was ever so
the
picture
foolish
as
those
people in
were. Freeman D. Fowler, MD Idaho Springs, Colo
To the Editor.\p=m-\The article by Gutman et al, "Ski Injuries in 1972-1973" (230:1423,1974) was very informative. I agree there should be more research. However, some of the information needed to answer the questions raised could have been obtained with very little effort by the authors. They note that although the "rate" of injuries per skier-days has remained roughly the same in 12 years, they "do note a distinct change in distribution of injuries among ability groups." Although they cannot obtain the distribution of skiers falling into each ability group in 1960-1961, they can obtain a reasonable estimate for 1972-1973 by just asking the ability level of the next few hundred people buying tickets and at least have it now. My own clinical impression is that the percentage of good skiers has gone up since 1960 and that a "skier-day" now contains more faster "skier-miles" and that without the use of the modern safety equipment, the rate of injuries would have in¬ creased. It would also be helpful to know the rate of injuries in each abil¬ ity group to help clarify these points. Harry Z. Coren, MD
San Francisco
Pneumocystis carinii Pneumonia Editor.\p=m-\Therecent report by Redman (230:1561, 1974) concerning To the
Pneumocystis carinii pneumonia in an adopted Vietnamese infant was of interest to us, as we previously reported the first such case in an adopted Korean infant in The Jour-
cases the infants were born in Asian countries afflicted by recent wars and cared for in orphanages until their adoption by American parents, and the symptoms of the disease became apparent on arrival in the United States. The infant we reported had severe clinical manifestations, and death resulted from respiratory failure on the 19th hospital day. The infant reported by Redman also had a fulminant course but recovered, probably because of effective therapy consisting of pentamidine isethionate and leucovorin calcium. The importance of epidemiological surveillance of American adopted orphans for pneumocystosis, as urged by Eidelman et al,2 was also men-
nal.1 In both
tioned in our previous publication, in which we quoted the pioneer work of Lim,3 Lim and Moon,4 Kim5 and Post et al,6 who reported the epidemic na¬ ture of the disease in Korea and Iran. The contributions of these authors, I believe, add to the timely report of Redman. B. H. Hyun, MD Rutgers Medical School
Plainfield, NJ 1.
Hyun BH, Varga CF, Thalheimer LJ: Pneumocystis pneumonitis occurring in an adopted Korean in-
carinii
fant. JAMA 195:784, 1966.
2. Eidelman A, Nkongo A, Morecki R: Pneumocystis carinii pneumonitis in Vietnamese infant in US, abstracted. Pediatr Res 8:424/150 (No. 4), 1974. 3. Lim SK: Studies on Pneumocystis carinii pneumonia: Part I. First report of cases from Korea, thesis. Soodo Medical College, Seoul, Korea, 1959. 4. Lim SK, Moon CS: Studies on Pneumocystis carinii pneumonia: II. Epidemiological and clinical studies of 80 cases. Johnhap Med 6:77, 1960. 5. Kim SE:
of 3
cases
cholangiopancreatography troduodenoscopy.7
C, Dutz W, Nasarian I: Endemic Pneumocystis pneumonia in South Iran. Arch Dis Child 39:35, 1964.
