Prehospital Recognition and Management of Pediatric Sepsis: A Qualitative Assessment

BACKGROUND AND PURPOSE

Sepsis is a life-threatening disease in children and is a leading cause of morbidity and mortality. Early prehospital recognition and management of children with sepsis may have significant effects on the timely resuscitation of this high-risk clinical condition. However, the care of acutely ill and injured children in the prehospital setting can be challenging. This study aims to understand barriers, facilitators, and attitudes regarding recognition and management of pediatric sepsis in the prehospital setting.

METHODS

This was a qualitative study of EMS professionals participating in focus groups using a grounded theory-based design to gather information on recognition and management of septic children in the prehospital setting. Focus groups were held for EMS administrators and medical directors. Separate focus groups were held for field clinicians. Focus groups were conducted via video conference until saturation of ideas was reached. Using consensus methodology, transcripts were coded in an iterative process. Data were then organized into positive and negative factors based on the validated PRECEDE-PROCEED model for behavioral change.

RESULTS

Thirty-eight participants in six focus groups identified nine environmental factors, 21 negative factors, and 14 positive factors pertaining to recognition and management of pediatric sepsis. These findings were organized into the PRECEDE-PROCEED planning model. Pediatric sepsis guidelines were identified as positive factors when they did exist and negative factors when they were complicated or did not exist. Six interventions were identified by participants. These include raising awareness of pediatric sepsis, increasing pediatric education, receiving feedback on prehospital encounters, increasing pediatric exposure and skills training, and improving dispatch information.

CONCLUSION

This study fills a gap by examining barriers and facilitators to prehospital diagnosis and management of pediatric sepsis. Using the PRECEDE-PROCEED model, nine environmental factors, 21 negative factors, and 14 positive factors were identified. Participants identified six interventions that could create the foundation to improve prehospital pediatric sepsis care. Policy changes were suggested by the research team based on the results of this study. These interventions and policy changes provide a roadmap for improving care in this population and lay the groundwork for future research.

Implementation of an Automated Sepsis Screening Tool in a Children's Hospital Emergency Department: A Cost Analysis

OBJECTIVE

To determine the effect of implementation of an automated sepsis screening tool on the median cost of affected patient encounters.

STUDY DESIGN

This retrospective cohort study used propensity score-matched comparison groups to assess the difference in median cost for comparable affected patient encounters before and after the implementation of an automated sepsis screening tool in a large US children's hospital emergency department (ED) with >90 000 annual visits. All patient encounters in 2018 impacted by the automated sepsis screening tool were included and compared with a propensity score-matched comparison group drawn from patient encounters in 2012 that might have been affected by the screening tool had it been active at that time. The main outcome was the change in the median cost for comparable affected patient encounters.

RESULTS

The overall median cost for those affected by an automated sepsis screening tool decreased by 21.2%, from $6454 (IQR, $968-$21 697) to $5084 (IQR, $802-$16 618). The median cost for encounters with an associated International Classification of Diseases sepsis code decreased by 51.1%, from $58 685 (IQR, $32 224-$134 895) to $28 672 (IQR, $16 796-$60 657).

CONCLUSIONS

The median cost for comparable patient encounters decreased with implementation of an automated sepsis screening tool in the pediatric ED. Costs were decreased even more substantially for patients with sepsis. In addition to improving outcomes, an automated sepsis screening tool appears to be at least cost-effective and may be cost-saving, an incentive for more widespread use of this technology.

Field triage of children with abdominal trauma

Objective

Identify physical findings in children with abdominal trauma to inform prehospital providers regarding appropriate hospital destinations.

Methods

This is a secondary analysis of the Pediatric Emergency Care Applied Research Network Abdominal Trauma Public Use Dataset. Children involved in motor vehicle collisions; struck by motor vehicles at >20 mph; involved in all-terrain vehicle, motorcycle, or scooter accidents; or who fell from >10 ft ( n = 5575) were included. Stepwise multivariable multinomial logistic regression was used to compare clinical findings at presentation between children with no intra-abdominal injury, intra-abdominal injury without intervention, and intra-abdominal injury with intervention (laparoscopy/laparotomy, embolization, red blood cell transfusion, or admission >48 h on intravenous fluids).

