Out-of-hospital paediatric emergencies: a prospective, population-based study.

BACKGROUND: We wanted to study the incidence, distribution and characteristics of paediatric out-of-hospital emergency care on a population level. This knowledge could ameliorate the design and education of emergency medical services and their personnel. METHODS: We studied all (n = 1863) emergency medical services responses and the patient records for paediatric patients (age 0-16 years) in Helsinki, Finland (population 603,968, paediatric population 92,742) during a 12-month period (2012). Patient characteristics, diagnoses, time intervals, medical treatments, procedures, vital measurements and outcome of out-of-hospital treatment were available for analysis. RESULTS: The incidence of emergency medical services -treated paediatric out-of-hospital emergencies was 3.8/1000 inhabitants and 20/1000 1-16-year-old inhabitants. This formed 4.5% of all emergency calls, while children have a threefold share of the population (15%). Falls, dyspnoea, seizures and poisonings account for half of all emergencies. Few patients suffered from a life-threatening condition or trauma. Cardiac arrest or need for advanced life support measures (e.g. intubation) was rare. After evaluation by the emergency medical services, only half of the patients (56%) needed ambulance transportation to hospital. Only 30 (3.7%) of the non-transported patients made an unpremeditated visit to the emergency department after the original contact with the emergency medical services. All of them were well upon arrival to the emergency department. CONCLUSION: Paediatric out-of-hospital emergencies are infrequent and have specific characteristics differing from the adult population. The design and training of emergency medical services and their personnel should focus on evaluation and management of the most frequent situations.

Suspicion of aortic coarctation in an outpatient clinic: how should blood pressure measurements be performed?

We conducted a study on blood pressure (BP) measurements in 40 healthy children (aged 11.0 +/- 0.4 years), in 20 healthy students (18.8 +/- 0.9 years), and in 19 children with a history of coarctation (9.3 +/- 4.0 years). Both a standard sphygmomanometer and an oscillometric device (Dinamap, Critikon Inc, Tampa, FL, USA) were used. BP measurements in the arms, thighs and ankles were performed according to a fixed protocol. Although the site of measuring was switched each time successive measurements in the same limb resulted in lower systolic values than the first measurement. In patients with coarctation all gradient estimates correlated well with each other and with the gradient estimates obtained by Doppler-echocardiography. In healthy children, the systolic BP measured by Dinamap was 2 mmHg lower in the right arm than in the thighs, and 12 mmHg lower than in the ankles. In young adults, the differences were 12 and 16 mmHg, respectively. The BP difference between the right arm and the thighs by sphygmomanometer was +4 mmHg in children and -4 mmHg in adults. The cut point value to warrant further examinations was similar with both methods: 5-10 mmHg higher readings in the arm than in the leg. The first BP measurement should be ignored. After that, repetitive measurements in the arm with the higher systolic BP and the legs should be performed.

Serum lipid concentrations and growth characteristics in 12-year-old children born small for gestational age.

According to Barker's hypothesis, children born small for gestational age (SGA) are at increased risk for cardiovascular diseases in adulthood. The aim of our study was to determine whether retarded fetal growth is associated with dyslipidemia in childhood and, if so, to find predictive factors in the growth characteristics of SGA children. We studied the serum lipid concentrations of 55 SGA children and their 55 appropriate for gestational age control subjects at the age of 12 y. Growth variables were recorded at birth, 5 y, and 12 y of age. The study group consisted of all full-term SGA children born at our university hospital during a 22-mo period in 1984-1986. Nearly half of the SGA children (47.3%) were in the highest quartile for serum total cholesterol of the appropriate for gestational age children (p = 0.038). In multiple logistic regression analysis, poor catch-up growth in height (odds ratio, 13. 8; 95% confidence interval, 2.0-97.5), female sex (odds ratio, 8.1; 95% confidence interval, 1.3-48.9), and early stage of puberty (odds ratio, 7.5; 95% confidence interval, 1.2-46.5) predicted high cholesterol level in the SGA children. By the age of 5 y, 20 (36.4%) SGA children showed catch-up growth of > or =2 SD scores in height, and 21 (38.2%) SGA children showed catch-up growth of > or =2 SD scores in weight from birth. At the age of 12 y, the SGA children were still significantly shorter (p<0.001) and lighter (p< 0.05) than the appropriate for gestational age children, even though their pubertal development was similarly advanced. In conclusion, to be born SGA has long-term consequences for later growth and may already influence the level of serum total cholesterol before the teens. SGA children with poor catch-up growth in height may be at the highest risk for hypercholesterolemia.

Non-invasive blood pressure measurements and aortic blood flow velocity in neonates.

