Paediatric cardiac arrest and resuscitation provided by physician-staffed emergency care units

BACKGROUND

Most paediatric cardiac arrest studies have been conducted in the USA, where paramedics provide prehospital emergency care. We wanted to study the outcome of paediatric cardiac arrest patients in an emergency medical system which is based on physician staffed emergency care units.

METHODS

We analysed retrospectively the files of 100 prehospital cardiac arrest patients from Southern Finland during a 10-year study period. The patients were less than 16 years of age.

RESULTS

Fifty patients were declared dead on the scene (DOS) without attempted resuscitation, and cardiopulmonary resuscitation (CPR) was initiated in 50 patients. The sudden infant death syndrome was the most common cause of arrest in the DOS patients (68%) as well as in those receiving CPR (36%). Asystole was the initial cardiac rhythm in 70% of the patients in whom CPR was attempted. Resuscitation was successful in 13 patients, 8 of whom were ultimately discharged. Six of the patients survived with mild or no disability and 4 of them had near-drowning aetiology. In multivariate analysis, the short duration of CPR (< or = 15 min) was the only factor significantly associated with better survival.

CONCLUSIONS

Although prehospital care was provided by physicians, the overall rate of survival was found to be equally poor as reported from systems with paramedics. The only major difference between physician- and paramedic-staffed emergency care units is the ability of physicians to refrain from resuscitation already on the scene when prognosis is poor.

Whey mineral supplementation and arterial tone in mineralocorticoid-NaCl hypertension

OBJECTIVE

The aim was to study the effects of supplementation of rat chow diet with whey mineral concentrate (Whey), a diet rich in milk minerals, on arterial responses in vitro in mineralocorticoid-NaCl hypertension.

METHODS

Forty young Wistar rats were allocated to four groups: Wistar, Whey-Wistar, deoxycorticosterone (DOC), and Whey-DOC. DOC (10 mg kg-1 s.c.) was given twice a week and these rats drank 0.7% NaCl solution, while the others received equal volumes of vehicle (sesame oil) and drank tap water. The supplementation was performed by adding 25% whey mineral concentrate to the chow, which in particular increased the intake of potassium and also that of calcium and magnesium in the rats. Responses of mesenteric arterial rings were examined in standard organ chambers after 10 study weeks.

RESULTS

During the 10 week study the DOC-NaCl treatment had a marked hypertensive effect in rats, while the whey mineral supplementation was without significant effect on blood pressure in the Whey-DOC and Whey-Wistar groups. Arterial relaxation induced by nitroprusside was attenuated in the DOC-treated rats, but was significantly shifted towards that of controls in the Whey-DOC group. Interestingly, endothelium-dependent relaxation to acetylcholine (ACh), which was clearly impaired in the DOC group, was comparable in the Whey-DOC and Wistar groups. Moreover, only in the DOC group the relaxation was improved by diclofenac suggesting that ACh was releasing cyclo-oxygenase-derived contractile factors from the endothelium, and the response was completely abolished by NG-nitro-L-arginine methyl ester (L-NAME). In contrast, diclofenac had a negligible effect on the response in the other groups which also showed distinct relaxations to ACh in the presence of L-NAME. This remaining response to ACh in Wistar rats was inhibited by the addition of apamin and glibenclamide, inhibitors of calcium-activated and ATP-sensitive potassium channels, respectively, suggesting that it was mediated by endothelium-dependent hyperpolarization. In the Whey-Wistar group arterial function did not differ from control Wistars.

CONCLUSIONS

Supplementation with whey mineral concentrate had a protective effect on endothelium-mediated control of arterial tone in experimental DOC-NaCl hypertension.

Pediatric prehospital care provided by a physician-staffed emergency medical helicopter unit in Finland

During an 18-month period ending on March 15, 1994, data on all patients treated by the Helsinki Area Emergency Medical Air Service (HEMS) in Southern Finland were collected. The HEMS operates a physician-staffed helicopter unit which is dispatched by alarm centers connected to a national 112 emergency phone system. Of 1481 emergency missions during the study period, 89 (8%) involved children less than 17 years old. Common pediatric emergencies were trauma (31%), seizures (29%), respiratory problems (14%), and cardiac arrest (9%). Fourteen patients were intubated, an intravenous line was started in 58 patients, and 32 patients received intravenous medication. Cardiopulmonary resuscitation was initiated in nine patients. Ten patients were evacuated by helicopter, and 22 patients were transported by ground ambulance with a HEMS physician escort to the hospital. According to this study, the HEMS physician play an important role also in pediatric prehospital care in their operating area.

