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*This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.*

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Hello.

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You know what I was doing?

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A United States Army Medical Department Continuing

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Education Program,

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the 22nd Annual Armed Forces Seminar on

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Obstetrics and Gynecology.

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Prenatal detection of Genetic Disorders

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with Henry Nadler,

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M D professor and chairman of Pediatrics,

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Northwestern University.

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The slide is a little bit out of date that cannot be made

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fast enough.

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Thio Keep up with him.

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The number is well over 2000.

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Now,

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pregnancies have been monitored

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to detect fetal

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abnormality.

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The single most common group is an

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unquestionably will remain,

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certainly for the foreseeable future.

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Unless some overwhelming new development in

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screening for biochemical disorders occurs.

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And I personally do not believe that it will,

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uh,

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theme.

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Most common indications are gonna be for chromosomal

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defect.

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And clearly the most common

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indication single one within that particular

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group is going to be maternal age.

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If you took the numbers that I told you about and you

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would Thio say that you wanted to screen

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women past the age of 35 or 36

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those women who wish to be screened for

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chromosomal defects,

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one could make a very significant argument that the

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yield would be quite high if you screen women

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above 40.

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You're going to find,

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in fact,

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that you yield for a chromosomal abnormality is

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probably gonna be in the order of about 2%.

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If you screen above 36 or 37 will probably be about

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1%.

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This means down syndrome and other chromosomal

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aberrations Out of this group,

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you see,

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roughly nine out of 350

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were detected.

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So the numbers that I'm talking about on an ideal fashion

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really are not significantly different.

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There is some argument as to what the ages that one

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would consider a maternal age indication.

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I don't think that's particularly important.

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I think that you can choose whichever you prefer.

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But you should recognize this phenomenon,

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and I personally believe that it should be presented to

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parents.

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Parents can opt as to whether or not they like to have this test

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performed,

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but I think it should.

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They should be made aware that this is so.

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And as a matter of fact,

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I think even if you might not like to do it,

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you may,

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in a medical legal point of view,

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in fact,

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be placed in doing it.

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There is one lawsuit which is about to be ruled on,

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and it's unquestionably is gonna be removed.

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Is unquestionably going

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thio come out?

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I think that the physician

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will be judged guilty of malpractice because

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ah,

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year and a half ago in a large

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center in the United States,

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such a physician did not make a wear

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to a 45 year old woman.

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That,

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and their synthesis wasn't available.

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Technique.

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She gave birth to a baby with Down Syndrome and

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has brought a lawsuit against the obstetrician from

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not informing her off the availability of

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this test.

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That's an unfortunate way to practice medicine,

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But it has become enough of

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yeah,

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public knowledge,

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at least about this particular test,

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that it's likely to be a fuzzy area for a

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while.

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The second group,

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which will continue to be a fairly high indication

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Ah,

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women who have previously given birth to Children with Down syndrome,

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who,

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even though the recurrence risks are essentially usually less than

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1%.

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Unless there 38 or 39 or 41 it would be

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three times.

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Whatever the number I gave you would be,

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uh,

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these women,

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even though the overwhelming odds are that the

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baby will be perfectly normal are going to continue to

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request and the S and thesis.

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That's because of the fact that they have already had a baby with Down

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syndrome,

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and,

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uh,

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they really will have an amniocentesis for

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two reasons.

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Some unquestionably would opt to terminate the

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pregnancy if they found that the baby were affected with Down

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syndrome.

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On the other hand,

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some who might not even do that would be willing

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to take a gamble at the risks of the procedure.

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And I'll get into those in a minute just on buying the

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last five months of their pregnancy.

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Peace of mind,

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knowing that they were in fact really not carrying another baby with

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down syndrome.

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So I think one can make a logical argument that although the risks are

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small,

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but they certainly are there,

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that the

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ability to reassure the family perfectly well in

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a significant number of instances may well be itself an

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indication for MGs and pieces X linked

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disorders.

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The majority of those will continue to be hemophilia,

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excellent muscular dystrophy and a whole host

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of other ones,

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which will be extremely rare on a

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whole variety of metabolic disorders,

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and I will give you an example of many of the metabolic disorders and

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how they can be done again.

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The important thing is not to try to remember

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here each of the disorders that can be detected.

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But when you do have a patient with an unusual metabolic

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disorder,

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etcetera,

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find out.

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You can just pick up a telephone and call any number of centers,

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which would be readily available to you.

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The information.

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Is this a disease that is detectable in utero?

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Yes or no.

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It's the test of ballot,

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one ISAT reliable on.

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Then you can handle particular

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situation.

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You can see in this group obviously the highest

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yield about normal in terms of potential,

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because most of the metabolic disorders that we talked about today are

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inherited as either excellent recessive on the overwhelming

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majority them at the present time order somewhat

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recessive disorders.

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Now I haven't gotten to a whole other group,

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which we'll get to later Now,

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the potential risks of the procedure of the ones which are well

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known to you obviously infection

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abortion in terms of the

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fetus.

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Maternal bleeding,

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the possibility of Rh sensitization,

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uh,

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intra uterine puncture of the fetus.

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Suffice it to say the experience of amnesty thesis

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early in pregnancy up to the present time.

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And there will be a study completed by the end of this

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year in which eight centers in the United

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States have done a prospective collaborative

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study with controls.

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Age matched parody matched income

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matched etcetera to determine the accurate risks to

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mother and fetus of amniocentesis early in the

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second trimester of pregnancy.

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At the present time,

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that does not appear to be any significant increase or any

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increase,

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really in congenital malformations of the fetus

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or of the newborn.

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And the only possible

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thing,

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at least at a preliminary plants,

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is that the incidence of spontaneous abortion may be somewhat

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higher in our own group.

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And I can only talk about our own groups experience at the present

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time over 500 pregnancies that have been monitored

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since we've been doing a control study.

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It's interestingly enough in our center,

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uh,

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or in the data that we've collected in our center,

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women in the control group managed so far

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had a higher incidences of abortion,

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uh,

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than the control group,

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then the group having,

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um yes and pieces.

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There is very poor data in the obstetrical

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literature.

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At least faras.

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I'm concerned as to what the accurate risk

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of spontaneous abortion in the second

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trimester of pregnancy is.

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There is reasonable data about the first trimester of a very poor

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data about the second,

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including the collaborative study.

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Now,

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theoretically,

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the way one could go about decreasing the

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risk of maternal

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fetal bleeding,

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fetal puncture,

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etcetera,

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eyes on this particular technique.

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And this is a slide of Dr Valenti.

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And I guess Dr Valenti ran a session here two years

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ago.

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Uh,

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I'll take a little bit of

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the other tack with this procedure.

