Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial

BACKGROUND

Minimal pain and opioid use after operative treatment for pediatric supracondylar humeral fractures have been previously described; however, opioid-prescribing practices in the United States remain variable. We hypothesized that children without an opioid prescription would report similar postoperative pain compared with children prescribed opioids following closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures.

METHODS

Children who were 3 to 12 years of age and were undergoing CRPP for a closed supracondylar humeral fracture were prospectively enrolled in a multicenter, comparative study. Following a standardized dosing protocol, oxycodone, ibuprofen, and acetaminophen were prescribed at 2 hospitals (opioid cohort), and 2 other hospitals prescribed ibuprofen and acetaminophen alone (non-opioid cohort). The children's medication use and the daily pain that they experienced (scored on the Wong-Baker FACES Scale) were recorded at postoperative days 1 to 7, 10, 14, and 21, using validated text-message protocols. Based on an a priori power analysis, at least 64 evaluable subjects were recruited per cohort.

RESULTS

A total of 157 patients were evaluated (81 [52%] in the opioid cohort and 76 [48%] in the non-opioid cohort). The median age at the time of the surgical procedure was 6.2 years, and 50% of the subjects were male. The mean postoperative pain scores were low overall (<4 of 10), and there were no significant differences in pain ratings between cohorts at any time point. No patient demographic or injury characteristics were correlated with increased pain or medication use. Notably, of the 81 patients in the opioid cohort, 28 (35%) took no oxycodone and 40 (49%) took 1 to 3 total doses across the postoperative period. Patients rarely took opioids after postoperative day 2. A single patient in the non-opioid cohort (1 [1%] of 76) received a rescue prescription of opioids after presenting to the emergency department with postoperative cast discomfort.

CONCLUSIONS

Non-opioid analgesia following CRPP for pediatric supracondylar humeral fractures was equally effective as opioid analgesia. When oxycodone was prescribed, 84% of children took 0 to 3 total doses, and opioid use fell precipitously after postoperative day 2. To improve opioid stewardship, providers and institutions can consider discontinuing the routine prescription of opioids following this procedure.

LEVEL OF EVIDENCE

Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Interobserver and Intraobserver Agreement are Unsatisfactory When Determining Abstract Study Design and Level of Evidence

BACKGROUND

Understanding differences between types of study design (SD) and level of evidence (LOE) are important when selecting research for presentation or publication and determining its potential clinical impact. The purpose of this study was to evaluate interobserver and intraobserver reliability when assigning LOE and SD as well as quantify the impact of a commonly used reference aid on these assessments.

METHODS

Thirty-six accepted abstracts from the Pediatric Orthopaedic Society of North America (POSNA) 2021 annual meeting were selected for this study. Thirteen reviewers from the POSNA Evidence-Based Practice Committee were asked to determine LOE and SD for each abstract, first without any assistance or resources. Four weeks later, abstracts were reviewed again with the guidance of the Journal of Bone and Joint Surgery (JBJS) LOE chart, which is adapted from the Oxford Centre for Evidence-Based Medicine. Interobserver and intraobserver reliability were calculated using Fleiss' kappa statistic (k). χ2 analysis was used to compare the rate of SD-LOE mismatch between the first and second round of reviews.

RESULTS

Interobserver reliability for LOE improved slightly from fair (k=0.28) to moderate (k=0.43) with use of the JBJS chart. There was better agreement with increasing LOE, with the most frequent disagreement between levels 3 and 4. Interobserver reliability for SD was fair for both rounds 1 (k=0.29) and 2 (k=0.37). Similar to LOE, there was better agreement with stronger SD. Intraobserver reliability was widely variable for both LOE and SD (k=0.10 to 0.92 for both). When matching a selected SD to its associated LOE, the overall rate of correct concordance was 82% in round 1 and 92% in round 2 (P<0.001).

CONCLUSION

Interobserver reliability for LOE and SD was fair to moderate at best, even among experienced reviewers. Use of the JBJS/Oxford chart mildly improved agreement on LOE and resulted in less SD-LOE mismatch, but did not affect agreement on SD.

LEVEL OF EVIDENCE

Level II.

Klippel-Feil Syndrome: Clinical Presentation and Management

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Klippel-Feil syndrome (KFS) is a rare multisystem constellation of findings with congenital cervical fusion as the hallmark. The etiology is not fully understood.

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Recent studies have indicated that KFS is more prevalent than previously described.

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Hypermobility in the nonfused segments may lead to adjacent segment disease and potential disc herniation and myelopathy after minor trauma.

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Most patients with KFS are asymptomatic and can be managed nonoperatively. Surgical treatment is reserved for patients presenting with pain refractory to medical management, instability, myelopathy or radiculopathy, or severe adjacent segment disease.

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Patients with craniocervical abnormalities and upper cervical instability should avoid contact sports as they are at increased risk for spinal cord injury after minor trauma.

Significant Variation in Blood Transfusion Practice Persists Following Adolescent Idiopathic Scoliosis Surgery

STUDY DESIGN

Retrospective case control study.

OBJECTIVE

To review current transfusion practise following Adolescent Idiopathic Scoliosis (AIS) surgery and assess risks of complication from transfusion in this cohort.

SUMMARY OF BACKGROUND DATA

No study to date has investigated variation in blood transfusion practices across surgeons and hospitals following AIS surgery.

METHODS

Data were extracted from the Statewide Planning and Research Cooperative System. Using International Classification of Diseases (ICD-9) all patients with (ICD-9) code for AIS (737.30) ("idiopathic scoliosis") and underwent spinal fusion between 2000 and 2015 were included. Bivariate and mixed-effects logistic regression analyses were performed to assess patient, surgeon, and hospital factors associated with perioperative allogeneic red blood cell transfusion. Additional multivariable analyses examined the association between transfusion and infectious complications.

RESULTS

Of the 7689 patients who underwent AIS surgery, 21.1% received a perioperative blood transfusion. After controlling for patient factors, wide variation in risk-adjusted transfusion rates was present with a 10-fold difference in transfusion rates observed across surgeons (4.4%-46.1%) and hospitals (5.1%-50%). Patient factors did not explain any of the surgeon or hospital variation. Use of autologous blood transfusion, higher surgeon procedure volume, and greater surgeon years in practice were independently associated with lower odds of allogeneic blood transfusion (P < 0.001), and surgeon and hospital characteristics explained 45% of surgeon variation but only 2.4% of hospital variation. Allogeneic blood transfusion was independently associated with postoperative wound infection (OR = 1.87, 95% CI = 1.20-2.93), pneumonia (OR = 1.68, 95% CI = 1.26-2.44), and sepsis (OR = 2.42, 95% CI = 1.11-5.83).

CONCLUSION

Significant variation exists across both surgeons and hospitals in perioperative blood transfusion utilization following AIS surgery. Use of autologous blood transfusion and implementing institutional transfusion protocols may reduce unwarranted variation and potentially decrease infectious complication rates.Level of Evidence: 3.

Operative Reduction for Developmental Dysplasia of the Hip: Epidemiology Over 16 Years

BACKGROUND

The burden of surgical treatment for infantile developmental dysplasia of the hip (DDH) is unknown. We aimed to investigate the epidemiology of operative DDH reductions in the United States and identify potential at-risk populations.

METHODS

The Healthcare Utilization Project Kids' Inpatient Database (1997 to 2012) were analyzed. International Classification of Diseases (ICD-9) codes identified inpatient hospitalizations for DDH reductions excluding neuromuscular cases. Hospital variables and patient demographics were captured. Weighted population-level counts were calculated to allow for national estimates.

RESULTS

An estimated 5525 (95% confidence interval, 4907.8-6142.2) operative reductions were performed. In total, 73.3% were open with a mean age at the reduction of 2.3 years (95% confidence interval, 2.1-2.5). In total, 70.0% were female and 42.3% were white. Regional distribution varied: 36.4% of reductions occurred in the West, 22.8% in the South, 21.9% in the Midwest, and 18.9% in the Northeast. Operative reductions decreased over time; open reductions decreased by 5.6% and closed by 53.4%. Mean age at treatment increased from 1.6 to 3.7 years (P<0.001). On multivariate analysis, age (P<0.001) and geographic location (P<0.05) were associated with open reduction. Patients in the West had increased odds of being Hispanic or Asian/Pacific Islander [odds ratio (OR), 4.9, P<0.001 and OR, 2.8; P=0.008]. In the South and Midwest, the highest income quartile was protective (OR, 0.4; P=0.001 and OR, 0.5; P=0.018).

CONCLUSIONS

The frequency of closed reductions decreased more over time compared with open reductions. However, the mean age of children undergoing reductions increased suggesting a possible delay in diagnosis. The data suggests that there is room for improvement in screening. Targeted research in identified populations may reduce the burden of surgical disease in infantile DDH.

LEVEL OF EVIDENCE

Level III.

Postoperative Pain and Opioid Use in Children with Supracondylar Humeral Fractures: Balancing Analgesia and Opioid Stewardship

BACKGROUND

Effective postoperative analgesia remains a priority in orthopaedic surgery, but concerns with regard to opioid diversion and misuse have brought overdue attention to improving opioid stewardship. Normative data for postoperative pain and opioid use are needed to guide and balance these dual priorities. We aimed to characterize postoperative pain and opioid use for an archetypal pediatric orthopaedic procedure: closed reduction and percutaneous pinning of a supracondylar humeral fracture.

