- Email: [email protected]
DEFECT OF URINARY DEHYDROEPIANDROSTERONE EXCRETION IN HYPERTENSIVE PATIENTS
99
(3) Ratios outside the normal range appear to be associated with retarded protein synthesis. In a child whose progress is unsatisfactory and whose total serum-proteins are falling instead of rising, the ratio rises. (4) The control of the ratio is probably an important homceostatic mechanism that has a high priority. A raised ratio is a sign of distress, not merely a reflection of the quality of the diet. The raised ratio is reduced by a meal containing only a few grammes of milk protein; the concentration of the " essential " aminoacids rises but that of the " inessential" is unchanged. The reduction of the ratio is not permanent until treatment has been continued, under favourable circumstances, for about 48 hours if the diet supplies 6 g. protein per kg. body-weight or for several days if it supplies only 4 g. per kg. The ratio may revert to a high level despite the uninterrupted intake of a high-protein diet-a point suggesting impairment of the homoeostatic mechanism and also the possible need for reconsideration of the concept of " initiation of cure " advocated by Brock5 as a criterion of the value of a therapeutic diet. (5) We think it possible that the ratio may be intimately related, in ways we cannot yet understand, to the control of normal and abnormal growth. Dr. J. M. Tanner, in a most lucid exposition,6 has discussed the relationship between protein synthesis and growth at various rates, including the accelerated rate of the malnourished child during rehabilitation and the slower rate of the well-nourished one. Work on the balance of aminoacids in growth failure from various causes is urgently needed. The method we have used is relatively crude and, for other purposes, adaptations may be more suitable. Our experience has convinced us that the chief cause of kwashiorkor in Uganda is lack of protein in the diet: we have no evidence of a specific aminoacid deficiency. We think there is a long period of imperfect nutrition during which various devices, such as growth retardation and autophagy, maintain tissue metabolism until their possibilities are exhausted. The period may be shortened by an infection or other contributory disaster. There then supervenes the phase of reduced serum-proteins and severe derangement of metabolism affecting particularly histidine,phenylalanine and tyrosine,8 and lysine,9 and undoubtedly many other compounds. Recovery is usually possible, even at this stage, if the child is given a diet based on milk protein, poor in or devoid of lactose, and rich in calories. We doubt whether any advantage can be gained by supplying nitrogen in any form other than protein. It would certainly be less simple and probably more costly: in " any case, the need for an ample supply of essential " aminoacids appears to be inescapable. We have, since the beginning of this year, admitted 72
children for the treatment of kwashiorkor in our wards. They were not all severe cases: many mothers in Uganda are now willing to bring children to hospital before they are moribund. On admission, 40 (55%) had total serumproteins in the range up to 4-0 g. per 100 ml., 17 (24%) in the range 4-1-5-0 g., and 15 (21%) in the range 5.1 g. or more. Under regimens of the kind mentioned above, 2 of the children died; they were both in the first group. It would be valuable to know whether different treatment would be
more
successful.
Medical Research Council, Infantile Malnutrition Research Unit,
Mulago Hospital, Kampala, Uganda.
R. F. A. DEAN
R. G. WHITEHEAD.
ACUTE FIBRINOLYSIS IN A NEWBORN INFANT
SIR,-Reporting a possible second case of acute fibrinolysis in a newborn infant, Dr. Reerink-Brongers and Dr. de Koningh 10 refer to a 1962 paper as possibly the first report of this publication about this 5. 6. 7. 8. 9. 10.
syndrome. There is condition.
In
1958
earlier Dr. G.
an
Brock, J. F. Recent Advances in Clinical Nutrition. London, 1961. Tanner, J. M. Diet and Bodily Constitution. London, 1964. Whitehead, R. G. Clin. Sci. 1964, 26, 271. Whitehead, R. G., Milburn, T. R. ibid. p. 279. Whitehead, R. G. Unpublished. Reerink-Brongers, E. E., de Koningh, M. J. Lancet, 1964, i, 985.
Valentine, of St. Thomas Elgin General Hospital, St. Thomas, Ontario, Canada, presented what he believed to be the first report of fibrinolytic hemorrhagic disease in both a mother and her newborn baby ".11 "
Memorial Hospital of Long Beach, Long Beach, California, U.S.A.
