done within 5 minutes. iCa nvnol/L pH iCa at pH 7.4 mmol/L Blood 1.29+1. Both showed features of PBS, chronic renal failure and had intra-abdominal testes. AA was S 10/12 old, his height was 35'', weight 29 lbs and BP 94/58. The serum electrolytes were normal. Serum testosterone rose to 1.8 ng/ml after HCG injections. The basal serum LH, FSH and the LH response to LHRH was similar to that in a 4 year old control subject with undescended testes but the FSH response was much less (9.7 vs 25.3 (peak), 7.5 vs 21.55 (mean)). The patient TS was evaluated twice; in January 1979 (15 11/12 age) and in January 1981 (17 11/ 12 age). Left orchiectomy was done in Aug., 1979. His maternal cousin suffered from PBS: In 1979 his height was 56 1/2'', weight 69 lbs and BP 120/90 and no sign of sexual maturation. In 1981 his height was 60'', weight 94 1/4 lbs, pubic hair stage IV, axillary hair +. but no facial hair. His bone age was 14 years. Basal, peak and mean LH/FSH values (mIU/ml) after LHRH in 1979 were 22.1/19.3, 104/32.1, 86.5/28.7 respectively and the corresponding values in 1981 (after orchiectomy) were 32/138, 313/299, 164.6/ 191 respectively. CONCLUSION: In PBS the impairment in FSH regulation is more pronounced and is seen at an early age. The LH response in 1979 was similar to that of castrate subjects, but the FSH was normal. In 1981 the more marked rise in FSH than in LH suggests greater limitation of inhibin than testosterone production by the remaining testes. ( 2) 2.9-16.6 -11.7-Control Group (10) 3.6+0.32 13.1 +1.7 9.7±1.0 Exaggerated TSH response was observed in primary hypothyroidism, regardless of duration or baseline TSH level, and in one neonate with TRH deficiency. In four of these children T4 was normal & in two baseline TSH was minimally elevated. Suppressed TSH re- The importance of Mg in PTH and CT homeostasis in infancy is unclear. Magnesium deficiency theoretically may be associated with decreased secretion of PTH. We evaluated 6 infants with hypomagnesemi a (HM), serum Mg 1.18±0. 06 mg/dl (mean± SE) and 4 with normomagnesemia (NM), following infusion of 6 mg/kg of elemental Mg over one hr. In HM infants, mean serum Mg rose to 2.25±0.1 mg/dl with Mg infusion; mean serum PTH was 42±11µ1-Eq/ ml (RIA 1-84 PTH, Ni 57) initially and rose to 77±15, 82± 19, 66±18, 60±27 and 41±14 µl-Eq/ml at 1,2, 4,6,12 and 24 hrs vs 45±24, 44±19, 40±14, 41±19, 27±4 and 42±14 µl Eq/ml in NM infants. By analysis of covariance there was a significant difference between the groups, p < 0.01. Serum CT was 50±17, 54±19, 31±15 and 31±19 (RIA, N < 107 pg/ml) at 0,1,2, and 6 hrs with Mg infusion in HM infants and 221±36, 243±56, 226±38 and 231±40 pg/ ml in NM infants (HM lower than NM, p<.0001, no changes with infusion). Thus 1) in hypomagnesemic infants, serum calcitonin is low and does not significantly respond to Mg infusion, 2) serum PTH rises with Mg infusion in hypomagnesemic infants, 3) PTH response with Mg infusion was significantly greater in hypomagnesemic vs normomagnesemic infants. Thus serum Mg appears to play a significant role in neonatal parathyroid hormone homeostasis, supporting the thesis that infantile hypomagnesemia results in hypoparathyroidism. While receptors for 1,25-(0H)2 vit Dare known to exist in parathyroid glands and PTH is a known stimulus for l,25-(0H)2 vit D production, it is unclear whether this metabolite has feed-back control on PTH secretion, and especially without concommitant elevation of serum Ca. We evaluated 8 infants who were given calcitriol {1,25-(0H)2 vit D) within the first 12 hrs, at 24 to 36 hrs and at 48 to 60 hrs of age as prophylaxis for neonatal hypoca lcemi a. Gestational age was 30. 6±1.1 wks (mean±SE) and birth wt 1188±178 gms. Doses studied were 0.1, 0.3, 0.5 and 0.75 mcg/kg/dose given intramuscularly; the "physiologic" dose of the vitamin is approximately 0.05 mcg/kg/ day. Serum Ca and PTH levels were evaluated through the first 5 days of life. Serum Ca was 7.67±0.46 mg/dl prior to calcitriol injection and 6.8±0.22, 8.5±0.45, 7.2±2.0 mg/dl at 24 to 36 hrs of age, 48 to 60 hrs of age and at 24 hrs after the last injection of calcitriol. The corresponding serum PTH (radioimmunoassay, 1-84 PTH, N < 57) concentrations were 21±4, 19±3, 20±3.5, and 22±1 There was no significant change in serum Ca and PTH over the first 5 days. By analysis of variance, there was no significant dose related difference in the Ca or PTH response elicited. Thus in preterm neonates, administration of relatively high doses of l,25-{0H)2 vitamin D does not suppress parathyroid hormone secretion. In a model of maternal lipemia (L) in the rat, mimicking the conditions occurring in poorly controlled maternal diabetes (DB), we investigated whether glycerol (Ge) metabolism or the levels of its intermediary metabolites were altered in fetal liver and brain. L was induced in pregnant rats by feedings of a high-fat (45%) diet during the second half of gestation. Controls (C) were fed a co111T1ercial ration (4.5% fat). Serum triglycerides were elevatei in L dams ind fetuses. 3-HO-butyrate was higher in L pups (303 -45 vs 179 -22)JM, P< 0.05). Fetuses were studied one day before term. Liver dihydroxyacetone phosphate (DHAP) was highe+ in L than in C fetuses (means ± SEM: 0.86 ± 0.03, n=26, vs 0.64 -0.03, n=26, nmoles/g tissue, P< 0.001). The ratio of GcP0 4 to DHAP in liver was lower in L fetuses (3.87 ± 0.17 vs 4.55 ± 0.28, P< 0.05). However, there were no changes in hepatic Ge kinase, GcP04 dehydrogenase and GcP04 oxidase. Ge metabolism enzymes were also unaltered in brain. These data indicate that in gestational L, fetuses are exposed to a more reduced redox potential environment than in normal conditions. This may contribute to alterations of glucose utilization and be an additional deleterious factor in the intrauterine development of fetuses of DB individuals (Supported in part by NIH grant SOB RR-09128-03). The role of thyroid status on ventricular growth and a-AR's was determined in rat pups rendered 1) Hypothyroid with propylthiouracil {PTU), 2) Euthyroid with PTU and thyroxine (T4), 3) Hyperthyroid with T4 or 4) Control, sham saline injections. Myocardial weight, protein and DNA i.ere similar in Euthyroid and normal rats at postnatal days 5, 15 and 28. Growth in Hypo pups was normal until postnatal day 14 after which heart i.eight and protein content i.ere significantly decreased {p< .01). Ventricular DNA content was not decreased in Hypo rats, thus postnatal hypertrophic but not hyperplastic ventricular growth, is dependent on thyroid honoone. The nuirber of a-AR' s was decreased in Hypo myocardium at all ages studied, e.g. on day 5 of the (-)-[3H]DHA binding (Bmax) was 37±g in Hypo compared to 63±8 froole per mg protein m± S.D. in Euth myocardium, p<.01. The function of the B-AR's was also decreased in Hypo as compared to Euth as demonstrated by a decrease in catecholamine sensitive adenylate cyclase, p<.01. Treatment of Hypo or control pups with T4 (Hyperthyroid) resulted in an increase in heart size, and a-adrenergic receptors. a-AR's are decreased in ventricles from Hypothyroid rats at all ages studied and the decreased production of c-AMP in response to (-)-epinephrine may relate to the decreased nurrbers of a-adrenergi c receptors present on the sarco l emna l membrane. We speculate that thyroid honoone is an important regulator of both myocardial hypertrophic growth and B-adrenergic receptors during development. Free thyroxine levels (FT4) were determined by radioimmunoassay in 96 infants from our Intensive Care Nursery (ICN) and in 32 healthy term infants. Sera for FT4 levels were obtained simultaneously with filter paper specimens for total T4. The mean FT4 level in infants from the ICN was 3.48 • 0.18 (SE) ng/dl and in the healthy term infants was 4.24 i 0.23 ng/dl. FT4 levels from both groups of infants were significantly higher than levels found in normal adults (1.38 i 0.03 ng/dl, p < 0.001). A correlation was noted between FT4 and T4 levels (r=0.52). Like T4, FT4 correlated with increasing gestational age (r=0.60) and birth weight (r=0.59) and was lower in infants with RDS (p < 0.001). Although 66% of the ICN infants had total T4 levels below the statistically selected screening level (5th percentile), these infants all had FT4 levels > 0.8 ng/dl. All of these infants had normal TSH levels and were judged clinically euthyroid. Two additional infants with untreated congenital hypothyroidism had FT4 levels of 0.3 and 0.4 ng/dl. The high incidence of hypothyrox- Wolfsdorf, Abdallah Sadeghi-Nejad, and Boris Senior. fufts University School of Medicine, New England Medical Center, 3oston. ternative fuel for the brain, spare glucose. Because utilization )f ketones relates directly to their concentration, children with the highest concentrations of ketones use the most and by being 110st dependent on ketones for fuel would be most prone to develop hypoglycemia were ketones in short supply. We examined whether fasting hypoglycemia of growth hormone deficiency could be ascribed to a shortage of ketones. We studied 45 normal and 17 growth hormone deficient children. In both groups fasting concentrations of ketones varied over a 20-fold range and correlated inversely with both the glucose levels and with the ages of the subjects. KETONES vs. GLUCOSE r P KETONES vs. AGE r P CONTROLS y=6.47-1.16x -0.63 < 0.001 y=3.9-0.22x -0.83 <0.001 Adjusted for glucose levels and age, by analysis of covariance, the concentrations of ketones in the growth hormone deficient patients were significantly lower than in the control children, P40.0l. Only the five youngest growth hormone deficient patients became hypoglycemic. These were precisely the patients with the greatest degree of relative hypoketonemia. Cartilage of rats with growth retardation due to neonatal headirradiation (X) has paradoxically increased protein and collagen synthesis. Females exhibit greater growth recovery than males. We have tested whether cartilage metabolism reflects this sex difference. Incorporation of 35 s-sulfate (S), 3 H-thymidine (T), 14 C-leucine (L) and 3 H-proline (P) by cartilage of irradiated rats were determined with and without su1ierimposed fasting (F) and during a subsequent recovery period. The groups were non Xnon F; non X-F; X-non F; and X-F. 600 rads were given to the head only at 2 days of age; all non X rats 'were sham-X littermates. Fasting was for 2 days from 40 days of age. At 70 days of age cartilages from each rat were divided among media containing the labeled substrates. In males, X had greater L incorporation than non X (p<0.05); however, in females X had both significantly increased L (p<0.025) and P (p<0.05) incorporation than non X. In addition, in females and not in males, X-F showed increased L (p<0.05) and P (p<0.025) incorporation than non X-F. Neither sex had a difference between non X and non X·F or between X and X-F. correlates with greater growth recovery. In both sexes this was independent of the catch-up growth from fasting; thus, a different growth mechauism iS inv()lved in the slow growth recovery after brain injury than is in catch-up growth after F. Radiological Sciences, Irvine, California. X-irradiation (X) of the head of the neonatal rat results in a dose related growth retardation which is resistant to growth hormone and/or thyroxine. In order to determine whether the stunting results from damage of catch-up growth controls we have observed growth during recovery after fasting (F) in X rats and ,.ham-X littermate controls. 36 males and 35 female rats were distributed among non X -non F, non X -F, X -non F, and X -F. 600 rads X-irradiation was given to the head only at 2 days of age. Fasting lasted for 2 days from 40 days of age. Head irradiation per se resulted in a highly significantly lower body weight (p<0.0005) and tail length (p<0.025). At the end of the fast there was a highly significant added reduction of body weight in both sexes in X (p<0.0025) as well as in non X (p<0.0005). At 70 days of age, however, X-F and non X-F of both sexes did not differ from their respective controls with respect to body weight, tail or tibial length. We conclude that although X creates a permanent growth deficit, the catch-up control continues to operate after F. Growth stunting after diffuse head irradiation thus results in a new setting for body size wldch in Blood lead (PbB) itself is a relatively unstable index of lead exposure. An increase in red cell cytidine phosphates (rbc CP) occurs with excess lead exposure during erythrocyte maturation and thus provides evidence of cumulative lead exposure over the antecedant three months. Pyrimidine-5'-nucleotidase (Py5N) is an enzyme of the red cell and reticulocyte cytosol that dephosphorylates UMP and CMP and permits their diffusion from the cell. Rbc Py5N activity is directly and rapidly inhibited by increases in the PbB. Although rbc Py5N fluctuates with PbB, rbc CP remains elevated. Stability of rbc CP was shown in four children, 2-5 years old, with PbB of 58.3 ± 3.8 ug/dl. Chelation with I.M. CaEDTA 50mg/kg/d x 4 rapidly reduced PbB to 28.5 .t 1.5 ug/dl. Py5N was restored from < 40 units/g hemoglobin to normal values of above 100 u/g. Rbc CP remained elevated at 10-50 nmoles/1010 rbc. Persistence of rbc CP despite correction of Py5N suggests that Py5N has limited function in the mature rbc. Fluorescent erythrocyte protoporphyrins (FEP) are also cumulative during rbc maturation in the presence of increased PbB and reflect the inhibition of heme synthesis. Although rbc CP and FEP result from two distinct modes of toxicity of Pb for the developing rbc, both can be used as indices of cumulative exposure to lead. The effects on birth-weight (BW) of gestational age (GA), fetal sex, maternal anthropometric measurements, sociodemographic characteristics, and smoking were studied in a stratified random sample of 1501 singleton pregnancies delivered in Hamilton hospitals over an 18-month period. Information was collected prospectively by maternal hospital chart review, maternal postpartum interview and anthropometric assessment, and newborn examination. Mean BW among singletons was 3316 g. At 40 weeks GA, the 50th percentile BW was 3540 g for males and 3350 g for females. After controlling for GA and fetal sex, the following maternal variables were positively correlated with BW: prepregnant weight, weight gain in pregnancy, stature, bicristal diameter, biacromial diameter, calf circumference, upper arm circumference, triceps skinfold, upper arm muscle area, and subscapular skinfold. Stepwise multiple linear regression, controlling for GA and sex, showed that the most important predictors of BW were: for primigravidas, weight gain in pregnancy, pre-pregnant weight and number of cigarettes smoked daily during pregnancy; for multigravidas, birth-weight of the last sibling. number of cigarettes smoked daily, weight gain during pregnancy, and prepregnant weight. Smoking during pregnancy reduced birthweight by 13. 3 g per cigarette smoked daily. Women who smoked before pregnancy but not during pregnancy delivered inf ants of BW's similar to infants of non-smokers. The present study was to evaluate the effect of total body bathing with 4% Hibiclens (chlorhexidine gluconate) on the rate and extent of neonatal bacterial colonization. Full-term newborn infants were randomly assigned to receive either bathing with HIB or a control solution (castile soap}. Blood samples were obtained on days 1, 2, and 3 of life and analyzed by GC for chlorhexidine. Cultures of the anterior nares and umbilical area were obtained on days 1, 2, 3 and 14 and analyzed bacteriologically. A total of 38 infants (19 in each group) have been studied to date. During the first three days of life HIB had little effect on the bacterial colonization of the anterior nares but resulted in marked protection against colonization of the umbilical region. Eighteen of 19 infants had no bacterial growth by the third day of life. By day 14 colonization of HIB infants was indistinguishable from those washed with castile soap except for a slight increase in colonization by gram-negative bacteria. No percutaneous absorption of chlorhexidine was observed during the first three days of life. In addition, washing with HIB resulted in no increase in adverse clinical reactions when compared with castile soap. Thus perinatal infant bathing with 4% chlorhexidine gluconate is effective in preventing colonization with bacterial pathogens. During years of study in Washington, D.C., hospitalization of children for rotavirus gastroenteritis tended to be more common following a month of cold or dry weather than following a corresponding calendar month of warm or wet weather. Overall, there were 84% more (178 vs 97) inpatients with rotavirus following a set of relatively colder individual months taken as a group than following an equal number of warmer corresponding calendar months taken as a group. Comparable differences were not seen with non-rotavirus gastroenteritis patients. There also were 45% more rotavirus hospitalizations following a set of months with the least depth of precipitation as compared to a set of corresponding calendar months with the greatest depth of precipitation. Rotavirus infection in young infants, the children least likely to be directly exposed to outdoor conditions, showed some of the most marked weather-associated effects. These findings suggest that weather-related low indoor relative humidity and indoor crowding may be key factors in the epidemiology of rotavirus disease. Cases of extrahepatic biliary atresia have generally been observed to occur sporadically. We compared the incidence of extrahepatic biliary atresia in Utah and Idaho to U.S. incidence andevaluated cases for time-space clustering. Cases from 1974-1981 in Utah and Idaho were ascertained by contact with all pediatricians and pediatric surgeons in the two states as well as pediatric surgeons and gastroenterologists in Denver, Seattle, and Portland; the closest referral centers outside the two states. Death certificates were also reviewed in the two states for the past 10 years to assure complete ascertainment. Diagnosis was confirmed by surgical exploration or autopsy in most cases. Expected cases were calculated from the U.S. mortality rate for biliary atresia in 1975 (5/100,000 births). Relative rates were calculated as observed to expected ratios for each time period and geographic area. The incidence of biliary atresia in Idaho was double that in Utah. Cases were found to cluster in eastern Idaho with a 3-4 fold increase over that expected from national rates (p<.01). In both states the majority of cases for the 8 year period occurred in the past three years. Our data suggests that time-space clustering of biliary atresia occurs. This suggests that environmental factors may play a role in the etiology of biliary atresia, but changing diagnostic practices must also be considered. Cohen and.!:!· William Taeusch, Harvard Medical School, Dept. Pediatrics, Boston. Studies of approaches to decreasing the risk of BPD have been hampered by failure to define prospectively a high risk population. Therefore, we tried to design a screening test that could be easily applied early in the hospital course that would predict which inf ants would develop BPD. From a population of inf ants -t;l2c;Og, who were alive at 48h, we selected those who had received ventilator support (IMV) within 48h after birth. From this group we selected those receiving IMV for and F 1 o 2 L .6 for 2h/48h. If these criteria were met, the screen was positive. BPD was defined as F 1 o 2 Two major trends affected the BW distribution of neonatal survivors in opposite directions in recent years: a decline in low weight(LBW) was attributed to primary prevention (such as the WIC nutrition and prenatal care program) while increased survival rate among LBW infants was attributed to NICUs. We calculated the impact on expected CP rates of these two trends, using three data sources: (1) two studies, each of which provided BW jata on all CP cases in a geographic population; (2) computerized vital records from North Carolina for 1968-77; and (3) BW and nortality data from the Massachusetts WIC Evaluation Project. We first quantitated the relationship between BW and CP risk(Rcp) Jsing data sources 1 and 2: Rep rose exponentially with decreasing 3W using data from either of the CP studies (Rcp=83e-l.01BW, r=-. 93, and RcP=239el. 43BW, r=-. 97). We then applied the derived regression equations to the observed changes in BW-specific survival data (data source 2), using 500g BW categories. illy fewer total births and fewer survivors occurred in most categories below 3500g in 1977 compared to 1g68, resulting in a predicted fall in CP rates of about 6%. Applying the same inalysis to WIC program data (source 3), we found a calculated jecline in CP rate of about 4%. These results indicate that re-:ent advantageous shifts in population BW distribution such as ioted with improved nutrition and prenatal care have more than :ompensated for the increased LBW survival attributed to NICUs in their impact on predicted CP rates. >symptomatic HBsAg carriage, and very rarely fatal fulminant hep-1titis B. Maternal seropositivity for HB 5 Ag and HBeAg is associited wltl1 increased risk of HBV transmission from mother to infant. We report four unrelated infants to 16 weeks of age Nho died of fulrninant acute hepatitis B. In each instance the lsymptomatic mother was found retrospectively to be seropositive for HBsAg. One mother was found to have chronic active hepatitis Two mothers were U.S. immigrants from areas of high HBsAg eniemici ty. Since recent trials have demonstrated the efficacy of lepatitis B immunoglobulin (HBIG) in reducing the rate of infan-:ile HBV acquisition, these fatalities likely were preventable. rhe potential value of hepatitis B vaccine in prevention of vertical transmission of HBV is being explored. These four infant leaths dramatize the importance of screening pregnant women for iBsAg, particularly those from populations at increased risk of iB 5 Ag carriage: Orientals, medical personnel, drug addicts, )rostitutes, and those with history of hepatitis. Such prenatal lBsAg screening, with HBIG and/or hepatitis B vaccine immunopro-)hylaxis for infants at risk, will reduce the incidence of infan-:ile HBV infection, with its potentially fatal outcome. Table I To describe the contents of the middle ear in chronic otitis media (OM), a population of 898 children less than 12 years of age having chronic OM of at least three months duration was studied at the time of myringotomy for tympanostomy tube placement. Mucoid effusion, which was found in 48% of the 1,796 operated ears, occurred more often in younger than in older patients, and was bilateral more often than was serous or purulent effusion. Serous effusion was found in 10% of operated ears and occurred more often in older than in younger patients. Purulent effusion was found in 7% of operated ears and was equally distributed by patient age. No effusion was found in 36% of operated ears. Mucoid effusion was the most stable chronic OM state among 117 patients that had repeat surgery an average of 13 months after initial surgery. Preoperative otoscopy showed subtle differences between effusion-free and effusion-containing ears, but did not distinguish among effusion types. Known middle ear bacterial pathogens were cultured from 23% of effusion samples, other bacteria were cultured from 7% of samples, and 17% of the sterile effusions showed bacteria on gram-stain. Effusions which cultured bacterial pathogens contained more phagocytic cells than sterile effusions. Thus, chronic OM is characterized by mucoid, serous and purulent effusion or by absence of effusion. Respiratory bacteria may contribute to the pathogenesis of chronic OM. These observations provide a descriptive base for further investigation of chronic OM. as etiologic determinants in OME. The study waS""PerfOrmed i; -;-research day care center. Children had nasopharyngeal cultures for viruses and bacteria at the onset of each illness and every two weeks routinely. The incidence of OME was increased significantly (p<.0001) in the two weeks following infections with respiratory syncytial virus(RSV;33.3%), adenoviruses(AV;28.2%), influenza viruses(Inf A and B;27.9%), oarainfluenza and viruses (15.5%), and enteroviruses(l6.0%), in comparison to the OME incidence when viral infections were not identified(6.6% per 2 weeks). Colonization of the nasopharynx with Str . .!!!!.· and R· inf. had smaller but significant effects on OME incidence(relative risk for OME: 2.!.!:.· .!!!!.• 1.35; !!_. inf. 1.76). Primary acquisition of Str • .!!!!.· serotyPes was not identified as an OME orecipitant. Prevention of OME cases attributable to these bacteria would have reduced OME incidence aoproximately 25%. Early and repeated infections with the closely OME-linked viruses were correlated with more freQuent OME; no parameter of bacterial colonization was identified as a correlate of OME frequency. The data identify microbiologic parameters which deserve consideration in future design of preventive intervention programs. Research in community paediatrics frequently requires an objective assessment of socio-economic status. Traditional methods e,g. the Registrar General's classification in the United Kingdom, are not always applicable in developing countries. The Child Development Study required such an assessment. In the study a cohort of 1000 consecutive live births was identified and a rand0m sample of 187 selected for follow-up over a 5 year period. A socio-economic index was developed for the sample comprising 5 items viz 1) marital status, 2) family cohesiveness and child orientation, 3) available income expressed as a percentage of a household subsistence level, 4) the degree of crowding measured by an occupancy ratio and 5) the presence of social pathology e.g. alcohol abuse. Item analysis was applied. On the basis of the reliability indices, the items were weighted to give a total score out of 14. The theoretical hypothesis that socio-economic status would influence growth and development was used to evaluate the validity of the index. (1-141.l . The common !(roun was B, but in July 1% were Groun C, in Oct 21', and in Dec 7%. C increased to 27% in March 1981 and has been the common groun since. In Nov 63/103 infants in 1 nursery carried C (umb) at discharge: 3 carried B; no staff throat cultures (T) yielded C. C colonization rate of infant umb varied from oj( to lOOj(/day. Infants who became colonized hasociated with family size. Only 8. 5% of the study children had Mean blood lead levels of 10,065 Columbus, Ohio, preschool 1ildren were evaluated from 1975 through 1979 to determine the )tential relationship to ambient air lead levels, race, and age. JWnward trends in the blood lead levels sampled as well as in nbient air lead levels were apparent in the study period. In •neral, blood lead levels sampled in 1979 were significantly )Wer than four years previously. Absolute values for blackchilden fell more during this period than they did for white child-'"· Age related values for both races followed a virtually idenical pattern. When the three independent variables, race, age, nd ambient air lead levels were employed in a regression analyis, ambient air lead proved to be the best predictor of blood ead. Apparently, the regulation of lead in the air is associated ith lower lead levels in preschool children. arly introduction of solid foods may influence early weight ain regardless of breast or formula feeding. Preliminary findngs from our investigation on the effects of maternalnutrition-1 and environmental factors on infant growth and development ndicate that consideration of precise infant feeding groups is ecessary to determine iron status differences -infants excluively breast or formula fed were found to have higher serum ron levels than infants who were not. We emphasize that the 1ost important criterion is that of 11 Alaskan Eskimos have the highest known incidence of invasive HIB disease, with 3% of Eskimo infants developing bacteremia or meningitis before l yr. of age. To evaluate measures which might prevent disease in infancy, we studied the influence of BF by assessing nutritional histories in a matched case-control study. We also measured levels of HIB anticapsular antibody in breast milk (BM) and sera of Eskimo mothers. Infants with invasive disease (N=l9) and 2 controls for each case, matched for age (susceptibility) and village or neighborhood (exposure), were studied. A history for BF was considered positive if the subject was predominantly BF until an age equal to that of the case at the time of hospitalization. BF was significantly less prevalent among cases 1/19 than controls (18/38) (p<.Ol, Pike-Morrow). HIB anticapsular antibody (Ab) was measured in breast milk specimens and sera from 10 Eskimo mothers 2-6 months postpartum by RIA and ELISA. Ab in BM was predominantly IgA (ELISA: IgA 67%, IgM 33%, IgG 0%) and total levels ranged from 10-390 ng/ml (RIA mean 95 ng/ml). These levels were similar to controls from elsewhere in the U.S. Antibody in maternal sera was predominantly IgM (ELISA: IgM 72%, IgG 21%, IgA 7%) and total levels ranged from 2.0-6.4 µg/ml (RIA mean 3.4 µg/ml). There was no correlation between levels in BM and sera. Breast feeding appears to reduce the risk of developing invasive HIB disease, but the mechanism needs further clarification. Wat.er A single measurement of blood nutrient levels & other characteristics at midpregnoncy in 539 women, 215 having uncomplicated pregnancies, was used to develop on equation to predict birth weight. The equation could account for 64% of the variance in birth weight, allowing for gestational age & sex of the baby. The correlation between observed and predicted birth weight for the 215 babies was r=0.74. In a field trial, a screening equation involving only demographic/clinical variables derived from 129n mother/baby pairs was used at midpregnoncy for preliminary stratification of mothers likely to hove babies in the lower or upper thirds of a birth weight frequency distribution. Measurements of blood levels of those nutrients & leukocyte biooctivities at midpregnoncy comprisinq the prediction equation were added to further narrow the identification of mothers likely to hove fetolly malnourished or Jorge babies. Two thirds of the mothers in each of these selected groups were randomly assigned a food supplement. The remaining third were controls. To dote, data hove been analyzed for 245 initially screened mothers. For the selected test mothers, correlation between observed & predicted birth weights was r=.68. Thus prediction is both feasible & practical but the number of babies born to mothers whose fetus was thought to be nutritionally disadvantaged is still too small to evaluate the effect of a selective nutritional intervention on fetal growth. S. viridans has been thought to be nonpathop,enic in the neonate although it has been widely accepted as pathogenic in SBE and other conditions. During a 30 month period in the NICU, we have identified 18 infants with septicemia S. viridans as the causative organism. During this period it was the most common etiologic agent in neonatal sepsis. Mean birthweight of the infants was 2990 g (range 900-4500g): mean gestational age was 39 weeks (range 28-42 weeks). 5 of the infants were premature and 6 were low birthweight. There was prolonged rupture of the membranes (PROM) in 8/18 patients and 1 mother had fever prior to delivery. 5/18 infants developed respiratory distress: 3 of these were term. No infant with PROM developed respiratory distress. The majority of the infants presented within 24 hours of birth with signs of sepsis. All infants had blood and other cultures drawn prior to antibiotic therapy. Blood cultures were taken from a peripheral vessel. The blood was incubated in trypticase-soy broth at 37oc for 3 days. The organism was subcultured in SXT medium and after inoculation in Todd-Hewitt broth it was centrifuged and the supernatant was tested with specific alpha-hemolytic streptococcal antibody. The single mortality in the group was the smallest and most premature who also had findinp.s consistent with severe hyaline membrane disease. In the remainder there was a good correlation with the beginning of antibiotic therapy and clinical improvement. The findings sugp,est that S. viridans is pathogenic in the neonate. Acquired rronosaccharide intolerance (!\MI) is a fonn of chronic diarrhea which is relieved by fasting and is characterized by the recurrence of diarrhea after feeding any fonn of dietary carbohydrate including rronosaccharides. An epidemiological descriptive study of !\MI is being conducted at the Ben Taub General Hospital in Houston, TX. All patients 3 rronths of age or less with diarrhea woo visit the Pediatric Outpatient service or who are admitted to the hospital are seen and entered into the study. Infonnation concerning history of the diarrhea, feeding history, hare and family conditions, nutritional assessnent, collection of stool samples for viral and bacterial pathogens, and clinical course are obtained. The data at the present time do not implicate specific pathogens, feeding practices, rraternal health factors, and socioeconcmic conditions in the etiology of !\MI. Malnutrition is prevalent among all patients. These children fit the nonnal distribution for weight at birth. The nutritional deficit suffered by these infants by the time of admission (rrean age, 37 days) is evidenced by a reduction in the rrean weight/height, height/age, a!'d wei36 'lours. infants born to colonized mothers significantly increased. Only 18% of mothers whose infants had culture proven sepsis had nembrane rupture for >24 hours. This leads u.> to conclude that duration of MR among GBS (t> nothers does not increase the incidence of GBS colonization in infants and leads us to speculate that factors other than of exposure to the pathogen predispose to inf ant colonization. The incidence of NEC among 27,540 inborn infants at UTMB has fluctuated markedly from 1974 to 1981. Attack rates per 1000 births were 1.9, 6, 1.3, 1.4, 4.1, 2.1, 0.9, and 5.6 in '74, '75, '76, '77, '78, '79, '80 and '81 respectively. Three formulas were used on a rotation basis in the nursery. Attack rates calculated by formula years were as follows: Time 9/74-9/75-9/76-9/77-9/78-9/79-9/80- By X2 analysis, NEC incidence in Formula A years was significantly higher and in C years significantly lower than expected based on total population. When attack rates for each formula year were combined for the same formula, differences among formulas were even greater. Occurrence of NEC was higher than expected during Formula A years (p < 0.001) and lower than expected during Formula C years (p < 0.005). These retrospective data indicate year to year variability in incidence of NEC and a strong association with type of formula in use in the nursery at that time. Further investigation with changes in order of formula use will be required to confirm the association between use of a particular formula and incidence of NEC. Because nbella CCl'ltimi=s to be a ro!TITOn illness in ac'Dlescents and young adults and because it has been suggested that booster nbella imnunizaticos should be perfomed, we studied antibody prevalence in 459 prec'Dminantly ac'Dlescent patients. Of the total group 86.5% had antibody (PHA titer >1:13.5). RWella antibody in Cbcurrented previously inmuniz.ed patients (89.6% of 386) was significantly nore ro!TITOn than antibody in tninmunized patients and patients with a qusstionable history of inmunization (70.3% of 74) (p = <0.005). Of 33 seronegati'l.e patients that we inmuniz.ed all but 1 serooan'l.erted (HAI titer >1:8). Of 23 with a c'Dcurrented history of prior inmunization,-coly 1 had a specific IgM antibody response (determined by sucrose gradient separation and HAI antibody determination). In contrast 3 of 3 patients with a history of clinical rubella and 1 of 4 patients with a questionable history of past inmunization had a specific IgM antibody response. Since 89.6% of previously va=inated patients had derronstrable antibody and since 96% of tlnse without rreasurable antibody had a seoondary irrmune response following revaccination it seeirs likely that the le'l.el of protection in previous va=inees is ronsiderably greater than 90%. Because of this high degree of protection in vaccinated persons and the rarity of docurrented rubella vaccine failure, attention today should be directed at finding and imnunizing 1.mvaccinated teenagers and yomg adults and not in najor unnecessary booster va=ine prograrrs. Previous studies show progressive, age-related acquisition of antibodies to CT in children. The antecedent infection(s) causing seroconversion is unknown. Because of the observed association of CT with infantile pneumonia and conjunctivitis, we searched for the stimulus for this seropositivity among children with URI. From November 1980 to November 1981, 164 children older than 6 months who presented to the Oklahoma Children's Memorial Hospital outpatient clinics for URI were cultured for CT. Patients who had received antibiotics within the past 7 days were excluded. presentations included coryza, nasopharyngeal congestion, cough, and sore throat with or without fever. Nasopharyngeal specimens were collected with calcium alginate swabs, placed in transport media, and kept at 4oc for 1-8 hours prior to freezing at -7o 0 c, or prior to inoculation into cycloheximide-treated cells. Frozen specimens were inoculated, in most cases, within one week of collection. Eighty-eight females and 76 males were studied; 156 10 years. Twenty-one had otitis media 10 had conjunctivitis. Sixty-two patients had pharyngeal for group A streptococcus; 27 were positive. CT was not isolated from.any CT does not appear to be an important cause of URI in children. By Poisson distribution, a sample size of 156 97% chance of yielding at least 1 positive culture if the incidence of CT-URI were 1/30 and 67% chance if the incidence were 1/100. YE infection is well recognized worldwide but only infrequently described in the USA. Serotype 0:8 is, reportedly, the predominant US strain in contrast with 0:3 & 0:9 in Canada and Europe, respectively. Efforts to isolate YE in 3,000 stool specimens submitted to our laboratory during the past year have been unrewarding. We tested the sera of 643 children, ages 1-15 yrs., for antibodies against YE 0:3, 0:8, & 0:9 -the serotypes commonly responsible for human yersiniosis. Formalin-inactivated organisms, suspended in saline to McFarland #1 density, were used as antigens in a tube agglutination test. A reciprocal titer of 40 or higher was considered positive. Sixty-two (9.6%) of 643 were seropositive -42 (6.5%) to 0:3, 18 (2.8%) to 0:8 and 4 (0.6%) to 0:9. Two had titers against 2 serotypes. Titers ranged from 40 to 320. Antibodies to 0:3 were observed from infancy through adolescence with comparable frequency whereas antibodies to 0:8 and 0:9 were not seen before age 4 and 8 years.respectively. These sero-epidemiologic data suggest that, in Oklahoma: 1) YE infection may be more prevalent than reports indicate, 2) humoral antibody to serotype 0:3 is more corrmon than to 0:8, 3) subclinical or clinical experience with YE other than gastrointestinal infection, or with YE-related antigens, may be responsible for the observed seropositivity. Nontypable strains of Haemophilus influenzae were obtained from middle-ear exudates of children with otitis media. Two strains (BCH-37567 and H-Pr) were shown to have different antigenic determinants of complement-mediated killing by immune rabbit sera. Rabbit antisera to these isolates contained bactericidal antibody in varying titer to additional strains of a small collection. Each of six otitis media isolates cross-reacted with one or both of the two test strains. Circulating antibody in humans may protect against middle-ear infections caused by these bacteria. Sera of healthy humans were assayed for bactericidal antibody directed against strains BCH-37567 and H-Pr. Specific absorption of human sera with bacterial cells showed human antibody to be directed against strain-specific surface determinants. The importance of IgM in the bactericidal reaction of human serum was indicated by failure of bactericidal antibody to cross the placental barrier in most cases and by the susceptibility of this antibody to reduction by 2-mercaptoethanol. The distribution of antibody by age was similar for the two strains. Antibody was not detectable in most cord sera or in those of young infants but had developed in most subjects by two years of age. Thus, prevalence of bactericidal antibody to each of the test strains was inversely correlated by age with the period of greatest susceptibility to otitis media. An unexpected decrease in infection rate in ICU neonates was investigated. We renorted that infection in our ICU occurs in 15-20% of infants with high titer abnormal bacterial colonization of the pharynx. 50-60% of those given antibiotics (during and/or after Rx) and 8% of those not so treated were abnormally colonized. Infection occurred rarely in infants with "normal" flora (•><-streptococci predominant) . Investigation of the decrease in infection rate in 1980 showed that (1) An outbreak of chickenpox, including three patients and one nurse on a pediatric ward, necessitated rapid identification of susceptible employees in conjunction with standard epidemiologic intervention in order to prevent spread to other high-risk patients. Fifteen of 46 hospital personnel (33%) gave a negative or unknown history of prior disease. Response to a varicellazoster (VZ) skin test was compared to antibody determination as measured by fluorescent antibody to membrane antigen (FAMA). Correlation of these two screening methods was absolute. Four of 46 hospital personnel (9%) were susceptible to infection (negative skin test and antibody < 1:4) requiring their removal from the ward. All with positive histories for prior disease with the virus and 11 of 15 (73%) with negative or unknown histories were iDIDune as indicated by both tests. A readily available VZ skin test would be an extremely useful epidemiologic tool for screening hospital personnel. SUDDEN INFANT DEATH (SIDS): ASSOCIATION WITH DPT IMMU· "5" NIZATION. \.Im. C. Torch (sponsor, Burton A. Dudding), U of Nevada, School of Medicine, Dept. Pediatrics, Reno Because of recent reports of DPT-associated SIDS and fami 1 iari· ty with 5 cases of sudden death in 4 infants and a 3 yr. old, 3.5 to 20 hr after vaccination, the immunization, clinical and autops• records of 70 of over 200 SIDS cases reported in Nevada and surrounding States in the past 5 years were analyzed. 48 infants had received one or more DPT immunizations prior to death (DPT-SIDS); 22 had received none (n-DPT-SIDS). Mean age of DPT-SIDS at death was 4.5 mo; of n-DPT-SIDS, 2.3 mo. Age-frequency analysis at deatl showed a single peak at 2 mo.of age in then-DPT-SIDS group, and< biphasic peak at 2 and 4 mo. in the DPT-SIDS group. Thedistribution of SIDS cases fol lowing DPT #1, 2, 3 & 4 was 32: 11·4:1. SIDS was not sexually related in either group. Although n-DPT-SIDS cluster· ed during the Fal 1-Winter months, DPT-SIDS was non-seasonal. Obvi· ous clusterinq of DPT-SIDS occurred within the first three postvaccinal weeks: 6.5% died within 12 hr of immunization, 13% withi1 24 hr, 26% within 3 d., and 37%, 61%, and 70% within 1, 2, and3wl respectively. Such clustering occurred irrespective of the DPT dose received. In bormal throughout the study period including those neonates with .evated liver enzymes and/or TPN hepatitis. Abnormal values for liver enzymes (SGOT, SGPT) were not ;eful in predicting which neonates would eventually develop TPN •patitis (direct bilirubin >2.2mg%). Although those enzymes •re frequently elevated in patients with elevated direct bilirubin 1 lues. Nutritional failure is implicated in the etiology of intractable diarrhea syndrome (IDS) following an acute diarrheal illness. Eleven patients (6 wks to 31 mths.) developing IDS were evaluated by history, nutritional assessment, stool studies, stool volumes, electrolytes, small intestinal biopsy. Mean number of days (outpatient plus inpatient) between onset of illness and provision of caloric intake greater than 100 kcal/kg was 26. Nutritional deficiency was identified in 91% of the patients. The serum albumin was less than 3.0 mg% in 50% and less than 3.5 mg% in 80%. Mear. stool volume was 78 gm/kg/24 hr; mean stool sodium was 93 mg/L. Stool studies for pathogens were negative. 100% had a moderate to severe non-infla11111atory villous-crypt lesion. Nutritional correction was the primary mode of therapy; greater than 100 kcal/kg/24 hr was required for a mean of 25 days. Refeeding was successful in 100% using an elemental formula by continuous nasogastric infusion. Factors have been identified which place patients at increased risk for the development of IDS: l) prolonged history of illness with inadequate caloric and protein intake; 2) ratio of actual:ideal weight<.09; 3) serum albumin less than 3.5%; 4) fasting stool volume greater than 35 gm/kg/24 hr and stool sodium greater than 65 meq/L. Nutritional failure following acute diarrhea was the major identified cause of IDS. Early identification employing these risk factors and nutritional management should interrupt the cycle of progressive malnutrition and diarrhea and should decrease duration of illness. Abnormal i11111unoregulation may contribute to the pathogenesis and progression of liver disease in children. Utilizing a pokeweed mitogen (PWM)-driven lymphocyte culture technique we evaluated suppressor and helper T-cell regulation of B-cell function in children with various forms of liver disease. Different combinations of B-cells and T-cells from patients and controls were co-cultured in the presence of PWM and the cell culture supernatents were harvested and assayed for IgG. Lymphocytes from 4 patients with hepatocellular cholestasis were evaluated; two of the 4 showed suppression of IgG at 40 and 25% of expected IgG production (BnTnTp)* compared to normal controls of 132±77% (MtSD for BnTn1Tn2). Neither suppression nor enhancement of immunoglobulin synthesis occurred in the other 2 children. Three patients with hypoplasia or paucity of bile ducts showed normal T-cell function, but B-cells were unresponsive to normal regulatory influences with 60, 30, and 34% of expected IgG levels (BpTn-irradiated) compared to normals of 162±70% (M±SD for BnTn). Another patient in this ductal cholestasis group had biliary atresia and diminished T-helper function with only 26% IgG (BnTp)_ while one other infant with biliary atresia had normal Band Tcell function. The results suggest that host immunoregulatory mechanisms may be ootentially important in the recovery from acute hepatitis and in the perpetuation of chronic liver disease in children. *Bn = normal control B cell, To= oatient T cell 2) The fetal liver may be transiently protected from hepatic injury by placental transfer of bile acids. Chronic constipation may be caused by abnormal rectal (r) and sigmoid (s) sensation. R and s sensation were studied initially in 18 Pts and in 18 healthy children (C) 4-12 years old. At I year after initiation of treatment with milk of magnesia, 3 Pts did not comply and were not studied, 8 recovered (Rec), and 7 still required medication (QRec). A latex balloon (2.5x3 cm) was placed II (r) and 20 (s) cm and the strain gauge I cm above the anal verge. We measured the smallest volume (ml) of r and s distension necessary to cause a passing sensation of balloon distension (SV) by transiently inflating the balloon, a constant relaxation of the internal anal sphincter (CR) and a persistent urge to defecate or pain by filling the balloon stepwise in increments of 30 ml/2 min (CV). Hean+ SD of SV, CR, and CVs are given below. Only CR and CVs were significantly lower in untreated Pts than in C (p<0.05)*. In the follow-up studies of the 8 Rec and the 7 QRec, CR and CVs remained significantly lower. These findings suggest that in Pts a normal fecal bolus does not cause a sensory stimulus for defecation even in patients who recovered. c (18) Pts: Initial (18) 12 mo. Rec (8) Plasma, erythrocyte, and urine amino acid levels and nitrogen balance were measured in 8 infants (age 1-63 d, wt 1.2-2.8 kg) receiving no enteral feedings, while on 3 different parenteral feeding regimens. Each infant was studied after 3 days on each regimen: dextrose only (D); dextrose, lipid emulsion, and TravasolR (T); and dextrose, lipid emulsion, and Neopham™ (N). NeophamTM (Cutter) is a new amino acid solution containing glutamate (7. 1 g/L), aspartate (4. 1 g/L) and cystine (1.0 g/L), in addition to the other amino acids present in TravasolR. Free amino acid levels in plasma, erythrocytes, and urine generally reflected the composition of the solutions. Of particular interest were these results (mean, *P<0.05 T vs N): Plasma ( 1 Although amino acid intake was the same (2.0 g/kg/d), nitrogen intake was higher on T (758 vs 661 mg/d). Nitrogen balance (intake -urine excretion) was higher on T (430 mg/d) than on N (347 mg/d), but nitrogen retention (balance/intake) was similar: T 58%, N 52%. The glutamate and aspartate provided by Neopham™ did not produce levels of plasma or erythrocyte free amino acids in excess of postprandial values in these infants. Hepatic function, assessed by the N-Demcthylation of aminopyrine (AP) and mcthacetin (HE) may now be accomplished at high precision without radiation hazard, using non-invasive breath tests and 13c isotopically-labelled, stable substratl.!s. To extend these diagnostic capabilities to infants and children, we have studied in the rabbit the influence of postnatal age on hepatic function, using a closed system for quantitativ1.:ly trapping 14co2 after an IV or IP dose of 14c-AP or 14c-HE. The dose-response was determined for 0.5 to 5mg/kg at 0-10, 11-23, 24-30 and) 30 days of age; the linear was at 2mg/kg ME and Smg/kg AP. A steplike in of both AP and HE was seen, showing earlier and higher l4co2 peak and a IO-fold in the percent dos-= 1...:xcreted at 40min. occurred for both HE and AP at weaning ('";t 23 days). Ndemdhylation of Hr: and AP exhibit developmentally-related increases with marked changes at of weaning. Thus, quantification of hepatic function in children must includ-= consideration of developm1.:ntal chang1.:s. This may h-= safely facilitated by the use of non-radioactive 13c-tracers in normal as Wt:>ll as those with liv-=r disease. (1/18) . Their diagnosis at time of gallbladder evaluation included severe short bowel syndrome (9/18), chronic idiopathic pseudo-obstruction syndrome (CIPS) (5/18), or intractable diarrhea (4/18). The duration of parenteral nutrition p1·ior to evaluation varied from 4 to 79 months with mean of 24 months. Mean SGPT value at evaluation was 97±17 IU/L (mean ± SE), nornal (N) < 45, alkaline phosphatase was 422±65 Il'./L (N < 210) and total bilirubin was J.6±.5 mg/dl (N < 0.8). 6/18 (33%) of children were found to have GS compared to 0.1% of an autopsy age and sex matched incidence of GS. Of the children with GS, 2 were female with CIPS on TPN for greater than 4 years each and 4 were male with SBS all on TPN greater than 10 months. One patient was found to have calcium bilirubinate stones at cholecystectomy. Of four autopsied children (three male) age 5 to 23 months on TPN 5 to 21 months, one was found to have GS. These findings indicate the need for periodic screening for GS by ultrasound of patients requiring prolonged TPN. Presence of GS may result from prolonged fasting or the primary illness requiring TPN and may contribute to TPN related liver disease. Suckled newborn animals experience more rapid postnatal growth of small intestine mucosa than do control animals fed water, fonnula, or mature milk. Investigations with fibroblast cell cultures suggest that this effect is produced by epidermal growth factor in colostrum. To detennine whether endogenous gastrin, a hormone known to be important in GI growth, is involved in colostrum-induced small intestine growth, we measured serum gastrin concentrations and antral and duodenal tissue gastrin concentrations in li ttennate newborn dogs that were suckled (S), hand-fed expressed bitch colostrum (C), or hand-fed EsbilacR, a synthetic formula (E) (2) Colostrum promotes 6-fold greater serum gastrin levels cf synthetic formula in the first 48 hr; gastrin levels in the tissues of origin are not different, suggesting increased production and release of gastrin. (3) Colostrum-stimulated small intestine growth involves enhanced endogenous serum gastrin levels. ( normal esophageal biopsies, only 20 were found to be normal on endoscopy (specificity, 31%). There were 69% false positives and 14% false negatives. Endoscopically, friability correlated best with biopsy-proven esophagi tis (p<0.05); ulceration was an infrequent finding (11%). We conclude that endoscopic evaluation for esophagitis in children is not specific,and the must be made histologically. Suction biopsies in conjunction with studies of acid clearance are therefore the most efficient approach to the diagnosis of esophageal inflammation in children. Portosystemic encephalopathy (PSE) may complicate portocaval shunt procedures in children with extrahepatic portal hypertension (EHPH) more frequently than is generally recognized. Reviews including over 400 children with EHPH fail to mention this complication. We observed two children with EHPH who suffered recurrent Abnormal absorption, metabolism, or excretion of minerals may occur in cholestatic liver disease which cruld result in either mineral deficiency or excess. In 11 patients ages 6 months to 4 years who had had the Kasai procedure for biliary atresia, trace minerals were measured every 3 to 6 mcrrt:hs. Plasma and red blood cell levels of magnesium (Mg), zinc (Zn), co.'Jer (Cu), manganese (Mn), were determined using atomic absorption spectrophotmetry. Values were compared to healthy age-matched controls. RBC level ± SD Plasma level + SD 6.3!3.4 o< .001 than controls and correlated with serum albumin (r;.61 p<.001); zinc levels correlated inversly with SGOT (r;,81 p<.001) and direct bilirubin (r;.89 p<.001). Manganese levels were significantly increased and correlated inversly with zinc levels. Zinc and manganese levels are strikingly abnormal in our population of biliary atresia patients who have had the Kasai procedure and appear to correlate with disease severity. The potential clinical significance of these observationsdeserve further investigation. Infants who have had small bowel resection may have malabsorption of minerals and vitamin D; therefore, bonr mineralization could be impaired in these children. We evaluated 18 children two months to five years after they had had resection of 10 to 90% of their small intestine. Serial measurements were made of height, weight and bore 'llinP.ral content and serum values determined for calcium, phosphorus, alkaline phosphatase and 25-0H vitamin D. Anthropometric parameters were within 2 SD of the mean of normals in 77% (14/18) of short bowel patients. However, bone mineral content was >2 SD below the mean of age-matched controls in 14 of 18 patients. The bone mineral content vs weight regression line was significantly lower for short bowel patients than for controls (F;6.6 P<.025). The amount of intestine remaining positively correlated with bone mineral content (r;.73 P<,01) in 15/18 children. Mean serum calcium was 9.8 mg/dl (8.6-11.3) and phosphorus 4.7 mg/dl (2.5-6.7). Serum alkaline phosphatase was increased in 5 of 16 and 25-0H vitamin D was normal (10-40 ng/81) in all but one. Impairment in bone mineralization was proportionate to the percentage of small intestine removed in children with small bowel resection. Decreased bone mineral content was identified even when levels of 25-0H vitamin D, calcium and phosphorus were normal. This suggests there may be inadequate mineral absorption or utilization in children with short bowel syndrome. Several reports have shown the superiority of preterm (PT) over term (T) milk in terms of total nitrogen content but a progressive decrease has been noted with postpartum age and little is known about the effect of gestational age. Total nitrogen (TN) in PT milk obtained during the first 8 postpartum weeks was higher than in T milk. The highest TN and the lowest NPN/TN ratio was found in early PT milk. Preterm .01 These data from full 24hr collections show that nitrogen composition of PT milk was different from that of T milk. Little change was seen between 26-35 weeks of gestation and the concentration of total nitrogen in PT milk showed no decrease after the first postpartum week. PT milk has a nutritional advantage which is independent of gestational and of postpartum age. Lactase and sucrase have distinctive developmental patterns in rat jejunum. The distribution of these enzymes along the VCU also varies with development, but previous studies separating cells along the VCU by the Weiser "washing" technique have yielded conflicting results. In this study, cryostat sectioning of frozen jejunum provided sequential histological separation of cells along the VCU, enabling comparison of distribution of enzyme activity at various heights of the VCU during development (Table) . While total jejuna! protein increased with age, the protein concentration along the VCU was constant at all ages tested. Intestinal sucrase activity (SA), absent in the rat, is evoked precociously by thyroid honnones. Since enterocytes migrate from crypt to villus tip the question arises: at which level of the villus-crypt columns (VCC) do the enterocytes respond with an increase of SA to thyroxin (T4). Suckling rats (11-day-old) were injected daily s.c. with T4 (2µg/g B.W./day}. They were sacrificed 1, 2 and 3 days later; SA was detennined in homogenates of entire jejunal wall and in serial homogenates of VCC using cryostat sectioning. Maximal increase of SA was seen after 3 days in the lower villus. This resembled the effect of glucocorticoids (Biochem. J. 126:471, 1972) . To exclude the effect via precocious maturation of adrenal cortex, same experiments were repeated using rats adrenalectomized on day 10. The SA in the mid-third of the jejunoileum two and three days after the 1st injection was [ µmol/mq prot/hr (mean± SEM:N) * = significant from uninjected controls] : .06 ± .02;20 .05 ±.02 .07 ± .02* .12 ± .03* 3 .10 ± .04;16* .18 ±.04* .29 ±.06* .37 ± .08* Conclusion: Enterocytes nearest the villus-crypt junction respond to T4 with the highest increase of sucrase activity. effect is independent of adrenal glands. Hypergastrinania has been documented in adults with chronic renal failure (CRF). Its role in the increased incidence of peptic ulcer disease in renal patients is unclear. Radioinmuneassays using region specific antisera were enployed to examine total serum gastrin (TG) ard G-17 concentrations in 4 groups of children: with acute renal failure (ARF), nephrotic syndrane without renal failure (NS), chronic renal failure (CRF), ard stable end stage renal disease on harodialysis (HD). Specirrens were obtained following a 6 hour fast. Sinrultaneous serum creatinine (Cr) determinations were also perfonned. Results are presented below: Normal ARF NS CRF HD Cr 0.05) or CRF (p > 0.05). These studies show that TG but not G-17 is elevated in children with ARF ard CRF. G-34 is therefore the predaninant qastrin !lVlecule. Since it is 1/6 as potent as G-17 as a secretogogue, it is una significant role in the etiology of Excretion of H 2 in breath commonly persists despite an overnight fast. While elevation of H 2 above the fasting value (FH2 in ppm) after administration of a test sugar is evidence of carbohydrate mulabsorption, the signific;ance of FVi2 is unknown. :::·H 2 was measured in randomly selected patients with cystic fibrosis (CF) maintained on 1 or more oral antibiotics, normal subjects (N), and subjects with lactose malabsorption (LM). All were >2 years old. in 3/5 CF subjects studied repeatedly. Since sulfa-containing antibiotics were used most frequently in CF subjects, the effect of sulfa on H 2 production from glucose by fecal homogenates from 3 normal adults was assessed in vitro. Sulfa increased H 2 production by 26\ compared with sulfa-free controls. Conclusion Recent studies demonstrated that the bioavailability of a trace mineral is greatly affected by its chemical environment and molecular form as evidenced by the fact that iron and zinc are more available in human than in cow's milk. is desirable to study the molecular localization of minerals such Our previous studies have shown that taurine (T), a 6-amino acid, is conserved in the kidney of rats fed a low-sulfur amino acid, but normal protein-containing, diet. Urinary T falls by 90% and uptake by isolated tubule segments increases by 60% (Life Sci 23:2415 , 1981 . Using renal brush border membranes prepared by a double CaCl2 precipitation method, the uptake of T was found to be Na+-dependent. A typical T overshoot is found with Na 0 ut > Nain• Mannitol, K and Li do not support this uptake. Only other 8-amino acids inhibit uptake and do so in a competitl.ve fashion. BBM were prepared from rat£ fed a high (HTD), normal (NTD) and Low (LTD) sulfur amino acid diet for 14 days. Both the initial rate of uptake (30 sec) and peak uptake (7 min) indicated that T is accumulated LTD > NTD > HTD. The enhanced and blunted accumulation in relation to diet occurs over a wide range of concentrations (10-2500 µ11) and throughout the time course of uptake. The Km of uptake, 150 µM, is unaltered by dietary change, but the Vmax is 182 pmole/30 sec/mg BnM protein for LTD animals, 140 pmole for NTD animals and 91 pmole for llTD animals. These findings indicate that alterations in dietary sulfur amino acid intake lead to changes in the Na-dependent uptake process for G-amino acids and that the affinity for the substance is unaltered, but the rate of uptake varies according to dietary load. Moreover, the findings in the BBM parallel the changes in vivo and in tubules. Organic solutes may be conserved by such a process in nutritional disorders. Vitamin E deficiency in younq rabbits has been shown to induce chanqes characteristic of iron deficiency due to sequestration of iron in muscle. When iron wns inject1:d parentera1ly, increase in storaqe iron in the thigh muscles 6-8 days later was much qreater in the deficient than in the control group. Even larger differences were noted when more iron was given. Iron Injected 0 25mg 30mg 75mg Cont ro 1 TNH I 5. 0+ 1. 2 ( 6) 6. 2+0. 9 ( 3) 6. 7+0. 1 ( 3) 11. 7 ( 1) SNHI 2.l+0.4 (6) We analyzed paired end-tidal (ET) breath samples from 52 neonates for both CO and H 2 • The ETCO values were more reproducible than the ETH2 results; the mean coefficients of variation were 2.25 + 2.1,4 (range 0-11.2) for the ETCO, and 13.4 + 18.7 (range for the ETH2 (p<.001). The coefficient of variation of the paired ETH2 samples was greater than that for the corresponding ETCO samples for 46 of the 52 patients (p<.001). With CO as an "internal control," this indicates that despite reliable sampling, short-term variability in breath H2 can occur, The causes of this variability are uncertain, but potentially include changes in respiratory function, gut perfusion, gut gas content, and gut surface area for diffusion. Based on 28 paired, simultaneous determinations of the pulmonary excretion rate of 112 (VeH2) and ETH2 in 5 neonates studied repeatedly over a 3-hour postprandial period, the mean difference between individual ETH2 and VeH2 values standardize 75% normal peristaltic sequences We conclude: 1) Abnormal peristaltic activity is correlated with delayed acid clearance 2) ACT is significantly delayed in sitting vs. supine position. We speculate that abnormal peristaltic activity may be important in the pathogenesis of GER and that the traditional chalasia chair may result in delayed acid clearance. In a 12 month period we studied 25 patients (3 mo-17 yr) with a variety of gastrointestinal complaints. After clinical and laboratory evaluation, CA-1-AT was performed on 72 hour stool collections with serum A-1-AT obtained on day 1. Stool and serum A-1-AT values were determined by radial immunodiffusion against standard anti-sera. CA-1-AT was calculated: CA-1-AT = S x V/P (cc/day) S=stool A-1-AT concentration (mgm/gm); V=stool volume (gm/day); P=serum A-1-AT concentration (mgm%). Ten controls (functional abdominal pain, psychosocial FTT, chronic non-specific diarrhea) with normal albumin values, had a mean CA-1-AT of 2.35+1.77 cc/ day. 9 patients with IBO and/or a history suggesting proteinlosing enteropathy (PLE) were divided into those with and without blood loss (defined as any gross blood or guaiac + stools within one month of the A-1-AT determination). Blood Strong evidence now exists that prolonged deficiency of vitamin E (E) can result in progressive neurologic disability characterized by ataxia, ophthalmoplegia, sensory loss, and areflexia in children with chronic cholestasis. Moreover, normalization of serum E levels, which usually requires intramuscular injection of alpha-tocopherol, can reverse the neurologic abnormalities (Rosenblum et al, NEJM 304:503, 1981; Guggenheim et al, J. Peds., in press) . To further understand the development of this nutritionally-induced neurologic disease, we have prospectively evaluated serum E levels and neurologic status in 42 children with underlying cholestatic disease. We found that 34 (81%) have subnormal E levels ranging from less than 0.05-0.35 mg/di (N=0.5-1.5 mg/di). Only 2 patients were able to normalize serum E levels with high dose oral treatment. Correlation of the age of the child, the neurologic status, and serum E levels will be presented and supports the following hypotheses: I) clinically apparent neurologic abnormalities do not become manifest until 4 years or more of an E-deficient state; 2) 6 years or more of an E-deficient state result in a 90% probability of clinical disease; and 3) areflexia is the initial neurologic finding. Parenteral administration of alpha-tocopherol, which currently requires an experimental protocol, may be indicated in the majority of children with congenital biliary atresia or other cholestatic syndromes. In order to assess whether mammary gland function is normal inCF we have analyzed milk specimens obtained from a 20 year-oldwoman with CF at 3 days, 7 and 10 wks of lactation. CYSTIC There is controversy over feeding premature infants their own mother's milk. We studied the nutrient content of milk from 45 mothers delivering infants of 26-36 weeks gestation. Milk being fed to their infants during the first month of life was analyzed for phosphorous, calcium, protein, fat, and lactose . This human milk has a large variability of nutrient contents. Phosphorous and calcium were both strikingly below recommended levels in all samples. Using a minimum standard of 110 kcal/kg/d, if these infants were fed 150 cc/kg/d, 41% of the milks would not provide adequate calories. Over 50% of the milks analyzed did not meet AAP recommendations for three or more nutrients. If prematures infants are fed their own mother's milk, calories, phosphorous, calcium, protein, and fat as recommended by the American Academy of Pediatrics may be seriously deficient. Hei tlinger, Pina-C Lee, l•'illiam Fmanuel Lebent:hal. Divisions of C,astroenterology and Obstetrics, Children's HosTJital and SUNY at Buffalo, Buffalo, N.Y. In the first few rronths of postnatal life, infants have little ar no !Ja11creatic amylase detectable in ducdenal fluid, serum, or urine. Des;>ite this physiologic deficiency, intolerance to dietary gluoose polyrrers occurs in few infants. Human breast milk has illl\Ylase ooncentrations in the range of 10 to 100 times that of adult human seruM, an anount far greater than reoorted in the saliva and ducdenal fluid in early infancy. In order to evaluate the likelihood that a siqnificont pronortion of the activity ¥JOuld withst:nnd passage through the starach, purified and unfl\.Jiified I"alTIT1al'.Y amylase was exposed, in vitro, to acidity o::K'lf1aXahle to that found in the stanach of a young infant followinq a breast milk meal. l'bre than one-half ard one-third of the oriqinal activity was !'1aintained for four ard six hours respectively. Physiol0qic ooncentrations of pepsin did not affect any greater decay, desoite a decrease in large rrolecular weight proteins, and an increase in amino acids ard S!lli'tll pentides in the reaction mectit.nn. Purified mamnary aMylase decayed rrore rapidly; when albul'lin or breast milk r>mteins were present, the stability was caiparable to that of whole, fresh frozen breast milk, incubated under the srure oonditions. I!uman !'lal'11lary amylase may oorrect, in part, the rhv'3iolcgic Tlill1creatic aMylase deficiency of early infancy, and allCM the infant to digest ard absorb polymers of glucose. Supported in part by NIH qrant #12586 ard NSF' grant 1'(}1-8021817. A circadian rhythm of jejuna! sucrase activity has been shown previously to make its developmental appearance in the rat at the time of weaning (day 22). The process of weaning constitutes a complex environmental change for the intestinal tract because the diet changes in terms of: a) physical consistency (liquid --+ solid); b) relative proportions of carbohydrate (CHO) and fat (high fat/low CHO --+ low fat/high CHO; and c) nature of the CHO (predominantly lactose--+ starch, sucrose, etc.). There is also a significant change in the rhythmic pattern of ingestion. The aim of this work was to clarify the relative roles of the weanling diet £.EC!_ se and the timing of the feeding rhythm as cues for the appearance of the circadian rhythm of jejuna! sucrase activity. We found that the rhythm was not present on day 23 if the onset of feeding was not coordinated with the onset of darkness. Conversely, the sucrase rhythm appeared precociously (day 19) in pups weaned onto chow on a schedule in which the onset of feeding was coordinated with the onset of the dark period. To determine whether the composition of the weanling diet is important, pups were weaned onto 3 different liquid diets: A= low CHO (glucose); B =high CHO (glucose); and C =high CHO (lactose). By day 19 a distinct sucrase rhythm was present in B pups, but no rhythm was present in A and C pups. It is concluded that nocturnal ingestion of a high-CHO diet is responsible for the developmental appearance of the circadian rhythm of jejuna! sucrase activity. This work was supported by NIH grant number HD 14094. .46 Conclusions: 1) TC transport is exclusively passive in both ileum and jejunum of 1 and 2-wk rats. 2) Age-related differences in permeability do not facilitate BA recycling before the development of ileal active transport. 3) At the time of weaning, ileal active transport first appears and persists into adulthood. 4) The development of efficient entcrohepatic cycling of BA in the rat in Metoclopramide (M) and Bethanechol (B) are being used to treat reflux of infancy but little is known of their mechanism of action on the developing intestinal tract. We examined their effects on esophageal peristaltic amplitude, lower esophageal sphincter pressure (LESP) and gastric emptying (GE) in 6 week old kittens. Amplitude and LESP were determined with double lumen perfusion catheters ( *At 10 min. gastric emptying with M was significantly faster than the pre-treated state (p< 0.05). We conclude:B in the 6 week old kitten increases LESP but has no effect on esophageal peristaltic amplitude or GE; M increases LESP less than B, has no effect on esophageal peristaltic amplitude and significantly increases GE of a liquid meal. We postulate that M may be of significant value in infants with gastroesophageal rP.flux and delayed GE. 10 premature infants of mean gestation 29.l + 1.5 weeks and mean birthweight 1049 + 127 gms were fed their mothers breast milk. Serum and urine-25-0HD, calcillll, phosphorus, and magnesillll were monitored weekly. Over the first 8 weeks of llfe serum and urine phosphorus fell. Concomitantly urine calciun increased. Serum calcium transiently rose then fell to low levels. By 7 to 8 weeks the degree of these changes prompted therapeutic phosphorus supplementation in 5 of 10 infants. Mean serum 25-0HD fell. Analysis of individual 25-0HD patterns showed that the infants who did not require supplementation had sustained high 25-0llD concentrations or low 25-0HD concentrations which increased whereas infants requiring phosphorus supplementation had high 25-0HD concentrations which fell or persistently low 25-0HD. Breast milk feeding of very premature infants produces a progressive phosphorus deficiency because of the milk's low phosphorus content; however, this may be further exacerbated by 25-0HD insufficiency and both parameters require monitoring. Week of (n) 2(6) 3(9) 4(7) 5(8) 6(10) 7 (9) 8(8) Changes in hepatocellular function should be reflected in the distribution and elimination of compounds which are preferentially secreted into bile. Technetium 99m labeled 2,6-diethylacetanilide-iminodiacetic acid (diethyl-IDA) is ideal. The present study was designed to quantify surgically and biochemically produced hepatic injury, A three compartment model with simultaneous elimination from two compartments described the elimination. Concurrent computer fitting of the cardiac and hepatic time-activity curves with the model quantified the rate constants. Sprague-Dawley male rats (200-400 gm.) were divided into three experimental groups: normal (n=13), bile duct ligated (n:6), and galactosamine treated (n=3. 