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Renal arteriography remains the only study to identify and define correctly both location and extent of renal artery stenosis. Because other studies do not adequately identify all children who have renal artery disease, it is reasonable to perform renal arteriography in those children with severe hypertension who do not have another readily identifiable cause for their hypertension. On the other hand, in children with less profound elevation of blood pressure in whom there is no other definable cause, it is possible to defer renal angiography. In these children with mild or moderate hypertension, studies such as the captopril 99mTc-DTPA scan or intravenous digital subtraction angiography may identify those for whom arteriography is more likely to have abnormal results.

A controlled clinical trial was performed using two dosage regimens of chlorambucil to treat childrenwith frequently relapsing nephrotic syndrome. All children concurrently received prednisone (60 mg/m 2 on alternate days). Ten children (Group I) were given chlorambucil as a stable dose (0.2 mg/kg/day) for 56 to 60 days, and 11 children (Group II) received increasing doses (0.2 to 0.63 mg/kg/day) for 42 to 77 days. Two children in each group subsequently relapsed. Follow-up averaged 28.6 and 27.2 months in Groups I and II, respectively. Three children in Group II developed infectious complications. The data indicate that a stable dosage regimen for chlorambucil is as effective as an increasing dose regimen in achieving long-term remission of frequently relapsing nephrotic syndrome.

Parental actions and beliefs shape every aspect of a child's health and development. Green and Solnit described a vulnerable child syndrome in which the child's development was impaired when the parents treated him or her in an inappropriate fashion because they had an unreasonable expectation that he or she would die. We recently cared for a child who suffered a life-threatening event (status epilepticus due to hyponatremia) because the parents were trying to avoid reproducing a serious, but not life-threatening, problem (nursing bottle caries) that had occurred in the older sibling. This distortion of professional advice created vulnerability to significant neurologic problems.

Four preadolescent children had paroxysms of intractable sneezing. After days of hospitalization and numerous local and systemic drug treatments had failed, a psychogenic cause of their problem was entertained. This uncommon form of conversion reaction most often occurs between the ages of 9 and 15 years, and prognosis is good if the appropriate interventions are undertaken.

The incidence of neonatal HSV infection is approximately one case per 7,500 del iveries: The occurrence o f HSV infections in two infants born within a one-month period to mothers who had been living together in the same commune is highly unlikely to be fortuitous. HSV viruses were cultured from both infants and serotyping proved that they were of the genital type II. There is substantial evidence that this type is transmitted exclusively in adults through sexual contact? A likely explanation for our case would involve a common male source o f the virus, venereal transmission to the mothers in the third trimester near term, and the subsequent infection of the infants during parturition. Neither infant manifested signs or symptoms of a prenatal infection. There is reasonable clinical evidence o f in one mother (No. 1) a localized genital viral infection and in another mother (No. 2) a systemic viral illness presumably both from HSV within one month prior to the births of their children. The acquisition of HSV infection by the mothers must have occurred late in gestation, since infectious virus persists in the urogenital canal for on the average only 27 days in primary infection and for only 16 days in nonprimary infections. If the mothers shed viruses in their urogenital tracts at delivery, the infants had at least a 40% risk of becoming infected. ' The risks are significantly less if the mothers were infected earlier in gestation. Overall, only one in 28 infants born to mothers who have had HSV genital infection at some point in gestation will acquire neonatal disease? Thus, it is likely that our infants acquired their infection during parturit ion passing through an infected canal.

A distinct neurologic syndrome characterized by varying degrees of myoclonus, dysarthria, seizures, dementia, coma, and abnormal EEG occurred in 6 children with chronic renal failure. EEG findings were similar to those described in adults with dialysis dementia and consisted of diffuse slowing with bursts of 2-4 hz polyspike wave discharges. The children (4 male and 2 female) had congenital renal disorders. The encephalopathy could not be attributed to hypertension or known metabolic disturbances due to uremia. Encephalopathy occurred between the ages ot 26 months and 10 years, when renal failure was advanced (GFR 5-10 ml/min/ 1.73 m2). All had received high doses (340-800 mg/kg/day) of aluminum containing phosphate binding gels for periods of 9 months to 5 years prior to the onset of their encephalopathy. Dialysis and successful renal transplantation did not significantly alter the clinical course. The encephalopathy may be related to aluminum intoxication. However, these children differ from previously described adults with dialysis related encephalopathy attributed to aluminum toxicity in that they had not been dialyzed prior to the onset of neurologic signs. Perhaps the nervous system of growing children is more susceptible to trace metal intoxication. These observations suggest that the use of large quantities of aluminum containing gels needs reevaluation in children with renal failure. Supported by NIH grants KR-75 and RR 5624.

Cefazolin has not been studied before in children with renal insufficiency. A single dose of 7 mg/kg was administered to 10 children (1½-16 yr) with varying degrees of renal impairment (Grp I), and to 10 children (7-14 yr) undergoing hemodialysis (Grp II). Serum half-life (T/2) in hours was calculated from disappearance curves and creatinine clearance was obtained (ml/min/1.73 m2). In Grp I one child had a ClCr of 57 ml/min and a T/2 of 4.8 hr. Three children with ClCr of 15-25 ml/min had a T/2 of 19-23 hr. Four children had a ClCr of 8-10 ml/min and had a T/2 of 29-40 hr. Two children with ClCr less than 5 ml/min had T/2 values greater than 58 hr. Normal adults have T/2 of 1.8-1.9 hr. Studies have shown adults with ClCr of 40-60 ml/min to have T/2 of about 5 hrs. Adults with lower ClCr had less prolongation of T/2 than did the children. The drug did not alter the tubular reabsorption of phosphate or the clearance of uric acid. In Grp II the T/2 was 8.25-29.5 hrs. A value of 6.5 hrs. has been reported for adults. The T/2 increased as the efficiency of dialysis, estimated by per cent reduction of BUN and creatinine, fell. T/2 of cefazolin is prolonged in children with renal insufficiency and the degree of prolongation is comparable to adults when the ClCr is only moderately reduced. As the ClCr falls further, the T/2 increases more among the children. T/2 for children on hemodialysis varies with the efficiency of dialysis. Supported in part by NIH grants RR-75 and RR-5624.