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COORDINATED CARE OF THE CHILD WITH SPINA BIFIDA
824
Suppose further that the patient has an initial Since stored thrombocyte-count of 150,000 per c.mm. whole blood does not replenish thrombocytes, the attending physician might elect to switch to fresh whole blood (which supplies thrombocytes) once a volume of stored blood had been transfused sufficient to dilute the thrombocyte At this critical point in the count to 50,000 per c.mm. transfusion, the dilution index would be 50,000/150,000 or
blood.
1/3;
so:
The clinician will therefore switch from stored to fresh whole blood after 5-5 litres (11 units) of stored blood are transfused.
VIRUS-LIKE PARTICLES IN INFECTIOUS HEPATITIS SIR,-At the G. Gaslini Institute in Genoa, azathioprine is used therapeutically for hxmolytic anxmias, thrombocytopenic purpura,l nephrotic syndrome, and infectious hepatitis. In infectious hepatitis, treatment with azathioprine has produced a rapid fall of serum-transaminase titres and the appearance of virus-like particles in liverbiopsy specimens examined by electron microscopy. This ultrastructural investigation was carried out in 3 children, in whom liver biopsies were done on the 7th, 12th, and 13th days of disease, respectively, after treatment with azathioprine (8 mg. per kg. daily, for 3 days in 2 cases and for
Department of Pharmacology, School of Medicine,
University of California, San Francisco Medical Center, San Francisco, California 94122.
WILLIAM STEINSMITH.
COORDINATED CARE OF THE CHILD WITH SPINA BIFIDA am SiR,—I glad Dr. Hide and Mr. Semple have drawn attention to the need for coordinated care of the child with spina bifida (Sept. 19, p. 603). Ideally, of course, all aspects of the child’s inpatient care are dealt with in the same hospital. The next best thing is the establishment of a combined clinic for follow-up and aftercare, but Dr. Hide and Mr. Semple are clearly describing a hospital visit in addition to attendance at the monthly combined clinic; although the parents appreciate this extra visit, it is to my mind an undue extra burden to these hard-pressed families, and the aim should surely be for ordinary outpatient attendances always to be at a combined clinic. It may well be that that visit is primarily to consult a single specialist, but we ourselves have often found that the opinion of a colleague is unexpectedly needed. If this necessitates a visit on another day, or a visit to another hospital, the coordination of treatment breaks down and the child and the family suffer. If this pattern of combined clinic is organised, this will mean attendance of many patients at a time, and the leisurely type of consultation Dr. Hide and Mr. Semple advocate will be
quite impracticable.
It is essential for the consultants working at the combined clinic to be in easy and frequent touch with each other, by occupying adjacent or nearby rooms. This type of clinic should also make it possible for all the consultants to meet in one room when a problem of integrated care is to be discussed. easy matter for consultant staff to change their but the advantages of the combined commitments, weekly clinic are so tremendous that some sacrifice and compromise is going to be essential on the part of some specialists if this goal is to be achieved. A more difficult matter may well be the provision of accommodation where they can all be
It is
present
no
at
the
same
time.
This may well have to be in
a
hospital where one or more of the specialists has no regular duties, or it could even be in a specially constructed unit outside the hospital. The need for coordinated care of children with spina bifida is important and urgent, and no hospital or group of hospitals dealing with these patients should remain satisfied until an adequate combined follow-up clinic is established. Pædiatric Surgical Unit, Children’s Hospital, Sheffield S.10 2TH.
R. B. ZACHARY.
Liver-biopsy specimen from treated with azathioprine.
a
child with infectious
hepatitis
Left, viruses (arrows) emerging from a viroplasm (VP) formed by elementary 200 A particles. Right, two complete virus particles (arrows) and one incomplete particle (B) budding from cell-membrane (x77,000, reduced by a sixth). 5 days in the 3rd). The patients were 2 girls, aged 2 and 3, and a boy aged 8. Electron-microscopical examination of these specimens revealed the presence of virus particles 800-1600 A in diameter in the cytoplasm of parenchymal liver-cells and Kupffer cells. The particles resembled coronaviruses, having an external membrane with club-like projections arranged in the shape of a radiating corona. Similar viruses had previously been detected by Zuckerman et awl. in the serum of a patient with chronic hepatitis and by Holmes et al. 3 in the serum of 2 patients with acute hepatitis. In our material the viruses emerged from a sort of viroplasm formed by elementary 200 A particles, as well as from cell-membrane buddings (see figure). Elementary particles in the nucleus arranged in parallel rows were also detected.4,5 These 200 A particles might conceivably represent Australia antigen and reach the peripheral circulation through the numerous gaps that were seen in the liver-cell membranes. Children with viral hepatitis usually have Au antigen in their blood; and we have found Au antigen in 100% of 25 children with infectious hepatitis tested by immunodiffusion with a serum supplied by Professor Del Prete.g G. Gaslini
Institute, Genoa, Italy.
CARLO SIRTORI.
1. Massimo, L., Mori, P. G., Cottafava, F. Minerva paediat. 1966, 18, 2010. 2. Zuckerman, A. J., Taylor, P. E., Almeida, J. D. Br. med. J. 1970, i, 262. 3. Holmes, A. W., Deinhardt, F., Harris, W., Ball, F., Cline, G. J. clin. Invest. 1970, 49, 45a. 4. Minerva med. Torino, 1970, 61/18, Quotid. XX, 18. 5. Sirtori, C. Gaslini, 1970, 2, 5. 6. Del Prete, S., Costantino, D., Doglia, M. Lancet, 1969, ii, 1250.
