Hello. You know what I was doing? A

United States Army Medical Department Continuing Education Program, the

22nd Annual Armed Forces Seminar on Obstetrics and Gynecology.

Prenatal detection of Genetic Disorders with Henry Nadler, M

D professor and chairman of Pediatrics, Northwestern University.

The slide is a little bit out of date that

cannot be made fast enough. Thio Keep up with

him. The number is well over 2000. Now

, pregnancies have been monitored to detect fetal abnormality.

The single most common group is an unquestionably will remain

, certainly for the foreseeable future. Unless some overwhelming

new development in screening for biochemical disorders occurs. And

I personally do not believe that it will, uh

, theme. Most common indications are gonna be for

chromosomal defect. And clearly the most common indication single

one within that particular group is going to be maternal

age. If you took the numbers that I told

you about and you would Thio say that you wanted

to screen women past the age of 35 or 36

those women who wish to be screened for chromosomal defects

, one could make a very significant argument that the

yield would be quite high if you screen women above

40. You're going to find, in fact,

that you yield for a chromosomal abnormality is probably gonna

be in the order of about 2%. If you

screen above 36 or 37 will probably be about 1%

. This means down syndrome and other chromosomal aberrations Out

of this group, you see, roughly nine out

of 350 were detected. So the numbers that I'm

talking about on an ideal fashion really are not significantly

different. There is some argument as to what the

ages that one would consider a maternal age indication.

I don't think that's particularly important. I think that

you can choose whichever you prefer. But you should

recognize this phenomenon, and I personally believe that it

should be presented to parents. Parents can opt as

to whether or not they like to have this test

performed, but I think it should. They should

be made aware that this is so. And as

a matter of fact, I think even if you

might not like to do it, you may,

in a medical legal point of view, in fact

, be placed in doing it. There is one

lawsuit which is about to be ruled on, and

it's unquestionably is gonna be removed. Is unquestionably going

thio come out? I think that the physician will

be judged guilty of malpractice because ah, year and

a half ago in a large center in the United

States, such a physician did not make a wear

to a 45 year old woman. That, and

their synthesis wasn't available. Technique. She gave birth

to a baby with Down Syndrome and has brought a

lawsuit against the obstetrician from not informing her off the

availability of this test. That's an unfortunate way to

practice medicine, But it has become enough of yeah

, public knowledge, at least about this particular test

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

a while. The second group, which will continue

to be a fairly high indication Ah, women who

have previously given birth to Children with Down syndrome,

who, even though the recurrence risks are essentially usually

less than 1%. Unless there 38 or 39 or

41 it would be three times. Whatever the number

I gave you would be, uh, these women

, even though the overwhelming odds are that the baby

will be perfectly normal are going to continue to request

and the S and thesis. That's because of the

fact that they have already had a baby with Down

syndrome, and, uh, they really will have

an amniocentesis for two reasons. Some unquestionably would opt

to terminate the pregnancy if they found that the baby

were affected with Down syndrome. On the other hand

, some who might not even do that would be

willing to take a gamble at the risks of the

procedure. And I'll get into those in a minute

just on buying the last five months of their pregnancy

. Peace of mind, knowing that they were in

fact really not carrying another baby with down syndrome.

So I think one can make a logical argument that

although the risks are small, but they certainly are

there, that the ability to reassure the family perfectly

well in a significant number of instances may well be

itself an indication for MGs and pieces X linked disorders

. The majority of those will continue to be hemophilia

, excellent muscular dystrophy and a whole host of other

ones, which will be extremely rare on a whole

variety of metabolic disorders, and I will give you

an example of many of the metabolic disorders and how

they can be done again. The important thing is

not to try to remember here each of the disorders

that can be detected. But when you do have

a patient with an unusual metabolic disorder, etcetera,

find out. You can just pick up a telephone

and call any number of centers, which would be

readily available to you. The information. Is this

a disease that is detectable in utero? Yes or

no. It's the test of ballot, one ISAT

reliable on. Then you can handle particular situation.