400 mg.,i.p./kg.). Bolus diethyl-IDA (250 mCi.) was injected. The observed rate constants (Table) It is concluded that the rate constants 1) are a function of the tracer distribution, 2) classify experimentally induced hepatic pathology, and 3) quantify relative elimination. Samples of saliva and gastric fluid from fed and fasting infants 30 to 42 weeks of gestation were assayed for A activity. The A in the gastric fluid was further analyzed by polyacrylamide gel electrophoresis. In addition, degradation products of CSS in tl1e gastric fluid were analyzed by thin layer chromatography (TLC). Activity of A was detected in the saliva of infants as early as 29 to 30 weeks of gestation. The level of A did not change from 29 to 42 weeks and to relate to the secretory activity of the salivary glands. The majority of gastric fluids was shown to contain A with electrophoretic mobility identical to salivary A. The presence of A activity was pH dependent and was invariably present at a pH>3.5. The activity of gastric aspirates was sl1own to be related to feeding. Up to 90 min. after a gavage feeding, the pH of the gastric fluid remained above 3.5. TLC of gastric fluid containing CSS did not reveal significant degradation. The results suggested tl1at the salivary A was present in premature infants. Thus A could survive the gastric environment in these infants and may be important as an amylolytic agent in the small intestine where the conditions arc optimal for its activity. Two children of brothers married to unrelated women, a girl age 12 months and a boy age 8 months, had vomiting, lethargy, coma, hepatomegaly, hyperammonemia, elevation of serum transaminases and "Tom cat" odor. Diagnostic considerations included: Reye's syndrome, carnitine deficiency, urea cycle defect, glycogenosis and deficient hydroxy-mcthylglutaryl CoA (HMG-CoA) lyase. Skin fibroblast cultures and needle biopsy specimens of liver and muscle were studied biochemically and by light-and electronmicroscopy (EM). Tissue concentration of glycogen and carnitine was normal as was liver urea cycle activity. EM of liver showed normal mitochondria but marked micro-and macrovesicular fatty infiltration. EM of muscle showed large mitochondria with tightly packed cristae, increased numbers of lipid droplets (=non-specific changes). HMG-CoA lyase activity in fibroblast cultures was not detectable; HMG-CoA lyase activity in liver was (in µm acetoacetate/min/g): 0.26; 0.32 in the patiPnts and 3.52 ± 1.28 in 16 controls. We conclude that the initial differential diagnostic dilemma that has been reported repeatedly in the literature can easily be resolved by the described analysis of a needle liver biopsy Pentagastrin (PG), the C-tenninal tetrapeptide of gastrin, is a gastric acid secretogogue. Tenn infants do not respond to administration of pentagastrin in the first two s.o meq/L, Cl->109 meq/L, and HCo 3 -<19 meq/L. Age at onset averaged 4 wks. All were <3rd percentile for weight at diagnosis. Vomiting was present in 5/6, and symptoms suggestive of viral illness in 3/6. Diarrhea remitted in all during parenteral therapy, but recurred repeatedly in 4/6 upon advancement to full-strength formulas. Oral HC0 3 sufficient to raise serum Hco 3 ->23 meq/L reversed the diarrhea induced by entcral feedings. In the remaining 2 infants, institution of HC0 3 following NPO was associated with tolerance to enteral feeding. Hco 3 requirements sufficient to maintain normal acid-base status ranged from 2.5-15 meq/Kg/day. All patients demonstrated catch-up growth following institution of alkali, and 2 who no longer require alkali at age 12-18 mare >25th percentile for weight. Conclusion: Infants with growth retardation who develop protracted diarrhea may have RTA IV. Such infants may not tolerate the osmotic load of full-strength formulas until HC03 therapy is instituted. End-organ resistance to aldosterone, present in the distal renal tubule, may also cause inhibition of aldosterone-mediated water and electrolyte reabsorption in the small and large intestine. Published studies have reported LNHC as a normal radiographic finding in children with lower GI bleeding. Over 3 years, 95 children (2-48 mo) were referred for evaluation of hematochezia. Sixty were examined with fiberoptic proctosigmoidoscopy or colonoscopy. Examination revealed colitis (15), juvenile polyps (10), normal (15), LNHC (20) and rectal ulcer (1) . All 20 patients with LNHC exhibited diffuse nodularity of the bowel, 13 had friable mucosa and 2 had discrete ulcerations. Thirteen patients in this group had rectal biopsies (11 suction and 2 grasp). All were abnormal on pathologic examination. Review of the biopsies revealed 1) a diffuse lymphoplasmocytic infla1T111ation in 12 (9 mild, 2 moderate, 1 severe), 2) enlarged lymphoid follicles (#1-6 phf) extending from mucosa to submucosa, and 3) 8 of 11 had mucosal thinning overlying the follicles. All stool examinations for bacterial and parasitic pathogens were negative. In children biopsied, there was a good correlation between endoscopic findings and pathologic abnormalities. The finding of inflammation with diffuse LNHC in a group of chil< 1 ren with lower GI bleeding suggests that LNHC is not always a normal finding. speculate that this previously unreported finding may be related to an unidentified intestinal pathogen that stimulates gut-associated lymphoid immune systems. We feel that LNHC as an endoscopic and pathologic lesion represents a potential source of GI bleeding in children. 23 healthy breast-fed term infants and their mothers were admitted tor 24 h. Mean milk Na concentration (XNa> was the average ot 6 samples, 4 h apart. Blood and urine were obtained from tne infants to determine indices ot Na excretion: In the boys, UNa in mEqNa/kg/24 h; in all infants, mEqNa/gm creatinine, fractional excretion (FeNa> and plasma renin activity (PRA), Milk XNa decreased from 7.3 mEq/1 !_ .8 at 3-8 wk postpartum to 5.4 + .3, s.e. at 8-20 wk then was constant to 32 wk. The decrease in XNa was highly significant by t-test (p<.005). From 3 to 20 wk ot age in exclusively breast-fed infants, UNa decreased from 0.95 + 0.19, to 0.28 + 0.04 p<0.01, Na/gm creatinine from 97 .!_ 15 to 43 .!_ 10, p<.Ol and FeNa from .23 .!_ .05 percent to .15 + .05, p<0.05. PRA increased over this period from 17.0 + 4.2-ng/ml/h to 39.4 + 11.0, p<0.01. Data for infants by nonparametric statistical methods. The decrease in XNa plus previous estimates of milk volume suggest decreased total Na delivery to the infant. Decreasing indices ot Na excretion plus increasing PRA from 3-20 wk suggest a response to decreasing availability of Na to the infant. Between 20 and 32 wk PRA decreased or remained constant. When PRA was 0-15 ng/ml/h, FeNa was .34 .!_ .14 in the younger infants (3-8 wk) and 0.11 + .07 in the older subjects p<0.05. This suggested decreased efficiency ot sodium conservation in younger infants. Supported by USDA #58-7B30-9-60 Children's Nutrition Res. Ctr. We measured horseradish peroxidase (HRP) (MW 40,000) transport rates across stripped piglet jejunum in vitro in Ussing chambers, comparing segments containing Peyer's patches (n=l7) with segments containing no patch tissue (n=2S). The appearance of HRP in the serosal chamber was determined enzymatically at intervals for 80 minutes after the addition of HRP to the mucosa! compartment (final cone. 20 mg/ml). In patch and control (no patch) segments, HRP appeared in the serosal chamber after a lag of 30 min. and steady state conditions were observed from 40 to 80 min 2 Transport rates across segments with patches, 22.4:4.4 ng/min/cm + . (M-SE), weri increased 3-fold (p<0.002S) compared with control tissue (7.S-2.9). In both preparations, release of endogenous peroxidase activity was negligible and light microscopy showed the tissue well preserved at 90 minutes. HRP transport rates did not saturate with increasing concentrations of HRP in either preparation. lmM NaF consistently inhibited transport across patch tissue (48:6%, n=S, p<0.002S) but produced inconsistent results with control tissue. Reduction of temperature from 37° to !S 0 c resulted in 7S-9S% inhibition of transport in both tissues. We conclude that macromolecular uptake is increased across jejuna! mucosa containing Peyer's patches; this phenomenon does not involve specific receptors and depends Oil metabolism. Our findings support the concept that Peyer's patches perform an antigen sampling function in the gut. The cancer patients showed significant Sl-112% elevations in rates of S (p < 0.02S) and B (p < 0.01); however, the patients were not in a hyperalimentary state and actually had a lower protein intake (p < 0.005) than controls (Table) (two sample t test). The rates of S (p < O.OS) and B (p=O.Ol) were also significantly higher in the L group using the Wilcoxon test. Serum concentrations of ketone bodies in suckling rat pups are six fold greater than in the adult. Serum fatty acids are two fold greater. Pyruvate dehydrogenase in adult rat intestine is inhibited by fatty acids and 3-a hydroxybutyrate (aHB). To detennine if this increase in ketone bodies and fatty acids may influence neonatal intestinal glucose metabolism, we measured the effect of aHB and palmitate on glucose and pyruvate oxidation by suckling and adult rat intestinal slices. Glucose oxidation to C02 by developing rat intestine increased from suckling rates of 0.69 to 1.26 n mole/mg/hr in the adult. In the presence of aHB (2 mM), glucose oxidation by adult intestine decreased by 50%. However, aHB did not inhibit glucose oxidation in suckling rat intestine. Palmitate (l mM) inhibited glucose oxidation by approximately 25% in both suckling and adult intestine. Pyruvate decarboxylation to C02 by developing intestine increased from 2.1 n mole/mg/hr in suckling rats to 2.88 in the adult. aHB inhibited pyruvate decarboxylation by 30% in adult intestine and only by 10% in suckling intestine. Exogenous aHB does not inhibit glucose or pyruvate oxidation in the suckling rat intestine but does inhibit oxidation in the adult intestine. Glucose oxidation in suckling rat intestine therefore appears to be inhibited by endogenous ketones. Exogenous palmitic acid inhibits glucose oxidation in both suckling and adult intestine. these data suggest that ketones are important for regulation of intestinal metabolism during development. • 538 W •. :. Klish, W . .1. Cochran, G.B. Forbes, A. Gordon. Dept of Pediatrics, Univ. of Rochester, Rochester, N.Y. The determination of lean body mass in infants is difficult and unreliable. We describe an innovative, safe and rapid (1 sec) for the dcterminotion of lean mass which cdn applied to infants. This machine, called an EMME(EMME Corp.Phoenix, AZ), operates on the principal that a biological specimen in an electromagnetic field perturbs the field proportional to its conductivity which is dependent upon the amount of electrolyte present. It operates at 10 megahertz and delivers lmW/cm2 for l sec. about 1000 times below the permissable standards set by OSHA. Phantoms containing Na, K, Ca, Mg and P0 4 in concentrations simulating lean body mass and in volumes of 2-6 liters were measured. Varying amounts of corn oil (S-40% by vol.) were added and the measurements repeated. I-3 kg samples of ground beef (10-IS% fat) were measured and the fat content chemically determined. The EMME reading increased in an exponential fashion with increases in the total "lean" volume. The regression line for the phantoms was: Ln EMME reading =. 78+.41 x "lean" vol. (L). r=.99. The addition of oil to the phantoms showed the ability of the instrument to discriminate the "lean" volume from fat. The regression line for the ground beef was: Ln EMME reading =.44+1.S x lean wt in kg. r=0.96. Live rabbits are currently being investigated. The initial studies reveal: Ln EMME reading =2.B+.42 x lean wt. in kg (chcm1c.,l aosny); r=.96. The EMME instrument appears to hold promise as a rapid non- of Pediatrics, Detroit Picolinic acid (PA) is a chelating agent that was recently shown to decrease the zinc requirements of patients with acroder-. matitis enteropathica to 1/3 of minimum therapeutic dose. PA alone was ineffective. The role of PA in zinc absorption was therefore studied in groups of rats, 6 each. r,roup A received a tryptophan (tryp) deficient diet that contained half normal dietary zinc requirements, 6ppm, while pairfed controls received the same diet with normal tryp and 12 ppm zinc. Group A lost weight, developed CNS symptoms (6/6), alopecia (6/6) and diarrhea (2/6). Plasma zinc was 2S -48 pg/dl; controls 91 -llB)lg/dl. r.roups B and C received a tryp and B 3 deficient diet and either 6 ppm (B) or 9 ppm (C) dietary zinc. Pairfed controls were supplemented with PA, 0.2µg/ml in drinking water. Plasma zinc was lS -S9 ,ug/dl in group B and 38 -88 ,ug/dl in group C. PA supplemented controls had significantly higher values (S3 -77 and 63 -98,ug/dl, respectively) but only a slightly lower incidence of clinical symptoms. In a fourth experiment, tryp and s 3 deficient rats on normal dietary zinc (12 ppm) developed the same symptoms but had normal plasma zinc values. Pairfed controls received either PA or zinc supplements (24 ppm, total). Plasma zinc was normal in all three groups and there was no difference in bone zinc concentration. The data are consistent with the presence of two separate absorption mechanisms, one for low and one for high dietary zinc. PA did not raise body zinc uptake when dietary zinc was normal or increased, but did prevent hypozincemia in rats on a zinc deficient diet. With prolonged survival of CF patients, hepatic involvement has become an important complication. Conventional liver tests may not be helpful since portal hypertension may occur with little changes in liver function studies. Abdominal ultrasonography was performed on a group of 14 patients selected at random from our adult CF population numbering 35. The age span was 20-44 years. The real-time sector scanner was used, delineating longitudinal, transverse and oblique planes. Measurements of portal vein were obtained just proximal to the fonnation of the PV by the junction of the splenic and superior mesenteric veins. Of 108 non-CF patients without clinical or laboratory evidence to support cirrhosis, the PV diameters ranged between 8.5rrm + 2.7 SD under 20 years and 10rrun+2.S SD for those over 20 years of age. Of the 14 CF patients, 9-had diameters between 15 and 20mn. Those with PV diameters greater than 12rrrn had elevated serum alkaline phosphatase. Of those with the widest PVs 3 had splenomegaly and thrombocytopenia. The data suggests that PV diameter measurements by the real-time scanning may be a valuable diagnostic test for recognizing portal hypertension. .001 In summary, infants with onset of NEC in the first 24 hours of 1 ife were larger, more mature and less asphyxiated than infants with later onset of disease. They were fed more vigorously at an earlier age, and the latency period between onset of feedings and onset of NEC was significantly shorter. We speculate that, in these infants, the feedings were more directly involved in the pathogenesis of NEC. We have previously shown that acidic steroids with fewer carbon atoms than are found in conventional bile acids (24 carbons) exist in meconium. Thus, etianic acids (20 carbons) and bis-nor cholanoic acids (22 carbons) are demonstrable. We now show that large quantities of 21 carbon acidic steroids exist in normal human meconium. Methods: Extracts (containing sodium borohydride) from normal full-term infants were subjected to solvolysis and mild alkaline hydrolysis. An acidic fraction was obtained, and was separated into hydroxylated components by adsorption chromatography of the methyl esters. The preparative technics employed have been standardized and extensively tested to rule out artefact formation. Results: Two dihydroxylated C2 1 acidic steroids were obtained and characterized by MS, and by protrn and carbon NMR spectroscopy. The major component was shown to be 3a, dihydroxy-Sa-pregnan-21-oic acid, while the SB-isomer was a second component. Additional minor components were identified. The concentrations of the major component were comparable to those of chenodeoxycholic and cholic acid in meconium. Conclusions: (1) This is the first demonstration of C21 acidic steroids in meconium; (2) In vi•.·w of the quantity in meconium, it will be essential to study their effect on hepatic function; (3) Their origin is unknown, but it is probable that C2 1 acidic steroids are hormone degradation products. Preduodenal fat digestion is an important compensatory mechanism in newborns because of immature pancreatic (lipase) and hepatic (bile acid synthesis) function. Hydrolysis of fat in the stomach is catalyzed by enzymes of lingual (LL) and possibly gastric (GL) origin. The developmental pattern and quantitative contribution of these two enzymes to intragastric fat digestion was studied by measuring lipase activity in lingual glands and gastric mucosa of rats from birth until after weaning . AGE ( LL and GL activity was optimal at pH 5.4 and was 2.5-5.0 fold higher on medium (tri 14c-octanoin) than long chain triglyceride. Low activity of GL (1-4% of LL level) and characteristics similar to LL, suggest that GL represents LL adsorbed onto gastric mucosa. High activity immediately after birth, suggests that LL is a major digestive enzyme in the newborn. Fenrentation and nutritional scavenging of malabsorbed OfO reaching the =lon was studied semi"-"'ekly by rreasuring peak breath H 2 (PBH) production between feedings in 32 H 2 -proclucing, hospitalized infants (<3 => re=vering fran diarrhea. PBH (alveolar pµn) was calculated using the rrethof of Niu et al. (J. Lab. Clin. Med. 94:755, 1979) fran breath H 2 and co 2 levels obtained by a:: analy·· sis of end expiratory gas =llected with a m:xlified oxygen therapy mask. Patients who required less than 1 wk hospitalization had lCMer PBH on admission than those who required longer stays (PBH:21±18, n=l2 vs 244±183, n=9, P<.01). Patients hospitalized for less than 1 wk had lCMer PBH at discharge (44±25, n=9, P<.012) than on admission. PBH decreased when glu=se was substituted for glu=se polymer in formulas (34±33 vs 150±82, n=7, P<.01). PBH decreased when milk drip was used in place of bolus feeding (219±185 vs 13±23, n=6, P<.025). Glucose-positive and acidic stools ""'re en=untered occasionally and were associated with decreased PBH. Changes in PBH levels and stool pH and glu=se following changes in patient management and/or intestinal handling of CHO =uld be interpreted as the balance between proxirral intestinal absorption ar.d distal colonic fermentation. Malabsorbed CHO reaching a ccnpetent colon is utilized via microbial =nversion as denonstrated by high PBH levels in the absence of glucose-positive and acidic stools. The presence of the latter two signifies =Ionic failure. _(Supported by USDA/ARS). Although a considerable amount of information is available about lysosomal enzymes in various mammalian organs, very little is known about lysosomal enzymes of the colon. We have therefore studied changes in lysosomal enzymes, B-N-acetyl-D-glucosaminidase (HEX), B-D-galactosidase (G), (F) and e-Dglucuronidase (GL) in proximal and distal portions of the large intestine of fetal, newborn, suckling, weanling and adult rats. All these enzymes exhibit substantial changes in activity perinatally. The activity in the proximal colon peaks around the middle of the first week. In the distal colon either no substantial change (G,GL) or a transient peak around day 14 (F) or a steady increase from day -1 until day 80 (HEX) is observed. These changes lead to a shift of the locus of maximal activity from proximal to distal colon. Whereas l to 8-day-old suckling rats exhibited higher enzyme specific activities in the proximal than in the distal colon, the activities were always higher in adult rats in the distal than in the proximal colon. The gradient of enzyme activity along the colon varied more in sucklings (2.3 to 10 fold) than in adults (1.3 to 3.0 fold). Demonstration of substantial changes in activity of these enzymes known to be involved in the turnover of carbohydratQ-COntaining macromolecules both during development and along the length of the large intestine, clearly stresses the need for further studies of metabolism of glycoproteins and glycolipids in this organ during development. 4.6±0.5 d, wt: 3.37±0.45 kg) after 30 mg/kg 13c-l-lactose was added to the 8 am formula feeding (intake: 97±14 Kcal/kg/d, 14±3 Kcal/kg/feed). Breath was collected a.c. and 0.5, 1, 1.5, 2, 3, All fecal 13c was dialy:!able, suggesting little or no incorporation into bacteria or macrorrolecules, as previously documented in adults. Fecal 13c excretion was unrelated to 112 production status. Both breath and stool data suggest that less lactose reaches the colon in term than in premature infants. Colonic salvage is variable in term infants at the ages studied and appears to be less quantitativ,.ly important than is suspected in premature infants. Four patients with severe burns (average 48% TBS) requiring from at least one to five surgical eschar debridement and autografting procedures, and who failed to ingest at least 80% of their prescribed protein and/or kilocalories were studied using a multiple baseline (time series) analysis. After a varying number of baseline days, Informational Feedback was introduced consisting of (a) daily reminder of their prescribed levels of protein and kilocalories, (b) the protein and kilocalorie count of every item available, and (c) their actual intake of protein and kilocalories. Bar graphs on the wall next to the bed of the showed the prescribed levels of daily protein and kilocalories and the actual daily intakes of these nutrients. Menus listed protein and caloric values for each food available as well as the minimum number of protein and calorie values needed for each meal to assure the prescribed levels of protein and ki localories for the day. Daily kilocalorie intake improved from 5104 per day to 6143 per day (a 20% improvement), with the intake of prescribed levels improved from 0% of baseli.ne days to 35% of treatment days. The informational feedback techniques described herein suggest an effective and practical method for improving the eating behavior of burn patients. In order to investigate further whether or not cyst(e)ine (sulfhydryl and dissulfide form) is an essential amino acid during infancy, plasma and urine amino acids were measured in two groups of low-birth weight infants (mean birth wei!(ht = 1497 gm). Five infants received cysteine-supplemented (S) TPN (72 mg/kg/day cysteine-HCl) and 5 infants received unsupplcmented (US) TPN. For both groups the non-protein calorie intake was 63 cal/kg/day and the mean nitrogen intake was 0.243 g/kg/day. PGE2 is cytoprotective to gastric mucosa, and endogenous production may play an important role in prevention of serious gastrointestinal complications in neonates. Gastric secretions were obtained from 7 premature (P) and 8 full-term (FT) infants with pulmonary disease in the neonatal ICU. Gastric secretions from 16 children (6mo-12yr) admitted for elective surgery served as controls (C). Infants were studied in the first 10 days of life. /Ill patients were NPO 24 hrs prior to collection. was determined by single-phase antibody radioimmunoassay and compared to [H+] and volume in timed colelctions. There was a correlation between PGE2 and gestational age (r=.35, p<.05). No correlation between PGE2, [H+] or chronologic age was found. Comparison of PGE2 concentration among the groups is showri p vs c -.1 Above data demonstrate that PGE2 production in P infants is less than FT infants similarly stressed. FT infants responded to stress with gastric PGE2 concentration greater than controls. PGE 2 production in P infants may represent deficiency in an importantcytoprotective mechanism which could increase the risk of serious gastrointestinal complications to these severely ill infants. HBV infection is endemic among the institutionalized retarded, who usually have mild, anicteric hepatitis after non-parenteral exposure. We studied long term effects of HBV exposure and risk to caretaker contacts during brief home exposure. Six retarded patients, known HBSAg+ (m=4.6yrs) were institutionalized 4-12yrs (m=lO) by ages 11-23 (m=l6). All had abnormal tra nsami na ses; two had portal hypertension. Liver biopsies ( 5 pts) showed chronic active hepatitis with cirrhosis(2) chronic persistent hepatitis(2) and ground glass, aldehyde fuchsin positive cells(5). Viral was integrated into hepatocyte genome in 3/3. Caretakers shaved, bathed, and changed diapers for patients during home visits or foster home placement. 7/14 caretakers exposed 5-12 mos (m=6) developed antibody to HBSAg or Only 1/9 play contacts and 0/7 other casual contacts had of past or present HBV infection. Conclusions: (l) Retarded institutionalized llBSAg carriers can have progressive liver disease, with integration of HBV-DNA, and are at risk for future hepatocellular carcinoma. (2) 50% of caretakers had serologic evidence of silent HBV infection following brief non-parenteral exposures, whereas other contacts had a risk no greater than the general population. These data may help form guidelines for active immunization against HBV for communities providing non-institutional care for the retarded. Tanaka. Univ.of ... PedS:-,-Neurol. Fetal malnutrition is associated with deviations of structure or function of the placenta. In an attempt to aid in assessing the nutritional status of a neonate at birth, the subcellular metabolic properties of human placenta were studied. Two preparations were used: mitochondria, obtained by classical techniques and a postmitochondrial supernatant containing microsomes and other cytosol components of placental parenchyma. Results: Human placental mitochondria obtained from full-term normally grown infants consume 02 at specific rates (11.00 to 20.00 nmoles 02/ min/mg mitochondrial protein). Measurements of state 3 and 4 respiration rates led to respiratory control ratios from 1.00 to 1.74. Adding some essential nutrients (e.g. thiamine pyrophosphate) increased frequently the 02 consumption this suggests a state of unsaturation with respect to the nutrient tested. Postmitochondrial supernatants were used for multi-test evaluation and demonstrated consistency of albumin, globulin, SGOT, lactic dehydrogenase, alkaline phosphatase, and creatinine content. Because placental parenchyma was found to contain high concentration of ascorbic acid (from 8.9 to 11.6 mg/100 g tissue) and this is associated with oxygen metabolism, the level of superoxide dismutase in the umbilical blood was assayed and found to be consistent from 9 to 24 units/g Hb). These studies indicate that the subcellular metabolic profile of the placenta may be used to characterise fetal nutritional status. The influence of protein calorie malnutrition on UCR excretion was estimated through determination of the weight for height index (WHI) (actual weight I 50th percentile weight for height). The mean WHI was 0.99 ± 0.21 (13.5% below O.B). There was no significant correlation between CHI and WHI in this study population (r = 0.417). Nor was there any significant difference in WHI between medical (mean 0.9B ± 0.23) and surgical (mean 0.99 ± 0.17) subgroups. This study shows that I) CHI does not accurately reflect the protein calorie nutritional status of critically ill children, and that 2) surgical injury may be associated with greater muscle catabol ism than that encountered with most medical i I lnesses. Farrell, Sara W. Parrell, and Richard J. Lemen, Univ. of Wisconsin, Department of Pediatrics, Madison, WI. The significance and possible effects of previously described fatty acid abnormalities in CF are controversial, particularly the decrease in linoleate(l8:2), an essential fatty acid. The 18:2 deficit, however, provides evidence of biochemical malnutrition which is commonly found in CF patients with steatorrhea and may contribute to growth retardation and membrane dysfunction. Therefore, we evaluated plasma and erythrocyte fatty acid composition, identified 43 CF patients with low 18:2 (67% of those surveyed), and l1ave carried out a dietary supplementation protocol. The pathologic triene characteristic of essential fatty acid def icicncy (S ,8, 11-eicosatrienoic acid) was found in 43 patients, and one had a triene/tetraene ratio above 0.4. Fifteen patients, aged 10 to 24 years, agreed to take Microlipid (a safflower oil emulsion containing 72% linoleate) for one year, and nine have completed a 6 month trial thus far. As shown below, % 18:2(mean .•. SD) increased in plasma (p< .01) and erythrocytes (p< .002). --There were no significant differences in concentrations of nutrients between mothers :: 30 wks vs 32 weeks gestation except for Zn at !st and 2nd week (lower in s_ 30 wks gestation). Daily output of all nutrients did not change significantly with duration of lactation and it was not influenced by length of gestation. Our data illustrate 4 unreported findings: (I) daily output of Zn, Cu, Vits. A, E, C and Carnitine is constant during 7 wks lactation, (2) concentration of Zn, Cu, Vit E and Carnitine decreases during lactation, {3) Zn content is lower in the first 2 wks of lactation in mothers .::_30 wks, (4) individual variation in concentration is enough to suggest that some infants may need vitamin or zinc supplements in addition to their own mothers milk. EGF is a small polypeptide that stimulates proliferation and differentiation of a variety of cell types, including bowel epithelium. Since there is biologically active EGF in breast milk, it is possible that EGF may promote optimal growth and/or maturation of the bowel epithelium in premature infants. Immunoreactive (IR) EGF has previously been found at concentrations of 50 ng/ml in isolated samples of mature breast milk, but its levels have not been systematically analyzed. We studied the IR-EGF content in breast milk as a function of duration of lactation in 13 mothers delivering at or before 32 weeks gestation. Expressed breast milk was collected for 24 hours once a week for 6 weeks. Representative results are as follows: These data indicate that: (!) IR-EGF production in milk is not a function of duration of lactation; (2) concentration of IR-EGF varies widely from the milk of one mother to another, but (3) total daily production is similar; and (4) IR-EGF concentrations in the breast milk of mothers delivering prematurely may exceed those of mothers delivering at term. Studies have shown that low-birth-weight (LBW) infants experience a faster rate of weight gain when fed a more calorically dense formula with a higher protein content than those receiving pooled human milk. Recent data indicate that the composition of "preterm" human milk differs significantly (protein, Na, Cl) when compared with pooled term human milk and may be adequate to meet the preterm, LBW infant's needs. It has not been shown that the pre term LBW infant fed his own mother's milk "ad 1 i bi tum" wi 11 simulate the growth of the formula-fed infant. To compare growth, 9 breast-fed (BF) and 9 standard 20 calories/oz formula-fed (FF) preterm LBW infants were matched for gestational age (GA) and To determine if exogenously administered prostaglandins affect growth or biochemical ontogeny, prostacyclin(PGI2) and 16,16 dimethyl prostaglandin E2 (l6,l6DPGE2) were administered to infant and weanling rats. PGI2 was injected at 0.0, 0.1, 0.2 and 0.3 mg/kg three times a day between 10-13 and 19-22 days of age with sacrifice at 14 and 23 days respectively. 16,l6DPGE2 (0.3 mg/kg/ min) was infused continuously from days 10-16 using subcutaneous minipumps. The following decreased after PGI2: body, kidney, intestine weights and intestinal protein content. Similar effects on growth were detected after 16,l6DPGE2. Representative data are tabulated below for sucrase(S) and maltase ( Protein turnover was studied in 12 premature babies with a conceptual age of 26-37 weeks. A stochastic model based upon [lSN]urea excretion following an injection of [lSN]glycine was used. Muscle protein breakdown was estimated from 3-mcthylhistidine excretion. A significant inverse correlation obtained between nitrogen flux, protein synthesis and breakdown, and the degree of maturity. Muscle protein breakdown increased linearly with conceptual age and comprised from 7-38% of the total protein catabolism. Efficiency of protein synthesis with respect to protein and caloric intake were many times higher in the least mature infants. We conclude: (1) Mean rates of protein synthesis and breakdown are 2-5 times higher in premature infants than in young adults and are especially high in less mature babies; (2) Muscle protein breakdown increases with maturation and One hundred children had nutritional and socioeconomic status assessment performed on admission to SVH,a 667 bed general hosp. in the indigent area. Anthropometric(A)abnormalities included 14% height (<5th percentile),19% weight,23% weight for height,15%head circumference,8% triceps skinfold (<15th percentile),25%upper arm circumference,32% upper arm muscle area and 23% upper arm fat area. Lab(L) abnormalities included 29% hemoglobin,3% albumin,11% total lymphocyte count,15% transferrin and 21% serum iron.One anthropometric and/or lab abnormality was found in between 40 to 86% of the children and more than one in 29 to 71%. Chi-square analysis comparing the frequency of abnormalities in the socioeconomic groups found significant differences (level of significance in parenthesis). Nearly 50% of the children were in the lower socioeconomic group. Asr.e ! Welfare vs. Insurance 3-5 33 A(l%),A&/or L(l%) 6-12 14 L(l%) Clinic vs.Private 1 vs. 2 Parents A(5%),A&/or L(1%) A(l%),A&/or L(l%) A(l%),A&/orL(l%) Our results confirm our expectation that a significant number of children have nutritional deficits that may adversely affect the hosp. course and increase morbidity and mortality and that nutrition is affected adversely by poor socioeconomic conditions. Breast milk necrophages cultured in vitro, synthesized and secreted increasing amounts of protein, lysozyme and prostaglandin E 2 (PGE ) into the extracellular medium, These cells were also shown actively phagocytose labelled zymosan particles in culture. Concanavalin A, endotoxin and zymosan particles, but not latex partic'es, all resulted in an increased PGE 2 secretion (3-lD into the medium co1T4Jered to basal secretion (lng/ml/lD cells), A dose dependent increase of PGE 2 production was also observed when lactoferrin (optimal dose 50 µg/ml) was added to the macrophage cultures, while neither lactalbumin nor lactoglobulin had any stimulatory effect. Varied effects on the secretion of lysozyme and phagocytosis were found with the different stimuli, These findings indicate that phagocytosis and the secretory products of milk necrophages nay be altered depending on the nature of the stimulating agent, The principal manifestations of Cystic Fibrosis (CF) include elevated sweat electrolytes and a generalized exocrinopathy. Subnormal net transport of Na+ across affected epithelial cells could underlie both the sweat ion abnormality and the exocrinopathy in CF. This unifying concept was tested by assessing electrogenic Na+ transport in colon where the epithelium is involved in the disease and generates a measurable transmucosal potential difference (PD) by Na+ transport. The resting PD across the rectal mucosa was measured in 22 CF patients and 20 normal controls, together with the effect on this PD of the diuretic drug amiloride, which specifically blocks channels for passive Na+ diffusion and inhibits electrogenic Na+ transport. The resting PD was determined between an isotonic saline-filled, rectal catheter connected to the recording electrode and a silver chloride-silver plate applied to a site of intradermally injected normal saline as the reference electrode. The mean resting PD was -26.5 ± 6.0 mV (mean ± SEM) in controls and -14.5 ± 5.0 mV in CF patients, a difference not statistically significant (P> 0.25). Amiloride induced a dose-related decrease in the transmucosal PD in all subjects, confirming Na+ transport as the basis for the PD. The decrease was 6.0 ± 2.5 mV at 10-6M, 15.8 ± 3.0 mV at l0-5M and 27.0 ± 4.4 mV at l0-4M amiloride in controls as compared with 1.0 ± 1.3 mV, 7.4 ± 1.9 mV and 18.9 ± 3.4 mV in patients, respectively. The lesser amiloride effect in CF was significant at lo-SM (P<.01) and l0-6M (P<.05) amiloride and suggests alteration of Na channels in CF. (Supported by NIH Grant AM-10956). The effect of a high protein (2.5g/kg/d) diet consisting of lean meat, fish and poultry on the mineral status of 10 obese adolescents was studied. The diet was continued for a total of 3 months and was supplemented with minerals and vitamins. K, Mg and Ca balances were measured during the baseline and after 2 weeks on the diet. Total body potassium (TBK) and red cell (RBC), Kand Mg were measured during the bascl ine 7 at 2 weeks and 60-90 days. Nr.> change was seen in Ca balance; the data for Mg and K are given below. Of particular note is the absence of any significant change in RBC K despite a significant fall in TBK. Over 95% of TBK is in cells. It follows since there were no cl1anges in hemoglobin, 11ematocrit or red cell count, that in this model the red cell does not reflect the K changes in other cells. Although there was no worsening of Mg balance after 14 d on the diet there was a consistent fall in RBC and serum Mg (from 1.82±011 to 1.68±0.08 mEq/L). Both values are still within normal ranges but the falls are of particular note in light of the obese adults who died of ventricular fibrillation on liquid protein diets. Sci. 119:1109 Sci. 119: , 1965 . A similar event was identified in two children who developed metabolic acidosis and peculiar neurologic symptoms in response to increased dietary carbohydrate after major small bowel resections. Both children were found to have t·lcvated plasma levels of D-lactic acid (4.0-9.87 raM/L, normal 0. 05-0. 07 mt1/L) • Acid-bast· and ncurologic abnormalities respondvd immediately to neomycin therapy. runongst a number of microorqanisms isolated from stool cultures of these patients, one THI is thought to be uncommon; gastrointestinal manifestations have only recently been recognized, and potential small bowel lesions have not been defined.From a group of 370 children evaluated for chronic diarrhea in a subspecialty clinic over a 5-year span, we identified 40 patients with THI (10.8\). Criteria for diagnosis were: reduction in one or more of the 3 major immunoglobulins (lg) of 2 S.D. or more below the mean for age, absence of nonspecific gut protein loss, presence of specific antibody production, and subsequent rise in lg levels with age. Investigation of diarrhea included small bowel biopsy in 26 patients; normal mucosa was present in 14, patchy enteropathy in 7, and partial or severe diffuse villous atrophy in 5. Duration of diarrhea was similar in those patients with and without histologic abnormalities (16-1-ll vs 2 mos.). lg deficiency was prolonged in patients with patchY enteropathy as compared with patients having normal bowel mucosa (36.8+9.0 vs 17.2+8.0 mos., p<0.01). Six patients had serial small bOwel biopsieS over a mean observation period of 39 months; in 4, repeat biopsies were normal. In 65\ of patients with THI, diarrhea resolved before Ig began to rise. CONCLUSION: 1) These data describe for the first time the histologic spectrum of enteropathy associated with THI, 46% of patients having patchy or diffuse villous lesions; 2) chronic diarrhea may be the sole clinical manifestation of THI; 3) small bowel mucosa! abnormalities in THI are associated with more prolonged lg deficiency. To compare the effect of human colostrum (l-3 days) and mature milk (314 + 150 days) on PMNL function, Ficol l-Hypaque separated PMNL from bl cod of 78 heal thy volunteers were i ncubated with whole colostrum, colostral lipid and colostral aqueous phase from 39 mothers or with mature whole milk, and its separated components from 39 mothers and tested for resting and zymosan stimulated oxidative metabolism, functional activity and the presence of Fe receptors. Stimulated oxygen consumption, quantitative NBT dye reduction, 1-14c glucose utilization and Fe receptors were significantly (p<0.05 to p<0.001) less in PMNL exposed to whole human colostrum or colostral 1 ipid than in non-lipid exposed cells or cells exposed to the aqueous phase of colostrum. In contrast PMNL exposed to whole mature milk or to its lipid or aqueous phase had no significant decrease in any of these parameters when compared to non exposed cells. In assays of phagocytosis, colostral PMNL or blood PMNL exposed to colostral lipid had a significant (p<0.001) decrease in their ability to ingest 3H methyl thymidine labeled S. aureus when compared to non-1 ipid exposed PMNL. Blood PMNL exposed to lipid from mature milk had no decrease in ability to ingest S. aureus. Lipid or lipid soluble material present in human colostrum but not mature milk causes inhibition of phagocytosis and respiratory burst related activities in PMNL. Supported by NIH grant HD13021. critically ill children. In order to better define the effects of these depletions, we related them to physiologic stability. The nutritional status of 60 critically ill medical patients with normal hydration status and without chronic organ failure was evaluated by anthropometric techniques within 48 hours of admission to the ICU. Daily assessments of physiologic stability were done using a new, validated, scoring system (Physiologic Stability Index, PSI) based on the degree of abnormality of 34 physiologic variables (e.g. BP, HR, CVP, PCWP, cardiac output, ABG's electrolytes, ICP, Glascow Coma Score). Overall, the incidenc·e of nutritional depletion was acute PEM -13%, chronic PEM -10%, fat store depletion -38%, and somatic protein store depletion -8%. Pts. with acute PEM had PSI scores indicative of more physiologic instability (higher scores) compared to pts. without acute PEM. Chronic PEM and depletion of fat or somatic protein stores were not significantly associated with high PSI scores. We conclude that critically ill children with acute PEM have a higher level of physiologic instability compared to children without acute PEM. Acute PEM seems to be a contributing factor to this instability. This information is important in evaluating the need for nutritional therapy. We studied specific features of emotional adjustment in children age 8-16 with abdominal pain. In 4 study groups I) Crohn's disease, n=24 2) ulcerative colitis (UC) n=20 3) non-organic, recurrent abdominal pain (RAP), n=l6 4) healthy school children, n:=30, we used a self report technique to measure self-esteem, helplessness, self-blame and depression as well as psychological stress occurring in the year preceding onset of symptoms. Controls were similar with respect to age, sex and socio-economic status. Compared with controls, children with Crohn' s disease demonstrated depression (p( O. 025) and low self-esteem (p<0.005); those with UC, depression (p<0.05); and those with RAP, very low self-esteem (p<.O. 005). Incidence of stressful events also differentiated the 4 groups (pr 49 days. Both A and L, however, rose> to control levels after 14 days. Lactase declined in all rroups after 7 days. Witl1 restricted feeding, both malnourished and control pups had higher di.saccharidases. Pan. enzymes showed n<1 distinct pattern. Differences in BW, Int. and Pan. masses were maintained throuAhout subsequent feedings. Roth restricted fed groups were lower compared to the corresponding ad lih groups. (A) increased hy 14 days, hut (L) remained dc- Serial serum prealbumin (PALB), albumin (ALB), transferrin (TF) and retinal-binding protein (RBP) concentrations were prospectively monitored to evaluate 1) relationship of serum protein concentrations to disease activity and 2) visceral protein response to therapy in 7 hospitalized children with Crohn's disease (5) and chronic ulcerative colitis (2). All children (9.5-15.5 yrs) presented with weight loss (range 4-13 kg) which reflected a 10-25% change in body weight and had clinical scores consistent with severe disease. Therapy consisted of bowel rest, intravenous prednisolone, 1.5 mg/kg/d (maximum 60 mg/d) and parenteral nutrition. Parenteral nutrition was administered for a x 34 days and provided a minimum of 55 Kcal/kg/d and 0.3 gm N/kg/d. Serum protein concentrations were determined in duplicate utilizing a radial immunodiffusion technique. Prior to therapy, PALB ar.d RBP were abnormal in all children. Despite the severity of the disease, 5 of 7 children had normal ALB, and 7 of 7 children had normal TF concentration. PALB, ALB and RBP normalized with therapy. PALB was the most sensitive indicator of disease activity and response to therapy. During followup, a decrease in PALU preceded clinical signs of disease activity, suggesting that it may be useful as an objective parameter for prospective monitoring of children with inflammatory bowel disease. There is a considerable interest in the biological importance of taurine particularly in species dependent on a dietary source. is cholestatic in the rat while taurine conjugates have no cholestatic properties suggest that the glycine/taurine (G/T) ratio of conjugated bile acids may be an important determinant of certain forms of cholestasis (Gastroenterology 80:233, 1981) . Thus it was of interest to explore the role of taurine supplements in the guinea pig which conjugates over 90% of its bile acids with glycine. Body weight, liver morphology, bile flow and bile acids were monitored at 1,3,5,10 and 21 days in 4 groups of 20 animals each. Although the exact pathophysiologic defect remains to be determined, the data are consistent with a disorder in the final assembly or secretion of chylomicrons. >IO 6 (8%) /l;ri Ind 6 (8%) Others 2 3% No cases occurred in February. Twenty-one 27% were < 1 yr of age; the youngest were twins who developed bloody stools at age 3 days; they were otherwise well. Diarrhea with or without blood and mucus, abdominal pain, & fever were prominent. Unusual presentations included: fever and abdominal pain without diarrhea in 2 cases; asymptomatic rectal bleeding, without diarrhea -1 case; 1 case; dehydration followed by hemolytic uremic syndrome -1 case. Most cases were outpatients. Thirteen presented with chronic diarrhea of several weeks duration. Campylobacter is a coITTTion pediatric pathogen with protean manifestations. The metabolic effect of oral feeding with 1.3 g/kg bw lipids EFFECT OF ORAL with an appropriate birth-weight (AGA) and to 7 AGA preterm neonates. Plasma glucose concentration rose from (m+sern) 65 3,5 to 80 + 5,5 mg/dl at 30 minutes and 86 + 5 at 60-minutes.-While no change was observed in the control-group, this glycemic effect was found also in AGA term and preterm infants. In term SFD infants, the disappearance rate of glucose in plasma after the lipid load 1,24% per minute was similar to SFD control infants. The lipid load produced no change of insulin/glucagon molar ratio in SFD infants. SFD infants ( + 220%) than in AGA infants ( + 40%) . These data show that lipids with 67% MCT increase the blood levels of glucose and KB in SFD infants. They suggest that the rise of glucose is due to stimulation of gluconeogenesis. Forty-four children with irritable colon syndrome, diagnosed because of frequent, small stools without evidence of infection or malabsorption, seen over a three year period, had an average age of 23.9 months and duration of symptoms of 11.3 months. They were treated with a high fiber diet and counseling to assure the parents their child was not ill, the stooling pattern was not harmful, and enhanced dietary bulk would improve the symptom. They were instructed that this was not a "diet" but a pattern of healthy eating for both children and parents. The outcome, one to three years after the initiation of the diet, was evaluated by questionnaire, and 26 responded. Compliance with the diet was good; an 89% increase in fiber foods was observed. This increase did not reflect a general liberalization of the diet although many patients had been on elimination diets. For example, dietary fat, considered by some to be important in the pathogenesis of this syndrome, increased only 13%. These changes in diet resulted in marked improvement of the stool number and character, as noted in the Pediatrics, Oklahoma City and *Department of Pediatrics, SUNY UpState Medical Center, Syracuse, New York. Vigorous supportive therapy has led to the survival to reproductive age of an increasing number of cystic fibrosis (CF) patients. Because the breast is a modified sweat gland and the electrolyte composition of sweat is abnormal in CF, concern has been expressed that CF breast milk also might contain high levels of Na an 25ng/ml, his urine cleared of abnormal organic acids and his leukocyte enzyme activities returned to normal. Enzyme activities and urinary organic acids remained normal after 6 wks of biotin at 300 µg/d (U.S. RDA). Although developmental delay and ataxia continued, a CT scan of his brain and an EEG were normal. The present case is the second report of biotin deficiency in a child caused by dietary indiscretion and indicates that the biochemical abnormalities may precede the cutaneous symptoms. Furthermore, it reemphasizes biotin's important nutritional role. 603 Sh an Sun, Zane i da Aranda, Kam torn Vangvan i ch akorn. Span. R. Levine New Jersey Medical School, Dept. Cronen et al (1981) reported that lndomethacin reduced mucosa! blood flow of stomach and terminal ileum by 50% in dogs and the area of ischemia in this animal model corresponded to clinical pathology noted in NEC. Prompted by this observation, we reviewed the outcome of our neonates (BW 500-1500 gm) who received lndomethacin during the past 5 years (1976) (1977) (1978) (1979) (1980) (1981) Juvenile multiple carboxylase deficiency (MCD) produces characteristic clinical findings of altered biotin metabolism (ataxia, alopecia, lactic acidosis, dermatitis, keratitis) associated with subnormal plasma and urinary biotin. A 5 yr old WF developed this syndrome in spite of a normal dietary biotin intake and required biotin supplementation to remain symptom-free. To investigate the source of her biotin abnormality, biotin (10 mg/day) was discontinued and her biotin absorption and excretion kinetics were measured. After 30 days she showed increasing signs of irritability; at 35 days an erythematous periocular rasil at 42 da}S she complained of muscle pains. Acidosis, ketonuria and ataxia did not occur. A friable hypopigmented longitudinal band 10 mm long appeared at the growing end of her hair following this period. Plasma biotin declined from 29,639 pg/ml (while on 10 mg biotin/ day) to 143 pg/ml (on day 42). (Nl 200-500 pg/ml) Urinary biotin declined from 30 1,g/mg creatinine to 25. 9 ng/mg creatinine in a biphasic manner (Ta l/2=2d; Tb l/2=8d). Plasma biotin concentration measured 1 hr and 24 hrs after orally adminstered biotin was:290 and 155 pg/ml (after 0.1 mg biotin); 2970 and 254 pg/ml (after 0. 25 mg biotin); 6187 and 343 pg/ml (after 0.5 mg biotin). Thus this patient requires 0.25 mg exogenous biotin per day to maintain normal plasma biotin. This is 2.5 times the average daily adult requirement. 24° urinary biotin excretion equalled 10% of each inoose, Tbese fJ'ndiags support defective intestinal biotin absorption 1n Juven1 e Meo. Various tests have been advocated to distinguish between neonatal intra and extra-hepatic cholestasis. Of these, liver biopsy (LB) has been the most valuable. The purrose of this study was to confirm earlier reports that PS can replace LB to exclude extra-hepatic biliary obstruction (EHBO). Ten infants with NC were studied with routine tests besides PS and J.B. Nonvisuali!;ation of the isotope in the bowel at 24 hours was taken as evidence of total obstruction (TO) consistent with EHBO. Eight patients had PS before and after at least 10 days of medi· cal treatment with phenobarbital and cholestyramine. In the remaining 2 patients, only one PS was done following at least 3 days of medical therapy. Percutaneous liver biopsy was done in all. Comparison of results of these two procedures in correctly identifying EHBO are shown below. Our results indicate that PS give positive results of EHBO if severe intra-hepatic c1:olestasis (IHC) is present even after a course of medical therapy. If LB was not done to confirm the diagnosis, 4 patients would have been subjected to unnecessary exploratory laparotomy. So LB is still the most reliable test available to differentiate between IHC and EHBO. G. Graham, Johns Hopkins Univ., Dept.of Pediatrics, Baltimore. Premature infants (1250-1750 g) were randomly assigned to receive standard formula (9% prot. Kcal., 82:18 casein-whey) or one identical in energy and mineral content but with protein level similar to breast milk (6% prot. Kcal.). The assigned formula was begun at 8 days and infants were followed to discharge with daily weights, 2 x wk anthropometric measurement of linear and circumferential growth & 4 skinfolds. Plasma proteins, amino acids, and total body water by H2l80 isotope dilution were determined at start and q. 2 wks. If wt gain was judged, double-blind, to be clinically unsatisfactory, all measurements were repeated and 9% formula was given. Five infants on the 6% diet had less wt gain and higher energy cost of gain during the first 8-10 days. Thereafter, 2 infants continued on 6% diet and 3 others changed to 9% formula attained a wt gain and energy cost of gain similar to 5 infants continuously on the 9\ diet. The rate of wt gain increased and energy cost decreased with age for all infants, but over 25 days the 2 infants continued on 6% formula had consistently lower linear growth despite a similar skinfold thickness increase suggesting greater fat accumulation in relation to smaller body size increment. No consistent differences among diet groups were observed in TBW as % body wt, total amino acids, ratios of essentials to totals or plasma proteins. Feeding healthy prematures this 6% prot. Kcal. formula is associated initially with inferior wt gain and greater energy cost of growth and, if continued, with inferior linear growth. Support: USDA/SEA #78-50-2243-0-1-129-1. Total body water (TBW) measurement in infants requires isotope safety, accuracy from small samples, least invasive procedures and adjustment for any intra-study feeding. H2l80 isotope is stable and has minimal isotopic effect compared to deuterium. Automated mass spectrometric analysis for 180/160 ratio of sample volumes from 1 ml down to 0.05 ml showed similar variability (average S.D. of TBW estimates <±1.0\). Oral H218o administration and micro Although the clinical association of GER and obstructive pulmonary disease is well established, the physiologic mechanism that results in airway obstruction is unclear. This study was designed to evaluate the effects of intraesophageal and intratracheal acid on airway resistance in the cat. Anesthetized cats breathed spontaneously a hyperoxic gas mixture(50%02) through an endotracheal tube. Upper and lower esophageal sphincters were located by manometry. Intrathoracic pressure(P) was measured by intrapleural catheter, air flow(V) by pneumotachograph and Jung volume(V) by flow integration. Total pulmonary r.esistance(R) was calculated from the simultaneous measurement of P,V and V. Results show: I) Esophageal instillation of up to IOcc of 0.2N HCl at various levels produced no significant change in R from control. 2) As little as 0.05cc of intratracheal 0.2N HCl produced an instantaneous increase of 455%+70%(mean+SE,p<.OOI) from baseline resistance,an effect which was reversible by I minute postinfusion. In contrast, up to 0.5cc of intratracheal saline had no effect on R. 3) Bilateral cervical vagotomy abolished the response to intratracheal acid. Conclusion: These studies demonstrate a dramatic vagally mediated reflex bronchoconstriction following minute quantities of intratracheal acid,but no effect on airway resistance of esophageal acid alone. The results suggest that acid-induced bronchospasm may occur in GER without clinical evidence of aspiration. The relationship between serum ceruloplasmin, the major copper containing protein in serum, as measured by radial innunodiffusion, and copper oxidase (J. Lab. Clin. Med. 58:161, 1961) , which is a measurement of the oxidizing capacity of ceruloplasmin, was serially determined in 31 relatively well, growing premature infants over the first 16.5 weeks of life. Mean birth weight of infants was 1230gms. (range 820-1560gms) and mean gestational age was 30.l weeks (range 26 to 33 weeks). A total of 134 ceruloplasmin and copper oxidase measurements were compared using linear regression by the method of least squares. Correlation coefficient between the two tests was r=. A score of 0 (no significant deviation from norm for age) to 3 (significant deviation from norm for age) was given in each of 10 categories: % ideal body weight, % weight change, percentile for weight/height, right triceps and subscapular skin fold thickness, arm muscle circumference, skin tests (dT, Candida, and transferrin, and absolute lymphocyte count. Absolute lymphocyte count was not found to be a helpful indicator of nutritional deficiency in any age group nor was percent weight change in the child under two years of age. A minimul of 5 tests or 15 possible points had to be scored for the assessment to be considered reliable. Actual points scored was divided by total possible points and a percentage score was derived. Scores of <20% were considered indicative of normal nutritional status, 21-35% mild, >35-50% moderate, and >50% severe malnutrition. Serial assessments were used to quantitatively document the nutritional progress of patients hospitalized for longer than two weeks. Using this assessment, children hospitalized for deprivational failure to thrive, for example, generally displayed preservation of visceral proteins, but depletion of body fat, decreased arm muscle circumference and ultimately poor growth depending on the duration and degree of the deprivation. intestinal rinse (SIR) tryptic activity and SIR iBSA were measured after four hours. Plasma from the trypsin-BSA treated group hRd significantly less (p<0.005) iBSA (0 ug/ml) than the saline-BSA (4.72:_0.8 ug/ml) and aprotinin-BSA group (7.42:_1.2 ug/ml). SIR tryptic activity was significantly increased (p<0.05) and SIR iBSA significantly decreased (p<0.005) in the trypsin-treated animals compared to controls and aprotinintreated animals. In additional studies, newborn (n=29), two (n= 11) and four (n=8) week old rabbits were given aprotinin or saline followed by gavage with 200 mg BSA/100 gm body weight. The newborn and two week old animals treated with aprotinin had significantly increased plasma iBSA compared to saline-treated controls (p<0.001). However, no plasma iBSA was detected in any four week old rabbit. These studies suggest that pancreatic function may influence the uptake of intestinal antigens r.arly in life, but later in development it does not appear to be as important in protecting tt1e animal from antigen absorption. 612 Jon A. Vanderhoof. Dean L. Anton"on. and Carol R. Lactose has recently been shown to enhance lead absorption. Because lead intoxication is most common in infants and young children at an age when dietary lactose is great, this study was conducted to determine if the presence of intraluminal lactose or its constituent monosaccharides enhance lead absorption directly, or whether this effect occurs indirectly through chronic stimulatory affect of dietary lactose on the mucosa. Fourteen 150 gm Sprague-Dawley rats were given 10% lactose in their drinking water for four weeks, 14 control rats were p,iven sucrose. Ten cm of proximal and 10 cm of distal small intestine in each animal were perfused by recirculation for two hours at 1 nil/minute with a 125 mM NaCl "olution containing 1 mcg/ml of lead DIMIT (3,5-dimethyl-3'-isopropyl-L-thyronine), an analogue of tri-iodothyronine (T3), crosses the placenta readily and exerts thyromimetic effects upon the maturation of fetal liver and lung. DIMIT (5µg/100g BW) was injected into pregnant Sprague-Dawley rats on days 17-20 of gestation; DWIT or T3 (10,5(lµg/100g BvJ) were oiven to sucklin0s on days f-7 (I) and 11-1' (II). All were killed 24 hours after the last in.iection. Sucrase activity (SA) was increased in all small intestinal segments[proximal (P), middle (M), distal (D)] in the fetuses and older sucklings (Group II). In Group I the effect was seen only in the M and D segments. In Group II the response was greater, and the effect 0f DIHIT equaled that of T 3 . Sucrase Activity ( .54 ±.12H .01 ±.01 .17 •.05+t .03 ±.015 X ±SEM (n=6/group) t p < .05,ttp < .002 from control. Conclusion. DIMIT and T 3 have a maturational effect upon sucrase activity in the SI. The lack of sucrase reactivity in proximal segment of the 8-day-old sucklings is noteworthy but unexplained. Five term infants with appropriate birth wts fed Similac 20, a "humanized" cow's milk formula (P 39 mg/dl, Ca:P ratio 1.2:1) had hypocalcemic tetany at 5-9 d. Initial serum Ca (mean±S.E.) was 6.8±0.12, P 9.5±0.2, and Mg 1.6±0.1 mg/dl, and parathyroid hormone (PTH) was elevated 78±14 µlEq/ml (RIA 1-84 PTH, Ni57). On restoration of normocalcemia with Ca supplements, feeding was resumed with "humanized" formula. Controls were 18 term exclusively breast fed (breast milk P 10-14 mg/dl Ca:P ratio 2.3:1) infants 3 wks. to 6 mos of age. In tetanic infants, relative hypercalcemia 10.4±0.05 mg/dl occured at 6 wks (vs. 9.2±0.3 in breast fed, p<.025) till 12 wks; relative hypermagnesemia 2.26± 0.01 mg/dl occured at 4 wks (vs. 1.92±0.07 in breast p<0.05) till 8 wks. Mean serum P declined steadily to 6.2 mg/dl at 16 wks (n.s. vs. breast). Mean serum PTH progressively rose to 74, 73, 143, 103, 96 and 75 µljEq/ml at 2,4,6,8, 12 and 16 wks (vs. mean 28 to 35 in breast p< 0.005). Serum calcitonin ranged <10-118 pg/ml (N < 107), 250H vit D were 25-63 ng/ml (N 11 to 63), and l ,25(0H)2 vit D 12-60 pg/ml (N 11-85 pg/ml). We speculate that acute hypocalcemic tetany was induced by the relatively high P load even in "humanized" cow milk formulas (vs. breast milk); with continued P loading, serum PTH rises as secondary hyperparathyroidism develops, maintaining normophosphatemia and eventually resulting in relative hypercalcemia and hypermagnesemia. In preterm infants, the bile acid(BA) pool increases nearly two-fold from 11-35 days independent of dietary regimen(ie, human milk(HM), formula(F1l.F1 supplemented with taurineOO umoles%)(F2),or F1+ Taurine + Cholesterol 12.7mg/dl(F3) whereas,maintenance of BA conjugation with taurine requires HM or taurine supplementation (Pediatr. Res.14:512, 1980) . In these previously studied infants and 41 additional preterm infants fed the same dietary regimens from 3 days of age, intraluminal BA concentrations were higher by II days of age in the HM fed vs. F1,F2 or F3, 8.1±_1.3 vs. 4.0±_1.0, 2.5±_0.5 vs. 4.3±_0.5 mM (p.R (1-24) months duration were e•1aluated for the presence of gastroesophageal reflux (GER). A history of vomiting was present in 8. GER was documented in all 19 patients; barium swallow was positive in 18/19, 99m-TC sulphur colloid scan was positive in 19/19, manometry was positive with lower esophageal sphincter pressure less than 15 in 9/15 and endoscopy (with or without biopsy) was positive for esbphagitis in 14/16. Three patients had 2, 10 had 3, and 6 tests. Al 1 patients were treated with alginic acid-antacid combination and routine medical management and 14 were seen 6 weeks later. Seven of 10 previously anemic had normal hemoglobins and 3/5 with previous pneumonias had not had subsequent pneumonias. One child died and one child required fundoplication. Conclusions: 1. Severely retarded children with these symptoms even in the absence of vomiting have a very high incidence of GER. 2. The simplest tests, barium swallow and nuclear medicine scan, may be adequate in this group. 3. These children have a very high incidence of esophagitis. 4. Medical treatment is difficult. Two different isotc;°pes are used simultaneously in each study to measure Ca kinetics by determining time dependent changes in Ca isotope ratios for each tracer relative to a third isotope at natural levels. Measurements are made on aliquots of Jiet, plasma, urine and feces. Physiological rates of absorption, urinary and fecal excretion, as well as bone deposition and resorption are calculated from the kinetic data. Results of studies with a subject with dystrophic calcification (A), a patient with osteogeni8is imperfecta (B) and a normal neonate (C) are reported here as fractions of total Ca turnover (g/kg.day). There were no observable differences between the rates of dietary absorption and bone resorption as functions of turnover for subjects A,B, and C. The values for urinary (vu) and endogenous fecal (vf) excretion and bone deposition (v 0 +) showed marked differences as functions of turnover: In contrast to the relative inactivity in utero, after birth the SI becomes highly active in absorbing dietary nutrients. The adaptation of BF during this period has not been studied. We evaluated growth and BF of SI in the perinatal period from difference in weight and BF of fetal (120-140 gestation) and (5-32 day old) lambs proximal jejunum (J) and distal ileum (Il). BF was determined from amount of radioactive labelled microspheres (12-15 µM), injected into the left ventricle, trapped in the microcirculation of SI. Portions of J and Il 18 cm long, were flushed with 150 mM NaCl solution and air and weighed. In alternating 3 cm long segments weight and radioactivity were determined in full thickness wall (W) 4. 54 1.45 As expected, both weight and BF of SI increased in the neonatal period. However, while in .I weight of M increased 1.5 fold, BF increased 3.5 fold, in 11 both weight of Mand BF increased 2.5 fold. The true significance of the discrepancy in increased weight and BF between J and Il in the neonatal period is unknown, but could be related to differences in functional properties of J and Il. In SBR growth of the remnant intestine is enhanced. We evaluated the effect of route and type of nutrition on growth of the St, Ce and Co in rats with >85% SBR. After surgery rats (140-170 g) were nourished orally ad libitum with a regular laboratory rat chow (Ch), or Flexical (Fl) or by vein with Travenol (T) along or in combination with oral Ch or Fl. A group of sham operated ( C) rats were treated as the SBR rats. Growth was assessed as difference in weight and weight/body weight ratio of the organs between C and SBR rats, 8 days after operation. At the time of study organs were weighed free of contents. The change in body weight (6, g) and organ weight ( Familial hypercholesterolemia (FHC) is associated with severe premature coronary artery disease, death, and is resistant to conventi0nal dietary treatment. Locust Bean Gum (LBG) iu food products was fed to children and adults with familial hypercholesterolemia. Twenty-eight children and adults (20 FHC, 8 N) were divided into two groups, using a cross-over design, and fed identical food products with and without LBG (8-30 gm/d) as outpatients in four-week periods. Diet records, food consumption, lipids, and lipoproteins were analyzed every two weeks. Total cholesterol was lowered 11% (m 275 to m 246) in Group A at four weeks and 16% (m 255 to 111 215) in Group B at six weeks (p < . 01). The difference in cholesterol between the LBG and control diet was 19% at four weeks (p< .01). l.01< -density lipoprotein (Ln!.) fell 10% at four weeks in Group .\ and 20', at six weeks in Group B. IIDL/LDL ratios increased. LBG food acceptance was good. There were no significant side effects of the diet. LBG was more effective than several pharmacological agents in lowering serum lipids, and, in outpatieats, appears to be one of the most effective dietary treatments of FllC. LBG in food products appears to be (; safe, effective means of lowerinP, serum lipids in normal and hypercholesterolemic children and auults in HIC-type families. courses of PN were employed in the treatment of 12 hospitalized patients with AN. All patients were more than 40% below ideal body weight and were unable to maintain their weight with intensive inpatient psychological and nutritional counseling. The average length of PN was 20 days (5-45). 