METHODS

Children at a single pediatric trauma center who underwent closed reduction and percutaneous pinning of a supracondylar humeral fracture were enrolled and were prospectively followed. Validated pain scores (Wong-Baker FACES Pain Rating Scale) and opioid utilization data were collected using an automated text message-based protocol on postoperative days 1 to 7, 10, 14, and 21. Data were analyzed with descriptive and univariate statistics.

RESULTS

Eighty-one patients with a mean age (and standard deviation) of 6.1 ± 2.1 years (62% of whom were male) were enrolled, including 53.1% who had Type-II fractures and 46.9% who had Type-III fractures. The mean pain ratings were highest on arrival to the emergency department (3.5 ± 3.5 points) and the morning of postoperative day 1 (3.5 ± 2.4 points). By postoperative day 3, the mean pain rating decreased to <2 (1.8 ± 1.8 points) and the mean opioid doses decreased to <1 dose (0.8 ± 1.2 doses). Postoperative opioid use decreased in parallel to reported pain (r = 0.972; p < 0.001). The interquartile range of opioid use was 1 to 7 doses, and patients used only 24.1% of the prescribed opioids (mean, 4.8 ± 5.6 doses used and 19.8 ± 7.1 doses prescribed). There was no significant difference (p > 0.05) in pain ratings or opioid use by fracture classification, age, or sex.

CONCLUSIONS

Following closed reduction and percutaneous pinning for supracondylar humeral fracture, pain levels and opioid usage decrease to a clinically unimportant level by postoperative day 3. Patients who report pain scores of ≥6 points following discharge are outliers and should be screened for compartment syndrome or ischemia. Patients used <25% of prescribed opioid medication, suggesting the potential for overprescription and opioid diversion. A prescription for 7 opioid doses after discharge should allow adequate postoperative analgesia in the majority of patients while improving narcotic stewardship.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

What's New in Pediatric Hip?

BACKGROUND

Developmental dysplasia of the hip (DDH), which encompasses a wide spectrum of disease from mild dysplasia to frank dislocation, is one of the most common developmental deformities of the lower extremities and one of the leading causes of future osteoarthritis and hip arthroplasty. Legg-Calvé-Perthes disease (LCPD) results from a vascular insult to the growing femoral epiphysis, which in turn can create permanent morphologic changes to the hip joint. Slipped capital femoral epiphysis (SCFE) occurs when the proximal femoral physis fails allowing the epiphysis to displace in relation to the metaphysis. Infections about the hip also create significant morbidity in the pediatric hip.

METHODS

We searched the PubMed database for all studies related to DDH, LCPD, SCFE, and pediatric hip infections that were published between July 1, 2014 and August 31, 2017. The search was limited to English articles and yielded 839 papers. This project was initiated by the Pediatric Orthopaedic Society of North America Publications Committee and was reviewed and approved by the Pediatric Orthopaedic Society of North America Presidential Line.

RESULTS

A total of 40 papers were selected for review based upon new and significant findings. Select historical manuscripts are also included to provide sufficient background information.

CONCLUSIONS

DDH, LCPD, SCFE, and infections about the hip continue to be important topics in pediatric orthopaedics and areas of vital research. This manuscript reviews the most important recent literature on the diagnosis and treatment of these pediatric hip conditions.

LEVEL OF EVIDENCE

Level V.

Atrial natriuretic peptide blockade exacerbates high altitude pulmonary edema in endotoxin-primed rats

High altitude pulmonary edema (HAPE) is associated with increases in pulmonary arterial and hydrostatic pressures and an increase in pulmonary vascular permeability. There is evidence to suggest that inflammatory mediators may cause some forms of HAPE, and Salmonella enteritidis endotoxin (ETX) is known to activate neutrophils and inflammatory mediators, such as TNF-alpha and IL1-beta. Since HAPE has been produced in rats primed with ETX, we hypothesized that ANP release and action may ameliorate HAPE and that ANP blockade may exacerbate HAPE in ETX-primed rats exposed to high altitude (HA). Plasma ANP, right atrial ANP mRNA, and indexes of lung injury were measured in rats primed with endotoxin (ETX) (0.1 mg/kg BW, i.p.) and exposed to simulated HA (4267 m; P(B) = 440 mmHg) for either 12 or 24 h. Catheters were chronically inserted into the right carotid artery, pulmonary artery, and jugular vein for assessment of hemodynamic parameters in response to ETX and/or HA. In addition, some rats were injected with an antibody against ANP (alphaANP) prior to normoxic (NX) or HA exposure. Pulmonary arterial pressure increased in the alphaANP group (50 +/- 20%; p < or = 0.05) and in the HA + alphaANP (51 +/- 15%; p < or = 0.05) group at 12 h compared to NX sham rats injected with normal rabbit serum. In addition, systemic arterial pressure was significantly lower in the HA + ETX rats compared to HA + ETX + alphaANP rats (p < or = 0.001). Plasma ANP levels were significantly higher at 12 and 24 h in ETX, HA, and HA + ETX groups (p <or = 0.05) compared to NX controls. There was an inverse relationship (p <or = 0.001) between plasma ANP levels and lung wet to dry (W/D) weight when data from NX, ETX, HA, and HA + ETX groups were pooled. The HA + alphaANP rats had significantly higher lung W/D ratios (p < 0.001) compared to sham rats. These results support the hypothesis that ANP, at physiological levels, modulates the development of pulmonary edema in HA-exposed ETX-primed rats.

Cellular mechanisms by which oxytocin mediates ovine endometrial prostaglandin F2alpha synthesis: role of G(i) proteins and mitogen-activated protein kinases

Oxytocin stimulates a rapid increase in ovine endometrial prostaglandin (PG) F2alpha synthesis. The overall objective of these experiments was to investigate the cellular mechanisms by which oxytocin induces endometrial PGF2alpha synthesis. The objective of experiment 1 was to determine whether G(i) proteins mediate oxytocin-induced PGF2alpha synthesis. Uteri were collected from four ovary-intact ewes on Day 14 postestrus. Caruncular endometrial explants were dissected and subjected to in vitro incubation. Pertussis toxin, an inhibitor of G(i) proteins, had no effect on the ability of oxytocin to induce PGF2alpha synthesis (P > 0.10). The objective of experiment 2 was to determine whether any of the three mitogen-activated protein kinases (MAPKs), extracellular signal regulated protein kinase (ERK1/2), c-Jun N-terminal/stress-activated protein kinase (JNK/SAPK), or p38 MAPK, mediate oxytocin-induced PGF(2alpha) synthesis. Eleven ovary-intact ewes were given an injection of oxytocin (10 IU; i.v.; n = 5) or physiological saline (i.v.; n = 6) on Day 15 postestrus. Uteri were collected 15 min after injection and caruncular endometrium was dissected. Endometrial homogenates were prepared and subjected to Western blotting. Membranes were probed for both total and phosphorylated forms of all three classes of MAPK. All classes of MAPK were detected in ovine endometrium, but oxytocin treatment had no effect on the expression of these proteins (P > 0.10). ERK1/2 was the only phosphorylated MAPK detected and its concentrations were higher in oxytocin-treated ewes (P < 0.01). The objective of experiment 3 was to further investigate the role of ERK1/2 during oxytocin-induced PGF2alpha synthesis. Uteri were collected from four ovary-intact ewes on Day 14 postestrus. Caruncular endometrial explants were dissected and subjected to in vitro incubation. PD98059, a specific inhibitor of ERK1/2 activity, blocked the ability of oxytocin to stimulate PGF(2alpha synthesis in a dose-dependent manner (P < 0.05). These results indicate that the ovine oxytocin receptor is not coupled to G(i) proteins. These results indicate that oxytocin induces phosphorylation of ERK1/2 and that this MAPK appears to mediate oxytocin-induced PGF2alpha synthesis in ovine endometrium.

Exposure to soy-based formula in infancy and endocrinological and reproductive outcomes in young adulthood

CONTEXT

A large body of evidence documents the role of phytoestrogens in influencing hormone-dependent states. Infants fed soy formula receive high levels of phytoestrogens, in the form of soy isoflavones, during a stage of development at which permanent effects are theoretically possible. However, a paucity of data exists on the long-term effects of infant soy formulas.

OBJECTIVE

To examine the association between infant exposure to soy formula and health in young adulthood, with an emphasis on reproductive health.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study conducted from March to August 1999 among adults aged 20 to 34 years who, as infants, participated during 1965-1978 in controlled feeding studies conducted at the University of Iowa, Iowa City (248 were fed soy formula and 563 were fed cow milk formula during infancy).

MAIN OUTCOME MEASURES

Self-reported pubertal maturation, menstrual and reproductive history, height and usual weight, and current health, compared based on type of formula exposure during infancy.

RESULTS

No statistically significant differences were observed between groups in either women or men for more than 30 outcomes. However, women who had been fed soy formula reported slightly longer duration of menstrual bleeding (adjusted mean difference, 0.37 days; 95% confidence interval [CI], 0.06-0.68), with no difference in severity of menstrual flow. They also reported greater discomfort with menstruation (unadjusted relative risk for extreme discomfort vs no or mild pain, 1.77; 95% CI, 1.04-3.00).

CONCLUSIONS

Exposure to soy formula does not appear to lead to different general health or reproductive outcomes than exposure to cow milk formula. Although the few positive findings should be explored in future studies, our findings are reassuring about the safety of infant soy formula.

Iron absorption during recovery from malnutrition

OBJECTIVE

In infants and children recovering from severe malnutrition, iron deficiency is common, and the ability to absorb iron during such recovery is uncertain. The objective of this study was to determine iron absorption during recovery from malnutrition.