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This is an ultrasonic localization,

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theoretically of the placenta,

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so that one could very niftily get the

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needle around it,

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miss the fetal head and put it in to the present

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time.

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Uh,

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if one says that this is a reasonable technique to

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use for this procedure early in pregnancy,

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I think it is,

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but not for the reasons that it's been originally proposed.

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The incidents in those groups who've done it a bloody taps

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is identical to the groups who

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don't use it.

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There's no decrease at all.

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There's been no difference in the ability to obtain amniotic

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fluid I think the one rial

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plus that it has is that it has the ability to

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localize a twin

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pregnancy,

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which those of us who don't use it have blown in each

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pregnancy in which we've done.

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In an instant thesis,

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uh,

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one potential disadvantage was published in

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a might as well get controversial and extremely poor.

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Article in The American Journal of Obstetrics and Gynecology about the

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risks of them use and thesis early in pregnancy

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that appeared a couple of weeks ago by the group

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from Denver.

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They suggested in this as faras the ability to culture

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the cells that they had some or greater difficulty

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when ultrasonic localization of the placenta was

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performed prior to the analysis.

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This article,

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By the way,

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which is entitled,

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I Think the Hazards of mes and thesis early in the

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second trimester or something else,

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I think we'll give you,

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if you will look at it.

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A nada quit example of how difficult it is to interpret

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any kind of data as to the risk figure

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almost all of the things that they listed his

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complications in almost every instance.

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When they did the end their synthesis,

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they had a marked abnormality when they got that original

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fluid brown,

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black amniotic fluid.

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Uh,

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no fetal heart tones,

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etcetera,

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which are obviously fetal deaths.

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Prior to the M.

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E s and thesis,

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we routinely recommend that this be done at roughly 15

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weeks of fetal gestation.

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Uh,

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now,

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this could be quarrel with me 14 to 16.

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It really doesn't make much difference.

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The point is that you'd like an answer in roughly

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three or four weeks,

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which you should get in the overwhelming majority of instances.

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And conceivably,

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this will give you some time in those states in which

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termination of pregnancy after 20 weeks is a problem

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on if any of you are practicing in other

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countries,

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this may be a really legal restriction.

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Here's an example of a fetus with down

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syndrome that really doesn't show you very much.

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So just go on.

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Here's one which again shows you

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e don't know if this projects very well the

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horizontal palma crease at 19 weeks,

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uh,

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in a fetus with down syndrome,

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and this will show you the difficulties when

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one monitors routinely for chromosomal

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aberrations.

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This fetus on this is,

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I think a 20 week gestational fetus,

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uh,

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was detected under routine screening

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for a woman of advanced maternal

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age.

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In this particular instance,

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the amniotic fluid cells were

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cultivated in a chromosome.

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Elaboration a 47 x

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y y carry a type

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was determined.

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This,

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as you remember yesterday,

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was the one that Dr Hershon referred to as being

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one conceivably associated with tall stature and male

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criminality.

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Well,

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and with criminal behavior,

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abnormal social behavior.

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Now,

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if one reviews the literature is Doctor Hershon tried to do

11:26.770 --> 11:27.490
yesterday,

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we really don't know what we're talking about with this disease.

11:30.080 --> 11:32.090
The ascertainment Aziz,

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how this disease was discovered in maximum security

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prisons obviously placed a huge bias on it.

11:38.040 --> 11:38.250
Now,

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when it will be that there is some relationship between this

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extra Y chromosome and psychosocial abnormal

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psycho social behavior.

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This all of this information was presented

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to the parents who in this particular

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instance,

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phrased it very nicely.

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Uh,

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I think in an interesting way,

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at any rate that they did not wish to do a control study

11:58.840 --> 12:01.750
on that particular child and up

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to terminate the pregnancy and did.

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The important point here is that unlike the women who have

12:07.900 --> 12:10.100
already had a baby with down syndrome.

12:10.110 --> 12:12.610
Unlike the people who are known carriers of

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chromosomal defects or of water,

12:14.960 --> 12:17.860
some will recessive disorders you have here

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a patient population who doesn't really know anything at

12:20.740 --> 12:21.590
all about Mangal is,

12:21.590 --> 12:22.000
um,

12:22.010 --> 12:24.800
they come in and the obstetrician or somebody informs

12:24.800 --> 12:25.040
them,

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or they pick up the Ladies Home Journal or Good

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Housekeeping and they talk about intruder in diagnosis.

12:30.970 --> 12:33.330
And do you know that 42 year it increased?

12:33.330 --> 12:35.410
They risk of having a baby with Mongol is,

12:35.410 --> 12:35.600
um,

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and the mother says,

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Well,

12:36.610 --> 12:37.530
that's a horrible thing.

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I'd better have that test.

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But she,

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in fact,

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didn't know anything at all about the disease.

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And so when you start detecting disease,

12:44.990 --> 12:47.930
you suddenly have a population which is not based and not

12:47.930 --> 12:50.500
has has really not even thought of the majority of the

12:50.510 --> 12:51.950
therapeutic abortion.

12:52.440 --> 12:54.050
They don't know anything about the disorder.

12:54.050 --> 12:56.820
And so you're placed in the position of having to describe the

12:56.820 --> 12:59.400
findings of on a routine screening procedure of a

12:59.400 --> 13:01.560
laboratories test

13:02.240 --> 13:04.010
with very difficult implications,

13:04.010 --> 13:06.930
implications which may be a bit more difficult to handle,

13:06.930 --> 13:09.870
and some of the problems that Dr Davidson pointed out about

13:09.880 --> 13:12.520
screening for disease and the neonatal period about

13:12.530 --> 13:14.360
what nobody is really sure about,

13:15.140 --> 13:17.350
so that this will be a real problem for you.

13:17.510 --> 13:20.510
And I think that if you do broach this and I think that you should broach this

13:20.510 --> 13:23.240
with increasing maternal age with patients that you

13:23.240 --> 13:24.620
describe what could be done,

13:24.620 --> 13:27.520
what the potential risks are the procedure and you ask them point

13:27.520 --> 13:27.950
blank.

13:28.340 --> 13:28.730
You know,

13:28.730 --> 13:31.070
what do you think you would do if you had an affected child?

13:31.720 --> 13:34.430
And the answer is that most times most patients don't

13:34.440 --> 13:35.450
really know the answer,

13:36.040 --> 13:38.040
so you can't tie them into a yes or no.

13:38.040 --> 13:38.520
Answer is.

13:38.520 --> 13:41.330
Some people have suggested that you do not do the

13:41.330 --> 13:44.150
procedure unless they tell you right then and there that they will have a

13:44.160 --> 13:45.250
pregnancy terminated.