3 patients required more than one course. Improvement in lethargy and affect occurred in all within 48 hours, and prompt improvement in psychotherapeutic progress was noted in 7. The most frequently encountered problems were catheter associated (6), failure to maintain ordered infusion rates (5), pneumothorax (2), rash (2), congestive heart failure (2) and liver toxicity (2) . There were no episodes of infection. PN was decreased and subsequently discontinued as food intake improved. The parenteral caloric intake provided a reliable guide to educate the patient as to oral caloric needs. Follow-up revealed no recurrence of weight loss and continued outpatient progress in 8 of the 11 teenagers who have been discharged. Although not without problems, PN is a relatively safe, effective method of treating severe weight loss in AN an.05). Of the infants <15019 and requiring ventilation, 5/15 DSPLY and 0/12 CONTROLS were living, extubated, and in room air at age 1 wk (p<.05). The elapsed times from abnormal pH to the next gas, to an improved pH, and to a normal pH were: Next Gas* Improved pH** Normal pH*** CONTROLS 96±10min 243±3lmin 421±45min DSPLY 88±6 min 173±15min 321±32min t-test *p>0.3 **p<0.05 ***p<.10 Fewer trends worsened in DSPLY (38/222 trends) than in CONTROLS (36/136) but more trends were overcorrected in DSPLY (12/222) than CONTROLS (1/136) (p=.03). The computer generated display was thus associated with improved outcomes in very low birth weight, ventilated infants, due to more rapid and improved physician responses to abnormal pH values. of Pediatrics, San Francisco, CA. We have developed a program on our pediatric ward in which parents are encouraged to "room in" and participate in the care of a hospitalized child. The parent of any child may participate in the program, regardless of the child's diagnosis or acuity. Staffing of the unit is based on acuity and is not modified by parent involvement in the program. A 5-item Likert-type questionnaire was developed to survey the effects of the program as perceived by medical and nursing staff. Although the nursing staff constantly interfaces with parents in the program and might be expected to have sharper criticisms of it, we found no significant differences between their responses and those of the medical staff. Eighty-seven percent of the staff felt that the program made their jobs easier; 7% felt that it made their jobs more difficult; 63% felt that the program improved their efficiency, while 13% felt it decreased efficiency; 33% thought the program decreased patient care errors while 11% thought it increased errors. Ninety-two percent felt that the time they spent with parents was satisfying while 8% found it frustrating. One-hundred Medical Center, Tulsa, Oklahoma. A black girl age 12 y and an unrelated black boy age 11 y had hyperactive reflexes, positive Chvostek, hypocalcemia, hyperphosphatemia, mental retardation, cerebral calcification. Serum parathyroid hormone (PTH) was increased and l,25(0H) 2 D was low normal. Diagnosis of pseudohypoparathyroidism (PHPT) type I was consistent with lack of increased urinary excretion of phosphate and after i.v. PTH. Both children had dental abnormalities typical of PHPT: enamel hypoplasia of permanent premolars and second molars; no eruption of permanent teeth (except lower central incisors in the girl) resulting in dentition as in a 6 y old child. In the boy abnormalities of teeth and serum were unchanged after 8 mo. of Vitamin D, 200,000-900,000 units p.o. every 2-5 weeks. The girl was treated for 8 mo. with l,25(0H) 2 D 1 (ROCALTROLR), lmcg p.o. daily. Her well being improved. Phosphare and calcium in serum became normal. Her primary canines exfoliated. Root resorption of remaining primary teeth increased. Eruption of permanent teeth resumed at a normal rate (retaining a 6 y delay). we conclude that teeth formed between ages 3-7 y (but not those earlier) suffered enamel hypoplasia. Hence PHPT seemed to reach clinical significance (with respect to teeth) when the patients were 3-4 y old. Enamel hypoplasia once it occurred could not be reversed. It might have been preventable if the patients had received l,25(0H) 2 D 3 before the age of three years. To describe some aspects of early sex education in U.S. families, 91 randomly-selected mothers of I to 4 year-Dld children were intereviewed at the time of well-child care in representative pediatric facilities. This age range was chc>sen because issues of sex differences and sexual identity are prominant during toilet training and the preschool years. The group was similar in racial and educational background to census data for the Cleveland area. 84% of the children were regularly exposed to adult nudity 0.50 had SI. The sensitivity of these 7 items for SI when combined with Hx and PE was 89%. This 7 item model, when used prior to Hx and PE is reliable, predictive, specific and sensitive for SI in febrile children. For maximum sensitivity, it should be combined with Hx and PE. • 647 CLJNICAL LABORATORY PROGRAM FOR PEDIATRIC RESIDENTS . In order to improve accuracy, save time and focus ICU personnel on physiologic monitoring of the critically ill patient, we have developed several programs for a relatively inexpensive programmable, conunercially available calculator. These include programs for calculations of: (1) Dilutions for constant infusion of frequently used medications such as dopamine, isuproterenol, nitroprusside, prostaglandins, etc. In order to avoid errors in data entry, safety flags have been incorporated. It is now customary for pediatric residents to take the Inrraining Examination (ITE) of the American Board of Pediatrics. oe reviewed our 10 yr. experience with the ITE in an attempt to determine if the performance on the exam during the PL-1 and PL-3 yrs. correlated with the performance on the written portion of the certification exam of the Board (ABP). We found that the peroentile rank during the PL-1 and PL-3 yrs. was significantly correlated with the eventual score on the ABP exam (PL-1, r•0.64; PL-3, r•0.44) with the PL-1 performance having a better predictive value. When the relationship between PL-3 scores and Board scores was examined it was found that 42% of the group scored at Least 10 points lower in the ABP; only 11% scored more than 10 >oints higher; 47% stayed within 10 points in the 2 exams. The >erformance of these 3 groups in terms of mean %tile scores was: ;roup with: PL-1 Score PL-3 Score Board Score io change 74 %tile 79 %tile 82 %tile >ecline in score 70 %tile 85 %tile 61 %tile lmproved score 74 %tile 62 %tile 90 %tile rhere was no way of predicting with certainty, from initial ;cores or PL-3 scores, the precise performance in the ABP. Even 1mong residents in whom PL-1 and PL-3 scores within 10 >oints of each other, 38% showed a deviation from this established pattern on the Board exam. Percentile ranks are subject :o change as a result of effort and emotional factors. In our >rogram the decrease in night call during the third yr. did not cesult in an increase in relative knowledge. • PEDIATRICS S PhiJJips, SB Friedman, J Parrish, & B Zebal Depts Ped and Psychiat, Univ Sch Med, Baltimore Three groups of residency programs were compared: 11 funded (F) to >rovide mandatory behavioral training, 7 not funded (NF) but providing nandatory training, and 6 controls (C) not requiring training. At the •eginning and end of academic year 80-81, 569 residents (70%) completed 1uestionnaires assessing attitudes regarding behavioral disorders (e.g., chool phobia), physical disorders (e.g., pharyngitis), and "mixed" disorders e.g., failure to thrive). Behavioral knowledge was tested by 60 multiple-:hoice questions. ANOV As evaluated amount of change, revealing that ·irtually all significant effects related to program type occurred in the 'L-2 year. Regarding attitudes, similar results were found for 3 measures: competence in management", "ability to advise parents", and "prediction ,f future relevance". Only Group F demonstrated significantly higher :hange scores for both behavioral and "mixed" disorders, relative to ·hysical disorders; F and NF were significantly superior to C regarding ·ehavioral disorders. A different pattern was found for 2 other measures: knowlege of resources", and "perceived faculty interest". NF change was ignificantly superior to F, which was marginally superior to C. Since F atings were higher initially, NF ratings became nearly as high as F by the ·nd of the year. Regarding knowledge, there was a trend in all 3 residency ears for Groups F and NF to show greater improvement than C. This was ignificant in the PL-2 year and marginal in the PL-3 year. These data emonstrate that changes in attitudes and knowledge are related to the resence of required training. Funded programs appear to generate the nost positive attitudinal effects regarding both behavioral and "mixed" isorders, though change was not dramatic. These data also suggest that he impact of Denavioral training is most evident in the PL-2 year. DEVELOPMENT It has been alleged that screening programs result in unnecessary diagnostic and therapeutic intervention. In order to test this hypothesis during a 3 year period we advocated rapid screening of mothers for colonization with GBS at the time of admission for delivery. Screening was performed at the discretion of the obstetrician caring for the mother, generating a screened (N = 6,324) and unscreened group (N = 2,422). Among the screened group 12.47. of mothers were GBS <:E} • Knowledge of culture status of each patient was made available to the pediatricians who would ultimately care for the newborn within hours of the mother's admission for labor and delivery. Prophylactic treatment was not advocated; rather, treatment upon recognition of symptoms was recommended. Under these guidelines 5.6% of infants born to mothers in the screened group vs 11% in the unscreened group were evaluated and treated for sepsis. Ratio of inf ants evaluated to those with proven sepsis was 9.1:1 in the screened group vs 11.3:1 in the unscreened group but 4.1:1 in the GBS (i) screened group. We conclude, that contrary to prevailing opinion, a screening program for GBS colonization did not increase the number of infants subjected to workup and treatment for sepsis, but significantly increased the sensitivity of the therapeutic decision making when culture status of the mother was known to the pediatrician. In the past years, we treated 71 children with AOM secondary to AmpR H.flu confirmed by myringotomy and culture of middle ear exudate. They ranged in age from 4 to 72 months (mean age 21.7 months); 9 6 months of age. At the time of myringotomy, 58 children (82%) had been receiving, or had recently completed therapy 3 days), with either ampicillin or amoxicillin. Cultures from all 71 children were plated on chocolate agar with bacitracin. A 10 µg ampicillin disc was placed on the streaked primary plate to select presumptive AmpR Hemophilus which grew near the disc. s-lactamase determination was done on all isolates. AmpR H.flu was recovered from all 71 children. Seven children (7/71) had myringotomy performed both before ampicillin therapy and on persistence of AOM. All 7 initially had H. influenzae sensitive to ampicillin recovered from the middle ter ampicillin treatment, when persistent AOM was diagnosed, AmpR H.flu was recovered from the middle ears of all 7. Antimicrobial therapy for persistent AOM included erythro/sulfa (38), TMP-SMZ (17), ceclor (13), and other (3). There was no apparent therapeutic superiority of one modality over the others as determined by the persistence of AOM. Simultaneous semi-quantitative throat cultures (TC) and nasopharyngeal cultures (NP) were obtained from 152 children. Sixtyfive were well with no recent exposure to antibiotic; 51 had purulent nasopharyngitis; 36 were seen at 10-day follow-up after ampicillin treatment of acute otitis media. All cultures were plated irrmediately on chocolate agar with bacitracin. A 10 µg ampicillin disc was on the streaked primary plate to select presumptive Amp Hem which grew near the disc. Over 18 months all inborn term NB who presented with bilious vomiting were transferred to the NICU. Seventeen NB presented within 72 hours (incidence 0.2%); work-up led to surgical intervention in 3 (2 malrotation, l jejuna! atresia). The remaining 14 rm were presumed to have TGD. TGD presented with bi 1 ious vomiting at <12 hours in 1 NB. between 12-24 hours in 9, between 24-48 hours in 2, and between 48-72 hours in 2. All 14 NB with TGD oassed meconium within 24 hours of birth; 3 had a meconium plug. Abdominal x-rays showed generalized distended bowel loops in 10 and normal gas pattern in 4. Eleven NB with TGD had normal contrast studies; the remaining 3 improved before contrast studies could be done. Eleven NB with TGD had negative septic work-ups; the other 3 were not cllnically septic and were not treated with antibiotics. Metabolic studies were normal except for 1 NB with hypocalcemia and 1 with hyponatremia. None of the mothers were given MgS04; 2 had demerol. One NB had fetal distress, 1 had a 1 min Apgar <3, and none were meconium stained. NB with TGD tolerated nipple feeding at a mean+S.D. of 4.3+1.5 days (range 2-6 days) and on clinical follow up had no subsequent GI Although bile-stained vomitus is thought to be uniformly an ominous sign, it is not invariably associated with surgical problems in the NB. Our data indicates that 82% of NB with bilious vomiting in the first 3 days of life had TGD; however, appropriate work-up is still necessary to insure early diagnosis of potential surgical lesions. The assumption that clinical diagnoses provide substantial information regarding the sequelae and treatment of chronic physical illness is based on the belief that great similarity exists among children with a particular diagnostic label. This hypothesis was tested using data collected at enrollment in a study of 209 children with diverse chronic physical illness. Data were analyzed on the child's functional status, impact of chronic illness on the family, child's and mother's psychologicRl adjust- Data comparing feeding and stooling patterns of breast-fed and formula-fed infants are not readily available in the literature. To provide such data, mothers of healthy, full-term infants (30 breast-fed, 12 bottle-fed) maintained diaries, recording each feeding and each episode of spitting and vomiting. Each stool was to be recorded, and the type of stool (formed, pasty, mucus or liquid) was to be noted. Diaries were maintained from nursery discharge to l month examination. (Statistical analysis was by Student's t-test or Fisher exact test. twotailed significance level.) Formula-fed infants were found to have fewer stools/day (2.5+1 .5 vs. 3.5+1 .4, p<.05) and their stools were usually either-pasty (62.5%) or firm (25.5%). Although 50.9% of the breast-fed infants' stools were described as liquid, nearly the same proportion (443) were described as pasty. The consistency of stools was more variable for formulafed infants than for breast-fed infants. Three or four different stool types were reported for 75% of the formula-fed infants while only 16% of breast-fed infants had more than 2 different stool types. (p<.001). Formula-fed infants were more 1 ikely to vomit (58% vs. 13% breast-fed, p<.01) and to experience greater number of episodes of vomiting/day. ( .199+.14 vs . . 113+.05, p<.05). They also tended to feed fewer times/day (6.7+-:-95 vs. 7 .5.:!:_l .7) but this difference did not reach statistical-significance. Members of medical team collected height (ht) and weight (wt) measurements from I ,650 children under I 2 years of age in Laotian and Cambodian refugee camps and in surrounding villages in Thailand. These ht and wt measurements were transformed to age-specific standard deviation (SD) values based on the U.S. reference data from the I st Health and Nutrition Examination Survey (!97 I-74). The mean values and percentages of refugee and Thai children whose measurements fell below -2SD value ( The refugee and rural Thai children had similar anthopometric measurements suggesting that their geographic and socioeconomic background is a major factor in the lower ht and wt of the refugee children. This contention is supported by existing growth reference data from Thailand and China which are approximately 1.5 SD lower than the U.S. reference. In evaluating the growth status of Indochinese refugee children against U.S. reference standards, one needs to take into account the lower ht and wt that is characteristic of Southeast Asians. Significant portion of refugee and rural Thai children have subnormal wt/ht ratio which is a more helpful index of undernutrition for these populations. The initial presentation and clinical course were reviewed in nine patients with glycogenosis lb. Eight of 9 had a significant incidence of infections including sepsis (in 2 patients), pneumonia (4), abscesses (4), wound infections (2), generalized pyoderma (2), recurrent otitis media (&), periorbital cellulitis (I), and osteomyelitis (I). Oral and anal mucosa! ulcers unrelated to the degree of neutropenia were a significant problem in 5/9. Aureus and streptococcus were most frequently isolated, but Proteus, E.coli and Pseudomonas were also cultured from infected sites. Eight of 9subjects exhibited neutrophil counts < 1500/cu mm3. However, seven patients were documented to have normal neutrophil counts during some episodes of infection. Abnormal chemotaxis was found in 5/5 and adherence was decreased in 2/2. Bone marrow examinations were performed in 7 patients, with one reported as normal, 4 demonstrating myeloid hyperplasia and 3 showing a myeloid maturation arrest at various stages of development. Five patients exhibited excessive epistaxis or bleeding from surgical sites. Although all patients had normal platelet counts, bleeding times were abnormal in 3 who were studied. Patients with glycogenosis lb exhibit an increased incidence of infections and bleeding. Further studies of neutrophils and platelets from these patients will increase our understanding of the metabolic basis for function of these cells in host defense and hemostasis. We have found a correlation between specific mutations and haplotypes obtained from seven polymorphic restriction sites in the p·globin gene cluster. Seven different mutations have been identified among 45 Italian ,6-thal genes; 6 of these were found among 42 Greek genes. An 8th mutation was found among 4 Turkish genes, and probably 4 new genes were present among 29 Asian Indian genes. Of the 120 genes 22 (18%) could be detected directly because either a) the mutation altered a restriction site [Hphl (8), Rsal (5), and Avril (l)}b) the mutation is a deletion (8). The mutation has been identified by DNA sequencing or restriction analysis in 35/122 (29%) of genes studied. The high correlation between specific polymorphism haplotypes and mutations allows estimation of the frequency of genetic compounds in affected individuals. Genetic compounds comprise about 85% of Italians and 50% of Greeks and Asian Indians with In our sample of 66 affected individuals there are 29 combinations of genes producing the disease. These data indicate that genetic heterogeneity is prevalent in leading to a high frequency of genetic compounds in affected individuals, and that prenatal diagnosis of j:!>-thal will usually rely upon linkage analysis of polymorphic restriction sites rather than direct detection of the mutations involved. We have prepared a cDNA library from poly(A)+RNA derived from human liver obtained at surgery. The cDNA was inserted into the PstI site of pBR322 using GC tailing. Recomhinants were screened using plasmid selection of mRNA isolated from human or baboon liver, followed by in vitro translation, immunoprecipitation and analysis by SOS gel electrophoresis. As many as 10 recombinants were screened on a sinqle DBM filter disk, and as many as 10 antisera were pooled at the immunoprecipitation step, so that a single lane on sos gel analysis could represent up to 100 tests. Positive signals were retested with individual recombinants and antibodies to identify each specific cONA. Studies to date have included antibodies against argininosuccinate synthetase, argininosuccinate lyase, arginase, a 1 -antitrypsin, albumin, antichymotrypsin, n 2 -HS-glycoprotein, antithrombin III, gC-qlobulin and apolipoproteins A-I, B and E. After screening 400 recombinants, we have identified the followinq cONA clones: >20 for albumin, >8 for a 1 -antitrypsin and 4 for apolipoprotein A-I. Identification rests solely on the antibody specificity at the present time. This library should be of general use for isolation of cDNA clones for moderately abundant human liver gene products for which antibodies are available. The a 1 -antitrypsin cDNA clones are being used to search for DNA polymorphisms which would be useful for prenatal diagnosis of a 1 -antitrypsin deficiency. The specificity of ganglioside neuraminidase was examined in fibroblasts fran patients with ML IV, their heterozygous parents and controls using roono-(Q-11), di-(GD:J.a & GD:J.b) and tri-(Gr1) sialo gangliosides radio-labelled in c 7 and C3 anal03s of their sialic acid residues. The release of sialic acid fran all four gangliosides was reduced in the patients fibroblasts (9-34% of control activity) and intermediate levels were found in cells fran the obligate heterozygotes (56-74% of control activity). However, the activity in the patients fibroblasts toward ™1 and GD:J.a gangliosides which contain only sialic acid linked to galactose was !IDre depressed than the activity toward GDJ.b and Gr1 gangliosides which contain an additional linkage of sialic acid to sialic acid. Analysis of the reaction products of cell preparations incubated with the various substrates have shown that control fibroblasts catabolized GT1 ganglioside mainly via GDJ.b ganglioside, presunably by cleaving first a sialic acid-galactose linkage. In contrast, cell preparations fran patients with ML IV converted GI'1 ganglioside !IDStly into GD:J.a ganglioside by cleavage of a sialic acid-sialic acid linkage. The apparent Kai values for neuraminidase activities toward Cl11 and GD:J. gangliosides were found to be 15-20 times higher in ML IV as canpared to those of controls. ML IV appears to be a ganglioside sialidosis due to catalytically defective, sialic acid-galactose specific, ganglioside neuraminidase. MO'!Ol"'.L0NA', ANTIBODIES TO THE CYSTIC FIBROSIS (CF) FAC-• 667 TOR AND ITS NORMAL COUNTERPART. Miriam Q. Blitzer and Emmanuel Shapira. Tulane Univ. Sch. of Med. '"he Hay-Genetics Center. Depts. of Peds. and Path. New Orleans. We recently described the purification of a glycopeptide with molecular weight of approximately5000 from sera of controls and CF patients. Both appeared to be very similar structurally. The purified glycopeptide from CF patients showed marked ciliary dyskinetic activity, whereas its "normal counterpart" had no apparent biological activity on rabbit tracheal explants. (PecJiat. Res 16, March, 1982) . In the present study the immunogenic and antigenic properties of the CF glycopeptide and its normal counterpart were compared. BALB/c mice were immunized with one of the glycopeptides and their spleen cells fused with X63NS1/l-Ag-4 (N:O ,) "'ouce myeloma cells. Six hvbridi zation experiments ( 3 with each glycopeptide) were in which different plating methods and screening assays were evaluated. Although an identical immun·· ization procedure was used, 53 hybridoma cultures producing specific antibodies to the control glycopeptide and only 11 producing anti bodies to the CF glycopeptide were obtained. The anti bodies from these cloned hybridomas were used to compare serum fractions from controls and CF patients (10 samples in each group). Indistinguishable immunological reactivity (antigenicity) between the controls and CF patients was demonstrated. These findings indicate that, although the CF glycopeptide and its normal counterpart differed markedly in their ciliary dyskinetic activity and in their immunogenicity, they revealed both structural and antigenic similarity. The genes for two enzymes involved in separate steps in the purine biosynthetic pathway are on chromosome 21, although the locus of the genes is not fully defined. Cytogenetic and biochemical studies on a family with an unusual translocation of chromosome 21 have provided further information on localization of the GARS locus on chromosome 21. The proband was referred for chromosome analysis to confirm the diagnosis of Down syndrome and was found to have one normal chromosome 21 and a structurally abnormal sub-metacentric chromosome interpreted as a t(21;21) non-Rubertsonian translocation, resulting in partial trisomy of chromosome 2lq. She was also mosaic for a minute dot-like marker. Cytogenetic studies on the phenotypically normal mother and sibling revealed 47 with a small supernumerary bisatellited marker chromosome in addition to the normal karyotype. Cell free extracts from sonicated fibroblasts cultured from the proband and her mother were assayed for GARS activity. The proband' s cells had approximately twice the activity of the mother's cells, a result consistent with a gene dosage effect. These results provide evidence that the locus of GARS is closely linked to the genes required for the expression of nown syndrome and is on the segment of the long arm of chromosome 21 which is trisomic in this patient. Three patients with PL have been evaluated and one of them also had MPGN associated with a 46,XX,del S (p21) chromosome constitution. Chromosome abnormality with PL and MPGN has not been previously reported. The few patients with Sp-syndrome in the literature may have been too young to exhibit the findings of PL at the time of reporting. According to the human gene map, the fibronectin (FN) gene is located on chromosome S. FN is a cell surface glycoprotein which is found on many normal cells including mesangium. In MPGN, FN is found in excess and C3 complement deposits are demonstrated in the same areas of mesangium. Therefore, the association of Sp-syndrome with PL and MPGN indicates the possibility of a genetically determined abnormal FN production. This may explain the occurrence of MPGN as a result of C3 complement binding to an abnormal FN causing dense deposit disease. An alternate explanation is that the genes for FN and PL are closely Patients with Sp-syndrome should be followed for possible development of partial lipodystrophy and renal disease because of the probable genetic mechanisms. bred rats did not show this PLI. To investigate the genetics of the syndrome and its relationship to the major histocompatibility complex of the rat, RTl, we crossed BB rats (RTl u/u) with inbred Lewis (RTl 1/1) or Wistar-Fruth (RTl u/u) rats. PLI was seen in 13-257. of progeny from both crosses in the Fl. ln the (Lew x BB) cross, PLI was seen in all three possible genotypes but was more common in animals with 1 RTl u haplotype derived from the BB. (Odds ratio= 3.8, p <.05). insulin-dependent DM occurred only in progeny of the (Lew x BB) in the F2 and subsequent gene- We have previously shown that three genes assigned to human chromosome 21 are also linked in the mouse and map to chrclmosome 16. These results suggest that mice trisomic for chromosome 16 may provide an animal model of human trisomy 21 (Down syndrome). Since trisomy 16 mice die before birth, we have aggregated trisomy 16 (Tsl6) embryos with diploid (2n) embryos at the 8-16 cell stage to generate viable chimeric mice with cells trisornic for chromosome 16. We have produced nine trisomy 16 +--+ diploid chimeras: five of these Tsl6 chimeras were in a group of fetuses sacrificed at 18 days of gestation and four were liveborn. All of the analyzed organs from the Tsl6 chimeras, including brain, liver, muscle, kidney, lung, heart, thymus, blood and bone marrow, contained Tsl6 and 2n cells. The proportion of Tsl6 cells in each organ, as estimated from coat color, enzyme markers, and/or karyotype, ranged from 5-70%, most commonly 20-40%. Of the liveborn Tsl6 chimeras, the oldest of which is now 6 months old, two appeared normal, one had unilateral anopthalmos, and one was severely growth retarded. One of the 1'sl6 chimeras sacrificed at day 18 of gestation t1ad the phenotype of a non-cl1imeric Tsl6 fetus. C>ur results indicate that it is feasible to generate viable adult trisomy 16 diploid chimeras which can be used to study the mechanisms by which trisomy 21 in man produces abnormalities of development and function. Argininosuccinic acid synthetase (ASAS) deficiency, the basic defect in citrullinania, can be diagnosed in cultured skin fibroblasts. Several laboratories have had difficulties in measuring this enzyme in cultured armiotic fluid (AF) cells due to low and variable activity. We have reported that strict control of tissue culture variables, especially the type of AF cell used and the degree of confluence of at-risk and control cultures, allowed us to diagnose an unaffected at-risk fetus. We have now diagnosed an affected fetus and confinned this diagnosis after termination of the pregnancy. ASAS activi!)' in cultured cells fran the fetus at-risk, as measured by 14{; citrulline/JH leucine uptake into TCA-precipitable protein.was less than 2% of control epithelioid AF cells (at-risk cells = 0.001, control epithelioid = 0.08 + 0.04, control fibroblastic = 0.48 + 0.28). In addition, an increased concentration of citrulline was found in the at-risk AF (0 .14;unoles/ml) as canpared to AF fran 6 controls and 1 atrisk unaffected pregnancy (trace). The in utero diagnosis was confinned by assay of ASAS activity in cUrtured fetal skin fibroblasts ( Bashan, and J. D. Schulman, NICHD, NIA, Bethesda, MD. Exposure of intact normal leukocytes to 0.25 mM Jss-cystine . Position effect related to the inverted segrrent could explain the clinical abnormalities. This has been p:>stulated in balanced translocations associated with deficits in language acquisition (AJO:: 133:1002, 1979>. It is also of interest that the interstitial deletion of llp associated with the aniridia-<111biguous genitalia -mental retardation {JIJJR) This report describes a 7 year old boy with a 3 year history of recurrent episodes of vomiting, acidosis, and coma. Althou9h electroencephalograms at ages 5 and 7 years showed generalized paroxysmal polyspike discharges, no seizure activity has ever been noted. In marked contrast to the clinical histories of previously reported children with glycerol kinase deficiency, the patient's neurologic exam is normal and his Stanford-Binet intelliqence scale IQ is 122. Since beginning a low fat diet, no episodes of coma have occurred. Family history is significant for migraine, hypertension and myocardial infarction. The patient's serum cholesterol, triglyceride, HDL, LDL, VLDL, and apolipoprotein levels (APOA-I, APOA-II, APO-B, and APO-CI!) were within normal limits, but serum acid phosphatase was elevated. Radiochemical assay of skin fibroblast glycerol kinase activity showed the patient's level to be less than 5% of control value. Urine glycerol is markedly elevated. The serum glycerol level of the patient ranges between 30-40 mg/dl, while those of the parents and two younger sibs are within normal limits. The pt. is an year old white female who weighed 2100 grams when born after a 36 week normal gestation. An occipital encephalocele was repaired at age 2 days; congenital dislocation of both hips was corrected at age 5 mos. The pt 1 s. height and bone age liave always measured more than 3 SD below the mean for age. At age The pt's. parents and female sibling appeared normal. Chromosome studies on cultured lymphocytes revealeddcl(Xp22.3) by G-& R-banding and prometaphase techniques in all cells examined. By BUdR technique the partially deleted X chromosome was late replicating in ten of ten cells examined. Chromosome studies of the parents and sib were normal. Xg(a) blood group family study was uninformative. Our data suggest that in females normal growth requires the presence of a double dose of Xp22.3-+pter, a chromosome region known to be near at least two other gene loci (Xg & STS) which regularly escape X chromosome inactivation. The physiokinetic properties of the residual acid p-glucosidase (1;-Glc) activities re characterized in cultured fibroblasts from Type l GD patients from six different ethnic backyrounds. Although the specific activities in all \iD fibroblasts were similar (5-12% of mean normal), the apparent Km (for 4-MU-pglucoside), thermostability (5U°C), and electrophoret1c (E) Recognition of the typical phenotype of the Klinefelter syndrome, which includes lack of normal virilization, tall stature, ew 1choid body proportions, small testes and gynecomastia, is generally delayed until the postadolescent period. We have observed two boys with failure to thrive, including delay in psychomotor development as well as somatic growth, with onset in early infancy who have a 47, XXY karyotype. other features include microcephaly, facial dysmorphic features, including micrognathia, flat nasal bridge, large and prominent ears, and biochemical abnormalities consistent with mild renal tubular acidosis in one child. Review of the literature reveals scattered reports of failure to thrive and/or renal tubular acidosis in boys with a 47, XXY karyotype. Although these may reflect chance associations, their frequency suggests that a subset of patients with Klinefelter syndrome can present with failure to thrive as a major manifestation. • 681. UNDESCRIBED We have recently evaluated two siblings with minor dysmorphic features, including prenatal onset growth deficiency, microcephaly, short palpebral fissures, and hallux valgus. Both manifest mild mental deficiency. Chromosome analysis of the family revealed that the mother was the carrier of an apparently balanced translocation between the short arms of chromosomes l and 4. The translocated material from the number 4 was inserted into the lp36.l band (46,XX,dir lp36.1::4pter+4pl2::lp36.l+ lqter; 4pl2-t4qter-,). Her two affected children had unbalanced karyotypes due to inheritance of the abnormal maternal number 1 and the normal maternal number 4. They are effectively trisomic for the segment 4pl2 to 4pter. Review of the literature reveals few similarities between the patients herein described and those previously reported with partial trisomy 4p, raising question as to the existence of a "partial trisomy 4p syndrome." Clinical variability may be due to the differing corresponding monosomic segments in affected individuals. The DiGeorge syndrome (DGS) is characterized by parathyroid and thymic hypoplasia/aplasia and cardiac conotruncus or great vessel malformations, usually in patients with mild facial dys-'·orphia. In three of fourteen patients with DGS whom we have karyotyped (six with banding) over fifteen years. we have found identical deletions of the short and proximal long arms of chromosome 22 (22pter-qll). The remaining long arm material of chromosome 22 was translocated to a different autosome in each with break points !Oq26, 3qter, and 20qll. All had classic DGS and few other anomalies despite being, respectively, partial monosomy lOq, partial monosomy 3q, and partial trisontt 20p, in addition to partial monosomy for 22. The chromosome 22 deletion in our patients appears to be identical to that reported by de la Chapelle et al. (Hum Gen 57:253, 1981) in four children with DGS in one family. Several other reported patients with partial or full monosomy for chromosome 22 have had incomplete forms of DGS. To our knowledge, no patient with complete DGS has had a chromosome rearrangement not involving chromosome 22. Taken together, our patients and other reports suggest that a gene or deletion of genes on chromosome 22, most likely at 22qll, is responsible for some cases of DGS. Our personal experience indicates that the number of patients with DGS and partial monosomy 22 may be significant. 193A GERTRUDE KOHN, ELI E. LASCH and ARIEL ROSLER. Human Genetics and Endocrinology and Metabolism, Hadassah University Hospital, Jerusalem, Israel, and Nasr Children's Hospital, Gaza. Post-pubertal gender role reversal in male pseudohermaphroditism due to 17 6-hydroxysteroid dehydrogenase deficiency. A highly inbred Arab kindred with male pseudohermaphroditism due to 17 6-hydroxysteroid dehydrogenase deficiency, extending over 6 generations, is presented. To date, 23 affected individuals, whose ages range from 14 months to 80 years, have been identified. Seven affected individuals were examined in detail and they and their families interviewed. Without exception, they were all raised as females until puberty. All post-puberty affected individuals virilized, had a male distribution of body hair and heavy beard, and a urogenital sinus with enlarged phallus. None had gynecomastia. Puberty was traumatic for all, behavior in school was frequently aggressive and school was often discontinued. Although this disease and its course was recognized and well known within the extended family over several generations, nevertheless, all newborn affected members continued to be raised as females. A few individuals in generations V and VI, on their own initiative and without psychiatric evaluation or help, changed gender role as young adults. Two such patients will be discussed in detail. The inheritance is most compatible with During the subsequent pregnancy of the mother, at 23 weeks gestation a fctoscopy with fetal skin biopsy was performed. Prominent stratum granulosum and orthokeratotic strntum spinosum with densely packed keratin suggested a hyperkeratotic state in the fetus. This was interpreted as i:.dicating Sjogren-Larsson syndrome. The parents decided to have the child. At 34 weeks gestation a liveborn female with congenital ichthyosis but no other major abnormalities was delivered. No scars were present at the sites of the biopsy. Thus, Sjogren-Larsson syndrome became a condition for which prenatal diagnosis is possible. The genetic abnormality in these two diseases are expressed by cultured skin fibroblasts derived from the patients. Both types of fibroblast cultures demonstrate elevated accumulation of copper. To further identify the functional and morphological consequences of these abnormalities of copper metabolism histochemical studies of fibroblasts have been undertaken. MD cultured fibroblasts showed markedly reduced succinic acid dehydrogenase and amine oxidase activities. Cytochrome oxidase activity was greatly reduced in some cells and almost normal in others. WD cultured fibroblasts showed moderately reduced succinic acid dehydrogenase and cytochrome oxidase activities. Amine oxidase activity was normal when compared to controls. Cytochrome oxidase, a cuproenzyme was variably affected in either MD or WD in spite of the profound abnormality in copper metabolism. Amine oxidase activity measured in these studies included monoamine as well as diamine oxidase which is a cuproenzyme. A significant difference in amine oxidase activities between MD and WD fibroblasts further demonstrates the phenotypic difference between the mutation in these two disorders. • 689 THE PRADER-WILLI SYNDROME. Robert W. Marion and Harold M. Nitowsky Albert Einstein College of Medicine, Department of Pediatrics, Bronx, New York The etiology and pathogenesis of the Prader-Willi syndrome (PWS), characterized by perinatal hypotonia, developmental delay, obesity, and hypogonadism, remain obscure. In recent years, reports of various chromosome abnormalities, including an interstitial deletion of 15q in patients with PWS suggests a chromosomal basis for the disorder. However, the demonstration of a normal karyotype in a substantial proportion of PWS patients suggests etiologic heterogeneity, and possible variability in the clinical, biochemical and epidemiologic correlates of the disorder. Review of parental ages of patients with PWS seen in our clinic (n=ll) and reported in the literature (n=34) compared with age and sex-matched controls reveals a significant increase in mean parental age at the time of birth of PWS patients (PWS: maternal age 31. 5 .:!: 6. 7 years, paternal age 35. 2 .:!: 6. 9 years. Controls: maternal age 27. 8 .:!: 7. 4 years and paternal age 28. 3 .:!: 5. 5 years). A plot of parental ages of all PWS patients suggests a bimodal distribution, with maternal and paternal age peaks of 26 and 34 and 30 and 38 years respectively, Parental age distribution of PWS patients with a chromosome aberration is shifted to older ages with only a single peak. Etiologic and genetic heterogeneity may account for the inconsistent finding of advanced parental age in PWS in previous reports. (!Omg/kg IV) reduced plasma phe from 1.0 to 0.27mM in 3 hr. and 0.40mM at 18 hr. Gastric administration of 6MPH4 (20-38mg/kg/day) was also effective: after 11 days of unrestricted diet, plasma phe was 0.19mM. On the 11th day of this study, the 6MPH4 level in CSF (60.Sng/ml) was similar to the patient's CSF neopterin level (48ng/ml) higher than the biopterin level of adult controls (18.6±12.7ng/ml,n=5) and the patient (0.59-0.8lng/ml). 6MPH4 did not increase CSF or plasma catecholamines or NT metabolites. NT synthesis in the patient was stimulated by 6MPH4, however, since increases were detected in urinary homovanillic acid (from 14 and 50 to 138 and 314µg/24 hr.), 5-hydroxyindolacctic acid (58, 64 to 100, 226pg/24 hr.) and dopamine (209, 216, 236 to 315, 346 µg/gm creatinine). These results indicate that 6MPH 4 (!)effectively controls the hyperphcnylalaninemia of BSD (2) crosses the This study involved 8 weeks of intensive PETs in order to increase the iduronosulfate sulfatase (IS) level to no less than 35% the normal IS activity. Four patients with Hunter's syndrome were Liven PETs. The volume of plasma infused at each PET was 50-55 ml per kg. IS activity on the donor's and patient's plasma was performed using tritium labeled disulfated disaccharide prepared following the degradation of heparin by nitrous acid. It was found that 2 PETs were needed per week. The average rise in IS activity following PET was 83.8% (± 10.4) and activity dropped to 43.8% (± 4.0) of normal prior to the next PET. After 8 weeks of PETs, liver and spleen sizes decreased on all patients, as determined by radionuclide studies. Urinary mucopolysaccharides (MPS) dropped in 1 child from 0.24 to 0.08 mg/mg creatinine but there was no significant change in the other 3 children. Liver biopsy in 2 children before and after PET indicated no significant change in MPS despite a slight increase in IS activity in 1 child following PET. These data suggest that PETs in Hunter's syndrome if performed frequently will sustain an adequate plasma IS level. Although reduced acid 13-glucosidase activity (13-glu) appears to be the primary enzyme defect in Type I Gaucher disease (GD), previous studies have shown marked elevation of serum acid phosphatase (AP) in GD. We have observed striking changes in the activity and isozyme distribution of serum 13-hexosaminidase (hex) In GD, and carrier testing for Tay-Sachs disease may offer a useful approach for the presumptive diagnosis of GD. Mendelian genetic disorders may not be recognizable at birth or even early in life, despite the presumed inborn nature of the defect. Non-recognition may result fr001 lack of an appropriate identifying characteristic or fr001 lack of gene expression at that time. Hhen a biochemical marker is identified, however, the phenotype is usually found to be congenital. Prol idase deficiency is an inherited disorder characterized by severe skin ulcers and iminodipeptiduria. Patients are diagnosed when clinical findings appear in childhood or later years. We detected prolidase deficiency in three sibs because one had iminodipeptiduria on newborn urine screening. Filter paper newborn (3 day) blood and cord blood specimens were recovered and examined for prolidase activity. No activity was detectable in newborn blood fr001 the proband or the ho older sibs. Cord blood from theo proband had 6.B% of control activity, the residuum possibly enzym£: passively transferred from maternal serum. Prolidase activity 1>0s detectable in control newborn blood specimens stored up to 4 years but 1>0s inversely related to duration of storage (for 9 mos. 3 yrs. and 4 yrs. activity in rmol glycine/disc/hr was respectively 463 ± 103, 142 ± 52, and 15 ± 12). Prolidase deficiency is expressed at birth and is biochemically detectable by appropriate enzyme analysis in cord blood and newborn blood. Mcnkes' kinky hair syndrome is an X-linked disorder of copper (Cu) transport and utilization. An animal model is provided by the blotchy (blo) mouse, mutant at the X-linkcd mottled locus. Since the defect may reside in abnormal regulation of metallothionein or of its function, we studied the metabolism of Cu, zinc (Zn) and cadmium (Cd) in fibroblasts of the blo mouse. Mutant cells rapidly accumulate added 64 cu to a level 10-fold higher than normal. While the kinctcs of 6 4 cu uptake are equivalent in mutants and controls, efflux of Cu in mutant cells is impaired. In con·trast, the kinetics of 65 zn and 109cd accumulation are not distinguishible in normal and mutant. 6 4 cu accumulation was measured in cells exposed to Cd and Zn. In controls the.)·c was a 2-3 fold increase in 64 cu accumulation in the presence of Cd, while mutant cells showed no change over baseline mutant levels. A similar qualitative difference was seen between control and mutant cells upon exposure to Zn. Exposure of both cell types to Cd effected no change in 65zn accumulation. We conclude that the defect in blo cells affects specifically the function of a Cu storage or transport protein, with the metabolism of Zn and Cd unaffected. The differential response nf normal and control cells tn induc-C'rs of metallothionein may be secondary to aberrant function of that specific Cu storage or transport protein, or may reflect altered regulation of a specific Cu thioncin. In order to study the involvement of human chromosomes in the expressio11 of human liver-specific functions, we have produced somatic cell hybrids between a rat hepatocarcinoma cell line and diploid cells from a human fetal liver. The rat hepatoma line was HPRT deficient, and hybrids were selected in medium containing HAT and ouabain. The presence of human liver-specific proteins was analyzed by immunoelectrophoresis techniques applied to concentrated serum-tree hybrid culture supernatants. A subset of hybrids secreted an antigen that was immunologically identical to human n1-antitrypsin (PI). Neither parental line supernatant, nor fetal calf serum, nor normal rat serum reacted with this antiserum. We conclude that interaction of the rat hepatoma genome with that of the human fetal liver cells has activated the human locus. In 19 primary HAT-selected and 5 azaguanine backselected hybrids, human PI production segregated concordantly with chromosome 14. All other chromosomes were excluded by discordant clones. Assignment Hyperargininemia is the rarest syndrome of the hereditary urea cycle disorders. Only seven affected families have been reported, including a French-Canadian family already described by us. We report here another unrelated French-Canadian family in which a newborn male was screened for cystinuria-lysinuria, but has been diagnosed by us recently to be affected by arginase deficiency. Enzymologic and biochemical indices were as follows: alcoholic and in children with the fetal alcohol syndrome (FAS). We have applied our own modification of the flourescence plus Giemsa staining technic to short term lymphocyte cultures established from adult patients admitted to our alcohol detoxification unit and children with the fetal alcohol syndrome attending our developmental clinic. Thus far, we have obtained cultures from 5 children, aged q months to 6 years, and 5 adult alcoholics, aged 28 to 48 years and from age and sex !'latched controls. The cultures were exposed to 3 mcgm/ml of BrdU to obtain chromatid differentiation. A minimum of 25 cells from each individual were scored. The mean frequency of SCE's in PHA stimulated lymphocytes of children with FAS was 9.01/cell compared to 6.54/cell for controls. The range for patients was 3 to 18 and controls 2 to 16. The mean frequency of SCE's varied significantly No significant increase of SCE 1 s was observed in our adult patients. We have applied the SCE test as a cytogenetic assay for the mutagen ic effect of ethanol on cultured lymphocytes from chronically FUdR induction of the Xq28 fragile site has been re ported and cited as evidence for folic acid and thymidine inhibition of this fragile site. The lymphocytes of 8 males affected by this X-1 inked recessive form of mental retardation were analyzed for the presence of Xq28 fragile sites utilizing the method of Sutherland (Medium 199, 2-5% fetal bovine serum) and a new method utilizing l0-6M FUdR, RPMI-1640 medium and 10% fetal bovine serum in a 96 hour culture. Medium 199 Mean-16% positive Xq28 (range 5-40%) (range 15-79%) No Xq28 fragile sites were found with either method in controls. Enhanced expression and simplified identification of affected males was possible scoring as few as 20-50 cells with the use of RPMI-1640 with FUdR resulting in direct clinical application. R. Sloan, Ohio State Univ. Coll. of Med., Cols. Children's Hosp., Dept. Peds., Columbus, Ohio. NPD-C is characterized clinically by the onset at age 2-15 yrs. of psychomotor deterioration and chemically by tissue accumulation of sphingomyelin (Sph) and cholesterol (Chol). In this study, Sph-cleaving activity (Sphase), and Chol were determined in livers (Livs) from 32 patients with forms of NPD: A(l5); B(8); C(9). Sph and Chol were elevated in tissues from all NPD patients (p<.01). Sph, Chol, Sphase (uns/mg prot/hr), and the rates of formation of Sph and Chol (pmoles/mg prot/hr) were measured in skin fibroblasts (Fibs) from 27 of these patients: A(l3); B(7); C(7). Sphase is deficient in NPD-A and B, but not in NPD-C. 107±34 67±32 of Sph and Chol is much less in NPD-C than in A or B. Although, for the group, Sphase is not significantly deficient in NPD-C Fibs or Livs (p=0.45; 0.49), three patients had low Sphase in Fibs (34, 42, and 51% of normal) and two had low activity in Liv (28 and 47% of normal). In these patients, there was no correlation between Sph or Chol content and Sphase. The rates of formation of Sph and Chol are normal in NPD-C. Classifying patients with modestly depressed Sphase activity as NPD-C is of questionable value; the key to phenotypina an infant remains the clinical course of an affected sibling. The cause of NPD··Cretra'ns unknown. Difficulties with the semi-synthethic amilXJ acid limited diet in the treatment of hyperargininemia in arginase deficiency have caused us to explore alternative rreans of therapy. These studies were performed to determine the feasibility of direct enzyrre replacanent of arginase, a cytoplasmic enzyrre. Purified rat liver arginase labelled with 1 2 SI was injected into bi.u 2.5 kg. rabbits. Circulating enzyme was foun:l. only in the plasma an:l. had a half-life of 1.5-5.0 hours. The animals were sacrified at 6.5 an:l. 7.5 rours. Intact arginase was determined by Tc:A precipitation and validated by :imnu1XJprecipitation and SDS polyacrylamide gel electroproreses. 95% or IrOre of plasma 125 I was in arginase, whereas urrlergraded enzyme represented 40-50% of the total counts in liver, spleen an:l. kidney. These organs contained fewer than 10% of the total counts with approximately equal aioounts in each on a per 98% of liver arginase an:l. is absent in hyperargininemia. A secorrl fonn (KA) canprises 50% or IrOre of arginase activity in kidney, brain an:l. GI tract arrl is distinguishable fran IA by electroproretic an:l. i..rrmurx:Jlogic rrethods. It is augmented in hyperargininemia. Rat hepatana cell line H4-II-F.-c3 (H4) expresses IA. The enzyme is canpletely precipitated by anti-rat liver arginase antilxxl.y an:l. its pKi of 9.0 is characteristic of IA. PhysiolorJiC levels of hydrocortisone (l.OµM) irrluce IA activity 10-fold to levels canparable to those in rat liver (4 U/rrg protein). Human enbryonic kidney (HEK) an:l. brain (HEB) cells transformed with BK vi.rus establish lines that express arginase at levels canparable to 1XJnnal human kidney and brain (0.2-0.6 U/ng). The activity is IXJt precipitated by anti-rat liver arginase antilxxly. The pK,. is 6.2-6.5, characteristic of Y-A. f' .' (n for arginine, Ki for ly!:ine an:l. ornithine an:l. µ1 optinrum (9. 5J are identical for Y-A an:l. IA an:l. in both tissue culture systems. The u,.u cell lines provide rn:xl.els in which to study the differential regulation of IA an:l. KA. The ahility to in:l.uce augmented expression of KA in IA deficiency wo..ild represent autoenZ}'m2 replacanent therapy an:l. may eliminate the need for exogenous enzyme or gene administration. The metabolism of endogenously and exogenously radiolabeled sphingomyelin was studied in normal and Niemann-Pick Type A (NP-A) cultured fibroblasts. NP-A cells had <4% normal lysosomal sphingomyelinase activity and contained 2-3 x normal amounts of sphingomyelin. However, NP-A cells degraded endogenously [ 32 P] or [ 3 H-choline]-labeled sphingomyelin at normal or near-normal rates when labeled in culture for up to 120 h then transferred to unlabeled medium for a further 148 h. Exogenous ( 3 11-methyl] choline-labeled sphingomyelin was taken up by both normal and NP-A cells, with NP-A cells accumulating 2-4 x more of the labeled lipid. Following removal of labeled sphingomyelin from the medium, cell associated [ 3 H]sphingomyelin decreased in both cell lines, and the label appeared in cellular lecithin, and in free choline and phosphorylcholine (30-70%) and in sphinp,omyelin and lecithin in the culture medium. Thus, (1) despite a <95% decrease in lysosomal sphingomyelinase activity, NP-A fibroblasts are able to degrade endogenous and exogenous sphinr,omyelin; and (2) in both normal and mutant cells, the phosphorylcholine headgroup of sphingomyelin is conserved for lecithin biosynthesis. These findings support the concept of a non-lysosomal site of sphingomyelin turnover, possibly in the plasma membrane, with a close relationship between phosphorylcholine turnover in lecithin and sphingomyelin. We report a case of duplication Sq31__. qter with renal abnormalities, only 6 other cases have been reported but without renal malfonnations. K.K. is the product of a full tenn l.Dleventful pregnancy, born to a 28 year old Gr 2 Ab 1 Par 0 white mother and 24 year old father. The birth weight was 2,800 g., length 49 cm, o.f.c. 32 cm. J::ue to dysmorphic features, chromosome analysis was carried out on peripheral blood lymphocyte culture which revealed a karyotype of 46,XX,22q+. M:>ther's karyotype was 46,XX. The father's karyotype by G-banding was 46,XY,t(5;22)(q3l;ql3) and proband's karyotype was interpreted as 46,XY,-22,der(22),t(5;22)(q3l;ql3)pat. Over the past 30 months, she has had recurrent episodes of otitis media and urinary tract infections. Evaluation of the kidneys by sonogram, renal scan and an IVP showed bilateral hydronephrosis and obstruction at the right uretro pelvic jl.Dlction. On her last examination, at age 22 months, she was below 5th percentile for weight (8.0 kg), length (68 cm) and head circumference (42.S cm). Other findings were plagiocephaly, ptosis of left eye with antimongoloid slant, hypertelorism, epicanthal folds, beaked nose, low set and malfonned ears, hypoplastic philtrum, thin lips, small mouth, high arched palate, right simian crease, bilateral clinodactyly and slight puffyness of feet. The cardiovascular system was nonnal and the skin showed cutis marmorata. Developmentally, she was fl.Dlctioning at 6-9 mos, level (cognitive) & (gross motor). Altered biotin metabolism produces a common clinical presentation including ataxia, alopecia, keratitis and dermatitis. Three separate etiologies are known: 1. A genetic deficiency of biotin holocarboxylase synthetase (BHS). 2. An apparent defect in biotin absorption or transport. 3. Dietary biotin deficiency. Distinguishing groups 2 and 3 from l requires measurement of plasma and urinary biotin. The only current method sensitive enough to measure physiologic biotin concentrations requires a bioassay not widely available. We have developed an isotope-dilution assay for biotin utilizing avidin to bind 3 (H)-biotin, and nitrocellulose filters to separate bound from free of urine or plasma ultrafiltrate are mixed with 10• of (H)-biotin (0.41 pmol; 36.4 Ci/mmol), and 30• of an avidin solution (4 pmol/ml). The tubes are mixed and 225• of the mixture are then vacuum aspirated through nitrocellulose filters, followed by a 0.6 ml wash of 0.01 M NaAcetate buffer, pH 5.0. The filters are dried and the bound radioactivity determined in a liquid scintillation counter. Known biotin standards prepared in 150 mm NaCl are run simultaneously. A semilog plot of 3 radioactivity bound versus biotin concentration is linear over the range of 50 to 750 pg biotin. Usirg this method, the mean urinary biotin excretion for 19 neonates was 118 76 ng/ml creatinine.This agrees with the ?Ublished range of urinary biotin excretion via the bioassay (4.3 to 95 ng/ mg creatinine). Normal plasma biotin concentration by this method was 300-750 pg/ml (bioassay = 200-SOO). DENTAL HYPOPHOSPHATASIA: A GENETIC STUDY. Charles F. • 705 Timmons (Spon. by H. N. Kirkman), Univ. of North Carolina Sch. Med., Dept. of Pediatrics, Chapel Hill. Families of 5 dental hypophosphatasia (DH) propositi (premature loss of deciduous teeth) were compared to maternal and paternal families of a case of lethal, infantile hypophosphatasia (IH). By criteria of low serum alkaline phosphatase (AP) and elevated urinary phosphoethanolamine (PEA), autosomal inheritance was construed in all 7 pedigrees. The gene appears to reduce by 50-70% the basal AP level. A wide normal range of this basal level, however, renders individual carrier screening, out of family context, uninterpretable. In DH families, penetrance for premature loss of deciduous teeth is low. The non-carrier parent of all DH sibships has "low normal" AP, suggesting that penetrance depends on interaction of the DH gene with familial AP levels. As expected, there were no IH cases seen in the DH pedigrees; however, in each IH line, an individual with dental symptoms was ascertained. Acrylamide gel electrophoresis and selective inhibition by amino acids and urea indicate a reduction of bone and liver isoenzymes in some members of each family. No anomalous bands of activity were seen. Electrophoretically isolated serum isoenzymes have to date revealed no kinetic differences between normal, IH carrier, and DH residual activity. These data are in line with the hypotheses that serum AP levels are multifactorial and that cases of dental hypophosphatasia may be manifesting heterozygotes of the severe, autosomal recessive condition. A partial deletion of the short ann of chromosome 9 is a cally recognizable cytogenetic disorder. JXnnatoglyphic findings when reported have shown an excess of digital whorls. In our case' arches were fol.Dld on 9 digits. L.L. is a 28 week old Black female born at tenn to a yol.Dlg couple. J::uring this pregnancy, the mother took some over-thecounter reducing medication. On examination at age 28 weeks, her weight was 6,136 gm, length 59 cm and o.f.c. 41 cm. The other findings were: trigonocephaly, prominent metopic suture, small palpebral fissures, prominent eyes with monogloid slant, hypotelorism, small upturned nose, long philtrum, thin upper lip, microstomia, low posterior hair line, capillary hemangioma in the nape of neck, extra flexian creases on the middle phalanges of third left digit and second and third right digits. she was functioning at four months level. The karyotype was 46, XX,del(9)(p22). Karyotypes of parents and a 3 year old healthy male sib were nonnal. Dennatoglyphics revealed axial triradii in t' position, 9 digital arches and an ulnar loop on second right digit. None of the first degree relatives had an excess of digital arches (mother, 8 UL, 2 W; father 8 UL, 1 RL, 1 A; sib 5 UL, SW). Dennatoglyphics of other 9p-patients need to be studied before excess of whorls can be taken as a characteristic feature of 9p-syndrome. Table) . Eighteen rea were familial, five de nova, and one undetermined; one subject carried a familial and a de nova rep. The familial cases had r.ormal outcomes. Two de novo were normal, one abnormal, and two were aborted. The advent of high resolution chromosome banding has allowed the discovery of a growing number of subtle but complex chromosomal rearrangements. We here report a child who has both a short arm deletion and a pericentric inversion in one chromosome number 3. This abnormal chromosome arose from a recombinational event in maternal gonadal cells. Recombination occurred between one chromosome 3 which displayed a double pericentric inversion and its normal homologue. The double inversion in chromosome 3 was present in the mosaic state with approximately one-half of the peripheral lymphocytes exhibiting a normal karyotype. The phenotype of the proband is generally consistent with previous reports of duplication-deficiency syndrome of the short arm of chromosome 3, namely, mental retardation, microcephaly, unusual facies and small size. This child has frank seizures of petit mal status with left focal origin and has developed bruxism as well as self-stimulating behavior. The proband's karyotype is designated as 46 ,XX, -3, +rec( 3) ( qter+q29:: p25+p 13: :ql l+pl 3:: qll-• qter)mat. The maternal chromosome constitution is designated as mos46, XX/46 ,XX, inv( 3) (qter+q29: :p25+p 13: : qll-•p 13: :q l hq29:: p25+ pter). The observation of a mosaic double inversion is, in itself, an unusual finding. The involvement of such a chromosome in a recombination event is truly unique. The best current test for PKU carrier status is the ratio of p2/T where P is plasma phenylalanine and T is plasma tyrosine after phenylalanine dose loading (reliability is claimed to -> 100% by some). The test is cumbersome requiring two venipunctures, and the phenylalanine dosing often produces nausea, dizzyness and occasionally syncopy. Therefore, in order to develop a more benign test 31 adult 11 controls" (carrier status unknown) an0.05). Myocardial infarction has been observed after conventional mediastinal irradiation. In the animal model radiation also acts synergistically with high cl1olesterol diets to produce severe atheromatous lesions. A decrease in vascular PGI2 without any concomitant change in platelet TXB2 may provide an explanation for some of the vascular complithat occur post irradiation. Measurements of the survival of RBC in hemolytic anemias of childhood are encumbered by a requirement for radioactive isotopes and/or by the inability to measure the o' populations of RBC simultaneously. Therefore, we have devised a method to overcome these oroblems which takes advantage of modern atomic absorption spectrophotometry. RSC of 5 rhesus monkeys were labeled with Bug/ml RBC of non-radioactive and with 0.01 ug/ml RBC of . These results show that is non-toxic to RBC and provides an excellent assay of RBC survival without a requirement for ragtoactivity. Only when dual population studies are required is Na2 Cr04 necessary. The double labeling procedure permits refined assays to be performed on cohorts of RBC which differ with respect to age,and susceptible to hemolysis, in a variety of clinical disorders. Complete remission was successfully induced in an 11 year old ANLL patient using low-dose ARA-C after failure of chemotherapy (CT) utilizing high doses of this agent. Initial CT consisted of two courses of ARA-C, Daunomycin, vincristine, and methylprednisolone; the> ARA-C was given by continuous IV infusion at a dose of 150-200mg/M 2 /day x 7 days for each course. A bone marrow aspirate (BMA) obtained 17 days after the second course of treatment contained essentially no normal hematopoietic precursors and >80% blast cells. Low-dose ARA-C 0.7mg/kg/day (20mg/M 2 /day) by continuous IV infusion was then begun. After 1 week, normal hemopoiel ic eel ls were increased and BMA blast count was reduced to 20%; after two weeks, the blast count was <5%. CT was stopped at this point because the patient was pancytopenic, a consequence of marked marrow megaloblastosis. Within one week, the megaloblastosis and pancytopcnia had resolved. Repeat BMA 6 weeks later remains in complete remission. A patient with myeloblastit.: transformation of chronic myelogenous leukemia has also shown a favorable response to low-dose ARA-C and is now back in chronic phase. Neither patient experienced nausea or vomiting; both were treated on an ambulatory basis. The rapid effect and relatively mild toxicity of low-dose ARA-C suggest a noncytotoxic mechanism of action consistent with experimental data demonstrating induction of maturation in ANLL <..·ells (Sa<..·hs, L.: Br.J.Haematol. 40:509, 1978). We have previously shown that PMNs from cord blood produce normal or increased amounts of superoxide anion but decreased amounts of ·Oil compared to adult PMNs. Both myeloperoxidase (MPO) and LF have been shown to enhance ·OH generation. To detennine whether the decreased ·OH production by newborn PMNs is related to abnonnalities of granule contents or their release, degranulation and the total content of MPO, lysozyme (LYSO) and LF, as well as ·OH production, were measured. Release of LYSO Significant alterations in hematologic function in cystic fibrosis were suggested by the observation that polycythemia was uncorrmon even among cyanotic patients. To elucidate those factors which influence hematologic equilibrium, 39 stable cystic fibrosis patients were evaluated with CBC, RBC morphology, reticulocyte count, serum Fe and TIBC, serum ferritin, vitamin E, and carboxyhemoglobin assay. Hemoglobins were within 1ow normal range, including 23% who were cyanotic. The majority of patients had evidence of hemo lys is, with elevated carboxyhemogl obi n va 1 ues. Hyper ferremia was seen in 28%, and serum ferritins were diminished in 59% of patients. The range for ferritin values was 5 to 55 ng/dl. Vit. E (cx-tocopherol) levels were less than 5 ng/dl in 33'.\. These! data suggest that some children with cystic fibrosis are relatively anemic, and that iron and vit E. deficiency may significantly contribute to their apparent failure to compensate for hypoxia. Next 22 patients with either low ferritin, Fe, and/ or vit E. were serially given 2 weeks of oral FeS04 followed by 2 weeks of oral FeS04 and vit. E. Variable responses to this therapeutic trial were found. Over half the patients had a significant rise in Hgb of greater than 0.6 gm/dl after the month of FeS04. Those whose ferritin did not rise, did not show a ri,e in Hgb. in relation to vit E. was variable. These results suggest that the cause of the relative anemia in cystic fibrosis is multi-factorial, but Fe deficiency does make a contribution. Hypersplenism in Type 1 uU has been managed by total splenector.1y (S). Although several reports have suggested that S accelerated the progression of bone pathology, the question has remained controversial, due to the variable expression of the disease and lack of prospective studies. Insight into this problem was gained from the µrospective assessment of a 5 y/o Hispanic male with marked acid 1.>-glucosidase deficiency and severe non-neuropathic liU. Prior to S (performed for severe cardiopulmondry insufficiency secondary to massive splenomegaly), there was no radiographic or nuclear scan evidence of bone pathology. Within three months of S (4. 5 kg), the patient was unable to ambulate and there was collapse of T 1 0 , T 1 ?• L 1 and Ls, bilateral aseptic necrosis of the femoral heads and Ehrlenmeyer defonnities of both distal femora. Since the onset of severe skeletal involvement directly fol lowed S, it is likely that these manifestations resulted from enhanced marrow infiltration, by substrate previously destined for splenic deposition rather than from natural disease µrogression. These findings provide further evidence for accelerated bone involvement following S. Therefore, S in GU should be delayed as long as possible and partial splenectomy should be considered. 02115 Although araC is a major drug in the treatment of pediatric leukemia, its mode of action is unclear. One hypothesis involves fraudulent incorporation of araC residues into DNA, known to occur randomly at deoxycytidine( dC)positions. This presumes araC DNA is in some way functionally abnormal, but direct evidence is lacking. In mammalian DNA 3-5% of dC residues normally undergo a process thought to control gene expression. We have carried out studies to determine whether araC in DNA undergoes methylation nor·mally. L1210 cells were incubated for 18hr with 14c araC and/or 14C dC added as shown below. DNA was isolated and exhaustively hydrolyzed enzymatically to nucleosides. These were separated by HPLC and the radioactivity of each component determined. The fractionof each nucleoside converted to its methylated derivative is shown: Addition( 10-7M) TlrfaraCOn-ly I4c dC only 14uc + araC 14CdC + 14C araC Although araC does not influence the degree of dC methylation, araC in DNA is methylated either less or more slowly than dC. AraC DNA thus appears to be abnormal in this regard. This rny explain the ability of araC to induce differention. Antibody mediated platelet destruction is a major cause of childhood thromhocytopcnia. Advances in the detection and quantitation of platelet antibodies have aided the diagnosis of these disorders, but little is known about the platelet antigens or receptors involved. We describe a method for separating and im-mobiJ izing platelet proteins, retaining their ability to bind antibodies specifically. Gel filtered human platelets are solubilized in SOS and separated on polyacrylamidc gels. The compon'ent proteins arc elcctrophorctically transferred to nitrocellulose paper. After blocking nonspecific binding sites with albumin and qamma globulin, the inunobilizcd proteins are incubated with antiplatelet antiserum. Antibody bound to a specific protein is then visualized by incubation with 125 1 labeled goat anti-human IgG followed by autoradiography. The PLAl antigen, important in neonatal isoinunune thrombocytopcni.-(NIT), has been linked by indirect evidence to the 100,000 MW protein, GPIIIa. When PLAl positive platelet proteins are studied as above with serum from a PLAl negative mother of an infant with NIT, the radioactivity binds specifically to a single band of 100,000 MW. No specific binding occurs with PI.Al negative platelets or with control serurrL These findings provide direct confirmation that GPIIIa contains the PLAl antigen. The technique developed is rapid, is not limited to the study of 1>rccipitating antibodies, and should be applicable to other immune mediated disorders. MCLNS has been reported to be associated with hematologic abnormalities. We have examined the severity and etiology of these changes in 12 patients who met the standard diagnostic criteria of On admission, the mean hemoglobin level was l0.2g/dl(range 8. 4-12.7) . A mild to moderate anemia usually persisted throughout the illness and the lowest mean hemoglobin was seen on the 5th to 6th hospital day (mean 8.9, range 5.9-12.0g/dl). The anemia was normocytic or mildly microcytic. Leukocytosis was usually present on admission (mean 19,500, range 5,000-28,600/mm3) and increased to a maximum value on the 5th to 6th hospital day (mean 22,700, range 7 ,900-59,80D/mm3). The mean leukocyte count returned to normal by the 16th hospital day. More than 10% band forms were present in 9/12 patients; myelocytes or metamyelocytes were present in 11/12 patients. The mean platelet count on admission was 438,000/mm3 (range 160,000-898,000) with a maximum platelet count between the 11th and 16th hospital day. The platelet counts were > l ,000,000/mm3 in 3 patients but were < l00,000/mm3 in 2 patients. Platelet counts, hemoglobin level and WBC were similar in patients with and without cardiac involvement. MCLNS is commonly associated with a mild to moderate anemia, leukocytosis with a marked left shift, and thrombocytosis. The similarity of these changes to.those found in other inflammatory diseases sugsests a common etiology. The hematologic abnormalities are not predictive of cardiac complications in MCLNS. ----we-have studied the molecular basis of 8-thalassemia in 20 patients, using recombinant DNA cloning and nucleotide sequence analysis of defective 8 globin qenes, analysis of 8 globin gene transcription in vivo and in vitro, and/or analysis of the structure and content of abnormal" 8 mRNA species by s, nuclease mapping and primer extension techniques. The most common form of B+-thalassemia (10/19 pts) observed was due to a mutation within intervening sequence-1 (IVS-1), creating an alternative mRNA processing splice site. The anomalous splice site is utilized preferentially, creating an abnormal B mRNA species incapable of translation into B globin; a reduced amount of normal 8 mRNA is also qenerated by this qene. The abnormal species accumulates poorly, leaving only the small amount of normally functioninq 8 mRNA. The other patients exhibited either no structurally abnormal B mRNA species or different remnants of IVS-1 or IVS-2. One patient with s 0 -thalassemia exhibited abnormal accumulation of r, mRNA precursor sequences containing IVS-2, due to a mutation abolishing the normal site for IVS-2 splicinq at the 5'-end of IVS-2. In a second patient with 8°-thalassemia, substantial evidence for a primary transcriptional defect has been obtained by studies of mRNA synthesis in vivo, cloninq of the defective gene, and transcriptional anaTYsis in vitro. Hb Lepore, a structurally abnormal hemoqlobin associated with 8°-thalassemia, is also due to defective transcription. In most ch JI dren "'Ith Immune thrombocytopen le purpura (I TP); however these techniques are complex, often require large volumes of blood, and are generally aval I able only In special I zed laboratories. We have quantltated PAlgG In children with a variety of 11 lnesses using a simple radial lmmunodiffuslon (RIO) technique. 0.25 to 1 x 10 8 platelets harvested from 6 to 10 ml of \lfhole blood were solubl 1 lzed and plated Immediately or after storage at -20°C on low level, commercially aval I able, lgG lnwnunoplates*; PAlgG I eve Is were proport Iona I to the s I ze of the I mmunod If fus I on r I ngs and exact va I ues were ca I cu I ated by reference to a standard curve. In 15 Delayed-cutaneous hypersensitivity to 2,4-dinitrofluorobenzene (DNFB) was measured by an ear swelling assay in C57BL/6J (B6) and DBA/2J (D2) inbred mice and their F1, backcross and F 2 progeny. Treatment with MC (80mg/kg) prior to DNFB sensitization suppressed the ear swelling response ('80%) in B6, F 1 and aryl hydrocarbon hydroxylase (AHH) inducible backcross and F 2 mice but not in D2 or non-inducible backcross or F 2 mice. Similar observations were made with four additional AHH-inducible and four non-inducible strains of mice. This immunosuppressive response to MC showed the same dose-dependence as AHH induction in responsive mice. Induction of AHH activity by s-naphthoflavone prior to MC treatment resulted in a shift of the dose-response curve for suppression to the left. Thus an ED20 dose of MC was converted to an ED80 dose. Phenobarbital pre-treatment had only a moderate effect on MC-mediated immune suppression. This suggested a requirement for an induced form of the enzyme in the immunosuppressive response. Finally the immunosuppressive response to MC could be completely blocked by prior administration of suggesting a requirement for MC metabolism in the production of the immunosuppressive response. These results suggest a strong positive correlation between carcinogen-mediated suppression of cell-mediated immunity and aromatic hydrocarbon responsiveness in Aggregate GST activity was measured in LPC sonicates usingCDNB as the substrate. The activity in LPC from leukemic children in remission was indistinguishable from that found in cells from unaffected individuals averaging 70 to 120 nmol/min/mg. LPC GST activity was compared to that found in human liver cytosol. While enzyme specific activity was 5 to 7-fold higher in liver, the GST activities in the two tissues were identical with respect to pH, ionic strength and substrate concentration dependence as well as thermal inactivation. The response of GST activity to exposure to various antioxidant compounds was studied in LPC cultured in the presence and absence of mitogens. The antioxidants studied were BHA, BHT, ethoxyquin (E) and (AT) . Culturing in the presence or absence of mitogen had little effect on GST activity. In the absence of mitogen antioxidants were without effect. In the presence of mitogen all four compounds caused a dose-dependent increase in GST activity in cells from non-leukemic individuals. The maximal increase was 2 to 3-fold and the order of potency was AT>E>BHA>BHT. BHA was tested for its ability to induce GST activity in cells from leukemic children in remission. At doses of 5 to 10 which results in maximal GST induction in normal cells no increase in activity was observed. These results suggest that the cytoprotective enzyme GST is inducible in human cells and that leukemic children are deficient in this response. The efficacy of corticosteroids in childhood acute ITP is controversial and has not been evaluated in a controlled randomized study. We examined the value of prednisone (2 mg/kg/day for 14 days with subsequent tapering and discontinuation by day 21) in 27 children with newly diagnosed ITP. Patients were randomized to receive either prednisone or placebo. Platelet count, bleeding time (a test of the integrity of the platelet-microvasculature interaction), and clinical bleeding tendency (scored on a 0-4+ scale) were determined before (day OJ and six times following initiation of drug therapy (days 1-2, 3-5, 7, 14, 21, and 28) . Patients in the steroid and placebo groups were similar with respect to age, sex, initial platelet count and bleeding score, duration of bleeding symptoms, and history of antecedent infection. There were no statistically significant differences between the two treatment groups in any of the three parameters except on day 7 of therapy when children receiving prednisone had higher platelet counts and lower bleeding scores than those receiving placebo. Bleeding score and bleeding time generally correlated with the platelet count. Prednisone did not influence bleeding time or clinical bleeding score independent of its effect on platelet count. We conclude that prednisone does not improve hemostasis or reduce bleeding tendency in childhood acute ITP except transiently at the end of one week of treatment. J NT!' '.!lT!l t.ORMAL l'LATELE'l' ANTIBODY. James ll. !\ussel, 729 t!