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At the dawn of the twenty‐first century, immigrants were coming to the United States in near record numbers, reminiscent of the great waves that engulfed its shores at the beginning of the previous...

The immunological and clinical effects of levamisole were studied in 10 children with frequently relapsing steroid responsive nephrotic syndrome (SRNS). The efficacy of the drug was tested during remission of the disease with all patients on alternate day steroid therapy. The lymphocyte proliferative response to phytohemagglutinin (PHA), concanavalin-A (Con-A) and pokeweed mitogen (PWM) were normal. The Con-A induced suppressor T-lymphocyte activity of 7 patients was low before treatment with levamisole 8 +/- 3.7% and increased to normal values during therapy 34 +/- 6%; p less than 0.001 (control 32 +/- 5%). In these 7 children prednisolone dosage could be decreased significantly or discontinued altogether (44.1 +/- 5.3%). Patients without immunoregulatory abnormalities did not respond to levamisole. In 3 out of 4 children tested the percentage of OKT8+ cells rose during levamisole therapy from 19.7 +/- 2.1 to 37 +/- 2.3 (p less than 0.001), thus correcting the elevated pre-treatment OKT4+/OKT8+ ratio from 3.1 +/- 0.2 to 1.5 +/- 0.2; p less than 0.001 (control 1.47 +/- 0.2). These data support the hypothesis that abnormal immunoregulation may play a role in the pathogenesis of SRNS. Treatment with levamisole can be useful in some patients with the frequently relapsing form of the disease.

Thirty children with frequently relapsing idiopathic nephrotic syndrome (INS) were treated with levamisole (2.5 mg/kg BW) twice a week for a mean period of 9.9 months. A beneficial effect was observed in 16 children in whom corticosteroids could be significantly decreased without relapse. Levamisole was ineffective in 14 patients. There was no difference between the two groups in the duration of INS, the number of relapses and the duration of treatment with levamisole. The mean age at onset of INS was higher in the group of patients where levamisole was effective (5.8 years versus 2.8 years). In 7 patients who responded to levamisole neutrophils decreased below 4 X 10(9)/l. Transient granulocytopenia was observed in 3. It is concluded that levamisole may be effective in frequently relapsing INS with minimal side effects.

1. 1. Digital circulatory tests were carried out prior to treatment in 41 cases of primary hypertension and repeated during a period of treatment with drugs in 8 patients, and during a period of placebo therapy in 5 patients. 2. 2. Intrinsic vascular caliber as derived from the flow-pressure ratio in the vasodilated state was somewhat decreased in the “moderate to severe” as compared to the “mild” cases. 3. 3. Neurogenic vasoconstriction as measured by the work of digital vasoconstriction was somewhat increased prior to treatment as measured in the “good” as against the “fair to poor” responders. The overlap, however, was too great for individual predictions except for the extreme values.

Sixty-eight children (ages ranging from 5 months to 16 years) with urolithiasis were treated between 1966 and 1979. There were 36 females (53%) and 32 males (47%). Sixteen children (24%) had associated urinary tract infection; 4 out of these (6%) presented with urinary tract malformation. Fifty-five calculi (89%) were found in the upper urinary tract (kidney and ureter); 24 of the chemically studied calculi (80%) were made of calcium salts. In 30 children, metabolic investigations were carried out, leading to the discovery of hypercalciuria in 17 (57%). In one patient, important vesico-ureteral reflux associated with urolithiasis led to renal failure.

Continuous ambulatory peritoneal dialysis (CAPD) is widely used as maintenance therapy in patients with end-stage renal disease (ESRD). CAPD was introduced as a treatment for children in 1978, and the use of CAPD has increased steadily since then [1–4]. Although this technique is a valuable short-term therapeutic approach, little information is available concerning the long-term side effects of this mode of treatment in children. Several reports in adults have described a permanent loss of ultrafiltration associated with increased glucose absorption from the dialysate [5–8]. Several factors are probably responsible for this complication; for example, prolonged exposure of the peritoneum to acetate-containing dialysate has been incriminated [6, 7]. The histologic changes of the peritoneal membrane associated with isolated loss of ultrafiltration have not been documented. Some patients develop an encapsulating sclerosing peritonitis, in which a thick, fibrous membrane surrounds and compresses the bowel [9]. Most patients with sclerosing peritonitis suffer loss of ultrafiltration. However, it is not known if isolated loss of ultrafiltration and encapsulating peritonitis represent two extremes of the same disease process.