Results

Compared to children with no intra-abdominal injury, children with intra-abdominal injury (with and without intervention) were more likely to have evidence of abdominal wall trauma, abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and evidence of thoracic trauma. Children with intra-abdominal injury requiring intervention were more likely to have evidence of abdominal wall trauma (OR 3.32, 95% CI 2.03–5.44) and be intubated (OR 4.93, 95% CI 3.17–7.65) when compared to children with intra-abdominal injury without intervention.

Conclusions

The findings of abdominal tenderness, peritoneal irritation, decreased breath sounds, distracting painful injury, and thoracic trauma may be used to identify children who warrant evaluation at any trauma center because of increased risk of intra-abdominal injury, whereas intubation and evidence of abdominal wall trauma help identify children with intra-abdominal injury in need of transport to a pediatric trauma center due to risk of undergoing intervention.

Automating a Manual Sepsis Screening Tool in a Pediatric Emergency Department

OBJECTIVE

This article describes the method of integrating a manual pediatric emergency department sepsis screening process into the electronic health record that leverages existing clinical documentation and keeps providers in their current, routine clinical workflows.

METHODS

Criteria in the manual pediatric emergency department sepsis screening tool were mapped to standard documentation routinely entered in the electronic health record. Data elements were extracted and scored from the medical history, medication record, vital signs, and physical assessments. Scores that met a predefined sepsis risk threshold triggered interruptive system alerts which notified emergency department staff to perform sepsis huddles and consider appropriate interventions. Statistical comparison of the new electronic tool to the manual process was completed by a two-tail paired t-test.

RESULTS

The performance of the pediatric electronic sepsis screening tool was evaluated by comparing flowsheet row documentation of the manual, sepsis alert process against the interruptive system alert instance of the electronic sepsis screening tool. In an 8-week testing period, the automated pediatric electronic sepsis screening tool identified 100% of patients flagged by the manual process (n = 29), on average, 68 minutes earlier.

CONCLUSION

Integrating a manual sepsis screening tool into the electronic health record automated identification of pediatric sepsis screening in a busy emergency department. The electronic sepsis screening tool is as accurate as a manual process and would alert bedside clinicians significantly earlier in the emergency department course. Deployment of this electronic tool has the capability to improve timely sepsis detection and management of patients at risk for sepsis without requiring additional documentation by providers.

Substrate specificity of plasma lecithin: cholesterol acyltransferase in abetalipoproteinemia

The lecithin: cholesterol acyltransferase (LCAT) activity of lipoprotein-depleted plasma from a patient with abetalipoproteinemia has been assayed in a modified Glomset-Wright incubation system with three different normal lipoprotein substrates consisting of an authentic mixture of very low (VLDL), low (LDL) and high (HDL) density lipoproteins for the assay of total LCAT activity, HDL to assay alpha-LCAT activity and combined VLDL and LDL to assay beta-LCAT activity, respectively. Although reduced to about half the normal control values, both alpha- and beta-LCAT activities were present in the patient's plasma. It has been shown earlier that secretion of LCAT is linked to that of VLDL, but since patients with abetalipoproteinemia cannot form either chylomicrons or VLDL, our results suggest that a secretion of these triglyceride-rich lipoproteins do not seem to be a prerequisite for a basal secretion of beta-LCAT.

Canine antibody response to Blastomyces dermatitidis WI-1 antigen

OBJECTIVE

To assess whether dogs with blastomycosis produce antibodies against the WI-1 and A-antigens of Blastomyces dermatitidis and whether the antibodies are useful in serodiagnosis.

SAMPLE POPULATION

359 serum samples obtained from 245 dogs.

PROCEDURE

233 samples from 122 dogs with blastomycosis, and 1 sample each from 24 dogs with suspected blastomycosis, 51 control dogs without infection, and 48 healthy dogs from an enzootic region were obtained. Antibodies against WI-1 antigen were detected by radioimmunoassay (RIA). Serum samples were tested in parallel for antibodies against the A-antigen of B dermatitidis by commercial agar-gel immunodiffusion (AGID) in a reference laboratory.