13:47.740 --> 13:50.550
Now here's an example of one of the biochemical defects that can

13:50.550 --> 13:52.700
be detectable in utero.

13:52.710 --> 13:54.520
The reason for showing it

13:55.840 --> 13:58.640
is because I think it's we've learned a great deal

13:58.640 --> 14:01.520
about the potential problems of interview during diagnosis

14:01.520 --> 14:02.330
from this disease.

14:02.330 --> 14:05.240
This is a baby who died at a little over three months

14:05.240 --> 14:07.750
of age with a large heart big liver.

14:08.340 --> 14:10.050
If you look at the cross section of the heart.

14:10.060 --> 14:12.800
You'll see the glycogen is the

14:12.810 --> 14:15.160
positive and tremendous amounts within the heart.

14:15.170 --> 14:17.650
This is an example of so called type two

14:17.650 --> 14:20.370
glycogen storage disease of Pompeii's disease.

14:20.740 --> 14:22.960
It's an absent of a particular

14:23.540 --> 14:24.060
acid,

14:24.060 --> 14:24.550
multi,

14:24.780 --> 14:25.420
uh,

14:25.430 --> 14:25.970
enzyme,

14:25.970 --> 14:27.640
which is present within the license zones.

14:27.640 --> 14:30.470
And so the glycogen accumulates and can be broken down.

14:31.440 --> 14:34.400
You can use a histological techniques to

14:34.400 --> 14:35.430
make this diagnosis,

14:35.430 --> 14:37.150
as we've done a number of years ago,

14:37.160 --> 14:39.510
and here you'll see an amniotic fluid

14:39.510 --> 14:40.230
cells.

14:40.240 --> 14:42.810
Large double

14:42.810 --> 14:43.970
membrane bounded,

14:44.140 --> 14:47.060
presumably license owns with increased amount of like

14:47.060 --> 14:47.450
kitchen.

14:48.240 --> 14:50.540
Now in about 1967 or 68.

14:50.550 --> 14:53.450
I think we reported the first instances of the intra uterine

14:53.450 --> 14:54.900
detection of this disease,

14:54.900 --> 14:57.780
and the first pregnancy that we monitored very

14:57.780 --> 15:00.170
nicely did all the things that we would like it to dio.

15:01.040 --> 15:01.900
The enzyme,

15:01.900 --> 15:03.830
which we knew was present in amniotic fluid,

15:03.830 --> 15:04.550
was absent.

15:04.940 --> 15:07.410
It was absent in uncultured cells.

15:07.420 --> 15:07.720
Then,

15:07.720 --> 15:09.550
if you grew the cells up in culture,

15:09.560 --> 15:12.170
you could then make the diagnosis and confirm it.

15:12.740 --> 15:15.570
And so we predicted that one could use

15:15.580 --> 15:17.970
probably amniotic fluid alone are

15:17.980 --> 15:18.920
uncultured cells,

15:18.920 --> 15:21.810
but we suggested that until a tely east were a little bit

15:21.810 --> 15:24.810
cautious that one should rely on cultivated sells for

15:24.810 --> 15:25.770
the diagnosis.

15:26.540 --> 15:28.020
Since that time,

15:28.020 --> 15:30.910
I think six or seven instances we have detected

15:30.910 --> 15:32.660
Pompey's disease in utero,

15:33.340 --> 15:35.950
and in none of them was there ever an

15:35.950 --> 15:38.730
absent Alfa glucose ideas in the amniotic

15:38.730 --> 15:39.450
fluid again?

15:40.940 --> 15:41.460
Uh,

15:41.470 --> 15:42.450
needless to say,

15:42.460 --> 15:45.350
when the second one came around where it was present and then we didn't find any

15:45.350 --> 15:46.450
activity in the cells,

15:46.450 --> 15:47.990
we were really quite concerned about it.

15:47.990 --> 15:50.840
And so they started us off on a major research project,

15:50.850 --> 15:53.780
which is just a nice way of saying that we probably should

15:53.780 --> 15:54.740
have done it before we did.

15:54.740 --> 15:57.540
The first study on what we were able to

15:57.540 --> 16:00.320
show was that the enzyme which was present in amniotic

16:00.320 --> 16:00.800
fluid,

16:00.810 --> 16:01.880
was in fact,

16:01.890 --> 16:04.630
not even the enzyme that had anything to do with the disease it

16:04.630 --> 16:07.250
interacted with the substrate was just another form.

16:07.740 --> 16:10.470
And I think if people try to sell you and we'll come back to this a little bit

16:10.470 --> 16:13.080
later on using cell free amniotic fluid

16:13.090 --> 16:15.420
for the diagnosis of biochemical defects,

16:15.420 --> 16:17.070
at least using enzyme assets,

16:17.440 --> 16:19.030
we best know first of all,

16:19.030 --> 16:20.780
what the normal levels are.

16:20.790 --> 16:23.540
That's easy whether that form of the enzyme has

16:23.540 --> 16:25.020
anything to do with the disease,

16:25.030 --> 16:27.910
whether it is a fetal form of an enzyme which has nothing again

16:27.910 --> 16:30.770
whatsoever the disease but would be confusing

16:30.770 --> 16:30.970
you.

16:32.640 --> 16:33.700
Now here's an example.

16:33.700 --> 16:36.390
We showed you a picture before of a child with Hurler

16:36.390 --> 16:36.880
syndrome.

16:36.880 --> 16:38.590
One of them You go Polish sacra doses.

16:38.590 --> 16:40.240
This is perfectly evident.

16:40.250 --> 16:40.540
See,

16:40.540 --> 16:41.070
big liver,

16:41.070 --> 16:41.780
big spleen,

16:41.780 --> 16:42.710
protruding abdomen,

16:42.710 --> 16:44.300
the claw like hands again,

16:44.310 --> 16:47.080
This disorder can be screened in a variety of ways in

16:47.080 --> 16:47.760
utero.

16:47.800 --> 16:49.170
The easiest way at least,

16:49.170 --> 16:49.480
I think,

16:49.480 --> 16:50.230
at the present time.

16:50.230 --> 16:53.170
Although this will not be three easiest way within a matter of

16:53.170 --> 16:55.860
four or five months from now is to

16:56.240 --> 16:57.390
just grow the cells,

16:57.390 --> 17:00.110
exposed them to a sulfate labeled compound,

17:00.110 --> 17:02.860
and the cells from patients with this disease accumulate

17:02.870 --> 17:05.480
uh s 35 labeled compounds that are

17:05.480 --> 17:06.210
abnormal.