GEORGE X. TRIMBLE.
PUBLIC DRINKING-FOUNTAINS
SIR,-I assume that typhoid is spread by bacteria entering the mouth. I was in London in June. During the Aberdeen outbreak I visited the British Museum and was appalled to find at the entrance two public drinking-cups (metal) chained to the two fountains. A multitude of people-and pigeons-drank from the cups. I told two attendants at the door that all London needed for its own typhoid epidemic was an Aberdeen family (or traveller), exposed to the bacteria, to drink out of the cups. I got laughs for a reply. In recent years I have visited many institutions here and abroad, and I cannot recall ever seeing a " public " drinking-cup at their fountains. Maybe 40 years ago-
but
not within recent North Rose,
decades. r
LEON J. LEON J. SALTER.
New York, U.S.A.
DEFECT OF URINARY
DEHYDROEPIANDROSTERONE EXCRETION IN HYPERTENSIVE PATIENTS SIR,-Raised levels of blood-uric-acid have been reported in hypertensive patients 12-14 and even in those with normal kidney function. Dehydroepiandrosterone (D.H.A.), the potent inhibitor of glucose-6-phosphatase, diminishes the activity of the pentose-phosphate cycler which again is important for the reduction of folic acid. In this way, D.H.A., among other metabolic pathways, could also
regulate uricosynthesis. We investigated the urinary neutral
17-ketosteroids
excretion of
D.H.A.
and total
(Y,.s.) 11 and blood-uric-acid level,
VALUES OF BLOOD-URIC-ACID, TOTAL NEUTRAL 17-KETOSTEROIDS, AND DEHYDROEPIANDROSTERONE IN THE URINE OF HEALTHY SUBJECTS AND INVESTIGATED PATIENTS
AVERAGE
Standard
error
of
mean
in
parentheses.
after reaction with
phosphotungstic acid, 1in 26 hypertensive patients (blood-pressure 155/95 mm. Hg and over)-14 men and 12 women. 16 of them were overweight. There was a disposition to depressive moods in 7 patients; 5 had manifest gout; and another had a typical acute gouty arthritic attack during treatment with chlorothiazide. The blood-uric-acid level in our patients, even after the elimination of patients with manifest gout exceeded 6 mg. per 100 ml. on five occasions and was between 5 and 6 mg. per 100 ml. on seven occasions (see accompanying table). Total 17-K.S. excretion was slightly lower than in controls. None of our patients, hypertensive or gouty, excreted D.H.A. in the urine. Obstet. Gynec. 1958, 12, 462. Dollery, C. T., Duncan, H., Schumer, B. Brit. med. J. 1960, i, 832. Arch. intern. Med. 1962, 110, 230. Pomerantz, H. Z. Canad. med. Ass. J. 1960, 82, 842. Marks, F. A., Banks, J. J. clin. Invest. 1960, 39, 1010. 16. &Sbreve;onká, J., Gregorová, I., Slabochová, Z., Rath, R. Endokrinologie, 1963, 45, 115. 17. Yi-Yung Hsia, D. Inborn Errors of Metabolism; p. 286. Chicago, 1959. 11. 12. 13. 14. 15.
100
In our opinion, at least some hypertensive patients have metabolic changes akin to gout-notably the raised blood-uric-acid level, the slightly depressed total 17-K.s. excretion in the urine, and the deficiency of D.H.A. in the urine. The importance of this deficiency in hypertensive oatients will be further studied. Third Medical Clinic, Charles University, Research Laboratory for Endocrinology and Metabolism, Prague, Czechoslovakia.
PATIENTS
4 SEROLOGICAL PREGNANCY DISTURBED PREGNANCIES,
(PREGNANCIES,
AMENORRHQEA)