METHODS

During the later stages of recovery from malnutrition, erythrocyte incorporation of orally administered 58Fe was determined as a surrogate for iron absorption. Based on four indices, subjects were classified as iron-sufficient, iron-deficient or indeterminate.

RESULTS

Of the 25 subjects, 9 were classified as iron sufficient, 5 as indeterminate and 11 as iron deficient; all but 5 had evidence of inflammation or infection. Geometric mean erythrocyte incorporation of 58Fe was 32.0% of the dose in the iron-deficient subjects, which was not significantly different (p = 0.073) than the 13.1% in the iron-sufficient subjects. Incorporation of 58Fe by the iron-sufficient subjects did not differ significantly from that by normal subjects in the same age range. Surprisingly, we found no correlation of erythrocyte incorporation of 58Fe and reticulocyte count.

CONCLUSIONS

Even in the presence of infection or inflammation, iron absorption by children during a late stage of recovery from malnutrition is not impaired.

Gas production by feces of infants

BACKGROUND

Intestinal gas is thought to be the cause abdominal discomfort in infants. Little is known about the type and amount of gas produced by the infant's colonic microflora and whether diet influences gas formation.

METHODS

Fresh stool specimens were collected from 10 breast-fed infants, 5 infants fed a soy-based formula, and 3 infants fed a milk-based formula at approximately 1, 2, and 3 months of age. Feces were incubated anaerobically for 4 hours at 37 degrees C followed by quantitation of hydrogen (H2), methane (CH4), carbon dioxide (CO2), hydrogen sulfide (H2S), methanethiol (CH3SH), and dimethyl sulfide (CH3SCH3) in the head-space.

RESULTS

H2 was produced in greater amounts by breast-fed infants than by infants in either formula group, presumably the consequence of incomplete absorption of breast milk oligosaccharides. CH4 was produced in greater amounts by infants fed soy formula than by infants on other diets. CO2 was produced in similar amounts by infants in all feeding groups. Production of CH3SH was conspicuously low by feces of breast-fed infants and production of H2S was high by soy-formula-fed infants. CH3SCH3 was not detected. Only modest changes with age were observed and there was no relation between gas production and stool consistency, although stools were more likely to be malodorous when concentrations of H2S and/or CH3SH were high.

CONCLUSIONS

Gas release by infant feces is strongly influenced by an infant's diet. Of particular interest are differences in production of the highly toxic sulfur gases, H2S and CH3SH, because of the role that these gases may play in certain intestinal disorders of infants.

Binding of agonist but not antagonist leads to fluorescence resonance energy transfer between intrinsically fluorescent gonadotropin-releasing hormone receptors

We have used spot fluorescence photobleaching recovery methods to measure the lateral diffusion of GnRH receptor (GnRHR) fused at its C terminus to green fluorescent protein (GFP) after binding of either GnRH agonists or antagonist. Before ligand binding, GnRHR-GFP exhibited fast rates of lateral diffusion (D = 18 +/- 2.8 x 10(-10)cm2 x sec(-1)) and high values for fractional fluorescence recovery (%R) after photobleaching (73 +/- 1%). Increasing concentrations of agonists, GnRH or D-Ala6-GnRH, caused a dose-dependent slowing of receptor lateral diffusion as well as a decreased fraction of mobile receptors. Increasing concentrations of the GnRH antagonist Antide slowed the rate of receptor diffusion but had no effect on the fraction of mobile receptors, which remained high. To determine whether the decrease in %R caused by GnRH agonists was due, in part, to increased receptor self-association, we measured the fluorescence resonance energy transfer efficiency between GnRHR-GFP and yellow fluorescent protein-GNRHR: There was no energy transfer between GnRHR on untreated cells. Treatment of cells with GnRH agonists led to a concentration-dependent increase in the energy transfer between GnRH receptors to a maximum value of 16 +/- 1%. There was no significant energy transfer between GnRH receptors on cells treated with Antide, even at a concentration of 100 nM. These data provide direct evidence that, before binding of ligand, GnRHR exists as an isolated receptor and that binding of GnRH agonists, but not antagonist, leads to formation of large complexes that exhibit slow diffusion and contain receptors that are self-associated.

Retention of iron by infants

Throughout the world, the most common nutritional deficiency disorder of infants is iron deficiency. Developing effective strategies for preventing iron deficiency requires detailed knowledge of iron retention under ordinary living conditions. For the adult population, such knowledge is at an advanced stage, but relatively little is known about infants. Many reports of iron retention by infants have been based on the assumption that, as in normal and iron-deficient adults, 80%-100% of newly absorbed iron is promptly incorporated into circulating erythrocytes, but this assumption is not supported by available data. This communication presents a review of iron retention by term and preterm infants, as determined by metabolic balance studies or (59)Fe whole-body counting studies, and it explores the relationship between iron retention and postnatal age, iron nutritional status, iron intake (or dose), and type of feeding.

Conceptual structure and social functions of behavior explanations: beyond person--situation attributions

The traditional approach to studying behavior explanations involves treating them as either person causes or situation causes and assessing them by using rating scales. An analysis of people's free-response behavior explanations reveals, however, that the conceptual distinctions people use in their explanations are more complex and sophisticated than the person-situation dichotomy suggests. The authors, therefore, introduce a model of the conceptual structure of folk behavior explanations (the network of concepts and assumptions on which explanations are based) and test it in 4 studies. The modes and features of behavior explanations within this conceptual structure also have specific social functions. In 2 additional studies, the authors demonstrate that people alter distinct features of their explanations when pursuing particular impression-management goals and that listeners make inferences about explainers' goals on the basis of these features.

Conceptual structure and social functions of behavior explanations: beyond person--situation attributions

The traditional approach to studying behavior explanations involves treating them as either person causes or situation causes and assessing them by using rating scales. An analysis of people's free-response behavior explanations reveals, however, that the conceptual distinctions people use in their explanations are more complex and sophisticated than the person-situation dichotomy suggests. The authors, therefore, introduce a model of the conceptual structure of folk behavior explanations (the network of concepts and assumptions on which explanations are based) and test it in 4 studies. The modes and features of behavior explanations within this conceptual structure also have specific social functions. In 2 additional studies, the authors demonstrate that people alter distinct features of their explanations when pursuing particular impression-management goals and that listeners make inferences about explainers' goals on the basis of these features.

Intestinal blood loss during cow milk feeding in older infants: quantitative measurements

OBJECTIVE

To determine the response, in terms of fecal hemoglobin excretion and clinical symptoms, of normal 9 1/2-month-old infants to being fed cow milk.

DESIGN

Longitudinal (before-after) trial in which each infant was fed formula for 1 month (baseline) followed by 3 months during which cow milk was fed.

SETTING

Healthy infants living in Iowa City, Iowa, a town with a population of about 60,000.

MAIN OUTCOME MEASURES

Hemoglobin concentration in spot stools, 96-hour quantitative fecal hemoglobin excretion, stool characteristics, feeding-related behaviors, and iron nutritional status.

RESULTS

Fecal hemoglobin concentration during formula feeding (baseline) was higher than previously observed in younger infants. Nine of 31 infants responded to cow milk feeding with increased fecal hemoglobin concentration. Fecal hemoglobin concentration (mean +/- SD) of the 9 responders rose from 1,395 +/- 856 microg/g of dry stool (baseline) to 2,711 +/- 1,732 microg/g of dry stool (P=.01). The response rate (29%) was similar to that in younger infants, but the intensity of the response was much less. Quantitative hemoglobin excretion was in general agreement with estimates based on spot stool hemoglobin concentrations. Cow milk feeding was not associated with recognizable changes in stool characteristics, nor were there clinical signs related to fecal blood loss. Iron status was similar, except that after 3 months of cow milk feeding responders showed lower (P= .047) ferritin concentrations than nonresponders.

CONCLUSIONS

Cow milk-induced blood loss is present in 9 1/2-month-old infants but is of such low intensity that its clinical significance seems questionable. Nevertheless, infants without cow milk-induced blood loss were in better iron nutritional status than infants who showed blood loss.

Time course of and effect of dietary iron level on iron incorporation into erythrocytes by infants

As a part of our effort to explore various aspects of ferrokinetics in infancy, the present study was designed to determine the timing of entry of an orally ingested iron isotope into circulating erythrocytes, and the effect of the level of dietary iron [0.3 mg/100 kcal (418.4 kJ) vs. 1.8 mg/100 kcal] after isotope administration on erythrocyte incorporation of the isotope. We administered the stable isotope, (58)Fe, orally to 56-d-old and 168-d-old infants. All infants were fed a low-iron formula (LF) before and until 5 h after isotope administration. Thereafter, half the infants were fed a formula high in iron (HF group) while the remaining infants continued to receive the LF (LF group) for an additional 28 d. The quantity of (58)Fe in circulating erythrocytes increased from 14 to 28 d after isotope administration was nearly constant from 28 through 84 d of age (plateau value) and decreased between 84 and 112 d. Erythrocyte incorporation of (58)Fe was greater by the 168-d-old infants than by the 56-d-old infants, presumably because of the lesser iron stores of the older infants. In the 56-d-old infants, erythrocyte incorporation of (58)Fe was greater by the LF than by the HF group, but this difference was not significant in the 168-d-old infants. Thus, at least in younger infants, the level of iron intake after administration of an iron isotope affects erythrocyte incorporation of the isotope. The fact that less isotope was present in erythrocytes 112 d than 84 d after administration indicates that the life span of erythrocytes of infants, even beyond the immediate newborn period, is less than the 120-d life span of erythrocytes in the adult.