Sevoflurane-nitrous oxide or halothane-nitrous oxide for paediatric bronchoscopy and gastroscopy

We have studied 120 infants and children, in three age groups (3-11 months, 1-5 yr and 6-15 yr), to compare anaesthesia with sevoflurane or halothane for bronchoscopy or gastroscopy, or both. Premedication or i.v. anaesthetic agents were not used. Patients were allocated randomly to receive either 7% sevoflurane or 3% halothane in 66% nitrous oxide in oxygen for induction of anaesthesia. The same inspired mixture was continued during bronchoscopy while the concentration of the inhalation agent was reduced by 50% during gastroscopy. Induction times were shorter for infants than for children and shorter for sevoflurane than for halothane. Cardiac arrhythmias were significantly more frequent during halothane than during sevoflurane anaesthesia. Physiological and psychomotor recovery were more rapid after sevoflurane than after halothane. At 24-h follow-up, children who received sevoflurane had significantly less nausea and vomiting. We conclude that sevoflurane was superior to halothane for paediatric bronchoscopy and gastroscopy.

Prolonged granulocyte activation, as well as hypoxanthine and free radical production after open heart surgery in children

OBJECTIVE

To investigate granulocyte activation, as well as hypoxanthine and free radical production in children during the first day after cardiopulmonary bypass.

DESIGN

A prospective study of pediatric patients undergoing either cardiac surgery with a cardiopulmonary bypass or thoracotomy and extracardiac vascular surgery not requiring a cardiopulmonary bypass.

SETTING

Operative and intensive care units, Children's Hospital, University of Helsinki, Finland.

PATIENTS

Seven consecutive patients undergoing elective correction of a ventricular septal defect and six patients undergoing extracardiac surgery for ligation of a patent ductus arteriosus or repair a coarctation of the aorta.

MEASUREMENTS AND MAIN RESULTS

Plasma concentrations of myeloperoxidase (140-334 micrograms/l preoperatively, 460-1692 micrograms/l at 0.2 h after declamping, 471-1386 micrograms/l at 0.5 h after declamping) and lactoferrin (77-258 micrograms/l preoperatively, 533-1783 at 0.2 h, 404-1482 micrograms/l at 0.5 h) as markers of granulocyte activation, and hypoxanthine (0-5.7 mumol/l preoperatively, 4.3-17.0 mumol/l at 0.2 h, 6.5-17.9 mumol/l at 0.5 h) increased in a biphasic manner at 0.2-0.5 h and 6-10 h postoperatively (all p < 0.05). Expired ethane, as an index of free radical activity, increased at 10 h postoperatively (36-119 pmol/kg per min preoperatively, 72-152 pmol/kg per min, p < 0.005).

CONCLUSION

Granulocyte activation, and hypoxanthine and free radical production occur at least 10 h after cardiopulmonary bypass. In children undergoing open heart surgery, attempts to reduce free radical activity should be extended to the postoperative period.

Paediatric out-of-hospital cardiac arrests--epidemiology and outcome

OBJECTIVE

To determine the epidemiology and aetiology of out-of-hospital paediatric cardiac arrest and the outcome of resuscitation and to apply the Utstein template for the paediatric cardiac arrest population.

DESIGN

Retrospective cohort study.

SETTING

A middle-sized urban city (population 516,000) served by a single emergency medical services (EMS) system.

PATIENTS

79 consecutive paediatric (age under 16 years) prehospital cardiac arrest patients between January 1, 1985 and December 31, 1994. No patient was excluded.

INTERVENTION

Advanced paediatric life support according to the recommendations of American Heart Association.

MAIN OUTCOME MEASURES

Survival from cardiac arrest to discharge and factors associated with favourable outcome defined as alive 1 year after discharge with Bloom category I or II.