17:06.220 --> 17:07.460
And if you want to confirm it,

17:07.470 --> 17:10.110
you just take a normal and mix it and you can correct the

17:10.110 --> 17:10.580
defect.

17:10.580 --> 17:11.770
If you take another heroism,

17:11.770 --> 17:12.150
mix it,

17:12.150 --> 17:13.970
it stays abnormal.

17:14.340 --> 17:17.320
This is the easiest one to screen for the Mucha Polish sack

17:17.320 --> 17:17.900
right disorders,

17:17.900 --> 17:20.670
in which known abnormalities occur in many of them.

17:20.680 --> 17:21.660
in cell culture.

17:22.140 --> 17:24.030
It will not be the procedure of choice,

17:24.030 --> 17:26.580
though specifically for Hurler syndrome war hunter

17:26.580 --> 17:28.790
syndrome in a matter of a matter of months.

17:28.800 --> 17:31.160
As for almost all of these diseases,

17:31.160 --> 17:33.500
the precise by chemical defect is known,

17:33.510 --> 17:34.570
and secondly,

17:34.570 --> 17:35.820
that we do have.

17:35.830 --> 17:38.400
There is now available artificial substrate or made

17:38.400 --> 17:40.260
available in the last month or so,

17:40.440 --> 17:43.170
which will convert this into a disease that could be

17:43.170 --> 17:45.940
done or handled in very few laboratories in 12

17:45.950 --> 17:47.460
laboratories with a great deal more,

17:47.740 --> 17:48.280
um,

17:48.840 --> 17:49.770
larger numbers.

17:49.780 --> 17:50.370
At any rate,

17:51.940 --> 17:54.060
there are other techniques that can be used here.

17:54.060 --> 17:56.330
Amniotic fluid cells were a history.

17:56.340 --> 17:58.110
Chemical technique is used.

17:58.110 --> 17:59.260
And here you see,

17:59.640 --> 18:01.220
read the blue materialism beta,

18:01.220 --> 18:04.180
go outside a scram mules here the cells where there's

18:04.180 --> 18:05.720
no beta Glock decide days.

18:05.730 --> 18:08.480
Remember that little baby I showed you with generalized cannula

18:08.480 --> 18:11.120
psychosis with the large L Villa

18:11.120 --> 18:12.090
hypertrophy.

18:12.100 --> 18:13.610
This shows you that this fetuses,

18:13.610 --> 18:16.460
in fact affected with the disease it takes a matter of a week to

18:16.460 --> 18:18.570
do it after the animals and thesis.

18:19.840 --> 18:20.540
Uh,

18:20.550 --> 18:23.420
here's a slide of Dr Davidson's

18:23.420 --> 18:26.300
demonstrating the absence of the enzyme

18:26.310 --> 18:26.750
uh,

18:26.760 --> 18:28.710
Hexcel cemented a say,

18:28.720 --> 18:31.150
uh conceivably a fetus with haystacks

18:31.150 --> 18:31.780
disease.

18:32.140 --> 18:32.820
Uh,

18:32.830 --> 18:35.130
Dr Davidson was a little bit for hurry,

18:35.130 --> 18:35.890
and I'm not quite sure.

18:35.890 --> 18:38.800
He mentioned one of the confusing factors about this disease,

18:38.800 --> 18:40.090
which isn't so nice.

18:40.220 --> 18:43.040
It is nice that you can screen the population for carrier

18:43.040 --> 18:43.740
status.

18:43.750 --> 18:46.380
Those were two carriers are at risk you can provide,

18:46.380 --> 18:47.860
interviewed her and diagnosis.

18:48.340 --> 18:49.100
The little thing,

18:49.100 --> 18:50.310
which is the hooker,

18:50.310 --> 18:51.310
as it always is,

18:51.310 --> 18:54.250
is that there are at least two families described now who don't

18:54.250 --> 18:55.420
have any heck so cemented,

18:55.420 --> 18:56.220
they say,

18:56.230 --> 18:58.870
in which the patient's perfectly normal doesn't have the

18:58.880 --> 18:59.560
disease.

18:59.940 --> 19:02.920
So if somebody would routinely screen,

19:02.920 --> 19:05.160
you could get yourself into a bit of difficulty with this.

19:05.170 --> 19:06.000
Despite that,

19:06.000 --> 19:08.490
I would still think it's a perfectly reasonable test to

19:08.490 --> 19:10.990
use in pregnancies at risk for this disease.

19:10.990 --> 19:13.670
And there are a whole host of other license on the enzyme deficiency

19:13.670 --> 19:16.530
diseases where qualitative differences as

19:16.530 --> 19:19.220
well as quantitative differences can be used test.

19:19.220 --> 19:19.370
Um,

19:20.540 --> 19:21.380
uh,

19:21.390 --> 19:23.460
now that this next disease is one

19:23.470 --> 19:26.190
where I think the questions,

19:26.200 --> 19:26.820
uh,

19:26.830 --> 19:29.590
that are raised as to whether or not this is a disease

19:29.600 --> 19:32.360
capable or important for intrigue and diagnosis,

19:32.740 --> 19:33.490
uh,

19:33.500 --> 19:34.310
raises.

19:34.320 --> 19:36.070
I think some interesting questions.

19:36.070 --> 19:38.640
This baby has died five weeks of age,

19:38.650 --> 19:40.320
totally preventable disease.

19:40.330 --> 19:42.970
If the physician caring for the infant had even thought of it,

19:43.440 --> 19:44.870
this baby was probably joined.

19:44.870 --> 19:45.930
Us had vomiting,

19:45.940 --> 19:46.640
diarrhea,

19:46.650 --> 19:48.020
big liver of explain.

19:48.030 --> 19:49.050
Probably died of E.

19:49.050 --> 19:49.530
Coli.

19:49.530 --> 19:52.120
Septicemia had total reducing

19:52.120 --> 19:53.980
substance in his urine when the baby,

19:53.980 --> 19:56.540
when she was fed a galactus

19:56.540 --> 19:57.610
containing formula,

19:57.620 --> 19:59.080
which is routine milk.

19:59.090 --> 20:01.160
Most of the perfect

20:01.640 --> 20:04.400
preparations that have given this baby has

20:04.400 --> 20:07.180
died of Galactus e mia and still one out of every five

20:07.180 --> 20:09.660
infants in this country in which this diagnosis is

20:10.340 --> 20:13.000
one can clearly show that the diagnosis is missed and the

20:13.010 --> 20:13.850
infants died.

20:14.540 --> 20:15.000
Now,

20:15.010 --> 20:17.110
this is an enzyme deficiency disease.

20:17.110 --> 20:18.790
The enzyme assay is easy to do.