_a_r_t'.'"".L __ --·--·----NYH-C1J:-1c Div. Ped. Hem/One., N.Y., N.Y., S.E. \lb. Ctt·., \:is. Five newborn infants developed leukemia at the age of 1 day, 2 weeks, 8 weeks, 2 days, and 9 days (cases 1-5 respectively). In order to determine the role of oxygen and its metabolites on the activation and inactivation of the membrane bound superoxide (02) generating oxidase, we stimulated guinea pig peritoneal cavity granulocytes (PMN) under aerobic and anaerobic conditions and exami ned activity as a function of time. With a soluble stinulant phorbol myristate acetate (PMA), membrane enriched particles from PMN generated similar maximal NADPH dependent 02 production under aerobic (43.5 2.2 nlTOl 02/min/mg pro) and anaerobic (3B.4 2.4 nlTOl 02/ min/mg pro) conditions. However, under aerobic condi ti ans activity fell over I20 ninutes with a pseudo first order rate constant or .0283 min-I. Under anaerobic conditions, there was no significant change in oxidase activity for up to I20 minutes. NADPH dependent 02 prod!ction after I20 minutes was 36.8 + 1.5 nlTOl 02/min/mg pro for anaerobic stimulation, compared with T.7 + 0.3 n1TOl 02/min/mg pro for aerobic 5timulation. Neither cytochrome c, cyanide, superoxide dismutase, catalase, nor benzoate could prevent aerobic inactivation. NADPH dependent 02 production is phagocytic vesicles made from pmn which had ingested opsonized lipopolysaccharide coated oil droplets for 5 minutes was equivalent under aerobic (I9.9 + 2.5 n1TOl 02/min/mg pro) and anaerobic (23.2 + 4.6 n1TOl 02/min/mgpro) conditions. However, inactivation of the oxidase occurred to the same extent under both aerobic and anaerobic conditions. We conclude that for PMA but not for opsonized particle stimulated cells, inactivation of the oxidase is dependent entirely on oxygen or an .internally generated oxygen metabolite. Membrane glycoproteins have been strongly implicated in certain platelet-associated hemostatic phenomena, i.e., adhesion, aggregation, and secretion. As part of our continuing evaluation of the platelets of the newborn infant, washed intact platelets prepared from samples of platelet-rich plasma, obtained from EDTA-anticoagulated whole blood taken from the umbilical vein at delivery or the antecubital vein from normal adult volunteers, were solubi l ized in 2% sodium dodccyl sulphate, reduced with dithiothreitol, and electrophorcsed on 7.5% polyacrylamide gels using the discontinuous buffer system of Laemmli. Gels were fixed, and stained with periodic acid-Schiff's reagent or Coomassie blue. Distribution of glycoproteins was measured by scanning densitometry at 525 nM. In both newborn and adult platelets, ten identically-migrating peaks ranging in molecular weights from 50,000 to 185,000 were observed. Analysis of apparent molecular weights revealed all major membrane glycoproteins to be present in both platelet populations. In Individuals with the Fanconi syndrome due to nephropathic cystinosis reqularly develop substantial anemia many years before proqressing to renal failure. The mechanism of this anemia is unexplained. In 7 male and 3 female cystinotics with mean aqe 5.Sy ± 2.3 S.D. (ranqe 2.4-8.ll with mean serum creatinine I.4 ± I.2 (ranqe 0.54-4.5), the mean Hqb was II.I± 2.0 (ranqe 7.6-I4.2). Reticulocyte counts were inappropriately low for the deqree of anemia. Patients were not Fe or folate deficient and there was no evidence of hemolysis. Serum erythropoietin determined by radioimntJnoassay was markedly decreased in all cystinotics: mean 7.4 mU/ml ± 2.4 (range 4-IO). Two males ages 7.5 yrs and A.6 yrs with Fanconi 5yndrome unrelated to cystinosis (Lowe's syndrome) had no anemia and serum erythropoietin of 47 and 36 respectively. Normal adult erythropoietin levels in this laboratory average 21 ± 6. The anemia of cystinosis is thus consistently associated with low concentrations of circulatinq erythropoietin. We speculate that kidney cystine accu!T!Jlation may impair renal erythropoietin production. nisappearance of anemia in cystinosis after renal transplantation suqqests that, in contrast, cystine deposits do not qrossly impair marrow responsiveness to erythropoietin. Prothrombin (factor II) precursor is synthesized by the liver and converted to biologically active protein by a carboxylasevitamin K dependent reaction. Since both the inactive and active proteins are antigenically similar, methods using antibody to factor II measures both. The difference between total imrnunoreact ive protein (II-Ag) and the active fraction or coagulant activity (II-CA) in plasma represents the inactive precursor. were studied and compared to 11 warfarin treated patients and 50 normal controls. Reduced II-CA ( < 50% of normal) and II-Ag ( < 52% of normal) was noted in 96% and 62%, respectively, of the 24 cases with moderate to severe LD. Also, II-Ag levels exceeded Il-CA (normal, < 11% difference) in 66% of these patients. In contrast, in mild LD II-CA and II-Ag was abnormally reduced in 0% and 13% respectively. There was no case of reduced II-Ag in the warfarin group although all had reduced II-CA and excess II-Ag. reactions that are difficult to distinguish from acute myelogenous leukemia. We studied 2 infants presenting with blast forms in the peripheral blood (PB) and bone marrow (BM). ST had hepatosplenomegaly, a platelet count (pit.) of 80,000/dl, white blood cell count (WBC) of 20,100/ul, hemoglobin (HGB) 15.1 gm/dl, PB differential cell count (dif f) included 36% blasts and BM revealed 17% blasts. Six mos. later SD had no clinical manifestations of leukemia and the BM contained 0.2% blasts. JR presented with failure to thrive, petechiae, hepatomegaly, HGB 10.6 gm/dl, pit. 32,000/dl, WBC 7,800/Ul, diff. included 34% blasts, and BM dis- During the first few months of life the hgb. concentration of the newborn decreases to a level which would be considered anemia at any other age. The mechanisms controlling this so-called "physiologic anemia" are not clearly defined. One mechanism which has been previously suggested is the presence of a serum inhibitor of erythropoiesis. The in vitro colony assay of hematopoietic progenitor cells affords the opportunity to test this hypothesis. We studied the effects of serum from five 6 wk. old term infants (TI} and from 5 cord blood (CB} samples on the circulating peripheral blood late erythroid progenitor cells (burst forming units erythroid•BFU-E) in the plas11Bclot assay. All serum samples were tested using mononuclear cells from the peripheral blood of a single normal laboratory volunteer (C). Tests were carried out with and without the addition of 4 µ/ml of sheep erythropoietin (EPO}. Maximum growth of BFU-E was achieved with 4xlo4 cells per micro well and 4 µ/ml EPO. There was no growth of 8FU-E in the absence of EPO. Maximal colony growth of BFU-E in the presence of Tl serum was 97.6+47.6 colonies. Maximum colony growth in the presence of G was 80.4+36 colonies. Peripheral blood BFU-E in the presence of CB serum showed maximum colonies of with the C serum showing 42.3+30.7 colonies. No inhibitory effect of Tl serum or CB could be demonstrated at any cell or EPO gradient. This study provides evidence against the presence of a serum inhibitor of erythropoiesis as a mechanism involved in the "physiologic anemia" of the newborn. ienced 20 EMR episodes. Normal appearing marrow lymphocytes obtained at the time of EMR were tested against anti-sera defining leukemia associated antigens (LAA) and human la-like antigens and found to be reactive to I or both in 11/20 (55%) instances (50% LAA +,50% Ia+). In contrast, 0/20 morphologically normal marrow specimens on 20 patients in complete, continuous remission demonstrated reactivity. All EMR's were treated locally and, in most instances, with brief intensification of systemic cl1emotl1crapy. Three patients remain disease-free 3+-17+ mos following a single EMR. 6 patients have had a BM relapse (med. 21 mos after EMR). The other 3 patients have had more EMR episodes but remain in BM remiss ion, 3+-52+ mos following the first EMR. We conclude that extramedl1llary relapse is freq11ently not an isolated event. This is evidenced in -,SO% of patients immunologically, by tl1e ability to detect abnormal surface antigens on marrow lymphocytes and clinically, by the generally poor ultimate outt·ome. Therefore, we recommend that he treated with both systemic intensification and local tl1erapy. Si'il; AL EVALUATION OF llEXOSAMINIIJASE ENZYME l'i\'"'J"ERNS Certain enzymc/isocnzymc patterns in cl1ildhood letikcmia may be usef11l in the differential diagnosis, outcome 1>rccliction and detection of subclinical residual disease. Thi;;> lysosomal hydrolase, hexosaminidase, is one of the enzymes currently tinder close scrutiny. Serial peripheral blood lymphocyte samples from 21 leukemic children have been analyzed for total 11exosaminidase activity and isoenzyme profiles. Total enzyme activities were virtually identical at diagnosis (48.5 nm/mg cell protein/minute) and during remission (48.3), while column chromatography revealed an elevated isoenzyme peak (defined as as I/A peak 0.2) in certain initial let1kemic samples: II Wi ALL, null cell, cALL+ 7/12 ALL, null eel 1, cALL-3/ j ALL, null ce 11 , < ALL unknown 013 ALL(T or B cell), AML 0/5 Elevated initial I/A returned to low lcvels(mecl 0. 11,rangc 0.06-0.16)during remission. Two patic>nts with high initial val11C'S haVl" relapsed in the marrow. The I/A rose above baseline remission levels in both these patients. We conclude from our data that hexosami11idase isoenzyme pat-tPnif may be useful as a tumor marker of childhood leukemia. Staley, George University of Minnesota Hospitals, Department of Pediatrics, Minneapolis. Aspirin (ASA) inhibition of platelet (P) cyclooxygenase (CO) re sults in a fully compensatory increase in lipoxygenase (LP) products of arachidonic (AA) metabolism. The effect of ASA on AA metabolism of the nucleated avian thrombocyte (Thb) is unknown. ASA was given (60 mg/kg, PO) to 8 white turkeys (Nicholas) ages 75-205 days. At 3,24 48,72, and 168 hr after ASA, Thb rich plasma was incubated with i4c-AA and the percent conversion to thromboxane B 2 (TBx), 12L-hydroxy-5,8,l0-heptadecatrienoic acid (HHT), and 12Lhydroxy-5,8,10,14-eicosatetrainoic acid (HETE) was determined using thin layer radiochromatography. Nonnal human P were examined. 4) 56.9+3.2 19.7•3.9 8.2±1.5 15.0+2.9 Mean+ SE: *P<0.01, unpaired t-test, Thb-con vs. P-con (control). Like human P, ASA transiently inhibits CO products (TBx, HHT). The limited ability to increase HETE production suggests that; l) ASA may have a partial inhibitory effect on Thb LP, or 2)HETE production may be relatively "fixed" at a low level which is poorly responsive to f'A modulation of Thb CO. Thus, the turkey Thb may be a useful for defining the relative roles of LP and CO pathways in cardiovascular physiology. CHEMOTACTIC ENHANCEMENT OF NEUTROPHIL MEDIATED CYTOTCXICITY. Denis English and Juhn N. Lukens, Vanderbilt University School of Medicine, Na>hville. Stimulation of neutrophil oxidative metabolism is associated with the release of free radicals which are potentially injurious to neighboring cells. To determine if chemoattractants exert a regulatory influence on neutrophil cytotoxic responses, and target cells were preincubated with chemoattractants and subsequently exposed to 5ng/ml phorbol myristate acetate. Cytotoxicity was determined by assaying 01 Cr release from prelabeled target cells and by measuring changes in small ion permeability. Both myeloid leukemia K562 cells and freshly isolated mononuclear leukocytes were used as turget cells. Two types of chemoattractants were studied; those which stimulate neutrophil oxidative metabolism at concentrations higher than those required for chemotaxis (C5a, FMLP) and those which do not stimulate neutrophil oxidative metabolism at any concentration (casrin, unheated serum). At low concentrations, the former chemoattractants strikingly enhanced PMA-stimulated cytotoxicity. In contrast, chemotactic concentrations of casein and serum failed to augment the cytotoxicity of neutrophils. Cytotoxicity enhanced by different concentrations of FMLP correlated with the rate of superoxide release and with the degree of chemiluminescence, but not with the extent of superoxide release. We conclude that cellular processes activated initial encounters of neutrophils and certain chemoattractants enhance subsequent cytotoxic activity. These processes may contribute to tissue damage at sites of inflammation. OF STIMULATED NEUTROPHIL ADHEREtKE 744 TO EXOCYTOSIS OF SPECIFIC GRANULES. Denis English and John N. Lukens, Vanderbilt University School of Medicine, Nashville, TN Neutrophil hyperadherence stimulated by phorbol myristate acetate (PMA) was characterized by assessing the attachment of labeled cells to plastic surfaces. PMA failed to stimulate adherence in the presence of N-ethyl maleimide, 2-deoxyglucose, or at low temperatures. However, adding these inhibitors to adherent cells, or exposing adherent cells to o 0 c for extended times, failed to effect surface detachment. These results suggest that an activity energy consuming process was involved in the initiation but not the persistance of adherence. That adherence was mediated by an intracellular factor was further supported by a close correlation between lysozyme release and the degree of adherence under a variety of conditions. Thus, inhibitors and suboptimal temperatures consistently affected adherence and er.zy1><2 release to the same extent. Further the kinetics of stimulation of adherence closely paralleled the rate of lysozyme release at each concentration of PMA tested. On the other hand, adherence, lysozyme release, was completely inhibited by omission of Mg++. However, the neutrophil adherence factor, from specific granules, was also found to require Mg+ for expression of activity. These results support the hypothesis that a preformed Mg++ dependent intracellular factor is integrally involved in the process of neutrophil adherence. years, who had ALL diagnos(.>d no lc>ss than six months before the study hcgan and who had no relapses, or signs of CNS leukemia. Tlw childrl.'n wen_• divided into a somnolent and a nonsomnolent group. Th0re no significant differences between these groups in sex, age at diagnosis, proportion who received more than 2000 rads, or psychological disturbances in the parents, as determined by a standardized psyclliatric inventory (BS!). We noted no significant differcncf's between the groups with regard to 1) functioning, as measured by WISC-R intellip,ence quotients and PIAT reading scores, 2) symptoms of psychological abnormalities as measured by the Achenbach Child Behavior Checklist ;md the Achc>nbach 'l\_•acher Report, or 3) seizures, as an indicatic>n of a neurological dysfunction. The results of the checklists do, howf'vcr, indicate that, as a group, the lel1kPmic cl1ildrPn in this study have a significantly higher rate of psychopathology than does the general population The effect of RSV-antibody complexes on the metabolism of ficoll-hypaque separated human neutrophils was determined by examining the generation of luminol-dependent chemiluminescence, superoxide, and thromboxane B2 (a product of arachidonic acid metabolism with bronchoconstrictive activity). Incubation of neutrophils with RSV-antibody complexes resulted in a significant increase in chemiluminescence production. The increase in chemiluminescence appeared to be due to l. active phagocytosis of RSV-antibody complexes as evidenced by its inhibition with cytochalasin B (p<.001) 2. increased superoxide production as evidenced by its inhibition with superoxide dismutase (p<.001). The generation of superoxide was confirmed by specific analysis in a superoxide dismutase inhibitable ferricytochrome C reduction assay. Of particular importance was the observation that RSV-antibody complexes induced the release of significant quantities of thromboxane B2 from neutrophils as determined by a radioil11llune assay. These data document the release of superoxide and thromboxane 82 upon ingestion of complexes by neutrophils. It is proposed that oxygen radicals and products of ardchidonic acid metabolism may, in part, mediate pathogenesis of RSV infection through direct tissue damage and bronchoconstriction. . The drugs were also tested on "normal" bone marrows. Sensitivities to prednisolone, vincristine, methotrexate, adriamycin and bactrim were determined using a clonal assay in which leukemic lymphoblasts and CFU-GM formed colonies in methylcellulose medium. Normal CFU-GM were more resistant to prednisolone, methotrexate and adriamycin than were the leukemic cells. Line KT-2 (T cell) was more sensitive to Bactrim than line 697 (transitional B cell). A permanent human MBT cell line lTE-67 was subcutaneously transplanted into athymic nude mice (BALB/c), producing progressively growing subcutaneous tumors. Tumors were serially passed, with growth stability occurring after 3 generations. Mean latency from transplantation to 500 MM3 tumor volume was 22.4 + 4.4 days. Mean doubling time was 4.92 + 1.7 days. HistologicaTly they contained small round cells with hTgh N/C ratios, high mitotic rates, perivascular pseudorosettes, focal necrosis, and no change in serial passage. Chromosome analysis at passage 19 revealed a near tetraploid chromosome count. There were multiple marker chromosomes including a 4q+, 9q+, 17p+ and Gq-, each present in duplicate. At the first and seventh nude mouse passages the same 4 marker chromosomes were identified. Groups of randomly assigned mice were treated with antineoplastic compounds at 75% of the LD10 by the i.p. route when the median tumor volume exceeded 200 Response was assessed by per cent regressors, mean treated vs. control tumor volumes (T/C) and difference in days to 1000 MM3 tumor volume (T-C): Macrocytosis is commonly observed in children with malignancy. This may be either a consequence of the disease process or its treatment. A study was undertaken to determine whether macrocytosis was seen in association with Hodgkin's disease (HD) and what the significance of this finding might be. Twenty three children (<16 yrs) with varying stages of HD were studied throughout the course of their illness. Macrocytosis was not present in any child at the time of diagnosis. The mean MCV was 77.5 fl with 28% of the children 2 S.D. 2 S.D. above normal mean MCV for age. Macrocytosis was noted in 4/4 patients with S-IVB disease treated with chemotherapy (MOPP) alone and in 13/15 subjects with S-II-III disease treated with chemotherapy and radiation. Subjects treated with irradiation alone did not exhibit macrocytosis. Following cessation of therapy macrocytosis persisted in 9/15 subjects for 1 to >6 years. These data indicate that macrocytosis may occur during the course of treatment of H.D. as a result of chemotherapy, not the disease itself or radiation. The reason for tl1e persistance of macrocytosis in some subjects and its ship to risk of second malignancy requires further study. Congenital dysgranulopoietic neutropenia (CON) is a recently proposed entity that describes a small subgroup of children with clinically severe neutropenia. We followed and studied a 3-yearold female with neutropenia (<500/1111l3) and recurrent severe infections in whom repeated marrow evaluations revealed large (30-50 um) multinucleated promyelocytes to polymorphonuclear cells with as many as 4 to 16 nuclei or nuclear lobes respectively. In addition to the nuclear endoreduplication, ultrastructural and cytochemical evaluation of these cells demonstrated abnormalities in granule genesis and centriole structure. Concomitantly, immunoperoxidase staining indicated that many of the granules were devoid of lactoferrin but not lysozyme. In vitro proliferation studies from blood and marrow mononuclear cells revealed normal to increased thymidine labelling, normal numbers of colony-forming cells and normal colony stimulating activity. These findings support ineffective myelopoeisis and provide a cause for the neutropenia. Serum folate, Bi2 and lysozyme levels were normal. Conceivably, the marked nuclear and cytoplasmic abnormalities in this patient could be secondary to abnormal centriole directed microtubule function, resulting in this unique example of CON. Two hundred ninety-five children with SS disease less than three years of age were prospectively evaluated for: a) the development of severe bacterial infection (i.e., bacteria cultured from CSF, blood, pleural fluid or lung tissue); b) splenic function (i.e., the presence of vesiculated rbc; and c) whether they had received prophylactic penicillin or vaccination for Streptococcus pneumoniae. There were 16 severe pneumococcal infections per 253.89 person years for an overall incidence rate of 6.3 per 100 person years. Ten of 13 patients had abnormal splenic function, as evidenced by vesiculated rbc >3%. Since mononuclear cell ADA activity (mean EU/mg protein ± SD) is markedly elevated in T-cell leukemia {140 ± 39, 9 patients) compared to normal 4.8 ± 1.1, 25 controls, we examined whether ADA activity could be used to detect small fractions of malignant cells in the presence of normal lymphoid cells. We observed that ADA activity could discriminate normal mononuclear cells (4.9 ± 1.2) from mixtures of normal mononuclear cells containing 5% malignant T-cells (9.4 ± 1 .2). In addition, adenosine deaminase activity in normal peripheral blood mononuclear cells (4.9 ± 1.2) was markedly increased (15.0 ± 3.2) when a small fraction of ma-1 ignant T-cells (equivalent to 2% of peripheral blood leukocytes) was added to whole blood before mononuclear cell separation. Lastly, ADA activity in normal bone marrow mononuclear cells (5.6 ± 1.5) also was increased (14.l ± 3.1) when a small fraction of malignant T-cells {equivalent to 1% of marrow nucleated cells) was added to normal bone marrow before mononuclear cell separation. Current evaluation of bone marrows for residual disease in lymphoid malignancies is limited by the lack of a specific morphologic marker of the malignant cell. Based on the data reported here, measurement of ADA activity in lymphocyte enriched populations from "normal appearing" bone marrows or peripheral blood may be useful in the detection of minimal T-cell disease. HulFN is being evaluated as a potential therapeutic agent for human malignancies. Unfortunately clinical trials are being initiated with minimal background data from preliminary studies in animal models. We developed an experimental model utilizing the sc transplantation of HOS cells into athymic mice. Prior to treatment in vivo, the growth of HOS cells in culture were shown to be inhibited by lymphoblastoid HulFN 32u-63%, Bu-36%). In contrast a human melanoma cell line was resistant to the antiproliferative effect of Hu!FN {500u-10%, 32u-0, Bu-0). In athymic mice HuIFN administered sc for 7d completely prevented or inhibited the growth of HOS tumors (control-35 tumors/35 mice, 50,000u-2/30, 25,000u-1/12, 12,500u-4/12, 6,250u-4/6). The in vitro resistance of the melanoma cells was also reflected in vivo (control-6/6, 100,000u-5/6, 50,000u-6/6, 25,000u-6/6). The mechanism thru which Hu!FN exerts its antitumor activity in vivo remains only partially defined. Because of the species specificity of IFN, we postulated that HuIFN would only express antiproliferative activity in the mouse. This was confirmed by the that in vitro HulFN augmented human (21% specific Cr release to 75r.), but not murine NK cell activity; activated human monocytes to be cytotoxic for HOS cells, but failed to activate murine macrophages. In summary, the in vitro sensitivity of the tumor cells was reflected in vivo and the antitumor activity of HuIFN in this model appeared to be due to a direct antiproliferative effect on the human tumor cells. Central nervous system (CNS) prophylaxis is an accept(.-'Cl crnponent of treutrrent of children with ALL and it is inportant to evaluate the long-term neurological sequelae of this therapy. Brainstem auditory evoked potentials (BAEPs) and visual evoked potentials (VEPs) were evaluated serially from t:im:> of diagnosis in children with NJ,: Group 1, prophylactic cranial irradiation and intrathccal (IT) Il'Cthotrexate; Group 2, prophylactic IT chem:ithcrapy alone. 13Al'.:Ps sha.icd no significant abnonnalities. At diagnosis VEPs to diffuse flash (FVEPs) or pattern reversal stimuli were abnormal in 12/13 patients (pt), Group l; and 15/27 pt, Group 2. The findings suggested dysfunction of visual pathways or of higher cerebral centers. Follc:Ming t11e initiation of prophylactic CNS therapy, 7/13 pt, Group 1, and 8/27 pt, Group 2, the FVEPs showed an overall increase in arrplitude consisting of relative suppression of early C011ponents and enhancement of longer latency C011ponents and had t11e appearance of regression of the VEP to a rrore inrnature pattern. Qie year after diagnosis these FVEPs had not normalized and no pt. had developed CNS leukemia. These findings indicate a significant occurrence of functional danelinical CNS abnormality and that it may be useful in the subsequent clinical evaluation of CNS prophylaxis therapies. --2,3-Dihydroxybenzoic acid (2,3-DHB), an iron-chelating agent has been shown to have an additive effect with desferrioxamine (DFO) in hypertransfused iron overloaded rats. 2,3-DHB in humans is both effective and non-toxic. Its efficacy combined with s.c. DFO in thalassemic patients was assessed. Nine thalassemic patients on low iron diets were studied for 15 days while receiving s.c. DFO at 20mg/kg. as an 8-hour nightly infusion. 100 mg/kg of 2,3-DHB was given orally with meals during the latter 8 days. Daily urine & stool collections from the last 5 days of each trial period were compared for changes in iron content. 2/9 patients experienced gastrointestinal discomfort and were given antacids during which time iron excretion decreased. In 7/9 patients the mean urinary iron excretion increased from 15.6 to 20D mg/day as a result of combination therapy while fecal excretion increased from 15.9 to 17.2 mg/day. Unlike previous studies in 2,3-DHB was used alone, the major increase in iron excretion occurred in the urine. Thus, combined use of the two drugs appears to cause an increase in the total iron excretion. It is suggested that the combination would be of use in patients who are good compliers to DFO therapy. Haemophilia A is caused by sex linked 760 congenital lack of clotting factor VIII. In current treatment of haemophilia A, concentrated human factor VIII plasma is administered intravenously for hemorrhagic episodes. Although oral useful therapy has been desired and oral ingestion of factor VIII entrapped in liposomes has been attempted, there is some problem in acquiring antibodies against F VIII. Kanpo (Japanese traditional medicine), transmitted from China in the seventh century and modified in Japan since then, recentry attracted increasing attention in modern medicine in Japan because of its effectiveness without side effects. The extract of Huang-chieh-tu-tang (HLCT) is one of the Kanpo medicines consisting of four medical herbs, Corptis sp., Scutellaria baicalensis, Gardenia jasminoides and Phellodendrom amurense, which has been believed to possess anti.inflammatory and hemostatic effects. HLCT was clinically very effective for bleeding episodes in haemophilia A so that both in vivo and in vitro experiments were done. Extract of HLCT was given orally 0.15g/kg to a patient with severe haemophilia A. Plasma concentration of factor VIII rose from less than 1% to 41% one hour after oral administration. APTT also shortened from 102"9 to 70"9. In vitro experiment, HLCT revealed to have activities of factor VIII, IX and X at concentrations around 0.08%. to yellow red and brown. Identical patterns were observed in multiple runs of the same sample. Initial Analysis included the 400 major spots in the gels. Analysis was facilitated by cytocomputer imaging of specific constellations of spots. A total of five spots were present in all five AMI.. samples and consistently nondetectable in ten ALL samples including seven non-T, non-Band three T-cell ALL. Four spots were presen: in ALL but not in AML samples. Five spots were present in ALL samples but not in normal lymphocytes. It is concluded that 2-DE is a useful tool for the delineation of characteristic protein patterns in leukemia. The 2-DE approach could be used to identify a protein basis for monoclonal antibody specificity and to systematically search for key antigenic differences between cell types for monoclonal antibody production. hemarthrosis with resultant synovial thickening and joint damage is a common affliction of patients with severe hemophilia A (factor VIII< 1%). Synovectomy to remove the diseased synovium and thereby reduce the likelihood of recurrent hemorrhage has not been attempted often in hemophiliac patients with a high-level inhibitor 5 Bethesda Units). Two patients with severe hemophilia A and high-level inhibitor (68 BU and 10.5 BU respectively) underwent synovectorny while receiving anti-inhibitor coagulant complex (Autoplex). The first patient received two doses of 28 units/kg each, immediately before and during the surgery, with maintenance continued at 40-60 units/kg/dose for 9 doses over 5 days. The second patient received a dose of 63 units/kg before and one of 77 units/kg after the surgical procedure. Maintenance was continued at 40-60 units/kg/dose for 20 doses over 6 days. Recurrent bleeding occurred on the 10th and 8th postoperative days in the two patients, necessitating further therapy. Blood loss during the surgery was estimated at 150 ml for patient I and 932 ml for patient 2. The hoys received 4 and 9 units of packed red blood cells respectively during the intraand postoperative periods. Side effects of therapy included headache and perhaps low-grade fever. Neither patient developed thrombocytopenia or hypofibrinogenemia, nor clinical signs of thrombosis. Synovectomy is possible in severe hemophiliacs with high-level inhibitor using Autoplex at 40-60 units/kg/dose, with doses given at 6-8 hour intervals for a minimum of 10 days. "'f£5 LYMPHOBLASTIC LEUKEMIA (ALL). Raymond J. HutcJli.n.s..Qn. l\J Mary J. Waskerwitz, Nancy J. Hopwood, University of Michigan Medical School, Ann Arbor, MI 48109. In order to assess the effects of ALL and its therapy upon linear growth, growth curves were plotted for 72 surviving children and adolescents diagnosed with ALL between the years 1972-78. All of these patients received systemic chemotherapy, including daily steroids during induction therapy, and central nervous system (CNS) radiotherapy. Seventeen patients experienced a transient growth deceleration during therapy, but all regained their losses. An additional 17 patients demonstrated marked growth deceleration from which they have not recovered. Linear growth velocities ranged from 0-3.8 cm/year during the period of deceleration. This group serves as the basis for the rest of the reported data. Twelve of these patients are off therapy from 8 mos to 5 yrs, while 5 remain on. In 3 patients the growth deceleration was probably secondary to normal postpubertal changes. In 2 patients it appeared to be temporally related to administration of a second course of CNS radiotherapy. The remaining 12 patients exhibited deceleration beginning early in therapy. Five independent prognostic indicator in adult ANLL. Patients with no normal karyotypes at the time of diagnosis had significantly shorter survival period than those with normal metaphases. The t(8q;2lq) without sex chromosome loss indicated good prognosis. We examined the initial karyotypes of 8 consecutively studied children with ANLL during the last 6 months, All 8 patients had at least 20% of metaphases with normal karyotypes. Five patients two with 46XX only, one with t(8;21), one with the 18p-and one with a monosomy 7 are alive and in remission. All of them had typicnl Ml and M2 morphology. An 8 month old girl with hemohistiocytic leukemia (normal karyotype) and a 7 year old girl with initial erythroleukemia-like picture with very large platelets (1-2 times as large as a red cell) preceding progressive increase of monoblasts (46XX in 85% and monosomy 10 in 15% of cells) failed to achieve remission and died. The 8th patient, an 18 month old girl with monomyelocytic leukemia with bilateral orbital chloroma had t(8;21). She was not treated and died. The type of cytogenetic abnormalities in childhood ANLL appears to be similar to that seen in adults. In this small series, the morphological and clinical factors were more useful in predicting the outcome than cytogenetic data per se. We report the feasibility of doinq olatelet aqqreqations on only 45 lambda of platelet rich olasma (PRP) using the Sienco Dual Channel Aggreqometer. (90 lambda is reauired if the olatelet count is 150,000.) The 45 lambda of PRP are diluted 4 fold with phosphate buffered saline to which 20 lambda of aggreqatinq aqent is then added. Results can be reported as presence or absence of 1st and 2nd phase aggregation and as percent aqqreqated for each Phase. B1ond is collected into a polyethylene micro centrifuqe tube calibrated at the l .5 mark and containing 150 lambda of 3.8% citrate. Heel stick blood can be used providinq the heel is warmed and coated with a thin film of vaseline and a free blood flow is obtained. Results are highly reproducible and aqree precisely with duplicate assays using a larger sample size. In agreement with previous reports, we have found the areat majority (BO%) of newborn infants with birth weiqhts ...:2000 qm have platelets which are unresponsive to epinephrine as an aqgregating aqent. The remainder (20%) show a response of low magnitude. Aggregation with adenosine diphosphate (ADP) is also impaired, but not to as great an extent. Term infants show similar but less striking trends. In all birth weight groups, an increasing responsiveness to epinephrine is seen with increasinq age, the majority of aqqregation assays beinq positive by aae 3 weeks. The SS patients had significantly higher serum ferritin levels than age-matched nondnemic controls. The SS+Tx patients showed a marked increase in ferritin levels compared to non-transfused SS patients, but lower levels than B-thal patients. The datu s 1 Jggests that partial exchange transfusions result in hemosiderosis but tre transfusional iron load may be less than that produced by packed cell transfusions. For this reason SS+Tx patients should be monitored iur iron overload and chelation therapy may be indicated in these patients for prevention of transfusional hemosiderosis. ATT has been shown to suppress the function of B lymphocytes. We studied the effect of AAT on phagocytic Index (Cl) and chemotactic index (Cl) of PMNs derived from 10 healthy subjects. Pl was determined by incubating PMN and latex particles with and without AAT. Chemotaxis was perfonned with a modified Boyden's technique. PMN were placed in the upper compartment with and without AAT and chemotactic factor(s) in the lower. Ratio of migrated to total cells represented Cl. In separate experiments Hank's solution with and without AAT was placed in the lower compartment to determine chemo-attractive index (CAI). Mean (+ lSD) Cl, CAI and Pl are presented (table) . Concentration of 500 mg/dl decreased the Pl (P<0.01) and su press ion was in-AAT mg/dl N Cl CAI PI versely dose related 0 5 76 (14) 16 (4) (7) --CAI increased pro-500 5 28(7) 44(6) 16 (7) gressively with 100 1000 5 32Jfil_ 44 l IJ 16 9 to 500 mg concentrations (r<..O. 79 and P.c:_0.05 in each instance AAT in z200 mg/dl concentration decreases PMN function. Comparably high concentrations of AAT, as occurs in malignancies including leukemia may contribute to the well known defects of PMN function and increased susceptibility to infection. Defective Cl appears to be due to AAT acting as a chemotactic factor. We have examined over 4,000 fine needle aspirates of thyroid nodules of which 53 were from 50 children and adolescents. Sixteen aspirates were from tumors of miscellaneous sites from 15 patients, ranging from 18-months to 18-years of age. Of 53 thyroid aspirates, 12 papillary carcinomas, 2 follicular carcinomas, 2 Hurtl1le cell tumors, 2 follicular adenomas were cytologically diagnosed and confirmed histologically. Of 16 miscellaneous aspirates, the following cytologic diagnoses were made: 1 malignant sacrococcygeal teratoma, 1 Wilm's tumor, 2 rhabdomyosarcoma, 1 metastatic thyroid carcinoma and 1 leukemic infiltrate. These were also confirmed histologically. With adequate cellular material, the fine needle aspiration biopsy offers a high degree of accuracy. Malignancy not only can be diagnosed but typed accurately. Prompt chemotherapy c.-m be initiated in advanced malignancies. A preoperative diagnosis helps in planning proper surgical therapy. A benign diagnosis in many instances may prevent unnecessary surgical procedures. Severe aplastic anemia is associated with a 70-80% mortality in patients treated with supportive care, with or without androgens. While marrow transplantation is a preferred option, clear improvement in survival in all patient groups has not been achieved. In particular, Elfenbein et al. have recently documented poor transplant results in Black patients with aplasia. Over the past two years, we have treated 15 patients with severe aplastic anemia with either anti-thymocyte or anti-thoracic duct lymphocyte globulin. Of these patients, 10 are alive 2-36 months post treatment (Median; 12 months). Of 5 Caucasian patients, only 2 are alive, and only one has enjoyed a partial remission of his disease. In contrast, of 7 Black patients treated, 5 have achieved complete hematologic remissions. Five patients are surviving. One patient died of sepsis during treatment; another died of an accident while in complete remission 9 months post therapy. These preliminary results suggest the possibility that Black patients may be at particular risk for "autoirrrnune" forms of aplastic anemia responsive to this form of immunosuppressive therapy. Blood coagulation factor activities are dependent upon gestational age as shown in both premature infants and in chronically catheterized fetal lambs. Eight sets of chronically catheterized twin lamb fetuses were studied to determine if cortisol would the development of blood coagulation. One twin from each pair was infused intraperitoneally with cortisol (2 mg/ 0.8 cc/hr for 48 hrs) while its twin sib was infused with normal saline (0.8 cc/hr). Changes in coagulation factor activities measured before and after the infusions were analyzed using a paired T test. Significant differences between cortisol infused (c) and saline infused (s) sibs were apparent: blood cortisol +31.8 pg/dl (c), +2 pg/dl (s), p;0.001; Factor II +16.6% (c), +2% (s), p;0.006; Factor V +54% (c), +18.2% (s), p;0.002; Factor VII +24% (c), +0.1% (s), p;0.01; Factor X +26% (c), -1% (s), p;0.001; Factor XII +9.4% (c), +l .4% (s), p;Q.025. No differences were seen with fibrinogen +24 mg% (c), +21 mg% (s); Factor VIII +2% (c) +9% (s); Factor IX +12% (c), +4% (s) or Factor XI -4.2% (c), +l .8% (s). Betamethasone at 15 mg/day for 2 days given to pregnant ewes resulted in changes in fetal coagulation factors similar to those observed when lambs were given cortisol directly (Factor II +14%, Factor V +58%, Factor Vil +31%, Factor X +22%, Factor XII +10%). Results indicate that cortisol accelerates the development of blood coagulation and suggest that coagulation factor activities might be improved by giving betamethasone to mothers at high risk for premature delivery. process. Diamond-Blackfan Syndrome (DBS) is a CMA of humans in which steroids repair the anemia in many patients. In this study the clinical course of 8 children with DBS was correlated with the ability of their bone marrow mononuclear cells to form erythroid colonies in methyl cellulose culture. One child did not respond to steroids but produced large numbers of erythroid colonies in culture. This child may have a defect in the hematopoietic microenvironment. Three children maintained satisfactory hemoglobin levels on low dose alternate day steroid therapy and produced normal numbers of erythroid colonies in culture. Four children required higher doses of steroids to maintain satisfactory hemoglobin levels and produced low numbers of erythroid colonies in culture. The latter two groups of children 2'-Deoxycoformycin (dCF), a potent inhibitor of adenosine deaminase (ADA), has been effective in the treatment of T-cell, but not B-cell leukemias, a finding that appears to be related to the ability of T, but not B-lymphoblasts to trap deoxyadenosine (dAdo) as dATP. Both increased ability of T-cells to phosphorylate dAdo, and of B-cells to degrade deoxyribonucleotides could explain this distinction. However, differences in activities of c!Ado kinases and cytoplasmic deoxyribonucleotidase in T-and B-cell lines are not sufficient to account for the 100-fold difference in their capacity to accumulate dATP. To further evaluate the basis for this phenomenon we have developed human B-cell/T-cell hybrid cell lines, and evaluated 1) sensitivity to the cytotoxic effect of dAdo, 2) ability to accwnulate dATP, and 3) ability to degrade intracellular dATP after expansion of this pool by prior incubation with c!Ado. We fused CEM(T) cells with either Wl-L2 (B) cells, or with a double mutant derived from Wl-L2 that lacked both enzymes necessary to phosphorylate dAdo (adenosine and deoxycytidine kinases D AK--dCK-). The concentration of dAdo required for 50% growth inhibition of CEM, WI-L2, and several CEM/WI-L2 hybrids were respectively, 0.35µM, 45µM, and 15-35µM. The hybrids were intermediate in their capacity to accwnulate dATP, and in their capacity to catabolize an expanded dATP pool. CEM/AK--dcK-hybrids were resistant to dAdo. Our results thus far indicate that "Bness" is dominant over nT-ness", and are consistc11t with the opertion in B-cells of a mechanism, possibly enhanced nucleotidase activity, that diminishes the ability to accwnulate dATP from dAdo. Prior studies implicated a tightly-linked membrane in the NB rat as responsible for decreased deformability and survival (Ped. Res. 14:536,1980) .To test for a similar change in human NB RBC, we studied spectrin extractability by lmM EDTA (pH 8,37°C,25min) from fresh RBC ghosts of normal adults and from cord blood of normal fullterm NB. We also studied solubility of Triton X-100 (0.5%,30min,OOC) treated ghosts in cyanate-free urea (0.25-1 M). Washed Triton shells were suspended in buffer to an optical density(OD) of 0.4 at 360nm. Aliquots were added to urea and rate of change of OD determined (OD units/8min Formyl-Met-Leu-Phe (FMLP) causes polymorphonuclear leukocytes (PMN) to secrete and become "sticky" in vitro, We related these events to FMLP-induced neutropenia. FMLP was intravenously administered to anesthetized rabbits in doses ranging from O. 01 ug to 1.0 ug. Controls received phosphate-buffered saline (PBS). Blood pressure (BP), heart and respiratory rate (RR), arterial gases and pH were monitored. At intervals over one hour following injection, blood samples were obtained for absolute PMN count (AGC) and plasma lactoferrin (PLF), a constituent of PMN specific granules. High and intermediate doses of FMLP caused a dramatic but transient decrease in BP, and increase in RR. Prior to FMLP infusion, PLF levels were 6.4 + 4.lug/ml and AGC were 2,008 + 1,229 (mean+ s.o.). There was a-positive linear correlation-between AGC and PLF prior to injection of FMLP (R2=o. 74,p L.,.01). At one minute after FMLP injection, the percent change in AGC decreased as an exponential function of dose to as low as 10% of baseline (R2=0.86, pL...01) and PLF increased as an exponential function of dose to as high as 30ug/m1 (R2=0.84,pL.Ol). Thus FMLP-induced neutropenia is associated with increased levels of PLF suggesting that PMN are induced to degranulate, aggregate and manifest increased adherence to microvasculature. Furthermore the rise in PLF can be employed as a marker of PMN activation in vivo. Zeltzer. (span. by Charles Grose). The Univ. of Texas Health Science Ctr., Department of Pediatrics, San Antonio, Texas. The effectiveness of behavioral treatment (beh. Rx) for control of nausea and vomiting was evaluated in our study of pediatric cancer patients (pts.). Twenty-eight pts. prospectively rated their nausea and vomiting, and the extent to which these symptoms "bothered" them (i.e., made them sad, worried, or physically uncomfortable) and disrupted their daily routines (e.g., school, peers, etc.). Pt. compliance with data gathering was 100%. Thirteen of these pts. (46%) reported minimal vomiting and 8 had vomiting but died or tenninated their The remaining 7 pts. rated their symptoms during a mean of 2.7 chemotherapy courses before and 4.4 courses following beh. Rx. Courses were matched for drug types and dosages for each pt. Drugs included adriamycin, cytoxan, vincristine, high-dose methotrexate, 5-Azacytidine, Ara-C, and L-asparaginase. Beh. Rx was designed to reduce anxiety, distract the pt., encourage positive expectations, reward "well" behavior, reduce rewards for "sick" behavior, and induce relaxation. Mean course ratings for each pt. were derived for baseline and for post-intervention time periods and were analyzed by paired t-tests. Following intervention, reductions were obtained in nausea (p<.03), vomiting (p<.05), "bother" (p<.05), and "disruption" (p<.025). We conclude that behavioral techniques can reduce vomiting and disability associated with intensive regimens of chemotherapy. Neonatal red blood cells (RBC) are less filterable and have a shorter life-span than adult RBC, suggesting that neonatal RBC are less deformable. We have studied cellular deformability of RBC by means of a counter rotating Rheoscope (D) and by measuring the pressure (Pt) required to aspirate whole cells into micropipettes with internal diameters of 3.311m. Smaller pipettes were used to study geometric properties: viz, volume (V), surface area (SA), excess surface area beyond that required to enclose the cell volume (ESA), and mechanical properties: viz.elastic shear modulus ( l'), time constant of viscoelastic recovery (tc), membrane viscosity (n=:ixtc)., of RBC. Results from 10 neonatal (N) and 10 adult (A) blood samples were: We have previously demonstrated that adults and children with steroid resistant OBA exhibit low to absent bone marrow EP colony growth in culture. However, OBA is usually sensitive to steroids suggesting that EP may be present in many newly diagnosed patients. To evaluate this possibility we measured EP frequency in the plasma clot cultures of marrows of 10 newly diagnosed or relapsed steroid resistant patients who were not receiving steroid therapy. 5 of 6 newly diagnosed patients (age 2-8 mos.) had normal or nearly normal marrow EP derived colonies, and all 5 responded promptly to steroid therapy. One had low EP and failed to respond. In contrast, 4 steroid resistant patients (age 13-64 mos.) had reduced to absent EP derived colonies that were in 2 cases stimulated to develop in reduced numbers only after addition of T cell derived burst promoting activity (BPA) to the culture medium. This requirement for BPA suggests immaturity of the residual EP population. These results show that OBA is a heterogeneous disorder at the progenitor level. Some patients exhibit blocks in EP maturation between CFU-E and erythroblasts and have nonnal EP numl>ers. Others have blocks l>etween CFU-S and BFU-E, lack EP and fail to respond to steroids. Responsiveness to steroids may therefore relate to the level at which EP maturation is impaired. To determine if fetal hemoglobin accumulation in erythroid cells is controlled by the level of progenitor matur'ity from which these ce 11 s derive or by environmenta l factors acting on erythroblasts, we measured the growth characteristics and. by radio ligand-immunoessay proportions of HbA and HbF in normal adult rhesus marrow erythroid colonies cultured in plasma clots. Pooled CFU-E colonies contained 3-12% Hbf while pooled BFU-E colonies contained 25-45% Hbf. A subpopulation of CFU-E was found to form colonies in the absence of added erythropoietin(epo). These "highly epo responsive cells" (HERCs) produced small colonies with no Hbf. These findings, show that simian bone marrow contains a hierar•:hy of erythroid progeni tors which differ in globin gene expression(decreasing HbF with increasing maturity)in the colonies to which they give rise. The HbF: Hb·' ratio in BFU-E and CFU-E derived colonies increased in prorortion to the level of crude epo in cultures, burst promoting activity influenced the HbF:HbA ratio in BFU-E derived C'-1G· nies only. Thus the ability to express maximal HbF in progenitor derived erythroid cells is influenced by environmental factors and progenitor maturity. We propose that erythrocytes produced in normal steady states are derived from the most mature progenitors, whereas increased HbF oroduction in stress results from the direct differentiation of immature progenitors. HbF synthesis may be further influenced by epo and BPA action on erythroid precursors and/or progenitors. A clinical trial of Li therapy was undertaken in a S-year-old boy with GSD, Type IR, variable neutropenia, and neutrophil dysfunction. Prior to therapy, absolute granulocyte numbers (AGN) ranged: 234-774/mm1. Neutrophil function and assays revealed diminished random motility (30% of control value) and directed migration (4S% of control values), by modified Boyden technique; diminished bipolar configuration change; absence of enhancement of adherence properties and distribution of surface adhesive sites with conditions of chemotactic stimulation. Colonyst imulating activity (CSA) production of patient (PT) and control (C) mononuclear cells (MNC), +/-Li at 1 meq/L, was studied using standard agar clonogenic assays and reported as colonyforming units in culture (CFUc) per 1 x lOS/ml normal bone marrow cells. The PT was started on Li therapy at SO mgm q 8 hours, with escalating doses. AGN > 1000/mm3 was observed by one week and remained so for the study period (8 weeks Determination of the optimal duration of maintenance therapy is important in ALL to minimize potential late effects. Previous CCSG studies showed a significantly higher relapse rate in patients (pts), particularly males, whose therapy was discontinued after 3 years of complete continuous remission (CCR). In CCG 141, pts in CCR for 3 yrs. were randomly assigned to 1 of 3 regimens: A= discontinue (DC) therapy; B = reinduction then DC; C =continue maintenance for 2 more years then DC. 235 boys had bilateral open wedge testicular biopsies; 21 (8.9%) with occult disease were not randomized. Of 880 pts entered on study, 490 (56%) were in CCR at 3 yrs. Of the 310 pts randomized (R), 100 were in Reg. A, 103 on Reg. B, and 107 on Reg. C. Of the 157 nonrandomized (NR) pts, 94 received Reg. A, 5 Reg. 8, and 58 Reg. C. 23 pts were randomization exceptions. 226 pts (161 R, 65 NR) have been followed for 5 yrs or more in CCR. Disease-free survival (DFS), hematologic remission (HR), and extramedul lary relapses were not statistically significantly different in Rand NR pts on Reg. A, B, and C. The death rate was higher in pts on Rey. C but the differences were not significant. Of 34 first adverse events (FAE) 22 occurred in males, 12 in females (p=0.03). Off therapy (Reg. A & B) 17/23 FAE were in males. Nine of the 11 pts on Reg. C with FAE (5 males, 6 females) have died; 5 after BM relapse and 4 unrelated to relapse. In conclusion, 3 years of maintenance therapy in pts in CCR appears adequate. but boys have a higher relapse rate than girls. ,., 85 Tables I & II show gene frequency for 9-6PD def. a-Thal, 13-Thal, and Hb E. Among 184 unrelated males 27% had G-6PD def. Hb E is in Khmer and Lac Loum but thus far none is found in Viet and Hmong. The Tai Dam show 8-Thal-minor, and they have a predictive prevalence for severe thalassemic disorders (B-Thal major and E/13thalassemia) of 6/1000. This prevalence is about 10X that of Italians and Greeks. Although microcytosis (Tab. III) is in 199 (35%), Fe Def. was infrequent; & Hb E & a-Thal were more frequent. Stockman, III). Depts. of Pediatrics and Medicine, SUNY Upstate Medical Center, Syracuse, NY CB-CFU-C's of 25 newborns (18 normal full term, 4 infants of diabetic mothers (IDM), 2 preterm infants and 1 infant of a mother treated for acute leukemia (AL) during pregnancy) were evaluated using a double layer agar culture technique. Normal full term CB yielded a mean of 1425 colonies/ml. The number of CB-CFU-C's was not influenced by mode of delivery, apgar scores, or CB total WBC, absolute neutrophil count (ANC) or hemoglobin. The mean CFU-C/ANC ratio was 0.41. Cultures of CB obtained from IDM's formed a mean of 2700 colonies/ml with a CFU-C/ANC ratio of 0.72. Cultures of CB from 2 preterm infants yielded less colonies (200/ml) than observed in normals. A 34 wk gestation infant, born to a woman receiving chemotherapy for AL was also evaluated. The number of CB-CFU-C's from this infant was not significantly increased (3210/ml) but the ratio of CFU-C's/ANC (2.68) was well outside the range determined for normal full term or preterm infants. Thus, CB-CFU-C's were not affected by the various maternal and newborn parameters in CB, however, this was not statistically significant in our small group of patients. The data on the infant born to the mother with AL suggest that when marrow suppressive agents are given to a pregnant female, they may affect fetal hematopoiesis. Harvard Medical School, Boston; Univ. North Carolina, Chapel Hill. We describe a patient whose peripheral blood neutrophils (PMN) and bone marrow precursors (beyond promyelocyte) contained multiple large azurophilic granules. There were also giant granules in eosinophils, basophils, melanocytes, renal tubules, thyroid, and neurones. Irnmunofluorescent staining with fluoroscein-and rhodamine-conjugated antibodies to i 0 and 2° granule markers showed virtually all of the PMN granules to be fusion products containing both markers. Electron microscopy showed the granules to be large peroxidase-containing lysosomes. Only rare normal 1° and 2° granules were present. Superoxide generation in response to opsonized zymosan(OZ) was 7.3 nmol/min/106 cells (control 8.9); but in response to phorbol myristate acetate(PMA), only 2.2(control 9.4). OZ by 90% of PMN (control 91%) and to PMA by 22% (control 99%). Degranulation was normal, as was ingestion of opsonized particles. Killing of Staph. Aureus was 60% at 90 min incubation (control 92%). PMN cyclic AMP content was 4 pmol/107 cells (control 3.1). In order to determine whether these characteristics derived from the cells' genetic program or their environment, the patient's bone marrow was grown in long term culture. PMN produced in vitro demonstrated the same morphology and normal cAMP level as those in vivo. These studies describe a new disorder of PMN; the structural similarity to, but biochemical differences from, Chediak- Eleven patients (6 male, 5 female) who had received standard neuraxis radiation with (n=7) or without (n=4) chemotherapy for treatment of posterior fossa tumors (medulloblastoma (n=lO), ependymoma (n=l )) , had hypothalamic-pituitary target organ axis evaluation at 3-53 months after completion of treatment. The age range at initiation of treatment was 3 7/12-23 8/12 yrs and age range at time of evaluation was 4 1/12-24 1/2 yrs. The radiation treatment consisted of approximately 3600 rads to the neuraxis with a 1500 rad boost to the posterior fossa. The approximate mean radiation dose to the hypothalamic-pituitary region and thyroid gland were 3600 and 2300 rads respectively. In 9/11 patients the skeletal age was within one year of the chronological age. Growth hormone reserve was deficient in 5/11. Somatomedin C was decreased for age in 2/9 patients. Cortisol response to insulin-induced hypgolycemia was inadequate in 1/7. TSH response to TRH testing performed in 9 patients and was normal in 3, compatible with 1 thyroid dysfunction in 5 and suggestive of hypothalamic dysfunction in 1. One patient developed abnormal thyroid function 12 mos after an initially nonnal evaluation. Since endocrine evaluation was not obtained prior to therapy, we cannot be certain that the decribed abnonnalities were a consequence of treatment. However our results argue that children who have received CNS radiation formal ignant posterior fossa lesions should have continued evaluation to allow for early detection of honnonal deficiencies and institution of appropriate reolacement therapy. Fanconi's anemia is a genetic disorder characterized by congenital malformations, abnonnal chromosomal instability and progressive marrow failure. Inheritance patterns suggest an autosomal recessive disorder but with heteroqeneity. Histocompatibi lity studies were performed on 11 patients Fanconi 's anemia documented by clinical and cytogenetic findings. Parental consanguinity could be established in only 1 case. Nevertheless, by virtue of oarental sharing of HLA haplotypes, 6/11 patients were found to be HLA-A,B identical to either the mother (5 cases) or the father (1 case). Of these 6 patients, 5 were also shown to be HLA-D identical to one of their parents. An additional patient, found to be HLA-D compatible with his mother, was mismatched only for an HLA-B specificity. Patients did not exhibit common HLA phenotypes, nor was an abnormal frequency of any phenotype observed. That the disorder is not 1 inked to HLA, is suggested by the i dentifi ca ti on of norma 1 heterozyoo+rtion of lymphoid cells, B and pre-B cells in marrow aspirates from rl1ildrcn with ;1eutc lcukcmi:1 in long-term rcmissic1n and off of all cl1cmotherapy. rontrol marrows were from healthy adults and from children with disorders not involving bone marrow. Results arc expressed as percent of lymphoid cells. -------- For the Cooperative Study of Sickle Cell Disease As part of our national study of the clinical course of sickle cell diseases, splenic function has been systematically assessed in more than lOG'l patients with various sickling disorders. Blood was collected in the 27 individual centers, fixed in buffered 3% glutaraldehyde, and shipped to a central lab for enumeration of percent pocked RBC using interference phase-contrast microscopy. In HbSS disease, a rapid and progressive increase in pocked RBC was seen after 6 months of age. Although there was considerable individual variability, most patients had >3% pocked RBC after 1-2 years of age. A pocked RBC percentage of >3-5% correlated with functional hyposplenia by 99mTc scans. 14 children who developed severe bacterial infections had high percentages of pocked RBC. Patients with SC disease had slight impairment of splenic function which did not progress with age. Distinctly different patterns of splenic function were seen in patients with Hb SB 0 and those with Hb ss+ thalassemia. Hb SB+ thalassemia approximated SC disease, while Hb SB 0 thalassemia resembled HbSS. These patterns provide insights into splenic function in the various sickling disorders. They may also assist in formulation of management strategies for anticipation and prevention of serious bacterial infections in these patients. The median age at diagnosis (dx) was 5 yr.; 17 were male and 15 female. One pt had microscopic residual tumor (Group II) after grossly complete removal. 24 pts bad gross residual local tumor (Gp. III) after biopsy (20 pts) or mastoidectomy (6 pts). 7 pts had distant metastases at dx (Gp. IV). Currently 14/25 pts (56%) with localized sarcoma continue in relapse-free survival (RFS) at 1-5. 7 yr. after dx (median, 2 yr.). Only 1/7 Gp. IV pts is in RFS. 17 pts relapsed at 0.3-6.6 yr. after dx (median, 0.6 yr.); 15 died. Sites of initial recurrence included the meninges (7 pts), distant metastases or local regrowth (4 pts each), regional recurrence (1 pt), or contralateral glioma (I pt). Outcome was also influenced by signs at dx indicating risk of meningeal tumor: intracranial extension (ICE), petrous bone erosion (BE), or cranial nerve palsy (CNP). RFS rates were 0/6 pts with ICE, 4/9 with BE, 5/8 with CNP, and 6/9 without meningeal risk signs. The addition of cranial RT and intrathecal drugs, begun in 1977, appears to prevent meningeal relapse in 80% of high-risk pts. We conclude that current treatment programs can often cure pts with middle-ear RMS, formerly a universally fatal disease. 797 Sudha Rao, Arvind Shukla, Raym:?nd Olesinski and !?_. Vidyasagar. Abraham Lincoln School of Medicine, University of Illinois Hospital, Department of Pediatrics, Chicago, Illinois. Platelets from nornal newborn infants derronstrate impaired aggregability to "in vitro" testing when canpared with platelets from nornal adults. In order to detennine if "in vivo" platelet aggregability is altered in newborn infants, we detennined the circulating platelet aggregates (CPA) and the microthranbus index (MI) in 20 nornal newborn infants between 1-7 days of age (mean age ll:i days) by the method of WU and Hoak. M:>thers of infants chosen were not on any antenatal n-edications. 20 nornal adults were used as controls. CPA% in the infants ranged from 0-35% which was slightly higher than the adult CPA range of 0-25%. The CPA% (mean ± SEM) for the infants was 8.02 ± 5.34 and 10.38 ± 3.98 for the adults. There was no significant difference between the two groups. The MI ranged from 0.5-1.5 in the infants as compared to O. 4-1. 3 in the adults. The MI (mean ± SEM) was 0.89 ± 0.39 for the adults and 0.919 0.053 for the infants. Again, there was no significant difference between the two groups. There was no apparent correlation between either sex, race or age and the CPA%. We conclude that although "in vitro" platelet aggregability is impaired in newborn infants, platelet aggregation "in vivo" is apparently adequate. There is no evidence of hyperaggregability "in vivo" (suggestive of endogenous activation) to account for the decreased aggregability "in vitro". This report concerns a 12 month old black female infant with hemolytic anemia. Hb values range between 8.0-9.0 gms.%, Hct 19%-27% and reti3 counts 20-36%. Despite the high reties MCV ranged from 46-63 u . Osmotic fragility was markedly increased. Peripheral smears showed extreme microspherocytosis, poikilocytosis and fragmentation of red cells -a morphology resembling that of hereditary pyropoikilocytosis. However, thermal sensitivity could not be demonstrated with by incubating the red cells for up to 6 hours at 45°c or by measurement of circular dichroism of separated spectrin at 220 nm. Intracellular electrocyte determinations showed markedly increased Ca and slight lowered K (see table) . SOS gel electrophoresis of the membrane polypeptides demonstrated a relative lack of spectrin as measured by densitometric scanning of Coomassie Blue stained gels. In an attempt to demonstrate biological explanations for factors which appear to have prognostic importance in children with acute lymphoblastic leukemia (ALL), we compared the random and directed motility of leukemic cells from 32 pts. with ALL (4 T cell, 28 non-T, non-BALL) to that of normal peripheral blood lymphocytes (PBL). Random motility was assessed in a closed, double chambered system by determining the percentage of cells crossing a nucleopore membrane filter with a pore size of Su following a 3 hr. incubation period. Directed motility of leukemic lymphoblasts was examined in response to a casein gradient and was found to be <50% of that of normal PBL. Mean random motility of both T and non-T, non-BALL cells (15%) was similar to that of normal PBL (18.3%). However, a marked correlation between increased locomotor activity and Fc-IgMR expression was observed for both normal T lymphocytes and leukemic lymphoblasts. A nearly two-fold increase in random motility was observed in Fc-IgMR+ ALL cells. Fc-IgMR expression and increased motility were observed in the lymphoblasts from 8 of the 28 non-T, non-BALL patients. Furthermore, all 8 of these pts. were < 3 or > 10 years of age and had WBC counts > 10,000/UU113. These data demonstrate that ALL cells exhibit diminished chemotactic ability and suggest possible biological differences in leukemic lymphoblasts from pts. with known adverse prognostic characteristics. Perfluorotributylamine (FC-43), a very perfluoro-compound, was used to study its effect on the rheology of sickled ervthrocvtes Erythrocyte indices in cord blood samples from 277 black newborn babies were determined using an electronic cell counter (Model 7.BI, Coulter Electronics). The mean red cell volume (MCV) was 109pJ (± 7. 93 SD). The mean corpuscul i r hemoglobin (MCH), a value that remains constant despite possihle time-related changes in red cell volume, had a lower coefficient of variation (6%). The mean MCH was 35.57±2.13µµg with a mode of 36.0µµg. The MCH was unrelated to sex or birth weight. The mean MUI in 20 newborn babies with an FAS blood hemoglobin phenotype (35.38± 2.5lµpg) wa·s not significantly different from that of the total population. The incidince of electrophoretically detectable Bart's Hemoglobin was 3.2%. The mean MCH in these cord blood samples was 32.18±2.5 µµg (N=9), a value that was not significantly lower (plOOO/cu mm for >5 days) and non-responders (NR). In R (n=6), E increased from 353±76 (mean± SEM) at birth to a peak of 2783±430/cu mm at 21-25 days. NR (n= 4) had significantly lower E from birth (75±26/cu mm, p<.05) to 21-25 days (332±190/cu mm, p<.01). R had significantly lower neutrophils at birth (2499•428 vs 4843±984/cu mm, p<.05), and 5 of 6 R increased neutrophils by within 10-15 days vs 0 of NR (p<.03). Lymphocytes, suppressor and helper cells increased progressively in both groups over the period of study, with no differences between R and NR. Birth weight and gestational age were similar in both groups, and there were no apparent causes for the lower neutrophils in Rat birth (e.g., maternal disease, drugs, neonatal sepsis). Rand NR had similar exposure to blood transfusions, antibiotics, intravenous nutrition and artificial formula. Bacterial sepsis was not observed in any infant. Eosinophilia was not related to an IgE response. The incidence of eosinophilia is similar to that reported previously, and appears to be a maturational response occurring after an initial neutrophilia in those premature infants born with a lower neutrophil count. Childhood ALL is composed of subgroups defined by immunologic markers and certain markers are known to have prognostic significance. Null cell ALL is the largest subgroup and additional markers are needed to identify patients at increased risk of early relapse within this non-T, non-B category. We have used a direct immunofluorescence assay to identify the presence of receptors for the lectin peanut agglutin (PNA) on blasts from 26/46 (63%) of our null cell ALL patients and have subsequently noted a high rate of relapse (17/26) in this PNA+ group. Relapse has occurred in only 5/20 patients whose blasts lacked the PNA receptor. The PNA+ and PNA-groups were comparable in clinical features (i.e., age, leukocyte count, follow-up times) and the striking difference in relapse rate was correlated only with the presence of receptors for the lectin (p<0.01). PNA receptors are commonly found on fetal thymocytes but not on mature peripheral lymphocytes 3 except after neuraminidase treatment. SOS-PAGE analysis of NaB H 4 -galactose oxidase labelled solubilized cell membrane extracts revealed a 68,000 dalton glycoprotein found only on PNA+ ALL lymphoblasts. Neither PNA-blasts nor PNA+ normal thymocytes expressed this component. The lectin PNA seems to define a high risk group of null cell ALL patients and to be associated with a specific cell membrane component. ThP management of AML dif f crs markedly from that of acute lymphocyt le leuko,mia (ALL). The differences in underlying disease and the types of therapies used might be expected to lead to differing 1·ates of infectious complications in these two forms of let1kemia. In an attempt to identify any relationship between fever, granul0cytopenia (<1000 polys/ul), infection and disease status, 20 patients with AML were observed over a period of 16. 5 patient years and comparisons were made with our previous experience with ALL (Wolk et al, Am J Dis Child 131:157, 1977) .In AML an infectious origin for fever was found in 70% of fevers d11ring induction, in 25% in remission, and in 67% in relapse. In ALL, the cause of the fever was identified in 27% of fevers d11ring induction. in 65% in remission, and in 8% in relapse. In AML, the most common infectious causes for fever in induction and relapse were sepsis (33% of fevers) and pneumonia (45% of fevers). In induction and relapse among patir>nts with AML wLo had pneumonia the most common causative organism recovered from needle aspirations or open lung biopsies was mycoplasma pneumoniae (50% of all pneumonias). This organism was rarely seen during induction or relapse nf ALL but arco11nted for 14.5% of fevers in remission. Persistance of M. pneumonia in the throat for many months was common. These data indicate that most febrile granulocytopenic episodes during induction of remission and relapse of AML are caused by definable organisms unlike the situation in ALL in which the di-.sease apparently may cause fever. In t'ioth diseases, M. pneumoniae sho11ld be considered as a possible etiology for fever. Half of the study families provided some home care (range: day to 3-1/2 mos.) for their terminally-ill child. Two-thirds of these children died at home. Readmission to the hospital occurred within 48 hours of death for many of the others. Special equipment or parental training was seldom needed, and most families did not seek help from home care agencies. Rather. ongoing contact with the oncology staff was their most frequently cited need. Whereas home visits by hospital staff were rarely required, telephone or direct contact ranged from weekly contacts during quiescent periods to several times daily during crises. In almost every instance, the patient preferred to be at home 1-20 yrs (mean 7.2 ± 6.2) after recovery from P. carinii pneumonitis (23 pts) or varicella pneumonitis ( 10 pts). The results were derived from clinical spirometry, expiratory flow-volume curves, pulmonary gas-transfer factor, arterial blood gases, specific airway conductance and volume of isoflow, and expiratory flow at SCY' ,0 of FVC (Vmax 50 ) after patients had breathed an 8CY' ,0 helium -20% oxygen mixture. Methotrexate had been administered to 32 f,atients, cyclophosphamide to 27 and mediastinal irradiation to I. Residual pu monary function abnormalities were present in 21 patients (64%). An increased volume of isoflow in 14 patients (> 21.8% of FVC), indicating small airway disease, was the most common abnormality; 7 of these also had a reduced Vmaxs 0 • Five patients had restrictive lung disease (as determined from decreases in total lung capacity, FVC and inspiratory capacity below 2 SD of the predicted mean for age-and sex-matched normal controls); 4 had decreased pulmonary gas. transfer factor; 6 had arterial hypoxemia at rest; and 5 had an increase in specific airway conductance. Eleven patients had more than one abnormality. Clinical variables significantly related to dysfunction were: need for ventilatory support, higher oxygen concentration, and total dose of methotrexate (P < 0.05 each). On repeat measurements in 7 patients after bronchodilation, volume of isoflow had decreased and Vmax 5 0 had increased in each. The data indicate (i) a high prevalence of residual pulmonary dysfunction after "apparent" recovery from diffuse pneumonitis in children with cancer (not previously reported) and ( Increasing numbers of children surviving after treatment of acute lymphoblastic leukemia (ALL) have drawn attention to questions of long-tenn morbidity, including disease-or treatmentrelated growth retardation. Southwest Oncolooy Group project #7581 was initiated in 12/1975 to evaluate the effect of ALL as well as chemotherapy and irradiation on body growth, serum growth honnone (GH) and somatomedin (Sm) concentrations. The study included 127 children from 5 participating institutions, 83 males and 44 females, with a mean age at ALL diagnosis of 6.6 years. Height, weight, and honnonal concentrations were determined at the time of initial diagnosis and at reqular intervals for up to 5 years of follow-up. 84% of children were observed for longer than 12 months. Boys <4 years showed significant growth retardation (P<.Ol) at diagnosis. Growth retardation persisted through ALL therapy so that 83% of these patients were qrowing below the 50th percentile by the end of observation (P<.Oi). Linear regression analysis of growth rates in children with ALL versus nonnal standards confinned differences in growth patterns. Serum GH and Sm concentrations were similar to controls. However, honnone levels at initial diagnosis were significantly higher than during remission (P<.001). In conclusion, our data suggest that a significant number of children with ALL are shorter than their peers prior to onset of therapy. GH and Sm levels appear to be elevated at the time of disease onset and to decrease with therapy. The median length of the initial hospitalization was 4 days (range 0 to 51 days); the median length of subsequent hospitalizations was 3 days (51.1% primarily for the administration of chemotherapy, 19.2% because of suspected or proven infection, and 5.6% for transfusions). The median number of hospitalizations per Only 13 pregnancies (25.5%) resulted in full term births. There were 18 premature births (58.1% of total live births). Total fetal wastage (abortions and death in utero) occurred in 17 instances (33% of total pregnancies). The mean birth weight of the 13 full term infants was 3336. Gm. with a range of 2758-4508 Gm. Cesarean section was performed in 11 mothers. The average hemoglobin levels in the patients was 9.4 grams (SD± 2.1) and the average hematocrit was 28% (SD± 5.8%). In 8 (17%) of the subjects, the diastolic blood pressure was greater than 140 mmHg. Urinary trace infections occurred in 34.1% of the mothers. Other maternal complications were edema 3 (6%), pelvic inflammatory disease 2 (4.5%), chest syndrome 2 (4.5%) and one case of jaundice (2.2%). There were seven episodes of crises, preeclampsia/eclampsia occurred in A method which can be used to determine susceptibility to chickenpox rapidly, accurately and which can be performed routinely is sorely needed. This is particularly important in the management of children who are at high risk of complications should they develop chickenpox. Determination of varicella-zoster (V-Z) antibody by ELISA, using antigen coated plates that can be stored at 4°C for at least two months, has correctly predicted the outcome of exposed individuals following household exposure. There has been a 97% correlation (140/144) with the fluorescent antibody against membrane antigen -FAMA assay. Results have been reproducible with different lots of antigen and conjugate. In testing children in our oncology program, 2 of 27 who were said to have had varicella were found to be susceptible; 10 of 30 with a negative history were seropositive. Of the 10, three had recently received ZIG and 2 others blood transfusions. On retesting of sera obtained subsequently from these 5 children, all were found to be susceptible. Testing of children who are at a high risk of complications of chickenpox for immunity by ELISA should replace reliance on past history. Testing should become a routine part of their care to provide guidance as to the risk of exposure to chickenpox and the need for passive immunization. The technique is also useful for rapid identification of susceptibles, should a patient develop chickenpox on an inpatient service. Carnitine, a1i essential cofactor for transport of long-chain fatty acids into mitochondria for oxidation, is normally synthesized in liver and kidney. Dietary carnitine is not sufficient to prevent lethal disease in patients with congenital defects in carnitine biosynthesis (carnitine deficiency). Twin girls presented with Hgb 4 to 5 gm/dl and absent bone marrow erythroid precursors at 3-1/2 mos, while receiving a soy formula, which contains no carnitine. Erythroblastopenia resolved spontaneously when diets were liberalized. Both children developed fatty infiltration of liver, heart and muscle and recurrent hypoglycemia with fasting. Systemic carnitine deficiency was documented in both, with deficient butyrobetaine hydroxylase activity in liver. One child died. The other is doing well on oral L-carnitine, but mild anemia (hgb 10 gm) and reticulocytosis (2-3%) persist. Red cells are normocytic without i antigen. Hgb F is 1-2%. Marrow erythroid precursors are not vacuolated. Five other patients with carnitine deficiency have been reported to be anemic. Supplementation with carnitine at levels which improved liver, muscle and cardiac function has not completely prevented anemia, suggesting that accumulated metabolites such as butyrobetaine may be toxic to marrow erythroid precursors. However, small amounts of dietary carnitine appeared to reverse the severe erythroid hywith which these patients presented, whose me:.._·hdn-i.sii i:.; Concentrations of l:oth adenosine 3':5' rronophosphate (cJ\MP} and guanosine 3': 5' rronophosphate (cGMP) were determined during incubations of rrononuclear cells isolated fran marrows of ALL patients at diagnosis and at subsequent remission periods. Incubations for 1-20 min. in the presence of l-rrethyl-3-isobutylxanthine resulted in equal increases of l:oth nucleotides whereas addition of sodiun nitroprusside resulted in large elevations of cGMP only. Both isoproterenol and epinephrine increased markedly concentrations of cAMP in cells (>70% lymphocytes) isolated fran patients undergoing remission of ALL. carbamylcholine addition resulted in slight increases of the cGMP concentration, whereas serotonin exhibited pronounced stimulatory effect upon guanylate cyclase activity. Cells isolated fran ALL patients at diagnosis ( > 90% blasts) exhibited diminished responsiveness of l:oth cyclic nucleotides to hornonal stimuli, the catecholamine activation of adenylate cyclase being alrrost absent. The sensitivity rad reappeared already by 2 weeks after the initiation cherrotherapy. Attanpts are made to correlate the characteristics of the cAMP and cGMP systems with the growth behavior of the cells in longterm cultures. The techniques may eventually be used to determine the effectiveness of particular therapeutical interventions in intlivitl'.lal patients. 