During an epidemic of poststreptococcal acute glomerulonephritis (PSAGN) in Israel during the second half of 1968, 155 children were hospitalized. All of them were initially followed up for 6 mo to 2 yr, during which period no evidence of continuing kidney damage was found. Fifty-five of the group were hospitalized over the next 2 to 10 yr for reasons unrelated to their original illness, at which time they also were found to be free of renal damage. Eighty children were examined 11 to 12 yr after the epidemic, and in them, too, urine examination, blood chemistry and blood pressure were within normal limits. It seems reasonable to conclude that the PSAGN of the 1968 epidemic was a benign disease with no lasting ill effects. Since most of the cases were associated with an M-55 skin Streptococcus and pyoderma, we suggest that glomerulonephritis due to pyoderma associated with this strain does not give rise to chronic renal disease.

In this study in seven primary care facilities the proportion of children recognized as having behavioral, educational, or social problems was much higher than generally assumed. Although there was great variability among the facilities, at least 5% and as many as 15% of children seen in one year were diagnosed as having these problems in all but the hospital teaching facilities. The prevalence was even higher among children from poor families. The variability among facilities was much less for psychosomatic problems, which were diagnosed in 8% to 10% of the children. For both psychosocial and psychosomatic types of problems, but especially for psychosocial ones, the proportion of visits with the diagnoses was much lower than the proportion of children with them, so that these problems engendered fewer visits for their management than might have been expected from their frequency in the population. However, available evidence suggests that individuals with unresolved psychosocial problems make more than their share of visits for other diagnoses. The findings of this study have implications for the content of educational programs for primary care practitioners, for the organization of primary care practice, and for the current debate over policy concerning reimbursement and benefit packages.

During peritoneal dialysis, some blood proteins including bound substances, are lost via the peritoneal membrane. There is considerable interpatient variability in protein loss, but the factors responsible for this variation have not been elucidated. The aim of this study is to examine the factors which may influence the ability of the peritoneal membrane to restrict protein leakage and to evaluate the consequences of these losses.

Twenty-one children and adolescent patients, 2-19 years of age, on renal replacement therapy were immunised at monthly intervals with three doses of 20 micrograms hepatitis B vaccine (Heptavax B, Merck Sharp & Dohme). In the absence of seroconversion, vaccination was continued with monthly doses of 40 micrograms hepatitis B vaccine until antibody to hepatitis B surface antigen became positive. The rate of seroconversion increased from 33.3% (7 of 21) to 76.1% (16 of 21) and 85.6% (18 of 21) with three, four and five vaccine injections respectively. Three patients had no immune response despite six to seven vaccine dosages; they had previously received immunosuppressive therapy. Antibody titres measured 1 year after seroconversion were found to be within the protective range (85-2500 mIU/ml). These results show that the impaired immune response to hepatitis B vaccination in young dialysis patients can be overcome by increasing the number of injections and the dose of the vaccine. Protective antibody titres are maintained for at least 1 year after vaccination. Immunosuppressive therapy may interfere with the vaccine response.

A 16-year-old boy developed bullous lesions on fingers, ears, tongue, and buccal mucosa as well as cauliflower-like growths on the epiglottis and vocal cords 1 1/2 years after a second renal transplantation and exposure to sunlight while receiving cyclosporin A (CsA). Withdrawal of CsA was followed by complete resolution of skin and mucosal lesions. A predisposition for adverse reactions to CsA is suggested, as additional side effects of CsA therapy were also present.

