A family study of vesicoureteric reflux

Vesicoureteric reflux is now considered to be due essentially to congenital malformation of the vesicoureteric junction. It is also considered to be a major cause of renal failure in early adult life. The condition is associated with recurrent urinary tract infection and in some instances with renal scarring. When reflux is detected clinically, in the investigation of patients with recurrent urinary tract infection, renal scarring is often already present. The reflux tends to disappear in later childhood.

A family study has been made based on 186 index patients with established primary reflux, with special attention to a history of genitourinary symptoms in the sibs and parents of these patients. There were 39 sibs under the age of 4 years. For these the parents were offered investigation by micturating cystogram. The parents of 20 accepted. Reflux was shown in 3, and in 2 of these there was already renal scarring. The proportion of all infants and young children who have reflux is not accurately known, but the few published surveys of screening of normal infants and young children by micturating cystogram suggest that the prevalence is of the order of 1%. The prevalence in sibs is, then, about 10 times higher. There was a main group of 214 sibs over the age of 4 years. For these the parents were offered investigation by intravenous pyelogram only for those sibs who had a history of recurrent urinary tract infection. If renal scarring was found then a micturating cystogram was done. Of 110 sisters, 12 were `symptomatic', renal scarring was found in 5 of these (1 was on haemodialysis), and reflux was still present in 3. Of 104 brothers 7 were `symptomatic', renal scarring was found in 2 and reflux was present in both. For comparison, the published reports of several surveys of schoolgirls indicate that about 2 in 100 have recurrent urinary tract infection, and in about a quarter of these (0·5%) reflux was present and in about one-eighth (0·25%) renal scarring was present. The prevalence in sibs is, then, 10 to 20 times higher. Similarly in the parents: of 183 mothers 7 (1 was on haemodialysis) and of 181 fathers 2 had renal scarring.

The family findings are consistent with multifactorial inheritance, as with other common malformations.

Routine investigation, in infancy, of younger sibs of patients with vesicoureteric reflux would identify patients in whom the reflux was recognised very early. These would be valuable for the study of the natural history and management of the disorder, and the degree to which it was possible to prevent the development of renal scarring.

Use of creatine kinase for detecting severe X-linked muscular dystrophy carriers

Women thought to be at risk of being carriers of Duchenne muscular dystrophy were given "odds" against their having an affected child. These were calcuated from a combination of the genetic risk from the family history and an estimation of the biochemical risk from measuring the serum creatine kinase concentration. The women were told the actual risk estimate and it was put into perspective for them as a high, medium, or low risk. Of 25 women at high risk six have had children, all girls; the two in the medium-risk group have had no children; and the 46 women at low risk have had 19 boys and 25 girls. None of the boys has the disease. With detailed counselling most potential carriers of this disease reach decisions in child bearing that are in line with their degree of risk.

Measurement of pituitary hormones: clinical applications. 5. Prolactin

A sensitive and specific assay for human prolactin has been developed using human prolactin and antiserum distributed by the United States National Pituitary Agency. Plasma prolactin concentrations in control subjects ranged from 0-20 ng/ml. No sex difference in prolactin concentration was observed. A brisk increase in plasma prolactin levels occurred in normal subjects during the administration of chlorpromazine and thyroid stimulating hormone releasing factor (TRH). These stimulatory tests of prolactin release should therefore be useful in the assessment of hypothalamic pituitary function. Basal plasma prolactin values were raised in most patients who were being treated with phenothiazines and were helpful diagnostically in patients with amenorrhoea, galactorrhoea, hypogonadism, cranio-pharyngioma, "non-functioning" pituitary tumours and acromegaly. In many of these disorders a significant reduction in the plasma prolactin concentration was observed following oral administration of bromocriptine. Plasma prolactin determinations should be useful in evaluating the response to medical treatment or pituitary ablation.

The effects of stilboestrol and quinestrol upon coagulation and fibrinolysis during the puerperium

Two oestrogens, stilboestrol and quinestrol, were used to inhibit lactation and their effects upon coagulation and fibrinolysis were compared with control patients before delivery, during the puerperium and six weeks after delivery. During the first week of the puerperium, stilboestrol therapy was associated with rises of factors IX and X and quinestrol therapy with rises of factors IX and II. Six weeks after delivery, the clotting factors were similar to the control values in those who had received stilboestrol but factor II was still raised in the quinestrol treated patients. Additionally, a significant rise of factor X in the quinestrol group was noted at this time. Plasma antithrombin levels rose during the first week of the puerperium in all three groups but, six weeks after delivery, they were lower in those who had received oestrogens. Stilboestrol and quinestrol were also associated with a rise of plasminogen and antiplasmin concentration during the first week of the puerperium. Six weeks after delivery, quinestrol treated patients still had raised levels of plasminogen and antiplasmin while the stilboestrol treated patients only had raised levels of antiplasmin. These changes in coagulation and fibrinolysis are similar to those reported during oral contraceptive therapy. The persisting changes six weeks after delivery in women who had taken quinestrol might indicate an increased thrombogenic risk when long acting oestrogen preparations are used to inhibit lactation.