You can see in this group obviously the highest yield

about normal in terms of potential, because most of

the metabolic disorders that we talked about today are inherited

as either excellent recessive on the overwhelming majority them at

the present time order somewhat recessive disorders. Now I

haven't gotten to a whole other group, which we'll

get to later Now, the potential risks of the

procedure of the ones which are well known to you

obviously infection abortion in terms of the fetus. Maternal

bleeding, the possibility of Rh sensitization, uh,

intra uterine puncture of the fetus. Suffice it to

say the experience of amnesty thesis early in pregnancy up

to the present time. And there will be a

study completed by the end of this year in which

eight centers in the United States have done a prospective

collaborative study with controls. Age matched parody matched income

matched etcetera to determine the accurate risks to mother and

fetus of amniocentesis early in the second trimester of pregnancy

. At the present time, that does not appear

to be any significant increase or any increase, really

in congenital malformations of the fetus or of the newborn

. And the only possible thing, at least at

a preliminary plants, is that the incidence of spontaneous

abortion may be somewhat higher in our own group.

And I can only talk about our own groups experience

at the present time over 500 pregnancies that have been

monitored since we've been doing a control study. It's

interestingly enough in our center, uh, or in

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

in the control group managed so far had a higher

incidences of abortion, uh, than the control group

, then the group having, um yes and pieces

. There is very poor data in the obstetrical literature

. At least faras. I'm concerned as to what

the accurate risk of spontaneous abortion in the second trimester

of pregnancy is. There is reasonable data about the

first trimester of a very poor data about the second

, including the collaborative study. Now, theoretically,

the way one could go about decreasing the risk of

maternal fetal bleeding, fetal puncture, etcetera, eyes

on this particular technique. And this is a slide

of Dr Valenti. And I guess Dr Valenti ran

a session here two years ago. Uh, I'll

take a little bit of the other tack with this

procedure. This is an ultrasonic localization, theoretically of

the placenta, so that one could very niftily get

the needle around it, miss the fetal head and

put it in to the present time. Uh,

if one says that this is a reasonable technique to

use for this procedure early in pregnancy, I think

it is, but not for the reasons that it's

been originally proposed. The incidents in those groups who've

done it a bloody taps is identical to the groups

who don't use it. There's no decrease at all

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

amniotic fluid I think the one rial plus that it

has is that it has the ability to localize a

twin pregnancy, which those of us who don't use

it have blown in each pregnancy in which we've done

. In an instant thesis, uh, one potential

disadvantage was published in a might as well get controversial

and extremely poor. Article in The American Journal of

Obstetrics and Gynecology about the risks of them use and

thesis early in pregnancy that appeared a couple of weeks

ago by the group from Denver. They suggested in

this as faras the ability to culture the cells that

they had some or greater difficulty when ultrasonic localization of

the placenta was performed prior to the analysis. This

article, By the way, which is entitled,

I Think the Hazards of mes and thesis early in

the second trimester or something else, I think we'll

give you, if you will look at it.

A nada quit example of how difficult it is to

interpret any kind of data as to the risk figure

almost all of the things that they listed his complications

in almost every instance. When they did the end

their synthesis, they had a marked abnormality when they

got that original fluid brown, black amniotic fluid.

Uh, no fetal heart tones, etcetera, which

are obviously fetal deaths. Prior to the M.

E s and thesis, we routinely recommend that this

be done at roughly 15 weeks of fetal gestation.

Uh, now, this could be quarrel with me

14 to 16. It really doesn't make much difference

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

roughly three or four weeks, which you should get

in the overwhelming majority of instances. And conceivably,

this will give you some time in those states in

which termination of pregnancy after 20 weeks is a problem

on if any of you are practicing in other countries

, this may be a really legal restriction. Here's

an example of a fetus with down syndrome that really

doesn't show you very much. So just go on

. Here's one which again shows you e don't know

if this projects very well the horizontal palma crease at

19 weeks, uh, in a fetus with down

syndrome, and this will show you the difficulties when

one monitors routinely for chromosomal aberrations. This fetus on

this is, I think a 20 week gestational fetus

, uh, was detected under routine screening for a

woman of advanced maternal age. In this particular instance

, the amniotic fluid cells were cultivated in a chromosome

. Elaboration a 47 x y y carry a type

was determined. This, as you remember yesterday,

was the one that Dr Hershon referred to as being

one conceivably associated with tall stature and male criminality.