RESULTS

Antibodies were detected in 92% of infected dogs by RIA and in 41 % by AGID. For 29 serum samples that were obtained 11 to 1,545 days after diagnosis, antibodies were detected in 92% of samples by RIA and 7% by AGID. For 93 serial serum samples from 29 dogs with blastomycosis, the mean anti-WI-1 titer was 1:18,761 at the time of diagnosis, and decreased to a mean of 1:1,338 by 210 days after treatment was initiated. Of 24 dogs with suspected infection, antibodies were detected in 67% by RIA and 33% by AGID. Control dogs without blastomycosis had no detectable antibodies in either assay. Thus, sensitivity was 92% for RIA and 41 % for AGID, and specificity was 100% for both tests.

CONCLUSIONS AND CLINICAL RELEVANCE

Anti-WI-1 antibodies are readily detected by RIA in dogs with blastomycosis. Titers become high, decline during treatment, and persist for months. Anti-A antibodies are sometimes detected with AGID, but these decrease quickly.

Response to drugs and diet in a compound heterozygote for familial hypercholesterolaemia

A boy with a total plasma cholesterol concentration of 20.9 mmol/l which fell significantly with a low fat diet, cholestyramine and simvastatin, was shown to have two different mutations in the low density lipoprotein receptor gene, demonstrating that some patients with homozygous familial hypercholesterolaemia show a good lipid lowering response to treatment.

Nodular transformation of the liver associated with portal and pulmonary arterial hypertension

A case of multiple focal nodular hyperplasia (FNH) of the liver associated with noncirrhotic portal hypertension and later complicated by pulmonary arterial hypertension leading to death from right heart failure is reported. In retrospect, the portal hypertension diagnosed in early life was most likely due to a congenital hypoplasia of portal vein branches and multiple FNH, a hyperplastic response of the liver parenchyma in association with anomalies of hepatic arterial branches as found within the lesions. This case may represent a form of multiple FNH syndrome restricted to the liver, because neither extrahepatic vascular malformation nor brain tumor was identified at autopsy. The FNH lesions had considerably expanded over the years, and the severe sinusoidal congestion due to chronic right-sided heart failure with subsequent prolonged parenchymal exposure to blood-borne hepatotrophic factors is a likely explanation for both the massive enlargement of FNH lesions and the nodular regenerative hyperplasia observed in the intervening parenchyma.

Non-invasive detection of endothelial dysfunction in children and adults at risk of atherosclerosis

Endothelial dysfunction is an early event in experimental studies of atherogenesis, preceding formation of plaques. We have devised a non-invasive method for testing endothelial function, to find out whether abnormalities are present in symptom-free children and young adults at high risk of atherosclerosis. With high-resolution ultrasound, we measured the diameter of the superficial femoral and brachial arteries at rest, during reactive hyperaemia (with increased flow causing endothelium-dependent dilatation), and after sublingual glyceryl trinitrate (GTN; causing endothelium-independent dilatation) in 100 subjects--50 controls without vascular risk factors (aged 8-57 years), 20 cigarette smokers (aged 17-62 years), 10 children with familial hypercholesterolaemia (FH; aged 8-16 years), and 20 patients with established coronary artery disease (CAD). Adequate scans were obtained in all but 6 cases. Flow-mediated dilatation was observed in arteries from all control subjects. Dilatation was inversely related to baseline vessel diameter (r = -0.81, p < 0.0001); in arteries of 6.0 mm or less, mean dilatation was 10 (SE 2)%. In smokers, FH children, and adults with CAD, flow-mediated dilatation was much reduced or absent (p < 0.001 for comparison with each relevant control group). Dilatation in response to GTN was present in all groups. Endothelial dysfunction is present in children and adults with risk factors for atherosclerosis, such as smoking and hypercholesterolaemia, before anatomical evidence of plaque formation in the arteries studied. This may be an important early event in atherogenesis.

Cholesterol: should we screen all children or change the diet of all children

Hypercholesterolaemia is a major risk factor for coronary heart disease and may present during childhood. Dietary measures can reduce plasma cholesterol and may thus delay or prevent the development of the atherosclerotic process. Although plasma cholesterol concentrations measured during childhood track into adult life with a correlation coefficient of about 0.6 this in itself is insufficient to justify total population screening of children especially as the mechanisms for management and follow-up and their social, psychological and economic implications have not been adequately evaluated. Targeted screening of children in families with the genetic disorder of familial hypercholesterolaemia, where the risk of premature coronary heart disease is very high, should, however, be undertaken even though such screening may only identify half of all affected children. Dietary change designed to lower plasma cholesterol can be applied to the whole population including children over the age of 2 years, does not require pre-determination of plasma cholesterol, and is to be recommended. The effects of such change on the growth and health of children should be monitored.