I. GREGOROVÁ
J. &Sbreve;ONKA.
SIR,-Between 1937 and 1942 we studied the formation of antihormones to gonadotropic hormones,’ and concluded that this reaction is an antigen-antibody reaction which (at that time) could not be made visible for lack of proper immunological techniques. Twenty years later new methods, such as the adjuvants for immunisation (Freund, Ramon), new techniques for purification of protein antigens, and the hxmagglutination-inhibition tests for antibody detection enabled a new serological approach to be made.23 Since then four serological methods have been devised by various workers and developed by the pharmacological industry. The hsemagglutinationinhibition test has been applied for quick evaluation with thePregnosticon ’ test (2 hours) by Organon; with the ’U.C.G. ’ test (2 hours) by Denver Chemicals; and with the ’Prepuerin ’ test (12 hours) by Burroughs Wellcome. The latex agglutination-inhibition test has been employed by Ortho with the ’Gravindex ’ slide test (2 minutes). Most of these tests are quite easy to perform and render clear-cut results in regular or routine cases of pregnancy or amenorrhoea. When, however, these tests are compared with the standard Aschheim-Zondek test (A.Z.T.) in the rat, as described by us for normal pregnancies in 1945 4 and for disturbed pregnancies in 1948,5 quite another picture emerges. We have compared the results of our rat-A.Z.T. with the above four serological tests in cases including a high proportion of disturbed pregnancies, such as abortion, missed abortion, and extrauterine pregnancy, all at various stages offceial death. It is especially in such cases that the serological methods have to be judged. Our results are shown in table I. Table I shows that the rat-A.z.T. seems to be superior to the serological tests used. It should, however, be borne in mind that a serological test aims at establishing pregnancy on one test-tube only and not to make a quantitative evaluation of the gonadotrophic hormone present in the patient’s urine. The 1.
100
REACTIONS IN
F. KÖLBEL
COMPARISON OF ASCHHEIM-ZONDEK TEST WITH FOUR SEROLOGICAL PREGNANCY TESTS
2. 3. 4. 5.
TABLE I-COMPARISON OF RAT-A.Z.T. WITH
Zondek, B., Sulman, F. G. The Antigonadotropic Factor with Consideration of the Antihormone Problem. Baltimore, 1942. Brody, S., Carlström, G. Lancet, 1960, ii, 99. Wide, L., Gemzell, C. A. Acta endocr., Stockh. 1960, 35, 261. Zondek, B., Sulman, F. G., Black, R. J. Amer. med. Ass. 1945, 128, 939. Zondek, B., Sulman, F. G., Black, R. ibid. 1948, 136, 965.
technique employed in our rat-A.z.T. uses different quantities of urine injected:
4 rats which receive
It is only the last value which establishes the existence of a normal pregnancy. If lesser values are obtained, the pregnancy is either disturbed or at a very early stage. Moreover this test allows the use of part of the same rats for 4-day appraisal, where still smaller quantities than the i.u. may be recognised by the three so-called follicle-stimulating-hormone (F.S.H.) reactionsi.e., positive vaginal smear, thickened uterus, and enlarged ovaries without corpus-luteum formation. It is only logical to assume that a serological test such as pregnosticon, which gave highly reliable results (98 % correct diagnoses), can be improved by using the quantitative approach. This has been done
recently. We have received from Organon special ampoules of pregnosticon for quantitative assays. Table 11 shows our results where we have compared biological titration on rats with serological titration in 10 cases of high gonadotrophin excretionmostly moles or chorionepitheliomas. These comparative tests have shown such clear similarity that they greatly encourage the use of serological titrations in all cases of disturbed pregnancy. Twenty years of experience in our laboratory has shown that our rats are extremely reliable for the differential diagnosis of mole and chorionepithelioma. Based on the abovementioned F.S.H. reaction the following evaluation could be established: 1 million 2 " 3 "
R.U.