Confirmation of confocal microscopy diagnosis of Acanthamoeba keratitis using polymerase chain reaction analysis

BACKGROUND

Acanthamoeba keratitis has commonly been identified with in vivo confocal microscopy and confirmed with histologic examination of an epithelial biopsy specimen.

OBJECTIVE

To determine if Acanthamoeba keratitis can be verified using polymerase chain reaction (PCR) of epithelial biopsy specimens.

METHODS

Epithelial specimens from patients with suspected Acanthamoeba keratitis by confocal microscopy were tested for Acanthamoeba with PCR of Acanthamoeba ribosomal DNA.

RESULTS

Twenty-four of 31 patients with evidence of Acanthamoeba keratitis were positive for Acanthamoeba on PCR analysis using 3 sets of primers. In 22 cases, the sequence obtained closely matched Acanthamoeba castellanii.

CONCLUSIONS

This study demonstrates that PCR analysis of epithelial biopsy specimens can provide definitive verification of the confocal microscopic and histologic identification of Acanthamoeba organisms associated with keratitis. Acanthamoeba keratitis is probably quite common, especially in contact lens wearers, although more than half of the patients in this study did not wear contact lenses.

Less than 80% of absorbed iron is promptly incorporated into erythrocytes of infants

Erythrocyte incorporation of an administered iron isotope has been used as a surrogate for iron retention on the assumption (validated in normal and iron-deficient adults) that 80-100% of the retained isotope is promptly incorporated into circulating erythrocytes. This assumption has not been validated in infants or children. The purpose of our study was to determine concurrently in normal infants absorption and erythrocyte incorporation of the stable isotope, (58)Fe. In a preliminary study (Study 1), we demonstrated that fecal excretion of ingested isotope occurs predominantly during the first 4 d after administration but continues beyond 7 d after ingestion, that is, beyond the point at which isotope in feces can be explained either by excretion of isotope that failed to enter enterocytes or by exfoliation of isotope-enriched enterocytes. In Study 2, we administered (58)Fe to nine younger (age 20-69 d) and nine older (age 165-215 d) term infants and collected feces for 11 d. Geometric mean retention of (58)Fe by the younger infants was 31.2% of intake at 4 d and 26.9% at 11 d, and by the older infants, 35.0% at 4 d and 32.5% at 11 d. Erythrocyte incorporation of (58)Fe 14 d after ingestion was 5.2% of the dose by the younger infants and 12.5% by the older infants. Utilization of retained (11 d) isotope thus was 19.8% by the younger infants and 38.3% by the older infants. We conclude that far less than 80% of retained isotope is promptly incorporated into erythrocytes (utilized) by infants.

Cow's milk and intestinal blood loss in late infancy

OBJECTIVES

Young infants commonly show occult intestinal blood loss when fed cow's milk, but in older infants blood loss may be less common. This study examined intestinal blood loss in response to cow's milk feeding in normal 7(1/2)-month-old and 12-month-old infants.

STUDY DESIGN

Infants (n = 62) were fed formula for 1 month and then pasteurized cow's milk for 2 months. Stools were collected for quantitative determination of hemoglobin. Iron nutritional status was assessed.

RESULTS

Infants fed cow's milk from 7(1/2) months of age showed a significant increase in guaiac-positive stools and in stool hemoglobin concentration. These effects were largely limited to those infants who had been breast fed early in life. Infants fed cow's milk from 12 months of age at baseline had greater stool hemoglobin concentrations than 7(1/2)-month-old infants, but cow's milk produced no significant increase. In neither age group did cow's milk affect iron nutritional status.

CONCLUSION

The response to cow's milk is attenuated in infants aged 7(1/2) months compared with younger infants. By 12 months of age, the response has disappeared entirely. We conclude that the gastrointestinal tract of healthy infants gradually loses its responsiveness to cow's milk.

Infant formula with protein-energy ratio of 1.7 g/100 kcal is adequate but may not be safe

BACKGROUND

An adequate protein-energy ratio of infant formulas has been defined as one that permits growth similar to that of infants fed relatively generous protein-energy ratios, and serum concentrations of albumin and urea nitrogen no less than those observed in breast-fed infants. A safe ratio has been defined as one with no detectable adverse effects. The hypothesis was that a protein-energy ratio of 1.7 g/100 kcal is adequate and safe.

METHODS

Healthy male infants were fed Formula 1.7, a milk-based formula, as the sole source of energy from the 8th to the 112th day of life. Weight, length, and energy intake were measured; serum albumin and urea nitrogen were determined; and the results were compared with data from appropriate reference groups of infants.

RESULTS

Energy intake from 8 through 55 days was significantly higher than that of infants in the formula-fed reference group. Gain in weight was significantly more than that of the formula-fed reference group or of a breast-fed reference group, whereas gain in length was similar to that of the formula-fed reference group. Body mass index was significantly higher than that of either reference group, suggesting more fat accumulation in infants fed Formula 1.7. Plasma concentrations of albumin and urea nitrogen were similar to those of the breast-fed reference group.

CONCLUSION

Infants fed Formula 1.7 received adequate intakes of protein. Because of the possibility that ad libitum feeding of diets with moderately inadequate protein-energy ratios is associated with increased food intake leading to excess weight gain, it is not possible to conclude that a protein-energy ratio of 1.7 g/100 kcal is safe.

Absorption of fat and calcium by infants fed a milk-based formula containing palm olein

OBJECTIVE

The study tested the hypothesis that inclusion of palm olein (45% of fat) in the fat blend of a milk-based infant formula decreases the absorption of fat and calcium.

METHODS

Formula PO contained palm olein (45%) in addition to soy, coconut and high-oleic sunflower oils (20%, 20%, and 15%, respectively); Formula HOS contained high-oleic safflower oil (42%) in addition to coconut and soy oils (30% and 28%, respectively) and no palm olein. Fat and calcium levels in the two formulas were similar. In a balanced crossover design, fat and calcium absorption were determined in 10 normal infants ranging in age from 22 to 192 days. In three infants metabolic balance studies with complete separation of urine and feces were performed, whereas in seven infants excreta were in part collected at home, resulting in incomplete separation of urine and feces.

RESULTS

Mean (+/- SD) fecal excretion of fat was higher when Formula PO was fed than when Formula HOS was fed (0.55 +/- 0.29 vs. 0.09 +/- 0.04 g/kg/day; p < 0.001). Hence % fat absorption was lower with PO than with HOS (90.0 +/- 6.4 vs. 98.5 +/- 0.6% of intake; p < 0.01). The difference in percent fat absorption was explained by significantly (p < 0.05) lower % absorption of palmitic (16:0) and stearic (18:0) acids when Formula PO was fed than when Formula HOS was fed. Fecal excretion of calcium was higher with Formula PO than with Formula HOS (53.4 +/- 12.0 vs. 37.4 +/- 14.9 mg/kg/day; p < 0.01), and hence % calcium absorption was lower with Formula PO than with Formula HOS (37.5 +/- 11.5 vs. 57.4 +/- 14.9%; p < 0.001).

CONCLUSION

Absorption of fat and calcium by normal infants is lower when palm olein provides a substantial proportion of formula fat than when formula does not contain palm olein.

Establishment and characterization of a simian virus 40-transformed temperature-sensitive rat luteal cell line

The primary culture of rat luteal cells and their long-term maintenance have been difficult. Low cellular yields have limited the possibility for the study of gene regulation in luteal cells. The goal of this study was to develop a cell line to serve as a model by which to study the expression and regulation of various genes specific to luteal cells. We attempted to develop a luteal cell line by transformation of large luteal cells through infection with a temperature-sensitive simian virus (SV-40 tsA209) mutant that has a temperature-sensitive mutation required for the maintenance of cell transformation. We report here the successful establishment of such a cell line, designated GG-CL cells. Large luteal cells were purified to homogeneity by flow cytometry from corpora lutea of day 14 pregnant rats, cultured for 24 h, and then infected with the SV-40 tsA209 mutant virus. Transformed cells were maintained at the permissive temperature (33 C) until colonies were identified. Several colonies of transformed cells were isolated and passaged. They multiplied at 33 C and formed multilayers. At the nonpermissive temperature (40 C), cells reverted to the normal differentiated phenotype similar to the primary luteal cells in culture. To determine whether GG-CL cells express the genes found in normal luteal cells, messenger RNA (mRNA) expression was examined by either Northern analysis or RT-PCR with primers specific to each mRNA. GG-CL cells were found to express receptors for interleukin-6 and glucocorticoid, as well as the newly discovered estrogen receptor-beta (ER-beta) and the orphan nuclear receptor nur 77. No receptors for ER-alpha, progesterone, LH, or PRL could be detected. This cell line also expressed 20alpha-hydroxysteroid dehydrogenase (20alpha-HSD), but not cholesterol side-chain cleavage cytochrome P450 (P450scc), 3beta-hydroxysteroid dehydrogenase, or aromatase cytochrome P450 (P450arom). Although the cells did not express the PRL receptor, they did express Janus kinase (JAK2) and signal transducers and activators of transcription (Stat5b), and, when transfected with the PRL receptor, they responded to PRL with a marked inhibition in 20alpha-HSD mRNA expression. In addition, estradiol enhanced ER-beta expression in a dose-dependent manner whereas cAMP stimulation caused a marked and rapid increase in the expression of the orphan receptor nur 77. In summary, a temperature-sensitive cell line was successfully established from the large luteal cells of rat corpora lutea. These cells express key genes encoding enzymes and receptors inherent to this defined luteal cell population and respond to stimulation by PRL, estradiol, and cAMP.