Well, and with criminal behavior, abnormal social behavior

. Now, if one reviews the literature is Doctor

Hershon tried to do yesterday, we really don't know

what we're talking about with this disease. The ascertainment

Aziz, how this disease was discovered in maximum security

prisons obviously placed a huge bias on it. Now

, when it will be that there is some relationship

between this extra Y chromosome and psychosocial abnormal psycho social

behavior. This all of this information was presented to

the parents who in this particular instance, phrased it

very nicely. Uh, I think in an interesting

way, at any rate that they did not wish

to do a control study on that particular child and

up to terminate the pregnancy and did. The important

point here is that unlike the women who have already

had a baby with down syndrome. Unlike the people

who are known carriers of chromosomal defects or of water

, some will recessive disorders you have here a patient

population who doesn't really know anything at all about Mangal

is, um, they come in and the obstetrician

or somebody informs them, or they pick up the

Ladies Home Journal or Good Housekeeping and they talk about

intruder in diagnosis. And do you know that 42

year it increased? They risk of having a baby

with Mongol is, um, and the mother says

, Well, that's a horrible thing. I'd better

have that test. But she, in fact,

didn't know anything at all about the disease. And

so when you start detecting disease, you suddenly have

a population which is not based and not has has

really not even thought of the majority of the therapeutic

abortion. They don't know anything about the disorder.

And so you're placed in the position of having to

describe the findings of on a routine screening procedure of

a laboratories test with very difficult implications, implications which

may be a bit more difficult to handle, and

some of the problems that Dr Davidson pointed out about

screening for disease and the neonatal period about what nobody

is really sure about, so that this will be

a real problem for you. And I think that

if you do broach this and I think that you

should broach this with increasing maternal age with patients that

you describe what could be done, what the potential

risks are the procedure and you ask them point blank

. You know, what do you think you would

do if you had an affected child? And the

answer is that most times most patients don't really know

the answer, so you can't tie them into a

yes or no. Answer is. Some people have

suggested that you do not do the procedure unless they

tell you right then and there that they will have

a pregnancy terminated. Now here's an example of one

of the biochemical defects that can be detectable in utero

. The reason for showing it is because I think

it's we've learned a great deal about the potential problems

of interview during diagnosis from this disease. This is

a baby who died at a little over three months

of age with a large heart big liver. If

you look at the cross section of the heart.

You'll see the glycogen is the positive and tremendous amounts

within the heart. This is an example of so

called type two glycogen storage disease of Pompeii's disease.

It's an absent of a particular acid, multi,

uh, enzyme, which is present within the license

zones. And so the glycogen accumulates and can be

broken down. You can use a histological techniques to

make this diagnosis, as we've done a number of

years ago, and here you'll see an amniotic fluid

cells. Large double membrane bounded, presumably license owns

with increased amount of like kitchen. Now in about

1967 or 68. I think we reported the first

instances of the intra uterine detection of this disease,

and the first pregnancy that we monitored very nicely did

all the things that we would like it to dio

. The enzyme, which we knew was present in

amniotic fluid, was absent. It was absent in

uncultured cells. Then, if you grew the cells

up in culture, you could then make the diagnosis

and confirm it. And so we predicted that one

could use probably amniotic fluid alone are uncultured cells,

but we suggested that until a tely east were a

little bit cautious that one should rely on cultivated sells

for the diagnosis. Since that time, I think

six or seven instances we have detected Pompey's disease in

utero, and in none of them was there ever

an absent Alfa glucose ideas in the amniotic fluid again

? Uh, needless to say, when the second

one came around where it was present and then we

didn't find any activity in the cells, we were

really quite concerned about it. And so they started

us off on a major research project, which is

just a nice way of saying that we probably should

have done it before we did. The first study

on what we were able to show was that the

enzyme which was present in amniotic fluid, was in

fact, not even the enzyme that had anything to

do with the disease it interacted with the substrate was

just another form. And I think if people try

to sell you and we'll come back to this a

little bit later on using cell free amniotic fluid for

the diagnosis of biochemical defects, at least using enzyme

assets, we best know first of all, what

the normal levels are. That's easy whether that form

of the enzyme has anything to do with the disease

, whether it is a fetal form of an enzyme

which has nothing again whatsoever the disease but would be

confusing you. Now here's an example. We showed

you a picture before of a child with Hurler syndrome

. One of them You go Polish sacra doses.

This is perfectly evident. See, big liver,

big spleen, protruding abdomen, the claw like hands

again, This disorder can be screened in a variety

of ways in utero. The easiest way at least

, I think, at the present time. Although

this will not be three easiest way within a matter

of four or five months from now is to just

grow the cells, exposed them to a sulfate labeled

compound, and the cells from patients with this disease

accumulate uh s 35 labeled compounds that are abnormal.