We studied the systolic blood pressure difference between the upper and the lower extremities in healthy newborn infants and the effect of the isthmic narrowing of the aorta on the possible difference. The blood pressure was measured with an oscillometric blood pressure device from every extremity of 36 healthy infants aged 2-5 days. A Doppler echocardiography was performed for each infant to measure the aortic blood flow velocity in the ascending aorta and in the aortic arch above and below the isthmic narrowing. The mean blood pressure readings (S.D.) were the following: the right arm 76.8 (7.3)/48.1 (6.9), the left arm 77.5 (7.4)/51.6 (7.0), the right thigh 77.7 (7.1)/40.7 (5.8), the left thigh 76.8 (6.4)/39.6 (5.8), the right calf 75.5 (7.1)/46.6 (5.7) and the left calf 77.1 (8.6)/48.7 (6.7). The aortic blood flow was faster below the isthmic narrowing of the aorta (1.15 +/- 0.19 m/s) than in the ascending aorta (0.93 +/- 0.12 m/s) or in the aortic arch above the isthmus (0.99 +/- 0.15 m/s). The calculated pressure gradient between the ascending aorta and aorta below the isthmus was 2.0 +/- 1.8 mmHg and between opposite sides of the isthmus 1.5 +/- 1.2 mmHg. Unlike in childhood and adolescence, the systolic blood pressure in the lower extremities of healthy newborn infants is not higher than in the upper extremities. The physiological narrowing of the aortic arch does not explain this phenomenon. If blood pressure measurements are performed on a neonate to rule out aortic coarctation, the readings obtained must be interpreted in respect to normal values in newborns.

Hexokinase deficiency in erythrocytes: a new variant in 5 members of a Finnish family.

15 cases of congenital haemolytic anaemia have thus far been attributed to hexokinase (HK) deficiency in erythrocytes. We report some clinical, biochemical and genetic findings from 5 members of a Finnish family with this deficiency. The proband, a 1-year-old girl, was the only patient with anaemia. All subjects had either mild or marked reticulocytosis. Red cell ATP levels were at the lower range of normal in all subjects and 2,3-DPG was abnormally low in one. The activities of red cell enzymes, other than HK, were within or above the normal range, respectively. The Km-values for glucose and fructose were elevated (ATP normal) in the subjects with HK deficiency. We speculate that the family represents heterozygosity of a mutant allele and that there is phenotypic variation associated with the HK mutant. The locus might be subject to mutations which lead to a variety of HK variants and to a spectrum of diseases. This point of view is in accordance with the overwhelming variation of reaction kinetics and metabolic effects of this and other reported cases.

Hb Helsinki: a variant with a high oxygen affinity and a substitution at a 2,3-DPG binding site (beta82[EF6] Lys replaced by Met).

A new haemoglobin, Hb Helsinki, in which beta 82-Lys (EF6) is replaced by Met, was found in a Finnish family. It was associated with familial erythrocytosis, and the oxygen affinity of the blood was higher than normal. The oxygen equilibrium curves of purified Hb Helsinki and HbA from the same haemolysate have been determined under vaious conditions. "Stripped' Hb Helsinki was found to show normal cooperativity, slightly low oxygen affinity and a reduced Bohr effect at physiological pH. However, the organic phosphates, 2,3-diphosphoglycerate (2,3-DPG) and inositol hexaphosphate (IHP) had a very small effect on Hb Helsinki, and the 2,3-DPG binding constant of deoxygenated Hb Helsinki is close to that of oxyhaemoglobin A. Thus, the replacement of Lys by Met at position 82 dramatically changes the nature of the central cavity of the tetramer and the effect of 2,3-DPG on the respiratory function of the molecule.

Oxidation of glucose and D-B-OH-butyrate by the early human fetal brain.

The isolated brains of 12 previable human fetuses obtained at 12 to 21 weeks' gestation, were perfused through the interval carotid artery with glucose (3 mM) and/or DL-B-OH-butyrate (DL-BOHB), 4.5 MM, plus tracer quantities of either glucose-6-14C (G6-14C) or beta-OH-butyrate-3-14C (BOHB3-14C). Oxidative metabolism was demonstrated by serial collection of gaseous 14CO2 from the closed perfusion system, and from the recirculating medium. Glucose and BOHB were utilized at physiological rates as indicated (mean plus or minus SEM): G6-14C at 0.10 plus or minus 0.01 mumoles/min g brain (n equal 7) or 17.5 plus or minus 1.9 mumoles/min kg fetus; and BOHB3-14C at 0.16 plus or minus 0.05 mumoles/min g (n equal to 5) or 27.3 plus or minus 7.4 mumoles/min kg. Based on fetal weight, glucose metabolism by brain apparently accounted for about 1/3 of basal glucose utilization in the fetus. On a molar basis BOHB3-14C was taken up at 1.47 times the rate of G6-14C. Both BOHB3-14C and G6 14C were converted to 14CO2. The rate of BOHB3-14C conversion to 14CO2 was equal to its rate of consumption, and exceeded the conversion of glucose to CO2 because 45% of the G6-14C was incorporated into lactate-14C. Accordingly, both substrates support oxidative metabolism by brain; and BOHB is a major potential alternate fuel which can replace glucose early in human development.