The tripartite basal enhancer of the gonadotropin-releasing hormone (GnRH) receptor gene promoter regulates cell-specific expression through a novel GnRH receptor activating sequence

The molecular mechanisms regulating restricted expression of GnRH receptor and gonadotropin subunit genes to gonadotrope cells have been the focus of intense interest. Using deletion and mutational analysis we have identified a tripartite enhancer that regulates cell-specific expression of the GnRH receptor gene in the gonadotrope-derived alphaT3-1 cell line. Individual elements of this enhancer include binding sites for steroidogenic factor-1; activator protein 1 (AP-1); and a novel element referred to as the GnRH receptor activating sequence (GRAS). Mutation of each element alone results in loss of approximately 60% of promoter activity. Combinatorial mutations of any two elements decreases promoter activity by approximately 80%. Finally, mutation of all three elements reduces promoter activity to a level not different from promoterless vector. Using 2-bp mutations, we have defined the functional requirements for transcriptional activation by GRAS. The core motif of GRAS is at -391 to -380 bp relative to the start site of translation and has the sequence 5'-CTAGTCACAACA-3'. Three copies of GRAS or GRAS with a 2-bp mutation (muGRAS) were cloned into a luciferase expression vector immediately upstream of the thymidine kinase minimal promoter (TK) and tested for expression in alphaT3-1 cells. When compared with TK promoter alone, activity of 3xGRAS-TKLUC was increased by more than 5-fold while activity of 3xmuGRAS-TKLUC was unchanged. When 3xGRAS-TKLUC was transfected into a variety of nongo-nadotrope cell lines, it did not increase activity of the TK promoter. We propose that basal activity of the GnRH receptor gene is regulated by a tripartite enhancer, and the key component of this enhancer is an element, GRAS, that activates transcription in a cell-specific fashion.

Expression of a murine gonadotropin-releasing hormone receptor-luciferase fusion gene in transgenic mice is diminished by immunoneutralization of gonadotropin-releasing hormone

A line of transgenic mice harboring a fusion gene consisting of 1900 bp of proximal 5'-flanking region from the murine GnRH receptor gene linked to the complementary DNA encoding luciferase was established to determine whether this promoter can direct tissue-specific expression in vivo and serve as a model for identifying the molecular mechanisms underlying hormonal regulation of this gene. Of 10 tissues screened, luciferase was detected predominantly in pituitary gland, but also in brain and testis. To assess hormonal regulation, luciferase activity was measured in intact males and ovariectomized females treated with an anti-GnRH serum alone, and in combination with testosterone or 17beta-estradiol. No effect of steroid treatment on transgene expression was detected. However, immunoneutralization of GnRH resulted in decreased serum LH concentrations and suppressed pituitary expression of luciferase. Furthermore, the effects of GnRH antiserum could be prevented by the administration of a noncross-reactive GnRH agonist. Thus, 1900 bp of 5'-flanking DNA from the murine GnRH receptor gene are sufficient to target luciferase expression in transgenic mice to established sites of GnRH receptor gene expression. Furthermore, we suggest that GnRH regulation of GnRH receptor gene expression is mediated by regulatory elements residing within 1900 bp of the 5'-flanking region.

Erythrocyte incorporation of iron is similar in infants fed formulas fortified with 12 mg/L or 8 mg/L of iron

Although feeding of formulas with iron concentration of 215 mumol/L (12 mg/L) is a reliable means of preventing iron deficiency, high intakes of iron may adversely affect absorption of copper and zinc. Because data are not available to establish whether fortification at a lower level would result in equivalent iron absorption, we tested the hypothesis that iron absorption is greater by infants fed formulas with an iron concentration of 215 mumol/L (12 mg/L) than by those fed formulas with an iron concentration of 143 mumol/L (8 mg/L). Fifty-two normal infants entered the study at 112 +/- 4 d of age, and 46 of these were successfully studied until 196 d of age. Using the stable isotope 58Fe, we determined erythrocyte incorporation of iron by infants fed Formula 8 [iron approximately 143 mumol/L (8 mg/L)] and by infants fed Similac with Iron [iron approximately 215 mumol/L (12 mg/L)]. On each of three test days beginning at 154 d of age, a major portion of the formula was labeled with 58Fe. Geometric mean erythrocyte incorporation of iron adjusted for plasma ferritin concentration at 168 d of age was 4.82 mumol/d (0.269 mg/d) by infants fed Formula 8 and 5.21 mumol/d (0.291 mg/d) by infants fed Similac with Iron. Corresponding values at 196 d of age were 5.12 and 5.41 mumol/d (0.286 and 0.302 mg/d). The differences in quantity of iron incorporated into erythrocytes by infants fed Formula 8 and Similac with Iron were not statistically significant (P = 0.66 at 168 d of age, P = 0.75 at 196 d of age) and were judged to be nutritionally trivial. Because we were unable to provide support for our hypothesis that iron absorption is greater by infants fed formulas providing 215 mumol (12 mg) of iron per liter than by those fed formulas providing 143 mumol (8 mg) of iron per liter, we conclude that, pending the results of further studies, It is reasonable to decrease the iron concentration of iron-fortified infant formulas.

A binding site for steroidogenic factor-1 is part of a complex enhancer that mediates expression of the murine gonadotropin-releasing hormone receptor gene

Expression of the GnRH receptor (GnRH-R) gene in the anterior pituitary gland, as with the genes encoding the gonadotropin subunits, is restricted to gonadotrophs. Thus, it is conceivable that a common mechanism is involved in activating cell-specific expression of these genes. In fact, expression of the alpha- and LHbeta-subunit genes appears to require binding of the nuclear orphan receptor, steroidogenic factor-1 (SF-1). Here we have used DNA protein-binding assays to identify a high-affinity binding site for SF-1 in the proximal promoter of the murine GnRH-R gene. Southwestern blot analysis using this site as a radiolabeled probe revealed binding to a 53-kDa protein in alphaT3-1 cell extracts. Furthermore, mutation of this site led to a 58% reduction in promoter activity in the gonadotroph-derived alphaT3-1 cell line. Thus, SF-1 may represent at least one common pathway for gonadotroph-specific gene expression. In addition, we used block-replacement mutagenesis to functionally scan approximately 100 base pairs (bp) in a region that we had previously identified as critical for cell-specific promoter activity. Mutation of a partial palindrome located at -393 bp relative to the start of translation led to a 63% loss of promoter activity. Finally, a region containing both the SF-1 binding site and the -393 site was sufficient to stimulate cell-specific expression from a heterologous, minimal promoter. Thus, we suggest that a complex enhancer that includes a binding site for SF-1 mediates cell-specific expression of the GnRH-R gene.

Palm olein in infant formula: absorption of fat and minerals by normal infants

Palm olein, a low-melting fraction of palm oil, and soy oil can be combined to obtain fat blends with proportions of palmitic and oleic acids similar to those of human milk. We compared the absorption of fat and calcium by infants fed a formula containing a blend of palm olein (53%) and soy oil (47%) (Formula PO/S) with that by infants fed a formula containing a blend of soy oil (60%) and coconut oil (40%) (Formula S/C). In a randomized crossover design, one study was performed with each formula in each of 11 normal infants ranging in age from 27 to 161 d. Six of the infants were admitted for 72-h metabolic balance studies. In the other five infants, feces (with some admixture of urine) were collected at home for 96 h by using acid-washed cloth diapers. Mean (+/- SD) absorption of fat was 90.6 +/- 1.6% of intake when Formula PO/S was fed and 95.2 +/- 1.1% of intake when Formula S/C was fed; the difference was significant (P < 0.001). The difference in excretion of fat by infants fed the two formulas was explained by the difference in excretion of palmitic acid. Absorption of calcium averaged 39.0 +/- 8.3% of intake with Formula PO/S and 48.4 +/- 10.3% with Formula S/C; the difference was significant (P < 0.01). We conclude that fat is less well absorbed from a mixture of 53% palm olein and 47% soy oil than from a mixture of 60% soy oil and 40% coconut oil, and that absorption of calcium is less from a formula containing palm olein, presumably because of the formation of insoluble calcium soaps of unabsorbed palmitic acid.

Erythrocyte incorporation of iron by 56-day-old infants fed a 58Fe-labeled supplement

In an effort to obtain information about absorption of supplemental iron by breast-fed infants during the early months of life, we determined erythrocyte incorporation of a stable iron isotope, administered to 56-d-old breast-fed infants in the form of a 58Fe-labeled vitamin-iron supplement. Infants of similar age fed a milk-based formula low in iron (approximately 4 mg/L) were also studied. The 58Fe-labeled vitamin-iron supplement was given between feedings. Fourteen days after administration of 58Fe, mean erythrocyte incorporation of the isotope was 7.8% of the dose by breast-fed infants and 4.4% of the dose by formula-fed infants. The feeding-related difference was statistically significant, probably reflecting the greater quantities of inhibitors of iron absorption in the intestines of formula-fed infants. With mean iron intake from the 58Fe-labeled vitamin-iron supplement of 7.99 mg for the breast-fed infants, erythrocyte incorporation of 7.8% of the dose corresponded to 0.62 mg, a value in the range of the estimated requirement for absorbed iron. We conclude that 2-mo-old breast-fed infants are able to absorb nutritionally significant amounts of iron from an iron supplement.