(F.S.H. values) suspicion of mole
"
"
"
"
"
mole
"
degenerating mole
or
twins
4-5 chorionepithelioma. There is no doubt that a similar evaluation may be obtained with a serological test once it is rigidly standardised for quantitative evaluation. It is a common experience that laboratories which handle a large number of disturbed pregnancies can never furnish the gynaecologist with an exact answer as to whether his patients "
"
"
have a disturbed pregnancy or an early pregnancy, unless titration is used. The only animal suitable for titration is the infantile female rat. It can be used for a 12-hour test or a 4-day test. Less suitable is the infantile female mouse, which can be used only for the 4-day quantitative test. Rabbits and frogs cannot be used at all since they give only a clear-cut luteinisinghormone (L.H.) reaction and do not respond in cases of reduced excretion of L.H. where rats and mice will still furnish their
TABLE II-COMPARISON OF RAT-A.Z.T. FOR MOLE AND CHORIONEPITHELIOMA WITH
QUANTITATIVE
PREGNOSTICON TEST
(3) Ratios outside the normal range appear to be associated with retarded protein synthesis. In a child whose progress is unsatisfactory and whose total serum-proteins are falling instead of rising, the ratio rises. (4) The control of the ratio is probably an important homceostatic mechanism that has a high priority. A raised ratio is a sign of distress, not merely a reflection of the quality of the diet. The raised ratio is reduced by a meal containing only a few grammes of milk protein; the concentration of the " essential " aminoacids rises but that of the " inessential" is unchanged. The reduction of the ratio is not permanent until treatment has been continued, under favourable circumstances, for about 48 hours if the diet supplies 6 g. protein per kg. body-weight or for several days if it supplies only 4 g. per kg. The ratio may revert to a high level despite the uninterrupted intake of a high-protein diet-a point suggesting impairment of the homoeostatic mechanism and also the possible need for reconsideration of the concept of " initiation of cure " advocated by Brock5 as a criterion of the value of a therapeutic diet. (5) We think it possible that the ratio may be intimately related, in ways we cannot yet understand, to the control of normal and abnormal growth. Dr. J. M. Tanner, in a most lucid exposition,6 has discussed the relationship between protein synthesis and growth at various rates, including the accelerated rate of the malnourished child during rehabilitation and the slower rate of the well-nourished one. Work on the balance of aminoacids in growth failure from various causes is urgently needed. The method we have used is relatively crude and, for other purposes, adaptations may be more suitable. Our experience has convinced us that the chief cause of kwashiorkor in Uganda is lack of protein in the diet: we have no evidence of a specific aminoacid deficiency. We think there is a long period of imperfect nutrition during which various devices, such as growth retardation and autophagy, maintain tissue metabolism until their possibilities are exhausted. The period may be shortened by an infection or other contributory disaster. There then supervenes the phase of reduced serum-proteins and severe derangement of metabolism affecting particularly histidine,phenylalanine and tyrosine,8 and lysine,9 and undoubtedly many other compounds. Recovery is usually possible, even at this stage, if the child is given a diet based on milk protein, poor in or devoid of lactose, and rich in calories. We doubt whether any advantage can be gained by supplying nitrogen in any form other than protein. It would certainly be less simple and probably more costly: in " any case, the need for an ample supply of essential " aminoacids appears to be inescapable. We have, since the beginning of this year, admitted 72
children for the treatment of kwashiorkor in our wards. They were not all severe cases: many mothers in Uganda are now willing to bring children to hospital before they are moribund. On admission, 40 (55%) had total serumproteins in the range up to 4-0 g. per 100 ml., 17 (24%) in the range 4-1-5-0 g., and 15 (21%) in the range 5.1 g. or more. Under regimens of the kind mentioned above, 2 of the children died; they were both in the first group. It would be valuable to know whether different treatment would be
more
successful.
Medical Research Council, Infantile Malnutrition Research Unit,
Mulago Hospital, Kampala, Uganda.
R. F. A. DEAN
R. G. WHITEHEAD.
ACUTE FIBRINOLYSIS IN A NEWBORN INFANT
SIR,-Reporting a possible second case of acute fibrinolysis in a newborn infant, Dr. Reerink-Brongers and Dr. de Koningh 10 refer to a 1962 paper as possibly the first report of this publication about this 5. 6. 7. 8. 9. 10.
syndrome. There is condition.
In
1958
earlier Dr. G.
an
Brock, J. F. Recent Advances in Clinical Nutrition. London, 1961. Tanner, J. M. Diet and Bodily Constitution. London, 1964. Whitehead, R. G. Clin. Sci. 1964, 26, 271. Whitehead, R. G., Milburn, T. R. ibid. p. 279. Whitehead, R. G. Unpublished. Reerink-Brongers, E. E., de Koningh, M. J. Lancet, 1964, i, 985.
Valentine, of St. Thomas Elgin General Hospital, St. Thomas, Ontario, Canada, presented what he believed to be the first report of fibrinolytic hemorrhagic disease in both a mother and her newborn baby ".11 "
Memorial Hospital of Long Beach, Long Beach, California, U.S.A.
GEORGE X. TRIMBLE.