14 children with NHL without BM involvement were diagnosed at KUMC between 6/76 and 6/81. Serial BM aspirates were processed for culture on soft agar and histologic review. 7 BM aspirates demonstrated lymphoma (histology +) and 6 grew lymphoma colonies (agar +). 35 BM aspirates were normal (histology -) and 29 failed to grow lymphoma colonies (agar-). However, 6 histology -BM aspirates were agar +. Both the Fisher's exact test and K statistic were significant (p < 0.002) indicating not only an association between histology and soft agar results, but also a close agreement. At this time, there is no statistical difference between duration of survival and 1) clinical stage at presentation (I, II vs. III), and 2) BM involvement with lymphoma (histology + vs. -) . However, the duration of survival of children who were agar+ was 6.8 months and agar -was 22.7 months (p< 0.02). Children whose BM aspirate grew lymphoma colonies on soft agar have all died. In this patient population,_!!:! vitro growth of lymphoma colonies was predictive of a very poor prognosis and their short survival was independent of both clinical stage an,.l histologic evidence of BM involvement with lymp!10ma. Iron deficiency (ID) may lead to cerebrovascular symptoms (CVS) in CCHD by lowering hemoglobin (Hb) and oxygen carrying capacity, by altering tissue iron proteins (neurotransmitter metabolism, mitochondrial respiration), or by increasinq red cell riqidity and blood viscosity (n}. The contribution of n to the CVS of an adolescent qirl with partially corrected transposition of the great vessels and ID was evaluated by measurinq oxygen delivery determinants before and after isovolemic exchange transfusion (ET) with iron sufficient blood. ID was due to menorrhea and was diagnosed by microcytosis (69fl}, low serum ferritin (16ng/ml), low serum iron/total iron bindinq capacity saturation (37/466;8%} and elevated erythrocyte porphyrin CVS were present daily for 2 weeks prior to the ET and included headache, vertigo, paresthesia, and transient loss of vision. A one blood volume ET with CPD blood in fresh frozen plasma jowered n from l7.4±0.9cp to l3.6±0.5cp at shear rate 11.25 sec , increased mean cell volume from 69 to 8lfl, and stopped all CVS. Cr51 red cell mass and blood volume, Hb, HCT, weiqht, pulse, blood pressure, and blood gases were not altered by the ET. CVS recurred in two weeks as the Hb and n increased in response to iron therapy, but were less severe. The experience sugqests that the increased blood n of iron deficient blood may be important in the CVS of ID and CCHD. Blood n may not be adequately reflected by Hb or HCT, and should be measured in CCHD with CVS. Neutrophils (N} with abnormal glutathione (GL) metabolism and decreased concentrations of GL exhibit dysfunctions that have been ascribed to oxidant damage. We measured GL reductase activity, total GL (GSH + GSSG) concentrations and GL depletion during oxidant stress in N from neonates to determine if the previously reported deficiency of GL peroxidase and increased susceptibility of neonates' N to oxidant damage could be related to additional GL abnormalities. GL reductase activity/mg N protein was similar in N of 14 neonates and controls (3.11 ± 0.01 and 3.91 ± 0.43 units, respectively). GL concentrations were significantly less (p < .04) in N from 32 neonates than controls (3.1 ± 0.3 and 3.5 ± 0.2 µg/5 x 10 6 N, respectively). Moreover, a greater depletion of GL occurred in neonates' N during oxidant stress produced by exposing N to H 2 o, generated enzymatically by glucose oxidasc + glucose. Total GL (GSP. + r.ssG) fell from basal concentration an average of 84% in neonates' N and 57% in control N exposed to 0.3 units glucose oxidase. Similar values for N exposed to 0.6 units glucose oxidase were 88% (14 neonates) and 75% (controls) In conclusion, neonates• N exhibit decreased GL peroxidase, normal GL reductase, decreased basal concentrations of GL and excessive depletion of GL during oxidant stress. Abnormalities of GL in conjunction with the previously reported deficie.ncy of catain neonates' N may render these cells prone to oxidant dam-· age with consequent dysfunction. Diminished chemotaxis has been consistently demonstrated in nE.utrophils (N) obtained from human neonates. We measured the binding of tritiated formyl-methionyl-leucyl-phenylalaniue (FMLP-H 3 i to N obtained from 10 human neonates and 10 adult controls to determine whether N assumed to exhibit decreased chemotaxis also have abnormal chemotactic factor binding. N were isolated from venous blood and were incubated at 22°C for 20 min with FMLP-H 3 (40 nM) either in the absence (total binding) or presence (nonspecific binding) of excess (l0-4 M) nonradioactive (cold) FMLP. N with bound FMLP were separated from free FMLP molecules by rapid centrifugation through silicone oil. N pellets were dissolved in scintillation fluid and radioactivity was measured. Neonates' N bound significantly less FMLP-H3 than did control N (total cpm bound per 2 x 10 6 N were 7,444 ± 677 and 10,435 ± 763, respectively). Likewise, specific binding (total binding -nonspecific binding) was less (p < .02) by neonates' N (6,223 ± 614 cpm) than by control N (8,903 ± 722 cpm}. Each neonatal N specifically bound 150,582 ± 15,661 FMLP-H 3 molecules; control N bound 219,851 ± 25,298 (p < .02). Binding was saturable, presumably via a plasma membrane receptor, because excess cold FMLP decreased uptake of FMLP-H 3 by 83 ± 1. 4% in neonate,..' and 85 ± 1. 3% in control N. Since binding of chemotactic factors to membrane receptors is the initial event in chemotaxis, decreased binding may be one of the mechanisms responsible for decreased chemotaxis in neonates' N. Megakaryocytes (megs) were isolated from adult guinea pigs by the method of Levine et al (J. Cell. Biol., 69:159, 1976 ) with yields of 1.4 to 5 x 105 megs per animal (purity of 75-90%). The metabolism of l-14c-AA(53-55 or 255 Ci/mole) by these cells and by platelets isolated from the same animals was evaluated using an AA concentration of 5 µM/for 5'. Megs were demonstrated to convert AA to metabolites of both the lipoxygenase (12 HETE) and cycloxygenase pathway (HHT and TXB2). These products were identified by their mobility in TLC analyses both as free fatty acids and methyl ester derivatives, as well as by their comigration with authentic standards or the AA metabolites of human platelets. As in other cell systems lndomethacin (30 µM, 15' preincubation) Serum lacti1' dehyd1oge-na::-:<" (LDM) activity in a brv.1cl spectrum of malignant diseases. This elevation has been used as a marker of tumor activity, also prognostic significance has been attributed to LOH levels in adults with NHL, particularly those with histiocytic type. LOH serum levels (Normal 98-230 U/L) were measured in 116 untreated children with NHL, 66 untreated cases with acute lymphoblastic leukemia (ALL) and 26 cases of acute nonlymphocytic leukemia (ANLL). LDH levels were not significantly different in ALL and ANLL (970 vs. 817 U/L, p=.329) but the difference between ALL and NHL was highly significant with p(.001 (970 vs. 551 U/L). Among the ALL cases 95% had elevated LOH, for the group was 96% and 77% in NHL. Only 13% of NHL cases had marked elevations ()1000 U) whereas 32% and 23% of ALL and ANLL respectively did. LDH correlated directly witl1 WBC counts and was significantly higher (p=.007) in patients with high counts compared to those with low counts. Patients with diploid stemlines as determined by computerized flow cytometry had significantly higher LOH levels than those with aneuploidy (p=.001). LOH levels did not corrc>latc with or Frcn{"h-Americ.10-Rritish cla.ssification though there was a trend to higher levels in females (p=.08) and Ll morphology (p=.06). In NHL the histiocytic type had lower mean LOH than the lymphocytic poorly differentiated (416 vs. 573 IU/L). In summary contrary to other reports LOH levels do not dis· tinguish between ALL and ANLL, LDH is significantly higher in ALL than in NHL, LOH in histiocytic NHL is not higher. We investigated the adequacy and reliability of Asp. for cell kinetic analysis in comparison to Bx. in 74 paired simultaneously taken samples from 40 pediatric patients and the cell cycle distribution for patients with acute lymphocytic (ALL) and non lymphocytic (ANLL) leukemia. Nononuclear cells from Asp. and Bx. were separated by Ficoll-Hypaque gradient and stained with Acridine Orange (Andreeff et al Blood 55, 1980) . DNA stemline, cell cycle distribution and RNA Index (RI) were determined. Paired samples were taken before therapy and during therapy. The Bx. shows significantly higher proportion of cells in the proliferation phases (S=l0%, S+G2+M=l4%) than the Asp. (S=6%, S+G2+M=85%) with p(.001. As expected the difference in proliferation became more pronounced during chemotherapy (p=.006 before therapy, p(.001 during therapy), The cell cycle distribution was essentially the same for cases of ALL (G0/1=90.4%, S=7%, S+G2+M=9.6%) and those with ANLL (G0/1=91%, S=G.1%, S+G2+M=9%}. We conclude that bone marrow biopsies more accurately reflect the proliferative status of the bone marrow; the difference is exaggerated in patients receiving chemotherapy due to dilutional effect of peripheral blood; adequate and reproducible cell kinetic studies should be based on biopsies and not aspirates; there is no significant difference in cell cycle distribution or cell proliferation in ALL and ANLL. Nonspherocytic hemolytic anemia associated with congenital red cell pyrimidine 5'-nucleotidase deficiency (PND) is characterized by abnormal elevation of red cell pyrimidine nucleotides and basophilic stippling. Studies have also demonstrated elevated erythrocyte GSH content, decreased PRPP synthetase activity and evidence of impaired glucose utilization associated with this disorder. However, at present the etiology of hemolysis in subjects with PND remains obscure. This study was performed on erythrocytes obtained from a young male confirmed as homozygous for deficiency of the enzyme via enzymatic and chromatographic techniques. Dilute suspensions of PND patient red cells were less filterable than normal cells using 3 micron pore-size filters. Anion exchange llPLC revealed an abnormally low ATP concentration accompanied by elevated CTP and UTP as well as other pyrimidine nucleotides in PND patient red cells. These cells were found to have a decrease in intracellular pH, as determined by 31P-NMR spectroscopy. Although the intracellular mag-nesium was increased, Mg-ATP, the biologically functional form of ATP, was calculated to be approximately one-half normal. Red cell calcium was normal. These studies have ·further characterized both physical and metabolic defects associated with this disorder. (Supported in part by USPHS Grant 1R01ES01857). Barnett, A1 tcin-C lTgliEeY-. TawTil<-lla 11 oneY,Nava1 Regi ona 1 MedTc-aT"Lente·r-:-s-a·n-llTeg-o·:ra·1 ffor-nTa·:-------Reports of accidental overdosage of vincristine (VCR) describe severe morbidity and mortality resulting from the neurotoxic and hematotoxic effects of large doses of VCR. Several authors have recommended the use of folinic acid (FA) in the management of patients with VCR overdose. This was based on experimental evidence in which mice given FA were protected from the lethal effects of VCR. Since the biochemical basis of FA rescue in VCR overdosage is unclear, we elected to repeat the animal experiments. Groups of 20 c 3 b 6 F 1 , hybrid mice received either al a single intravenous LD50 dose of VCR alone or the same dose of VCR followed by b) 10 daily intraperitoneal (IP) injections of FA (140 mg/kg) or cl 10 daily IP injections of normal saline (NS). The observed pattern of neuromuscular toxicity, i.e. hind leg incoordination and weakness (days 4-10) was similar in all three groups. However, 14/20 mice in group (a) died compared to 5/20 and 3/20 mice in groups (b) and (c) respectively (p<.001). In each group death occurred between days 6-11 and recovery of neuromuscular function in survivors was noted between days 12-16 following VCR. We conclude that an equal volume (0.3 cc) of daily IP NS is as effective as FA in preventing the lethal effects of VCR in mice. Survival may be related to improved hydration since survivors were noted to maintain a urine output during the observable period of toxicity (days 4-11), whereas mice who subsequently died did not. FA does not appear to be a specific antidote for VCR poisoning in mice. In the children with sickle cell anemia have frequently 'Jeen descdbed as having the "Sickle Cell Habitus". The majority of our patients do not have the body habitus so often described. Using height and weight as growth parameters, we compared the growth patterns of 178 patients with major hemoglobinopathies (SS, SC S-Thal) for 5 years. Severe Heinz body (HB) hemolytic anemia in association with therapeutic doses of phenazopyridine (PAP) in a subject with Hb ch (HbZ) and normal renal and hepatic functions led to a study of the susceptibility of HbZ red ce I ls (RBC) to oxidative injury by PAP. Incubation of whole blood from three asymptomatic HbZ subjects with PAP at a molar ratio of PAP/Hb of 1.3: I produced a marked increase in methemoglobin (Mllb) and HB formation and moderately decreased levels of reduced glutathione (GSH) in RBC from two of the subjects who were non-smokers with in vivo carboxyhemoglobin (HbCO) values of 4-69;. RBC from the third HbZ stbject, a smoker with llbCO%'s of 15-lil, exhibited minimal formation of HB. a moderate increase in Mltb formation and a slight decrease in GSH levels. Rates of MHb formation were pro;>0rtional to the concentrations of PAP. Increasing levels of HbCO from 8.2 to 14.3% by the in vitro addition of carbon monoxide (CO) caused a marked reduction in the rate of HB formation and a moderate decrease in MHb formation. tlormal rates of MHb formation occurred at HbCO of 89.2 and 99.2%. Red eel Is containing HbZ are extremely sensitive to oxidative injury by PAP, either in vivo or in vitro. The degree of oxidative injury diminishes level increases, a phenornenon that is enhanced by preferential binding of CO to the abnormal 6 stbuni t of HbZ. Phenolic disinfectant deterqents have been implicated in epidemics of neonatal hyperbilirubinemia. A hepatic mechanism involving inhibition of qlucuronyl transferuse activity has been proposed. Two premature female infants in our intensive care nursery simultaneously developed features characteristic of Heinz body hemolytic anemia (HBHA): decreased hemoglobin and hematocrit, red cell inclusion bodies (Heinz bodies), anisocytosis, fragmented cells, h_yperbilirubinemia and reticulocytosis. Laboratory investiqation failed to reveal an etiology. Epidemiologic studies indicated a possible association between the reaction and the improper use of an inappropriately high concentration of a phenolic disinfectant* to clean thP inside of the two infants' incubators. The hemolytic anemia resolved spontaneously in both infants. Extensive experimental effr.rts failed to produce Heinz bodies or HBHA. In vitro tests included incubation of the phenolic deterqent with human adult blood and qestational age matched human cord blood. Animal experiments included administration of various concentrations of the phenolic detergent by multiple (intravenous, dermal, subcutaneous and inhalation). Studies were made in cats, mice, and both intact and splenectomized rats. While we failed to prove a hemolytic reaction to phenolics, it should be considered in future epidemics of neonatal hyperbilirubinemia. EBV has an unique affinity for human B lymphocytes. It is associated with infectious mononucleosis, African (endemic) Burkitt's lymphoma, nasopharyngeal carcinoma, and an x-linked lymphoproliferative (Duncan's) disease. To better understand the nature of EBV receptors on B cells, we examined receptor expression on lymphoid leukemic cells representative of discrete stages of lymphocyte differentiation, using an immunofluorescent method. Cells were incubated with EBV, then FITC-F(ab') 2 fragments of human IgG anti-EBV membrane antigen. The proportions of each leukemic type with cells bearing EBV receptors were: We conclude that EBV receptors appear very early, at the pre-B stage, in B cell development and that they are lost at or shortly before terminal differentiation to plasma cells. Non-endemic Burkitt's cells lacked receptors for EBV, suggesting an origin of this malignancy from an unique set or developmental stage of B lymphocytes. 16 infants with an Apgar score of 5 or less at one minute ancl less than 7 at 5 minutes were studied. 14 infants liad estimated gestatior:al ages bet\1ecn 37 and 43 weel:s. Coa&ulation tests were performed on admission day 1, and on days 3 5. Blood was collected for PT, APTT, platelet count, fibrinogcn, P and P test factors V and Vll assay, F.D.?.'s an(l peripheral smear was examined for red fragmentation. Tl1e majority of hypoxic full-term infants did not s!1ow si&nificant coagulation and serial testiDg not reveal evolving abnormalities. One full-term did sl1ow features compatible with intravascular coaguiatiun with prolongation of PT, ana APTT, ei.evateci F.D.?.'s and reduction of platelet count. Tlie si:ulO gms and %S between 30-35%, and were administered as partial exchange or simple transfusion at intervals of 4-6 weeks. Three children completed the year of treatment. A splenectomy was performed on one of these children after she developed a third sequestration crisis one month after completion of transfusion therapy. The other two children have had no recurrence in 2 1/2 and 3 1/2 years post treatment. In our experience, recurrence of sequestration crisis is high, and consequently with conventional management would result in surgery for a significant number of young children. Treatment with transfusion therapy at the most will prevent surgery, and at the least will allow the young child to retain a functioning spleen for a longer period during his vulnerable years. Patients with WAS are thrombocytopenic (Tp). Their platelets (Pl) are half normal size and reported to be deficient in granules (G), dense bodies (DB) and mitochondria (M), poor in metabolic ATP and reduced in storage pool adenine nucleotides (AN). WAS Pl respond poorly to aggregating agents and have a shortened life span in patients and normal recipients. Splenectomy, however, has restored normal Pl count and volume in many WAS patients (N Eng J Med 302:892, 1980) . We have evaluated megakaryocytes (Mk) and Pl from 5 children with WAS. One patient was studied 6 times following splenectomy 3 years ago. His Pl count and volume became normal and have remained so, except during periods of infection. G, DB, M, levels of AN, capacity to form thromboxanes, 125I-labelled surface membrane glycoproteins, and responses to all aggregating agents were identical to controls. Ultrastructural features of Pl from Tp WAS patients were also normal, despite reduced size. Electron microscopy of Mk from Tp WAS patients and the non-Tp child were identical to controls. Our findings suggest that WAS Pl are intrinsically normal. Prolonged maturation in the bone marrow causing excessive development of Mkdemarcation membranes may result in small Pl size and Tp. Due to delayed maturation, small Pl would be l to 2 days older than normal on delivery to the circulation, explaining the shortened half-life and relative metabolic incompetence. Abnormal thrombopoiesis caused by cells or factors concentrated in the spleen may be responsible, rather than intrinsic faults in progenitor cells. Dev.Pharmacol.Ther.l: 40,1980) . After 24h incubation in l.OµM (JH)MTX,levels of nonexchangeable MTX, 4-NH2-lO-CH3-PteGlu2 and 4-NH2-lO-CH3-PteGlun in remission marrow were 152±80, 57±22 and 99±46 (mean±S.D;n=l6); in ALL at diagnosis were 73±55, 37±20 and 271±282 (n=l3); in ALL at relapse were 143±102, 71±27 and 484±185 (n=6); and in AML were 103±52, 127±123 and 344±165 (n=4) pmoles/109 cells respectively. Higher levels of total cell MTX and of 4-NH2-lO-CH3 PteGlun were present in ALL at relapse and in AML, where leukemic cells are more likely to be resistant to MTX, than in ALL at diagnosis. Decreased uptake of MTX and synthesis of increased levels of dihydrofo late reductase are two mechanisms of resistance to t1TX. Our data do not support the former as the mechanism of presumed resistance to MTX in our patients. Co-incubation of leukemic with both MTX and folinic acid (d,L,-5-CHO-H4PteGlu) resulted in a marked decrease in accumulation and polyglutamylation of MTX. This finding is similar to that described in fibroblasts. (Mal. Pharmacol. 19:87,1981) . Folinic acid also preserved DNA synthesis and cell growth in fibroblasts when co-incubated with MTX.These results provide evidence that folinic acid may "rescue" leukemic cells as well as host cells from MTX toxicity. *mean (range) mU/ml 2 = 6.50 p <0.05 maternal smoking. P infants with elevated Ep were more likely to be SGA. Ep levels from 5 newborns in the elevated Ep group were studied with sequential venous plasma Ep levels in the first 24 hrs of life. None had respiratory distress requiring 02 therapy. First order log disappearance curves were parallel with a mean half-life of 2.7 hrs (range: 2.3-3.0). It is speculated that an elevated cord Ep level indicates fetal hypoxemia at birth and is a frequent antecedent factor in neonatal P. The postnatal fall in Ep reflects norrnoxemia after birth. A serial fall in Ep after birth may be useful in differentiating ante-from postnatal hypoxemia. Williams, Robert J. Rothbaum, Cynthia C. Daugherty, James L. Lessard and Richard E. Harris, (Spon. by William K. Children's Hospital Medical Center, Cincinnati, Ohio. To assess PMN structure and function in SS, we studied PMN units vs 153; range: 45-120 vs 70-300). Random movement was near normal in all 3 (mean: 50 vs 58; range:20-80 vs 20-140). The% of total B-glucuronidase degranulated during exposure to zymosan was normal (73.5 ± 12.4% vs 79.0 ± 15%, mean ±SD). Distribution of fluorescein-conjugated Con A was distinctly abnormal showing a unique patched distribution in 27.5 • 7.4% Shwachman PMN vs 3.4 ± Patching was also associated with a significant increase in fluorescence photometric intensity (p<.01): Nine of 10 children chosen at random from those treated at St. Christopher's Hospital for Children were found to be functioning two grades below their expected levels by performance tests. Only one had been recognized previously in school. Neurometric testing, using EEG and evoked potential data, showed severity scores to be 1 to 3 standard .05)-:-During PGE-;-infusions, mean baseline PllN adherence values were 89+16% of pretreatment controls (p>.05). Phagocytosischemiluminescence values were g4+18% of pre-or post-treatment values (p>.05). Intracellular bactericidal activity aureus) of PMrls obtained during PGE 1 infusions was comparable to pretreatment bactericidal activity. tlo inhibitory effects of PGE 1 containing plasma obtained from the same infants were observed when reacted with healthy adult PMNs. No significant correlations between PGE 1 concentrations & any pr1t1 function tested were observed. These findings fail to demonstrate inhibitory effects of PGE 1 on PMN functions when administered therapeutically to CHO infants. NATURAL KILLER CELL ABNORMALITIES RELATED TO PREGNANCY. J. E.Baley and B.Schacter. (Spon. by A.A. Fanaroff) CWRU, RB&C Hosp., D.Peds.& Path., Clevc.,OH Natural killer(NK) activity, implicated in tumor surveillance and the response to so1·1e viral infections, may be important in the regulation of the immune response. Resistance of spontaneous NK activity to 3000 rads y irradiation is under x-linked control in adults. Since pregnant women and newborns have many immunological abnormalities, we have examined NK activity and radioresistance in infants and mothers immediately after birth. NK activity assayed with 5lchromium release from the target cell K562 was lower in 15 mothers (22.4±14.6%) than adult controls (30.0± 7.8%, p<.01). 24 neonates (26-42 wks gestation) had NK activity (11.5±7.8%) significantly lower than both controls and their mothers (p<.01). No relationship was noted with gestational age, birth weight percentile, sex of the infant or gravidity of the mother. Using the single cell assay, lymphocytes from 12 newborns were found to form slightly fewer conjugates (9.88±1.33%) with the K562 than the controls did (11.98±1.8%, p<.01), while conjugates formed by the mothers (11.9:t2. 35%) were not significantly different. Lymphocytes from 7 newborns caused significantly less killing of K562 in conjugates (12.9±7.3%) than their mothers (24.3±5.4%, p<.01) or controls (26.2±4.4%, p<.01). The radioresistance of NK activity in the newborns and mothers did not conform to the previously described pattern of x-linked inheritance, consistent with the hypothesis that NK activity in the mothers and infants is a property of a cell differ- Studies were performed to determine if the age-dependent variation in antibody (Ab) level following immunization with pneumococcal polysaccharide (PnPs) antigens also varied with the serotype of PnPs and immunoglobul in class of Ab. lgG and lgM Ab to PnPs types 3,6,18,19, and 23 were measured by enzyme-linked immunosorbent assay before and after PnPs immunization in 31 normal children aged 2-18 months and 13 normal adults. Prior to immunization, lgG Ab but no lgM Ab was found to all five serotypes in 2-6 month olds. Post-immunization lgG titers were significantly depressed for type 23 only. In contrast, post-immunization lgM Ab levels at this age were similar to the adult levels for all but type 3. By 12-18 months of age, pre-immunization lgG levels had fallen for al I but type 3; again, lgM Ab was rarely detected prior to inmunization. While lgG Ab levels following immunization were lower than adults for types 3,6,18 and 23, the rise in Ab titer for these serotypes was not significantly different than adults. others. lgG and lgM responses to type 3 could be found as early as 2 months of age, while types 6 and 18 were poorly immunogenic for either lgG or lgM Ab even at 18 months of age. Types 19 and 23 stimulated greater fold-increases in lgM Ab than lgG Ab. These results emphasize the complex ontogeny of the antibody response to PnPs antigens. Responses are age-dependent and serotype-dependent, for both the level and class of Ab Previous work with colostral lipid and lntralipid has suggested that lipid particles depress neutrophil function by exhausting metabolic substrates and decreasing availability of Fe receptors. In the current study, we examined the effect of mu 1 tilamellar vesicle (MLV) liposomes made of phosphatidyl choline, cholesterol, and phosphatidyl serine (10:5:1 ratio) on PMNL function. Small MLVs (<:lu in diameter) and large MLVs up to lOu in diameter (concentrations range from 0 to 35 mg/ml) were exposed to PMNL for Z hours prior to and immediately before assay. Zymosan stimulated hexose monophosphate shunt activity in CPM/l06PMNL (115Z + 51 control versus g89 + 50 for small MLVs and 1058 + 103 for large MLVs) was not significantly depressed in cells exposed to MLV when compared to unexposed cells. Fe receptors 88 + 1% for control versus 86 + Z% for small MLVs and 84 + 4% for large MLVs were likewise not significantly decreased. Uptake, internalization, and killing of 3H thymidine labeled S aureus 50ZA was unaffected by low concentrations of sma 11 or large MLVs. Low concentrations of liposomes do not induce defects in neutrophil function of the type seen when PMNL are exposed to colostral lipid or Intralipid. Supported by NIH grant HD13021. Several investigators have demonstrated that long-term cultures of human mononuclear cells produce functionally active C2. Human mononuclear cells were isolated by ficoll-hypaque sedimentation and cultured in RPM! or Ml99 supplemented with 15% heated fetal calf serum. C2 was measured at intervals by standard hemolytic assay. Cultures could be maintained for over 5-8 weeks with good viability of cells and C2 production. If the mononuclear cells were washed vigorously after two hours of initial incubation, the remaining adherent cells (all monocytes by nonspecific esterase staining) produced minimal CZ despite long-term cultures. If the vigorous washing was omitted, however, C2 was detected within the first two weeks and reached maximum levels at 4-5 weeks (2-10 x 108 effective molecules/culture). In a second series of experiments, non-adherent cells (lymphocytes by nonspecific esterase staining) were added to cultures of monocytes which had been thoroughly washed. Returning lymphocytes to the cultured monocytes restored their ability to synthesize CZ. The time of appearance of C2 and its maximum level was related to the number of lymphocytes added to the cultures. Cultured lymphocytes alone, however, did not produce C2. These data suggest a requirement for lymphocytes in order for cultured monocytes to synthesize C2. Whether this requirement is for a soluble lymphocyte-produced factor or for actual contact between the cells is not clear from these studies. Nevertheless, the lymphocyte appears to be a potent modulator of C2 synthesis. We report 2 new cases of Onenn's a variant of SCID, with characteristic rash, eoslnophilla and histlocytic prolifera-At age 4 rronths patient 1 had 4,216 lyrrchocytes (lcytes)/ nm of blood with 79% E-rosette+(T lcytes) and 3% surface lg+(B lcytes). Sen.111 lgG was low (49 mg/di) while lgE was increased (500 lU/ml ). Lcyte responses to mitugens were 1""1, but MLC reactivity was normal. Monoclonal antibody studies using an Ortho Cytofluorograf revealed a helper/suppressor (OKT4+/0KT8+) Icyte ratio of 0.64 (nl. 1.8-3.0) and was due to an absolute increase In OKT8+ lcytes. Patient 2, at 1, 3 and 4 rronths of age had OKT4+/0KT8+ of 6.5, 2.5 and 2.3, and the fluorescence intensity of the OKT8+ population became identical to patient 1 at 4 rronths. la+ cells fell from 50% at 1 rronth to 5% at 4 rronths. There were 17.6% OKT6+ lcytes present at 4 rronths, indicating circulating stage II thyrrocytes. In 90 healthy merrbers of this highly Inbred f'"11ily, 22 had OKT4+/0KT8+ < 1.6. Suppressor lcyte function assessed by reverse herrolytlc plaque assay revealed 70 to 80% functional suppression of normal lcytes by patient 2 but no suppression by a relative with OKT4+/0KT8+ of 1.1. Thus, Onenn's syndrome is associated with disturbed T lcyte subpopulations as tested with phenotypic markers and a functional suppressor assay; rroreover, phenotypic expression of the lcyte defect was found in an extraordinary nurber of f'"11ily merrbers. It has been shown that stimulated T lymphocytes enhance monocyte (Mn) production of CZ in adults; in the newborn,however, the T cell population appears to be balanced towards suppression of lymphocyte (Ly) function. Since the neonate is characteristically hypocomplementemic, the role of Ly in Mn C2 production in the newborn was, therefore, investigated. Mn were harvested from adult (Ad) or umbilical cord (Co) blood by ficoll-hypaque sedimentation followed by adherence onto plastic dishes. Ad and CoMnwere cultured with or without the addition of 106 Ad or Co Ly. CZ was measured hemolytically in supernates at regular intervals. Six experiments with 4 Co and 5 Ad bloods were done. Results of representative experiments reveal: Ad Mn produce minimal CZ without added Ly (peak=0.9 x 108 effective molecules/ml culture). With Ad Ly, 4x more C2 was produced, but with Co Ly only l.Sx more CZ was generated. Co Mn, like Ad Mn, produce minimal C2 without added Ly (peak=0.3 x 108 EM/ml). When mixed with Ad Ly, 26x more C2 was produced; with Co Ly, however, only 7x more C2 was produced. Ly mixed with Mn cultures also allowed for earlier production of CZ. Ad Mn alone first produce measurable C2ond11. CZ production began 4 d earlier with Ad Ly, but only l d earlier with Co Ly. Co Mn alone first made C2 on d 17. With Ad Ly, C2 was produced 8 d earlier, but only 3 d earlier with Co Ly. These data indicate that the lymphocyte is essential for efficient production of C2 in man. The newborn lymphocyte is deficient in this function, perhaps resulting in the hypocomplementemia seen inthe newborn. Little is known about the physiology of human tissue macrophages (M$) or the process of M $activation in the human. We have shown previously that mouse MP can be primed by exposure in vitro to the bacterial products lipopolysaccharide (LPS) and muramyl dipeptide (MDP), or by injection of MDP, so that they produce more of the bactericidal agent superoxide anion co:z> when stimulated by phagocytosis or contact ::vith phorbol myristate acetate (PMA). We have studied release of o 2 by breast M $ obtained from 30 normal mothers and have examined the capacity of these cells to undergo priming for greater 0-release, a characteristic of activated M$ in animals. Mi were isolated2i,y dextran, Ficoll-Hypaque, and adherence and were > 99% phagocytic. In 16 paired samples, PMA-stimulated 02_ release was similar with M$ from colostrum (0-3 days) or transitional milk (5-8 days) (585:!: 48 and 484± 45 nmol/mg protein, respectively, x±SEM). Release of oby milk M$ was almost identical to that by the mothers' blood monocyfes. Incubation of milk Ml> overnight with LPS, 10 ng/ml, "activated" the M$ for greater PMAstimulated 0-release (837±38 nmol/mg, vs. 382±27 for controls, n=6). Incubation wifh MOP, I-JOO ug/ml, did not activate; but incubation with the 6-0-steroyl derivative of MOP activated the M$ for greater 0release (672± 109, vs. 362 ±74 for controls, n=3). We conclude that breast released into both colostru:n and milk undergo a vigorous oxidative metabolic response that is equivalent to that of blood monocytes. Our data also suggest that human M$ have the capacity to be activated rapidly by exposure to certain bacterial products; this activation could enhance their capacity to resist infection. prusside, high-dose steroids and plasmaphoresis did not prevent progression of vasculitis and tissue loss. The last episode began with pain and swelling in the penis rapidly progressing to purpuric discoloration of the entire penis and base of the scrotum. Within 12 hours of the onset of symptoms, a 72 hour infusion of PGE1 was begun. The dose was increased slowly over 5 hours to a final concentration of 0.021 ug/kg/min and maintained·at that level for the remainder of the trial. The patient also received steroids. Over the next 4 days, the swelling and discoloration entirely resolved. CIC were found to be elevated (730 ug/ml) at the onset but were only minimally elevated (350 ug/ml) 5 days later. Skin flushing was noted 1 hour after the infusion was begun along with enhanced palpation of the popliteal, dorsalis pedis and posterior tibial arteries bilaterally. No other side effects were noted. We conclude that this therapeutic success was due in part to the vasodilating and antiplatelet effect of PGE 1 in preventing further vascular and tissue damage. Cell-mediated immunity was assessed in 74 children with Juvenile Rheumatoid Arthritis (JRA) using 2 in-vitro assays: (l)generation of Leucocyte In!•ibit ion Factor (LIF) by concanavalin A (ConA) stimulated lymphocytes and (2)Lymphocyte Transfor!'lation (LT) using 4 dilutions of phytohemagglutinin and optimal doses of ConA and pokeweed mitogen. Results were analyzed by onset types of JRA and compared to results from 42 normal adults and 30 hospitalized children. In LT, abnormalities were infrequent and occurred most often when autologous rather than AB+ serum was used in the cultures. Sera from some children depressed LT in normal cells. In LIF, abnormal responses were seen in all onset types and in hospitalized children in spite of normal LT to ConA. While inflammatory disease activity contributed to this finding in the polyarticular and systemic onset groups, it did not for the children with pauciarticular disease who were relatively well, but expressed other notable immunologic abnormalities such as antinuclear antibodies and uveitis. We concluded that there was a basic difference in immune reactivity as measured by lymphokine generation in children with pauciarticular JRA compared with healthy adults. St. Christopher's Hosp. for Child., Philadelphia, PA. In syndrome a wide spectrum of immunological abnormalities from complete deficiency to almost normal cellular immune response can occur. In 4 patients with partial DiGeorge syndrome we have noted exaggerated delayed hypersensitivity skin test responses by comparison with most normal children of the same age. For this reason we studied concsnsvslin A (Con A)-inducible suppressor activity in the peripheral blood lymphocytes of 3 children (6 mos, 15 and 17 yrs) with partial DiGeorgc syndrome but without evident infection. The percentages and absolute numbers of T cells were, respectively: 20-39%, 1200-1800/mm3; 40-6o%, 1200-2200/mm3; and 50-6o%, 900-1100/mm3. Peripheral blood mononuclear cells which were preincubated with or without con A for 48 hr were incubated with equal numbers (5x104/microtiter well) of unstimulated cells in the presence of 1/2, 1/6 and 1/18 of the concentration of con A causing optimal proliferative response ss measured by 3H-thymidine uptake. No cultures containing the patients' con A-pretreated cells showed greater than 2o% suppression, whereas control con A-treated cells caused 30-9o% (usually 55-8o%) depression of 3H-thymidine uptake by the same responder cells. This relative excessive depression of suppressor activity may be secondary or may indicate selective exhaustion of T suppressor cells. It is possible, however, that fewer suppressor cells are produced either because maturation of the latter is more sensitive to deficiency of epithelial thymus or because of absence of a portion of the thymus which is more important for aaturation_of jhe suppressor cells. At 4 years of age, a female developed thrombocytopenia, anemia, lymphopenia and hepatosplenomegaly which improved following splenectomy. Liver and spleen histopathology showed typical sarcoid granulomas. From age 4 to 12 she did well except for cough and dyspnea which improved with Prednisone therapy. At age 12 following 3 recent episodes of H. influenzae sepsis, immunologic studies revealed hypogammaglobulinemia (IgG:l64 mg%, IgM:48 mg%, IgA:9 mg%, IgE:5 IU) with deficient functional antibodies but normal B-cells, 14%. Cellular immune studies showed absent delayed skin tests with normal PllA, MLC and LIF to Candida. Studies using monoclonal antibodies showed total T-cells 20% (nl 68±20%), T-helper cells 13% (nl 50!10%), I-suppressor cells 34% (nl 20tl0%). C4 was decreased, 9.9 mg% (nl 17-50), but other complement components were normal. She had elevated angiotension converting enzyme, 157 (nl 80!20) despite high dose Prednisone therapy. Pulmonary function showed decreased flow rates, DLCO 75% of predicted with normal lung capacities. Gamma globulin therapy was instituted with marked clinical improvement. An immunoregulatory defect is suggested as the pathogenesis of this immunodeficiency syndrome with multi-system sarcoid granuloma, hypersplenism, pulmonary disease and SINUSITIS COMPLICATING IMMUNOLOGIC DISEASES. Roger 85'7 Friedman, Ellen Wald, Michael Ackerman, Gilbert Friday, Gregory Milmoe and Philip Fireman. Univ. of Pgh. School of Medicine, Dept. of Pediatrics, Pittsburgh, PA. Radiographic abnormalities of paranasal sinuses are frequent in children with asthma or immunodeficiency syndromes. Whether bacterial infection or other inflammatory mechanisms produce sinus x-ray abnormalities has not been determined. Six children, ages 2 to 15, with exacerbation of asthma, purulent rhinorrhea and sinusitis on x-ray had maxillary sinus aspirates. Cultures were positive in 4: B. catarrhalis (2), pneumoniae (1) and non-typeable H. influenzae (1) . Nose and throat cultures did not correlate with sinus cultures. Following antibiotic therapy, 5 showed clinical and x-ray improvement including the 4 with positive cultures. Pulmonary functions improved in 4 of 5 studied. Two antibody deficient children with cough, purulent rhinorrhea and sinusitis by x-ray underwent sinus aspiration. One child's culture grew H. influenzae, typed, resistant to Ampicillin and Cefaclor. Following TMP-SMX therapy, cough decreased, weight gain occurred and pulmonary function improved. Sinus x-rays improved slightly. The other child's aspirate culture grew S. pneumoniae. After antibiotic therapy cough and rhinorrhea improved but sinus x-rays remained abnormal. Bacterial sinusitis was documented in 6 of these 8 children with asthma or immunodeficiency and its treatment led to clinical improvement. Eight families, including twelve patients with AT, were investigated for parameters which tested the current models of pathogenesis for this autosomal recessive disorder. We found: T cells decreased, B cells elevated, PHA responses decreased, variable T suppressor activity, serum IgA and IgG? decreased. Serum alpha fetoprotein and liver enzymes were elevated. Increased Con A capping of lymphocytes and increased cyclic nucleotides of !-lymphocytes correlated in individual patients. Chemotactic responses of neutrophils were decreased in most patients. Thymosin-a-1 levels of patients and family members did not differ from age-matched controls. Excision repair of gamma-induced DNA damage was decreased in some patients and parents. Translocation of chromosome 14q was not noted in any of our patients. Taken together, these data are not easily reconciled with any of the current hypotheses but suggest that a primary or secondary cytoskeletal disorder may underlie the pathogenesis of AT. Heterozygotes could not be reliably identified, even by multiparameter analyses. Patients with familial reticuloendotheliosis and eosinophilia (Omenn's syndrome) are reported to have variable degrees of impairment of humoral or cell-mediated immunity. We have studied three children with this syndrome; all presented in the first year of life with hepatomegaly, lymphadenopathy, a generalized exfoliative dermatitis, frequent infections and failure to thrive. Common to all were markedly elevated levels of IgE (>4000 ng/ml). Despite the presence of relatively normal numbers of T lymphocytes, normal !-lymphocyte subset distribution and proliferative responses to lectins and allogeneic cells in two of the patients, thymic biopsies revealed marked lymphocyte depletion and the absence of Hassall's bodies. Band T lymphocytes from all three patients were totally deficient in ecto-5'-nucleotidase activity while other cells (bone marrow, fibroblasts, granulocytes) had normal 5'-nucleotidase activity. On the other hand, lymphocyte endo-5'-nucleotidase activities and sensitivity to the addition of deoxyadenosine or deoxyguanosine were entirely normal. The failure to express ecto-5'-nucleotidase activity may reflect abnormalities in lymphocyte differentiation which accompany this syndrome or alternatively, represent the consequences of an, as yet undefined, extrinsic process. The presentation of this syndrome in one patient with a lymphoproliferative disease, another with severe combined immunodeficiency and a third with cartilage-hair hypoplasia may suggest a common pathogenctic event being expressed in susceptible individuals. Previous studies have indicated the presence of islet cell antibodies (IC-Ab) and immune complexes (IC) in insulin-dependent diabetics sera (IDD-S). Present studies describe the isolation and characterization of IC-Ab and IC. Rat pancreas islets were dispersed by Dispase, the cells cultured and tested for insulin secretion. The results obtained showed the presence of 2 types of Ab in IDD-S. Islet cell surface Ab identified by a) immunofluorescence, b) reactivity with 125!-labeled sera and immunoglobulins derived therefrom (IG) and c) reactivity with 3H-labeled cell membranes. Assays were done by measurement of 1251-IG bound to unlabeled cells, 3H-labeled cells bound to cold IG and protein concentration in the supernate. The reaction of IDn-S or JG with cells or membranes was 2-5 fold higher than those of normals. Using the soluble fraction of islet cells (SF) as Ag, the reactivity of IDn-s was linear with SF concentration, whereas the normals had no detectable activity. The Ab found in I9n-S was differentiated from anti-insulin by inhibitiyn studies. The IC was precipitated by polyethyleneglycol using 251-labeled sera and IG. The amount of ppt. from Inn samples was higher than normals. IC was identified by m.w., C1q test and dissociation into Ag and Ab. Further evidence for presence of IC-Ab in Inn-s was obtained by inhibition studies. Addition of mouse-antirat islet cell Ab to 125!-labeled IDD-S incubated cells qave i·nhibitiqn, with no detectable chance 10 t e reactivity of sera. \Supported by NIH grant #AM 76315. Infection due to H. influenzae results in the production of antibodies directed against multiple antigens including outer membrane (OM) antigens such as lipopolysaccharide (LPS) and OMP. We studied immune antibody specificity in a patient with respiratory infection due to NrHI, using ELISA. When compared to normal human sera, the convalescent serum contained 10-fold higher specific antibodies of both IgG and IgM classes against LPS and OMP derived from the infecting strain. Since complement-fixing BC antibody may be important in protection against respiratory infection due to NI'HI in children, we examined BC activity of antibodies specific for selected OM antigens. We have reported (Pediat Res 15:611, 1981) that OMP inhibited human BC act1v1ty in direct absorption experiments. We employed purified OMP, affixed to solid-phase, as immunoadsorbents for human sera to define the antigenic specificity of OMP for BC antibody and to examine anti-LPS antibody for potential BC activitya The convalescent serum depleted of >80% of OMP specific activity (IgG and IgM) lost comparable BC activity. Two normal sera depleted of >60% of OMP antibody also lost comparable BC activity, while maintaining 97% of IgM and 80% of IgG anti-LPS activity. OMP may be an important OM target both for natural and immune BC antibody. The study included 14 women who delivered after and 13 women who delivered before 36 weeks of gestation. Milk was obtained between 2-12 weeks of lactation. Mean concentrations of lysozyme,, lactoferrin, total IgA, and secretory IgA (SlgA) were greater in preterm milk at each phase of lactation (p values 0.07, 0.003, 0.05, and 0.05, respectively). Whereas SigA levels in term milk were stable between 6-12 weeks (O. 6-0.7 mg/ml), mean levels in preterm milk rose from 1.3 mg/ml at 6 weeks to 2.9 mg/ml at 12 weeks (p 0.05). SigA antibodies to E.coli somatic antigens increased 4 fold or more in several individuals in both groups. In addition, antibody titers were significantly higher (p. 0.05) in milk from a subgroup whose preterm infants were appropriate size for gestational age. Lymphocytes and macrophages-neutrophils in term milk which were initially 2.4 and 6.5 x 104/ml, respectively, fell to 0.6 and 0.8 x 104/ml, respectively by 8 weeks. In contrast,, mean lymphocyte counts in preterm milk which were initially Oa3 x 104/ml rose progressively (3.3 x 104/ml at 12 weeks; p 0.07) and the number of macrophages-neutrophils remained relatively unchanged (1.5 x 104/ml at 2 weeks; 3 x 104/ml at 12 weeks). Thus, the duration of pregnancy significantly affects the development of the immunologic system in human milk during the first 3 months of lactation. In addition, this study raises the question whether these alterations may be beneficial for premature infants whose immunologic systems are not fully developed. Although dramatic changes in the levels of immunologic proteins• in human milk have been reported during abrupt weaning, there are no reports concerning the effects of gradual weaning upon the immunologic system in human milk. Seven women age 20-35 years began weaning at 6 months of lactation by reducing the frequency of breast feeding by 10-15% weekly for 12 weeks. The mean volume of milk collected from the subjects decreased to 67% of the initial volume at 4 weeks, 40% at 8 weeks, and 20% at 12 weeks. No leukocytes were detected in the milk specimens from these subjects during the study. The concentrations of lactoferrin and lysozyme remained unchanged in most of the subjects. The principal type of IgA in these milk specimens was secretory IgA (SigA). In contrast to the other immunologic proteins, the concentrations of total and secretory IgA steadily increased during weaning (total IgA, 0.6 ± 0.3 mg/ml before weaning and I.I ± 0.6 mg/ml at 12 weeks)(p<0.05). In addition, significant rises in antibody titers to E.coli somatic antigens in four of these individuals could not be explained by increases in total SigA in the milk. This finding indicated that the enteromammary gland pathway of SigA antibody production was operational during weaning. Thus, this study suggests that the effects of gradual and abrupt weaning are distinct and that the concentrations of certain protective factors in human milk are maintained or increased during the period of gradual weaning. 33 44 None of the differences was significant. Determinations after elimination of breast fed infants receiving supplemental feedings less than six wks of age or those who received supplemental feedings or discontinued breast feeding after six wks were not different than the means of the total or exclusively breast fed group. These data indicate that the influence on the of breast feeding during the first six months of life is not reflected by cellular or humoral differences measured in infants in this s tuay. Developmental deficiencies of the immune system are major determinants of host susceptibility to infection. The purpose of this study was to investigate the effect of severe stress on neonatal neutrophil (PMN) phagocytosis, and to compare the ability of neonatal and adult PMNs to ingest 3H-labelled group B streptococcus (GBS). Three patient populations were studied: healthy infants (n=l5, B.W. 3160.7 .!:: 648.3 g, (m .!:: SD) G.A. 38.0 .!:: 2.4 wk), "stressed" infants (n=33, B.W. 2019.3 .!: 990.4 g, G.A. 33.5 .!:: 4. 9 wk), and healthy adults (n=22). 32 of 33 "stressed" infants had acute respiratory illnesses requiring mechanical ventilation. Radiolabelled type le GBS was opsonized with 596 adult serum, and incubated with PMN monolayers adherent to coverslips. Bacterial uptake was determined at O, 40, 60, and 80 minutes and expressed as cpm/106 PMNs • For all study groups, there was a significant increase in uptake with time (p<: .05). PMNs from "stressed" infants demonstrated enhanced bacterial uptake when compared to adults: (40 min., "stressed" 7670.1.!::6187.1 (m .!:: SD), adult 4972.8 .!:: 4005.7, p< .05; 60 min., "stressed" 10522.2 .!:: 6634.5, adult 6368.5 .!:: 3855.4, p< .OJ, 80 min., "stressed" 13408.4 .!:: 8046.5, adult 8750.6 .!:: 7522.7, p<° .025. Phagocytosis was significantly greater in healthy infants vs. adults (40 min., healthy 5667.9 .!:: 4089.J, p<.05, 60 min., 9614.7 .!: 7644.7, p<.01, and 80 min., 12955.5 .!:: 8518.6, p<'..01) . There were no significant differences in bacterial uptake between "stressed" and healthy infants or between infants) or< 1500 grams. In conclusion, PMN phagocytosis of GBS is enhanced during the neonatal period and not adversely affected by severe stress or prematurity. Cerebral cysticercosis is the commonest cause of epilepsy in some African countries. It is also corrmon in Mexico and in areas of the United States which have large numbers of Mexican and other irrmigrants. It may involve children as well as adults and may be associated with hydrocephalus.aseptic meningitis, and cerebral calcifications of typical size and configuration. Cysticercus cellulosa antigen was bound to CNBr-activated cellulose discs. Five µl of serum or 20 µl of CSF were incubated overnight with an antigen coated disc and buffer to make 55 µl. After thorough washing, the disc was incubated with radiolabelled staphylococcal protein A for 3 hours. After 3 more washings the counts bound reflected IgG antibodies to C. cellulosa in the serum or CSF. An initial study involved the serum and CSF of 64 patients. All 15 patients with known cysticercosis had elevated serum IgG antibodies and most had antibodies in the CSF. Many had a selective increase in specific antibodies in the CSF, indicating specific production, or extraction, by the CNS. IgE, IgG4 and IgD antibodies were produced by most patients and were also present in the CSF, but not so consistently as total IgG antibodies. Nine of 17 patients with suspected cysticercosis and 0/32 with unrelated neurological diseases had antibodies in either serum or CSF. Cerebral cysticercosis is a virtual certainty when CSF antibodies are high. It should be suspected when serum antibodies are high and there are CNS signs. If neither fluid has antibodies the diagnosis is highly unlikely. Mast cell mediators are released during hypersensitivity episodes, associated with release or increased granulocyte, especially Eosinophil (Eos), inhibitory activity. In status asthmaticus in humans, Eos histaminase (Hx) and monocyte histamine methyl transferase activity along with plasma and urinary histamine metabolites increase. The increased Eos Hx (205±32 to 741±68 Units) correlated to the level of pulmonary obstruction (.'.:.20 to 65% decrease FEV 1 ). Asthmatic Eos Hx content increased (210±28 to 614±56 Units) by incubation with the histamine analog NaMethyl histamine (l0-1 '-l0-9 M); this analog did not affect control Eos Hx (192±21 to 232±25 -Units) nor the Hx assay at these concentrations. The increase Eos Hx increase was temp. (max. 40°C) time (max. 15 min.) and pH (max 7.2) dependent as well as inhibited by metabolic inhibitors. A trypsin sensitive protein component of asthmatic serum increased Eos Hx activity in a dose dependent manner 0.1-1.0 mcg/10 7 Eos; the maximum increase in asthmatic Eos (+286 Units) was twofold--the increase in control Eos (120 Units). Upon Sephadex G-200 separation this activity was found in glycoproteins of two fractions (160,000 MW and 40,000 MW); OTT reduction diminished the Hx inducing activity in both; control serum had no activity. Eos Hx activity was increased in an additive manner by histamine and the serum components. Thus, exogenous histamine and inflarrmatory proteins contribute to the increased Eos Hx. We previously demonstrated impaired T-lymphocyte colony formation (TLCF) by cord blood mononuclear cells when compared to the TLC forming capacity of adult mononuclear cells (AMC). Cocultures of irradiated AMC with CBMC results in enhanced TLCF by CBMC (284+72 colonies/plate vs. 752+78 p <0.001). A similar degree of-enhancement of TLCF is seen when a colony promoting factor (CPF) produced by PHA stimulated AMC is added to cultures of CBMC (361+98 vs. 766+138, p <0.005). CBMC do not produce CPF . CPF is not produced when AMC are treated with the monoclonal antibody OKT4 plus complement (C') prior to stimulation. Treatment of AMC with OKTB and C' does not affect the production of CPF. Supernatants From Supernatants From CBMC Alone CBMC + OKT4 Depleted AMC CBMC + OKT8 Depleted Cells 243+82 253+77 917+88 When-CBMC are cultured wTth CPF for 1-3 hrs prior to culture and then washed, the enhanced TLCF is still evident. Based on Sephadex column chromatography CPF has a molecular weight of less than 12,000. It is stable at 560C for 1 hr. Addition of lnterleukin-2 from two sources failed to enhance TLCF by CBMC. CPF is a soluble substance capable of enhancing the TLC forming capacity of CBMC. Failure of CBMC to produce CPF may account in part for the relative functional irrmaturity of newborn lymphocytes. The RC-RIA was used to detect CICs in 2 pts. with thyroglobulin (Httrg)-rrediated irrrnune ccnplex glorrerulonephritis (ICGl) and in an experimantal in vitro system of pre-forrred J::ovine serum al-Wnin (BSA-anti-BSA) CICs. Preincubation of (+) CIC sarrples with the suspected (HUI'g) or known Ag (BSA) resulted in a profound inhibition of 125r Protein A binding to RCs. HUI'g decreased binding l7y 25-50% in the 2 pts. with rem m:rliated l7y Hlil'g but did not decrease binding of CICs to RCs in pts. (+) for CICs without evidence of anti-'l'g Abs. Binding was not decreased l7y preincubation with related (B-'I'g) or unrelated (BSA) Ag. BSA-anti-BSA res pre-forrred @ (3X) Ag excess were (+) in RC-RIA. Preincubation of BSA-anti-BSA res with BSA resulted in a (70%) inhibition of binding in the RC-RIA. Preincubation of the res with a related Ag (ovalbJmin) resulted in an interrrediate inhibition of binding (65.5%) but was not decreased when sarrples were preincubated with unrelated Ag. Sucrose density gradient studies confirrred the IC nature of materials reactive with the RC-RIA, and also confirrred the irechanism responsible for the inhibitor of RC-RIA activity was an Ag-specific diminution in CIC size and number. This new technique can be used to evaulate the specific Ag content of CICs detected in human sera and may be helpful in differentiating i.rmrunopathJgenic from non-i.rmrunopathJgenic CICs. A. ,Calif. We recently descril:ed a new syndrOITe of acquired T-cell imbalance in previously healthy horrosexual rren which we terrred the gay-related innuncxleficiency syndrOITe (GRID). Patients experience nultiple opportunistic infections including Pneum::x:ystis carinii pneurronia, nucosal candidiasis and cyt01Tegalovirus (CMV) infection at rrultiple sites. Profound lymphopenia and virtual elimination of the helper/inducer T cell subset as defined with ronoclonal reagents were uniform features of the syndrOITe. Despite absolute B lymphopenia, these patients had normal levels of IgG and IgM and elevated levels of IgA (rrean 2-3 times normal). We believe that this syndrOITe represents an acquired irrrnunodeficiency resulting from CMV infection which is hyperendemic in the male horrosexual population. The majority of patients developed retinal lesions which had the appearance of the cottonwool spots seen in systemic lupus erythematosus and in other disorders involving the microvasculature. We therefore rreasured circulating irrrnune carplexes in these patients with three assays (Raji-RIA, Clq-SP.'< & IgG polyethylene glycol precipitation). High levels of irrrnune carplexes were uniformly de110nstrated. These findings may account for the prominent retinopathy. Irrrnune carplexemia may result from intense antigenic stirrulation and ca.ild be involved in the pathogenesis of the innune deficient state. Concanavalin A (Con A) activates a subset of peripheral blood lymphocytes to function as suppressor cells in a variety of inununologic assays in vitro. In several autoinunune diseases, depressed suppressor cell function has been documented with this technique. We have studied 11 normal young adults and 14 patients (aged 3-18 years) with autoimmune diseases: 7 with juvenile rheumatoid arthritis (JRA), 4 with dermatomyositis (DM), and 3 with Reiter's Syndrome (RS). Peripheral blood mononuclear cells were incubated for 48 hours either with or without 50 mcg/ml of Con A. These cells were then added to a standard one-way mixed lymphocyte culture on day zero. Suppression of uptake of 3H-thymidine was assessed on day 6 of culture as shown in the table. In these samples, disease activity and drugs did not distinguish recognizable subgroups of patients with regard to suppressor activity. 49±12 48±14 30±15 Group means for patients did not differ significantly fromcontrol (Student's t-test, P>0.05). In all groups except RS, Con A treated cells irradiated prior to addition to the MLC were less suppressive than those not irradiated. Our data suggest that pediatric patients with these autoimmune diseases retain activity of that subpopulation of suppressor lymphocytes stimulated by Con A. CORD BLOOD. L.K.L. Jung, R.A. Good, and S. Pahwa. Memorial Sloan-Kettering Cancer Center, N.Y., N.Y., 10021 The maturational defect of human cord B lymphocytes was investigated using polyclonal B cell activators and antigens as probes for the abilities of cord B lymphocytes to proliferate and differentiate. In the presence of T dependent mitogen, pokeweed mitogen (PWM) the mononuclear cells (MC) from cord blood proliferated equally well as the adult cells. However, the cord cells could not differentiate to become immunoglobulin secreting cells (ISC) in response to PWM as did the adult cells. In contrast, in the presence of T independent mitogen, Epstein Barr virus (EBV), cord cells proliferated and differentiated into 1SC in a manner similiar to the adult cells. Antigen specific antibody response of cord cells to sheep red blood cells following in vitro sensitization of MC cultures with antigen was found to be lower than the response of adult cells, although some cord samples were found to have responses comparable to adult samples. With the addition of T cell mitogen Con A to the cell cultures at 48 hours after the initiation of cultures as a means of amplifying T cell help, the antigen specific response of the cord cells was enhanced to levels comparable to normal adult cells unstimulated by Con A, but not to those of adult cell cultures stimulated with Con A 48 hours after culture initiation. With Con A, the percentage of enhancement of the antigen specific response of cord cells was comparable to that observed in cultures of adult cells. These findings suggest that the immaturity of the B cells in cord blood may be due, at least in part, to defect of B cell subpopulation(s) which require(s) T cell help to enter into differentiative stages. A male with severe combined immunodeficiency (SCIO) chimeric with nonfunctional maternal T cells derived from a transplacental infusion who did not develop Graft vs. Host Disease, was administered a transplant of maternal marrow, depleted of T cells by differential agglutination with soybean agglutinin and sedimentation of E rosettes. A dose of 7.8xlo7 marrow cells/kg was administered. Enqraftment was first detected in non-T lymphoid populations. Thereafter E rosettes rose from 20% to 66% of an 800-1400 absolute lymphocyte count. Over 4 mos, lymphocyte transformation responses to E.coli) and allooeneic cells increased to >90% of that detected in nonnal controls: Irrmunoqlobulins, which were not detected pretransplant, increased to IgG 318mq%, IqA 35mq%, 7fimo%. In addition, the patient developed lymph nodes, appropriate isoaqqlutinins, and delayed type hypersensitivity resoonse to DNCB. DPspite incoTTiratibilities for a ful I HLA,J\,!',,D hap1otype, no Gvf 1 11 has reen observed. The patient, now 7 mos. post transplant, is clinically healthy, living home. Ficol-hypaque separated human neutrophils (PMN) were stimulated with specifically prepared inrnune complexes of polio, measles. herpes simplex and respiratory syncytial viruses (RSV). The presence and quantity of immune complexes were determined by radioinrnunoassay. The functional effects of neutrophil metabolites released after interaction with inrnune complexes were determined by their ability to induce smooth muscle contraction in an in-vitro system employing guinea pig ileal smooth muscle strips in a grass polygraph. Interaction of RSV immune complexes with neutrophils resulted in a significant (p<0.001) degree of smooth muscle contraction compared to RSV or antibody alone. On the other hand the interaction of neutrophils with irrmune complexes of other viruses resulted in minimal or no smooth muscle contractions (p<0.001). Various inhibitors of arachidonic acid metabolism were tested in the system and were observed to decrease the magnitude of smooth muscle contraction. These observations suggest that RSV specific irrmune complexes may result in the release of soluble products with potential effects on the contractility of smooth muscles in the mucosal surface. Such neutrophil factors may contribute to the pathogenesis of mucosal disease and possibly bronchospasm in RSV infection. Published studies of HC have suggested local marrmary production of IgA and IgM, not IgG. We examined HC and plasma samples from 27 postpartum women to determine if IgG, may be locally produced or selectively transferred into HC. IgG, was measured using RIA, and IgG was measured using radial immunodiffusion. The geometric mean concentrations of IgG, were 9.4 µg/ml [0.9-160] for HC and 149.7 µg/ml [21-920] for plasma, and for total IgG were 39.8 µg/ml for HC and 7658.9 µg/ml [3250-16000] for plasma. The mean IgG, HC/plasma ratia [O. ll7±0.029] was 20 fold greater than the IgG HC/plasma ratio [0.006±0.001]. In 16 patients, the HC/plasma ratio for IgG4 was greater than 10 times the HC/plasma ratio for total IgG, suggesting preferential local production or concentration of IgG,. also examined the specimens using RIA for specific IgG, antibodies to S-lactoglobulin (BLG), bovine serum albumin (BSA), Bermuda grass (BG), and a-gliadin. Four patients had detectable IgG, anti-BLG in HC but not in plasma. Two others had an anti-BLG HC/plasma ratio 10 fold greater than the total IgG, HC/plasma ratio, indicating specific antibody production in the breast. Two other women had similar ratio evidence of local antibody production to BSA, three women to BG, and three to a-gliadin. One woman had a higher concentration of anti-BG in HC than plasma, and another woman had a higher concentration of anti-a-gliadin in HC than plasma. IgG, antibodies appear to participate in the enteromarrmary and COITlll' ()n mucosa! system of immune responses. Under normal conditions, C3 and factors B and D continuously react in the fluid phase resulting in low-grade formation of C3b and subsequent generation of the alternative pathway C3 convertase, C3bBb. Nonproductive utilization of all of the circulating C3 does not occur, however, because of two plasma inhibitors, factors Hand I. The present study has examined the control of C3 activity in the fluid phase to determine the relative roles of factors Hand I. If purified C3 and factors Band Dare mixed so as to maintain "physiologic ratios" of all 3 components, 80% of the C3 is utilized within 10 minutes at 370 C indicating that the utilization of C3 occurs readily in the absence of control proteins. Addition of factor Hat even 25% of this "physiologic" concentration, however, completely aborts C3 utilization. By contrast, factor I at 10 times the experimental concentration failed to control C3 turnover. These data indicate that factor H is the primary endogenous control protein for C3 utilization in the fluid phase and presumably acts by accelerating the decay dissociation of C3bBb with loss of factor B activity and concommitant loss of C3 reactivity. The role of factor I, therefore, would then be to control the serum level of factor B by inactivating C3b and preventing further utilization of factor B. Thus, regulation of the fluid phase of the alternative pathway may involve either factor Hor I and defective regulation involving these factors may play a major role in a variety of disorders. Memorial Sloan-Kettering Cancer Center, New York, N.Y. 10021 An 11 month old female with severe combined immunodeficiency (SCIO) developed scaling erythroderma, hepatitis, -unteritis and n'ldal enlar11ement suoqestive of materno-fetal Gv:m. Differential HLA typing of T cells,B cells and monocytes demonstrated selective engraftment of maternal-type r cells. Initial mixed lymphocyte cultures indicated that cells from the father were unresponsive to the patient's cells despite HLA-A,B,C and Dr incompatibility. Studies using primed lymphocyte typing techniques confirmed that the father's unshared HLA-0 determinant was identical to the patient's maternal HLA-0. To eliminate the maternal qraft, the oatient was i1T111unosuppressed with anti-thymocyte globulin 30m9/kax7 days and cycl ophosphar.li de 50mg/kgx3 days. Thereafter, the patient received an infusion of o·aternal marrow. During early en(]raftment, manifestations of GvllD were exacerbated, but controlled with prednisone. Engraftment of both hematopoietic and lymphoid elements was followed by full hematologic recovery and immune reconstitution. Over 18 months post transplant, the patient is clinically well, with mild chronic GvHD controlled with low dose prednisone. Thus, lethal GvHD can be reversed by immunoablative therapy and a secondary infusion of histocompatible marrow. This case also provides another rare example of discrepancies between HLA-D and HLA-Dr, and suggests that HLA-0 matchin 0 can be used to define suitably histocompatible related marrow donors. THE ONTOGENY OF HUMAN ANTIVIRAL CYTOTOXICITY. Steve Kohl, Susan E. Denson. Lniv. of Texas Medical School, Houston, Tx. The ability of leukocytes to destroy herpes simplex virus (HSV) infected cells in the of antibody (antibody-dependent cellular-cytotoxicity, AOCC) and the absence of antibody (natural killer cytotoxicity, NKC) has been correlated with the outcome of HSV infection. Anti-HSV AOCC has been reported as low or normal in cord blood, and dependent on the route of delivery. Using a 51 Cr release microcytotoxicity assay we studied the cytotoxicity to HSY-infected cells of peripheral blood lymphocytes of term babies during the first 3 months of life. Using an effector to target cell ratio of 30:1, AOCC of babies age 0-60 days (32.2+3.5, mean + SEM, n= 21) was lower (p<.001) than matched adults There was no difference between AOCC of older babies [52.2+12.8, n= 5) and adults (68.3+8.3). NKC of babies age 0-60 days [14.9+2.5) was lower (p <.001) than adults (38.8+3.3). NKC was-not significantly different in older babies (32.8+15.9) and adults (49.6+12.2). Cytotoxicity of babies' lymphocytes was lower than aduits• at all times using lower effector cell ratios. Babies' polymorphonuclear leukocyte cytotoxicity was low at all times tested. Post partum cytotoxicity did not vary with route of delivery. These data demonstrate a gradual normalization in antiviral cytotoxicity, correlating with the age at which humans become resistant to severe HSV infection. Reconstitution of these defects in the human neonate, as demonstrated in mice, may prevent severe HSY-infection. Newborn mice and humans have low antiviral natural killer cytotoxicity and are unusually susceptible to severe HSV infection. Newborn C57Bl/6 mice were protected by a combination of IFN and MC (32% survival, p<.001} but neither alone when given i.p. one day prior to a 100% lethal i.p. HSV infection. The effective dose of IFN (100-10 units), MC number (5x106 to 5x105) and active MC (lymphocyte or monocyte but not polymorphonuclear leukocyte) was determined. Protection did not depend on the anti-HSV immune status of the MC donor. Treatment of mice with IFN and MC after infection did not affect the outcome. WISH cells are human fibroblasts that secrete an IFN induced antiviral protein in vitro. Protection by WISH cells and IFN {55% survival, p<.001} suggested IFN induced cross species antiviral protein production in vivo. Mice receiving IFN, MC and subneutralizing doses of anti-HSV antibody were nearly completely protected {95.2% survival), and protected significantly better {p<.001} than with either MC plus IFN or MC plus antibody. Protection was not due to viral neutralization. While MC from adult humans mediated this protection, those of neonates did not This is the first evidence for defective in vivo IFN stimulated natural killer cytotoxicity or antiviral protein production of neonatal MC. Understanding this defect may facilitate rational immunostimulation or replacement therapy for neonatal HSV infection. Supported by NIH grants lHD 13021 and Al32506. , NIH, Bethesda, MD Immediate hypersensitivity reactions both in the lung and the skin may be followed by delayed-in-time responses termed latephase allergic reactions (LPR). Human cutaneous LPR are characterized histologically by mixed cellular infiltrates; immunofluorescent analyses suggest that immunoglobulin and complement deposition do not play a significant role in either initiating or propagating these reactions. To better establish the role complement plays in the genesis of LPR, Sprague-Dawley rats (200-250 g}, known to produce LPR following skin testing with either rabbit anti-rat IgE or isolated mast cell granules (MCG), were depleted of serum complement. Cobra venom factor (CVF} (200 units/kg. n = 5) or saline (n = 4) was injected IV; CH and hemolytic c 1 titers, WBC counts and differentials were at 0, 6, ana 30 hrs following injection. Compared to controls, CVF-treated rats demonstrated a rise in total WBC counts (p < .01) and absolute neutrophil counts {p < .01} at both 6 and 24 hrs following treatment. CH 50 titers in CVF-treated rats decreased from 220 ± 20 units/ml at baseline to < 1 unit /ml at 6 and 30 hrs. c 3 titers in CVF-treated rats were < 10 units/ml compared to 50,575 ± l,070 units/ml in controls. LPR were induced with either anti-lgE {1:10) or MCG {25 µg) and analyzed 8 and 24 hrs later. Despite the alterations in peripheral leukocyte counts and CH and C titers, both the histologic characteristics and the of LPR induced in CVF-treated rats were similar to controls. Thus, complement depletion does not affect the normal expression of rodent LPR. "'e are testing the hypothesis that the immune complexes which are frequently present in CF inhibit antibody-dependent cellular cytotoxicity (ADCC) or deplete the K cells which mediate ADCC by binding to their receptors for the Fe portion of IgG (FcR). It was expected that the function of other R:R-bearing cells such as NK cells would be less affected, but preliminary results reveal greater suppression of NK cells. The activity and numbers of functioning NK and K cells among peripheral blood mononuclear cells (MC) were assayed in 12 CF patients and in normal adults and non-CF pulmonary patients. Release of Cr from labeled K562 human leukemia cells or antibody-coated P815 mouse mastocytoma cells was measured at lymphocyte-to-target ratios of 5:1 to 40:1. Cytotoxic lymphocytes were counted as those conjugated with trypan blue-staining target cells after a 1 :1 mixture of MC and the same target cells was incubated in soft agarose. NK activity and/or % of NK cells were markedly depressed in 10/12 patients. Six of those with depressed NK cells had normal K cells. Other data suggest that the pulmonary infP.ction in Cr' is responsible for the observed deficiency in NK cells, and it is postulated that the latter contributes to the intensity of CF ex-·acerbations due to viral infections. The dissociation of NK and K cell activity in some of these patients is confirmatory of our other data indicating that NK cells are distinct from K cells. Of particular importance is the finding that rubella virus was recovered from the nasopharynx in 56% of breast feeding infants. Of these, 44\ developed a modest antibody and CM! response in blood and nasopharynx, which disappeared by 4-5 months. The remaining breast fed infants with nasopharyngeal virus shedding, did not manifest any r:.iloella specific immune re- In the initial work up of children with suspected or known immunodeficiency. antibody titers to (AD) and tetanus (AT) are frequently measured to assess humeral immunity. This can be done in the previously immunized child or following an active challenge immunization. To define a reference range for AO and AT, we have used a passive tanned cell hernagr,lutination assay and have obtained values in 86 healthy children from 0 to 17 years of age and 52 healthy adults. Washed, tanned type O red cells are coated with either diptheria toxoid or tetanus toxoid. Utilizing microtiter plates, serially diluted patient sera and anti!;en coated red blood cell suspension are incubated. Agg lu-· tination of the red cells is uced to define titer. 