1051 ELECTROCARDIOGRAPHIC CHANGES DURING PERCUTANEOUS LIVER NEEDLE BIOPSY
PHENOBARBITONE IN THE PROPHYLAXIS OF FEBRILE CONVULSIONS
is increasing awareness of the risk of latent and/or ST-T changes during diagnostic procedures. These changes could be especially relevant to percutaneous liver needle biopsy since biliary tract disease is often associated with cardiac disturbances 1,2 and pulling on the liver or manipulation of the gallbladder can cause arrhythmias in laboratory animals and in
SIR,-The paper by Dr Bacon and colleagues (Sept. 19, p. 600) adds age of onset to heterogeneity of mechanismI among the factors influencing the effect ofphenobarbitone on recurrences. In our own trial2 only 14% of the continuously treated group were under 14 months. Bacon et al. do not mention an earlier placebo-controlled
man. 3,4 Forty-four inpatients aged 45-65 underwent Menghini liver biopsy. Nine had ischaemic heart disease, three had had a myocardial infarction, and two patients presented with primary
cardiomyopathy. Patients were not on antiarrhythmic medication at the time of the biopsy. The patients fasted overnight and a baseline ECG was recorded. The procedure was then explained and a second 12-lead ECG was recorded. Local anaesthesia was with 5 ml 1% lignocaine. Lead II ECG was continuously recorded during the biopsy until 3 min after the Menghini needle had been withdrawn, and a 12 lead ECG was again recorded at that time. Eleven patients had transient pain at the site of the puncture. The ECG findings are summarised in the table. ECG ABNORMALITIES BEFORE AND DURING LIVER BIOPSY
study of phenobarbitone3whose double-blind design allowed recognition of a specific drug-associated behavioural effect-a4 combination of daytime fussiness and nocturnal wakening. Bacon’s final recommendations go further than the data justify. What is the evidence for either the safety or the efficacy of rectal diazepam as a supplement to continuous phenobarbitone? Respiratory depression has occurred after rectal diazepam solution in a patient on concomitant phenobarbitone.5 Fraser of Allander Unit and EEG Department, Royal Hospital for Sick Children,
J. B. P. STEPHENSON
Glasgow G3 8SJ
CHILDHOOD CANCER AND PREGNANCY DRUGS
SIR,-We read with interest the report by Dr Kinnier-Wilson and colleagues (Aug. 8, p. 314) of an apparent association between drugtaking in pregnancy and subsequent childhood cancer, which, they suggest, could be explained by an action in concert of drugs and another unidentified factor. We wonder, however, whether the
Birmingham study includes information on social status. Studies in the U.S.A. have shown that Blacks with acute lymphoblastic leukaemia (ALL) fare worse than Whites, a difference possibly associated with
APB = atrial premature beat; VPB = ventricular premature beat.
The most frequent arrhythmia was sinus tachycardia: this developed before any pharmacological or surgical manipulation in twelve patients and seems to be related to emotional factors. Nine patients presented sinus bradycardia, which occurred in seven cases during the manipulation. Its very short duration makes us believe that it is related to reflex mechanisms. Transient bradycardia associated with hypotension during liver needle biopsy has been reported by Sullivan and Watson,5 but not by others, though it must have been encountered not infrequently, according to the incidence of this arrhythmia in our series. There was a minor increase in atrial and ventricular premature beats, but none of them was clinically important. No patient had supraventricular or ventricular tachycardia or any severe, longer lasting, or life-threatening arrhythmia. Two patients had had a myocardial infarction 6 and 8 weeks before the biopsy, neither had significant arrhythmia or T wave abnormalities during the procedure. Although liver needle biopsy is relatively safe more observations are needed to establish the cardiac risk. There is no basis for us to advise the prophylactic use of antiarrhythmic drugs in such Datients.
JOHANAN E. NASCHITZ Departments of Medicine A and B, Rothschild University Hospital, Haifa 33394, Israel
HARRY BASSAN CARMELA BARAK DANIEL YESHURUN
2. 3 4 5
difference in social status. Our
data support this
SURVIVAL IN ALL IN RELATION TO SOCIAL CLASS
significant (p = 0 - 0 14).
Social class may have a two-fold effect on an association of events in pregnancy and subsequent development of malignancy in the children. Its association with prognosis may result in overrepresentation of lower classes in studies based only on non-living patients and social class per se may have an effect on drug-taking habits and frequency of X-ray examinations in pregnancy. Queensland Childhood Malignancy Registry, Queensland Cancer Fund, Spring Hill, Queensland 4000, Australia
W. R. MCWHIRTER G. PETRIE H. SMITH
Two types of febrile seizure: anoxic (syncopal) and epileptic mechanisms differentiated by oculocardiac reflex. Br Med J 1978; ii: 726-28. 2. Heckmatt JZ, Houston AB, Clow DJ et al. Failure of phenobarbitone to prevent febrile convulsions. Br Med J 1976; i: 559-61. 3. Camfield PR, Camfield CS, Shapiro SH, Cummings C. The first febrile seizure:
1. Stephenson JBP.
instruction plus either phenobarbitone or placebo to prevent J Pediatr 1980; 97: 16-21. Camfield CS, Chaplin S, Doyle AB et al. Side effects of phenobarbitone in toddlers; behavioural and cognitive aspects. J Pediatr 1979; 95: 361-65. Hoppu K, Santavuori P. Diazepam rectal solution for home treatment of acute seizures
Presbury G, Bowman P, George S, Aur R, Dahl G, Simone J. Proc Am
1. Breitwieser R.
Electrocardiographic observations in chronic cholecystitis before and after surgery. Am J Med Sci 1947; 213: 598-602. Hampton AG, Beckwith JR, Wood JE. The relationship between heart disease and gallbladder disease. Ann Intern Med 1959; 50: 1135-48. Owen SE. A study of viscerocardiac reflexes I: The experimental production of cardiac irregularities by visceral stimulation. Am Heart J 1933; 8: 496-506. Hodge GB, Messer AL. The electrocardiogram in biliary tract disease and during experimental biliary distension. Surg Gynecol Obstet 1948; 86: 617-24. Sullivan S, Watson WC. Acute transient hypotension asa complication of percutaneous liver biopsy. Lancet 1974, i: 339-40.
hypothesis. The Queensland Childhood Malignancy Registry is a population based registry which includes all cases of childhood cancer from this State. Follow-up information is available on all cases of ALL diagnosed since 1973. We have found that social class is one of the most important prognostic indicators in this disease. On the basis of the fathers’ occupations we allocated the cases to one of seven social classes.7 To study the effect of social class on survival we selected only those patients given CNS therapy as well as systemic chemotherapy given with the intention of being curative. The results are shown in the following table.
children. Acta Paediatr Scand 1981; 70: 369-72. Soc Clin Oncol
1981; 22: 480. 7.
Congalton AA. Status and prestige in Australia. Melbourne 1969.