Abetalipoproteinemia with an ApoB-100-lipoprotein(a) glycoprotein complex in plasma. Indication for an assembly defect

Patients with autosomal recessive abetalipoproteinemia (ABL) lack in their plasma all lipoproteins containing apolipoprotein (apo)B-100 or B-48. Previous studies have suggested that this is due to the complete absence of apoB. We have investigated whether such patients (n = 10) are able to secrete the lipoprotein(a) (Lp(a] glycoprotein (apo(a] which, in normal plasma, exists as a complex with low density lipoproteins containing apoB-100 (Lp(a) lipoprotein). All 10 patients had reduced but detectable apo(a) levels in plasma (mean, 0.49 mg/dl; range, 0.2-2.03 mg/dl) but no Lp(a) lipoprotein. However, we also detected small amounts (0.2-2.8 mg/dl) of apoB in all patients with ABL. The apoB in the ABL patients had the size of apoB-100 and occurred as a lipid-poor complex with the Lp(a) glycoprotein in a fraction of density 1.22 g/ml. This material may represent partially assembled Lp(a) lipoprotein. There was also uncomplexed apo(a) and apoB-100 in the ABL plasma. The distribution and relative concentration of both proteins in the density fraction greater than 1.06 g/ml varied among patients. The data suggest that in ABL, the assembly of apoB-containing lipoproteins is defective and that apoB-100 may be secreted without its full lipid complement when complexed with apo(a).

Nephrocalcinosis in Shwachman's syndrome

Nephrocalcinosis has been reported only infrequently in Shwachman's syndrome. We describe a case in which nephrocalcinosis occurred and speculate that this may be due to increased urinary oxalate excretion.

Genetic evidence from two families that the apolipoprotein B gene is not involved in abetalipoproteinemia

Abetalipoproteinemia (ABL) is a recessive disorder in which affected individuals have extremely low or undetectable levels of serum apo B-containing lipoproteins. Using restriction fragment length polymorphisms, we have studied two families, each with two children with classical ABL born of normal parents. In each of these families, the two affected children have inherited different apo B alleles from at least one parent, whereas the siblings would be anticipated to share common alleles if this disorder were due to an apo B gene mutation. This linkage study shows that in these families, the apo B gene is discordant with ABL and therefore the disorder is caused by a defect in another gene, which is important for the normal synthesis or secretion of apo B-containing lipoproteins from both the liver and intestine.

Timing of strict diet in relation to fetal damage in maternal phenylketonuria. An international collaborative study by the MRC/DHSS Phenylketonuria Register

64 infants born to women with phenylketonuria (PKU) were grouped according to the mother's dietary treatment in pregnancy. 17 infants, whose mothers were receiving a strict low phenylalanine diet and had blood phenylalanine concentrations below 600 mumol/l at the time of conception, had normal birthweights and head circumferences and no malformations. In the 29 infants whose mothers were receiving either a relaxed diet or a normal diet at conception but who started a strict diet at some time during pregnancy, birthweights and head circumferences were below those in healthy infants and there was an excess of malformations; the findings closely resembled those for the 18 infants whose mothers received no treatment during pregnancy. The birthweights and head circumferences of the 64 infants were inversely related to the maternal phenylalanine concentrations around the time of conception. Only a strict diet started before conception is likely to prevent fetal damage.

Plasma lipoprotein disorders in childhood

Disturbances of the plasma lipoproteins occur as a secondary manifestation in many diseases and usually resolve with treatment of the underlying condition. Of the inherited primary disorders familial hypercholesterolaemia is the most common and important, carries a high risk for premature coronary heart disease in adults, and should be diagnosed and treated in childhood.

Stomatocytosis, abnormal platelets and pseudo-homozygous hypercholesterolaemia

A 13-yr-old girl with congenital haemolytic anaemia associated with pseudo-homozygous hypercholesterolaemia is described. The erythrocyte morphology showed 50-80% stomatocytes, but no abnormality of membrane lipid or protein composition or of cation transport was detected. The platelets were reduced in number, abnormally large and showed reduced adhesion. Successful treatment of the hypercholesterolaemia did not influence the stomatocytosis.