95% of all adults had AD of 1:2187 or higher while 96% had AT of 1:19,683 or higher. However, titers were lower in 3 foreign born adults. Age dependent increases are seen for both titers with 78% of the children reaching adult values for AO by one of age. Similarly, 79% of all children had adult AT by one year of ao,e. laboratory. By one year of age AT and AD can be used to accu·· rately reflect immunization status anct B cell immune competence. Epidemiologic and clinical features of Kawasaki syndrome (K.S.) suggest a possible infectious etiology while pathologically K.S. appears to be a vasculitis of medium sized arteries. To determine what role circulating il1'1lune complexes (CICs) might play in K.S., the sera of 42 patients with K.S. were tested for CICs by the Raji cell radioimmunoassay (RC-RIA) and Clq solid phase assay (Clq-SPA). Overall 29 patients (59%) were positive by or both assays; 22 (52%) by RC-RIA and 20 (48%) by Clq-SPA. CICs were detected as early as 2 days and as late as 35 days of illness. Clinical data was available for 32 of the patients. An established clinical scoring system was used to estimate severity of disease. No correlation was found between disease severity and incidence or concentration of CICs found. four patients had coronary artery aneurisms (CAA) detected by 2 dimensional echocardiography and confirmed by angiography. The Two recombinant DNA produced Hu JFNa preparations (A and D) were evaluated to detect their invnunoregulatory effect on oxidative metabolism and functional activities of PMNL. Ficoll-Hypaque separated PMNL from blood of healthy volunteers were incubated with five concentrations of HulFNa ranging from 125 to 5000 IU/ml. Utilization of l-14c glucose by resting PMNL was significantly (p<0.05) greater after incubation with 500 JU/ml of Hu!FN when compared to control cells or PMNL incubated with 125, 250, 1000, or 5000 JU/ml. There was no significant difference in l-14c glucose oxidation or in oxygen consumption by zymosan stimulated PMNL exposed to the various concentrations of both Hu!NFa preparations when compared to control cells. No significant difference in uptake, internalization or killing of 3H methyl thymidine labeled S. aureus by PMNL incubated with interferon at 250, 500, or 1000 JU/ml was detected when compared to contro 1 PMNL. I FN-A had no effect on non antibody-mediated killing of Herpes simplex virus infected target cells in a 5lcR release cytotoxicity assay. These data suggest that the two HuIFNo. preparations tested had little effect on the oxidative metabolism, antiviral natural killer cytotoxicity, or uptake and killing of radiolabeled S. aureus by human PMNL. Few neutrophil specific antigens (NA), (NA1,NA2, NBl, NCl) of paternal origin have been shown to be responsible for the stimulation of maternal antibodies (Ab), which crossed the placenta and destroyed the neutrophils (PMN) causing neonatal neutropenia (NN). In order to evaluate the nature of NN and to understand the involvement of various NA we systematically investigated several cases of NN with and without infection. EDTA-microagglutination and indirect immunofluorescent assays were used to detect Ab. We identified 4 Ab that specifically agglutinated PMN from the father. No maternal auto-agglutinins were detected. We were successful in obtaining blood samples from one of the 4 neonates and identified Ab in the serum. PMN from this patient also was agglutinated by the maternal Ab. These Ab also agglutinated PMN from normal donors of known NA phenotype ranging from 5-40%. But no correlation was found with the pattern of reactivity with the already known NA apparently identifying new antigenic .'pecificities. The NN persisted from 2-5 wks. In follow-up studies we found that in one of the 4 mothers, the Ab dissappeared at 3 mos. In the other 3 cases, the Ab persisted even after 5-9 mos. of delivery. Thus •. investigations of the irrmune destruction of PMN in NN not only is U$eful in evaluating the causes of neutropenia but also to identify characterize the polymorphic NA. Lymphocyte stimulation is coDDDonly used for measuring cellmediated iDDDunity in suspect ioununodeficiency and for examining the effects of serum factors or potentially toxic drugs on lymphocyte 3 function. The assays most coounonly used employ the uptake of H-thymidine(UT) to quantitate mitogen or antigen induced stimulation. This method, however, does not allow analysis of mechanisms for suppression. We compared UT to flow cytometric analysis(FCA) using a Coulter TPS-1 Cell Sorter. Parametric, and non-parametric analysis of DNA fluorescence histograms provided the data base. Antiviral agents previously shown to suppress CMI were examined as well as serum inhibitors such as free fatty acids (FFA). FCA was a more rapid and reproducible method as compared to UT. In addition, FCA revealed blocks at various stages of cell cycling for antiviral agents. Some purine and pyrimidine analogues produced enzymatic blocks at the late synthetic(S) or G 2 and M phase or interfered with late replication resulting in a buildup in the S phase. The antiviral thymidine analogue BVDU at low concentrations suppressed UT which was not the case with FCA; at higher concentrations, a block in G 2 or M resulted. Ara C, FFA, and serum from leukemic children produced lysis of lymphocytes during early cycling. Flow cytometry appears to be a sensitive and useful method for delineating mechanisms of iDDDunotoxicity. Inthis report, we provide evidence that specific bovine inmunogl•>bulins resist in vivo and in vitro proteolysis. Methods: (1) Anti-CT were isolated from the colostrum of immmized cows and characterized by immunochemical analysis. Biologic activity was assessed in the rabbit ileal loop (RIL) assay. (2)In vitro pepsin and trypsin digests of anti-CT were similarly characterized. (3) After in vivo digestion, stool proteins from young rabbits fed anti-CT-and non-immune colostral IgG were isolated and characterized by immunochemical, RIL, and radioimmunoassay (RIA) techniques. Results: (1) The Recent reports indicate that specific bovine colostral, IgGl lmmunoglobulins can resist in vitro and in vivo proteolysis, and may provide passive immunoprotection at risk for enteric disease. In this study, we evaluated the immunoprotective quality of specific anti-CT BCI fed to infant rabbits. Method: 3-5 day old infant rabbits were fed 9 ml in 24 hr. of anti-CT (immune) BCI (3.1 mg anti-CT/100 mg IgG1). Control groups were similarly fed non-immune BCI or D5W. After completion of feedings, all animals were anesthetized. The distal ileum of each animal was ligated and inoculated with 100 ng of CT. Some animals were injected with I cc of saline as negative controls. 18 hours after injection of CT, mortality rates were noted. The fluid accumulation index (FAI=gm fluid/gm intestine) was calculated on surviving animals. The mortality rate of immune BCI-fed rabbits is the same as saline-injected controls, and less than non-immune BCI and D5W-fed controls (p<0.01). The FAI of immune-fed animals is less than non-immune and D5W-fed controls (p<0.01). This study clearly shows the potential benefit of orally administered specific bovine colostral immunoglobulins in the prevention of enteric disease. The orientation (chemotaxis) and locomotion (chemokinesis) of human polymorphonuclear leukocytes (PMNs) are controlled by an internal movement mechanism (involving active cytoplasmic movement) and are influenced by external environmental and ionic conditions. We have studied the degree to which the orientation and movement mechanisms of PMNs are self-contained (built-in) within the cell and the degree to which they are under membrane control. Cells were partially demembranated by treatment with the non-ionic detergent octylphenoxyl-polyethoxyethanol (Triton-X-100), thus providing small openings in the membrane through which ATP and necessary ions could achieve unrestricted passage. Upon contact with Triton-X-100, PMNs became spherical and acquired a very compact and rigid morphology. Addition of ATP to the media was followed by activation of the PMNs to motile cells with active cytoplasmic extension and pseudopod formation. Although these PMNs actively locomoted, they did not respond to a chemotactic oradient. Thus, the activation process restored physical movement parameters, but did not re-establish the orientational capacity of live PMNs. Tritonated models of human cord blood PMNs were reactivated and compared with similar studies of adult PMNs. Optimal movement and locomotion attained in the reactivation were identical to that of adult PMNs. Similar to reactivated adult PMNs, cord PMNs did not respond chemotactically or chemokinetically to chemoattractants. The data thus establish that the chemotactic deficiency of cord PMNs is membrane-associated and reflects a developmental functional abnormality of the membrane during ontogeny. Anne Morris-Hooke, Pedro J.Arroyo, Joseph A. Bellant1, and Max P.Oeschger. International Center for Interdisciplinary Studies of Immu•;o]ogy, Georgetown University, Washington, D.C. Temperature-sensitive (ts) live bacterial vaccines, in contr<1st to killed or chemically-extracted cellular preparations, offer several specific advantages -simulation of +;,e initiation of natural infection, stimulation of local antibody formation and, usually, longer-lasting immunity. The presence of significant numbers of virulent revertants (ca. 10-7) in such vaccines has orecluded their use in man. We have-overcome this problem by constructing a strain of H.influenzae containing 3 attenuating ts mutations of identical phenotype, thus reducing the reversion rate to levels (10-SM), binds predominantly to the less affinite but more numerous H2 receptor and suppresses lg synthesis. This effect is blocked by cimetidine but not by diphenhydramine. The HI agonises, 2-pyrid;•lethylamine and 2-thiazolylethylamine, increase lg synthesis, while the H2 agonises, dimaprit and 4-methylhistamine, suppress it. Xoreover, when lymphocytes are sorted and subsequently studied for their effect on lg synthesis of autologous lymphocytes, we found that HIR+ cells (those bearing HI receptors) are helper cells, while H2R+ cells are suppressor cells (decrease synthesi"). These data suggest a dual feedback mechanism by which histamine, released during an imr.1une response, can regulate the immune system. When the released histamine is at low concentration, it activates HlR+ helper cells and amplifies the immune response. This, in turn, causes even greater histamine release which can bind to H2R+ suppressor cells resulting in immuno- Investigations of _i!! vitro humoral immune responses were done in a pair of identical twins with AT, both lgA deficient. Peripheral blood mononuclear cells (PBM) failed to generate inmunoglobulin secreting cells (!SC) as quantitated in a reverse hemolytic plaque assay following stimulation of PBM cultures with pokeweed mitogen (PWM) which is a T-dependent stimulus. In contrast, stimulation with Epstein Barr virus, a T-independent stimulus, resulted in adequate !SC responses, but with secretion of only IgG and IgM and not IgA. In an antigen-specific assay in which anti-SRBC antibody secreting cells are quantitated in a direct hemolytic plaque assay following in vitro sensitization of PBM cultures with SRBC antigen, no responses were elicited even after maneuvers aimed at amplifying T-cell help in the cultures. PWM induced !SC responses of B-cell enriched cultures were only partially reconstituted by providing allogeneic T helper cells. T-enriched populations from the patients did not manifest immunoregulatory abnormalities. The autologous mixed leukocyte reaction (MLR) between patients' own T and non-T cells was grossly defective, but their T and non-T cells functioned adequately as responders and stimulators in allogeneic MLR. The findings in these 2 patients with AT are suggestive of 1) intrinsic B cell dysfunction and 2) defective interaction between T and non-T cell populations. The observed B cell dysfunction might result from the lack of a B-cell subset or an immaturity of the B-cell pool. E.M. Smithwick and R.A. Good, Memorial Sloan-Kettering Cancer Center, lmmunobiology Section, New York, N.Y. 10021 Six patients with CMC were investigated for antibody production in vitro in polyclonal and antigen-specific assay systems. Cultures---ci1'Peripheral blood mononuclear cells (PBM) differentiated poorly into immunoglobulin secreting cells as tested in a reverse hemolytic plaque assay using protein A coated sheep erythrocytes, following stimulation of PBM cultures with either pokeweed mitogen, a T-dependent stimulus or with Epstein Barr virus, a T-independent stimulus. Cocultures of isolated T and B cells from patients and normal volunteers revealed the defect to be intrinsic to B cells, although associated abnormalities of increased suppressor cell activity were frequently present. T helper function was adequate in all patients. Antibody responses to sheep red blood cell (SRBC) determinants, tested for by quantitating anti-SRBC plaque forming cells following in vitro sensitization of PBM cultures with antigen, were found normal in 2 and decreased in 3 patients. In the latter patients the responses were augmented following delayed addition of the T cell mitogen Con A to the cultures as a means of amplifying T cell help. In one patient with associated hypogammaglobulinemia, no responses were elicited despite these manipulations. These findings indicate that 1) abnormalities of in vitro humeral immune function are frequently present in CMC besides the described defects of cell mediated immunity, and 2) polyclonal and antigen-specific responses might be mediated by different activation mechanisms, possibly involving distinct B cell subsets. Human T-lymphocytes (TL) generate chemiluminescence (CL) in the presence of luminol. We investigated this phenomenon in terms of age dependency, nature of oxidants produced and relationship to cellular immune competence. Sixteen adult and 8 cord rosette purified TL preparations purity) were tested for spontaneous and concanavalin A (Con-A) stimulated CL. The chemiluminescence index (CI) is an expression of peak photon emission, adjusted for luminol drift and the spontaneous emission of a dark adapted blank. Mean spontaneous CI was 88 ± 23 in adults and 19 ± 9 in cords, p200 units/ml, caused 090% suppression of plaque forming cell (PFC) responses by human peripheral blood mononuclear cells (PBMC) stimulated with pokeweed mitogen (PWM). Suppression was not significant before day 6 and peaked at 'days 7-8, suggesting stimulation of a suppressor cell by IFNaA. Small numbers of PBHC incubated with IFNaA for 24 hrs. suppressed PFC responses by 80% compared to cells incubated with inactive IFNaA when added to fresh autologous PBMC at culture initiation. Concentration of lgM in culture fluids on day 6 and 7 was suppressed >50% by IFNaA at doses >200 units/ml. Suppression of 3H-thymidine incorporation in mixed lymphocyte responses (MLR) was not significant on day 4 and peaked at 50% on day 5. IFNaA and IFNaA-activated cells did not suppress PFC responses in the presence of catalase or 2-mercaptoethanol (2-ME), and MLR was not suppressed in the presence of 2-ME and dithiothreitol (OTT). Delayed onset of suppression, activation of a suppressor cell, and reversal by catalase, 2-ME and OTT suggest that human IFNaA activates a suppressor pathway analogous to that activated by interferon in murine cells and suggest that a SIRS-like mediator may be involved. In previous studies, we demonstrated that opsonic antibody (Ab) is effective in altering the course of group B streptococcal infection in humans and in a neonatal animal model. Although high titer human serum or whole blood afforded excellent protection, the available conrnercial ganrnaglobulin preparations are less satisfactory. In the present studies, we prepared mouse type-specific hybridoma Ab and examined it for protective efficacy against four strains of type Ill group B streptococci. fjeonatal rats received 5xlo6 organisms by intraperitoneal injection. Type specific hybridoma Ab (0.25 ml/kg) was administered in a separate IP injection. The survival rate of the animals receiving Ab vs controls was: l) 58% VS 3%; 2) 74% VS 36%; 3) 95% VS 0%; 4) 86% VS 9%. Significant protection was provided when hybridoma Ab was administered as late as 12 hrs postinfection (25% vs 0%; p<0.0005), an interval at which ganrnaglobulin gave no protection. In spite of the fact that the hybridoma Ab was of the IgM class, it also protected against respiratory infection. When inoculation was via the intranasal route, survival of Ab treated animals remained significant (94% vs 0%). The hybridoma type Ill specific Ab did not protect against type II group B streptococci. These studies indicate that monoclonal antibody preparations could provide a reliable source of large quantities of opsonic Ab for passive immunotherapy of neonatal group B streptococcal disease. The release of histamine from human basophils induced by Sendai virus, a parainfluenza virus which had been adapted to a human (HEp-2) epithelial cell line, was investigated in vitro. Dilutions of a stock suspension of virus were incubated with washed suspen-si0ns of human peripheral blood leukocytes (PBL) for 2 min at 37°; either buffer or phosphatidyl serine (PS) at 10 µg/ml was added and the incubation continued for an additional 10 min at 37oc. Controls included buffer and uninfected HEp-2 cells. Histamine released into the supernatants was measured using an enzymatic isotopic assay and was expressed as net percentage released above buffer controls. Results are shown in the Table: Di With PS (%release ± SEM) Without PS 20.9 ± 6.0 9.1 ± 7 .6 10-2 8.3 ± 3.1 0.6 ± 4.3 lo--0.3 ± 1.3 -6.5 ± 4.o lo-3 1.9 ± 3.7 -4.6 ± 2.6 Buffer -0. tions might be at risk for developing chronic pulmonary disease. To evaluate pulmonary function in patients with various types of immunodeficiency, we performed spirometry and pletheismography. Eight patients had primary or acquired hypogammaglobulinemia, one had dysgammaglobulinemia, and one had hyper-IgE syndrome. Nine had received immunoglobulin replacement therapy since diagnosis. Mean age at testing was 13.7 years (range 7-18 years). Seven patients with a history of two or more episodes of proven or presumed bacterial pneumonia had abnormal FEF 25 _ 15 %: five of these had decreased FEV1 as well. Two patients had Increased RV and RV/TLC (hyperinflation): two had decreased TLC (restriction). Of the three patients without repeated pulmonary infections, two had normal spirometry. The other, who had a family history of asthma, showed hyperinflation only. Two of the eight patients with pulmonary function abnormalities showed improvement in response to inhaled bronchodilator; one of these had a family history of asthma. We conclude that children with immunodeficiency who have repeated pulmonary infections are likely to develop pulmonary function abnormalities. However, immunodeficiency without pulmonary infection does not necessarily predispose to abnormal lung function. Bronchodilator therapy might benefit some of these patients, especially those with a family history of asthma. Different inrnunoprophylactic regimens have been proposed to overcome or prevent Pseudomonas lung infection in patients with cystic fibrosis (CF). Although current vaccines generate excellent serum antibody responses, they have changed neither the clinical status nor Pseudomonas colonization. In the present studies, lung lavage fluids were studied in mice following Pseudomonas aerosol challenge with either the oarental (lmmunotype I) or TS mutant strains. The cellular resoonses were auantitatively and aualitatively similar in both immunized and non-inrnunized animals. Protection was induced in mice receiving a single aerosol dose of 2-4 x 105 colony forming units of TS mutant of P.aeruginosa. The results sugqest that this orotection may be a result of the oresence of local opsrinizing antibodies. Since recent oublications have shown impaired opscnizing activity of serum IgG from CF patients, the present results also suggest that local immunization of the resoiratory tract might be oreferable in these patients. Neuro • Br., NINCDS, NIH, Bethesda, MD 20205 Gaucher's disease is a lipid storage disorder characterized by a deficiency of glucocerebrosidase and the accumulation of its substrate, glucocerebroside in cells believed to belong to the monocyte-macrophage system. In the present study, we evaluated cellular and humoral immunity in 30 patients (pts) with Type l Gaucher's disease. 9/30 pts bad lympbopenia and/or monocytopenia, although cell surface marker studies revealed normal percentages of peripheral T and B lymphocytes. Skin testing with candida, tetanus and mumps antigens yielded positive responses only in 1/29, 15/20 and 0/13 pts respectively. In addition, in vitro lymphocyte proliferation studies revealed further evidence of a cellular immune defect in that the pts' lymphocytes showed abnormal responses to concanaval in-A (1 /2 normal), pokeweed (1 /3 normal), streptokinase-streptodornase(l/4 normal) and candida{l/3 normal). In contrast,humoral immunity was intact. Isohemagglutinin titers, quantitative serum immunoglobulins and antibody response to primary immunization with pneumococcal polysaccharide antigen were normal. We also evaluated monocyte-mediated antibodydependent cytotoxicity and found it normal in 12 pts tested. The apparent cellular immune defects did not correlate with clinical severity of disease, splenectomy, serum triglyceride or alpha globulin levels. In summary,our data indicate that there is a defect in cellular immunity in pts with Gaucher's disease. Further studies are underway to determine its mechanism. Anergy and secondary infections during viral illnesses suggest the presence of acquired cellular and/or humoral defects. Weanling strain 2 guinea pigs were inoculated with gpCMV-infected or uninfected control gujnea pig fetal tissue culture cells. Four infected (I) and 3 control (C) animals were studied daily (x 10) and results were compared by the t-test. All (I) became viremic and shed virus from the nasopharynx. Concurrent with viremia but not with shedding, there was a 51% reduction in neutrophil directed migration towards C5a (p 0.001), and a 77% reduction in the chemotactic activity of activated plasma (p 0.001). Neutrophil random migration, monocyte random migration and monocyte directed migration were unaffected. Heated plasma from (I), incubated with normal C5a or normal neutrophils, inhibited both CSa activity and neutrophil directed migration. Three inhibitory components, designated as gpCMV-Associated-Chemotactic-Inhibitor (MW "' 80,000), Helper 1 (MW"' 30,000) and Helper 2 (MW "' 15,000), were identified by gel column chromatography. The chemotacticactivity of C5a was inhibited following its incubation with either Inhibitor+Helper 1 or Inhibitor+Helper 2. The directed migration of neutrophils was inhibited following their incubation with In-hibitor+!lelper 2, but not with Inhibitor+Helper 1. No inhibition was seen following their incubation with any of the components alone or with Helper l+Helper 2. The inhibitors therefore affect- Epstein-Barr Virus (EBV) infectious mononuclec;is (IM) is a lymphoproliferative disorder in which infected B cells are transformed and cellular immunity is depressed. To study the changes in cellular immunity during childhood EBV IM we measured helper (T4) and suppressor T cells using monoclonal antibodies during the course of the illness and in normal children. The EBV IM illness was diagnosed by clinical, hematologic and serologic criteria. All the children had VCA-IgM antibodies, but only 2 of 11 bad heterophile antibodies. Week .0 In acute disease, the percentage of helper T cells was lower (p< .01), the percentage of suppressor T cells was higher (p<.01) and the ratio of helper to suppressor T cells was lower (p <.01) compared to normal children. During the course of the illness these percentages gradually returned to normal levels. In the acute stage the children had less lymphocytosis than an adult group studied, probably reflecting the less marked suppressor T cell response in children, 41%, compared to adults, (p< .05). We conclude that the cellular immune response to childhood EBV IM is primarily one of increased suppressor T cells, which may limit the continued proliferation of infected B cells. We have previously described that colostral lymphocytes (CL) are hyporesponsive to mitoQens when compared to blood lymphocytes (BL). To determine if a predominant suppressor substance or cell population was present in CL, CL and BL from 12 patients cocul-tu3ed and stimulated with PHA. The addition of 25 x 10 to 100 x 10 CL to BL, added to but did not alter the dose-response curve. Production of a suppressor substance or predominant suppressor cell population was not found. The added response was more than expected for CL. To substantiate lack of a predominant suppressor cell population, CL and BL of 12 patients were evaluated usinq monoclonal antibody labeling with fluorescein and alkaline phosphatase. The triad of recurrent facial swelling, facial nerve palsy, and lingua plicata ("Scrotal tongue") tharacterizes Rosenthal syndrome. A twenty-year-old girl with typical features of this syndrome bas been followed for five years. Otolaryngologic and oral surgical evaluations showed no cause for her recurrent facial angioedema. She was otherwise bealthy,and labaratory studies including anti-DNA titers, rheumatoid factor, and tests for cryoglobulins were negative. The serum level of C4, however, was consistently depressed both functionally and immunochemically, ranging from 16% to 41% of adult normal on 9 determinations. The C4 hemolytic efficiency (ratio of functional to immunochemical C4) averaged . 72 (normal for our lab is 1.01 + .26). Al 1 other comp 1 ement components (Cl , C2, C3, C5-9, properdi n, factor B, factor H, and factor I) were normal. Cl inhibitor was normal both functionally and immunochemically. No correlation existed between the patient's C4 level and exacerbations of her disease. The patient's father, paternal aunt, paternal grandmother and 3 brothers all have identical complement profiles; none of them, however, have any features of Melkerssen-Rosenthal syndrome or of any collagen vascular disease. These studies document a familial complement deficiency in this patient. The relationship between her complement deficiency and recurrent edema is unclear. The mechanism, however, is different from that found in patients with hereditary edema who may present with a similar phenotypic expression. Se1ttle, HA. The placenta is a fetal organ that functions as a barrier to inununologic rejection of fetus by mother and to the spread of infection from mother to fetus. When we digested chorionic villi from 32-42 week gestation placentas with collagenase or trypsin, (M0) were 25-50% of the cells recovered. The large number of Ml' ) present suggested a potential role for these cells in fetal reticuloendothelial function and maternal-fetal immunologic interaction. Therefore, we have purified these by sequential density gradient centrifugation and differential adherence. Cell preparations obtained were >80% mature !10 by morphology, phagocytosis of IgG-coated RBC and by light microscopic and ultrastructural cytochemistry; these Ml' ) are >75% fetal in origin by Y chromosome fluorescence. Initial studies of these M0 suggest that deficits in their antimicrobial activity correlate with the neonates' susceptibility to certain pathogens. Placental M0 effectively phagocytosed but did not kill type III Group B streptococci (%surviving= 142+41%). These Ml' ) destroyed only 43 + Human peripheral blood lymphocytes from over 90% of normal adults produce specific anti-influenza antibody in vitro when stimulated with A/Aichi (H3N2) influenza virus. --Cumulative antibody synthesis measured by ELISA using an anti-F(ab')2 antibody is expressed in units (U), 1 U being the amount of antibody in a 1:105 dilution of a pooled reference serum. Antibody production requires the cooperation of B cells, T cells, and monocytes. In the present study, we investigated the ability of CBL to respond to influenza virus in vitro. CBL obtained from each of 6 neonates made no measurable anti-influenza virus antibody in vitro ((0.5 U/ml) when stimulated with A/Aichi influenza viruB;"" whereas 6 normal adults produced 42.8 1.8 U/ml (GM SEM). In addition, 1) CBL failed to proliferate to A/Aichi influenza virus (Mean stimulation index 0.7 vs. 13.3 for adult controls), and 2) cord blood B cells produced little or no specific antibody when stimulated either with Epstein-Barr virus or with influenza virus plus irradiated, adult T cells (1200R). These results are consistent with a lack of previous exposure to influenza virus and/or immaturity of the newborn immune system. In each of two cases where it was examined, however, cocultures of irradiated cord blood T cells (1200R) with allogeneic adult B cells produced anti-influenza virus antibody when stimulated with A/Aichi. Thus, in spite ·af a lack of previous exposure to influenza virus, cord blood T cells are able to mediate a positive allogeneic helper effect for specific in vitro antibody production. In the l.?.l phase, newborn (NB) rats were challenged with Group B streptococci (GBS) following which, sequential responses of pheral, spleen, and bone marrow N were examined. The results of N responses following challenge with 104 GBS/gm body weight, a dosage shown previously to be 100% lethal for NB and 15% lethal for 7 day old rats, revealed that the susceptibility for the NB was associated with the following: l)smaller baseline numbers of myeloid elements in peripheral blood, spleen, and bone marrow; 2) a failure to maintain these pools during infection; and 3) a lag in initial responses of N to infection. Based upon these findings, studies were initiated in the human infant using cord blood (CB) and heel prick srecimens fro1.: 1-3 day old infants. Chemotactic responses (CTX) of N from infants than 50% of adult values. A striking redu::tion in the chemotactic capacity of the band form, compared to the mature N, was seen in specimens from CB as well adults. This may, in part, account for the differences in CTX since 30% of the N in infants were bands vs 9% in adults. These data suggest that both the quantity and quality of N responses contribute to the known susceptibility of the newborn infant to infection. NIH grant lPSOAl-15321-04. PMN dysfunction occurs during early stages of IAV infection. We have found that incubation of PMNs with unopsonized IAV causes depressed metabolic responses to particulate and soluble stimuli and decreased bactericidal activity. Additionally, attachment and ingestion of IAV directly stimulated the respiratory burst; this could cause the subsequent PMN dysfunction (e.g., by exhausting the cell or by loss of normal membrane receptor function). These possibilities were studied using 3 infective types of IAV, non-infective IAV and purified IAV glycoprotein incorporated into liposomes, Infective (Texas 77, X-31, X-47) and non-infective X-47 virus, respectively, stimulated varying peak chemiluminescent (CL) responses to 15x, 6x, 3x and 3x that of cells in buffer alone. Incubation of PMNs with each type of virus for 30 min caused similar (-65%) depression of CL responses to receptor dependent and independent stimuli (zymosan, PMA or ionophore A23187), A similar degree of PMN dysfunction was observed when PMNs were incubated with X-47 virus for 0.1, 0.5, 1, 2, 3, 6 and 18 hours, Also, although liposomes stimulated CL (to lOx cells in buffer), incubation with liposomes did not inhibit later CL responsiveness to the above stimuli, The data indicate that the ability of IAV to depress metabolic responses of PMNs is: a) independent of direct netabolic stimulation of the PMNs by IAV (is not due to PMN "exhaustion") and b) independent of alteration of PMN receptors. Raymond D. Adelman and Gerald Ling, Univ. of Calif. Davis, Department of Pediatrics and Veterinary Medicine. Mongrel dogs were infected with pathogenic E.coli by percutaneous nephropyelostomy. Subsequent bladder urine samples were obtained by cystocentesis and pelvis urine samples by percutaneous puncture. Dogs with upper ITT!' s (bacterial growth in pe 1 vie urine), when compared to dogs with lower ITTl's (bacterial growth only in bladder urine) or no ITTl's (no bacterial growth), had higher values of Ur MUR* [1.13(0.12) In order to determine whether the antibody response to bacterial PS antigens is related to immunoglobulin allotypes, we examined Gm (z,a,x,f,n,g,b), A2m (1,2) and Km . technique, nucleic acid spot hybridization, permits sensitive, screening of small numbers of cells for specific sequences. This method detects EBV DNA in cultured cells. We now report preliminary data about its application to diagnosis of EBV infections in clinical samples. We used as DNA probes either whole EB viral genomes or EB viral DNA fragments propagated in plasmids in E.coli. The probes are radiolabelled with 32p, and the content of viral DNA is estimated from radioautograms or by scintillation counting of filters containing samples to which the probe has bound. Statistical analysis, aided by computer, shows that the relationship between genome copy number and the amount of 32Pin the probe bound by the sample, is best described by a loglog plot. We have studied lymph node, spleen, peripheral blood, bone marrow and tumor tissues from a group of 20 patients with a variety of disorders. Two of nine samples analyzed with an intact viral probe and 2 of 11 samples with probes of cloned fragments contained significant amounts of EBV DNA. Positive reactions, with genome numbers varying from 7-102 copies per cell, were found in patients with nasopharyngeal cancer, B cell lymphosarcoma, nodular sclerosing Hodgkin's disease, and chronic myelogenous leukemia. The spot hybridization technique should be valuable in clarifying the relationship between EB virus and a number of lymphoproliferative diseases. The method can also be adapted for diagnosis of a variety of othe1· diseases. Human type-specific antibody to GBS has been measured in this laboratory by ELISA, using carbohydrate antigens purified from culture supernatants and tyrosylated for binding to microtiter wells and affinity-purified antiglobulins conjugated with alkaline phosphatase. vJith this immunospecific and quantitative assay, we have confirmed an absence of type-specific IgG antibody in infants with Type III sepsis and have shown that 20-25% of sera from pregnant carriers of types II and III contain measurable lgG (>0.15 µg/ml) to the homologous antigen at term. By comparison: <5% of noncarriers were antibody-positive. We have now measured IgM and lgA antibody for Type III in the same maternal population. In contrast with the lgG findings, measurable IgM antibody (>l µg/ml) was present in 41/50 of all subjects studied (B2%). The prevalence was some what higher in carriers (25/27 or 93%) than in noncarriers (16/23 or 70%)while the mean level was slightly lower (3.7 vs 5.1 µg/ml). As expected, IgM antibody has been undetectable in all infant sera studied. IgA antibody was present in only 2 of 27 carriers (7%) and in no noncarriers at term. This striking prevalence of type-specific lgM was unexpected and is unexplained. However, if IgM is protective for human GBS disease, it may account in part for the infrequency of invasive infection outside the newborn period. Detailed information on varicella/zoster exposures and subsequent illness was obtained. Laboratory studies included detection of antibodies to VZV by FAMA and IAHA assays and for selected sera by ADCC and neutralization assays. In vitro lymphocyte proliferation to VZV antigens was done on peripheral blood of OKA-RIT-SK and KMcC vaccinees. The pathophysiology of Hib pneumonia is poorly understood and may be related to the host's nutritional status. Using .'l weanling rat model, pneumonia was produced by intratracheal installation of 105 Hib cells into control and iron deficient animals. The kinetics of pulmonary, blood, and splenic clearance were determined by quantitative bacteriology. Capsular antigenemia and antibody response were measured by CIE and an enzyme linked radioirranunoassay, respectively. Bacteremia was detected as early as 12 hours and as late as 12 days after inoculation with peak levels occurring between days 3 and 5 and coincided with gross and histologic evidence of pneumonia. Similarly, lung bacterial counts progressively increased reaching 10 7 -10 8 per gram of lung tissue within 72 hours and slowly decreased with positive lung cultures still present up to 24 days post infection. In Employing the techniques of immunofluorescence, neutralization of tissue culture infectivity and dermal response to VZV antigen, the development of VZV specific immune response and evolution of infection was studied in a population of infants under one year of age during outbreaks of varicella in a semiclosed domiciliary institution for infants in Japan. over a period of four years, 250 residentsranging in age from 27 days to 32 months were tested for cutaneous reactivity to VZV antigen, and VZV specific antibody activity before, during and after each outbreak of varicella. Of these, 85 subjects developed clinical varicella, with an overall attack rate of 100% for all susceptible subjects. Significantly, however, all infants under two months of age were infected following such exposure, despite the presence of pre-existing maternal antibody. The degree of cutaneous involvement appeared to be milder (<20 vesicles) in infants less than two months old and severe cutaneous disease (with over 300 eruptions or confluent rash) occurreC:: ITK>re frequently in subjects 2 to 11 ITK>nths of age. Pre-existing antibody did not prevent development of illness, or alter the degree of antibody or cellular irranune response to subsequent infection. However, the peak cutaneous reactivity to VZV antigen after infection was found to be significantly lower in infants under two months of age. Cytomegalovirus (CMV) infection has been associated with altered host defense and an increased susceptibility to infections. In a murine model, we demonstrated previously an impaired inflarrmatory response to a subcutaneous challenge with Kl E. coli during the acute phase of a sublethal murine CMV (MCRV)"""lnfection. To further define altered neutrophil function, we examined absolute neutrophil counts (ANC) in peripheral blood and in a subcutaneous sponge and the chemotactic ability of neutrophils in the sponge during MCMV infection. Results indicated that ANC in the sponge, but not the peripheral blood, were markedly decreased and neutrophil chemotaxis was depressed on days 1-4. For example, on days 1-2 the following mean values were obtained in MCMV-infected and sham-inoculated mice: peripheral blood ANC of 732 vs 899 (P=0.3), sponge fluid ANC of 1655 vs 5175 (P=0.001), and sponge fluid neutrophil chemotactic index of 1.9 vs 6.2 (P=0.004). These results indicate that the chemotactic ability of neutrophils migrating into subcutaneous tissues of mice is impaired during acute MCMV infection, and strongly suggest that impaired migration of cells from the peripheral blood is at least one mechanism accounting for decreased numbers of neutrophils in tissues. These alterations in host defense may be important in contributing to the development of CMV-related secondary infections. In recent years 8% of our infants weiP,hing <1.5 kg had documented sepsis, accounting for 14% of the deaths. These include fungal infections which have an insidious onset but dramatic sequelae. To facilitate earlier we report previously poorly recognized but dominant clinical features of fungal infection. In 1979-80, 10 infants with identifiable fungi (9 Candida, 1 Malassezia) representing 2.7% of LBW admissions, had a mean BW of 0.8 kg (0.6-1.1 kg), GA 28 wks and postnatal age of onset at 5 wks. Striking presenting clinical features included pulmonary infiltrates (pneumonia), radiographically indistinguishable from bronchopulmonary dysplasia and resulting in respiratory failure (8/10). Necrotizing enterocolitis was simulated in 7 with abdominal distention, guaiac positive stools, edema of the bowel wall, but ahsence of pneumatosis. Carbohydrate intolerance and glycosuria necessitating insulin therapy(?) and Candida endophthalmitis (4) were additional features. Predisposing factors included central arterial and venous lines, prolonged broad spectrum antibiotic usage(mean 23 days) for suspected (4) or confirmed bacterial infection(6}, and total parenteral nutrition(mean 37 days). Positive cultures for fungus were obtained from blood, ur5.ne, CSF and lung biopsy. In 6 infants cultures were intermittently positive. 4 had negative cultures despite microscopically visible fungus in urine and lung. 6 infants died, all responding with oliguria to amphotericin therapy. We conclude that in preterm infants fungal infections have protean manifestations necessitating a high index of suspicion. Nontypable Haemophilus influenzae are a frequent cause of otitis media in children and occasTOilally cause bacteremic illness in neonates and in older immunocompromised patients. The lack of specific strain markers has hampered studies on the relatedness and relative pathogenicity of different isolates. We applied the techniques of biotype detennination and SOS-polyacrylamide gel electrophoresis of outer memhrane protein (OMP} preparations to 35 epidemiologically-unrelated pathogenic nontypable Haemophilus influenzae isolates. Three of five isolates obtained from the blood of unrelated newborns with sepsis had concordant major OMP profiles and were biotype IV. Two of five isolates obtained from the blood of unrelated older children or adults with bacteremia had concordant major OMP profiles, distinct from the corrmon profile of neonatal strains, and were biotype II. The OMP profiles of the remaining five isolates from blood, two isolates from CSF, and 23 isolates from middle ear aspirates of children with otitis media were unique, although each isolate had peptides with apparent molecular weights of 16,000 and 31,500. No nontypable isolate had an OMP profile identical with that of any of the 256 type b Haemophilus influenzae isolates we have examined. These results suggest that a subset of nontypable isolates associated with bacteremia have distinctive strain markers. Their pathogenicity may relate to a predilection for colonizing the female genital tract in the case of the corrmon neonatal strain, or an increased ability to evade host defenses. Diphtheria-pertussis-tetanus (DPT) vaccine has a very high level of reactions when administered according to current recommendations. Reduction of side effects while maintaining adequate protection would enhance acceptance of this product. In a prospective study, patients were randomized to receive standard (0.5 ml) or half (0.25 ml) doses of DPT vaccine for all 3 immunizations administered at 2, 4 and 6 months of age. Side effects and antibody responses were determined in 74 children who completed the entire primary series. Clinical reactions were determined by questionnaire and home visits. Reactions were categorized into height of temperature, behavioral changes, and local reactions. 3 0 6% of children in both vaccine groups had temperatures of 102 F or greater and 35.6% had local reactions consisting of a combination of redness, tenderness, and swelling. No differences were noted between the 2 study groups. However, only 47.0% of the reduced dosage group had severe behavioral problems while 64.8% of the standard vaccine recipients had comparable reactions (p<0.01). This latter difference was most marked during the third immunization. Patients had serological evidence of protection to diphtheria, pertussis, and tetanus. The decreased reaction and adequate protection of the reduced dosage underlines the need to reevaluate current Six patients ranging in age from 3 weeks to 5 months with VP shunt infec· tions due to MRGR strains oT Staph epi were treated with intraventricular vanco· mycin (5 mg/day) via the VP shunt (5 cases). In one patient vancomycm (5 mg/day) was injected directly into the ventricles following removal of an infected shunt. An patients had previously received unsuccessful courses of other intraventricular antibiotics /rior to vancomycin therapy. Cerebrospinal fluid (CSF) sterility was achieve in all cases within 9 days (avg. 4.5 days); therapy was continued for an average 6 additional days. In 3 cases no simultaneous systemic antibiotics were used. Clinical symftoms and CSF cell counts improved within 3 days in all patients. Neutrophils/m CSF before & = 161 ± 138; neutro· phils/ml CSF after 3 days B = 55 ± 88 (x ± SD). Shunt devices were surgically removed and cultured in all cases upon completion of antibiotic therapy: 2 of 5 (40",{,) grew the original organism despite persistently negative CSF cultures obtained via the shunt reservoir prior to its removal. There was no evidence of toxicity during treatment, nor in up to 2 years follow-up. Relapse of infection due to the same organism did not occur although one patient had a new shunt infection (Staph a125), whereas 70% of controls' and only 30% of infected infants' BEC, respectively, adhered poorly (40°c, no identifiable source of infection and leukocyte count >"15,000 and/or sedimentation rate >30 were enrolled. All children had a blood culture, chest x-ray, urinalysis and urine culture. A lumbar puncture was performed if age <12 mos, Patients were randomized to receive either no antibiotic therapy or CR Bicillin 50,000 U/kg IM followed by Penicillin V 100 mg/kg/day for 3 days. Patients were examined at 24 and 72 hrs. Fifty patients were treated expectantly and 46 received no antibiotic therapy. Ten of the 96 patients were bacteremic (9 S. pneumoniae, 1 H. influenzae). Four of the 5 treated bacteremic cases were improved at the first follow up visit (afebrile and no obvious focus of infection We studied the ability of children immunized with DPT-polyribosylribitol phosphate (PRP) to mount a serum opsonic response to HIB. Twenty-seven children were randomly assigned to receive PRP (GpA, N=l2) or DPT booster (GpB, N=l5). Sertm1 was obtained before and 1 month after vaccination. HIB opsonic activity was determined using 3H-thymidine-labeled HIB and normal human PMN. Five children in GpA, but only l in GpB had a significant rise in serum opsonic activity to HIB (p<0.05). Mean GpA postiamunization opsonic activity, expressed as % phagocytized bacteria, (xzSEM, 60.8%4.1) was significantly higher than that from GpB (47.5±2.B)(p<0.05). Mean opsonic activity in the 5 responders was 64.8. Preimmunization serum from GpA and GpB had similar mean opsonic activity (GpA=52.7±. 2.8, GpB=46.fu, 2.9). Sera were also tested by radioimmunoassay for anti-PRP antibody. Ten children in GpA, including all 5 with an opsonic response, and none in GpB, had an increase in anti-PRP antibody. The presence of serum bactericidal and anticapsular antibody at the onset of HIB disease in some children suggests that other factors may be necessary for resistance to this organism. We have demonstrated an opsonic response to PRP vaccine which may contribute to host defense against HIB disease. • 95:3 STREPTOCOCCAL SEPSIS. Robert D. Christensen, Jane Macfarlane, Nancy Taylor, Harry R. Hill and Gerald Rothstein, University of Utah School of Medicine, S.L.C., Utah. Neutrophilia usually accompanies bacterial infection in adults but infected neonates frequently develop neutropenia. In an attempt to explain this difference, we studied neutrophil(neut) production and marrow pool sizes in groups of 6-9 adult and neonatal rats inoculated with 3xl06 type II group B strep(GBS)/gm body wt. All infected adults survived, developing neutrophilia with a peak count of 340+18% of control(x+SEM, p<.001). In contrast, infected neonates-developed profound neutropenia of control, p<.001) and 88% died. In adults the neut storage pool (NSP=all PMN+bands+metamyelocytes within the marrow) diminished to 65+4% of control, but the neonates' NSP became almost completely depleted(9+2%, p<.001). Infected adults increased their granulocytic stem cells(CFUc) by 320:!:_20%(p<.001) and their CFUc proliferative rate (determined by tridiated thymidine suicide) by 95+4%(p<.001). In the face of neutropenia and NSP depletion, however, infected neonates had decreased CFUc(48+8%, p<.001) and CFUc proliferation did not increase. Thus, adult rats responded to GBS infection with neutrophilia, a modest temporary reduction in NSP, and an increase in stem cell number and proliferative rate. In contrast, infected neonates developed profound neutropenia, an exhausted NSP and did not increase stem cell number or proliferative rate. It appears that both exhaustion of the NSP and inability to accelerate neut production result in the neutropenia in neonatal GBS sepsis. The deficient neut supply which results may contribute to the high mortality in this condition. Sickle cell disease patients (SCD) produce antibodies after pneumococcal polysaccharide (PPS) immunization, but increased opsonic activity has not been demonstrated. We studied the correlation between a rise in s. pneumoniae type 7 PPS antibodies (aPPS-7), measured by RIA (Dr. G. Schiffman), and increased opsonization in vitro. We measured the uptake at 30 min by human neutrophils of radiolabelled type 7 bacteria opsonized with the test serum. A 2 fold increase (FI) was defined as a positive antibody response, and a 1.45 FI as a positive opsonic response (>2 x coefficient of variation). Sera from 18 SCD >2 yrs, 6 SCD <2 yrs, and 6 controls before and after PPS immunization were tested: --The majority of ampR Hi clinical isolates are free of physically demonstrable extrachromosomal DNA. Properties of these "plasmid-free" (pf) strains include stability of the 8-lactamase phenotype and conjugal transfer of amp resistance determinants to ampS recipients at low frequency. Moreover, ampR transconjugants obtained from such crosses uniformly contain plasmids. These observations suggest that plasmid DNA in pf strains may be physically integrated into the bacterial chromosome. To test this hypothesis, we utilized the transfer technique of Southern to visualize plasmid specific DNA sequences in the chromosome of pf ampR Hi. Total cellular DNA from pf ampR donor, amps recipient, and plasmid containing transconjugants was digested with Sac! restriction endonuclease. The resulting fragments were fractionated by agarose gel electrophoresis and transferred to nitrocellulose where plasmid specific sequences were visualized by autoradiography after hybridization to 32p labeled plasmid DNA. These results demonstrate conclusively that maintenance of plasmid sequences in pf strains occurs via integration into the host genome. The clinical significance of the recognition of 2 modes of R factor carriage in Hi is derived from known evolutionary advantages enjoyed by bacterial strains with genetic elements of this versatility. Extrachromosomal R factors in Hi are easily Jost in the absence of antibiotic pressure but are readily transferred to other strains. Conversely, integration of R factors allows uniform stability of resistance determinants but inefficient dissemination in the species. SOM is a frequent residual of acute otitis media (AOM). This study was undertaken to determine the effect of oral antibiotics on the outcome of this residual SOM. The study was conducted in a private pediatric practice where pneumatic otoscopy and tympanometry were perfonned on all patients 30 days followina the diaqnasis of AOM. Patients were eligible for enrollment in the study if they were found to have SOM at this followup visit. Following enrollment, subjects were randomly assigned to either treatment with a combination of sulfisoxazole (150 mg/kg/day) and erythromycin ethylsuccinate (50 mg/kg/day) for 10 days or no treatment. Repeat pneumatic otoscopy and tympanometry was scheduled every 30 days for 4 months. Followup examiners were unaware of the initial. treatment regimen. Seventy subjects (50% treated) have been enrolled with a mean age of 3.5 years (range 0.8-11 years). At the first followup visit SOM was resolved in 31 subjects (58% treated) and persistent in 20 (55% treated). Nineteen patients returned with AOM prior to the first followup visit. Only 32% of these 19 patients were in the treatment group. Followup of the 20 patients with persistent SOM at 30 days post enrollment revealed 9 patients (44% treated) with persistent SOM at 60 days, 5 patients (60% treated) at 90 days and only 2 patients (50% treated) at 120 days. These data support the view that oral antibiotics will not hasten the resolution of SOM but may reduce the recurrence of AOM. A rrouse ITDdel of maternal-newborn (M-N) transmission of GBS colonization was developed. Pregnant swiss-Webster mice were colonized daily for 3 days before delivery with approximately 108 type III GBS delivered to the vaginal canal, oral cavity and nipples. Cultures frcm the ltDuth, perineum and nape of newborn mice were obtained at birth in Todd-Hewitt broth containing naladixic acid and gentamicin. LTA (2 m::i/ml), prepared frcm type III GBS, or pmsphate b.iffered saline (PB.5) was then applied topically to the 3 sites. Repeat cultures at 3 days of age revealed 35/75 (47%) PB.5 treated mice and 0/79 LTA treated mice were colonized if 2 doses of LTA were applied. No obvious toxicity was noted. In separate experilrents, O. 5 ng/ml of LTA was protective in the M-N rrodel and prevented colonization with 60,000 GBS in the oral cavity of newborn mice. LTA frcm type III organisms also protected against colonization with type I or II GBS. ' Ihis is the first in vivo evidence that colonization with GBS can be prevented by a substance knONn to interfere with their adherence to epithelial surfaces. 'Ibis may be a useful method of prophylaxis against GBS infection in neonates if it is nontoxic. 29-35 21-24 12-18 10-14 8-10 6-9 Results revealed a curvilinear relationship between adherence and GI\ with a significant decrease in adherence with increasing GI\. The polynanial regression ITDdel: adherence; -44.3844 + 7.6767 (GI\) -0.1582(GA2) was found to predict 92% (r ; -.96) of the variance in adherence. Background bacterial =unts before addition of GBS were zero in all patients. In 5 healthy adult controls, 88 GBS adhered/cell. Pre-treatlrent of adult BEX: with amniotic fluid fran a nonnal tenn pregnancy for 72 hours reduced adherence to 80 GBS/cell. 'Ibis data suggests that an inhibitor to GBS adherence develops late in gestation. 'Ibis may be a nonnal protective rrechanism for the first few days of life in tenn infants. Increased adherence in pranature infants may explain, in part, their higher incidence of GBS infection. 'Ibis i,,, the first report of GBS adherence in premature infants. Enterotoxigenic E. coli, in order to cause diarrhea, must also adhere to-mucosa! surfaces. In man, two of these adherence-mediating surface materials, called colonization factor antigens (CFA), have been defined. They may be presumptively identified by the organisms' ability to agglutinate red blood cells from different animal species in the presence of mannose. Antibodies to CFA and non-antibody adherence-inhibiting materials have been demonstrated in human breast milk in vitro hut r efficacy in vivo has not been reported-.--We compared episodes of diarrhea following fecal carriage of toxigenic-CFA+ bacteria in breast fed babies with the ability of their breast milk to inhibit CFA+ agglutination. Results were as follows: No diarrhea No inhibition 0 8 Results in this small number of subjects sugqests that breast milk inhibiti.on of bacterial adherence correlated with the babies' capacity to carry toxigenic-CFA+ organisms and r.ot have diarrhea. Secretory antibody to toxin, on the other hand, showed no such association. crete virus at any time and none of thEir infants acquired CMV. In contrast, 12 infants born to 34 seropositive women (mean follow-up 9.5 months, age 25 years, months breast feeding 3.2) acquired CMV between 1 and 6 months (p=0.01). None of the eleven infants who nursed less than I month became infected. Twelve of 23 infants who nursed long3.0 and net cpm >10,000) between V+ (12/20) and S+ (28/39) though both were significantly more often reactive than S-(3/33) (p<.001). Mean values for SI/net cpm were V+: 7.02±0.76/16547±2702; S+: 7. 79±0. 72/16789•3387: S-: 3.20±0.64/4854±948. There was no significant difference uetwcen V+ and S+ though both were significantly greater than S-(p<.001). Lack of viral contact with systemic immunocytes does not seem responsible for the lack or difference in systemic cellular immunity between V+ and S+ since the geometric mean CF titer of V+ {74.0±16.9) was significantly greater {p<.02) than that of S+ (37.3:':6.4). We could not demonstrate that systemic CMV-specific cellular immunity is an important factor in genitourinary CMV infections. Most infants born to CMV-shedding women are not congenitally infected. It is unknown if such uninfected infants are exposed to CMV in utero. We studied infants of 59 adolescent women followed through pregnancy with CMV cultures (cervix, urine, saliva, leukocytes), complement-fixing (CF) CMV antibodies, CMV-specific lymphocyte blastogenesis and general measures of cellular immunity. 16 mothers shed virus while pregnant (V+), 29 were virus negative but seropositive (S+) and 14 were virus and seronegative (S-). Infants were studied with CMV cultures (cord blood, urine), cord CF-CMV antibodies, CMV-specific cord lymphocyte blastogenesis and general measures of cellular inununity. No significant differences were found among infants of the 3 groups for E-rosette number or mitogen stimulation. Geometric mean CF-CMV titer for infants of V+ (121.0±34.5) was significantly greater (p<.001) than for infants of S+ (32.3±6.0). The one congenitally infected infant (mother V+) had CMV-reactive lymphocytes (stimulation in-dex>3.0 and net cpm>l0,000). 7 of the 15 uninfected infants of V+ had CMV--;=;;ctive lymphocytes, as did 7 of 29 infants of S+ and 0 of 14 inf ants of S-. Since 5 of 14 mothers whose uninfected infants had CMV-reactive lymphocytes lacked reactive lymphocytes themselves at delivery, passive transfer of reactivity at delivery is unlikely. Some S+ mothers may have shed CMV at times not studied. We suggest that CMV-reactive cord lymphocytes in unin- There was no significant difference between V+ and S+ overall or at any gestational time for frequency of CMV-specific lymphocyte reactivity (stimulation index>3.0 and net cpm>l0,000). There were downward trends for mean net cpm through gestation for both V+ and S+ though they failed to reach significance. Mean SI and mean net cpm for V+ and S+ were greater than for S-throughout; this was significant at all times except for V+ net cpm at 20-30wks and postpartum. No significant differences were noted bet••een V+ and S+. One mother (V+) had a congenitally infected newborn. We suggest that maternal viral shedding during pregnancy may not be to systcinic CMV-speci.fic cellular immunity. A prospective study of EBV infection in pregnant females was undertaken with 3 objectives: I) To define the current gy of EBV in this population and compare it with data collected previously 2) to test for serological evidence of reactivation of the latent, persistent carrier state and 3) to assess the effect of infection on the fetus. We measured antibodies from early and mid (20% of the women) pregnancy and cord sera to viral capsid antigen (VCA), early antigen (EA), and EB nuclear antigen (EBNA) using immunofluorescent assays. Thus far, 2000 women have been tested: 1386 in a clinic group (CG) and 614 in a private practice group (PG). Among the 1386 women in the CG, there were 8 (0.6%) seronegative [<20 yrs, 5/650 (0.8%); 21-30 yrs, 3/648 (0.5%); and )31 yrs, 0/88 (0%)]; 18 (2.9%) of the women in the PG were seronegative [<20, 2/42 (4.8%); 21-30 yrs, 12/388 (3.0%), and )31 yrs, 4/184 (2.J%)], By comparison, 17 (9%) of 185 pregnant women bled in 1959-1965 were seronegative (p(0.01). Titrations of 200 complete sets of sera have shown only occasional evidence of reactivation. Two infants born to women with asymptomatic primary seroconversions were normal and showed declining antibody titers in follow-up (Table) Further studies have been performed with live attenuated Towne strain CMV vaccine to determine: (!) the response to various dilutions (dil) and (2) the persistence of inununity beyond 1 yr and in vaccinees who become pregnant. (!) Volunteers (vol) who received 1:2, 1:5, and 1:10 dilutions of vaccine (10 3 · 5 pfu undiluted) were tested for complement fixing (CF) and anticomplement immunofluorescent (ACIF) anti bodies to CMV and for specific l1·1"phocyte proliferation (LP). Peak antibody responses ( Table) and the magnitude of the local reaction were compared with those seen in women previously receiving undiluted vaccine. All vaccinees developed an LP response which was of similar magnitude regardless of the vaccine dose. There was some diminution in the local reaction at dilution of !•IO (2) (39) 10(97) LP response (mean 4117 cpm). 