RESULTS

79 patients had cardiac arrest. The incidence of paediatric out-of-hospital cardiac arrest and sudden unexpected out-of-hospital death was 9.8 and 8.9/100,000/inhabitants aged under 16, respectively. The mean age was 2.9 years, 72.2% were under 18 months. SIDS was the leading cause of cardiac arrest followed by trauma, airway related cardiac arrest and (near)drowning. Fifty-two patients were considered for resuscitation in whom asystole was the most common initial rhythm (78.9%) followed by pulseless electrical activity (13.5%) and ventricular fibrillation (3.8%). Resuscitation was attempted in 34 patients. The overall survival rate was 9.6%, for attempted resuscitation 14.7%, for attempted resuscitation when cardiac arrest was witnessed 25.0% and for attempted resuscitation with witnessed arrest of cardiac origin 0%. Favourable outcome was registered in four of five survivors. Factors associated with favourable outcome were collapse in a public place, the near-drowning aetiology of arrest, bystander initiated CPR and short duration of resuscitation. Multivariate regression analysis showed no factor related to favourable outcome, but MICU time interval < 10 min was related with survival. Due to the retrospective nature of this study all core times could not be obtained. In spite of this, the Utstein template was applicable also in our paediatric cardiac arrest population.

CONCLUSIONS

Survival from paediatric cardiac arrest has remained low. The overall survival rate was 9.6%, survival after attempted resuscitation 14.7% and 0% when resuscitation was attempted in witnessed arrest of cardiac origin. Asystole was the most common initial rhythm and the four leading causes for cardiac arrest were SIDS, trauma, airway related arrest and (near)drowning. The Utstein template adopted for adult out-of-hospital cardiac arrests was was found applicable also in paediatric cardiac arrests.

Regional generation of free oxygen radicals during cardiopulmonary bypass in children

Studies on free radical generation during cardiopulmonary bypass have focused mainly on the heart and the lungs. However, low pumping pressure, nonpulsatile perfusion, and hypothermia affect the entire circulation, resulting in decreased splanchnic blood flow, increased intestinal permeability, and endotoxemia. To evaluate regional phenomena, we studied 16 children undergoing cardiopulmonary bypass. Free radical production, granulocyte activation, and hypoxanthine metabolism were assessed separately in the circulations drained by the inferior and superior venae cavae, as well as in the oxygenator. Three minutes after the onset of cardiopulmonary bypass, significant gradients between the inferior vena cava and the arterial line of the oxygenator existed in malondialdehyde (+0.60 +/- 0.12 mumol/L, lactoferrin (+18.21 +/- 7.65 micrograms/L), myeloperoxidase (+53.75 +/- 16.50 micrograms/L), hypoxanthine (-0.62 +/- 0.15 mumol/L), and urate (+8.87 +/- 4.03 mumol/L). These gradients decreased in parallel with decreasing body temperature. Except for a transient gradient in malondialdehyde at 3 minutes after the onset of cardiopulmonary bypass (+0.23 +/- 0.08 mumol/L), no changes were detected between the superior vena cava and the arterial line. In the oxygenator, granulocyte activation was observed only after aortic declamping. We conclude that during cardiopulmonary bypass, significant free radical generation, granulocyte activation, hypoxanthine elimination, and urate production take place in the region drained by the inferior vena cava. In the oxygenator, granulocyte activation occurs only after aortic declamping.

Effect of cheese on intestinal transit time and other indicators of bowel function in residents of a retirement home

Effects of increased intake of cheese on intestinal transit time and other indicators of bowel function were studied in 21 retirement home residents (18 women and 3 men; age, 68-87 years). The study was divided into four succeeding periods: 1) 1-week basal period (usual diet); 2)3-week cheese period (extra cheese was offered as such on bread or used in cooking); 3) 3-week no-cheese period (all cheese on bread was replaced with cured meats and cold cuts, and no cheese was used in cooking); 4) 3-week follow-up period (usual diet). During the last week of each period a questionnaire was filled out on fecal frequencies, consistency of feces (soft, normal, hard), and occurrence of abdominal pain and flatulence. Use of laxative medications and therapeutic foods (prunes) was registered. Eleven of the 21 subjects collected fecal samples for the determination of fecal wet weight and intestinal transit time by means of radiopaque Sitzmark capsules. Intakes of cheese, fiber-containing foods, and fluids by these 11 subjects during meals offered in the cafeteria were recorded on a prefilled questionnaire. In spite of a 10-fold increase in the intake of cheese no change in intestinal transit time, fecal frequency, fecal wet weight, consistency of feces, and occurrence of gastrointestinal symptoms was observed. The use of laxative medication was higher during the cheese period, but no change in the combined use of laxative medication and therapeutic foods (prunes) was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Lactobacillus strain GG supplementation decreases colonic hydrolytic and reductive enzyme activities in healthy female adults