Oral vitamin E supplements can prevent the retinopathy of abetalipoproteinaemia

Six patients with abetalipoproteinaemia are described who received large doses of oral vitamin E for between 12 and 18 years in addition to a low fat diet and supplements of the other fat soluble vitamins. The progressive retinopathy observed in untreated abetalipoproteinaemia was substantially modified and most probably prevented by this therapy. Angioid streaks were noted in one patient. Treatment with vitamin A alone did not prevent or arrest the progression of the retinal lesion.

The role of vitamin E in the treatment of the neurological features of abetalipoproteinaemia and other disorders of fat absorption

Studies in patients with abetalipoproteinaemia and other chronic and severe fat malabsorptive states, and neuropathological studies in the vitamin E-deficient human, monkey and rat indicate that vitamin E is important for normal neurological function. Appropriate vitamin E supplementation is, therefore, advisable for all patients with chronic fat malabsorption who have low serum vitamin E concentrations.

Double blind trial of bezafibrate in familial hypercholesterolaemia

A six month, double blind, crossover controlled trial of bezafibrate was conducted in 14 children with familial hypercholesterolaemia all of whom had a strong family history of early coronary heart disease. The bezafibrate was given twice daily in a dose of 10 to 20 mg/kg/day. The mean plasma total cholesterol concentration on bezafibrate was 22% lower than during the period on placebo and there was a moderate rise in high density lipoprotein cholesterol. Bezafibrate may be a useful adjunct to treatment in these children.

Slipped capital femoral epiphysis: a pathological study. I. A light microscopic and histochemical study of 21 cases

Core biopsy specimens of slipped proximal femoral epiphyseal growth plates and of normal controls were examined by light microscopy and histochemistry. Slipped growth plates showed diminished cellularity with an overall excess of matrix as well as severe disorientation and misalignment of chondrocytes. Decrease in number of argyrophilic fibers in the longitudinal septa suggested deficiency in collagen. Histochemical staining of slipped plates did not deviate from normal except in severely deformed areas. Anatomic and histochemical observations did not conclusively support or exclude biochemical or biomechanical factors in the etiology of epiphyseal slipping.

Slipped capital femoral epiphysis: a pathological study. II. An ultrastructural study of 23 cases

Twenty-three core biopsy specimens from patients with slipped capital femoral epiphysis and 11 control growth plates were studied by electron microscopy. Block staining with toluidine blue for demonstration of proteoglycans at the ultrastructural level was also used. The proliferative and hypertrophic zones of slipped growth plates showed diminished cellularity and marked distortion of the architecture with disarray of the cartilage columns. There was a deficiency and abnormality in the supporting collagenous framework of slipped plates. Chondrocyte degeneration and death were seen at all levels of the proliferative and hypertrophic zones, suggesting a disturbance in the life cycle of chondrocytes. The significance of these findings and their relationship to mechanistic, endocrine, and other proposed etiologies of epiphyseal slipping is discussed.

Vitamin E and neurological function: abetalipoproteinaemia and other disorders of fat absorption

Evidence that vitamin E is important for normal neurological function in humans is presented. First, in abetalipoproteinaemia early therapy with vitamin E delays and may prevent the development of the neurological complications, and in patients with established lesions treatment can arrest or reverse the neuropathy. Second, in other chronic disorders of fat absorption with severe vitamin E deficiency, neurological manifestations which are very similar to those described in untreated abetalipoproteinaemia can be improved by vitamin E. Vitamin E supplementation is therefore advisable for all patients with chronic fat malabsorption who have low serum vitamin E concentration. Serum vitamin E concentrations should also be measured in patients with spinocerebellar disorders, whatever the aetiology.

Vitamin E and neurological function

Three lines of evidence indicate that vitamin E is important for normal neurological function in man. First, in abetalipoproteinaemia early therapy with vitamin E delays, and may prevent, the development of neurological complications, and in patients with established lesions treatment can arrest or reverse the neuropathy. Secondly, in other chronic disorders of fat absorption with severe vitamin E deficiency, neurological manifestations can be improved by vitamin E. Thirdly, the neuropathological changes observed in vitamin-E-deficient states in man (such as abetalipoproteinaemia, chronic liver disease, and cystic fibrosis) are similar to those reported in vitamin-E-deficient rats and monkeys.