3 vol have become pregnant 6, 8, and 12 mos after vaccination and have maintained detectable responses by the CF, ACIF, and LP assays 4 to 8 mos into gestation. Dilutions (1:10, 1:5, 1:2) of CMV vaccine were irnmunogenic but had decreased potency for the development of humoral immunity. Following immunization with Towne strain vaccine, immunity appears to persist for more than 2 yrs and remains through gestation. CGD is a genetic disorder of bacterial killing by blood neutrophils (PMN). Patients usually present in the first 2 yrs of life with severe, chronic and recurrent bacterial infections. Approximately one third of reported patients die of infection before 7 yrs of age. Because of their susceptibility to infection we give all CGD patients TMP-SMX prophylaxis (2mg TMP/kgm/day) once daily. Our experience since 1972 includes 9 male patients given TMP-SMX for a mean of 5.6 yrs with a total patient experience of 51 patient yrs. Their mean age is 15 yrs (range [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] . The diagnosis was established in each case by the failure of PMN to reduce nitroblue tetrazoliurn dye and to kill Staphylococcus normally in vitro. Five of 9 patients have been free of infection during--Y-5---yrs-of observation. Of the 4 remaining patients, there have been 6 infections over 35 yrs of observation. One patient, followed for 6 yrs, had a dental abscess. One patient, followed for 10 yrs, had a perianal abscess and has occasional skin pustules. One patient, followed for 10 yrs, had a perianal abscess and a liver abscess. The ninth patient, followed for 9 yrs, had one episode of a paronychia, a skin abscess and died following an 8-month illness characterized by fever, an elevated ESR and weight loss without demonstrating any focus of infection. We have not observed any side effects of TMP-SMX prophylaxis. Compared to published reports, our patients appear to have fewer infections while taking TMP-SMX and have a better prognosis. Female health care workers are a largely middle class, young (median age 26 yrs.), and fertile group (average gravidity 2.4); many (48%) are cytomegalovirus (CMV) seronegative. Although primary acquisition of C1V infection during pregnancy has been accepted as the main contributor to congenital affliction, the role of reactivation of maternal CMV in congenital infection has not been completely elucidated. Health care workers, especially those caring for neonates, are thought to be at high risk for exposure to CMV. One hundred and fifty pregnant and nonpregnant women with direct patient contact (DPC) and without (NDPC) were matched for age, gravidity, parity, number of sexual partners, and age at initial sexual activity. These individuals were followed for up to 3 years and evaluated for CMV and HSV specific humoral and cell mediated immunity (CM!), cervical and urine viral excretion, and suppresion of CMI by serum and cellular factors. No significant differences were noted DPC and NDPC groups in terms of viral excretion, CMV or HSV seroconversion, or CMV or HSV geometric mean titers. Pregnant women demonstrated significant suppression of specific cell mediated immunity to CMV and HSV in all trimesters, particularly the third. This specific suppression is not related to serum factors but does seem to be related to a suppressor cell subpopulation. Natural varicella may be severe or fatal in children with leukemia. We therefore immunized 63 children with leukemia in remission with 1000 pfu of live attenuated varicella (Oka) vaccine, to induce primary immunity to varicel la-zoster (VZ) virus. Twenty-seven of children had received no chemotherapy for 1-12 months (mean 6) prior to vaccination. Maintenance chemotherapy was suspended for 2 weeks in 36 vaccinees. All tested seroconverted and developed cellular immunity (CMI) to VZ virus in 3-8 weeks. In children whose chemotherapy was finished the VZ fluorescent antibody to membrane antigen (FAMA) geometric mean titer (GMT) 8 weeks after immunization was 1 :11; 3% had mild rash. In children with chemotherapy suspended the VZ-FAMA-GMT 8 weeks after vaccination was 1:8; the incidence of mild to moderate rash was 54%. Rashes appeared 7-54 days (mean 28) after vaccination. VZ virus was isolated from a rash in 1 child. The VZ-FAMA-GMT of children with rash was higher than in those without rash. There was no spread of varicella to susceptible siblings or other virus shedding. Four vaccinees with household exposures to VZ virus did nut become ill. These preliminary data confirm that VZ vaccine is safe for leukemic children in remission and that vaccine induces antibody and CMI to VZ virus. The relationship between asymptomatic np carriage of Hib and protection against invasive Hib disease is unknown. The role of Hib np colonization, with and without bacteremia, in protecting against systemic Hib bacteremia was investigated in rats. Rats, intranasally colonized at age 10 days with 2-5 x 106 cfu Hib, were challenged at age 112 to 120 days with 6-26 x 106 cfu Hib intraperitoneally (ip). Among 31 rats who became bacteremic during np colonization (C-B), 1(3.2%) was bacteremic upon ip challenge. Among 14 colonized but nonbacteremic (C-NB) rats, 12 (85.7%) were bacteremic after challenge. Of 14 noncolonized and nonbacteremic (NC-NB) control rats, 10 (71.4%) were bacteremic after challenge. There was no difference in duration of bacteremia nor in peak bacteremic levels post-challenge between C-NB and NC-NB rats (p ) 0.05, rank sum test). Among C-NB rats, rates of bacteremia after ip challenge were identical (85.7%) in both heavily and lightly colonized animals. Likewise, in C-NB rats there was no correlation between either duration (r = -0.224) or degree (r = -0.41) of bacteremia after challenge, and duration of earlier np carriage (range = 2 to 28 days) of Hib. Thus, Hib np colonization of infant rats without systemic bacteremia did n9t appear to protect these animals against subsequent ip bacterial challenge. However, other protective mechanisms may be evoked by np colonization. Based on 5 years of prospective surveillance in a neonatal intensive care unit (NICU), We i.nvestigated the association of nosocomial infection (NI) with death during hospitalization for 911 infants who remained in the NICU 48 hours. Low birthweight and the diagnosis of patent ductus arteriosis (PDA) were the variables most strongly associated with NI, and after stratification for these variables there was a persistent (p=0.03) overall effect of NI on mortality. The presence of PDA signiricantly (p=0.02) modified the effect of NI on mortality. In infants without PDA there was a s4bstantial effect of NI on mortality (RR= 3.42, 95% confidence interval 1.68-6.95), whereas there was no effect in infants with PDA. Relocation of the NICU to a facility with improved infection control features and a 50\ increase in staff associated with a dramatic fall in the ad- Twenty children with cancer who developed zoster were enrolled in a long-term study of their humoral response to varicella-zoster virus (VZV) antigens. The immunoprecipitation profiles of acute zoster sera were easily distinguished and very similar to those of high titer VZV xenoantisera; they contained a mean of 16 polypeptides, which ranged in mol. wt. from 32 to >>200 kilodaltons (kd) and included the major VZV capsid polypeptide (155 kd), three major glycoproteins (118, 98 and 62 kd), actin (45 kd) and a low mol. wt. polypeptide. In comparison with post-zoster sera, pre-zoster sera were selectively deficient in precipitating two higher mol. wt. polypeptides (145 kd and 174 kd), one smaller µolypeptide (32 kd), and all 3 major VZV glycoproteins. Longitudinal analyses detected elevated human antibodies to VZV-specific glycoprotein antigens up to one year after zoster, while the humeral response as measured against nonglycosylated determinants fell within a few months. Occasional reappearance of the characteristic "zoster profile" in sera drawn during late convalescence presumably represented subclinical VZV reactivation. In summary, radioinmune precipitation is a sensitive techniq·.ie by which to characterize the humeral immune rP.sponse to individual VZV-specific polypeptides. To determine the duration of i11111unity to RSV and factors associated with reinfection, 15 young healthy adults with natural RSV infection were subsequently followed for over 2 years and challenged with RSV (NIH safety-tested pool) at increasing intervals (;2,4,8,14,20,26 months from time of natural infection). Thirteen (87%) became reinfected within 20 months, 12 (80%) within 8 months. Two (13%) remained immune. Of 13 reinfected, 7 (54%) acquired a third infect ion after mean i nterva 1 of 18 months ( nnge 12-24 months). Initial natural infections tended to be MOre severe than challenge reinfection, with third infections mildest. Asymptomatic infections occurred in 0/15 initial, 3/13 second, and 4/7 third infections. The titer and duration of RSV shedding diminished from second to third infections. The level of nasal or serum antibody did not correlate with the risk of infection. Serum antibody rose 4-fold (by ELISA, Neut or CF) in 55% of infections. Mean nasal antibody titer tended to increase with infection or sometimes with inoculation without other evidence of infection. These findings suggest that i11111unity to RSV after natural infection is often of short duration, or that important antigenic differences exist among RSV strains. But after > two infections, inmunity lengthens and infections become less symptomatic, along with diminished viral shedding. Successful i11111unization may thus require 2 or more inoculations and may provide protection only for a limited time, hopefully of sufficient duration to provide ilTITiunity for the period of greatest risk for an infant. , 1979) . After blood culture and sensitivity results were reported, infants were treated with a semi-synthetic penicillinase-resistant penicillin, cephalosporin, or chloramphenicol. Nine organisms (6596) were resistant to semi-synthetic penicillinase-resistant penicillins whereas all were sensitive to cephalosporins and vancomycin. Two infants died (1596). In conclusion: (I) critically ill neonates are susceptible to CNS bacteremia with significant mortality, (2) CNS bacteremia is a late onset, nosocomial event frequently associated with indwelling catheters, (3) cephalosporins or vancomycin may be preferred antibiotics in treatment of CNS bacteremia when organisms are resistant to penicillinase-resistant penicillins. Coccidioidal meningitis (CM) is an often fatal form of infection due to Coccidioides immitis-:-Standard therapy with systemic and intrathecal amphotericin B (AMB) has limited efficacy and major toxicity. We are now treating 5 children with CM, aged 2 -6 1/2 yrs., with intraventricular miconazole and orall. carinii-frec rat model was used to identify the mode of acquisition of I'. from the natural environment. The germfree rats were exposed in a selective manner to potential sources of I'. carinii, including air, water and food. Animals exposed in the isolator with filtered (sterile) air and to regular (unsterile) water and food did not acquire /'. carinii. Rats exposed in open cages to room air but maintained on sterile water and food acquired the infection. Duplicate experiments done in laboratories over 900 miles apart (Memphis and Baltimore) yielded similar results. Animals fed />. carinii infccccd lungs did not acquire the infcccion. Serial sacrifice of cesarean-section originated, barrier-sustained rats, exposed co room air revealed P. carinii infection to be evident by 9 weeks of age and all of the rats were infected by the age of 14 weeks. These findings show that P. carinii is naturally acquired as a de novv infection from airborne organisms. Bacterial invasion normally stimulates an inflammatory reaction which limits the spread of the microorganisms. However, inflammation may also have deleterious effects leading to tissue injury and vascular damage. We studied inflammation induced in the ·skin of rabbits by the intradermal injection of live or killed E. coli. exudation (using 1251 la.belled albumin), blood 8°RbCl), leukocyte infiltration (using 5lcr labelled leukocytes) and hemorrhage (using 59Fe labelled RBC's) were measured in the lesions. Severe inflammation, normally induced by injection of killed or live !• ££11. was significantly diminished by treating the!· coli with immune serum: protein exudation by 30% (p<.05), blood flow by 30% {p<,05), leukocyte infiltration by 36-54% (p<.01), hemorrhage by 56-74% (p<.005). Cross-over experiments with four different !· serotypes and four different antisera indicated that antibody to specific 0 antigens, but not to K or H antigen was important for modifying the inflammatory response. Treatment of 4 E. coli serotypes with antiserum to "core" glycolipid inhibited the inflammatory response to all four killed!· coli serotypes. Finally, treatment of killed E. coli with polymyxin B also inhibited their inflammation inducing poten- The results suggest that inflammation and vascular injury at the sites of!· coli infection is diminished by polymyxin B or by antjbody to endotoxin. Such a decrease in tissue and vascular damage may improve survival in coli infections. Hospital int ion for possible sepsis is common in young infants. Often no etiology is found for the suspected infection and the child is discharged with the diagnosis "probable viral syndrome." We prospectively followed infants from birth through the first month of life to determine: rate of and reason for admission, risk factors predicting admission, and the role of enterovirus infections. 588 residents of Monroe County, NY born at Strong Memorial Hosp. from June 24 through Sept. 30, 1981 were studied. Of these, 24 (4%) were admitted. Diagnoses were: suspected sei>sis (17), hyperbilirubinemia (2), and pneumonia, apnea, seizures, irritability, and abdominal mass (1 each). Hospitalization was associated with lower socioeconomic status, fever, lethargy or poor feeding, maternal concern sufficient to contact a physician, and the week of the year (all p (.01). There was no correlation with breast feeding, neonatal or maternal hospital course, or infant exposure to illness in the home or elsewhere {al 1 p > .05). 66% of the hospitalized group (82% of those admitted for possible sepsis) were culture positive (throatrectal ± CSF) for non-polio enterovirus on admission. 4 had culture-proven aseptic meningitis. No bacterial pathogens were isolated and no infants died. 75% of the admissions (81% of the enterovirus-posltive admissions) occurred from mid-Aug. through Sept. Admission rates ranged from 0 to 4% per week per infant at risk. Thus, during the late surrrner, neonates are at high risk for hospital admission with enterovirus infection. properties of streptolysin 0 (SO). In addition to neutralizing the hemolytic effect of SO, we showed that in-vitro preincubation of SO with cholesterol modifies the antigenicity as well as the myocardial cytotoxicity in tissue culture of this streptococcal extracellular antigen (SEA). We have now studied the biologic effects of hypercholesterolemia on the immune response to this SEA in the rabbit. Thirty-eight rabbits fed a 1% cholesterol diet (CR) and 39 animals fed a normal diet (NR) were immunized intravenously with 35 units of SO twice weekly for 18 weeks; 502 serum samples were obtained at regular intervals. Mean serum cholesterol levels in CR rabbits rose to almost 2 gm% as compared with< 100 mg% for NR; the proportion of free and esterified cholesterol in NR and CR sera were similar. After 7 weeks of inununization, geometric mean ASO titers (log) were significantly higher for NR than for CR animaL:: e.g., 1.90 vs 1.76 at 7 wks, p < .01; 1.99 vs 1.84 at 11 wks, p < .02; 2.07 vs 1.87 at 18 wks, p < .01 (students' T test). These data indicate suppression of the ASO response in the CR rabbit and provide additional evidence for a biologically signif- The treatment of HiTb meningitis has been compared to date in 15 children (mean agel5.8 mon) who received Mox 17 children (mean age 16.3 mon) who received Amp or Chloro. Three isolates in each group were Amp-resistant. The MIC of Mox for all isolates was <0.03 The median initial cerebrospinal fluidpolyribosephosphate quantity in both groups was 0.08 Two in the Mox group and 3 in the Amp/Chloro group received greater than 10 days of parenteral therapy; all others received 10 days. The mean±. SD duration of fever in the Mox group was 6. We used biotyping to study the epidemiology of AOM due to HI. Using macro-and microchemical technics, we determined the biotype (Bt) of 78 middle ear (ME) isolates of HI: Bt-I 10(13%); Bt-II 39(50%); Bt-III 21 (27%); Bt-IV 0(0%); Bt-V 6(8%); unclassified 2(3%). Six (8%) strains were serotypable (5-b, 1-f); 13(17%) were ,d-lactamase (ft-lac} positive. No correlation was found between Bt and production. Using isolates from children who had serial ME and nasopharyngeal (NP) cultures positive for HI, we observed the following: l)Right and left ME isolates in bilateral AOM yielded the same Bt in all 9 children tested. 2)Simultaneous NP and ME isolates were of identical Bt in each of 6 determinations. 3}Repeat ME cultures from 8 children with a 2nd episode of AOM showed a change in Bt in 4 cases. These data demonstrate that: l}Biotyping of HI is a useful technic for studying the epidemiology of ME disease, and perhaps other diseases caused by non-typable HI. 2)Recurrent attacks of AOM due to HI result from acquisition of a new strain in some cases, implying that reinfection is important in recurrent ME disease. Recombinant DNA technology has resulted in the production of highly purified human interferon (Hu!FN) preparations which are being evaluated as potential antiviral and antitumor agents in humans. We determined the biologic properties of a recombinant DNA interferon HuIFN<>-2 (Schering Corp.), in vitro and in vivo: (1) antiviral activity was documented by inhibition of CMV, SFV, VSV, HSV 1 and 2 and vaccinia virus in WISH, human embryonic lung, foreskin fibroblast and osteosarcoma cells; (2) seecies specificity was indicated by a > 1000-fold reduction in ant1-v1ral activity in murine cells in vitro; 3) immunomodulator activity was documented by augmentation--oTliUriian NK cells and activation of human monocytes to be cytotoxic for human tumor cells; (4) antiproliferative activity was determined by inhibition of growth of human osteosarcoma cells (HOS) in vitro and prevention of growth of transplanted HOS tumors in athymic mice. In summary, HuIFN -2 was found to have antiviral, immunomodulatory, and antiproliferative activity characteristic of standard reference preparations of Hu!FN. The feasibility of large scale production of pure preparations of HuIFN using recombinant DNA technology offers potential in the treatment of malignancies and viral infections of man. Kim, Herbert L. DuPont, Larry K. Pickering. University of Texas Medical School, Program in Infect iqus Diseases and Clinical Microbiology, Houston, Tx. We evaluated the occurrence of Cd and its association with diarrhea in 3 DCCs caring for children <2 yrs of age. Stools were collected from children during diarrhea outbreaks and 1-3 times a week thereafter. Environmental cultures for Cd were obtained before, during, and after outbreaks. DCC l was enrolled when diarrhea was not a problem and l of 13 children had Cd in stool. Within l month, 6 other children became colonized with Cd (none had received antibiotics). 4 of the 7 children with Cd developed diarrhea 2-4 weeks later at which time Cd was recovered from diaper change area pads as well as from other sites i.e., linen, sinks, and hands of a teacher and 2 children. DCC 2 and 3 were studied during and after diarrhea outbreaks. In DCC 2, l of 4 children with diarrhea and O of 4 children without diarrhea had Cd in stool. Within 3 weeks, the other 3 children with diarrhea became positive (2 had been given antibiotics). Cd was recovered from hands of l asymptomatic child and from the classroom floor. In DCC 3, 2 of 5 children with diarrhea and 2 of 14 children without diarrhea had Cd in stool; a third child with diarrhea became positive on day 5. Cd was recovered from hands of l child with Cd and diarrhea and environmental contamination was demonstrated. All colonized children in the 3 DCCs continued to excrete Cd during a 3 1/2 month period of observation. These results show that Cd can be detected commonly in DCCs and that transmission occurs probably by direct contact. We have evaluated TMP/SMZ in vitro and in vivo against a 8lactamase-positive Hib. In vTtro, bacteriaT killing was complete in 24 hours with 2 & 38 & SMZ, respectively. In we used the newborn rat model of Hib bacteremia and following intraperitoneal injection. TMP/SMZ given subcutaneously in a dose of 5 mg/kg of TMP twice daily produced serum levels of 0.5-2 µg/ml of TMP in 2 hours, comparable to clinical values. Bacterial counts in blood and cerebrospinal fluid (CSF) were determined at the beginning of therapy and daily thereafter for 3 days. Bacteremia and meningitis were produced in 100% of animals. The results are summarized below: At present, there are no consistently effective antimicrobial regimens for neonatal gram-negative meningitis (usually E. coli). We have evaluated the combination of A and C in vitro and in vivo against a K 1 strain of E.coli. The minimal inhibitory ancr-bactericidal concentrations were 2 and 4 µg/ml for A and 4 and 32 µg/ ml for C. In vitro experiments indicated antagonism with the both isobolograms and killing curves. In vivo, we used the newborn rat model of E. coli bacteremia andrneningitis following intraperitoneal injectiOii"-:-Bacterial counts in blood and cerebrospinal fluid (CSF) were determined daily and mortality recorded. A and C subcutaneously, 50 mg/kg twice daily, resulted in peak serum levels of 45±20 µg/ml and 20±12 µg/ml, respectively (mean±S.D.). Mean CSF/serum levels were 7.7% for ampicillin and 77.5% for chloramphenicol. Bacterial clearance was inversely related to the mortality, which is summarized below: We have studied the role of pili in E. coli Kl colonization of the pharynx both in a neonatal rat mOdel and in humans. Experiments were performed with a clinical strain which had been separated into 2 phases based on colonial morphology, hemaqglutination (HA), and electron microscopy: 1) a piliated (P+) phase which produced mannose-sensitive HA, and 2) a non-piliated (P-) phase. The P+ and P-phases were incubated with pharyngeal cells, and the P+ phase adhered in significantly greater numbers than the P-phase: Cept. Pediatrics, Los Angeles, Ca. 'Ihe role of fomi tes in transmission of genital or oral herpes sinplex infections (HSV) is undefined. I t has been believed that HSV "d::Jes not rerrain viable for any length of tirre at room tenperature unless inoculated into specific transport rredia. We therefore examined the ability of HSV ootained directly from patient's genital lesions to remain viable on various surfaces. Sanples inclu::led dry cotton gauze pressed to lesions, plastic gloves and speculum used in pelvic exarrs, fingerprints from gloves pressed on plastic petri dishes and cotton swabs from lesions. After collection from 10 patients, all sanples were kept dry at room ter!perature in non-sterile conditions. SWabs and sorre gauze specirrens were rti:Jbed on a ceramic toilet seat and a patient with HSV lesions sat on the toilet seat to test HSV survival on this surface. Sanples were cultured initially and at various tirre intervals post-rollection (0-90 hrs). Cultures were taken from sanples by nDbing a roistened cotton swab over the rontact area (gloves, petri dish, speculum and toilet seat) or mixing small pieces of exposed gauze in rredia and inoculating sanples into WI38 cells. 1€sul ts showed that HSV was recoverable from gloves and petri dish fingerprints after 1 hr, speculum after 18 hrs, and on dry gauze after 88 hrs. HSV was cultured from the toilet seat q:> to ll:i hrs after l:oth gauze rontact and direct patient contact. 'Ihe survival of HSV on fomite materials for hours to days gives rise to the speculation of possible non-venereal transmission of HSV to susceptible patients in the setting of the clinic exam room, hospital or during routine c'aily activities. Concerned that DTP immunizations are often delayed but aware that early immunization may produce immun9logic examined antibody titers by the ELISA technique following tional DTP immunization (Wyeth) at 2, 4 and 6 months (N=lB infants) or exP.erimental DTP immunization at time of discharge from the nursery (mean=3.5 days), plus 2, 4 and 6 months (N=l7). IgG, IgA and IgM values were measured for filamentous hemagglutinin antigen (FHA) -the respiratory attachment factor, lymphocyte promoting factor (LPF) -the probable pertussis toxin, . antigen (AA), and pertussis agglutinins (by standard agglutination technique) in blind coded sera from cord blood as well as sera from 4 6 and 9 months of age. Cord blood showed comparable antibod¥ in traditional and experimental groups. There was a antibody advantage to early immunization at 4 and 6 months in FHA/IgM only . (p<0.05; student t test). Final antibody titers at 9 not vary in the 2 groups in There was.a significant correlation of pertussis agglut1n1n and IgGMA (3 combined immunologic classes vs. pertussis p<0.05). Thus: 1) Initiating DTP immunization at nursery discharge does not produce evidence of immunologic tolerance, and 2) produces higher mean titers of IgM antibody which may reflect greater protection to pertussis. Thirty-five children 15-18 months were randomly assigned to receive a DPT-polyribosylribitol phosphate (PRP) (Gp. A) or DPT booster (18) (Gp. B). Febrile, local and systemic reactions were monitored. Pre and 1 month post immunization throat and rectal swabs were tested for presence of HIB or cross-reacting bacteria. Sera obtained at the same times were tested by radioimmunoassay for anti-PRP antibody (J. Immunol. Methods 1981:43:33-47 ). An antibody concentration of 0/15 µg/ml is considered protective. Fever to 1030F (R) occurred in 4 of each group at 6 and 24 hours in different subjects. Local reactions occurred in 1/3 and systemic reactions in half of each group. None was severe. One child in each group had HIB in the pre-immunization throat swab: both had initial antibody titers > 0/15 µg/ml. Twelve of Gp. A and 10 of Gp. B had initial antibody levels of < 0/15 µg/ml. Nine of Gp. A reached the protective level post immunization, and 12/17 had either a twofold increase in anti-PRP or the final con· centration of 0/15 µg/ml. Geometric mean titer increased from 0/10 to 0/89. No change occurred in anti-PRP titers in Gp. B. The addition of PRP to DPT results in no significant increase in reactions compared with DPT alone and a protective level of antibody to PRP was achieved in 70% with a single dose. Infants with lower respiratory infections caused by Chlamydia trachomatis have elevated serum IgM and IgG, but not IgE levels. Cellular concomitants of the hyperglobulinemia were studied by enumerating B cell and T cell numbers in peripheral blood monor.uclear cells (PBMC) from infected babies. Seven infants, 3-10 weeks old, with chlamydial pneumonia contained 34.3 + 9.7% surface IgM bearing B cells in their PBMC fraction compared to 8.7 + 3.3% of normal adult PBMC and 14.0 + 6.6% of PBMC from infants (< 6 months) with various other infections. Numbers of cells with surface IgD and IgG were also increased. Plasma cells with cytoplasmic IgM, IgG and IgA constituted more than 8% of PBMC compared to < 0.8% in control infants and adults. Except for a modest decrease in total T cell proportions, no gross abnormalities of T cells were revealed by enumerating cells stained with the monoclonal anti T cell antibodies OKT3, OKT4 and OKT8. When cultured in vitro without added mitogen, PBMC from 3 infants with chlamydial pneumonia secreted as much immunoglobulin as adult cells treated with pokeweed or mitogens and more than 20-fold greater than control infant PBMC either stimulated or unstimulated. These results suggest that B lymphocytes are polyclonally expanded and activated during We have been able to produce congenital infection and disease in fetal rhesus macaques after intrauterine inoculation of rhesus cytomegalovirus ( Rh-CMV) in seropositive mothers. At 80 days gestation, II rhesus macaque fetuses were inoculated intracerebrally by laparotomy of the mother and trans uterine injection into the fetus with 0.20 ml of Rh-CMV inoculum ( 104.25), At birth five animals showed hydrocephalus. Large intranuclear eosinophilic inclusion bodies were seen in periventricular neurons of all 11 fetuses. At 50 days gestation intraamniotic inoculation with 0.25 ml of the inoculum resulted in hydrocephalus in two of nine additonal animals. All fetuses inoculated with Rh-CMV had CMV antibodies at birth as detected by immunofluorescence, whereas uninoculated controls had little or no CMV antibody. The Rh-CMV was isolated from various fetal tissues, as well as placenta and amniotic fluid. Placentas from virus-inoculated animals showed placentitis, with intranuclear inclusion bodies consistent with CMV. Eight controls did not develop congenital disease nor did CMV antibody titers rise in the mothers. These studies demonstrate rhesus macaque fetal susceptibility to CMV infection and the induction of congenital disease. 3800 infants received in a double blind fashion 14valent pneumococcal vaccine or saline placebo at the age of 6 (15%), 7 (60%), 8 (20%) or 9 (5%) months. The vaccinations were performed at the local health centers as part of the routine vaccination program. A booster dose was given appr. 5 months later. The serum antibody response was monitored in a cohort of 100 infants by radio-and enzyme-immunoassay. The families were informed of symptoms and signs suggestive of acute otitis media (AOM) and told to bring the infant to the project clinic when suspecting AOM. After clinical examination, middle ear exudate was obtained for culture and typing of pneumococci. The patient was treated with antimicrobials, and followed until the exudate had cleared. The data from a period of 12 to 23 months after vaccination show that prevention of AOM was spec if ic for the pneumococcal types evoking a serum antibody response. However, the response to most of the polysaccharides was poor at this early age. Infant survivors of RDS are believed to develop residua which predispose them to increased respiratory illness (RI) morbidity. The frequency, severity and etiologies of acute RI were evaluated prospectively in 17 survivors of RDS and 10 pre-term infants who did not have RDS. They were compared to normal,full-term in'ants who were matched for sex and season of birth. For 12 months following discharge of the affected child, children were evaluated at three-week intervals by history, examination and nasal wash c.ulture for viruses, mycoplasmata, Chlamydia trachomatis, and aerobic bacteria. The total numbers of RI and non-respiratory illnesses were sim· ilar for the pre-term infants,with and without RDS, and their con· trols. The frequency of lower RI was greater in children surviving RvS, but this difference was not significant{p=0.11).However, the co-variates of duration of hospitalization for RDS and the duration of acidemia were related to the number of subsequent RI. Gestational age, duration of hypoxemia and duration of mechanical ventilation did not correlate with subsequent RI. Tlie organisms associated with RI were similar in all infant groups. Although we did not detect increased RI morbidity for pre-term infants, subsequent RI morbidity in RDS survivors may be related to duration of acidemia and factors related to the duration of the initial hospitalization.The data imply that any increased RI morbidity is related to increased severity of infection by the same which cause RI morbidity among infants. bit is a model for evaluating the toxin production by ETEC. In vivo toxin production by ETEC requires attachment to and colonization of the small bowel. The host specificity of the att;iclnt,·nt/ colonization process of some ETEC in man is attributed to CFA. In this study, we evaluated the dose response of CFA(+) and CFA(-) ETEC in the infant rabbit model. Varying concentrations of CFA(+) and CFA(-) organisms in 1 ml saline were injected into the small bowel of individual infant rabbits. After 18 hours of in vivo incubation, the small intestines were removed and the fluid accumulation index (FAI=gm fluid/gm intestine) determined. Fluid data from animals who died post-incubation were excluded. 0.13 (ll); *p < 0.01 The group mortality rate of CFA(+) ETEC 10 6 and 10 8 was greater than all other groups (p < 0.01). is 10 5 organisms/ml of CFA(+) ETEC. Greater concentrations of CFA(+} organisms result in a high group mortality rate. The response of CFA(--) ETEC is the same as saline controls. In previous studies which demonstrated an absence of detectable type-specific antibody in cord or acute illness sera of 30 infants with type III GBS sepsis, we observed that total serum IgG levels in the septic infants were distinctly less than those in the cord sera of healthy newborns. We therefore compared serum IgG levels (using radial immunodiffusion) in 14 infants < 7 days old with GBS sepsis and 14 well infants matched for birthweight (within 100 gm), gestational age (within 1 wk), and postnatal age (within 1 d). IgG levels were significantly less (p < .02) in the septic infants compared to the controls (901±473 mg/lOOml vs. 1305±268 mg/lOOml). Total protein in the two groups was not significantly different (5.3±.9 gm/lOOml vs. 5.7±.7 gm/lOOml), indicating that the difference was not due to a generalized increase in protein catabolism in sepsis. r!aternal sera, available for 8 of the septic newborns, did not have a corresponding decrease in IgG (1082± 260 mg/lOOml vs. 716±296 mg/lOOml in their infants). The IgG levels of three septic infants > 30 days old were not significantly different from of matched controls (457±55 mg/lOOml vs 580±101 mg/lOOml). These findings suggest that serum lgG is depleted in the course of neonatal GBS sepsis. Whether this occurs in other bacterial infections or in older infants is unknown. This suggests a rationale for the use of fresh frozen plasma or immune globulin in the treatment of newborn sepsis. Measles virus and five strains of SSPE virus were found to contain a virion associated protein kinase activity. Purified virus phosphorylated two of the known measles phosphoproteins, P and NP, in vitro, as well as an exogenous phosphate acceptor, the ,u lC polypeptide of reovirus. The cyclic nucleotide independent kinase showed a broad temperature and pH range. The P polypeptide contained phosphoserine as the only phosphoamino acid, while NJ> contained phosphoserine and phosphothreonine. Enzyme activity was retained after the viral envelope, indicating an association of this activity with the nucleocapsid. and rat coronavirus have similar effects. In the present study, all three of these respiratory viruses were found to potentiate nasal HIB colonization in infant rats. In virus-infected animals an dose of 200,000 cfu HIB results in nasal HIB titers at le:>c;!· 100-fold higher than in controls during the first two weeks after HIB inoculation, and as much as 10,00u-fold higher during the first week. Children with cough, sneezing or rhinorrhea could be effective disseminators of HIB if they were as heavily and persistently colonized as these virus-infected animals. During the last 2 years, 129 immunocompromised patients, including 42 children, at the University of Minnesota Hospitals have completed intravenous acyclovir (ACV) treatment protocols for symptomatic herpes simplex (HSV), cytomegalovirus (CMV), and vari cell a-zoster (VZV) infections. Sixty-two patients, 15 of them children, were enrolled in a randomized, double-blind, placebo-controlled protocol. Analysis of the 25 patients with mucocutaneous HSV infections demonstrated that the 12 ACV recipients experienced significantly more rapid resolution of pain (p = 0.032) and termination of viral shedding (p = 0.004). In the group of 16 patients who could be analyzed for CMV disease, 9 ACV recipients had a significantly faster rate of improvement (p = 0.0437) and a more rapid rate of defervescence (p = 0.0208). Of 17 zoster patients, the 8 who received ACV had more rapid healing and a shorter period of pain but these differences were not statistically significant. An additional 67 patients (27 under age 18) subsequently were enrolled in open-label studies. ACV was well tolerated by patients on both double-blind and open protocols' Children did not demonstrate transient increases in serum creatinine occasionally seen among adults. We conclude that ACV is a safe and efficacious therapy for HSV. CMV disease and zoster appeared to respond, but further study is needed to define the role of ACV in these infections. Strains of li.i. which cause systemic infections in humans usually elaborate ty;_.ic b capsular polysaccharide. It was shown previously that type b, but not type d, transfonnants (average size of donor DNA"-40 kb) of a capsule-deficient H.i. caused bacteremia and meningitis in rats following fotranasal inoculation. 'lb characterize forther the molecular basis of type b capsule elaboration and virulence of H.i.,a gene library was constructed. DNA fran the H.i. type b transfonnant was partially digested with pancreatic DNAse. Fragments ("-10-16 kb) were cloned into the lambda vector Charon 4 and amplified in E. coli (strain KH 802) to yield 24,000 independent clones. individual phages were amplified in E. coli and DNA fran these pools was assayed for its ability to transform a capsule-deficient, avirulent II.i. strain to yield irri 7000/mm3 (13/29 vs I 1/58, p < .05) and radiographic consolidation ( 16/29 vs 11/58, p < .001). In this study, ALRI was usually associated with V, often with multiple pathogens, and not with C after 3 months of age. Reynolds. The University of Alabama in Birmingham, Department of Pediatrics, Birmingham, Alabama. The prevalence of cytomegalovirus (CMV) excretion among children in a day care center was assessed in order to determine the effect of grouping young children upon transmission of CMV and to define the exposure to CMV experienced by female workers. Seventy of 75 (93%) children attending participated. Urine was obtained from 68 and mouth swabs from 33. Serum was available from 37 mothers and 16 employees. The children's ages ranged from 3 to 65 94% were caucasian. Median age at entry to day was 6 months; had been breast fed. The mean number of siblings was 0.5, and parental ages were 29.4 ± 3 for mothers and 31.6 ± 4 for fathers. Parents averaged over 16 years of formal education. CMV shedding was found in 51% of children and was related to age: Age (mo.) 0-12 13-24 25-36 37-48 49-50 +ve (%) 1/11 (9) 15/18 (83) 10/15 (67) 3/14 (21) 7/12 (58) Nineteen of 37 (51%) mothers were seropositive; 21 <>i their children shed CMV. Excretion was not related to maternal serology or to breast feeding. Four of 36 excretors and 0 of 34 nonexcretors had experienced serious bacterial infection (2 meningitis, 1 bacteremia, 1 facial cellulitis), p < 0.05. Twelve of 13 (92%) children under 2 with viruria who were sampled at both sites were also positive in the mouth. CMV was isolated from 4 plastic toys mouthed by toddlers, suggesting a possible means of transmission. Attachment of Hib to the nasopharyngeal surface is thought to be the initial event in pathogenesis of systemic disease. The adhesive component(s) of Hib and mechanism(s) of adherence were studied. Attachment of 3 H-labeled Hib (Eagon) to EC was quantitated following removal of unattached Hib by differental centrifugation. Buccal EC were used in most experiments; however, similar results but greater binding were observed with pharyngeal EC. Candidate "adhesins" isolated from the Hib cell surface included the capsular polysaccharide (PRP), lipopolysaccharide (LPS), and purified outer membrane (OM). Preincubation of EC with PRP did not inhibit subsequent ettachment of Hib. However, adherence of PRP to EC was observed if divalent cations were present at concentrations found in nasal mucus. A mouse monoclonal anti-PRP antibody caused agglutination of Hib and completely inhibited lttachment. Preincubation of EC with LPS did not inhibit Hib attachment, although high concentrations caused non-specific agglutination of Hib. Unexpectedly, preincubation of EC and/or Hib with OM resulted in enhanced attachment of Hib to EC, suggesting a role for OM protein. Enhanced attachrient was not a non-specific protein effect nor was it attributable to LPS contamination. The effect was reversed by heat denaturation of OM and did not occur with untypable Hi. Further study of the mechanisms of Hib adherence is relevant to understanding the of systemic Hib disease and the role of mucosal antn;,.Jy in human immunity. We prospectively evaluated the excretion of G. lamblia cysts (C) and trophozoites (T) by 72 young children ""in aDrr-over a 12 month period. Excretion by age was: 0-6 months = none; 7-30 months = 44% excreted C and 16% excreted T; over 30 months = 13% excreted C. Eight children between 7 and 30 months of age continously excreted C and/or T for periods of 3 to 10 months. These children were generally asymptomatic, had normal appearing stools, and normal height and weight increments. We have initiated a survey of approximately 400 children from 0-24 months of age in 30 randomly selected DCC's to determine the prevalence of G. lambl ia. Results from 12 centers collected thus far show that 32% of 112 children have G. lamblia C and 8% T in their stool specimens. The in children between 13 and 24 months of age (40%) and of similar occurrence in males and females. Preliminary results suggest that excretion of G. lamblia is greater in children who have been in their DCC for over one month ( 36% C, 9% T) when compared to those enrolled for less than one month (7% C, 0% T). The prevalence of diarrhea within the preceding month in children who excreted C and/or T was greater (60%) than in non excretors (40%) (p<.0.05). Children in DCC's may be a major reservoir for G. lamblia. The importance of these observations to DCC children;-their families and the community at large remains to be determined. A double-blind, placebo-controlled, multi-center investigation was conducted to assess the usefulness of ACV in the treatment of immunosuppressed children with chickenpox. Twelve patients received placebo and 8 received /\CV (500mg/m 2 /dose every 8 hours x 21 doses). If clinical deterioration became evident patients coul0 be removed from the to receive antiviral therapy. E.'i.ghtecm pati0nts hi SUNY at Downstate, School of Medicine. Kings County Hospital, Depts. of Pediatrics and Pathology \IC are useful in rronitoring ICP in the critically ill brain injured pt. but nay cause ventriculitis. We reviewed the charts of 40 pts. with \IC fran 1977-81 to determine the incidence of infectious axll'lications. Diagnoses included: head trallll'B (8), Reyes Syndrare (20), CNS infections (3), post-anoxic encephalopathy C 5), intracranial hem:lrrhage < 2), CNS neoplasm Cl) rralfunctioning shunt Cl>. \IC were tunnelled subcutaneously for 5-6 an proximal to the burr hole site. Oxacillin prophylaxis (200 mg/kg/day) was given IV to all pts. and periodic cultures of the \IC drainage system were obtained. Two pts. with pre-existing bacterial rreningitis had \IC placed to rronitor ICP, and were successfully treated with the \IC in place State University of N.Y. and Children's Hospital of Buffalo To evaluate the possible relationship bet\:een growth inhibition, increased urine calciwn (Ca) losn and bone composition during CMA, we studied ammonium chloride (NH4CL) induced CMA in the rapidly growing "canling rat. For a period of 30 days, rats were fed ad-lib on normal rat chow (1.2% Ca) Group A excreted a greater amount of urine Ca compar<>d to C (132±56 vs 96±12 µEq/day, p<.05gms, p<.001), the increase in body length of A was 81% of C (7.1±0.3 vs 8.8±0.l ems, p<.001). Although the femurs of A weighed less (0.458±0.042 vs 0.606•0.051 gms, p<.001) and were shorter(l.2110±0.025 vs l.149+0.0liO in., p< .001) than C, their bone Ca (6.690+0.263 vs 6.431±0.476 mEq/gm wet wt., p;ns),·.Pd collai:f!n(hyJruxyproline)(l4.4')0+1.051 vs lli.577 ±0.736 gms/mg wet wt., p;ns) content per unit wt. of lone bone were identical. 'I'herefore a change in the chemical compozi tion of cortical bone does not accompany the growth inhibition and the hypercalciuria caused by the CMA induced by Nl!4Cl. INSULIN RECEPTORS IN THE FETAL aNI'RAL NERVCUS •1082 SYSTEM, Michael s. Kappy and Mohan K. Raizada, University of Florida College of Medicine: Departments of Pediatrics and Physiolcqy; Gainesville. Recent studies have clerronstrated specific insulin receptors in the central nervous system (CNS) of adult rats IA GA II and EMA are clinically and biochemically related inborn errors of metabolism, characterized by hypoglycemia, acidosis and complex organic acidurias. Clinically, EMA appears to be a milder variant of GA II. The oxidation of PC and IVA was studied in fibroblast mitochondria from 4 normal individuals, and J individuals each with EMA/mild GA II and severe GA II. Mitochondria from GA II cells showed greatly decreased oxidation of PC (0.02 + 0.017 nmol/mg/hr Mitochondria from the patient with mild GA II revealed milder impairment of PC and IVA oxidation (0.08 0.08 and I.OJ ± 0.83 nmol/mg/hr, 16% and 58% of control nmole/mg/ hr, 94% and 88% of control, respectively; N=4). [l,6-14 C]succinate oxidation was normal in all EMA/mild GA II mitochondria and was 63% of control in one GA II cell line Ob-Gyn and Physiology, Denver. Fetal liver metabolism has eluded direct study in vivo, largely for technical reasons. Using a transthoracic approach Catheters were maintained for up to 2 weeks, and position was confirmed at autopsy. After recovery from surgery, whole blood samples were analyzed for concentrations of oxygen, glucose, lactate, ketoacids and acetate. Hepatic venous catheter position was assessed in vivo in 4 animals by injection of glucagon (I mg/kg), which elevated RHV glucose concentration to levels as high as 3 mM, significantly higher than in the UV, FA, or IVC. RHV glucose normally exceeded the glucose concentrations in the FA and IVC, and RHV glucose correlated with the UV glucose 15 mM in the RHV, significantly lower in the RHV than in the UV, UA or FA (each p<0.01, paired), consistent with net hepatic lactate uptake. We conclude that, under chronic unstressed conditions, the fetal liver I) normally consumes net lactate and 2) is capable of glucose release in response to hormonal stimulation or spontaneous fetal hypoglycemia Aminosyn (7%) contains twice the amount of titrable acid (37 mEq/L) compared to Freamin Ill (19 mEq/L) This study was designed to evaluate if this difference will be evident in newborn infants after infusion. 13 clinically stable preterm infants (BW 710-1800 gm) had baseline studies of pH, PC02, HC03, BE & anion gap done prior to infusion of 2% FreAmin TPN solution at the rate of 4 ml/kg/hr for 24 hrs. At the 25th hour, same biochemical studies were repeated 4 extra infants were studied only with 2% Aminosyn solution. The differences between pre and post infusion biochemical studies were compared: Pt Conclusions: 1) Hypophysectomy lowers serum concentrations of 2SOHD, independent of vitamin D intake; 2) Corticosterone may have a specific stimulatory effect on 24-hydroxylase activity Providence, RI at term (22 days), 6.2±0.3gm vs 5.5+0.2gm (M+SEM) for controls. Insulin injected fetal lung (190+10 vs 150+l0mg), liver vs 320+20mg) and carcass Fetal and insulin levels in the insulin injected group were 60+12mg/dl and 7760+1721 µU/ml respectively; in controls, 85+l0mgfdl and 153+46 µUfml, respectively. Fatty acid synthesis and content in the-liver and carcass were significantly in the 11voerinsulinemic fetuses. (Data below) Liver Carcass Insulin Rx Control Insulin Rx Control 3tt incorp. (cpm/organ) 690+124* 400+92 2136±172* 1139±122 Specific Act M:':: SEM No differences were observed for the above parameters in the lung, brain, and placenta between the two groups. The data indicate that hyperinsulinemia produced macrosomia and enhanced fatty acid synthesis Pneumopericardium is the most critically acute complication in premature infants mechanically ventilated for RDS. Mortality is reported at 57%. Intermittent mandatory ventilation (IM V) with positive end expiratory pressure (PEEP) and peak inflation pressure (PIP) have been implicated in the pathogenesis of pneumopericardium. To investigate the signllicance of PIP in pneumopericardium, 13 premature neonates (BW 1.25-2.90 kg, GA 29-38 wks) developing pneumopericardium while receiving mechanical ventilation for RDS were reviewed. Respiratory support OMV, PEEP, PIP, Fi02) and severity of disease (pH, PaC02, and Pa02/Fi02 ratio) were analyzed. Mean values for each parameter were calculated for 15 eight hour periods prior to the onset of pneumopericardium. The time from starting infants on IMV to the occurrence of pneumopericardium ranged Ii hrs to 13 days (mean 6.11 days). Ten infants developed pneumopericardium by Ii& hrs. At the time of pneumopericardium, all infants had high PIP (mean 112, range 26-60 torr). Mean PIP increased significantly from 30 ! I 0 S.D. torr 16 hr before pneumopericardium to 112 ! & torr just prior to the onset of pneumopericardium (p <-.05) These data suggest an acute increase in PIP is the major parameter associated with pneumopericardium. There was no significant increase in PEEP. ATTENUATION OF WARMING AND COOLING CYCLES BY 1191 SHIELDING THERMISTOR PROBES IN INFANTS UNDER RADIANT WARMERS preterm infants (mean birth weight 1254gms,gestation age 26-35 wks.) with IVH,documcnted by computerized axial tomography or ultrasound were evaluated with ABR. ABRs were performed as soon as feasible following IVH. IVHs were classified as follows: severe 11, moderate 1, mild 6. Sixteen infants survived and had follow-up ABR 77%) demonstrated major ABR abnormalities: the absence of one or more components,or significant I-V prolonggation,only 2/9 showed mildly abnormal ABRs. Of the 6 infants with mild IVH 3 showed threshold deficits only, 2 were normal and 1 showed grossly abnormal waveform which later adjunct in the management and INCIDENCE, ETIOLOGY AND MANAGEMENT OF PNEUMOTHORAX (PN): A RETROSPECTIVE REVIEW. Nishat Zedie, Bhakthan Chelliah, !lana W. Zarafu. (Spon. Franklin C. Behrle) College of Med. and Dent A s:inlJle and sensitive technique has been developed for detection of CMV (cytanegalovirus) antigen in tissue culture supernatant. The assay is a m:xiification of the indirect hem.agglutination assay (IHA) and is capable of detecting 103 TCID50 of virus in tissue culture fluid. In the perfonnance of the assay, sheep red blood cells are tanned and sensitized with cannercial CMV -CF antigen at dilutions detennined by checkerboard titration. A lot of carmercial CMV antisera having an IHA titer oi: 1:1024 or higher is chosen. The inhibition assay is perfonnecl by incubation of equal volunes of tissue culture fluid to be tested with the dilutions of the antisera of known strength for 15 minutes at roan A 1:100 dilution of the Cl1V-CF antigen and PBS buffer serve as positive and negative controls respectively. These incubated solutions are then assayed for antibody activity by IHA. A two fold or greater shift to lower titer as canpared with the antigen negative control is considered to be a positive test for the presence of viral antigen. The test is rpecific in that colsely related viruses such as herpes si.l'lplex do not interfere with the assay. Titls IIII assay technique may serve as a tool for screening and identification of tissue culture specimens. It also has potential for use in the direct detection of viral antir;en in clinical spec:i.rrens. BACTEC radiometric systems are used by many laboratories to process blood cultures (BC). In the hypertonic aerobic bottle of this system, pneumo will frequently produce a positive growth index (GI), chocolatize the contents and be visible on Gram stain; but will not grow on subculture. The organism is often, but not always, recoverable by subculture from the paired anaerobic BC. During 1978-80, 23% of patients with pneumo bacteremia at LSUMC had negative subcultures from aerobic BC's with positive GI's. In 1981 we performed CIE on aliquots from GI positive, chocolatized aerobic BC with Gram positive organisms on smear. A Hyland power pack was used. Pneul'!o antibody (Omniserum) was obtained from the Statens Seruminstitut, Copenhagen. Of 42 episodes of pneumo bacteremia, CIE was positive in all 9 of the cases in which the aerobic BC had a positive GI but failed to grow on subculture. In 7 of these patients, subcul- Clostridium difficile has been implicated as one cause of hospital-acquired diarrhea in children, yet the prevalence of this organism in outpatient children with diarrhea has not been estab-1 ished. We therefore prospectively studied 306 pediatric outpatients over a 12 month period. Children presenting with diarrhea and controls with non-diarrheal illnesses were cultured for C. difficile an(I potential bacterial pathogens. C. difficile isolates were identified on a selective medium and confirmed with gas chromatography. Toxin production was detected by counter-iTIITiunoelectrophoresis (CIE).Children ranged in age from 2 weeks to 16 years (median 11 mos). Bacterial pathogens were found in 10.5% of patients with diarrhea (18/171): 12 Salmonella spp., 5 Campylobacter jejuni, and l Shigel!2_ Grp. B. f. difficile was found in 7.0% of patients with diarrhea (12/171) and 14.8% of controls (20/135). Mean age of the 12 diarrhea patients with C. difficile was 9.8 ± 8.6 mos. vs. 8.2 ± 4.9 mos. for the 20 positive controls (N.S.).Antibiotic exposure during the previous month was found in only 22% of all C. difficile-positive patients (7/32). These 32 patients with C. difficile were clinically indistinguishable from the other study patients. All strains of C. difficile were capable of producing toxin as demonstrated-by CJE. C. difficile appears to comprise part of the normal bowel flora in some children despite a negative history of recent antibiotic usage. Disseminated HSV infection occurs more frequently in neonates than adults. To investigate the permissiveness of mononuclear cells for HSY replication, cord and adult peripheral blood mononuclear cells were separated into monocyte and lymphocyte enriched fractions by Ficoll-Hypaque centrifugation and adherence to plastic or fibronectin. Cells were then infected with HSV-2 at a multiplicity of infection (MOI) of 1, washed and serially assayed for HSY using a microtiter method. Mean HSV-2 titers expressed as log10 TCIDSO were:Day A 72 hour incubation time prior to addition of virus or varying the MOI from .001 to l did not alter these findings. HSV-2 did not replicate in freeze-thawed cells including the nonadherent cord blood fraction. The data indicate that nonadherent cord blood mononuclear cells are permissive for HSY infection. This observation may partially explain the higher During a province-wide outbreak of ..!:!· monocytoeenes infection, 25 stillborn or live neonates with systemic infection were identified compared to only 7 nonpregnant adults. AlthouBh lymphocyte and monocyte immaturity has been suggested as a predisposing of newborn illness, we wondered if a humoral defect might also exist. To test this hypothesis, we assessed (i) hemolytic complement by the classical (CCP) and alternative (ACP) pathways (ii) fibronectin (FNC, a nonspecific opsonin) and (iii) opsonization 0f listeria using a chemiluminescence assay (CL) on samples of blood obtained from 5 control and 5 infected infants during acute illness. Results were expressed as percent of adult .t SD.CL CCP ACP me Listeria Infants: 6*± 8 104±50 54t±13 211. 7*± 1, Control Infants: llt±20 75±25 65 ±35 57 ±10 *p<0.01, i"p<0.05 vs. adult controls.Since complement levels were considered adequate, we attributed the poor opsonic activity in newborn sera to other humoral factors which are absent or low such as IgM or FNCa Opsonic activity and FNC levels were partially corrected in the 4 infants Biven fresh frozen plasma (to 40% of adult control). This study suggests that the susceptibility of newborn infants to listeria may be due, in part to opsonic activity to this organism. Kenneth M. Boyer, Cynthia K. Pafierniak, Cecile A. Gadzaia, Jeffre:f D. Parvin, and Samuel P. Gotof. Pritzker Sch. of Med., Univ. of Chicago, Dept. of Pediatrics, Michael Reese Hosp., Chicago.Passive immunization of the fetus by maternal vaccination has been proposed as a means of immunoprophylaxis for neonatal GBS infection. Since attack rates of early-onset infection are increased in premature infants, the kinetics of transplacental antibody passage are critical to the success of such an approach. We measured levels of naturally occurring type-specific IgG antibody against GBS-Ia in paired cord and maternal serum specimens at gestational ages 22 and 41 weeks. A quantitative ELISA technique sensitive to concentrations of specific antibody ug/ml was used. Twenty-one of 130 maternal sera had IgG anti-GBS la concentrations "?0.25 ug/ml. Ratios of cord:maternal IgG anti-GBS la ranged from 0.11 to 1.01. Ratios ?.0.25 were found in 6 of 6 serum pairs at gestational ages ?.36 weeks, 11 of 11 at 30 to 35 weeks, and 2 of 5 (including one pair of twins) at gestational ages <30 weeks. Although antibody against GBS-Ia was not prevalent among the mothers tested, these data suggest that transplacental passage can provide protective levels of JgG anti-GBS Ia to premature as well as full-term newborns born to immune mothers. In an experimental model, antibody levels of 1.5 ug/ml uniformly protect against lethal GBS-Ia infection. Therefore, women with 960 UNSUSPECTED MENINGOCOCCAL BACTEREMIA (UMB). Barry Dashefsky, David W. Teele, and Jerome 0. Klein. Boston University School of Medicine, Boston City Hospital (BCH), Department of Pediatrics, Boston.To determine the incidence and clinical course of UMB in children we reviewed charts of all 21 children at BCH with meningococcemia from Sept. 1971 to Dec. 1981 . Of these, 13 (mean age 18 mo., range 2-70 mo.) were initially treated parenterally for sepsis (6), meningitis (4) , pneumonia (2), and arthritis (1) . Ten (mean age= 10.5 mo., range= 5-20 mo.) were considered well enough to be sent home.Eight of these 10 received oral antibiotics for otitis media (6) or pneumonia (2). At recall, of these 8, I with a previously normal lumbar puncture (LP) and without prior LP had menil"'!gitis, 4 were afebrile and without focus of infection, and 2 were still febrile with the same focus. Six were hospitalized and treated parenterally; 2 were continued on oral therapy as outpatients. All 8 recovered without further complications. At first visit, 2 without focal infection were not treated. On recall, 1 was treated orally for otitis media; 1 was treated parenterally for meningococcemia. Both recovered uneventfully.Meningococcemia has been considered an ominous event. These show that UMB occurred in mildly to moderately ill children of Pediatrics, Tulane University, New LA. Genes that code for ampicillin resistance in Hib are carried on extrachromosomal plasmids in 10/37 (27%) of strains. To assess the possibility that R+, ampR strains of Hib are at a selective disadvantage relative to genetically related amp 5 strains, we used the infant rat model to study infection in 277 pups inoculated with one of four strai.1s. Strains studied included Eagan (R-, amps) , A/Eagan (R+, ampR) -a laboratory derived transconjugant containing plasmid DNA encoding for ampR, C306(R+, ampR)a clinical isolate and C306(R-, amps)-a blood isolate from an animal inoculated with C306(R+, ampR). Major outer membrane proteins were analyzed by SDS-polyacrylamide *el electrophoresis and were identical between pair strains. R and R-strains readily colonized the nasopharynx. The incidence of bacteremia was greater in R-inoculated animals but this difference was not significant. However, the geometric mean number of bacteria in blood was significantly (p<.05) less in R+ inoculated animals as was the incidence of meningitis (p<.03). B-lactamase elaboration by R+ strains was unstable and associated with loss of detectable plasmid DNA at variable frequency. We conclude that in the infant rat model, strains of Hib containing 30 Md ampR plasmids are at a subtle selective disadvantage relative to genetically related, We assessed the relative importance of maternal excretion of CMV in milk and other sites for transmission in 47 breast feeding mother-infant pairs. The 13 seronegative women, (mean follow-up 10 months, age 23 years, months breast feeding 4.0) did not ex-TOXIC SHOCK SYNDROME: CLINICAL EFFECT Or STEROID 1044 TREATMENT. James K. Todd, Marilyn Ressman, Sharon A. with TSS, 20 having received CS and lS not (NCS). All patients met the C€nter for Disease Control strict definition, were hospitalized, had a proven or potential focus of Staphylococcus aureus infection, received appropriate antistaphylococcal antimicrobial therapy, and had shock or postural hypotension. Groups were compared by the Mann-Whitney U test for nonparametric, unpaired data. There were no significant differences between the CS and NCS groups when analyzed (mean ± S.D.) for age (18.8 ± 18.1), sex, month and year of admission, day of illness admitted (3 ! 1.2), maximum severity of illness, maximum fever, or weight.Patients with TSS of this initial severity not treated with corticosteroids l1ad fever for 5.8 ± 2.9 days and required supportive therapy until 7.6 ± 3.2 days. Patients in the CS group received a total dose of 36 : 25 mg/kg CS (prednisone equivalent) for 6.4 ! 3.7 days. CS therapy reduced duration of fever (p < 0.05) ifgiven within 3 days of TSS onset, however, a concomitant reduction in severity of illness could not be documented. A prospective, randomized, placebo-controlled trial of CS therapy in early (3.67) (0) (3.1) times higher than the mean MICs of the organisms. The ti, with IM dose was slightly l anger than with IV ( P > 0. 05). CTX appears to be a safe, effective antibiotic for children. Its efficacy in meni ngi tis reported in adults needs further evaluation in children. QUANTITATIVE The antibiotic susceptibility of certain bacteria is markedly affected by inoculum size. In patients with acute otitis media (AOM), clinical response to antibiotic treatment and persistence of middle ear effusion (MEE) may conceivably be influenced by initial MEE colony counts. To determine the usual bacterial burden in patients with AOM quantitative bacterial colony counts were performed on 46 samples of MEF recovered by tympanocentesis. On 25 of the samples Gram stains were performed and read independently. Significant bacterial isolates were recovered in 30 (65%) instances. In 3 samples the colony counts were <102 colony forming units (cfu)/cc while in 27 samples the colony counts ranged from 102 to .'.'._!0 4 cfu/cc. Organisms were seen on Gram stain in 8/10 instances when the colony count was >10 4 cfu/cc, 0ut in only 3/15 instances when the colony count was <10 4 cfu/cc. We conclude that (1) can be read in 3 minutes and detects coagulase (binding to fibrinogen) and Protein A (binding to IgG) which are produced by S. aurcus. Purified protein A (1 µg/ml) or crude coagulase detected equally well when suspended in saline or plasma at 37°c, thus suggesting that these 2 bacterial products were not neutralized under these conditions. We wondered, therefore, if the test might also detect these extracellular products in vivo and developed animal models for §.. aureus bacteremia, osteomyelitis, empyema and peritonitis to examine this possibility. Before S. au:reus infection, plasma obtained from all 54 animals were negative-i;y--the SALA test. After I.P. or I.V. injection with S. aureus, 76% (22/29) of bacteremic animals had positive tests compared to only 21% (3/14) nonbacteremic animals {p<0.05). The 11 animals with osteomyelitis, empyema or peritonitis with culture confirmed deep tissue infection but sterile blood cultures all had positive SALA tests when their plasmas were tested (but not their serum). In the 3 animals with osteomyeli tis the SALA test remained positive until the animals died or their infection was cleared by antibiotics (confirmed at necropsy). Control animals infected with S. In a prospective study of dodecavalent PV, 28 children with ALL, 2.6 to 16.8 years old, had antibody concentrations measured pre-immunization (PRE) and 3D days post-immunization (POST). We found that the geometric mean titers (GMT) of antibody to 7 of the 12 serotypes were> 200 ng/ml POST, but that 3 (serotypes 1, 8, and 12) had also been ) 200 ng/ml PRE. There was at least a 2-fold rise in GMT for 8 of the 12 serotypes. A group of 25 infants and children with acute PV infection were tested for the presence of PV-specific lgE in samples of NPS taken at various intervals after the onset of illness. lgE antibody to PV types I-III in NPS was determined by an enzyme-linked immunosorbent assay (ELISA), using purified PV strains and monospecific goat antisera to human lgE. During the acute phase of illness, antibody against the infecting serotype was detectable in NPS specimens taken from 60% of patients with wheezing and 42% of patients with croup without wheezing. None of 8 patients with upper respiratory illness (URI) alone manifested PV-specific IgE. PV-specific IgE was detectable during convalescence in some patients with all forms of illness, but was observed more commonly and in higher titer (p<0.05) in patients with croup or wheezing than in patients with URI alone. These observations suggest a possible role for the development of virus-specific IgE in the pathogenesis of both croup and wheezing due to PV, in a manner similar to respiratory syncytial virus as described previously. Minnesota Department of Health, Minneapolis. Toxic shock syndrome (TSS) is a recently described illness characterized by (a) fever, (b) mild or profound hypotension, (c) multisystem dysfunction, (d) skin desquamation 8-12 days after onset, and has been associated with a specific aureus pyrogenic exotoxin. TSS has been described pre ominantly in previously healthy, menstruating women in whom the association with tampon use and cervicovaginal colonization by S. aureus has been recognized. However, affected non-menstruating-patients have also been observed among whom wound infection by S. aureus has frequently been implicated. We describe the fatal course---ora-3-week infant with staphylococcal abscess related to previous heel puncture in the nursery. After three days of marked clinical improvement on IV nafcillin, the patient suddenly deteriorated with rapid progression from lethargy and diaphoresis to ileus, oliguria, cardiomegaly, profound shock and respiratory failure. Post mortem exam confirmed the impression of multisystem involvement including the visceral and cutaneous histopathology characteristic of fatal TSS cases. Multiple ante and post mortem cultures of blood and CSF were sterile, however, wound aspiration cultures grew penicillin-resistant, nafcillin-sensitive S. aureus productive of pyrogenic exotoxin type C. This case, the youngest reported patient with TSS, illustrates another clinical presentation of neonatal staphylococcal disease. Furthermore, it reiterates that TSS is a disease not limited to menstruating women but may also occur in patients with focal aureus infection. Groups of neonatal cotton rats seronegative for RSV antibody were breast fed irranediately after birth, either by their own seronegative mothers, or foster-fed by lactating females who had been infected with live RSV 3-5 weeks prior to delivery of their own litters. The neonates foster-fed by seropositive mothers elicited appreciable levels of RSV-specific JgG antibody in the serum after of breast feeding. However, such reactivity was not observed in the serum of infants breast-fed by their own seronegative mothers. All neonatal animals were infected intranasally with RSV 3 days after beginning of breast feeding. The animals were sacrificed at frequent intervals to determine the degree of RSV shedding and development of antibody response in the serum. Neonates breast-fed by their own seronegative mothers exhibited significantly more virus shedding in their respiratory tract, and earlier and higher degree of RSV-specific serum antibody response than observed in infected infants who EN'IBRIC T'fPE ADENOVIRUS: hN IMPORI'AN!' CAUSE OF GAS- An enteric type of adenovirus (ET Ad) has recently been identified as a causative agent of infantile gastroenteritis. We utilized enzyrrc :inm.moassay and tissue culture techniques to prosspectively evaluate the role of ET Ad in diarrhea occurring in hospitalized infants. We found that ET Ad was associated with 14 of 27 cases of diarrhea occurring during a twelve week study period in the late aut\.IIlU'l and early winter rronths. Ql the other hand, ET Ad was found in the stool of only 1 child without diarrhea (P<. 001) • While adenoviruses other than ET Ad were found in the stools of 2 children with diarrhea, such viruses were also found in the stools of 5 of 72 children without diarrhea. Children infected with ET Ad had diarrhea for a rrean of 8.0 days, a period that was longer than that observed in the children with gastroenteritis not associated with ET Ad. Also note\>.Orthy was the high rate of respiratory syrrptans noted in the children with ET Ad gastroenteritis. Thirteen of the 14 children with ET Ad gastroenteritis had respiratory syrrptans such as cough, rhinorrhea or wheezing and 6 had roentgenographic evidence of pneurronia. In sare cases ET Ad was also isolated fran the respiratory tract of infants with ET Ad gastroenteritis. This study docurents that ET Ad can be an important cause of acute gastrointestinal disease in hospitalized infants and young children. Children living in families at least one member is a carrier of hepatitis B virus (HBV) are at risk for infection with virus. While passive immunity via immune globulin is helpful, it is neither totally effective nor practical in such a situation. Active immunization with HBV vaccine in adults has been shown to be safe and efficacious. One hundred and twenty high risk chi 1 dren, ages 18 mos. to 16 years were screened for an.Y serologic evidence of previous HBV infection. Seventy-one who lhad no evidence of previous infection were enrolled in a doublelblind, randomized trial. The subjects received either two doses 1of 16 µg of formalin-inactivated, alum-adsorbed heoatitis B surface antigen (HBsAg) or an alum-formalin diluent in 0.4 ml ad-1ministered J.M. one month apart. Both preparations were pre-1pared by the NIAID. Systemic and local side effects have been 'remarkably absent as compared to adults which were limited to occasional mild discomfort at the injection site. 1Anti-HBs, as measured by radioimmunoassay developed in aporoxi-1mately 65% of the subjects within the first two weeks, and 75% 1within a month, a seroconversion rate that was comparable to ·that seen in adults. This vaccine appears to be significantly free of systemic or local reactions and equal in immunogenicity to responses seen in ,adults. It appears to be of potential benefit to children who ,are at risk. 1058 Festus 0. Adebonojo, Paul M. Coates and Jean A.Cortner. Jos. Stokes, Jr, Research Inst., Children's !Hospital of Philadelphia, Philadelphia, PA Hormone-sensitive lipase (HSL) is responsible for mobiliza-1tion of triglycerides from adipose tissue (AT). Characterization One RS patient received PA (250mg/kg); NH+4 fell from 316 to !30uM in 4 hr. No side effects resulted from SB or PA. AAA therapy is beneficial in UCE and possibly in other NAD. Malignant Hyperthermia (MH) is a disastrous metabolic disorder of muscle triggered by anesthetics and muscle relaxants which commonly presents in children without previous warning.Currently there is no definitive screening procedure to determine which patients might be susceptible to MH.This paper presents electrophoretic data of soluble proteins from the muscles of 2 patients who had previously experienced MH and from 8 control patients. The soluble fraction from biopsy specimens of the vastus lateralus of 2 MH patients demonstrates an increase in a low molecular weight protein (mw 13080 + 470). We have also observed an increase of this low molecular-protein in the muscle of individuals related to MH patients(#ll&l2) . This data is summarized in the We are exploring the hypothesis that Mg deficiency contributes to the pathogenesis of some crib deaths (SIDS). Since many cl inical and pathological features of SIDS might be explained by persistent elevation of blood catecholamines, we are investigating catecholamines in Mg deficiency. Weanling male Sprague-Dawley rats weighing 35.0+0.35 g were fed purified diets containing no added Mg (0-Mg) or-150 mg of added Mg (150-Mg) for one week.Plasma and bone Mg were measured by atomic absorption spectrophotometry, and plasma catecholamines, by radioenzymatic assay using 3H. Of 16 rats fed 0-Mg, 5 died, 5 inadvertently suffered stress (fits, etc), and 6 appeared stable. Eight 150-Mg rats were stujied. Plasma Mg of 0-20 rats was 0.47+0.07 mg/dl, 23% of control, There is a decrease in bone mass in insulin dependent diabetics and frequent periarticular changes in poorly controlled diabetics. Twenty-four adolescent diabetics taking insulin once a day and on poor control of blood glucose, were admitted to the Hospital and placed on good blood glucose control by administering insulin bidaily. Serum Ca, P, and alkaline phosphatase levels and radiographic bone density were obtained before and at 3 month intervals of good diabetic control. Bone density was determined by the method of radiographic photodensitometry of Colbert et al. (Cl in Orthop 65:39, 69 ) and compared to normal subjects of both sexes. Hb A1c significantly improved in bi-daily injections. At 3 months, M-value decreased from 108.4±20 in l injection to 37.5±4.2 on bi-daily, p<0.01 and Hb A1c from 12.1%±0.6 to 9.2%±0.6, p<0.01. Serum Ca, P and alkaline phosphatase were not significantly different in diabetics on poor and good control from normals. Two patients on poorly controlled diabetes had bone density one SD below normal for age and sex. After 6 months of improved glucose control with bi-daily injections, bone density in the 2 patients increased to normal values. These findings suggest normalization of bone density in poorly controlled diabetics with improvement in glucose control. Wilson's Disease (WD) is an autosomal recessive inherited metabolic disorder of copper caused by excessive deposition of the element in various orqan systems resultinq in copper toxicosis. The abnormal qene was shown to be expressed in cultured skin fibroblasts derived from the patients. WD cultured fibroblasts showed an increased accumulation of copper (threefold of that of normal cells) especially when the cultures were grown in Eagle's minimum essential medium supplemented with 20% fetal bovine serum.In spite of this, WO cultured fibroblasts demonstrated normal response towards cytotoxic effect of copper. Kinetic studies of uptake indicated that WD cells incorporated less copper than control cells initially; .025 GrCMth Velocity(% expected) 53±13 153±12 <.001 Urea synthesis and BUN were =rrelated before(r=0.85, p<.01) and after(r=0.79, p<.01) GH treatrrent. '!he decrease in urea synthesis in each patient was not significantly =rrelated with grCMth rate after 6 rronths of GH(O.l U/kg tiw). \oJe =nclude that in GH deficient children given rn: l)'lhe increase in nitrogen retention and decrease in BUN is due to decreased urea synthesis; 2) Fasting glucose turnover is not changed; and 3) Acut:e metabolic changes in response to Q-1 are poor predictors of subsequent grCMt:h rate. To evaluate the relationship between short-term glycemic control & both stable & labile fractions of GHb,we measured blood glucose(BG)hourly for 24h on 31 occasions in 13 IDD children(age: was measured 6 times/24h both in whole blood(WB-/Total GHb)& after 48h incubation at 4°C in normal saline (SI-/stable GHb)to remove the labile fraction(WB-minus Sl-GHb).SI-GHb(mean± lSD 10.3±1.5%)was always lower than WB-Gl!b(ll.S± !.6%;p<0.0001).To compare the variability of these 2 methods of GHb measurement,the standard deviations,coefficients of variation & ranges for each day were analysed.All 3 measures were much smaller in SI compared to WB specimens(p<0.005).Mean blood glucose (MBG)correlated more closely with mean WB-than SI-GHb(r=0.58,p< 0.001 & r=0.45,p<0.05 respectively).The mean labile fraction cor- To investigate the physiological significance of these observations, we measured the effect of infused glucagon at 5 or 50 ng/kg/ min on glucose turnover (GT), net glucose production (Ra) and net utilization (RU.), with an appropriate compartmental model via double isotopic dilution techniques.Results in 5 F at 129+3d gestation weighing 2.5+3 kg were compared to 5 non-pregnant aaults.Glucose (G), glucagon (IRG) and insulin (IRI) also were measured. B 12 (Cbl) defect with methylmalonic aciduria and sulfur amino acid abnormalities is an inborn error affecting the B 12 dependent metabolic systems (N5-methylTHF-homocysteine methyltransferase and methylmalonyl-CoA mutase). Two coenzj111atically active B1 2 forms are involved, respectively methyl-Cbl (MeCbl) and deoxyadenosyl-Cbl (AdoCbl). The basic defect in B 12 is unclear.In a 3 month old affected male with intrauterine growth retardation, megaloblastic anemia, and characteristic biochemical abnormalities, we measured Cbl distribution in blood. The factors regulating this increased uptake are incompletely understood. To examine glutamine transport independent of mitochondrial metabolism, we examined glutamine uptake into isolated brush-border membrane (BBMV) and basolateral membrane (BLMV) vesicles obtained from normal and acidotic rats. In normal BLMV,glutamine is transported by two saturable systems with Km1=0.04mM, Vmax1= 0.09nmoles/mg per min and Km2=3.2, Vmax2=2.2. These kinetic parameters did not change when the BLMV were made from acidotic rats. Glutamine uptake into BBMV from normal rats was also mediated by two systems with Km1=0.3mM, Vmax1=1.7nmoles/mg per 15 sec. and Km2=1.l, Vmax2=4.8. In BBMV from rats made acidotic with NH4Cl, glutamine was also mediated by two transport systems with Km1=0.3mM, Vmax1=2.2nmoles/mg per 15 sec and Km2=1.7, Vmax2=9.l. increase the Vmax of the high capacity, low affinity system by 1.9 times. There was no effect of acidosis on initial rate of glutamine uptake by BLMV. Metabolic acidosis increased the brushborder membrane transport of glutamine.However, such an occurrence in vivo cannot account for the marked increase in renal extract-ion during acidosis since 99% of the filtered glutamine is reabsorbed during normal acid-base conditions. The data suggest that changes in membrane transport parameters se do not account for increased renal glutamine uptake Cfiiring acidosis. 