Liver disease complicating severe haemophilia in childhood

Liver biopsies were performed in 5 boys aged between 2 and 9 years with severe classical haemophilia who had persistently abnormal liver function tests. Abnormal histology was present in all; 4 had chronic persistent hepatitis and the fifth chronic aggressive hepatitis with early cirrhosis. Evidence of previous hepatitis B infection was present in one patient, 3 had antibodies to hepatitis, A, and 2 had subnormal levels of alpha-1-antitrypsin. Haemobilia occurred as a late complication of biopsy in one. The significance of these findings in young boys is discussed, as is the role of exposure to factor VIII containing blood products. It is concluded that cryoprecipitate should be used in preference to large pool factor VIII concentrates in children with haemophilia.     

Proarrhythmia associated with cisapride in children

BACKGROUND: Cisapride is a prokinetic agent that facilitates gastrointestinal motility and is widely used for the treatment of gastroesophageal reflux disease (GERD) in adults and children. However, reports of ventricular proarrhythmia have been noted in patients taking cisapride, particularly in conjunction with other drugs that may inhibit hepatic metabolism of cisapride via the cytochrome P450 3A4 system. OBJECTIVE: We designed a prospective, blinded study to evaluate the effect of cisapride on ventricular repolarization in children with GERD. METHODS: We analyzed the electrocardiograms (ECGs) from 35 children (age 0.4 to 18 years, mean 5.2 years) including measurement of the resting QT interval (QTc), JT interval (JTc), as well as QT and JT interlead dispersion markers. Data from these patients were compared with ECGs from a control group of 1000 normal children. RESULTS: Eleven (31%) of 35 patients receiving cisapride had a prolonged QTc (> or = 450 ms). The JTc was prolonged > or = 360 ms in 16 of 35 patients (46%). The mean QTc in the cisapride group was 428 +/- 35 ms and mean JTc was 336 +/- 35 ms. An increased QT or JT dispersion (> 70 ms) was seen in only 3 of 35 children. Of the 11 children with QTc prolongation, 2 had documented torsades de pointes ventricular tachycardia. Both patients were taking cisapride concomitantly with a macrolide antibiotic. All other patients were treated with either cisapride alone or in conjunction with other GERD agents, such as ranitidine or omeprazole. CONCLUSIONS: Cisapride may cause prolongation of ventricular repolarization in children. There does not appear to be increased heterogeneity of repolarization or delayed depolarization in this small sample. The proarrhythmia may be exacerbated by medications that inhibit cytochrome P450 3A4 hepatic metabolism, overdosage, or mechanisms that result in decreased serum clearance. ECG intervals should be monitored in children maintained on cisapride, particularly when used in combination with other known QT-prolonging medications.     

LU TSU AND HIS RELATION TO OTHER MEDICINE GODS IN CHINESE MEDICAL LORE

Just who in Chinese mythology can rank as the Chinese God of Medicine ? This question is not easy to answer. In going through the North Kiangsu area, where Chinese medical and mythological lore is well developed, one sees several temples, altars and idols dedicated to various medicine gods. Probably none is more commonly wor shipped in drug shops of this part of the eountry than Shen Nung (神农）. The physicians of the scholarly type, however, seem to prefer LLi Shun Yang (吕纯陽) as their patron saint. There are seve:ral other names mentioned in Chinese medicallore of this district as gods of medicine and are even today worshipped there, by Chinese old school physicians. Fu Hsi (伏羲), Shen Nung(神农), Huang Ti (黄帝) Hua T’o （华佗), chang Chung Ching (张仲景), Sun Ssu Mao （孙思貌）, Pien Ch''iao (扁鹬) are all mentioned in North Kiangsti as gods of medicine. Some of these ate godsof specialists as some of their names indicate. Thus Chang Chung Ching is the god of medicine, Toh Wang(毒王) is the god of poison, Yen Kwang P''usa (眼光菩萨) is the god of eyesight.     

1IYGLIENE AND PUBLIC HEALTlI LEPROSY IN MACAO SOME COMMENTS BY THE PORTUGUESE DOCTORS IN MACAO

Ours was the first among the nations of Europe to set up institutions for rendering assistance to lepers in the Far East. . In 1569, but I2 years after the establishment of the Portuguese in Macao, an asylum for lepers was established within the territorial limits of the city of Macao, xvith a hospital and a chapel, maintained 4ut of funds of a pious institution the "Holy House of Charity".     

Combined pre- and post-surgical bupivacaine would infiltrations decrease opioid requirements after knee ligament reconstruction

PURPOSE: To test the efficacy of a combination of selective pre- and post-surgical local anesthetic infiltrations of the knee, compared with standard intra-articular injection at the end of surgery alone, to reduce postoperative opioid requirements following arthroscopic cruciate ligament reconstruction (ACLR). METHODS: In a double-blind, randomized, controlled trial, we studied 23 patients (ASA I or II) scheduled for elective ACLR under general anesthesia. The treatment group (n = 12) received infiltrations with bupivacaine 0.25% with epinephrine 1:200,000 presurgically (10 ml into the portals, 10 ml at the medial tibial incision site, 10 ml at the lateral femoral incision site, and 10 ml intra-articularly) and postsurgically (5 ml at the medial tibial incision and 10 ml at the lateral femoral incision). The control group (n = 11) received infiltrations with saline 0.9% in the same manner. All patients received a standard intra-articular local anesthetic instillation of the knee (25 ml of bupivacaine 0.25% with epinephrine 1:200,000) at the completion of surgery. RESULTS: Postoperative opioid requirements were lower in the treatment group (5.8 +/- 2.9 mg morphine equivalent) than in the control group ( 13.7 +/- 5.8 mg; P = 0.008). Treatment patients were ready for discharge approximately 30 min earlier than control patients (P = 0.046). There were no adverse events in the treatment group. In the control group, 2/11 patients vomited and a third experienced transient postoperative diaphoresis, dizziness and pallor. CONCLUSION: We conclude that a combination of selective pre- and post-surgical wound infiltration with bupivacaine 0.25% provides superior analgesia compared with a standard post-surgical intra-articular injection alone.