20:18.790 --> 20:21.710
You can tell if a hetero zygotes around and you can detect it in you

20:21.710 --> 20:23.870
to rose we first did in 1968.

20:24.640 --> 20:25.820
Now this disease,

20:25.820 --> 20:27.120
unlike fennel keeping area,

20:27.130 --> 20:29.790
does not have all the squabbles relating to

20:29.790 --> 20:32.440
therapy that have permeated literature in that

20:32.450 --> 20:32.890
disease.

20:32.890 --> 20:35.770
And the reason for it is I think most everybody would

20:35.770 --> 20:38.430
accept the fact that dietary restriction of

20:38.440 --> 20:41.440
galactus for these infants in the newborn

20:41.440 --> 20:44.040
period and for the first certainly years of life may be

20:44.040 --> 20:44.780
lifesaving.

20:46.740 --> 20:49.510
Whether it needs to be carried on later in life is

20:49.520 --> 20:51.840
unknown as it is in federal keep Nouriel.

20:51.850 --> 20:54.770
But I think there's no quarrel that this is a life threatening

20:54.780 --> 20:57.500
therapeutic approach.

20:57.510 --> 21:00.300
Therapeutic model in terms of this disease,

21:00.310 --> 21:03.270
albeit some patients have escaped to adulthood and

21:03.270 --> 21:06.200
then been detected having galactus galactus Siemian.

21:06.210 --> 21:07.790
Invariably they had vomiting,

21:07.800 --> 21:08.580
diarrhea,

21:08.590 --> 21:11.490
and somebody substituted a formula of some kind that

21:11.490 --> 21:13.770
did not contain lactose or galactus.

21:14.540 --> 21:17.540
Now I think that mhm there

21:17.540 --> 21:20.390
are in this slide demonstrates what I consider to

21:20.390 --> 21:20.830
be,

21:20.840 --> 21:21.210
uh,

21:21.220 --> 21:23.750
absolutely critical point in terms of intra uterine

21:23.750 --> 21:26.050
diagnosis and maybe more importantly,

21:26.060 --> 21:28.960
in terms of what were first beginning to appreciate

21:29.340 --> 21:31.360
about inborn errors of metabolism,

21:31.360 --> 21:32.280
if you will,

21:32.290 --> 21:34.950
and the fetus this is a

21:34.950 --> 21:37.190
photograph taken at the time of

21:38.940 --> 21:40.390
I may have put the wrong one in there.

21:40.440 --> 21:41.080
I'm sorry.

21:41.090 --> 21:43.860
The photograph that was supposed to be shown that may may not be it,

21:43.870 --> 21:44.620
I'm not sure,

21:44.630 --> 21:47.470
but Isa cataract there's no question about

21:47.470 --> 21:47.740
that,

21:47.750 --> 21:50.620
but cataract at in in the

21:50.630 --> 21:53.540
neonatal period of an infant with Galactus e

21:53.540 --> 21:53.870
mia.

21:55.200 --> 21:57.930
Now what is this telling you there are a number of such infants have been

21:57.930 --> 21:58.710
described.

21:58.750 --> 21:59.670
This tells you,

22:00.240 --> 22:03.140
as have all of the license on the enzyme

22:03.140 --> 22:04.200
deficiency diseases,

22:04.200 --> 22:04.750
for example,

22:04.750 --> 22:07.190
in which the fetus has been studied during

22:07.200 --> 22:09.570
the second trimester

22:10.340 --> 22:12.970
that the fetus does not escape all of the

22:12.970 --> 22:15.850
consequences of an inborn error of metabolism during

22:15.850 --> 22:16.820
intra uterine life.

22:16.830 --> 22:19.480
Just because the mother may go around metabolizing that

22:19.490 --> 22:22.340
particular substance every one of the

22:22.340 --> 22:24.980
license on mill enzyme deficiency diseases studied in

22:24.980 --> 22:27.600
fetuses at 20 weeks of gestation have Aled

22:27.600 --> 22:30.370
demonstrated abnormal accumulation of material.

22:31.040 --> 22:32.540
In the case of the Galactic Simic,

22:32.540 --> 22:34.960
you have the child with Galactus senior who may have

22:34.970 --> 22:35.900
cataracts.

22:35.910 --> 22:38.850
This may account for why all of the P K used don't in

22:38.850 --> 22:41.420
fact get up to with optimal therapy the

22:41.420 --> 22:43.670
identical like you of their siblings

22:44.640 --> 22:45.140
and I.

22:45.150 --> 22:47.070
It's because the fetus does,

22:47.070 --> 22:50.050
in fact suffer the consequences of his or

22:50.050 --> 22:51.260
her genetic disease.

22:51.260 --> 22:53.360
And this probably in the long run,

22:53.360 --> 22:56.170
is going to be one of the most important aspect

22:56.180 --> 22:59.070
of what we talk about for intra uterine diagnosis at the

22:59.070 --> 22:59.760
present time.

23:00.340 --> 23:02.970
And that is the potential for really studying

23:02.980 --> 23:04.280
human fetal development.

23:04.290 --> 23:07.290
Both abnormal and normal and conceivably developing

23:07.290 --> 23:08.720
therapeutic models.

23:08.730 --> 23:11.150
Galactus e mia might be one in which,

23:11.160 --> 23:11.530
certainly,

23:11.530 --> 23:14.400
dietary restriction of Galactus when the fetus were shown to

23:14.410 --> 23:17.120
have Galactus senior would clearly be a

23:17.120 --> 23:19.990
justifiable procedure much easier to do

23:19.990 --> 23:21.250
than that of restricting fennel.

23:21.250 --> 23:23.020
Allan E uh,

23:23.030 --> 23:25.980
one would have very little problems before one gets the idea

23:25.980 --> 23:27.770
that these ideas airy,

23:27.770 --> 23:30.590
that new a unique There's a book published in

23:30.590 --> 23:33.460
1902 that I think most obstetricians would

23:33.460 --> 23:33.900
read.

23:33.910 --> 23:36.140
I had an opportunity to read it a couple of months ago.

23:36.140 --> 23:38.340
It's called Antenatal Diagnosis by

23:38.340 --> 23:39.230
Ballentine,

23:39.240 --> 23:41.150
who is a Scottish

23:41.240 --> 23:44.150
obstetrician pathologist who

23:44.150 --> 23:47.070
described all of what's known about intra uterine diagnosis at

23:47.070 --> 23:49.950
the present time and pointed out that the only thing that had really been

23:49.950 --> 23:52.760
accomplished the major accomplishments of medicine in

23:52.760 --> 23:53.220
the,

23:53.230 --> 23:53.690
uh,

23:53.700 --> 23:56.680
19th century were the the

23:56.680 --> 23:58.660
ability to render

23:58.670 --> 24:01.610
childbearing in case of for the mother

24:01.620 --> 24:03.570
a reasonably safe procedure.