Pulmonary calcifications are known to occur in patients with chronic renal failure. Recently, scintigrams with bone-seeking radionuclides have been used to detect subclinical pulmonary calcium deposits. We studied 18 children on maintenance dialysis without evidence of pulmonary calcification on chest X-ray. Four children (22.2%) had a positive technetium 99m hydroxymethylene diphosphate scan (group 1), and 14 children had a negative scan (group 2). Mean serum aluminum levels were 2.68 +/- 0.30 mumol/l (mean +/- SD) in group 1 as compared to 1.66 +/- 0.72 in group 2 (p less than 0.01). No significant difference was found between the groups with respect to serum levels of calcium, phosphorus, bicarbonate, magnesium and the calcium-phosphorus product as well as parathyroid hormone and vitamin D levels. The patients with pulmonary calcifications were on dialysis a significantly longer time than those of group 2 (62 +/- 15 versus 35.7 +/- 23 months; p less than 0.01). These data show that pulmonary calcification occurs with high frequency in children undergoing long-term dialysis. They seem to be related to high serum aluminum levels. We propose that pulmonary scintigrams with bone-seeking radionuclides be used routinely for the diagnosis and follow-up of uremic pulmonary calcification.

Eleven children (7 girls and 4 boys) 2 1/2 to 17 years and 8 months of age were treated with CAPD for periods ranging from 6 to 31 months. All children were treated with commercially available dialysate solutions containing lactate. Peritoneal ultrafiltration capacity (PUFC) decreased progressively in all children without accompanying decrease in peritoneal urea and creatinine clearances. Five children developed membrane failure with negative ultrafiltration. One episode of peritonitis occurred in one of these 5 children and in 4 of them only 1.5% glucose solutions had been used. After an initial period (ranging from 14 to 31 months) of CAPD, 2 children were treated with Intermittent Ambulatory Peritoneal Dialysis (IAPD) and two others with Intermittent Cycling Peritoneal Dialysis (ICPD). In these 4 children, PUFC increased within one month from -3.75 ml/kg/day to + 5 ml/kg/day. By providing a shorter dwell time, IAPD and ICPD may allow a reduction in net inward transport of glucose, the maintenance of osmolar gradient and preservation of ultrafiltration capacity. Furthermore, periods of rest may allow some recovery from the progressive deterioration of the peritoneum resulting from long-term irrigation of the peritoneal cavity. These results indicate that IAPD and CPD may be superior to CAPD to maintain the ultrafiltration capacity of the peritoneum.

A 14.5-year-old boy with end-stage renal failure due to familial primary hyperoxaluria underwent cadaver donor renal transplantation. The graft function was stable for a period of 22 months, while he was on conventional immunosuppressive therapy (prednisolone and azathioprine) and additional oral pyridoxine, phosphorus, and magnesium supplementation. When ciclosporin A was introduced instead of azathioprine, the blood levels of oxalate rose, and oxalate deposition in the renal tubuli became evident. These observations suggest that ciclosporin A interferes with oxalate metabolism and, therefore, should be given with utmost caution in patients with primary hyperoxaluria.