The effects of yogurt containing viable Lactobacillus strain GG (L. GG) and/or fiber supplements on fecal enzyme activities (beta-glucuronidase, nitroreductase, beta-glucosidase, glycocholic acid hydrolase, urease) and on bacterial metabolites in urine (phenol, p-cresol) were studied in 64 females, 20-41 y old. The subjects were randomly divided into three groups: the first group received L. GG yogurt (2 x 150 mL/d, containing 10(11) colony-forming units (cfu)/L of L. GG), the second group received L. GG yogurt and a rye fiber product (30 g/d, equivalent to 9 g fiber/d), and the third group received placebo yogurt (pasteurized) and fiber. The supplementation period lasted 4 wk, with a preceding 2-wk baseline period and a 2-wk follow-up period. The mean fecal count of L. GG was approximately 10(6) cfu/g feces during the supplementation, and L. GG persisted in the fecal samples of 28% of the subjects for 2 wk after supplementation. L. GG yogurt alone or with fiber significantly decreased fecal beta-glucuronidase, nitroreductase and glycocholic acid hydrolase activities. These enzyme activities returned to baseline levels during the follow-up period. beta-Glucosidase and urease activities were not altered significantly during the study. The addition of fiber to L. GG and placebo yogurt had no effect on the enzymic activities. Urinary excretion of p-cresol decreased significantly in groups receiving L. GG. These data demonstrate that L. GG can modify the colonic environment with possible health effects.

Rehabilitation service evaluation: a follow-up of the extent of use of technical aids for disabled children

The increased awareness of the benefits of rehabilitation technology will lead to an increased demand for services and may lead to discrepancies between needs and resources available. The present study was a regional follow-up of the use of 1278 technical aids. In this study the satisfaction with aids was high and quite near the optimum, but unsatisfactory areas were also identified. A better follow-up of the use of technical aids should be part of rehabilitation practice. Careful assessment of functional and psychosocial needs, goal attainment and environmental factors, and a good system of selection with available alternatives and proper instructions are the basic considerations for satisfactory technical aids.

Technical aids for daily activities: a regional survey of 204 disabled children

Home-care of even severely disabled children is strongly favoured today. However, the role of technical aids for daily activities has not been emphasised in the assessment of the needs of families with disabled children. This study evaluated the extent of help needed for daily living among 204 disabled children and the uses and role of and need for technical aids for eating, dressing, toileting and bathing. The children needed much help. Severely disabled children and their parents benefited most from the use of aids. The structured interview unexpectedly revealed many problems, including a considerable need for extra aids for dressing, bathing and toileting. The parents were ready to accept technical aids, but needed more information on their possibilities, benefits and therapeutic aspects. The authors conclude that the need for technical aids for daily activities is not readily recognised during outpatient or hospital visits.

Fecal bile acid metabolic pattern after administration of different types of bread

Increased concentrations of fecal bile acids have been suggested to be associated with increased risk of colorectal cancer. Fecal bile acid profiles were determined in 12 healthy Finnish women who included in their normal diets for 2-week periods in turn three different types of bread, 200-300 g/day. The breads contained either low-fiber wheat, whole-meal wheat, or whole-grain rye. During consumption of rye bread, the total mean concentration of fecal free bile acids was 4.77 +/- 0.90 mumol/g of dry feces (mean +/- SEM), which was much lower than with the normal omnivorous diet (8.05 +/- 1.56 mumol/g) or during administration of the low-fiber wheat bread (8.83 +/- 1.56 mumol/g) or the whole-meal wheat bread (7.88 +/- 1.34 mumol/g) (P less than 0.05). This decrease was mainly caused by increased proportions of saponifiable bile acids (P less than 0.01). During intake of the whole-grain rye bread, 46% +/- 3% of the fecal bile acids were in their saponifiable forms; this percentage was 30% +/- 3% during the control period, 30% +/- 4% during the low-fiber wheat bread period, and 27% +/- 4% during the whole-meal wheat bread period. It is concluded that the type of bread significantly effects concentrations of cocarcinogenic and comutagenic free lithocholic and deoxycholic acids by changing modes of conjugation in the gut.