And if you want to confirm it, you just

take a normal and mix it and you can correct

the defect. If you take another heroism, mix

it, it stays abnormal. This is the easiest

one to screen for the Mucha Polish sack right disorders

, in which known abnormalities occur in many of them

. in cell culture. It will not be the

procedure of choice, though specifically for Hurler syndrome war

hunter syndrome in a matter of a matter of months

. As for almost all of these diseases, the

precise by chemical defect is known, and secondly,

that we do have. There is now available artificial

substrate or made available in the last month or so

, which will convert this into a disease that could

be done or handled in very few laboratories in 12

laboratories with a great deal more, um, larger

numbers. At any rate, there are other techniques

that can be used here. Amniotic fluid cells were

a history. Chemical technique is used. And here

you see, read the blue materialism beta, go

outside a scram mules here the cells where there's no

beta Glock decide days. Remember that little baby I

showed you with generalized cannula psychosis with the large L

Villa hypertrophy. This shows you that this fetuses,

in fact affected with the disease it takes a matter

of a week to do it after the animals and

thesis. Uh, here's a slide of Dr Davidson's

demonstrating the absence of the enzyme uh, Hexcel cemented

a say, uh conceivably a fetus with haystacks disease

. Uh, Dr Davidson was a little bit for

hurry, and I'm not quite sure. He mentioned

one of the confusing factors about this disease, which

isn't so nice. It is nice that you can

screen the population for carrier status. Those were two

carriers are at risk you can provide, interviewed her

and diagnosis. The little thing, which is the

hooker, as it always is, is that there

are at least two families described now who don't have

any heck so cemented, they say, in which

the patient's perfectly normal doesn't have the disease. So

if somebody would routinely screen, you could get yourself

into a bit of difficulty with this. Despite that

, I would still think it's a perfectly reasonable test

to use in pregnancies at risk for this disease.

And there are a whole host of other license on

the enzyme deficiency diseases where qualitative differences as well as

quantitative differences can be used test. Um, uh

, now that this next disease is one where I

think the questions, uh, that are raised as

to whether or not this is a disease capable or

important for intrigue and diagnosis, uh, raises.

I think some interesting questions. This baby has died

five weeks of age, totally preventable disease. If

the physician caring for the infant had even thought of

it, this baby was probably joined. Us had

vomiting, diarrhea, big liver of explain. Probably

died of E. Coli. Septicemia had total reducing

substance in his urine when the baby, when she

was fed a galactus containing formula, which is routine

milk. Most of the perfect preparations that have given

this baby has died of Galactus e mia and still

one out of every five infants in this country in

which this diagnosis is one can clearly show that the

diagnosis is missed and the infants died. Now,

this is an enzyme deficiency disease. The enzyme assay

is easy to do. You can tell if a

hetero zygotes around and you can detect it in you

to rose we first did in 1968. Now this

disease, unlike fennel keeping area, does not have

all the squabbles relating to therapy that have permeated literature

in that disease. And the reason for it is

I think most everybody would accept the fact that dietary

restriction of galactus for these infants in the newborn period

and for the first certainly years of life may be

lifesaving. Whether it needs to be carried on later

in life is unknown as it is in federal keep

Nouriel. But I think there's no quarrel that this

is a life threatening therapeutic approach. Therapeutic model in

terms of this disease, albeit some patients have escaped

to adulthood and then been detected having galactus galactus Siemian

. Invariably they had vomiting, diarrhea, and somebody

substituted a formula of some kind that did not contain

lactose or galactus. Now I think that mhm there

are in this slide demonstrates what I consider to be

, uh, absolutely critical point in terms of intra

uterine diagnosis and maybe more importantly, in terms of

what were first beginning to appreciate about inborn errors of

metabolism, if you will, and the fetus this

is a photograph taken at the time of I may

have put the wrong one in there. I'm sorry

. The photograph that was supposed to be shown that

may may not be it, I'm not sure,

but Isa cataract there's no question about that, but

cataract at in in the neonatal period of an infant

with Galactus e mia. Now what is this telling

you there are a number of such infants have been

described. This tells you, as have all of

the license on the enzyme deficiency diseases, for example

, in which the fetus has been studied during the

second trimester that the fetus does not escape all of

the consequences of an inborn error of metabolism during intra

uterine life. Just because the mother may go around

metabolizing that particular substance every one of the license on

mill enzyme deficiency diseases studied in fetuses at 20 weeks

of gestation have Aled demonstrated abnormal accumulation of material.

In the case of the Galactic Simic, you have

the child with Galactus senior who may have cataracts.

This may account for why all of the P K

used don't in fact get up to with optimal therapy

the identical like you of their siblings and I.

It's because the fetus does, in fact suffer the

consequences of his or her genetic disease. And this

probably in the long run, is going to be

one of the most important aspect of what we talk

about for intra uterine diagnosis at the present time.