Cell-specific expression of the mouse gonadotropin-releasing hormone (GnRH) receptor gene is conferred by elements residing within 500 bp of proximal 5' flanking region

Gonadotropin-releasing hormone (GnRH) is a decapeptide produced by the hypothalamus. Upon binding to specific high-affinity receptors on gonadotrope cells of the anterior pituitary gland, GnRH stimulates the synthesis and secretion of LH. In light of the critical role of GnRH in reproduction much effort has been directed toward understanding the regulation of this hormone and its cognate receptor. The recent availability of genomic clones for the GnRH receptor has facilitated research to address the molecular mechanisms underlying regulation of GnRH receptor gene expression. We have expanded the analysis of the promoter for the mouse GnRH receptor gene and report that in addition to transcriptional start sites located within 100 bp of the translation start codon there is a more distal transcriptional start site approximately 200 bp 5' of the initiation codon. The initiation of transcription from this more distal site was sufficient to confer cell-specific expression on luciferase. Further, transient expression assays of constructs containing progressive 5' deletions in the GnRH receptor gene promoter reveal the presence of one or morecis-acting elements located between -500 and -400 (relative to ATG) necessary for transcriptional activity in the gonadotrope-derived αT3 cell line. Finally, αT3 but not COS-7 cell nuclear extract contained protein(s) that bind to at least two separate motifs contained within the -500 to -400 region. We suggest that activation of GnRH receptor gene expression in the αT3 cell line requires the binding of at least two transcriptional regulatory proteins to basal enhancer elements located within a 100 bp region between -500 to -400 relative to the translation start codon in the mouse GnRH receptor gene.

What is the safe protein-energy ratio for infant formulas?

Infants eat primarily to satisfy energy needs and the safe amount of protein in infant formulas (ie, the amount adequate for nearly all infants) is therefore expressed as the protein-energy ratio. We studied male infants aged 8-112 d fed milk-based formulas. One group (experimental group) was fed formulas that provided protein-energy ratios of 3.73 g/MJ (1.56 g/100 kcal) from 8 to 27 d of age, gradually decreasing to 2.99 g/MJ (1.25 g/100 kcal) from 84 to 111 d of age. Growth rates and serum albumin and urea nitrogen of these infants were compared with those of a concurrently studied control group and a previously studied large reference group. Gains in weight and concentrations of serum albumin of the three groups were not significantly different. Gains in length were significantly less for the experimental group than for the reference group. Serum urea nitrogen was significantly less in the experimental group than in the control group or reference group. We conclude that the protein-energy ratios of the experimental formula diet were below the safe level. Because the decrease in growth rate of the experimental group was rather small (demonstrable only in comparison with the large reference group), and because serum albumin of the experimental group increased with age as in normally nourished infants, we suspect that the safe protein-energy ratio of infant formulas lies closer to the ratios fed to the experimental group than to the ratio [approximately 5.0 g/MJ (2.1 g/100 kcal)] in currently marketed milk-based formulas.

Pregnancy increases guanosine 3',5'-monophosphate in the myometrium independent of nitric oxide synthesis

The mechanism for myometrial quiescence during pregnancy is unknown. cGMP plays an integral role in the relaxation of smooth muscle, and nitric oxide (NO) is the most important endogenous activator of soluble guanylate cyclase. The purpose of this study was to determine the effect of gestational age on myometrial cGMP and NO synthase (NOS) activity in the guinea pig. Myometrial cGMP content (measured by RIA) rose slowly until 0.49 (fraction of pregnancy completed) gestation before abruptly increasing to 200 times the non-pregnant control value. It then declined precipitously after 0.87 gestation. Of the known isoenzymes of NOS, the messenger RNAs coding for both endothelial and neuronal NOS could be amplified from the myometrium of pregnant and nonpregnant animals using reverse transcriptase-polymerase chain reaction, but inducible NOS messenger RNA was not found. Myometrial calcium-dependent NOS activity (measured by the conversion of L-[U-14C]arginine to [U-14C]citrulline) declined slowly with advancing gestation (r2 = 0.096; slope = -0.34; P = 0.01), but never differed significantly from the activity in nonpregnant animals [31.1 +/- 11 (term pregnancy) vs. 56.9 +/- 16 (nonpregnant) pmol/min.g; P = NS]. Calcium-independent activity declined shortly after conception, and then rose toward the nonpregnant level (r2 = 0.19; slope = 0.45; P = 0.0009). However, at no time was it significantly different from that in the nonpregnant animal. Pregnancy had no effect on myometrial L-arginine and L-citrulline content. The administration of L-nitro-arginine methyl ester (200 mg/kg) to inhibit NOS dramatically increased blood pressure and reduced fetal renal NOS activity, but had no effect on the myometrial cGMP content. Estradiol (500 micrograms/kg for 5 days) modestly increased cGMP, but in contrast to many tissues in which estradiol increases NOS, it had no effect on myometrial NOS activity. We conclude that pregnancy dramatically increases cGMP by a mechanism independent of NOS. The stimulus remains to be identified. The temporal change in cGMP concentration is consistent with the hypothesis that cGMP mediates myometrial quiescence during pregnancy.

Decreased treatment time due to changes in technique and practice philosophy

A study was conducted to evaluate the impact of practice modifications on treatment time for patients in a private orthodontic office. Two patient groups were studied, consisting of Class I nonextraction, adult dentitions treated by one of the authors. One group (28 cases) was treated with the standard Begg technique and conventional motivation, hygiene, and finishing practices. The other (25 cases) was treated with the Tip-Edge appliance along with specific modifications to motivation, hygiene and finishing techniques. The average treatment time for the Tip-Edge group was 12.80 months versus 20.89 months for the Begg group. The use of motivational techniques and a specific mission and philosophy within a private orthodontic practice can help reduce total treatment time. The Tip-Edge appliance may reduce treatment time in Class I nonextraction therapy.

Absorption and retention of dietary and supplemental fluoride by infants

There is a widespread belief that an adequate intake of fluoride during the pre-eruptive stage of enamel formation (i.e., from the diet in frequent small doses throughout the day) will be protective against caries in later life. To obtain data on bio-availability and retention of fluoride in one age group (infants), we studied 3 treatment regimens: In Regimen A, small amounts of fluoride were obtained from the diet in frequent doses throughout the day; in Regimen B, a fluoride supplement (0.25 mg) was given once each day with a feeding; Regimen C was similar to regimen B except that the fluoride supplement was given 1 h before a feeding. For the 3 regimens, the respective mean absorptions of fluoride were 90.1, 88.9, and 96.0% of intake, and the respective retentions were 12.5, 47.1, and 52.3% of intake. Neither the difference in absorption nor the difference in retention between regimens B and C was statistically significant. By subtracting the background urinary excretion of fluoride (i.e., excretion of fluoride while diet was the sole source of fluoride) from the excretion after administration of the fluoride supplement, we calculated that 68.1% of the supplement was retained in Regimen B and 73.0% of the supplement in Regimen C. The difference was not significant.

Identification of a major prolactin-regulated protein as 20 alpha-hydroxysteroid dehydrogenase: coordinate regulation of its activity, protein content, and messenger ribonucleic acid expression

We have previously reported that an abundant 37,000 mol wt protein with a pI of 6.15 (37K) is expressed specifically in the corpus luteum and is markedly inhibited by PRL. To identify the 37K, amino acid sequence analysis of the protein was performed. The 37K protein showed sequence similarity with rabbit 20 alpha-hydroxysteroid dehydrogenase (20 alpha HSD), chlordecone reductase, prostaglandin synthase, and 3 alpha-hydroxysteroid dehydrogenase, which are members of the aldo-keto reductase group of enzymes that catalyze the NADPH-dependent reduction of carbonyl compounds. Comparison of 20 alpha HSD activity with the level of 37K in the corpus luteum throughout pregnancy demonstrated a close correlation between enzyme activity and luteal levels of the protein. Both protein and enzyme activity were low early in pregnancy, reached a nadir between days 5-19, and reappeared abruptly between days 19-21 of pregnancy. To establish that the enzyme activity is intrinsic to the 37K, the protein was purified from sodium dodecyl sulfate-polyacrylamide electrophoresis gels (SDS-PAGE), renatured, and assayed for 20 alpha HSD activity. The renatured protein exhibited substantial 20 alpha HSD activity. As 20 alpha HSD is known to play a major role in the termination of pregnancy in the rat, it was of interest to examine whether the rapid appearance of the 37 K protein at the end of pregnancy is accompanied by the induction of 20 alpha HSD gene expression. Northern blot analysis using a rabbit cDNA for 20 alpha HSD indicated that the pattern of 20 alpha HSD mRNA expression in the corpus luteum closely paralleled the ontogeny of 20 alpha HSD enzyme activity as well as 37K protein levels. Our studies demonstrated that 20 alpha HSD protein and mRNA levels are coordinately regulated, and that the profound inhibitory effect of PRL on 20 alpha HSD activity is apparently due to inhibition of 20 alpha HSD gene expression, leading to the disappearance of the protein from the corpus luteum.