Long-term follow-up of children with familial hypercholesterolaemia treated with cholestyramine

35 children with the heterozygous form of familial hypercholesterolaemia (FH) who were followed for up to 8 years after starting on cholestyramine treatment showed a progressive decrease in compliance with therapy with time, so that only 55% remained on treatment after 6 years and only 48% after 8 years. Long-term compliance was significantly better in those starting treatment before age 10. Plasma-cholesterol was lowered in all children taking cholestyramine: for the group the mean reduction in plasma-cholesterol ranged from 26 to 44% during the years of the study, on a mean cholestyramine dose of around 0.4 g/kg/day. Cholestyramine thus effectively lowers plasma-cholesterol in FH, but for long-term use compliance is a problem in many children.

Disturbance in parent-child relationship following preterm delivery

Increasing concern is expressed that the psychosocial development of preterm infants may be hindered by a disturbance of parental attitudes following the initial period of specialised care. Attitudes of parents of 17 preterm infants were compared with those of parents of 17 full-term infants at a single semi-structured interview six to 20 months after the birth. The groups of parents were matched for parity and did not differ in their social, ethnic and educational backgrounds. There was evidence of some disturbance in parent-child relationships in the preterm group, consisting of delays in maternal attachment to the child, negative maternal perception of the child compared with expectation of an 'average' baby, and persistent parental anxiety about leaving the child with a baby-sitter. In addition, two preterm children had been abused or neglected. Parental reaction to a preterm birth is discussed and the need for adequate support to be given to parents in the early period following the birth is stressed.

Surface binding and catabolism of low-density lipoprotein by circulating lymphocytes from patients with abetalipoproteinaemia, with observations on sterol synthesis in lymphocytes from one patient

Surface binding of low-density lipoprotein (LDL), degradation of LDL protein and sterol synthesis were investigated in freshly isolated lymphocytes from normal and abetalipoproteinamic human subjects. LDL binding as a function of LDL concentration showed no evidence of the presence of high-affinity binding sites in fresh lymphocytes from either group of subjects. The rate of degradation of LDL protein by lymphocytes from the patients was no greater than that from the normal subjects and, in the fresh lymphocytes of the one patient studied, sterol synthesis was not increased. We conclude that the formation of LDL receptors and the synthesis of sterol in circulating lymphocytes are largely suppressed and that in normal subjects this may be due to the presence of some plasma constituent other than LDL, possibly the apoE protein. This conclusion is discussed in relation to the possible contribution of LDL receptors to the degradation of LDL protein in vivo.

Sterol balance in a patient with abetalipoproteinaemia

Total-body cholesterol synthesis was measured in a woman with abetalipoproteinaemia and in a normal woman of similar age. The rate of synthesis of cholesterol was 15.4 +/- 4.1 mg/kg/day in the patient and 14.3 +/- 2.6 mg/kg/day in the control subject, indicating that cholesterol synthesis in the whole body is not increased in the complete absence of plasma low density lipoprotein.

Hyperlipidaemia, smoking and hypertension. The place of the hyperlipidaemias

Of the primary hyperlipidaemias, familial hypercholesterolaemia (hyerbetalipoproteinaemia, type II) is always expressed in childhood and carries a high risk for the early development of coronary heart disease. The diagnosis can be established with a high degree of certainty by estimating the serum cholesterol concentration in selected children in whom the genetic risk is known to be great, e.g. if a parent or other first-degree relative is known to have the disease, or if a parent has had an attack of ischaemic heart disease at a young age. Screening of the general population in order to detect this disorder is not advocated. Treatment by either diet or drugs will lower serum cholesterol but long-term compliance is poor and the effect of treatment on the atherosclerotic process has not been evaluated. Follow-up studies must be maintained.

Familial hypertriglyceridaemic states are rarely fully expressed during childhood, and screening for them at this age is not practicable. Control of co-existent obesity and dietary treatment are usually successful in lowering serum lipids but long-term results have not yet been evaluated.