And that is the potential for really studying human fetal

development. Both abnormal and normal and conceivably developing therapeutic

models. Galactus e mia might be one in which

, certainly, dietary restriction of Galactus when the fetus

were shown to have Galactus senior would clearly be a

justifiable procedure much easier to do than that of restricting

fennel. Allan E uh, one would have very

little problems before one gets the idea that these ideas

airy, that new a unique There's a book published

in 1902 that I think most obstetricians would read.

I had an opportunity to read it a couple of

months ago. It's called Antenatal Diagnosis by Ballentine,

who is a Scottish obstetrician pathologist who described all of

what's known about intra uterine diagnosis at the present time

and pointed out that the only thing that had really

been accomplished the major accomplishments of medicine in the,

uh, 19th century were the the ability to render

childbearing in case of for the mother a reasonably safe

procedure. And second was the development of the pediatrician

. And he pointed out that clearly the major development

of the 20th century was gonna be the development of

physicians and people who would start taking care of the

fetus during intra uterine life on, He pointed out

all of the goodies that we're talking about now.

80 years ago. These next few slides will list

and probably of more benefit for the audiovisual people than

the offer will. Have you been trying to remember

them? The disorders which have been detected in in

you carol thes air using cell free amniotic fluid alone

Katrina genital syndrome cannot be accurately detected in mid trimester

pregnancies. One could get a reasonable idea. Latent

pregnancies toe One or not, the fetus is affected

, and encephalitis and Milo Meninga Seal have been detected

on the basis of elevated Alfa fetal protein. And

there have been a number of instances, and where

this has been used for diagnosis, it's still a

little bit not sure as to what it means or

how it is. It's even been elevated in the

maternal serum, Uh, when the mother was carrying

a baby with this at risk for anencephaly and with

anencephaly. So I think we routinely would suggest that

certainly this might be a reasonable procedure to start to

entertain now, in terms of intruder, and management

will come back to it again because there are other

techniques which may be feasible, the ones at the

bottom of Mucha Polly sacharow disorders and I think we

need to pay attention to the particular Here are others

we heard about I Cell disease, where the amniotic

fluid license on hydra laces maybe increased myeloma legacy which

will come back to again later on amino acids,

five hydroxy Indal, acetic acid and abnormal spectrum photo

metric absorption is have been described. I think they're

a little bit questionable as to how reliable they are

. Neonatal graves, disease, abnormal PBS and Taste

Sachs disease. There are other diseases very few,

uh, in which the uncultured amniotic fluid cells have

been used and the problems here are those of getting

some red cells and white cells in with the preparation

, the ability in the fear of using up some

of these cells. Why one would what needs to

at any rate, grow the cells long term and

culture. But again have been a number of techniques

used the easiest ones that the excellent process of disorders

where I think it is reasonable to do sex chromosome

y chromosome fluorescence and then confirm it with chromosome analysis

on the cultivated cells, there are a whole host

of disorders now which have been detected. Uh,

and many of these are really, in fact,

reliable. I think cystic fibrosis is not a reliable

test at the present time for detecting the disease in

utero, and hopefully it will be within less than

a year, and the one at the bottom certainly

is not. But the others are relatively easily done

in laboratories with experience. They are almost, or

a significant number of this storage diseases and the degenerative

neurologic diseases can be detected in this fashion. And

I think this is the last one in the Syria's

which brings the list. I think, basically up

to date, there may be one or two that

are not on this list, but they're essentially all

of them. Uh, the point is here again

that there are a variety of techniques that can be

used accurately, foreign treater and detection. And I

think those of you who deal with such families can

quickly find out whether or not it is a reasonable

procedure for your particular family. And clearly the one

on the lower line will continue to be the most

important one used. Now there are a whole host

of Children born with multiple congenital malformations or variety of

syndromes in which interviewed were in diagnosis should be reasonably

entertained. Now here's the one attempting to show an

abnormal spectra photo metrics can, uh, of amniotic

fluid for, um, Milo Meninga seal. I

really personally don't believe, although it's been abnormal once

or twice, that this is a reliable index,

and most of you are much more familiar with this

area than I am. I. Amino acids have

been done and allow the one confined that there are

a number of patients in which the amino acids are

greatly increased. I think it again. It's too

difficult, too cumbersome black specificity and reflects many,

many other things besides just the fetal. The fetus

with this disorder to be a value, probably the

best cope for a technique, I think in the

future will resort. Uh, it's nicely illustrated.