1073 OF a-1\MINOBUTYRIC ACID AND LYSINE. Michael J. Chan and Gwen M. Rennert. University of Oklahoma Health Serum amino acid profiles were studied on a daily basis in 11 patients with RS throughout their clinical A characteristic variation in levels of a-aminobutyric acid (AB/\) and lysine (LYS) correlating with the clinical outcome of the patients was observed. Etiologic factors in the development of insulin-dependent diabetes mellitus,IDDM, in genetically susceptible individuals are still uncertain. In our continuing efforts to identify such factors, cross-sectional and longitudinal studies in families of IDDM patients are in progress. Serum immunoglobulin levels, antibody titers to adeno, rubeola, rubella, mumps and Coxsackie Bl-B5 viruses are measured. Historical data infections, antibiotic use and immunizations are obtained. All family members are typed for llLA antigens A,B,C and DR. Data from 72 families have been evaluilted. IgG, IgA and IgM levels of the IDDM patients were increased in comparison to their non-diabetic sibs: 805, 155, 141 vs. 786, 126, 118 mg/dl, even though the mean age of the sibs was greater, 17.5 vs. 15.4 years. In addition, IgM levels of the diabetics were equal to those, 138 mg/dl, of their older parents. No significant differences in antiviral antibody titers were found comparing the subgroups of diabetics, sibs and parents. However, subjects with HLA DR 3 and DR4 displayed increased titers to measles, mumps and rubella viruses as well as increased IgM levels. Sibs and diabetics had histories and birthweights. However, of and febrile illnesses were significantly increased in the diabetics compared with their nondiabetic sibs. The data add support for a role fr.r infections ip the development of Type I diabetes in genetically at-risk subJects. John .!!_. Scanlon, Columbia Hosp. for Women, Divs. of Neonatology and Anesthesiology, Georgetown Univ. Sch. of Med., Dept. of Pediatrics, Washington, D.C.Perinatal glucose (G) and insulin (I) homeostasis and the risk of neonatal hypoglycemia (NHG) were assessed in relation to prepartum i.v. infusions given to 59 mothers undergoing C-section at term without labor under epidural anesthesia. Group A (n=20) received 1000 cc of Ringer's lactate without dextrose for one hour; group B (n=20), 1000 cc of 5% Dextrose for one hour (50g/hr); and group C (n=l9), 1000 cc of 5% Dextrose for hours (20g/hr). Blood was sampled from the mother (M) and umbilical vein (UV) at birth, and from the newborn at one (N1) and 2 (Nz) hours.Mean± S.D. Plasma Glucose (mg/dl), Plasma Insulin (µU/ml) Although abnormalities of lipid and bile acid (BA) metabolism are described in patients with hGH deficiency, the contribution of cholesterol (C) and BA synthesis and BA pool sizes to these disorders has not been investigated. Therefore, we studied 7 children (mean age 9.8 yrs) with isolated hGH deficiency or multiple trophic hormone deficiencies (n=2) before and after 6 months hGH therapy (height velocity during hGH 9.3 + 1.2 cm/yr, mean+ SE). C and BA synthesis were calculated by sterol balance and BA pool size measured by isotopic dilution techniques using a stable isotope (chenodeoxycholic 11,12 dz acid). Plasma total C (200 ± 15 mg/dl), HDL-C (44 ± 4 mg/dl), LDL-C (135 ± 12 mg/dl) and triglycerides (114 ± 16 mg/dl) were higher than age-matched controls and not changed after hGH. There was no change in either C synthesis (164 + 34 mg/day before vs. 231 + 43 mg/day after hGH) or BA synthesis (49 + 9 mg/day before vs.-82 + 19 mg/day after hGH). Biliary lipid and C saturation were similar to controls and unchanged with hGH. However, chenodeoxycholic acid pools which were reduced prior to hGH (399 + 93 mg/m 2 ) compared to 7 controls (617 + 45 mg/m 2 , p < • 05) increased significantly (p < • 05) to 506 + 51-mg/m2 after hGH. Therefore, hGH may play a specific role in-bile acid metabolism through an effect on pool size regulation. Sch., St. Louis Children's Hospital, Dept. of Ped., St. Louts Both Insufficient minerals and vitamin D metabolites contribute to the hypomlnerallzatlon of extremely premature lnfants. Thus, 58 infants, 30.3 + 1.8 weeks and 1192 + 167 gms, were assigned to one of four-prevention groups; 400 I.U. D +standard formula (C) (14), 800 I.U. vitamin D +standard formula (D) ( 15), 2 25-HCC + standard formula (OHO) (l 5), and 400 I.U. D + high calciun-phosphorus formula (CaP) (14). Basellne (0) a.id weekly samples plus L wrist x-rays were taken during the study and at 9 and 12 weeks of age on 400 IU D + standard formula. Only D and OHO groups Increased serum 25-0110; however, both serum calciL111 and bone mineralization were improved by D and CaP but not OHO. Thus, both Increased mlneral availabillty and increased vitamin D improves mineralizatlon. Failure of 25 HCC to duplicate the effect of increased vitamin D ls unexplained. 9.2 9.4 9.4 9.7 21* 23* 13 9.2 9.5 9.0 9.3 21* 24* 14 9.0 9.6* 9.3 9.7* 24* 25* 18 9.2 9.5 9.2 9.5 20 25* 20 9.3 9.4 9.8 9.8 25* 24 15 9.1 9.5 9. Sialic acid storage disease has been defined in a patient with neurovisceral storage of the monosaccharide N-Acetylneuraminic acid (sialic acid) in lysosomes. Tissues and skin fibroblasts contain more than 200 times more sialic acid than normal. Studies have been undertaken to determine if the accumulation is due to excessive synthesis or defective degradation. Sialic acid lyase, the enzyme believed responsible for sialic acid degradation was normal in activity in liver extracts, although it could not be detected in normal or affected The lyase activity detected by the formation of c 3 N-acetylmannosamine from C-sialic acid. Incorporation of H-mannosamine into sialic acid-containing glycolipids and glycoproteins was slightly elevated. The pool of sialic acid available for synthesis is thus not increased despite excessive cellular sialic acid. This suggests enhanced de novo synthesis of sialic acid and a failure in reutilization of sialic acid derived from sialoglycoconjugate degradation. Sialic acid storage disease probably involves a defect in translocation of sialic acid from lysosomes to the site of biosynthesis. Two siblinqs, male and female, develoned obstructive cholanqiopathy by six weeks of aqe. At surgery at 3 and 5 months of aqe resnectively, each was found to have correctable extrahenatic biliary atresia. Followinq surqery, clinical heoatic disease resolved, but both children develooed cataracts, and a slowly nroqressive neuroloqic disorder characterized by mild mental deficiency, seizures, ataxia, and hyoerreflexia. In the third decade of life, the male has a xanthoma of the achilles tendon. Both siblinqs have normal olasma cholesterol, but elevated olasma cholestanol (10.2 and 18.0 mq/dl; normal 'l.6 +/-0.2) and erythrocyte cholestanol (8.1 and 12 mq/dl). Cholestanol accounts for 5.'l and 8.1% of total olasma sterols (normal 0.2 +/-0.2) and for 5.4 and 9.0Y. of total erythrocyte sterols (normal 0.2 +/-0.2). These findings are diaqnostic of cerebrotendinous xanthomatosis, an inherited disorder of sterol metabolism, and suaqest that abnormal bile acid '"etabolism in early life resulted in correctable extrahenatic biliary atresia. The addition of CN to rat tissue and mitochondrial preparations is said to increase the production of 1 4 co2 from [1-l'•c]LEU by stimulating the activity of the branched chain ketoacid dehydrogenase (BCKAD). In our laboratory, CN increased the oxidation of [l-14 C]LEU in rat muscle homogenates to 174 ± 12% of control levels (N=J); in contrast, CN decreased the oxidation of [2-14 C)LEU to 73 ± 19% of control levels in the same homogenates (N=J). Similarly, addition of CN did not increase the oxidation of [l-14 C]LEU by suspensions of human skin fibroblasts derived from either normal controls or patients with classical maple syrup urine disease. CN did not increase the dehydrogenation of [2,J-3 H]isovaleryl-CoA ( 3 H-IVA-CoA) or [2,3-3 H]butyryl CoA ( 3 H-BUT-CoA) in intact rat liver mitochondria (80 ± 30% and 111 115% of control values, respectivelv; N=7). However CN did enhance dehydrogenation of 3H-BUT-CoA. by rat muscle mitochondria (RMM) to 1025 ± 279% of control levels (N=7) while not increasing the oxidation of 3H-IVA-CoA by RMM (149 ± 85% of control; N=8; P>O.l). The CN-dependent increase in 3 H-BUT-CoA dehydrogenation was completely blocked by octylsulfobetaine, an inhibitor of acyl-CN translocase. CN does not seem to stimulate the overall rate of degradation of the branched chain amino acids (BCAA) in either human skin fibroblasts or rat tissues, and BCKAD does not appear to be the rate limiting enzyme in the catabolism of the BCAA. Insulin mediates rapid (transport) as well as delayed (e.g. cell growth) effects on cellular metabolism. Since the HL-60 cell, a human promyelocytic cell, can be cultured in defined medium plus insulin, we studied the effect of insulin concentration on cell duplication and [1251]-iodoinsulin binding parameters. The HL-60 cell line was grown in RPM! 1640 medium plus 10% heat inactivated fetal bovine serum (FBS) or in medium plus insulin (0-5 ug/ml; 0-8.3xl0-7 M). The insulin binding studies were performed with [1251]-monoiodoinsulin. The binding isotherms and displacement curves were analyzed by least-square fitting to a 2-site model and by the method of Scatchard. Cellular doubling times ranged from 1.85 days in 10% FBS and 2.08 days in insulin (8.3xl0-7M) to greater than 3.5 days at insulin concentrations below (l.67xl0-8M). There was net cell death below lx10-lOM. The half maximal doubling rate occurred at 4.0+10-9M insulin ("KD"=2.5xl08M-l). A high affinity, low capacity insulin binding site was defined with KA 3.l:t7.8mmol/l 2nd hr of OGTT) identified 19 sibs including 5 of the 6 who went on to develop !DD (5/19, 26.3% predictability, 83% sensitivity, 86% specificity). 4/6 sibs who later developed !DD were retested with 4hr OGTT; 3 had glucose areas outside normal mean+2SD but so did 8/36 sibs screened abnormal and retested, who dirl not develop IDD. Ratios of insulin area to glucose area were ryo, they are the significant placentae present during early organogenesis. This study deals with the ability of the parietal yolk sac (PYS) and visceral yolk sac 0/YS) to take up a nonmetabolizable amino acid an:! to perform pinocytosis during midgestation. Individual PYS or VYS obtained fran 14-day and/or 18/day pregnant rats were placed in flasks containing We measured cardiac output non-invasively with a pulsed Doppler device to help direct management and monitor the effects of clinical interventions on cardiac performance.Ascending aortic blood flow velocity (V) was measured with a 10 MHz transducer.Aortic diameter (d) was determined echocardiographically.Cross s'.'ftional area (A), calculated according to the equation A= TT d /4, was used in conj unction with mean velocity (V) to quantita_!e ascending aortic flow (QA), according to the equation: Q=AxV.Seven infants with pgtent ductus arteriosus ( PDA) showed dramatic increases in QA as ductal shunting increased.At a mean age of 6 days, QA iveraged 408 ml/kg/min when PDA symptoms emerged.Reduct.ion f'n mean QAo to 226 ml/kg/min was instantaneous after ductal closure.Tn 6 infants with persistent pulmonary hypertension, QA was used in conjunction with arterial and venous pressures 0 to calculate systemic vascular resistance (SVR).The values of Q and SVR were used to monitor and adjust medical therapy with '\?01azoline and inotropic agents.QA was also used to titrate inotropic medication in infants w1'th reduced myocardial performance. Lastly, serial QA measurements detected adverse hemodynamic consequences of pneimothorax in 3 of 7 patients studied. Cardiac output measurements quantifiy hemodynamic performance in a variety of settings and are useful for & monitoring. Non-invasive measurement of aortic blood flow mean velocity (V) was made in 33 children, ages 3 days to 17 years, by pulsed !Joppler technique at the time of cardiac catheterization. Measurements were made from a suprasternal approach with nonfocused, variable width (0.6 to 8.0 mm), range gated devices of 3 or 10 MHz frequency. The sample volume, 4 mm in width, was varied in range to maximize the recorded signal. Two dimensional echocardiography was used to verify sample volume position in selected patients.An incidence angle of o 0 was assumed; the aortic diameter ( d) was determined by M-mode echocardiography. Aortic flow (DA 0 ) computed from Doppler was according to tne equation: DA (ml/min)=V (cm/sec) x "d /4 (cm ) x 60 (sec/min).Values we'f.e compared with Fick determined systemic outputs (QA ) , calculated using measured oxygen consumption, oxygen caii'aci ty and oxygen saturations. Subjects with aortic valve abnormalities or left ventricular ?utflow tract obstruction were excluded from study.Agreement between the two methods was excellent (linear regression r:0.98, slope:l.14, S .;r=218 ml/min, range to 5500 ml/min). The Doppler method quick, non-invasive and accurate, especially in smaller patients. Liver dysfunction associated with prolonqed hyperalimentation is seen frequently during the neonatal period.It has been postulated that increased GGT activity is a specific reflection of hepatic canalicular dysfunction. Two groups of premature infants were followed for up to four months with weekly GGTs determined by the assay of Szasz.Infants receiving anti-convulsants were excluded from this study. One group of eight premature infants (BW x 1310 + 271 gms, x GA 32 weeks) received glucose infusions and breast and/or formula. From this qroup, the mean GGT level of 148 + 100 IU/L (range 41-354 IU/L).was found to be more elevated than-previously reported for premature infants. No significant correlation was found between GGT levels and age as determined by Pearson correlations and the Fisher 7 transformation method. Nine other infants (BW 1083 + 340 qms, GA 30 weeks) received hyperalimentation (glucose and amino acids) for variable periods with a range of 5-144 days and a x of 57 days.By the methods reported above, a significant correlation was found between duration of hyperalimentation and GGT levels (r=+.59). From these pre! iminary data, it appears that GGT levels may have clinical significance, that the ranae of normal levels for premature infants should be reevaluated, and that there is a positive correlation between GGT activity and duration of intravenous hyperalimentation. Infants that were sick on days l and 7 did not demonstrate a postnatal rise in activity 33 ! 6.4, 47 • 8.3, p=0.3), however, infants that had been sick on day l but by day 7 were healthy had increasing protease activity 24 ± 7.2 117 o l7.0, P<0.001). In addition, sick infants had significantly lower levels than healthy infants on all days studied (P<0.001). We conclude that there is increasing kallikrein-likc activity in unactivated plasma of healtl1y premature infants during the first month of life. Sickness significantly lowers the activity and prevents the postnatal rise. We speculate that in sick inf ants either the protease is not generated to the same degree or is largely bound to plasma 1bis study investigated the influence of gestational age (GA) and postnatal age mi the following plasma protease inhibitors: a 7 -macroglobulin (a 2 -M), c 1 -Esterase (C 1 E-!NH), anti-thrombin Ill (i'\T-11!) and a 1 -antltrypsin (a 1 -AT). Premature infants (28-36 weeks gestation) were studied on days I (N=31), 7 (N=31) and 28 (N=l l) of life.Inhibitors were measured by radial-immunodiffusion and expressed as a percent of normal pnoled plasma (mean SEM). infants witl1 disseminated intravascular coagulation (DIC) (fibrinogen <120 mg/dl, or factor VIII: coag <50%, or fibrin related antigen >6.7 µg/ml) were not included. Between 28 and 36 weeks there was no significant correlation with GA for any of the four inhibitors. fn contrast, regardless of GA, during the first of life all four inhibitors increased significantly Vitamin C is accumulated in the brain by active transport mechanisms which establish a high brain-plasma gradient of the vitamin A damaqinq insult to the CNS may result in an efflux of ascorbate into the circulation with a consequent rise of plasma levels. We have determined vitamin C plasma levels by the 2,4-dinitrophenylhydrazine method in premature newborns on days 1, 3 and 5 of life while no supplemental vitamin was given. The infants underwent ultrasonographic examinations to detect PVH/IVH and were qrouped accordinq to the following findings: Group I -normal; Group I Iperiventricular hemorrhage + minimal IVH; Group I I I -IVH + ventricular dilatation + intracerebral hemorrhage. Seventy consecutive preterm infants with birth weight (BW) of 1500 gm or less were screened daily for intraventricular hemorrhage (IVH) during the first week of life using real time ultrasound scans. Mean BW and gestational age (GA) were 1133 ± 282 gm and 31 ± 2.2 weeks respectively. Mean Apgar Scores at land 5 min were 4 ! 3 and 6 ± 3 respectively. Fifty-five (79%) infants developed IVH, and in 48 (87%), IVH was diagnosed within 24hours of age. Forty-two (60%) infants were delivered vaginally and 28(40%) by C-section. The following table compares vaginally delivered and C-sectioned infants according to the mean BW, GA, Apgar Sccrcs, the incidence of IVH, and mortality rate. Chi square analysis showed no statistical significant difference between the incidence of IVH and mortality rate in the vaginally delivered and C-sectioned infants. These data show that there appears to be no association between the incidence of IVH and mode of delivery. Postgrad. School Obstet. Gynecol., Univ. Auckland, Auckland, N.Z.Prenatal corticosteroid therapy is efficacious in preventing RDS, but optimal treatment conditions are not yet defined. We determined corticoid concentrations in cord serum of 75 premature (25-36 wk) infants whose mothers received 100 mg hydrocortisone (HC) q 8° prior to delivery, and compared results with previous data for Betamethasone (Beta) therapy (12 mg q 24° or 6 mg q 12°).Corticoids were assayed by competitive protein binding after petroleum ether washing, free corticoids were assessed by charcoal absorption, and dissociation of tritiated steroid from nuclei was studied after washing fetal rabbit lung in culture. Total corticoids were maximal 1-2 hr after HC (mean 32.1 µg/dl vs. 8.4 for 84 untreated infants) and levels declined with a -2 hr vs.12 hr for clearance of Beta. Endogenous corticoids were suppressed 8-20 hr after the last dose of HC (5.1 :!: 0.4 µg/dl, mean± SE), but less so than with Beta (3.3 ± 0.3 and 3.6 ± 0.5 for 12 and 6 mg regimens, respectively). Maximal serum levels of free glucocorticoid activity were 11.6 µg/dl with HC therapy, 8.3 µg/dl with 12 mg Beta, and 5.1 µg/dl with 6 mg Beta compared with 1.6 µg/dl in untreated infants. Dissociation values were 1.4 and 7.4 hr for HC and dexamethasone, respectively. We conclude that the 100 mg HC regimen results in higher unbound serum corticoid concentrations, greater fluctuations and faster clearance of steroid from serum and lung tissue, and less suppression of endogenous cortisol than treatment with Beta. Jeanne Ballard, Michael Maloney, Margaret Shank, Barbara Barnes, Vivian Gutterman, Lauren Hollister, Children's Hospital Medical Center, Cincinnati A randomized study of 38 families was conducted to determine the psychological effects of visiting a sick newborn on an intensive care unit. Twenty-three families with 31 children were randomized to enter the newborn intensive care unit under controlled conditions. Touching the infant was permitted. Fifteen families with 26 children (ages 2 to 16) were assigned to a control group. Fifteen boys and 16 girls were in the study group and 13 boys and 13 girls were in the control group. The mean age was 8.7 yrs for boys and 6.7 for girls, and was similar for both groups. Assessment tools included: the Missouri Behavior Checklist (MBC) administered just before and two weeks following the visit; a Modified Vernon Questionnaire (MVQ), a Family Changes Questionnaire (FCQ) and a Child Psychiatry evaluation given two weeks after the visit. The number of behavioral problems (MBC) did not change for either group. Apparent improvement occurred for both child {MVQ) and family {FCQ) functioning in study and control groups. Parents perceived improvement in 74% of the study and 40% of control families (p<.05). By psychiatric evaluation none of the study children were upset by the visit; 72% enjoyed and 28% enjoyed and demonstrated benefit. In surrrnary, family visitation had no detrimental effect by behavioral assessment; child and family functioning improved under the conditions of the study; the actual visit enhanced parental well being and was reported as a positive experience by all of the siblinps. Med., Mt. Zion Hosp., San Francisco, and Dept. Peds. Harbor-UCLA Medical Center, Torrance, CA. T3 concentrations in fetal sheep, raising the possibility that glucocorticoids could affect lung development in part through thyroid hormones. We have determined by radioimmunoassay the concentration of T3, T4 and rT3 in cord serum of premature G 35 wk) infants exposed prenatally for 8-72 hr to either betamethasone (12 mg q 24 hr or 6 mg q 12 hr) or hydrocortisone (100 mg q 8 hr The effect of double volume ET on the serum albumin (SA), total bilirubin (TB) and RBBC was studied in 7 premature infants. There was no Rh or ABO blood group incompatibility. None of the infants exhibited clinical or laboratory signs of hemolysis. Two of the infants required a second ET. One to two day old whole blood with citrate-phosphate-dextrose as anticoagulant was used. The gestational age (mean• SE) was 29" 1.5 weeks and the birthweight was 1347 365 grams. RBBC was measured by Sephadex G-25 adsorption. The Table shows The effect of ET on RBBC appears to be a transient phenomenon. Until more data are available, the criteria for a repeat ET should be the same as for the initial one, as previously recommended (Pediatrics, 59:881, 1977) . This study was to determine the pattern of T 4 values of PI (n=l43) who had recovered from ANP and determine if the T 4 of FF (n=l04) differs from the BF (n=39) infants. ANP were: RDS (n=57) asphyxia (30), sepsis (36) and hyperbilirubinemia (20). The gestational age (GA) at birth ranged from 24-37 weeks with a mean :!: SD of 33.3 t 3.1 weeks. At the time (11-45 days postnatal) of test (T 4 RIA), the corrected GA was 38.8 ± 2.4 weeks. Table l shows the increase in T 4 as the postnatal weight and age increase. TSH values of PI (16) with T 4 below 6.5 µg/dl was 4.7 ± 2.9 µU/ml. No case of hypothyroidism was identified during the study and none developed clinical or laboratory evidence of hypothyroidism within a 1 year follow-up. Table 2 shows that breast feeding does not significantly affect the T4 values in PI. (mean±SD) and the teflon catheters for 49.5!3'l.9 hrs (mean•SD). tion whereas only 17/30 (57Z) of the catheters infiltrated. A local inflammatory reaction occurred with 11 /30 (37:;) of the teflon catheters but was not related to infection. Following removal, Staphylococcus cpidermidis was grown from the culture of 1/19 steel needles and 1/25 catheters. In both instances blood cultures were negative and this was felt to be a contaminant. Teflon catheters remain functional three times longer than steel needles with no apparent increase in complications. The use of these catheters, therefore, appears to be the preferred method for administering intravenous fluids to premature infants. Increased lung superoxide dismutase(SOD) and glutathione peroxidase(GP) activity during hyperoxic exposure has been shown to be associated with tolerance to pulrronary oxygen(0 2 ) toxicity in newtorn animals of several species. Antioxidant enzyme RBC levels were monitored prospectively, as a reflection of lung changes, in 44 newtorns requiring O therapy and/or exchange transfusion, to detennine if in SOD or GP could be related to the clinical course of these infants. Clinical Grouping (n) Serial SOD Levels* Serial GP Levels* Severe One Hundred and Fourty cases of NEC have been diagnosed between 1975 and 1981 in this center. Sixty-Eight infants(49%) required only medical managenent. The mortality in this group was 24 percent (16 infants). Of the surviving 52 infants, follow-up evaluations ranging fran 6 months to 5 years performed in 26 infants (50%) indicate that 73% are growing normally and 77% have normal develop mental exams. In marked contrast to these medically managed infants are the 51 percent who required surgical intervention. Ten of these infants required surgery late for strictures that developed after their initial medical rnanagenent. One infant died during surgery, 57% had abnormal developnent exams and 43% had abnormal growth patterns. In the 62 infants undergoing inrrediate surgical interventions, there was a 69% mortality rate, alrrost triple that of the infants not requiring surgery. Of the 19 infants who survived, 12(63%) were seen in follow up between six months and five years. Sixty-Six percent of these infants have significantly retarded growth patterns and 66% are developnentally delayed for their age. This dismal outccrne of infants requiring surgical intervention for NEC is in marked contrast to previously published reports. NEC is a frequent and often catastrophic event in critically ill infants who usually have already survived the initial insults of their acute disease. Prevention is manditory, as current therapy does not seen to of fer an acceptable outccrne in many of these infants. continuously for skin temperature by an electronic thermistor taped to the abdomen. Skin temperature feeds back to the servocontrol mechanism which determines the radiant power density delivered to the infant. Characteristically, the radiant warmer cycles through warming and cooling phases. Shielding temperature probes with a small square of foam rubber covered by reflective foil is recommended to prevent artifactual heating of the thermistor by the radiant warmer during the warming phase.To determine the effect of thermistor shielding on infant heat demand, 10 premature neonates (birthweight 1.70 ! .12 SEM kg, gestational age 32.6 ! .7 wks) were studied to measure mean radiant power density for one hour with and one hour without probe shielding. Data were also analyzed to determine the average duration of warming and cooling cycles under the warmer. There was a significant increase in cycle duration with shielding (1.76 ! .15 min/cycle vs. 3.06 ! .39 min/cycle, p <..02). Shielding had no effect on mean radiant power density received by infants (15.6 ! 1.0 mw/cm2 vs. 15.9 ! 1.2 mw/cm2 shielded, p >.5). Shielding had no effect on skin temperature, heart and respiratory rates, or ambient temperature and humidity. These data demonstrate that shielding probes produces lower frequency cycling for infants under radiant warmers without changing radiant power density received at the infant's skin. The effect of attenuated warming and cooling cycles on peripheral vascular stability and oxygen consumption remains to be determined. Previous studies of intravenously and orally administered alanine to normoglycemic small and large for gestational age newborns have not resulted in increased gluconeogenesis. This study was done to evaluate the effect of alanine loading in the presence of hypoglycemia in the first hours of life, Twelve infants 1-3 hours of age (mean weight:3280 grams; 37 weeks gestational age with apgar scores of 7-10) who maintained initial blood glucose values of less than 38 mg/dl for 30 minutes were given 500 mg of L-alanine/kg as a 10% solution in .45% sodium chloride by nasogastric tube. Venous samples were taken pre-gavage and at 30,60 and 180 minutes thereafter for serum glucose, insulin, alanine and glucagon determinations with the following results: Because of the increased risk of premature inf ants for infantile apnea and sudden infant death syndrome, we selected 11 of 38 infants ready for discharge for 12 hour nocturnal cardiorespirogram recordings. Birthweights were under 2000 g and gestational ages 34 weeks or less. They had completed a course of theophylline for apnea and/or had intraventricular hemorrhage, or neurologic abnormalities. 10 of 11 recordings were abnormal: excessive (>3.5%) periodic breathing (PB), apnea (>15 sec), or brndycardia (<80 bpm). After reinstitution of theophylline treatment (mean level 9.07; range 7.25-12.13 mcg/ml) the repeat recordings of 9 infants were normal; one required phenobarbital for normalization. III vs I) were more common in group III and pulmonary hypertension and coagulopathy in group II (p<.01 II vs III). There were no differences in the incidence of asphyxia, CNS hemorrhage or PDA.Doi.>arnine and isupr.el were used more often in group II (p< .03 III vs I, II). Pavulon was used more often in group II (p<.03 II vs III). There was no difference in the use of tolazoline. The mortality of group III was 73% compared to 43% for group II and 22% for group I (p<.001 III vs I; p<.05 II vs I). Abnormalities in variability probably reflect poor peripheral circulation.We suggest that evaluation of tc tracings for variability may provide information concerning the adequacy of the peripheral circulation and may be of prognostic value. To determine factors contributing to SEH/IVH, confounding variables related to neonatal disease were eliminated by analysis of 44 of 246 infants (<34 wks/2000gm) selected by Apgars at 5 minutes, normal fetal pH, <15 hr intermittent mandatory ventilation (IMV), and no POA. SEH/IVH was diagnosed by frequent tri-dimensional ultrasound within the first hours of I ife. Major (8) (16) were similar for al I variables. Vaginally delivered infants had a higher incidence of total & major SEH/IVH than C-section infants (no major IVH/SEH). Follow-up (6-24 months) reveals only 2/16 infants with major neurologic deficit. The factors identified here for SEH/IVH represent the risks of prematurity alone for SEH/IVH and its consequences during development. Raul F. Bejar, Ola D. Saugstad, Hector James, Louis Gluck. Univ. of Cal if., San Diego, Dept. of Pediatrics, La Joi la, Ca Ii f.Hydrocephalus is a frequent complication of large intraventricular hemorrhages. Hypoxanthine, the end product of purine metabolism, which is elevated during brain ischemia indicating icant compromise of cell integrity, was measured in 13 hydrocephal ic tiny infants (12 posthemorrhagic, I congenital hydrocephalus) to determine whether hydrocephalus is associated with anaerobic metabolism of brain tissue. lntraventricular hemorrhages & progressive ventricular size were diagnosed with repeated ultrasound studies of the infants' brains. Hypoxanthine concentrations in CSF (normal 0-3µm/L) increased significantly (x=l4.8µm/L, range 7.5-28µm/L) in progressive hydrocephalus, with or without overt signs of intracranial hypertension. Normal values or significant decrease in hypoxanthine were obtained when hydrocephalus was successfully treated or ventricular size was transiently stabilized by LP's or VP shunts. Actual ventricular size seemed not to correlate with hypoxanthine concentration although each case tended to have high concentrations when there was progressive ventricular enlargement. Patients with posthemorrhagic hydrocephalus in the first month of 1 ife had similar high concentrations (x=14.5µm/L) as patients with "late" (age 1 or> mos) posthemorrhagic or with congenital hydrocephalus suggesting that anaerobic metabolism is mainly a consequence of ventricular enlargement. Plexiglas head hoods (PGH) are often used to administer supplementary oxygen or to measure respiratory gas exchange of infants. Since Plexiglas is impermeable to heat energy radiated from the body, we theorized that PGH might reduce radiant heat loss (R) from the head and, thus, possibly reduce body heat loss (HL). We measured metabolic heat production (M) and HL of 6 AGA premature infants in an incubator with PGH (top replaced with 0.013-fllll polyethylene, Glad and with a head hood (PEH) of polyethylene stretched over a rectangular frame made of thin tubular steel. Each infant was studied with PGH and PEH on the same day, with skin temperature servocontrolled to 36.5°C. After thermal equi]ibration, oxygen consumption (vo,), carbon dioxide production (VC0 7 ), and insensible water loss (IWL) were measured continuously for 2 hours with each hood. M and HL were calculated and partitioned into evaporation (E) , radiation (R), and the sum (C) of convection and conduction. The means are shown below, V0 2 and VC0 2 in ml/ (kg·min), IWL in ml/(kg·h), and M, HL, E, Rand C in kcal/(kq-h): Premature infants treated for respiratory distress syndrome (RDS) may develop reversible bronchospasm during the first year of life. It is unclear whether this airway hyperreactivity is related to initial management or to hereditary factors. Twenty-one premature infants, mechanically ventilated for RDS, followed for bronchospasm beginning before 6 months of age, were matched with 21 similar infants with no bronchospasm during the first year of life. No significant differences existed between infants with bronchospasm (B) and their matched controls (C) for (mean! SEM): birth wt. (1.15 ! .06 vs. 1.13 ! .09 kg); GA (30 ! 0.5 vs. 29 ! 0.4 wks); duration of oxygen exposure (35.6 ! 6.5 vs. 39.6 ! 6.4 days); and duration of ventilatory assistance (455 ! 10& vs. 451 ! 9& hrs). 13/21 B babies and 14/21 C babies had radiologic evidence of BPD. Family history of bronchospasm was considered positive if first or second degree relatives had asthma prior to age 20 requiring hospital treatment and bronchodilators. 14/21 (67%) infants with bronchospasm vs. 3/21 (14.3%) control infants had positive family histories (p <.001). Patients requiring continuous bronchodilator therapy for symptom control (n= 15) were compared to those needing only intermittent therapy for acute exacerbations (n=6). 9/15 (60%) requiring continuous therapy had first degree relatives with positive histories vs. 1/6 (17%) in the intermittent therapy group (p <.02). Thus, a strong family history of bronchospasm may be a predisposing factor in the development of airway hyperreactivity in premature infants requiring ventilatory therapy for RDS. The closer the affected relative, the greater the tendency for the bronchospasm to be of a more severe nature. Oxygenation decreases after nasogastric (NG) feeding but increases during nonnutritive sucking (NNS/pacifier) in premature infants recovering from RDS. To evaluate changes in oxygenation during NG feedings given with a pacifier, we studied 15 clinically stable premature infants (mean! SEM birth wt. 1.2 ! 0.3 kg and GA 31.0 ! 1.5 wk) who were given a pacifier during and for JO min. after an NG feed (NNS). The same infants were studied within 24 hrs. during an NG feed without a pacifier (control). Studies were done during transition from NG to oral feeds when the sucking reflex was well-developed. Transcutaneous Oz (TcP02) was monitored prior to, during and for 30 min. after each NG feeding. Pre-feeding TcP02 levels were comparable in both studies (5& ! 3.0 vs. 59 ! 2.9 mmHg, (N.S.) ). TcPOz values during NNS rose significantly to 64.7 ! 3.0 mmHg (p<. 0.001) by the end of the feeding, remained elevated for 20 min. and returned to baseline levels by 25 min. after feeding. Conversely, TcP02 measurements in control studies fell to 57.2 ! 2.& mmHg (p< 0.01) immediately after feeding, continued to fall for 20 min. (52.2 ! 3.0 mmHg, p < 0.001) and gradually returned to baseline levels by 30 min. Significant differences in TcPOz values between the 2 study periods were noted immediately after feeding and for 20 min thereafter (p< 0.1). Conclusion: Our study suggests that NNS during NG feedings prevents the decrease in oxygenation found after routine gavage feedings in premature infants. The improved TcPOz values while sucking might represent a physiologic response that is important to meet the increased caloric demands associated with feedings. Neurologic abnormalities occur commonly in low birthweight (LBW) premature infants during the first year of life, but often are transient. Developmental problems may be identified by the age at which abnormalities of muscle tone, reflex activity, and posture normalize. To determine the relationship between the age of normalization and developmental sequelae, we studied 21 infants with birthweight (mean :!: SD) 1.25 :!: 1.89 kg and gestational age 31 :!: 1.5 wks. Infants were evaluated for neurologic abnormalities at 3,6,9 and 12 mos adjusted age (AA). Development was assessed at 12 mos AA using the Bayley Scales of Infant Development.Neurologic exam revealed that infants were either l) normal at 3 mos; 2) normalized by 6 mos; 3) normalized by 12 mos; or 4) abnormal at 12 mos. Bayley scores varied in accord with these different ages of neurologic normalization. Mean scores were: Groups 1 and 2 (n=8) = 93.4 :!: 5.8 (normal range); Groups 3 and 4 (n=l 3)=70.5 :!: 11.2 (borderline to abnormal range), p '.001. Our study demonstrated a clear relationship between age of neurologic normalization and developmental progress. Early absence or resolution of abnormalities suggested favorable development at 12 mos. Persistence of abnormalities to 12 mos or beyond was related to either borderline or abnormal functioning. Conclusion: Although neurologic abnormalities are common in LBW preterm infants, they are not merely a transient phenomenon without significance. Regular neurologic assessment during the 1st year of life may be used to distinguish, as early as 3-6 mos, 16 preterm infants were given gentamicin (2.5 mg/kg/dose q 6 hours) orally as a prophylaxis against necrotizing enterocolitis (NEC). None of these infants received systemic gentamicin. Infants with NEC or NEC like symptoms were excluded from the study. Their weight and gestational age was 1.39 + 0.37 kg and 30.6 + 2. 7 weeks respectively. Their mean apgar sC"ore was 5 and 8 at one and five minutes respectively. All infants had respiratory distress syndrome and 12 out of 16 needed artificial ventilation. 12 infants had umbilical arterial catheters inserted. 9 out of 16 infants had serum gentamicin levels done at mean postnatal age of 1.7 days. l of those 9 infants had no detectible gentamicin level. The serum gentamicin level of the remaining 8 infants varied from 1.2 to 7 with mean of 2.5 Serum gentamicin level on other 7 infants was done at a mean postnatal age of 12 days. No gentamicin could be detected in the serum from 3 infants. The serum gentamicin levels on the remaining 4 infants was less than 2 µgm/ml. We suggest that orally administered gentamicin can be absorbed in preterm infants especially during the first few days of life. Infants on simultaneous oral and systemic gentamicin may be at a greater risk of toxicity .. 12 hour urinary excretion of VMA, HVA and MHPG were studied in 24 premature infants, 14 with apnea and 10 without apnea. Their birth weight and gestational age was 0.95 + 0.21 kg, 27.9 + 2.2 weeks and l.22 + 0.19 kg, 30.3 + 1.8 weeks-respectively. All infants were stud1ed before apnea-(l-3 days of postnatal age). Nonapneic infants were also studied at 10-15 days. Apneic infants were studied again 24 hours after apnea. The concentration of various biogenic amine metabolites expressed as µgm/kg body weigtt .i_ll_W) andcreatinine ( The excretion of VMA and MHPG did not significantly decrease with the onset of apnea. Only HVA when expressed as body weight was significantly lower in apneic infants. We conclude that apnea of prematurity is not associated with inhibition or immaturity of adrenergic pathways. Saralasin, an angiotensin II antagonist, has been used extensively to evaluate hypertension in adults. We measured the blood pressure (BP, rnrnHg) response to an infusion of saralasin in four hypertensive infants to determine its safety and efficacy in that age group. Prior to each infusion, we performed a renal scan and measured basal plasma renin activity (PRA, ng/ml/hr 3 months 0.2 125/73 112/52 Hyperaldosteronism The patients with high PRA levels (A and B) had marked decreases in BP during the infusion, while those with normal (C) or low (D) PRA had little or no response. The saralasin infusion was continued for two days in patient B, who had malignant hypertension unresponsive to conventional antihypertensive therapy, including nitroprusside. Patient D had normal findings on aortogram, renal angiogram, and renal vein PRA measurements, but a high plasma aldosterone level (36.7 ng/dl).We have demonstrated that the change in BP during an infusion of saralasin can rapidly and safely determine the contribution of the renin-angiotensin system to hypertension in infants and aid in the selection of appropriate antihypertensive therapy. Ninety-four patients with polycythemia and hyperviscosity (HV) were assigned randomly to partial pldsma exchange (Exch) or observation (NExch) and were matched with a non-polycythemic control. No group differed in socioeconomic class, apgar scores, resuscitation, meconiurn staining, weight or gestational age. Maternal pre-eclampsia was more conunon in HV patients (p<0.02). HV patients more commonly had necrotizing enterocolitis (NEC) and cyanosis (p<0.005) and required more IV's {p<0.001).Comparison of hyperviscous Exch and NExch groups revealed that maternal pre-erlampsia was more common among the Exch group (p<0.05) as was maternal smoking {p<0.01).Brazelton exams eval-· uated showed no differences at the time of diagnosis. Following Exch, GI symptoms were more frequent among Exch compared to NExch patients (p<0.02) as was NEC (p<0.001).At one year TfV patients did not differ from controls in mental or motor scores. Abnormal nPurologic exams were more common among HV patients (p<0.05) and speech was more likely to be delayed (p<0.02). At two years HV patients had more motor delays and neurologic diag ... oses (p<0.001). Comparison of the HV patients (Exch vs NExch) revealed no differences at one year. At two abnormal neurologic exams were more common among NExch patients (p<0.01).HV patients had more problems at follow up than controls. Exch seems to increase NEC but reduce neurologic problems. Hazinski, Gunnar E. Sedin, and Robert B. In 1942 Warren and Drinker reported that breathing movements have an important influence on filtration of fluid into the lungs (Am J Physiol 136:207). What happens when normal breathing movements stop, as they do during high-frequency vibratory ventilation? To answer that question, we measured pulmonary arterial (PA) and left atrial (LA) pressures, pleural (PL) and airway (AW) pressures, lung blood flow and lymph flow, and concentrations of protein in lymph and plasma of 7 healthy lambs, 2-3 wks old, during a 2-4 h period of spontaneous breathing (SB), followed by 4-8 h of mechanical ventilation (MV) at 30 breaths/min and 4-8 h of vibratory ventilation (VV), in which the lambs received 1500 whiffs of air/min from an Emerson Airway Vibrator. The lambs were unmedicated during SB, but received pancuronium and morphine dur!ng MV and VV. We alternated the sequence of MV Lymph flow was less and lymph:plasma protein ratio greater in VV than in MV, consistent with reduced lung fluid filtration during VV. In lambs killed after 8 h of VV, extravascular lung water was normal and microscopy showed no edema. We conclude that VV has no adverse effect on lung fluid balance and may provide a benefit to lambs by decreasing net filtration of fluid into their lungs. ln order to access the value of "booster transfusion" in the premature infant, a randomized trial was performed. Infants less than 1500 gms. at birth were randomized to be transfused to keep their hemoglobin level above 10.0 g/dl. or they were allowed to drop their hemoglobin. There were 56 infants enrolled on the study: 26 in the transfusion group and 30 in the non-transfused group. Analysis at the end of the study shows that the groups were well-matched for gestational age (mean 29.6 wks.) and birth weight (mean 1160 gms.). All children were transfused to replace iatrogenic blood loss, and in clinical states associated with acute blood loss or shock. Exchange transfusion was performed as necessary for the management of jaundice. In the non-transfused group, patients could also be transfused if required for surgery, if no weight gain for seven days on 140 cal/kg/day, or tachycardia greater than 170 BPM consistently for four days. cal analysis of the clinical course of these patients shows no difference between groups in terms of length of stay in the hospital, discharge weight, incidence or severity of apnea. There was a difference at the P (.001 level between groups in the discharge hemoglobin level and reticulocyte count. The non-transfused infants also had increased weight gain/day significant at the p (.OS level. This unexpected finding was not due_ to? difference in the incidence of clinical PDA. Our conclusion is that there is no clinical advantage to maintaining the hemoglobin above 10.0 g/dl in the pre-term infant. During the first 5 days of life, the phospholipid content of tracheal effluent from 12 infants (28-35 GA) with severe RDS was measured to identify specific deficiencies and to determine their rate of recovery. On each infant's daily pooled specimen, total phospholipid (PL) and disaturated phosphatidylcholine ( DSPC) were quantified and the presence of phosphat i dyglycero l (PG) detern1i ned. Values in the RDS group were compared to measurements on specimens collected during the first day of life from 7 control infants (27-36 GA) being ventilated for apnea or transient tachypnea. Compared to controls, infants with RDS had less PL and DSPC on Day l (p<.01). A gradual increase in both PL and DSPC began on Day 3 and reached values similar to controls after Day 4. No change in %DSPC in the RDS group was observed; %DSPC in RDS and control groups was similar. PG was always absent in the RDS group on Day l but appeared coincident with the rise in DSPC and PL. PG was a variable finding in controls. We conclude that the early deficiency of DSPC, PG, and PL in infants with severe RDS resolves by the fifth day of life. Most cases of GBS early-onset sepsis appear to have en intrepertum pathogenesis. A tteck rates ere increased in infants born to women with premature labor or prolonged rupture of membranes. We have carried out a randomized study of the effect of intrapartum parenteral empicillin (2 gm IV, followed by 1 gm IV Q4H) on GBS vertical transmission in infants born to high-risk perturient women with prenatal GBS colonization. Cultures of throat, umbilicus, rectum, external ear, gastric contents, end blood were obtained from study infants in the delivery room at birth. A dramatic reduction in GBS vertical transmission occurred in infants born to high-risk mothers who were treated with ampicillin. Blood cultures were positive (*) in 4 heavily colonized infants whose mothers were not treated with ampicillin; no blood cultures were positive among infants whose mothers were treated (p = .17 AMNIOTIC FLUID VOLUME AND FETAL SWALLOWING RATE. 1212 Brans, T. Kuehl, R. Hayashi, D. Shannon and P. Reyes. and Gynecology, and Southwest Foundation for Research and Education, San Antonio.Extreme similarities in the anatomy and physiology of the fetoplacento-uterine units in baboons and humans make the baboon an ideal model to investigate aspects of reproductive physiology. In order to obtain baseline data on normal baboon pregnancies, amniotic fluid volume (AFV) was determined by para-amino-hippurate (PAH) dilution in 39 pregnancies ranging from 88 to 173 days in duration. Amniotic fluid volume averaged 257"(Sll) 71.l ml (range: 126-392ml) and did not vary with gestational maturity. Fetal swallowing rate (FSR) was determined in 6 pregnancies at 138-149 days in animals whose PAH-determined AFV's ranged from 178 to 309 ml.Inulin dilution was used, AF samples being obtained prior to injection and approximately 4, 8 and 24 hours later. The Ln of AF inulin concentrations decreased as a straight line whose slope multiplied by PAH-dctermined AFV yielded FSR's that averaged 18.8!5.37 ml/hour (12.3-25.8ml/h). These data suggest (1) that AFV of baboons is similar to that of humans, considering the differences in body weight for mother and fetus (1/3 of human); and (2) No osmotic diuresis was seen. Urinary Na/K ratio was(l in 25/40 patients. A negative correlation was seen between FENa & GER (r = -.38, p c05). Serum Na was normal.Usually tubular water & Na reabsorption is not impaired after A in the absence of renal failure. Low values of CW are probably related to ADH hypersecretion. The absence of hyponatremia seems related to fluid restriction. 0/I variation could be dependent on the. degree of stimulation of prostaglandins & renin system (Weissman, 1981) . Neonatal asphyxia has been associated with an increased BP during the first hours of life (DIMICH, 1974) . Gentamycin tI/2 is related to mean blood pressure in asphyxiated prematures (FRIED-MAN, 1981) . We studied 50 A (Apgar 4.0 ± 2.3 at l' & 6.7 ± 2.4 at 5'). Shock (S: BP> 2SD below mean, BE '-lOmEq/l & ol iguria) was present in 3 prematures (PT) & 8 term (T)infants.In appropriate for GA controls ( Most of our patients were moderately asphyxiated only: this may explain the differences in the evolution of BP and its relation to GFR from previously reported studies in asphyxiated newborns. by M. L. The Anqar score is freouently assiQned hurriedly, casually or restrosnectivelv. We develoned. 8 neonatal case descrintions with sufficient information to nrovide a sinqle Anoar score but also includPd additional distractinQ information. These 8 cases were then scored hv 148 individuals includinQ 28 ohstetrical nurses, 54 nP.onatal nursP.s, ?3 nurses who care for both maternity and newborn natients in small communitv hospitals, 27 nediatricians and nediatric houseofficers and Hi ohstetricians and obstetrical houseofficers.The results (tahle) indicated that nediatric attendinqs and houseofficP.rs the Anoar score more accurately than any other oroun. Their accuracv was sti 11 only 611. Onlv two individuals, both nediatric houseofficers, scored all eioht patients correctlv. Item analysis commonly revealed incorrP.ctlv hioh Anoar scores assioned to very low Anqar cases. We concludP. the Anoar score will only be accurate and meaningful for developmental nroonosis when the simple criteria are carefully and conscientiouslv aoplied. Maniscalco, Susan Taylor-Brown, Catherine Johnson, Donald L. Shapiro, Univ. of Rochester, Dept. of Pediatrics & Div. of Social Work, Rochester, New York.Neonatology is reputed to be a stressful pediatric subspecialty. To objectively quantify this stress and assess the factors involved, a questionnaire was mailed to neonatologists in the northeastern United States. 97 (70%) replied. A 5-point scale was used to determine level of satisfaction with neonatology as a career and stress experienced at work. Preliminary analysis of these questionnaires has indicated the following: almost all neonatologists experienced stress at work: 32% moderately severe and 16% very severe stress. Open-ended questions indicated the major causes of stress were (a) excessive work load, e.g., on call too often or late calls (36%), (b) patient care (36%) especially dealing with infant death, and (c) staff disagreements (32%) especially nurse or housestaff conflicts. 20% of those surveyed suffered a stress related illness in the past 5 years. One sixth of the neonatologists were either moderately or very dissatisfied with neonatology. Major dissatisfactions were: (a) too much work (48%); (b) lack of resources (32%) including inadequate salary; (c) stress of clinical responsibility (20%); and (d) administrative demands (16%). Satisfactions included patient care (62%); teaching (24%), intellectual stimulation (22%) and research (15%). Altering subspecialty has been considered at some time by 58% (15% very seriously). Preliminary results of this study confirm that neonatology is a highly stressful career. Identification of causes of stress among neonatologists may ultimately lead to appropriate intervention strategies. According to current views, the Prostaglandin Ez (PGEz) that maintains patency of the ductus arteriosus (DA) is formed intramurally and exerts its action locally on muscle cells. We recently found that newborn lambs with patent ductus arteriosus (PDA) have higher plasma PGEz concentrations (pulmonary artery (PA)=l69±52, aorta (Ao)=80±11 pg/ml, n=6) than those with a constricted DA (PA=23±3 Ao=20±3 pg/ml, n=8). To see if these concentrations of PGEz could produce patency of the DA, we used 5 near-term lambs (137-147 days) delivered by C-section, paralyzed and ventilated with 100% o 2 . Cardiac output and DA flow were measured by radioactive microspheres. PGE 2 concentrations (PA= 64±22, Ao=69±31 pg/ml) and the DA resistance (1892±733 torr/l/ min/kg) stabilized by 2 hr after delivery. We then started a continuous PGEz infusion into the superior vena cava; PGEz concentrations and DA resistances were measured 20 minutes after each increase in rate (.005 to .133 ug/kg/min PGEz). We observed the first significant persistent decrease in DA resistance (889±493 torr/l/min/kg) at PGE 2 concentrations of PA=l93±33 and Ao=84±15 pg/ml. At the maximum PGE 2 concentrations obtained in each animal (PA=635tl95, Ao=l05tpg/ml) the DA resistance was even lower (468±288 torr/l/min/kg). The PGEz infusions had no significant effect on systemic or pulmonary vascular resistances. We conclude that elevated plasma PGEz concentrations found in n1·wborn lambs with PDA may be responsible for the DA patency after delivery. Elective cesarean section (C/S) has been increasing over the last decade. This study was performed to determine if respiratory morbidity (RM) is different if labor has occurred. The records of all neonates assessed by prenatal clinical uation as 38-42wks gestation and born by non-emergent C/S at Rose Med. Center from Jan-Dec, 1980, were reviewed. Of these, 196 were free of significant maternal and fetal illness. C/S was performed in 111 after the onset of labor and in 85 without labor.RM defined as >15minutes o 2 requirement after admission to the nursery, occurred with greater frequency in the no-labor group (p<.001), as indicated in the table below which also gives the incidence of RM by gestational age (GA) on postnatal examination. Even in the sub-group 39-40wks, the difference was significant. -__ ____ Labor (L) 12/111=10.8% 9/103= 8.7% 3/8 =37.5% 5/71= 7.0% No Labor (NL) 25/85 =29.4% 19/74 =25.7% 6/11=54.5% 13/52=25.0% p<.001 p<.002 n.s. o<.005 Regardless of GA, the severity of RM was also greater in the no-labor patients. In the study group RM>4hrs occurred in l.8%(L) vs 9.4% (NL, p<.001). The average cost of hospitalization for NL patients was also excessive being 3 times that of study infants without RM and 1.5 times the cost for L group patients with RM.RM was greater in neonates born by non-emergent C/S without labor. Awaiting the onset of labor may significantly reduce RM in neonates delivered by non-emergent C/S. Erythroid cell lines are a major heme source in the newborn. The most important humoral for erythropoiesis is erythropoiet in (Ep). Elevated Ep levels have been noted in the cord blood of hyperinsulinemic rhesus monkey fetuses, infants of diabetic mothers (IDM), and hypoxic neonates. Evidence of stimulated erythropoiesis also has been found in each of these instances. Therefore increased heme catabolism in IDM may be related to stimulated erythropoiesis. We studied 6 IDll, 7 infants who were large for dates (LGA), and 6 infants who were appropriately grown for their gestational age (AGA); they were delivered 36 weeks gestation, and had a mean birthweight of 3.70 ± .53 (SD) kg (range 2.32-4.37 kg). Cord blood samples were analyzed for Ep levels. The pulmonary excretion rate of carbon monoxide (Ver,o), a valid means of determining the bilirubin production rate, was measured in the first few days of life, and found to have a positive linear correlation with Ep (n=l9, p<.02). The two infants with the highest Veco resl!lts also had the highest Ep values, and were both InY. These data suggest that increased erythropoiesis, effective or ineffective, mediated by Ep, may be a significant factor in the hyperbilirubinemia seen in certain neonatal populations such as IDM and Lr.A infants. Postrotatory nystagmus is an easily elicited reflex reported to be abnormal in developmentally delayed children. PR-N has been recorded in newborns, but methodological difficulties have compromised its full understanding. Eight healthy adults were compared with 19 full-term and 13 prematures, all neurologically normal, tested at 2,6,9, and 12 months. All subjects were positioned in a rotational chair, spun for 1 minute at a constant angular velocity (150°/sec) and then abruptly stopped. Electronic recording of PR-N in absolute darkness continued for 5 min. Two types of PR-N were observed. Primary PR-N consisted of an average of 80 eye movements (beats) lasting 40 sec., in direction opposite to the rotation and was followed by Secondary PR-N (mean of 130 beats, 200 seconds duration, same direction as the original rotation). ANOVA and Scheffe's method of post hoc multiple comparisons were used. Results for full term and prematures were similar in all recorded variables, hence the entire group of infants was compared to adults. The number and frequency of beats in both Primary and Secondary PR-N were significantly greater in adults. However, the angular displacement, duration and velocity of each beat was significantly higher in infants of all ages. All components of PR-N, whether Primary or Secondary, can be recorded and identified under 1 year of age and are significantly different from that obtained from adults. These differences may reflect anatomical and neurophysiological immaturity of eye control in the infant. Hypoglycemia has been reported in infants whose aortic catheter (UAC) was placed above the celiac axis. It was postulated that hypoglycemia resulted from direct infusion of glucose into the pancreas stimulating the beta cell. To evaluate this hypothesis, 9 term lambs [birthweight 5.2±0.3 kg (M±SEM); age 4.8±0.6 days] were infused with 6 mg/kg/min of dextrose into a UAC below the celiac axis for 2 hrs following which 25 µCi/kg D-[6-3H) glucose was given by the prime constant infusion technique to measure Ra. After a recovery period of 1 hr, the study was repeated with dextrose infusion above the celiac axis. Blood was drawn for pl. glucose, insulin and glucose specific activity from the carotid artery and Ra was calculated. Position We have found a five-fold increase in incidence of neonatal hyperbilirubinemia {>12 mg/dl) in full term normal weight infants born at 3000 m. In order to assess the contributions of altitudeinduced polycythemia and impaired conjugation and excretion of bilirubin to this problem, rats kept at a simulated altitude of 4600 m for 6 weeks were given loading doses (0.5, 1.5, and 3.0 mg/100 g) of bilirubin and hematocrit, hemoglobin, total and unconjugated bilirubin determined on samples taken 17 min. later. Hematocrit rose from 42.5% to 67.2% and hemoglobin rose from 14.6 to 20.9 g/dl with exposure to simulated altitude and contribute to the significant (p<.05) increase in serum bilirubin in rats given no exogenous bilirubin. However, the loading dose conditions indicate that an impairment in conjugation, but not excretion, also contribute to the altitude effect: at every dose, the high altitude rats had significantly higher total serum bilirubin levels than sea-level rats, due entirely to a rise in unconjugated bilirubin as conjugated bilirubin levels were significantly reduced in high-altitude rats at all doses. Impaired excretion would have led to increased rather than decreased conjugated bilirubin in the serum.We conclude that both polycythemia and an impairment in bilirubin conjugation, but not in excretion, occur at high altitude. Effects of mechanical ventilation upon pulmonary dynamics of the premature newborn lung were studied during the 1st week of life for 13 infants. Dynamic compliance (CL) and lung resistance (RL) were determined for spontaneous and mechanical breaths of pressure-cycled intermittent mandatory ventilation using a multichannel recorder with scalar and loop output. Volume-pressure and pressure-flow loops were measured by planimetry (mm2/g) to determine compliance loop-area (CL/area) and resistance loop area (RL/ area). Seven infants (13llg ± 62) recovered from respiratory distress syndrome (RDS) and were extubated on day 13(!3).Six infants (1178g ± 95) developed bronchopulmonary dysplasia (BPD) by week 3 of life and required mechanical ventilation until day 56(±12). During the 1st week of mechanical ventilation, mean airway pressure for both groups decreased progressively from 10.4 to 6.3 cmH20 (r=0.932). Mechanical vs spontaneous breath CL/areas for RDS patients on day 7 were 2.40 vs 0.45 (p=0.001) and for BPD patients were l. 62 vs 0. 52 ( p=O. 003). RLf areas of mechanical breaths for BPD patients on day 7 were 6 times greater than spontaneous breaths (8.42 vs 1.17; p=0.02). We conclude: 1) CL/areas revealed that excessive mechanical volumes and pressures were maintained, despite conventional ventilator settings and changes, 2) RL/areas increased during the 1st week for infants susceptible to BPD, and 3) respiratory loop-area analyses may identify degrees of barotrauma to be avoided. We conclude that maintaining Tab at 36.0 C. 1) decreased the frequency of pauses )2 and >5 sec in the RW. 2) did not alter the frequency of pauses >10 sec. 3) decreased the %AP and % PB in the RW, and 4) increased V02. We speculate that the reduction in the frequency of short pauses ((10 sec) associated with PB during even mild cooling may reflect the effect of an increased metabolic rate, Angiotensin converting enzyme activity in the fetus is modulated by Pao 2 and enzyme activity increases 3-fold with elevation in Pao 2 from fetal to neonatal values. Because of the synergism between angiotensin II (All) and catecholamines (CATS), we hypothesized that both play a role in the systemic circulatory adjustments with oxygenation at birth. Six unanesthetized lambs, chronically instrumented in utero, were delivered by C-Section near term and ventilated insure an unasphyxiated birth. Systemic arterial pressure (SAP), Pa0 2 (mmHg), plasma renin activity (PRA), All and CATS (pg/ml) were measured before and immediately after birth. Simultaneously we determined systemic va3cular resistance (SVR, mmllg/L/min) and blood flow distribution postnatally (PN). Seven children with recurrent gross or microscopic hematuria were studied. All have normal blood pressure, growth, and renal function; none has proteinuria. All of these children have decreased serum levels of C4 as measured by a functional (hemolytic) assay. When determined immunochemically, however, their C4's are within the normal range. The ratios of their hemolytic to antigenic C4's ("hemolytic efficiency") average .36 + .15 (range .16 to .56). The values for hemolytic efficiency in 18 normal patients average 1.01 + .26 (range .7 to 1.6). Fifteen patients with other hypocomplementemic diseases have ratios averaging .83 + .32 (range .14 to 1.36). All other complement components C2, C3, C5-9, properdin, factor B, factor H, factor I, Cl inhibitor) are normal in these patients. The patients' C4 molecules are identical to those of normal serum with respect to charge, mobility, and antigenic configuration as determined by double immunodiffusion and immunoelectrophoresis. When incubated with normal serum, the patients' sera do not decrease the C4 titer as would be the case in the presence of a nonspecific inactivator of C4 or an excessive concentration of C4 binding protein. Finally, incubation of the patients' sera with a preformed immune complex made at equivalence leads to complete C3 and C4 consumption suggesting that the abnormal C4 is able to help form a stable and efficient classical pathway C3 convertase. These data suggest either a genetic cause for this abnormality or excessive production of pro-C4 as an underlying defect. Furosemide (F) has been shown to increase urinarv excretion of PGs in premature infants. To evaluate if PG inhibitor, I, would affect the diuretic and natriuretic response ofF, 20 oremature infants with PDA were divided into two rroups: 10 received F alone O.rw/kr-,IV) and 10 received F and I (0. imp/kr-,IV). The BH (mean+SEM 1.13+0.15 vs l.l9+0.llkp-), GA VS ar-e vs 9.5+2.ldvs) and cardiooulmonarv status before the study-were comparable between the rroups. Urine Output FENa FEel GFR Before studv (ml/kr-/hr) After stud.v 12-24 hrs -Gr (F) 3.8+0.5* 5.1+0.9** 8.7+0.8 Gr (P+I) 2.1+0.3 1.9+0.4 2.6+0.5 At 12-24 hrs after the studv, infants in Gr-F had an increase in urine output, FENa and FEel which was sip-nificantlv r-reater (*o< .05, **p<.Ol)than that of infants in Gr I+F. The results of this study sup-p,est that the diuretic and natriuretic effects of F may be mediated by PGs in premature infants. of Pediatrics and Pathology, Miami, Florida.Sera from patients with INS have been reported to inhibit lymphocyte blastogenesis. Characteristics and pathogenetic significance of the circulating factor(s) involved have not been established. To assess specificity of this growth inhibition for lymphocytes, we studied the effect of INS sera on HF. Sera were obtained from 5 children (Y. age: 13 yrs; range 10-16 yrs) with INS (MCNS 2, FSS 2, and membranous GN I) in relapse (protein-uria> lg/m2/day). All patients had hypoalbuminemia, hyperlipidemia and normal creatinine clearance; when studied, none were receiving prednisone. Sera were incubated with an HF primary cell line derived from foreskin or skin biopsy. Control medium containing F-12 + FCS was compared to F-12 + FCS + human normal or nephrotic sera at 5, 10 or 20% concentration; HF growth was followed for 8 days. Nephrotic sera produced a 2-8 fold increase of HF growth. Cell counts: normal sera x 94,800 ± 21,407 SEM;INS sera x 500,700 + 153,000 SEM (p < 0.001). Peak effect was observed at 20% ser; concentration in media. Heat treated sera at 56°C for 30 min or dialysis reduced minimally sera's activity. Thus, INS sera during relapse inhibit lymphocyte blastogenesis but stimulate fibroblast growth. FUrther studies are needed to characterize the circulating factor(s) and determine its pathogenetic rol·e in the progression of renal disease. • 1515 WITH MINIMAL CHANGE NEPHROTIC SYNDROME (MCNS) • Gaston Zilleruelo, Sung L. Hsia, Michael Freundlich, Helen Gorman, and Jose Strauss, Univ. of Miami School of Medicine, Depts. of Peds. and Biochem., Miami, Florida.Hyperlipidemia (HL) is common during relapse in MCNS. This study assessed severity and duration of HL in MCNS children during relapse and remission as compared with age matched controls (Morrison, J. et al.: Pediatrics 62:990, 1978) . Serum total cholesterol (TC), triglycerides (TG), low density lipoproteins (LDL), and high density lipoproteins (HDL) were measured in 39 MCNS children; 22 were in relapse (proteinuria > I g/m2/day) and 17 were in remission (no proteinuria for> 3 mos, x: 2 yrs). Results are expressed in mg/dl (x ± SD; * p: < 0.01) and age in yrs (x and range).GROUP AGE TC TG LDL HDL MCNS, relapse 9 (2-17) 361±131* 258+188* 238±71* 62±18 MCNS, remission 10 (4-20) 223± 77* !Oo± 52* 160±79* 59±17 Control 10 (6-17) 160± 25 55± 21 95±24 56±11 LDL/HDL ratios> 2 (normal 1.6-2.0 for ages studied) were observed in 88% of children in relapse and 58% in remission. Duration of lipid changes in remission correlated well with duration of disease and frequency of relapse. Lipid changes in MCNS may last for prolonged periods of time and arc frequently associated with abnormal LDL/HDL ratios. This study suggests that MCNS children need lipid evaluation at regular intervals, and follow-up even in remission. Further data should clarify the pathogenesis of persistent HL in MCNS children and its role as a risk factor for premature coronary atherosclerosis. Factors associated with alteration in systemic vascular pressure (volume expansion, pneumothorax, etc.) have been associated with intracranial hemorrhage in ill preterm infants and seem to implicate deficient regulation of cerebral blood flow in the etiopathogenesis of SEH/IVH. We have been involved in a prospective study using range gated pulsed Doppler ultrasound to determine carotid and anterior cerebral flow characteristics in ill preterm infants. Serial studies are performed on each infant, and response of cerebral flow to changes in mean arterial pressure is assessed. Thus far, 9 infants have been studied. Five infants demonstrated increased (decreased) cerebral flow velocity in response to increased (decreased) mean arterial pressure and had intracranial hemorrhage. SEH/IVH occurred prior to velocity studies in 4 of the 5 infants. Four infants demonstrated no change in cerebral flow velocity with change in mean arterial pressure, and none of these bled. In conclusion: (1) Cerebral blood flow velocity alterations as a response to changes in mean arterial pressure appear related to intracranial hemorrhage in the ill preterm infant. (2) Some ill preterm infants can effectively regulate cerebral blood flow. Ligation of the right common carotid (LRCC) for venoarterial extracorporeal membrane oxygenation (VA ECMO) is always of concern, although no neurologic deficit has been shown to occur from this procedure. We did Doppler studies to measure ACA pulsatilit) indexes (Pis) in 3 infants who had LRCC, to try to detect changes in cerebral blood flow (CBF).One infant had ACA Pis measured before LRCC, and her left and right Pis were equal then. 2.5 hours following LRCC the Pis were unequal, with the R PI 0.75 and the LPI 0.62. Two months later the difference persisted, with the R PI 0.76 and the L ri 0.52. Another infant had ACA Pis measured 5.5 mos. following LRCC, with the R PI 0. 76 and L PI 0.69. Both infants had CBF and brain scans showing normal and equal perfusion of cerebral hemispheres, without cerebral infarct. Both infants are developing normally.A third infant had an IVH a few hours after going on VA ECMO. ACA Pis done after the IVH were R PI 0.81 and L PI 0.73. This infant did not survive. U lly factors determining cerebral blood flow velocities (as measured by ACA Pis) have equal effects bilaterally. An example is asphyxia causing cerebral vasodilation and lowering of the Pis. After LRCC, left sided CBF must also supply the right brain. This increase in the vascular bed of the left internal carotid is reflected in the L ACA by lowering of the L PI with respect to the R PI. From l/78 to 6/81 21 infants developed Hydrocephalus :! 0 to IVH documented by ultrasound or computerized axial tomography (CAT), mean birth weight 1223gms. Eighteen survived. HD was classified: mild 5 (1 exp.) moderate 2(1 lost to follow-up) severe 14(2 exp.) Supportive treatment (Rx) was given as necessary. Mild and moderate HD didn't receive specific Rx. Rx of severe HD: 4 had repeated lumbar taps (RLT),9 had RLT+ventriculo-peritoneal shunt (VPS) 1 had no specific Rx (clinically well, CAT unchanged.)Seventeen infants were followed between 6 mos.-2 yrs. with CAT scans, neurologic, hearing, vision and Denver Development2.l screening test (DDST) corrected for gestational age. 5/5 with mild or moderate HD had normal DDST,2/5 had mild t reflexes. CAT showed no change in 4, improvement 1. Twelve infants with severe HD showed: Mild t of reflexes were DDST-delay/mos. RLT(3} RLT+VPS (8) The majority of studies of neonatal breathing patterns have involved wave shape analysis in the time domain. These include determination tidal volume, insp. time/exp. time, and respiratory rate (RR). Because currently used ventilatory parameters do not differentiate complex breathing patterns, a more critical wave shape analysis technique may be required. Power density spectral analysis provides a quantitative method for expressing a given wave shape as a function of its frequency components. Spectral analysis of breathing patterns was evaluated in 5 spontaneously breathing infants, mean study wt. 1.8 .!. 0.1 kg and study age of 35 .!. 17 days. Infants were breathing room air through a face mask which was attached to a pneumotachograph to measure air flow and this signal was integrated into volume. Data was digitized and recorded on flexible disk and analyzed by HP 9845B computer. Power spectral density was used to evaluate breathing patterns for frequency range, peak frequency (fp) and centroid frequency (fc>· Respiratory spectrum bandwidth was 50 to 202 breaths/min. (0.8 -3.4 Hz). Mean .!. SE of fp = 66.5 .!. 2.2 b/min., fc = 68.9 .!. 1.1 b/min. Resp. rate 70 .!. 4 b/min. There was a significant correlation between fp and RR. It appears that power spectral analysis provides a quantitative technique for evaluating breathing patterns. Of all various power and frequency parameters, fp and fc were most stable and reproducible. The applicability of high frequency ventilation (HFOV) in patients with dittuse alveolar disease is based on the assumption that pulmonary baroinjury will be less likely. We explored the relationship between proximal and distal airway pressures during HFOV in ten mongrel dogs with normal or oleic acid injured lungs. Distal airway pressure was measured through catheters of known frequency response inserted retrograde and wedged in the distal bronchi. Alveolar mean pressures were estimated atter equilibration following tracheal occlusion. Both pneumatic and mechanical oscillators were used with trequencies between 2 and 16 Hz and varying I:E ratios. In most animals studied, distal mean airway pressures and mean alveolar pressures were not signiticantly lower than proximal mean pressures regardless at trequency. distal pressureswere significantly lower at the higher frequencies (over 5 Hz) but when extremely high proximal airway pressures were required to maintain oxygenation, the distal pressures were signiticant. Prolongation at the I:E ratio or maintenance of distending pressure by use of a restrictive orifice resulted in circumstances where distal peak and mean pressures were higher than those at the proximal airway.The assumption that HFOV necessarily exposes the distal airway to lower pressures is not supported by this data. Distal pressure transmission during HFOV is dependent on the I:E ratio, trequency, oscillatory volume, and physical characteristics ot the lung.