Laubry-Soulle Syndrome To the Editor.\p=m-\TheLaubry-Soulle a syndrome of abnormal collections of gas in the colon and stomach following acute myocardial infarction, was discussed by Palmer (230:1575, 1974). He pointed out that an explanation of this phenomenon had not been offered. Abnormal collections of gas within the gastrointestinal tract are well recognized to be associated with abnormalities of gastrointestinal motility. Stasis of gas and other intraluminal contents is generally considered
syndrome,
in gastrointestinal hypomotility rather than in hypermotility, disorders with generoccur more
commonly
alized or localized ileus being the classic example. Recent investigations have shown that many of the gastrointestinal-released hormones affect gastrointestinal motility and may play a physiologic role in the regulation of gastrointestinal motility.1,2 The question then arises as to the possible role of these hormones in the pathogenesis of this syndrome. With this in mind, it is of interest to note the recent report of Willerson et al3 that serum glucagon levels are elevated in patients with acute myo¬ cardial infarctions one day after ad¬
mission, with no significant reduction
in the first 48 hours of hospitalization. One of the effects of glucagon is to decrease motility and tonicity of the
gastrointestinal
tract.45
Radiologists
have taken advantage of this action in the performance of hypotonie duodenography,6 and the gastrointestinal
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
and gas-
The documentation of hyperglucagonemia following myocardial infarction, along with the known ef¬ fect of glucagon to decrease gastroin¬ testinal motility, suggests that the clinical entity of the Laubry-Soulle syndrome may be due to the inhib¬ itory effect of this hormone, whether directly or indirectly, through inhibi¬ tion of the release of other gastroin¬
testinal hormones, such as gastrin and cholecystokinin, that stimulate intestinal motility. Further study will be required to evaluate this hypothe¬ sis. Robert L. Slaughter, MD University of Alabama School of Medicine
Pneumocystis carinii pneumonia: Report
in Korean infants. J Korean Med Assoc 4:1190,
1961. 6. Post
to
endoscopists in "paralyzing" the duodenum for endoscopie retrograde
Birmingham SE, Bertaccini G, Impicciatore M, et al: Evidence that acetylcholine released by gastrin and related polypetides contributes to their effect on gastrointestinal motility. Gastroenterology 64:268-277, 1973. 2. Dinoso VP Jr, Meshkinpour H, Lorber SH, et al: Motor responses of the sigmoid colon and rectum to exogenous cholecystokinin and secretin. Gastroenterology 65:438-444, 1973. 3. Willerson JT, Hutcheson DR, Leshin SJ, et al: Serum glucagon and insulin levels and their relationship to blood glucose values in patients with acute myocardial infarction and acute coronary insufficiency. Am J Med 57:747-753, 1974. 4. Lawrence AM: Glucagon. Am Rev Med 20:207-223, 1. Visi
1968. 5. Lawrence AM:
Glucagon in medicine: New ideas for old hormone. Med Clin North Am 54:183-190, 1970. 6. Chernish SM, Miller RE, Rosenak BD, et al: Hypotonic duodenography with the use of glucagon. Gastroenteran
ology 63:392-398, 1973. 7. Hradsky M, Stockbrugger R, Dotevall G, et al: The use of glucagon during upper gastrointestinal endoscopy. Gastrointest Endosc 20 162, 1974.
Reply.\p=m-\Ithink Dr. Slaughter's letthoughtful and constructive. I have believed that a neurologic mechanism must be responsible for the Laubry-Soulle syndrome because of the strictly localized nature of the gas collections (splenic flexure and stomach). Dr. Slaughter's idea is a good In
ter is
one, but I would think
hormonal exlikely if the gas were more generally distributed through the bowel. It doesn't explain the localization too well.
planation
would be
a
more
Eddy D. Palmer, MD Hackettstown, NJ
Diabetic Retinopathy To the Editor.\p=m-\Diabeticretinopathy is a leading cause of blindness in the United States. Certain patients who have been told in the past that their blindness is irreversible could benefit from recent advances. The purpose of this communication is to acquaint nonophthalmologists with these developments and to present some
tion of a strong flashlight held at various places in his visual field. 4. It is best if the patient can per¬ ceive colors, indicating that there is some functioning of the retinal cones. This relates to the condition of the macula. If these criteria are met, there is a reasonable chance that the patient will realize a significant return of vi¬ sion from this procedure. It is impor¬ tant to differentiate those who have proliferative traction-type retinal de¬ tachments from those who have only vitreous opacities. Vitrectomy in the former group would be of no avail and would not improve the visual acu¬
ity.
The illustration
was
prepared by Robert Etter. Frederick H. Davidorf, MD
Ohio State Columbus
The Sweet
University
Contraceptive
To the Editor.\p=m-\Thelighthearted editorial by Dr. Henry T. Ricketts (231:392, 1975) concerning the potential of 5-thio-glucose as a male contraceptive prompted a verse in the same
Vitrectomy instrument is inserted into eye via pars plana. Vitreous membranes and blood are removed by suction, while contents of vitreous cavity are replaced with a physiologic fluid.
screening techniques
to
identify
pa-
tients who might be helped. There are two major reasons for decreased vision in the diabetic patient. The formation of proliferative membranes with repeated vitreous hemorrhages and subsequent blindness is the most
devastating problem facing
This generally occurs in the juvenile diabetic who has had the disease for 15 to 20 years. The second type of blindness, not nearly so disabling, is a result of diabetic macular edema. This, in general, occurs in the adultonset diabetic patient and reduces vision to 20/400. These patients retain enough vision to get around in unfaus.