I least hope that nicely illustrating these last two.

These air some slides from not discriminator in Edinburgh,

who has been working with a two millimeter and the

A scope, which he has been used to look

for central nervous system defects in utero. This shows

you supposed to show you the finger of the fetus

photographed through the ami a scope. Here you can

see the genitalia. Uh, clearly so if you're

looking for sex determination, this is certainly it might

be more dangerous. And in fact, it is

. But it's certainly a lot he's to do than

having somebody grow up, sells for you for,

uh, side of genetic diagnosis. And most of

you know, you'd rather trust your own I.

Then you would one of those funny looking pictures that

get sent back to you. I think that's the

last slide could have the slide projector off, please

. The I think the development of Anam Knee a

scope is to me clearly one which is technically within

doing. I know there is a by medical engineer

at Northwestern who's developed Anania scope of sorts. Uh

, that can fit through a 21 gauge needle e

think when one clearly gets down to that size.

And there's no reason with all of the other things

that we can do with cameras and photo electric equipment

, that we can't develop some way of visualizing the

fetus, which I think would make interviewed her and

diagnosis and much more broadly, acceptable field and one

which you would have a much more impact, I

think, than we do at the present time.

In terms of looking for congenital malformation syndromes, there

are a number in which X ray can be used

and encephalitis in a classical example of where X ray

at roughly 20 or 22 weeks can clearly identify the

diagnosis, as can, um, ultrasonic, uh

, scan will show you an abnormal skull. I

think these techniques they're all becoming available now. How

do you put them into proper context and how can

you utilize them? Well, first of all,

everybody in this room should not be doing on GSN

thesis routinely. I think, as most of you

know, I think technically it's a very simple procedure

, sort of make it it. Ah kin thio

. I think I'd much rather have an obstetrician tried

to do in MSN thesis than a pediatric intern doing

a spinal tap. The difference is, I think

we have a great deal of experience and know how

as to what to do with that spinal fluid that

we have. But most people don't have any idea

really or any capability on hand locally as to what

to do with the fluid. I think a reasonable

way of thinking of it is that there are patients

that all of you deal with who are at high

risk. I think if you find such a patient

and you have facilities available on your Onley, likely

tohave the facilities available, uh, boast for I

think doing the chromosomal work on this must be a

facility which has demonstrated the capability of growing on the

other fluid cells. And although we all laugh,

how simply are now it's no place for you to

be sending fluids. Somebody who is working on his

first three to monitor pregnancy uh, you can find

the laboratory. And if the procedure is done in

, the laboratory is notified beforehand, they can accept

the cells. The ship, very readily at ambient

temperature on the cells, will be cultivated 95% of

the time on one insertion of the needle in one

and the S synthesis in 99% of the time.

It if one needs to do a second tap in

reliable laboratories at the present time so that one can

get you an answer, it's accurate. Over 99%

of the time in terms of chromosomal abnormalities on,

I think this could be a very useful adjunct.

The biochemical ones should be done clearly Onley in laboratories

that have a great deal of working knowledge about the

specific enzyme in question and the specific disease. I

think you will find the development in all of the

large cities of amniocentesis programs for chromosomal defects. Unfortunately

, in the city of Chicago, which I have

no reason to presume is any different than any large

city anyplace else in the country. Every hospital who

would do in MDS and thesis once every year is

deciding. It's extremely important for them to go through

the expense in setting up one of these procedures,

and and they're never gonna be ableto have any sort

of reasonable accuracy or reliability, so it should be

regionalized. They need to be either for the armed

forces, wherever the bases are locally. If they're

in a large city, they could be done is

part of a con joint program with one of the

hospitals in that large city. They could be sent

all over the country or the other possibilities of centralized

laboratory available to do them within the service personnel,

I think, Well, I think I'll sort of

stop in a second. But I just would like

toa leave the point, which is really the only

rationale for, uh, I think these two days

of the program genetics is not an isolated little goody

, uh, that has no bearing in clinical medicine

. A significant number of the patients who you take

care of with nonclassical genetic disease like cost a number

of the service costs a number of the breast,

leukemias or other general medical problems do, in fact

, as far as I'm concerned, probably have some

degree of genetic basis heritage in them. Prenatal Detection

of Genetic disorders With Henry Nadler, M D professor

and chairman of Pediatrics, Northwestern University was produced through

the mobile facilities of the TV division, Academy of

Health Sciences, United States Army, Fort Sam,

Houston, Texas