In a childhood population, single estimations of serum cholesterol or triglyceride should be interpreted with caution. Percentile rank correlations for serum cholesterol are of the order of 0·61 and for triglyceride of 0·31. Prediction of adult values cannot therefore be assured in childhood and the place of hyperlipidaemia in the childhood population as a risk factor for coronary heart disease in adult life is not established. Thus population screening of serum lipids in children cannot be justified. Evidence that a change in the diet of children which would be expected to lower serum lipids will also delay the development of atherosclerosis in general and coronary heart disease in particular is lacking. Nevertheless the dietary changes which have been recommended for adults can safely be followed by children, and changes in eating habits are perhaps more likely to succeed if promoted on a family basis rather than for individual sections of the population.

Serum lecithin-cholesterol acyltransferase activity in children with familial hyperbetalipoproteinaemia

Serum (non-fasting) was obtained from 71 healthy school children (12-14 years) and from 16 children with the heterozygous form of familial hyperbetalipoproteinaemia being treated by diet or ion-exchange resin. The activity of lecithin-cholesterol acyltransferase (EC 2.3.1.43) expressed as nmol cholesterol esterified/hour/ml serum did not change with increasing concentrations of unesterified cholesterol in the healthy children. In children with familial hyperbetalipoproteinaemia, lecithin-cholesterol acyltransferase activity was higher than in the healthy children and this activity increased with increasing concentrations of unesterified cholesterol.

Diagnosing familial hypercholesterolaemia in childhood by measuring serum cholesterol

The serum cholesterol concentrations of 134 children aged 1-16 years who had at least one first-degree relative with presumed familial hypercholesterolaemia showed a bimodal distribution, and, using the maximum likelihood technique, two overlapping curves could be fitted. The mean value of the affected children (heterozygotes) was 8-9 mmol/l and that of the unaffected 4-9 mmol/l. The two curves intersected at 6-77 mmol/l, and at this point 5% of the unaffected children had values over 6-77 mmol/l and 3-5% of the heterozygotes had values under 6-77 mmol/l. If this cholesterol concentration is used as a cut-off point 4-25% of cases would be misdiagnosed.

Long-term management of abetalipoproteinaemia. Possible role for vitamin E

Eight patients with abetalipoproteinaemia have been followed for 3-4 to 15-8 years. Management included dietary fat restriction and supplements of the fat-solublevitamins A, E, and K. In the 3 oldest patients serial studies of retinal and neurological function suggest that treatment with large doses of oral vitamin E may have delayed the development or progression of the neurological and retinal lesions.

Functional intestinal obstruction due to deficiency of argyrophil neurones in the myenteric plexus. Familial syndrome presenting with short small bowel, malrotation, and pyloric hypertrophy

In 3 infants functional intestinal obstruction, associated with a short small intestine, malrotation, and pyloric hypertrophy, was shown to be due to failure of development of the argyrophil myenteric plexus, with the absence of ongoing peristalsis. 4 infants with similar clinical features have been described previously, and there is evidence for an autosomal recessive mode of inheritance of this syndrome.

Screening for familial hyper-beta-lipoproteinaemia in children in hospital

1510 plasma cholesterol estimations were made in 1391 children admitted to hospital as part of a biochemical profile. Babies under 1 year and children known to have familial hyperlipoproteinaemia were excluded. The mean concentration was 4-28 mmol/l +/- 1-04 (1 SD) (165-3 mg/100 ml +/- 38-6), and levels exceeded 5-93 mmol/l (229 mg/100 ml) in 68 children. Repeat estimations on 55 of these children showed 34 still to have values greater than 5-93 mmol/l and family studies were performed in 19 of these. In 8 children hypercholesterolaemia was secondary and no familial lipoprotein disorder was present. Familial hyper-beta-lipoproteinaemia (FH) was diagnosed in 3 children and in 2 of the families there was a history of early ischaemic heart disease. In 2 children the diagnosis was in doubt. In the remaining 6 children FH and secondary hyperlipoproteinaemia were excluded so the hypercholesterolaemia was presumably environmentally induced, possibly in association with polygenic inheritance. In the present state of knowledge screening of the childhood population for FH by means of plasma cholesterol determinations cannot be recommended. Studies of lipoproteins should, however, be made in children from families known to have FH or early coronary heart disease.