Pharmacokinetics of intravenous diclofenac sodium in children

Diclofenac sodium 0.5 mg/kg i.v. was given preoperatively to small children (age 4-6 y). Vt and total plasma clearance were higher than in adults but the elimination half-life was similar.

Pharmacokinetics of intravenous buprenorphine in children

Buprenorphine (3 micrograms kg-1) was given intravenously as premedication to small children (age 4-7 years) undergoing minor surgery. Because of the rapid decline of the plasma buprenorphine concentrations, the terminal elimination half-life could not be estimated reliably. Given this constraint, values of clearance appeared to be higher than those in adults but values of Vss were similar.

Pharmacokinetics of postoperative intravenous indomethacin in children

The disposition of indomethacin was studied in children aged one to four years. Indomethacin 0.35 mg/kg was administered as an intravenous infusion during 15 min. Venous blood samples were collected until 24 hr after infusion. Serum indomethacin was determined with gas chromatography. Using a non-linear regression analysis, the individual data were fitted by a two-compartment open mammillary model with central elimination. Calculated pharmacokinetic parameters were (mean +/- SD); alpha half-life 25.2 +/- 11.3 min; beta half-life 366 +/- 295 min; steady-state volume of distribution 0.74 +/- 0.75 l/kg; volume during elimination phase 1.53 +/- 1.27 l/kg; total body clearance 3.2 +/- 1.7 ml/min./kg. Accordingly, with respect to the pharmacokinetics of indomethacin, children seem to mature early, not later than at the age of one year.

Kinetics and dynamics of postoperative intravenous morphine in children

The pharmacokinetics of intravenous morphine were determined in three groups (0 to 1/2, 2 to 4, and 6 years) of children and related to the respiratory rate, arterial PCO2, and postoperative analgesia. With respect to pharmacokinetics, children seem to mature very early, because in patients aged 5 to 6 months corresponding parameters similar to those in adults were encountered. The two youngest patients (11 days and 2.4 months) diverged clearly from the others. Their mean plasma clearance of morphine was 5.2 ml/min/kg and volume of the central compartment was 0.36 L/kg. In the other patients the clearance ranged from 25.8 to 75.6 ml/min/kg and volume of central compartment from 0.67 to 2.07 L/kg, respectively. The mean analgetic concentration of morphine was 26.2 micrograms/L in the youngest group and 3.8 micrograms/L in the other patients. The effect of morphine on respiration was similar in all groups and did not differ from that of adults. The respiratory depressant effect of morphine in the two youngest patients was not analyzed.

Comparison of buprenorphine with morphine in the treatment of postoperative pain in children

The safety and efficacy of buprenorphine and morphine as postoperative analgesics for children were compared in 60 boys and girls 4 to 14 years old having elective orthopedic operations on upper or lower extremities. The drugs were given in a double-blind manner initially intravenously and thereafter by sublingual buprenorphine or intramuscular morphine administered as required to relieve pain until the third postoperative morning. The IV dose needed to achieve complete initial analgesia was 5.2 +/- 2.8 micrograms/kg buprenorphine and 166 +/- 100 micrograms/kg morphine. The duration of effect was significantly longer with buprenorphine than with morphine, 248 +/- 314 and 114 +/- 109 minutes, respectively (P = 0.03). The most common side effects were nausea and vomiting (28 and 16%) and urinary retention (21 and 19%) in the buprenorphine and morphine groups, respectively. Analgesia with sublingual buprenorphine was as effective and reliable as with intramuscular morphine but a longer duration of action could not be demonstrated.

Does prophylactic intravenous infusion of indomethacin improve the management of postoperative pain in children?