PUBLIC DRINKING-FOUNTAINS
SIR,-I assume that typhoid is spread by bacteria entering the mouth. I was in London in June. During the Aberdeen outbreak I visited the British Museum and was appalled to find at the entrance two public drinking-cups (metal) chained to the two fountains. A multitude of people-and pigeons-drank from the cups. I told two attendants at the door that all London needed for its own typhoid epidemic was an Aberdeen family (or traveller), exposed to the bacteria, to drink out of the cups. I got laughs for a reply. In recent years I have visited many institutions here and abroad, and I cannot recall ever seeing a " public " drinking-cup at their fountains. Maybe 40 years ago-
but
not within recent North Rose,
decades. r
LEON J. LEON J. SALTER.
New York, U.S.A.
DEFECT OF URINARY
DEHYDROEPIANDROSTERONE EXCRETION IN HYPERTENSIVE PATIENTS SIR,-Raised levels of blood-uric-acid have been reported in hypertensive patients 12-14 and even in those with normal kidney function. Dehydroepiandrosterone (D.H.A.), the potent inhibitor of glucose-6-phosphatase, diminishes the activity of the pentose-phosphate cycler which again is important for the reduction of folic acid. In this way, D.H.A., among other metabolic pathways, could also
regulate uricosynthesis. We investigated the urinary neutral
17-ketosteroids
excretion of
D.H.A.
and total
(Y,.s.) 11 and blood-uric-acid level,
VALUES OF BLOOD-URIC-ACID, TOTAL NEUTRAL 17-KETOSTEROIDS, AND DEHYDROEPIANDROSTERONE IN THE URINE OF HEALTHY SUBJECTS AND INVESTIGATED PATIENTS
AVERAGE
Standard
error
of
mean
in
parentheses.
after reaction with
phosphotungstic acid, 1in 26 hypertensive patients (blood-pressure 155/95 mm. Hg and over)-14 men and 12 women. 16 of them were overweight. There was a disposition to depressive moods in 7 patients; 5 had manifest gout; and another had a typical acute gouty arthritic attack during treatment with chlorothiazide. The blood-uric-acid level in our patients, even after the elimination of patients with manifest gout exceeded 6 mg. per 100 ml. on five occasions and was between 5 and 6 mg. per 100 ml. on seven occasions (see accompanying table). Total 17-K.S. excretion was slightly lower than in controls. None of our patients, hypertensive or gouty, excreted D.H.A. in the urine. Obstet. Gynec. 1958, 12, 462. Dollery, C. T., Duncan, H., Schumer, B. Brit. med. J. 1960, i, 832. Arch. intern. Med. 1962, 110, 230. Pomerantz, H. Z. Canad. med. Ass. J. 1960, 82, 842. Marks, F. A., Banks, J. J. clin. Invest. 1960, 39, 1010. 16. &Sbreve;onká, J., Gregorová, I., Slabochová, Z., Rath, R. Endokrinologie, 1963, 45, 115. 17. Yi-Yung Hsia, D. Inborn Errors of Metabolism; p. 286. Chicago, 1959. 11. 12. 13. 14. 15.
100
In our opinion, at least some hypertensive patients have metabolic changes akin to gout-notably the raised blood-uric-acid level, the slightly depressed total 17-K.s. excretion in the urine, and the deficiency of D.H.A. in the urine. The importance of this deficiency in hypertensive oatients will be further studied. Third Medical Clinic, Charles University, Research Laboratory for Endocrinology and Metabolism, Prague, Czechoslovakia.
PATIENTS
4 SEROLOGICAL PREGNANCY DISTURBED PREGNANCIES,
(PREGNANCIES,
AMENORRHQEA)