24:03.580 --> 24:05.870
And second was the development of the

24:05.880 --> 24:06.900
pediatrician.

24:06.910 --> 24:09.490
And he pointed out that clearly the major development of the

24:09.490 --> 24:12.020
20th century was gonna be the development of

24:12.030 --> 24:15.030
physicians and people who would start taking care of the fetus

24:15.030 --> 24:17.420
during intra uterine life on,

24:17.420 --> 24:20.160
He pointed out all of the goodies that we're talking about now.

24:20.170 --> 24:21.160
80 years ago.

24:23.740 --> 24:26.660
These next few slides will list and probably of

24:26.670 --> 24:29.660
more benefit for the audiovisual people than

24:29.660 --> 24:30.260
the offer will.

24:30.260 --> 24:31.720
Have you been trying to remember them?

24:31.730 --> 24:34.450
The disorders which have been detected in in you carol

24:34.840 --> 24:37.540
thes air using cell free amniotic fluid

24:37.540 --> 24:40.050
alone Katrina genital syndrome cannot be

24:40.050 --> 24:42.550
accurately detected in mid trimester

24:42.550 --> 24:43.260
pregnancies.

24:43.260 --> 24:44.910
One could get a reasonable idea.

24:45.110 --> 24:46.770
Latent pregnancies toe One or not,

24:46.780 --> 24:47.950
the fetus is affected,

24:48.540 --> 24:50.780
and encephalitis and Milo Meninga Seal

24:51.640 --> 24:53.960
have been detected on the basis of

24:54.210 --> 24:56.170
elevated Alfa fetal protein.

24:56.610 --> 24:59.360
And there have been a

24:59.360 --> 25:00.340
number of instances,

25:00.340 --> 25:02.510
and where this has been used for diagnosis,

25:03.440 --> 25:06.400
it's still a little bit not sure as to what it means or how it

25:06.400 --> 25:06.710
is.

25:06.710 --> 25:09.280
It's even been elevated in the maternal serum,

25:09.290 --> 25:09.700
Uh,

25:09.710 --> 25:12.310
when the mother was carrying a baby with

25:12.320 --> 25:15.220
this at risk for anencephaly and

25:15.220 --> 25:16.090
with anencephaly.

25:16.090 --> 25:19.010
So I think we routinely would suggest that

25:19.010 --> 25:21.980
certainly this might be a reasonable procedure to start

25:21.980 --> 25:22.960
to entertain now,

25:22.960 --> 25:24.410
in terms of intruder,

25:24.410 --> 25:27.330
and management will come back to it again because there are other techniques which

25:27.330 --> 25:28.280
may be feasible,

25:28.840 --> 25:31.600
the ones at the bottom of Mucha Polly sacharow

25:31.600 --> 25:34.450
disorders and I think we need to pay attention to the particular

25:35.440 --> 25:38.100
Here are others we heard about I Cell disease,

25:38.100 --> 25:41.070
where the amniotic fluid license on hydra

25:41.070 --> 25:44.010
laces maybe increased myeloma legacy which will come

25:44.010 --> 25:46.640
back to again later on amino acids,

25:46.640 --> 25:47.710
five hydroxy Indal,

25:47.710 --> 25:50.360
acetic acid and abnormal spectrum photo

25:50.360 --> 25:53.040
metric absorption is have been described.

25:53.050 --> 25:56.000
I think they're a little bit questionable as to how reliable they are.

25:56.440 --> 25:57.840
Neonatal graves,

25:57.840 --> 25:58.450
disease,

25:58.980 --> 26:01.600
abnormal PBS and Taste Sachs

26:01.600 --> 26:02.170
disease.

26:04.140 --> 26:06.650
There are other diseases very few,

26:06.660 --> 26:07.000
uh,

26:07.010 --> 26:10.000
in which the uncultured amniotic fluid cells have been used and the

26:10.000 --> 26:12.580
problems here are those of

26:12.590 --> 26:15.490
getting some red cells and white cells

26:15.500 --> 26:16.970
in with the preparation,

26:16.980 --> 26:19.560
the ability in the fear of

26:19.570 --> 26:21.160
using up some of these cells.

26:21.160 --> 26:23.740
Why one would what

26:23.750 --> 26:25.260
needs to at any rate,

26:25.540 --> 26:27.690
grow the cells long term and culture.

26:27.700 --> 26:30.550
But again have been a number of techniques used the

26:30.550 --> 26:33.350
easiest ones that the excellent process of disorders where

26:33.360 --> 26:35.870
I think it is reasonable to do sex chromosome y

26:35.870 --> 26:38.530
chromosome fluorescence and then confirm it with

26:38.530 --> 26:41.050
chromosome analysis on the cultivated cells,

26:43.440 --> 26:46.280
there are a whole host of disorders now which have been

26:46.280 --> 26:47.040
detected.

26:47.050 --> 26:47.970
Uh,

26:48.540 --> 26:50.100
and many of these are really,

26:50.100 --> 26:50.490
in fact,

26:50.500 --> 26:51.270
reliable.

26:51.280 --> 26:54.250
I think cystic fibrosis is not a reliable test

26:54.260 --> 26:56.990
at the present time for detecting the disease in

26:56.990 --> 26:57.460
utero,

26:57.460 --> 26:59.950
and hopefully it will be within less than a year,

26:59.960 --> 27:02.120
and the one at the bottom certainly is not.

27:02.130 --> 27:04.840
But the others are relatively easily done in

27:04.840 --> 27:06.570
laboratories with experience.

27:07.140 --> 27:08.220
They are almost,

27:08.230 --> 27:11.050
or a significant number of this storage diseases

27:11.050 --> 27:13.550
and the degenerative neurologic diseases

27:13.560 --> 27:15.960
can be detected in this fashion.

27:17.240 --> 27:20.200
And I think this is the last one in the Syria's which brings

27:20.200 --> 27:21.510
the list.

27:21.510 --> 27:21.760
I think,

27:21.770 --> 27:22.880
basically up to date,

27:22.880 --> 27:24.810
there may be one or two that are not on this list,

27:24.810 --> 27:26.270
but they're essentially all of them.

27:26.940 --> 27:27.540
Uh,

27:27.550 --> 27:30.500
the point is here again that there are a variety of techniques that can be

27:30.510 --> 27:31.610
used accurately,

27:31.610 --> 27:33.170
foreign treater and detection.