The efficacy of prophylactic intravenous infusion of indomethacin as a postoperative analgesic was studied in 100 children aged one to 16 years. At the end of surgery a bolus dose of indomethacin 0.35 mg.kg-1 followed by an infusion 0.07 mg.kg-1.hr-1 for 24 hr or placebo was given in double-blind manner. The efficacy of the treatment was measured by the need of additional morphine given 0.1 mg.kg-1 intravenously in the Recovery Room and 0.15 mg.kg-1 intramuscularly on the ward according to clinical needs. The other measure of the efficacy was assessment of pain intensity in the Recovery Room and pain relief on the ward. In the Recovery Room the pain scores differed between the groups in advantage of indomethacin only at 30 minutes (p less than 0.05) but the need of morphine was significantly less (p less than 0.01) in the indomethacin group. On the ward the mean doses of morphine given and the nurses' pain relief scores were not different between the study groups. However, in the indomethacin group the total dose of morphine given during 24 hr was lower (p = 0.02) and the children assessed the pain relief to be significantly better (p less than 0.02). Twenty per cent of the children in both groups had transient nausea and vomiting. No skin reactions or other allergic manifestations were observed. Prophylactic indomethacin infusion diminished the need of morphine and resulted in better postoperative analgesia than morphine p.r.n. alone.

Double-blind, multiple-dose comparison of buprenorphine and morphine in postoperative pain of children

In a randomized double-blind study of 57 children (aged 6 months-6 yr), pain following lateral thoracotomy was relieved with repeated i.v. doses of morphine 100 or 50 micrograms kg-1, or buprenorphine 3.0 or 1.5 micrograms kg-1. The same drug and dosage were continued and cardioventilatory indices, pain intensity and sedation measured for an observation period of 24 h. The sums of the pain intensity differences were equal in all groups. The mean doses for the complete initial analgesia were 230 and 180 micrograms kg-1 with the larger and the smaller bolus doses of morphine and 5.8 and 3.7 micrograms kg-1 with buprenorphine, respectively. The mean duration of action of buprenorphine was slightly but not significantly longer than that of morphine. The total consumption of both morphine and buprenorphine was less when the smaller bolus doses were used. Two patients developed a degree of ventilatory depression following repeated doses of buprenorphine. Buprenorphine was equal to morphine as a postoperative analgesic.

Measurement of pain in children with self-reporting and behavioral assessment

There are several studies on the correlation of various pain-rating scales in adults but few such studies have been done on children. To gain information on the correlation of self-reporting pain scales (one verbal and two visual analog scales) with each other and with a scale based on behavioral assessment, we analyzed retrospectively the pain evaluations of 141 pediatric patients participating in our analgesic studies. Eighty-two patients were male and 59 were female. The ages ranged from 1.6 to 17.6 years. The patients were divided into three age groups. All pain-rating scales were correlated (P less than 0.001) with each other and they showed a good internal consistency. There were no differences in correlation coefficients between the age groups and the two sexes. Accordingly, any of the now-employed scales can be used in clinical analgesic studies in children on the condition that the child has comprehended the use of the scale during the preoperative visit.

Metabolic epidemiology of colon cancer: effect of dietary fiber on fecal mutagens and bile acids in healthy subjects

Because of potential significance of fecal mutagens and secondary bile acids in the pathogenesis of colonic cancer and of inverse association between dietary fiber and colonic cancer risk, the effect of dietary wheat and rye fiber on fecal mutagenic activity and bile acid levels was studied in 15 healthy men and women who were consuming high fat/moderately low fiber diets and excreting high levels of fecal mutagens and bile acids. Each participant provided two 24-h stool specimens and a 3-day diet record while consuming their normal diet (control). All subjects were then asked to consume their normal diet plus 11 g of supplemental fiber per day in the form of whole grain bread for 4 weeks. During the last week of diet intervention, each subject provided two 24-h stool specimens and a 3-day dietary record. Fecal samples collected from both periods were analyzed for bile acids and for mutagens using Salmonella typhimurium strains TA98 and TA100 with and without microsomal activation. The concentration of fecal secondary bile acids was significantly lower during the fiber supplemental period in all subjects. Fiber supplementation also inhibited the fecal mutagenic activity in TA100 and TA98 with and without microsomal activation. Thus, the increased fiber intake in the form of whole wheat and rye bread may reduce the production and/or excretion of fecal mutagens and decrease the concentration of fecal secondary bile acids in humans.