Fluoride pharmacokinetics in infancy

Fluoride pharmacokinetic data are presented for infants given a fluoride supplement. Seventeen infants participated in a total of 20 studies. On one day, 0.013 mmol (0.25 mg) fluoride was given as a supplement (fluoride supplement study), and on another day a placebo was given (control study). Samples of plasma and urine were collected for 5 h and analyzed for fluoride. During control studies fluoride intake averaged 0.15 mumol/kg (2.9 micrograms/kg), and plasma fluoride concentrations ranged from 0.05 to 0.11 mumol/L (10 to 20 micrograms/L). In nine instances, the quantity of fluoride excreted in the urine was more than twice that consumed. When the fluoride supplement was given, total fluoride intake averaged 1.93 mumol/kg (36.6 micrograms/kg). Plasma peak concentration was reached by 30 min in 14 studies and by 60 min in six studies. Mean plasma peak fluoride concentration was 3.3 mumol/L (63 ng/mL). Area under the plasma concentration curve averaged 236 nmol.m-1 x min (4479 ng.mL-1 x min) and was not related to the dose of fluoride. The rate of urinary excretion was significantly correlated with rate of urinary flow. When the dose of fluoride was expressed per unit of body weight, fluoride retention was strongly related to the dose. Retention of the fluoride absorbed from the fluoride dose ranged from 75.4 to 87.6%. Plasma clearance averaged 6.8 mL.kg-1 x min-1 and decreased significantly with age. Net fractional clearance (renal clearance of the fluoride dose/GFR) averaged 56.7%, which was significantly greater than the 29% observed during the control studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Erythrocyte incorporation of ingested 58Fe by 56-day-old breast-fed and formula-fed infants

As an index of iron absorption, erythrocyte incorporation of the stable isotope, 58Fe, was determined 14 and 42 d after the administration of 58Fe-labeled ferrous sulfate to 56-d-old exclusively breast-fed infants and to infants fed a low-iron (1.8 mg/L) formula. Each infant received a dose of 0.6 to 1.0 mg of iron with ascorbic acid between feedings on each of 3 consecutive d. Fourteen d after administration of the 58Fe-labeled iron doses (age 70 d), arithmetic mean incorporation of the 58Fe label into erythrocytes by breast-fed infants was 20.0% of the dose--only slightly less than that reported for erythrocyte incorporation of iron by fasting adults fed small quantities of 59Fe-labeled human milk. Erythrocyte incorporation of iron by the formula-fed infants was 6.9% of the dose, suggesting that, even between feedings, components of infant formula exerted a major inhibitory effect on iron absorption. For reasons that are not clear, the percentage of the administered label incorporated into erythrocytes was significantly greater in breast-fed (but not in formula-fed infants) at 112 d of age than at 70 d of age.

Hormonal and immunological characterization of the 32 kilodalton ovarian-specific protein

Recent studies from this laboratory have shown that the large luteal cell of the pregnant rat contains an abundant 32 kilodalton (32K) phosphoprotein which is up-regulated by estradiol. In order to assess the potential importance of this protein and to more fully understand its function, a specific polyclonal antibody was produced against the 32K and was used to examine its intraovarian localization, its tissue specificity, and its developmental regulation. Immunocytochemical localization of the 32K in the ovary of the pregnant rat found this protein to be selectively and abundantly expressed in the corpus luteum. Immunofluorescence study of small and large luteal cell populations clearly revealed an extensive localization of the 32K in the large luteal cells. Western blot analysis revealed that the 32K was absent from all steroidogenic and nonsteroidogenic tissues. Whereas this protein was absent from all other tissues examined in the rat, it was clearly expressed in corpora lutea of different animal species, including the mouse, hamster, cow, human, and pig. Although undetectable by immunohistochemistry, Western blot analysis showed this protein to be present in the follicle but at levels markedly lower than in the corpus luteum. Analysis of theca and granulosa cells revealed the presence of the 32K in both cell types. To further examine the developmental expression of this protein throughout gestation, Western blot analysis of microsomal fractions isolated from rat corpora lutea on days 3-21 of pregnancy was performed. The 32K was detected at low levels in early pregnancy, increased markedly on day 11, reached a peak on days 14-15, and remained elevated through day 21. Treatment with estradiol and PRL increased the content of the 32K in the corpus luteum. Human CG, known to cause follicular development to the preovulatory stage and to enhance luteal estradiol synthesis, also increased levels of the 32K in the corpus luteum, while it concomitantly decreased this protein in the follicle. In summary, the presence of a unique ovarian-specific 32 kilodalton protein has been established. This protein, which is present in low abundance in theca and granulosa cells, is localized to the large luteal cell and becomes abundantly expressed during midpregnancy, a time when there is a remarkable increase in luteal cell size and activity. Results of this study also demonstrate a multihormonal regulation of the 32K by tropic hormones. Thus, because of its apparent uniqueness and its timely and highly regionalized expression, the 32K may play a central role in the regulation of corpus luteum growth and function.

Differential capacity for cholesterol transport and processing in large and small rat luteal cells

The aim of this investigation was to determine whether a specific luteal subpopulation is responsible for the hypertrophic development of the corpus luteum at midpregnancy in the rat and to determine whether there was an underlying cellular basis for the differential production of steroids by the luteal cell subtypes. To examine this, we have dispersed and separated rat luteal steroidogenic cell populations into small (< 20 microns) and large (> 30 microns) cell types by elutriation. Luteal cells were examined at early (day 3) and midpregnancy (day 14) for differences in protein content and for differential expression of proteins required for steroid production. Specific proteins examined include the P450side chain cleavage enzyme (P450scc), adrenodoxin and adrenodoxin reductase, proteins required for cholesterol conversion to progestagens in the corpus luteum, and sterol carrier protein-2 (SCP2), a protein thought to be involved in intracellular cholesterol transport. The cytochrome P450(17)alpha hydroxylase (P450(17)alpha), a key enzyme responsible for androgen biosynthesis was also examined in the isolated luteal cells. The large luteal cell population displayed an increase in total cellular protein content while the small cell type did not change with luteal development. In addition, the large luteal cells expressed proteins unique to or elevated in that cell type. Analysis by two-dimensional polyacrylamide gel electrophoresis revealed that the large cell-specific proteins had molecular masses of 23 K and 32 K and that a 14 kilodalton (kDa) protein was elevated in the large cell type relative to the small cells. The small luteal cell on day 3 of pregnancy expressed a 36 kDa protein which was barely detectable in the large cell. Immunocytochemical and Western analysis indicated that the large luteal cells contain 5.3-fold more SCP2 (P < 0.05) and 5.6-fold more P450scc (P < 0.001) relative to the small cell type. Immunocytochemical staining of adrenodoxin and adrenodoxin reductase indicate these proteins were elevated in the large cell as well. Human CG administration stimulated P450(17)alpha expression mainly in the large luteal cell population. The results of this investigation indicate, for the first time, that the large luteal cell of the rat, in contrast to the small cell type, undergoes a dramatic increase in protein content with luteal development, and that with this increase in cell size there is a concomitant increase in the large cell capacity to produce steroids. This occurs as a direct result of the enhanced expression of SCP2, P450scc, adrenodoxin and adrenodoxin reductase, proteins specifically required to transport and process cholesterol for steroid production in the large luteal cell.

The cAMP-dependent signalling cascade in the two luteal cell types of the pregnant rat corpus luteum

Corpora lutea of rats, like those of many other species, contain two sub-populations of luteal cells. In this report we sought to determine whether the luteinizing hormone (LH)- and beta-adrenergic cAMP signal transduction pathways known to be present in rat corpora lutea were segregated into separate luteal cell types. Results showed that large rat luteal cells, obtained on day 3 of pregnancy, exhibited elevated LH- and most notably epinephrine-stimulated adenylyl cyclase activities but equivalent cAMP-dependent catalytic protein kinase and total regulatory subunit cAMP binding activities compared to small luteal cells. Progesterone production by the large cell was greater than that by the small cell but both cells were equally sensitive to stimulation of progesterone by LH. However, neither the large nor the small rat luteal cell produced significant progesterone in response to epinephrine despite a marked epinephrine-stimulated adenylyl cyclase in both cell populations. The LH-stimulated progesterone synthetic response of the two sub-populations of rat luteal cells is more similar to that of the developing monkey corpus luteum and contrasts sharply with that of ruminants.

Isolation, characterization, and culture of cell subpopulations forming the pregnant rat corpus luteum

The aim of this investigation was to isolate, characterize, and culture the small and large luteal cell subpopulations forming the corpus luteum of the pregnant rat. Since the large luteal cells are extremely fragile and do not survive standard cell dispersion, a method which allows the survival and the long-term culture in serum-free media of small and large cells was developed. The two luteal cell populations differed not only by their size but also by their morphology in culture. The small luteal cells (12-20 mu in diameter) are characterized by a large oval nucleus, contain few lipid droplets and have a stellate shape. In contrast, the large luteal cells have a smaller spherical nucleus, high lipid content, and do not flatten out completely in culture, most probably due to the abundance of lipid droplets. Both luteal cell types express 3 beta HSD and the cytochrome P450 enzymes involved in steroidogenesis. However, it is the lipid filled large luteal cells that secrete the most progesterone, androgen, and estradiol; express greater amounts of P450scc and P450AROM; and possess more PRL and LH receptors. Despite the greater expression of LH receptor in the large luteal cells, small and large luteal cells responded to LH with equal increase in steroidogenic output. In serum free culture, luteal cells produced progesterone for up to 20 days; however, an exogenous source of cholesterol was a prerequisite for maximal progesterone secretion. The pattern of progesterone secretion by cultures of small and large luteal cells differed remarkably from that of mixed cell population. When nonsteroidogenic corpus luteum cells were cocultured with the large luteal cells, a severalfold increase in progesterone secretion was observed. This stimulation occurred even when cells were cocultured in the absence of exogenous source of cholesterol. In summary, a successful method was developed to disperse, isolate, and independently culture the two luteal cell populations forming the rat corpus lutem. The results indicate that the marked difference in the steroidogenic capacity of these two cell populations is due, in large part, to the difference in their size rather than to their origin in the follicle. In addition, the results have revealed an important effect of the nonsteroidogenic cells forming the corpus luteum on luteal cell steroidogenesis.