I. GREGOROVÁ
J. &Sbreve;ONKA.
SIR,-Between 1937 and 1942 we studied the formation of antihormones to gonadotropic hormones,’ and concluded that this reaction is an antigen-antibody reaction which (at that time) could not be made visible for lack of proper immunological techniques. Twenty years later new methods, such as the adjuvants for immunisation (Freund, Ramon), new techniques for purification of protein antigens, and the hxmagglutination-inhibition tests for antibody detection enabled a new serological approach to be made.23 Since then four serological methods have been devised by various workers and developed by the pharmacological industry. The hsemagglutinationinhibition test has been applied for quick evaluation with thePregnosticon ’ test (2 hours) by Organon; with the ’U.C.G. ’ test (2 hours) by Denver Chemicals; and with the ’Prepuerin ’ test (12 hours) by Burroughs Wellcome. The latex agglutination-inhibition test has been employed by Ortho with the ’Gravindex ’ slide test (2 minutes). Most of these tests are quite easy to perform and render clear-cut results in regular or routine cases of pregnancy or amenorrhoea. When, however, these tests are compared with the standard Aschheim-Zondek test (A.Z.T.) in the rat, as described by us for normal pregnancies in 1945 4 and for disturbed pregnancies in 1948,5 quite another picture emerges. We have compared the results of our rat-A.Z.T. with the above four serological tests in cases including a high proportion of disturbed pregnancies, such as abortion, missed abortion, and extrauterine pregnancy, all at various stages offceial death. It is especially in such cases that the serological methods have to be judged. Our results are shown in table I. Table I shows that the rat-A.z.T. seems to be superior to the serological tests used. It should, however, be borne in mind that a serological test aims at establishing pregnancy on one test-tube only and not to make a quantitative evaluation of the gonadotrophic hormone present in the patient’s urine. The 1.
100
REACTIONS IN
F. KÖLBEL
COMPARISON OF ASCHHEIM-ZONDEK TEST WITH FOUR SEROLOGICAL PREGNANCY TESTS
2. 3. 4. 5.
TABLE I-COMPARISON OF RAT-A.Z.T. WITH
Zondek, B., Sulman, F. G. The Antigonadotropic Factor with Consideration of the Antihormone Problem. Baltimore, 1942. Brody, S., Carlström, G. Lancet, 1960, ii, 99. Wide, L., Gemzell, C. A. Acta endocr., Stockh. 1960, 35, 261. Zondek, B., Sulman, F. G., Black, R. J. Amer. med. Ass. 1945, 128, 939. Zondek, B., Sulman, F. G., Black, R. ibid. 1948, 136, 965.
technique employed in our rat-A.z.T. uses different quantities of urine injected:
4 rats which receive
It is only the last value which establishes the existence of a normal pregnancy. If lesser values are obtained, the pregnancy is either disturbed or at a very early stage. Moreover this test allows the use of part of the same rats for 4-day appraisal, where still smaller quantities than the i.u. may be recognised by the three so-called follicle-stimulating-hormone (F.S.H.) reactionsi.e., positive vaginal smear, thickened uterus, and enlarged ovaries without corpus-luteum formation. It is only logical to assume that a serological test such as pregnosticon, which gave highly reliable results (98 % correct diagnoses), can be improved by using the quantitative approach. This has been done
recently. We have received from Organon special ampoules of pregnosticon for quantitative assays. Table 11 shows our results where we have compared biological titration on rats with serological titration in 10 cases of high gonadotrophin excretionmostly moles or chorionepitheliomas. These comparative tests have shown such clear similarity that they greatly encourage the use of serological titrations in all cases of disturbed pregnancy. Twenty years of experience in our laboratory has shown that our rats are extremely reliable for the differential diagnosis of mole and chorionepithelioma. Based on the abovementioned F.S.H. reaction the following evaluation could be established: 1 million 2 " 3 "
R.U.
(F.S.H. values) suspicion of mole
"
"
"
"
"
mole
"
degenerating mole
or
twins
4-5 chorionepithelioma. There is no doubt that a similar evaluation may be obtained with a serological test once it is rigidly standardised for quantitative evaluation. It is a common experience that laboratories which handle a large number of disturbed pregnancies can never furnish the gynaecologist with an exact answer as to whether his patients "
"
"
have a disturbed pregnancy or an early pregnancy, unless titration is used. The only animal suitable for titration is the infantile female rat. It can be used for a 12-hour test or a 4-day test. Less suitable is the infantile female mouse, which can be used only for the 4-day quantitative test. Rabbits and frogs cannot be used at all since they give only a clear-cut luteinisinghormone (L.H.) reaction and do not respond in cases of reduced excretion of L.H. where rats and mice will still furnish their
TABLE II-COMPARISON OF RAT-A.Z.T. FOR MOLE AND CHORIONEPITHELIOMA WITH
QUANTITATIVE
PREGNOSTICON TEST