Suppose further that the patient has an initial Since stored thrombocyte-count of 150,000 per c.mm. whole blood does not replenish thrombocytes, the attending physician might elect to switch to fresh whole blood (which supplies thrombocytes) once a volume of stored blood had been transfused sufficient to dilute the thrombocyte At this critical point in the count to 50,000 per c.mm. transfusion, the dilution index would be 50,000/150,000 or
blood.
1/3;
so:
The clinician will therefore switch from stored to fresh whole blood after 5-5 litres (11 units) of stored blood are transfused.
VIRUS-LIKE PARTICLES IN INFECTIOUS HEPATITIS SIR,-At the G. Gaslini Institute in Genoa, azathioprine is used therapeutically for hxmolytic anxmias, thrombocytopenic purpura,l nephrotic syndrome, and infectious hepatitis. In infectious hepatitis, treatment with azathioprine has produced a rapid fall of serum-transaminase titres and the appearance of virus-like particles in liverbiopsy specimens examined by electron microscopy. This ultrastructural investigation was carried out in 3 children, in whom liver biopsies were done on the 7th, 12th, and 13th days of disease, respectively, after treatment with azathioprine (8 mg. per kg. daily, for 3 days in 2 cases and for
Department of Pharmacology, School of Medicine,
University of California, San Francisco Medical Center, San Francisco, California 94122.
WILLIAM STEINSMITH.
COORDINATED CARE OF THE CHILD WITH SPINA BIFIDA am SiR,—I glad Dr. Hide and Mr. Semple have drawn attention to the need for coordinated care of the child with spina bifida (Sept. 19, p. 603). Ideally, of course, all aspects of the child’s inpatient care are dealt with in the same hospital. The next best thing is the establishment of a combined clinic for follow-up and aftercare, but Dr. Hide and Mr. Semple are clearly describing a hospital visit in addition to attendance at the monthly combined clinic; although the parents appreciate this extra visit, it is to my mind an undue extra burden to these hard-pressed families, and the aim should surely be for ordinary outpatient attendances always to be at a combined clinic. It may well be that that visit is primarily to consult a single specialist, but we ourselves have often found that the opinion of a colleague is unexpectedly needed. If this necessitates a visit on another day, or a visit to another hospital, the coordination of treatment breaks down and the child and the family suffer. If this pattern of combined clinic is organised, this will mean attendance of many patients at a time, and the leisurely type of consultation Dr. Hide and Mr. Semple advocate will be
quite impracticable.
It is essential for the consultants working at the combined clinic to be in easy and frequent touch with each other, by occupying adjacent or nearby rooms. This type of clinic should also make it possible for all the consultants to meet in one room when a problem of integrated care is to be discussed. easy matter for consultant staff to change their but the advantages of the combined commitments, weekly clinic are so tremendous that some sacrifice and compromise is going to be essential on the part of some specialists if this goal is to be achieved. A more difficult matter may well be the provision of accommodation where they can all be
It is
present
no
at
the
same
time.
This may well have to be in
a
hospital where one or more of the specialists has no regular duties, or it could even be in a specially constructed unit outside the hospital. The need for coordinated care of children with spina bifida is important and urgent, and no hospital or group of hospitals dealing with these patients should remain satisfied until an adequate combined follow-up clinic is established. Pædiatric Surgical Unit, Children’s Hospital, Sheffield S.10 2TH.
R. B. ZACHARY.
Liver-biopsy specimen from treated with azathioprine.
a
child with infectious
hepatitis
Left, viruses (arrows) emerging from a viroplasm (VP) formed by elementary 200 A particles. Right, two complete virus particles (arrows) and one incomplete particle (B) budding from cell-membrane (x77,000, reduced by a sixth). 5 days in the 3rd). The patients were 2 girls, aged 2 and 3, and a boy aged 8. Electron-microscopical examination of these specimens revealed the presence of virus particles 800-1600 A in diameter in the cytoplasm of parenchymal liver-cells and Kupffer cells. The particles resembled coronaviruses, having an external membrane with club-like projections arranged in the shape of a radiating corona. Similar viruses had previously been detected by Zuckerman et awl. in the serum of a patient with chronic hepatitis and by Holmes et al. 3 in the serum of 2 patients with acute hepatitis. In our material the viruses emerged from a sort of viroplasm formed by elementary 200 A particles, as well as from cell-membrane buddings (see figure). Elementary particles in the nucleus arranged in parallel rows were also detected.4,5 These 200 A particles might conceivably represent Australia antigen and reach the peripheral circulation through the numerous gaps that were seen in the liver-cell membranes. Children with viral hepatitis usually have Au antigen in their blood; and we have found Au antigen in 100% of 25 children with infectious hepatitis tested by immunodiffusion with a serum supplied by Professor Del Prete.g G. Gaslini
Institute, Genoa, Italy.
CARLO SIRTORI.
1. Massimo, L., Mori, P. G., Cottafava, F. Minerva paediat. 1966, 18, 2010. 2. Zuckerman, A. J., Taylor, P. E., Almeida, J. D. Br. med. J. 1970, i, 262. 3. Holmes, A. W., Deinhardt, F., Harris, W., Ball, F., Cline, G. J. clin. Invest. 1970, 49, 45a. 4. Minerva med. Torino, 1970, 61/18, Quotid. XX, 18. 5. Sirtori, C. Gaslini, 1970, 2, 5. 6. Del Prete, S., Costantino, D., Doglia, M. Lancet, 1969, ii, 1250.