27:33.180 --> 27:35.830
And I think those of you who deal with such families can

27:35.840 --> 27:38.440
quickly find out whether or not it is a reasonable

27:38.450 --> 27:41.120
procedure for your particular family.

27:41.130 --> 27:44.070
And clearly the one on the lower line will continue to be

27:44.080 --> 27:45.960
the most important one used.

27:47.240 --> 27:49.850
Now there are a whole host of Children born with

27:49.850 --> 27:52.530
multiple congenital malformations or variety of

27:52.530 --> 27:55.470
syndromes in which interviewed were in diagnosis should be

27:55.480 --> 27:57.190
reasonably entertained.

27:57.200 --> 27:59.450
Now here's the one attempting to show an

27:59.450 --> 28:02.170
abnormal spectra photo metrics can,

28:02.180 --> 28:02.640
uh,

28:02.650 --> 28:04.510
of amniotic fluid for,

28:04.520 --> 28:04.850
um,

28:05.340 --> 28:06.510
Milo Meninga seal.

28:06.520 --> 28:08.110
I really personally don't believe,

28:08.120 --> 28:10.020
although it's been abnormal once or twice,

28:10.020 --> 28:11.670
that this is a reliable index,

28:11.680 --> 28:14.370
and most of you are much more familiar with this area than I am.

28:15.840 --> 28:16.350
I.

28:16.840 --> 28:19.470
Amino acids have been done and

28:19.480 --> 28:22.260
allow the one confined that there are a number

28:22.260 --> 28:24.830
of patients in which the amino

28:24.830 --> 28:27.360
acids are greatly increased.

28:27.360 --> 28:28.310
I think it again.

28:28.320 --> 28:29.560
It's too difficult,

28:29.570 --> 28:32.310
too cumbersome black specificity and

28:32.320 --> 28:33.210
reflects many,

28:33.210 --> 28:35.580
many other things besides just the

28:35.590 --> 28:36.290
fetal.

28:36.300 --> 28:38.850
The fetus with this disorder to be a

28:38.860 --> 28:39.450
value,

28:40.940 --> 28:43.660
probably the best cope for a

28:43.660 --> 28:44.220
technique,

28:44.220 --> 28:46.910
I think in the future will resort.

28:46.920 --> 28:47.610
Uh,

28:47.620 --> 28:49.140
it's nicely illustrated.

28:49.150 --> 28:51.680
I least hope that nicely illustrating these last two.

28:51.690 --> 28:54.380
These air some slides from not discriminator in

28:54.380 --> 28:55.020
Edinburgh,

28:55.030 --> 28:57.790
who has been working with a two millimeter

28:57.800 --> 28:59.000
and the A scope,

28:59.010 --> 29:01.840
which he has been used to look for central

29:01.840 --> 29:03.830
nervous system defects in utero.

29:03.840 --> 29:06.780
This shows you supposed to show you the finger

29:06.790 --> 29:09.520
of the fetus photographed through the

29:09.520 --> 29:10.850
ami a scope.

29:11.900 --> 29:13.680
Here you can see the genitalia.

29:14.140 --> 29:14.530
Uh,

29:14.540 --> 29:17.360
clearly so if you're looking for sex determination,

29:17.360 --> 29:19.860
this is certainly it might be more

29:19.860 --> 29:20.390
dangerous.

29:20.390 --> 29:20.870
And in fact,

29:20.870 --> 29:21.230
it is.

29:21.230 --> 29:23.830
But it's certainly a lot he's to do than having somebody grow up,

29:23.830 --> 29:25.110
sells for you for,

29:25.120 --> 29:25.840
uh,

29:25.850 --> 29:27.340
side of genetic diagnosis.

29:27.340 --> 29:28.170
And most of you know,

29:28.170 --> 29:30.000
you'd rather trust your own I.

29:30.000 --> 29:32.950
Then you would one of those funny looking pictures that get sent back to you.

29:33.530 --> 29:34.800
I think that's the last slide

29:38.040 --> 29:39.630
could have the slide projector off,

29:39.630 --> 29:39.990
please.

29:40.680 --> 29:43.490
The I think the development

29:43.490 --> 29:45.540
of Anam Knee a scope is to me

29:46.240 --> 29:49.020
clearly one which is technically within doing.

29:49.030 --> 29:51.890
I know there is a by medical

29:51.890 --> 29:54.750
engineer at Northwestern who's developed Anania scope

29:54.750 --> 29:55.820
of sorts.

29:55.830 --> 29:56.390
Uh,

29:56.400 --> 29:59.150
that can fit through a 21

29:59.150 --> 30:02.070
gauge needle e think when one clearly gets down

30:02.070 --> 30:03.050
to that size.

30:03.050 --> 30:05.860
And there's no reason with all of the other things that we can do with

30:05.860 --> 30:07.700
cameras and photo electric equipment,

30:07.700 --> 30:10.490
that we can't develop some way of visualizing the

30:10.490 --> 30:10.900
fetus,

30:10.900 --> 30:13.150
which I think would make

30:13.560 --> 30:16.230
interviewed her and diagnosis and much more broadly,

30:17.440 --> 30:20.290
acceptable field and one which you would have

30:20.300 --> 30:21.740
a much more impact,

30:21.740 --> 30:22.060
I think,

30:22.060 --> 30:23.250
than we do at the present time.

30:23.250 --> 30:25.900
In terms of looking for congenital malformation

30:25.900 --> 30:26.510
syndromes,

30:26.510 --> 30:28.890
there are a number in which X ray can be used and

30:28.890 --> 30:31.680
encephalitis in a classical example of where X

30:31.680 --> 30:34.180
ray at roughly 20 or 22 weeks can

30:34.180 --> 30:36.260
clearly identify the diagnosis,

30:36.260 --> 30:36.850
as can,

30:37.140 --> 30:37.680
um,

30:37.940 --> 30:38.970
ultrasonic,

30:38.980 --> 30:39.460
uh,

30:39.470 --> 30:41.700
scan will show you an abnormal

30:41.710 --> 30:42.690
skull.

30:42.700 --> 30:45.060
I think these techniques they're all becoming

30:45.070 --> 30:45.920
available now.

30:45.920 --> 30:48.450
How do you put them into proper context and how can you

30:48.450 --> 30:49.160
utilize them?

30:49.540 --> 30:49.770
Well,

30:49.770 --> 30:50.500
first of all,

30:50.500 --> 30:53.460
everybody in this room should not be doing on GSN

30:53.460 --> 30:54.460
thesis routinely.

30:55.100 --> 30:55.440
I think,

30:55.440 --> 30:56.220
as most of you know,

30:56.220 --> 30:58.640
I think technically it's a very simple procedure,

30:58.650 --> 31:00.170
sort of make it it.