Long-term anticonvulsant therapy and vitamin D metabolism in ambulatory pubertal children

Parameters of calcium metabolism were thoroughly examined in 28 adolescents with long-term (over 6 years) anticonvulsant therapy (phenytoin, carbamazepine or combination) and in 10 normal controls in September and in March. The adolescents did not receive any vitamin D supplementation during the study. Serum calcium, inorganic phosphorus, parathyroid hormone and alkaline phosphatase levels in the anticonvulsant group did not differ from those of the control group. Serum 25(OH)D and 24,25(OH)2D levels were in all groups consistently higher in September than in March, but no seasonal variation was found in the 1,25(OH)2D levels in any group. The serum 25(OH)D levels in the phenytoin group in March were the lowest among the three groups treated with anticonvulsants, but the levels in the anticonvulsant groups did not differ significantly from each other or from the control group in the same season. The 24,25(OH)2D and 1,25(OH)2D levels in the anticonvulsant groups did not differ significantly from those of control group in September or in March. There was no correlation between anticonvulsant serum free fraction levels and vitamin D metabolites. The bone mineral content in the distal radius was not significantly decreased in the epileptic patients. In conclusion, the long-term anticonvulsant therapy did not induce the so-called "anticonvulsant rickets" in this ambulatory adolescent material. Our data do not indicate that anticonvulsant drugs alter significantly the vitamin D metabolism. Thus, routine vitamin D supplementation does not appear to be indicated in children on anticonvulsant therapy.

Double-blind evaluation of a lignocaine-prilocaine cream (EMLA) in children. Effect on the pain associated with venous cannulation

The effect of the topical application of a lignocaine-prilocaine cream (EMLA) on the pain of venous cannulation was tested in a double-blind manner. Sixty boys and girls between the ages of 4 and 10 yr who were to undergo surgery participated in the study. No analgesic premedication was given and the venous cannulation was performed during the preparation for general anaesthesia. Pain was assessed by the anaesthetist and the patient using a verbal rating scale and two different pictorial scales. The effect of EMLA in the alleviation of the pain of venous cannulation was considered significantly better than placebo by both anaesthetist (P less than 0.001) and patient (P less than 0.05) (verbal scales). One conventional pictorial scale showed a statistically significant difference (P less than 0.05), but the other, based on facial expressions, did not. Local reactions to the cream were minor and transient in both groups.

The effect of different types of Finnish bread on postprandial glucose response in diabetic patients

The aim of the study was to investigate the effect of the fibre content of the bread and the effect of the state of graining on the postprandial blood glucose response in insulin-dependent and non-insulin-dependent diabetics. The breads were white wheat bread, mixed wholemeal wheat/rye bread, wholemeal rye bread and grained wholemeal rye bread. Finnish wholemeal rye bread induced a slower postprandial blood glucose response than the mixed wholemeal (wheat/rye) bread (P less than or equal to 0.05) and the white wheat bread (P less than or equal to 0.01). Grained wholemeal rye bread resulted in a similar blood glucose response to that from wholemeal rye bread.

Immune capacity of the chicken bursectomized at 60 hr of incubation: cytoplasmic immunoglobulins and histological findings

Chickens were surgically bursectomized at 60 hr of incubation, before the bursal anlage appears. Completeness of the bursectomy was confirmed at autopsy at 10 weeks of age. These embryonically bursectomized (Bx)3 chickens are known to produce immunoglobulins of IgM, IgG, and IgA classes but so far no specific antibodies have been observed even after heavy immunization. The Bx chickens had mature plasma cells in an almost normal frequency when studied at 10 weeks of age. The amount of germinal center formation in the spleen and cecal tonsils was markedly decreased when compared to the control (Co) chickens. Also, the frequency of cytoplasmic IgA-positive (c-IgA+) cells was severely decreased in the Bx animals, whereas the occurrence of c-IgG+ and c-IgM+ cells was not affected to the same extent. These findings support the hypothesis that heavy-chain class switch may occur without the bursal influence, and that the bursa of Fabricius is essential only for expansion or creation of the antibody repertoire.