Hypercholesteremia appears to be a common denominator for most patients with early coronary atherosclerosis. The frequency of the occurrence of this disorder and its possible genetic relationship become, therefore, important points in any studies designed to further our knowledge of coronary artery disease, particularly that occurring in the younger age groups. This report summarizes studies of hypercholesteremia in 250 men and 250 women, consecutive admissions to the Mount Sinai Hospital, New York, and an analysis of families of fifty-nine of the seventy-five probands who were found to have idiopathic hypercholesteremia. Serum cholesterol determinations were performed by the method of Schoenheimer and Sperry on blood drawn from patients who had fasted 12 hours. Hypercholesteremia was considered to be present if the serum cholesterol was 280 mg. per 100 ml. or greater. The age of the 250 men in the index group averaged 50.9 years, and their serum cholesterol averaged 215 mg. per 100 ml. The 250 women averaged 48.1 years, and their cholesterol 230 mg. per 100 ml. Ninetyseven of these 500 probands (41 men and 56 women) were hypercholesteremic. This group averaged 52.8 years of age, and 348 mg. per 100 ml. of serum cholesterol. Twenty-two of these ninety-seven patients were suffering from diseases associated with hypercholesteremia and were excluded from further consideration. Of the remaining 478 probands thirty-two of the 242 men (13.2 per cent) and forty-three of the 236 women (18.2 per cent) were hypercholesteremic. The frequency of hypercholesteremia was not significantly different between the two sexes. A thorough attempt was then made to examine the immediate relatives of the seventy-five hypercholesteremic probands. No relatives of sixteen of these patients could be examined. This was usually due to the fact that there was no living family member, or that those living were scattered throughout the world and therefore unavailable. Ninety-seven siblings and 110 children of the remaining fifty-nine hypercholesteremic probands were examined. The frequency of hypercholesteremia among the siblings was 51.5 per cent and among the children 29.4 per cent. Both these frequencies are significantly higher than those found among the 478 patients. Since the definition of hypercholesteremia used in the preceding calculations did not take into account the fact that serum cholesterol varies with age, the analyses were repeated using data of Keys and associates 11a in which age is taken into consideration; in these two age groups women have significantly higher cholesterol levels than men. Again it was found that the values for men and women are fairly close, differing at the 5 per cent level for only two age groups, 58 to 62 and 63 to 67. Keys and associates published serum cholesterol values which are expected to be exceeded by only 5 per cent of the population in each age group. The frequency of hypercholesteremia for the total usable sample, according to this method of analysis, was 12.0 per cent; the frequency among the siblings of the hypercholesteremic probands was 36.2 per cent and among the children 34.0 per cent. These frequencies, again, are significantly greater than those found for the index patients; but are not significantly different from the corresponding values obtained when levels of cholesterol above 279 mg. per 100 ml. were considered to represent hypercholesteremia. Of the 478 probands 266 were Jewish and 212 were non-Jewish. Hypercholesteremia was significantly more frequent among the Jewish probands (21 per cent versus 9 per cent), but the frequency among siblings and children was not different when Jewish hypercholesteremic probands and families were compared with non-Jewish. The mode of inheritance of idiopathic hypercholesteremia remains to be worked out. The finding that hypercholesteremia is as frequent among the siblings and children of the non-Jewish hypercholesteremic probands as compared with the Jewish may indicate that environmental factors are not of too great importance in determining the presence of hypercholesteremia. The validity of these tentative conclusions awaits the completion of a study now being done in a more representative and complete population group. However, even these preliminary observations shed some light on the complicated error of metabolism involved in hypercholesteremia and predisposition to early atherosclerosis.

CONSIDERABLE information is available concerning the hormonal control of carbohydrate and protein metabolism. The role of the pancreas, the thyroid, the anterior pituitary and the adrenal cortex in carbohydrate metabolism is well established by animal experiments and clinical experience. Similarly, the function of these endocrine organs, as well as of the gonads (particularly the testes), in controlling the metabolism of protein is well known. In contrast, our knowledge of the hormonal control of lipid metabolism is limited, although experimental and clinical observations indicate that such a mechanism exists. It is established, for example, that hypothyroidism as well as hyperthyroidism alter lipid metabolism, especially the cholesterol content of the serum (1). Crude extracts of the anterior pituitary produce an increase in the lipid content of the liver and provoke ketonuria (2). Following pancreatectomy increased mobilization of fat occurs with an elevation of serum lipids and production of ketone bod...

Excerpt In a previous communication,1aobservations on the clinical and chemical effects of cortisone and ACTH in the sprue syndrome were reported. Independently, similar observations by other autho...

This study is concerned with the development of hypercholesteremia during cortisone and pituitary adrenocorticotropic hormone (ACTH) therapy. It represents a continuation of previous observations on the effect of these hormones on serum lipids in man. In patients given cortisone a consistent elevation of the total serum cholesterol, esterified cholesterol and phospholipids was noted, whereas in those given pituitary adrenocorticotropic hormone less uniform and pronounced alterations were observed. 1 The patients reported here include those of the previous group who have undergone prolonged hormonal therapy as well as an additional number of treated patients. The factor of prolonged therapy assumes a particular importance because of the increased availability of these drugs. It may be expected that many patients with chronic diseases will now receive long courses of cortisone and pituitary adrenocorticotropic hormone therapy. During treatment with these drugs, especially when it was of prolonged duration, there developed in a number of