31:00.740 --> 31:01.830
Ah kin thio.

31:01.830 --> 31:04.470
I think I'd much rather have an obstetrician tried to do in MSN

31:04.470 --> 31:07.160
thesis than a pediatric intern doing a

31:07.170 --> 31:07.970
spinal tap.

31:08.640 --> 31:10.550
The difference is,

31:10.910 --> 31:13.810
I think we have a great deal of experience and know how as

31:13.810 --> 31:16.170
to what to do with that spinal fluid that we have.

31:16.640 --> 31:19.620
But most people don't have any idea really

31:19.630 --> 31:22.250
or any capability on hand

31:22.250 --> 31:24.070
locally as to what to do with the fluid.

31:25.020 --> 31:27.840
I think a reasonable way of thinking of it is that there are

31:27.840 --> 31:30.550
patients that all of you deal with who are at high risk.

31:32.040 --> 31:34.690
I think if you find such a patient and you have facilities

31:34.690 --> 31:36.430
available on your Onley,

31:36.430 --> 31:38.610
likely tohave the facilities available,

31:38.620 --> 31:39.610
uh,

31:39.620 --> 31:42.330
boast for I think doing the chromosomal

31:42.340 --> 31:45.210
work on this must be a facility

31:45.210 --> 31:48.200
which has demonstrated the capability of growing on the other fluid

31:48.200 --> 31:48.600
cells.

31:48.600 --> 31:49.560
And although we all laugh,

31:49.560 --> 31:52.280
how simply are now it's no place for you to be

31:52.280 --> 31:53.040
sending fluids.

31:53.040 --> 31:55.550
Somebody who is working on his first three

31:55.940 --> 31:58.560
to monitor pregnancy uh,

31:58.570 --> 32:00.200
you can find the laboratory.

32:00.200 --> 32:02.160
And if the procedure is done in,

32:02.160 --> 32:04.410
the laboratory is notified beforehand,

32:04.420 --> 32:05.710
they can accept the cells.

32:05.710 --> 32:06.150
The ship,

32:06.150 --> 32:09.000
very readily at ambient temperature on the

32:09.000 --> 32:09.380
cells,

32:09.380 --> 32:12.220
will be cultivated 95% of the

32:12.220 --> 32:15.130
time on one insertion of the needle in one and the S synthesis

32:15.130 --> 32:16.730
in 99% of the time.

32:16.730 --> 32:19.570
It if one needs to do a second tap

32:19.840 --> 32:22.770
in reliable laboratories at the present time so that one

32:22.770 --> 32:24.290
can get you an answer,

32:24.290 --> 32:25.040
it's accurate.

32:25.050 --> 32:27.850
Over 99% of the time in terms of chromosomal

32:27.850 --> 32:29.920
abnormalities on,

32:29.930 --> 32:32.580
I think this could be a very

32:32.580 --> 32:33.470
useful adjunct.

32:33.480 --> 32:36.380
The biochemical ones should be done clearly Onley

32:36.390 --> 32:38.970
in laboratories that have a great deal of working

32:38.980 --> 32:41.910
knowledge about the specific enzyme in question and the

32:41.910 --> 32:43.170
specific disease.

32:43.940 --> 32:46.940
I think you will find the development in all of the large cities

32:46.940 --> 32:49.590
of amniocentesis programs for chromosomal

32:49.590 --> 32:50.150
defects.

32:50.160 --> 32:51.000
Unfortunately,

32:51.000 --> 32:52.190
in the city of Chicago,

32:52.190 --> 32:55.130
which I have no reason to presume is any different than any large

32:55.130 --> 32:57.620
city anyplace else in the country.

32:57.630 --> 33:00.380
Every hospital who would do in MDS and

33:00.380 --> 33:02.260
thesis once every year is deciding.

33:02.260 --> 33:05.060
It's extremely important for them to go through the expense

33:05.240 --> 33:07.140
in setting up one of these procedures,

33:07.140 --> 33:09.720
and and they're never gonna be ableto have any sort of reasonable

33:09.720 --> 33:11.270
accuracy or reliability,

33:11.640 --> 33:13.620
so it should be regionalized.

33:13.630 --> 33:16.580
They need to be either for

33:16.580 --> 33:18.520
the armed forces,

33:18.520 --> 33:20.520
wherever the bases are locally.

33:20.530 --> 33:22.160
If they're in a large city,

33:22.160 --> 33:24.680
they could be done is part of a con joint program with one of the

33:24.680 --> 33:26.530
hospitals in that large city.

33:26.540 --> 33:29.060
They could be sent all over the country or the other

33:29.060 --> 33:31.830
possibilities of centralized laboratory

33:31.840 --> 33:34.480
available to do them

33:34.650 --> 33:36.680
within the service personnel,

33:37.750 --> 33:38.700
I think,

33:40.340 --> 33:40.620
Well,

33:40.620 --> 33:42.290
I think I'll sort of stop in a second.

33:42.290 --> 33:44.850
But I just would like toa leave the point,

33:44.860 --> 33:47.380
which is really the only rationale for,

33:47.390 --> 33:47.780
uh,

33:48.240 --> 33:50.970
I think these two days of the program

33:51.540 --> 33:54.380
genetics is not an isolated little goody,

33:54.390 --> 33:55.260
uh,

33:55.270 --> 33:57.270
that has no bearing in clinical medicine.

33:58.840 --> 34:01.840
A significant number of the patients who you take care

34:01.840 --> 34:04.670
of with nonclassical genetic disease like

34:04.670 --> 34:07.560
cost a number of the service costs a number of the breast,

34:07.570 --> 34:10.380
leukemias or other general medical problems

34:10.390 --> 34:10.770
do,

34:10.770 --> 34:11.260
in fact,

34:11.260 --> 34:12.240
as far as I'm concerned,

34:12.250 --> 34:15.090
probably have some degree of genetic

34:15.100 --> 34:17.050
basis heritage in them.

34:21.140 --> 34:24.010
Prenatal Detection of Genetic disorders

34:26.740 --> 34:27.640
With Henry Nadler,

34:27.640 --> 34:30.290
M D professor and chairman of Pediatrics,

34:30.290 --> 34:31.890
Northwestern University

34:33.940 --> 34:36.890
was produced through the mobile facilities of the TV

34:36.890 --> 34:37.500
division,

34:37.850 --> 34:39.500
Academy of Health Sciences,

34:39.500 --> 34:40.730
United States Army,

34:41.010 --> 34:41.580
Fort Sam,

34:41.580 --> 34:42.140
Houston,

34:42.140 --> 34:42.780
Texas