The short-term response to a drink of milk, lactose or casein in children with apparently normal gastrointestinal tracts

1. Drinks of milk, lactose and casein were given to children who, though suspected of having malabsorption, were subsequently found to have normal gastrointestinal tracts. The plasma concentrations of glucose, amino acids, urea and insulin following these drinks were measured. The results can probably be taken to represent control values when investigating children with gastrointestinal or metabolic disorders.

2. The rise in plasma amino acids after giving casein and the rise in plasma glucose after giving lactose were greater than those after giving equivalent amounts of milk.

3. The absorption of an individual food constituent and its uptake by the tissues are influenced by the presence of other food constituents so that ‘tolerance tests’ with individual nutrients may not be truly physiological.

Handicap and social status of adults with spina bifida cystica

The present physical handicaps and social status of 202 survivors of spina bifida cystica attending The Hospital for Sick Children, Great Ormond Street before 1954 are described. Ninety-three of the patients, mostly with uncomplicated meningocele, had escaped serious disability and were living normal lives. But 109 had a serious disability, including three who are mentally retarded. Some of the difficulties of living with spina bifida are described, and a record of work, marriage, and reproduction in the whole group of survivors is shown. Of the 106 with serious locomotor problems and/or incontinence, 58 work regularly, 17 have long spells off work, and 31 have never worked at all; 24 have married, 16 have 26 children none of whom has spina bifida. Of the 96 without physical handicap, 93 work regularly, 47 are married, and 34 have 75 children one of whom has spina bifida cystica and one anencephaly.

Spina bifida and anencephalus in greater London

In order to make comparisons with the findings in a high frequency area, South Wales, with those in a low frequency area, south-east England, a birth frequency and family study was made of all births with neural tube malformations (spina bifida cystica, encephalocele, anencephaly, and iniencephaly) in 32 of the 33 London Boroughs over a 3-year period from 1 April 1965 to 31 March 1968. The births were ascertained through local authority registers, stillbirth and infant death certificates, and hospital records. The frequencies found were 1·54 for spina bifida (including encephalocele) and 1·41 for anencephaly (including iniencephaly). This was less than four tenths of the South Wales frequency. Evidence of an excess of winter births was found for both types of malformation, with a peak for conceptions in February, March, and April.

The parents of 870 of the original 1209 index patients were traced and visited for the family survey. The usual social class effect was seen, a deficit of fathers in social class I and II. The birth order distribution of legitimately born patients standardized for maternal age showed only a small excess of firstborn and a deficit rather than an excess of lateborn. For maternal age, however, standardized for birth order, there was an excess of patients born to mothers under 20 and over 35 years of age. The whole family study sample showed a striking excess of patients born to parents from India and Pakistan compared to parents born in the West Indies in relation to households of immigrant parents in the 1966 sample Census. A small sample of 164 patients with matched controls had more parents born in Ireland and India and Pakistan and fewer born in south-east England and the West Indies than the controls.

The proportions of sibs affected with spina bifida and anencephaly were 3·42% for spina bifida index patients and 5·44% for anencephaly. For patients born after the index patient the proportions were 5·17 and 4·17%, respectively. The overall risk to sibs was lower than that shown in the South Wales survey, but substantially higher relative to the population birth frequency. The risk to sibs was not apparently influenced by father's social class but there was an indication of an effect of mother's father's social class, with a lower risk where mother had grown up in a class I, II, or IIIa home. There was no apparent influence of grandparental birth place. There was no apparent effect of a relative affected other than a sib. Among cousins a significant increase over the population birth frequency was seen only in mother's sisters' children.

The findings, like those of earlier surveys, suggest a multifactorial aetiology of the neural tube malformations, depending both on genetic predisposition and environmental triggers.

Abnormalities of insulin and growth hormone secreton in children with coeliac disease

The effect of intravenous tolbutamide on plasma levels of glucose, cortisol, growth hormone, and insulin, and the effect of oral Bovril on plasma growth hormone have been studied in 10 children with coeliac disease and 6 children who, though small, had normal jejunal morphology (`controls'). The growth hormone and insulin responses to tolbutamide in the children with coeliac disease were significantly smaller than in the controls. Growth hormone response to Bovril was normal in most of the children but 3 of them with coeliac disease failed to achieve a satisfactory response in growth hormone levels after both tolbutamide and Bovril. These results cannot be explained by malnutrition or by inadequate hypoglycaemia during tolbutamide stimulation, and a convincing hypothesis to explain them has not been formulated. Clinically, though tests of other conventional stimuli of growth hormone and insulin production require study, the diagnosis of coeliac disease should actively be considered in any child with low levels of insulin and growth hormone. These observations may partly explain the association of coeliac disease and diabetes mellitus.