miliar
surroundings. Although argon laser has helped many patients with diabetic macular
edema, this
treatment is not a pan¬ and there are still a number of patients who lose their central vision despite laser therapy. The most devastating type of blindness is due to proliferative dia¬ betic retinopathy. There are two basic mechanisms for this: Nonresolving vitreous hemorrhages result in a dense membrane within the vitreous, reducing the patient's visual acuity. The second mechanism is a retinal de¬ tachment secondary to vitreous tracacea
tion, which does not respond to the or¬ dinary retinal procedures. The visual prognosis for patients with retinal detachments secondary to prolifera¬ tive diabetic retinopathy is still quite poor. However, there has been a ma¬ jor breakthrough in the past several years with the development and re¬ finement of pars plana vitrectomy. This procedure has helped quite a number of individuals who are blind due to vitreous opacities without an
accompanying Since this procedure
retinal detachment.
is fairly new, there are a number of patients who have been told their blindness was ir¬ reversible who could benefit from the procedure. To determine which pa¬ tients might be helped by vitrectomy, several relatively simple rules can
guidelines. patient should be suffi¬ ciently handicapped so that he cannot get around by himself in unfamiliar surroundings. serve as
1. The
2. In the eye to be considered for vitrectomy, there should not have been any active hemorrhaging for 6 to 12 months. 3. There should be enough retinal function to allow the patient to iden¬ tify a light source accurately, ie, he should be able to determine the loca-
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
spirit:
Five-thio in mice competes with D\x=req-\ Perhaps it can work for you and me. Within the testis it gums the works So spermatogenesis no longer works.
No more hormones, IUDs, and the rest of that biz? Then hail 5-thio-glucose How sweet it is! Ira S. Schwartz, MD New Rochelle, NY
Drug Trademarks Erroneous. \p=m-\In the "Introduction" to the CURRENT CONCEPTS IN CANCER
series, published
in the Feb 3 issue (231:513-516, 1975), incorrect trademarks were given for fluorouracil in the "Nonproprietary Names and Trademarks of Drugs" list on page 516. The trademarks given were of formulations for topical use, while the form intended, for gastrointestinal use, is marketed under the nonproprietary name only and has no trademarks. Dr. McKusick, Not McCusick. \p=m-\In
the
INTERNATIONAL COMMENTS sec-
tion, published in the Feb 24 issue (231:873-874, 1975), an error oc-
curred in the item in column 2 on page 874 titled "Baltimore Physician Elected to French Academy." The surname of Victor A. McKusick, MD, was misspelled McCusick.
the
picture
foolish
as
those
people in
were. Freeman D. Fowler, MD Idaho Springs, Colo
To the Editor.\p=m-\The article by Gutman et al, "Ski Injuries in 1972-1973" (230:1423,1974) was very informative. I agree there should be more research. However, some of the information needed to answer the questions raised could have been obtained with very little effort by the authors. They note that although the "rate" of injuries per skier-days has remained roughly the same in 12 years, they "do note a distinct change in distribution of injuries among ability groups." Although they cannot obtain the distribution of skiers falling into each ability group in 1960-1961, they can obtain a reasonable estimate for 1972-1973 by just asking the ability level of the next few hundred people buying tickets and at least have it now. My own clinical impression is that the percentage of good skiers has gone up since 1960 and that a "skier-day" now contains more faster "skier-miles" and that without the use of the modern safety equipment, the rate of injuries would have in¬ creased. It would also be helpful to know the rate of injuries in each abil¬ ity group to help clarify these points. Harry Z. Coren, MD
San Francisco
Pneumocystis carinii Pneumonia Editor.\p=m-\Therecent report by Redman (230:1561, 1974) concerning To the
Pneumocystis carinii pneumonia in an adopted Vietnamese infant was of interest to us, as we previously reported the first such case in an adopted Korean infant in The Jour-
cases the infants were born in Asian countries afflicted by recent wars and cared for in orphanages until their adoption by American parents, and the symptoms of the disease became apparent on arrival in the United States. The infant we reported had severe clinical manifestations, and death resulted from respiratory failure on the 19th hospital day. The infant reported by Redman also had a fulminant course but recovered, probably because of effective therapy consisting of pentamidine isethionate and leucovorin calcium. The importance of epidemiological surveillance of American adopted orphans for pneumocystosis, as urged by Eidelman et al,2 was also men-
nal.1 In both
tioned in our previous publication, in which we quoted the pioneer work of Lim,3 Lim and Moon,4 Kim5 and Post et al,6 who reported the epidemic na¬ ture of the disease in Korea and Iran. The contributions of these authors, I believe, add to the timely report of Redman. B. H. Hyun, MD Rutgers Medical School
Plainfield, NJ 1.