Reference data on gains in weight and length during the first two years of life

Serial data from studies of infants at the University of Iowa and from the Fels Longitudinal Study were used to develop sex-specific percentiles for increments in weight and recumbent length for selected intervals during the first 24 months of life. Weight increments are presented for 1-month intervals from birth to 6 months, 2-month intervals from birth to 12 months, and 3-month intervals from birth to 24 months. Length increments are presented for 2-month intervals from birth to 6 months, and for 3-month intervals from birth to 24 months of age. Weights and lengths at the target ages were obtained for the Iowa data by simple interpolation, and for the Fels data by fitting families of three-parameter mathematical functions to the serial data from ages 1 to 24 months. The tabular presentations are based on the Iowa data from birth to 3 months of age, on the combined Iowa and Fels data from 3 to 6 months of age, and on the Fels data from 6 to 24 months of age. We believe that these reference data will be useful in screening for deviations from normal growth and may aid in early detection of failure to thrive or excessive weight gain during early life.

The development of virus-resistant alfalfa, Medicago sativa L

We have generated more than 100 transgenic alfalfa plants, via Agrobacterium-mediated gene transfer, from genotypes selected from five alfalfa cultivars. These plants express the genes for kanamycin resistance and for the coat protein of alfalfa mosaic virus (AMV). The strongest expressers accumulated nearly 500 ng coat protein per mg soluble leaf protein. AMV inoculation of protoplasts from these strong expressers indicated that they were resistant to infection by AMV, while protoplasts from plants containing about a hundred-fold less coat protein and from control untransformed plants were not. Transgenic alfalfa plants containing large amounts of coat protein were, likewise, resistant to AMV. These plants did not develop systemic infections following inoculation with up to 50 micrograms/ml AMV, while inoculated control plants developed systemic infections following inoculation with as little as 10 micrograms/ml AMV. These results demonstrate that expression of the AMV coat protein gene confers resistance to AMV infection in transgenic alfalfa plants.

Gender-related differences in iron absorption by preadolescent children

In a study of absorption of iron from meals by preadolescent children (Tanner stage 1), we had noted that erythrocyte incorporation of the extrinsic iron label was somewhat greater by girls than by boys. Although the difference was not significant, the observation seemed to warrant further study. Study A: A precisely determined quantity of ferrous sulfate enriched with the stable isotope 58Fe was given without food to 15 boys and 15 girls (Tanner stage 1) after an overnight fast and was immediately followed by a dose of 70 mg of ascorbic acid. 58Fe enrichment of the erythrocytes was determined by inductively coupled plasma mass spectrometry at baseline and 14 and 42 d after administration of the 58Fe dose. Geometric mean erythrocyte incorporation of the 58Fe label was 35.2% of intake by boys and 45.0% of intake by girls. The difference was significant (analysis of covariance with serum ferritin as covariate, p = 0.035). Study B: Fifteen boys and 15 girls (Tanner stage 1) were fed a breakfast labeled with 58Fe. Geometric mean erythrocyte incorporation of the 58Fe label was 14.8% of intake by boys and 24.7% of intake by girls. The difference was significant (analysis of covariance with serum ferritin as covariate, p = 0.004). Because serum ferritin concentrations were similar in boys and girls, the gender-related difference in iron absorption (as reflected by erythrocyte incorporation of the label) does not appear to be explained by a difference in body stores of iron. We hypothesize that hormonal differences between boys and girls in Tanner stage 1 favor iron absorption by girls.

Role of carnitine in utilization of dietary medium-chain triglycerides by term infants

The role of carnitine in oxidation of dietary medium-chain fatty acids (as medium-chain triglycerides) was studied in term human infants. Infants were fed, alternately, formulas with fat content that was predominantly long-chain triglycerides, or 40% medium-chain triglycerides. Urinary acylcarnitine excretion was significantly higher and the ratio of free to total carnitine was significantly lower when infants were fed the formula with medium-chain triglycerides. Two groups of 10 infants were fed a commercial soy-protein-based formula modified to contain 40% of fat calories as medium-chain triglycerides and with or without added L-carnitine. By 56 d, infants fed the formula without added L-carnitine excreted significantly more medium-chain dicarboxylic acids than did the same infants at 28 d and significantly more than infants consuming the carnitine-supplemented formula at either 28 or 56 d. Results are consistent with a role for carnitine in metabolism of dietary medium-chain triglycerides in infants.

Cow milk feeding in infancy: further observations on blood loss from the gastrointestinal tract

Because feeding of cow milk causes normal infants to lose increased amounts of occult blood from the gastrointestinal tract, we conducted a prospective trial to measure intestinal blood loss quantitatively and to monitor iron nutritional status. Fifty-two infants entered the trial at 168 days of age and were assigned at random to receive either cow milk or a milk-based formula. Initially, 31 infants had been breast-fed and 21 had been fed formulas. With the feeding of cow milk, the proportion of guaiac-positive stools increased from 3.0% at baseline to 30.3% during the first 28 days of the trial (p less than 0.01), whereas the proportion of positive stools remained low (5.0%) with the feeding of formula. The proportion of guaiac-positive stools among cow milk-fed infants declined later, but for the entire trial it remained significantly (p less than 0.01) elevated. Stool hemoglobin concentration increased markedly with the introduction of cow milk, rising from a mean (+/- SD) of 622 +/- 527 micrograms/gm dry stool at baseline to 3598 +/- 10,479 micrograms/gm dry stool during the first 28 days of ingestion of cow milk. Among infants fed formula, stool hemoglobin did not increase and was significantly (p less than 0.01) less than in the cow milk group. Among infants fed cow milk, the increase in hemoglobin concentration tended to be greater for those who had initially been fed human milk than for those who had initially been fed formulas. Iron nutritional status was not significantly different between the two feeding groups. However, one infant became iron deficient after 4 weeks of ingesting cow milk. We conclude that cow milk feeding leads to increased intestinal tract blood loss in a large proportion of normal infants and that the amount of iron lost is nutritionally important.

Feasibility of using the stable isotope 25Mg to study Mg metabolism in infants

The feasibility of using isotopic techniques to study Mg absorption and metabolism was explored in three full-term human infants. 25Mg (98.8 atom %) was administered orally as an in vivo tracer. Fractional 25Mg absorption, isotope retention, endogenous fecal Mg losses, and apparent Mg exchangeable pool size were then determined under three conditions of isotope administration: 1) 20 mg 25Mg, with single feeding; 2) 20 mg 25Mg, distributed over a 24-h period; and 3) 60 mg 25Mg, over a 24-h period. Mg isotope ratios were determined by inductively coupled plasma mass spectrometry. Fractional absorption was increased in all three infants after distributed versus bolus administration at the 20 mg dose; mean (+/- SD) fractional absorption was 64.0 +/- 3.9 versus 54.3 +/- 5.9%, respectively. 25Mg retention was also more in all three infants after distributed administration (55.8 +/- 3.0 versus 44.3 +/- 1.3% of dose). At the 60-mg 25Mg dose, compared to 20 mg, fractional absorption was reduced but absolute isotope absorption more than doubled in all infants; urine isotope losses represented a similar fraction of the absorbed dose, thus, 25Mg retention also more than doubled. Compared to the results of the isotope studies, net Mg absorption and balance were uninfluenced by total Mg intake. Isotope retention with distributed isotope administration resulted in measurable isotopic enrichment of plasma and erythrocytes at 72 h (i.e. plasma isotope enrichment was 6.3-10.2 and 19.2-23.5% for the 20- and 60-mg dose, respectively). With these doses, apparent Mg exchangeable pool size ranged from 5.5 to 7.6 mmol/kg body wt; these values showed a decrease with age both within and between infants.(ABSTRACT TRUNCATED AT 250 WORDS)

Utilization of dietary precursors for carnitine synthesis in human adults

Endogenous synthetic pathways are presumed to be sufficient to provide adequate amounts of carnitine to meet the needs of the body. However, circulating carnitine levels of strict vegetarian adults and children, and particularly of infants fed carnitine-free formulas, are significantly lower than normal. Therefore, we investigated loci at which rates of carnitine synthesis may be restricted in human adults. Excess amounts of the carnitine precursors lysine plus methionine, epsilon-N-trimethyllysine or gamma-butyrobetaine were fed as supplements to a low carnitine diet for 10 d. Rate of carnitine synthesis was estimated by changes in carnitine excretion and changes in serum and muscle carnitine levels. Dietary gamma-butyrobetaine dramatically increased carnitine production, epsilon-N-trimethyllysine had a somewhat smaller effect, and lysine plus methionine had even less effect on carnitine synthesis. We conclude that carnitine synthesis is not limited by the activity of gamma-butyrobetaine hydroxylase. Carnitine synthesis from exogenous epsilon-N-trimethyllysine is limited either by enzymatic processes that lead to the final intermediate, gamma-butyrobetaine, or by the ability of this substrate to enter tissues capable of carrying out these transformations.