Hyun BH, Varga CF, Thalheimer LJ: Pneumocystis pneumonitis occurring in an adopted Korean in-
carinii
fant. JAMA 195:784, 1966.
2. Eidelman A, Nkongo A, Morecki R: Pneumocystis carinii pneumonitis in Vietnamese infant in US, abstracted. Pediatr Res 8:424/150 (No. 4), 1974. 3. Lim SK: Studies on Pneumocystis carinii pneumonia: Part I. First report of cases from Korea, thesis. Soodo Medical College, Seoul, Korea, 1959. 4. Lim SK, Moon CS: Studies on Pneumocystis carinii pneumonia: II. Epidemiological and clinical studies of 80 cases. Johnhap Med 6:77, 1960. 5. Kim SE:
of 3
cases
cholangiopancreatography troduodenoscopy.7
C, Dutz W, Nasarian I: Endemic Pneumocystis pneumonia in South Iran. Arch Dis Child 39:35, 1964.
Laubry-Soulle Syndrome To the Editor.\p=m-\TheLaubry-Soulle a syndrome of abnormal collections of gas in the colon and stomach following acute myocardial infarction, was discussed by Palmer (230:1575, 1974). He pointed out that an explanation of this phenomenon had not been offered. Abnormal collections of gas within the gastrointestinal tract are well recognized to be associated with abnormalities of gastrointestinal motility. Stasis of gas and other intraluminal contents is generally considered
syndrome,
in gastrointestinal hypomotility rather than in hypermotility, disorders with generoccur more
commonly
alized or localized ileus being the classic example. Recent investigations have shown that many of the gastrointestinal-released hormones affect gastrointestinal motility and may play a physiologic role in the regulation of gastrointestinal motility.1,2 The question then arises as to the possible role of these hormones in the pathogenesis of this syndrome. With this in mind, it is of interest to note the recent report of Willerson et al3 that serum glucagon levels are elevated in patients with acute myo¬ cardial infarctions one day after ad¬
mission, with no significant reduction
in the first 48 hours of hospitalization. One of the effects of glucagon is to decrease motility and tonicity of the
gastrointestinal
tract.45
Radiologists
have taken advantage of this action in the performance of hypotonie duodenography,6 and the gastrointestinal
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
and gas-
The documentation of hyperglucagonemia following myocardial infarction, along with the known ef¬ fect of glucagon to decrease gastroin¬ testinal motility, suggests that the clinical entity of the Laubry-Soulle syndrome may be due to the inhib¬ itory effect of this hormone, whether directly or indirectly, through inhibi¬ tion of the release of other gastroin¬
testinal hormones, such as gastrin and cholecystokinin, that stimulate intestinal motility. Further study will be required to evaluate this hypothe¬ sis. Robert L. Slaughter, MD University of Alabama School of Medicine
Pneumocystis carinii pneumonia: Report
in Korean infants. J Korean Med Assoc 4:1190,
1961. 6. Post
to
endoscopists in "paralyzing" the duodenum for endoscopie retrograde
Birmingham SE, Bertaccini G, Impicciatore M, et al: Evidence that acetylcholine released by gastrin and related polypetides contributes to their effect on gastrointestinal motility. Gastroenterology 64:268-277, 1973. 2. Dinoso VP Jr, Meshkinpour H, Lorber SH, et al: Motor responses of the sigmoid colon and rectum to exogenous cholecystokinin and secretin. Gastroenterology 65:438-444, 1973. 3. Willerson JT, Hutcheson DR, Leshin SJ, et al: Serum glucagon and insulin levels and their relationship to blood glucose values in patients with acute myocardial infarction and acute coronary insufficiency. Am J Med 57:747-753, 1974. 4. Lawrence AM: Glucagon. Am Rev Med 20:207-223, 1. Visi
1968. 5. Lawrence AM:
Glucagon in medicine: New ideas for old hormone. Med Clin North Am 54:183-190, 1970. 6. Chernish SM, Miller RE, Rosenak BD, et al: Hypotonic duodenography with the use of glucagon. Gastroenteran
ology 63:392-398, 1973. 7. Hradsky M, Stockbrugger R, Dotevall G, et al: The use of glucagon during upper gastrointestinal endoscopy. Gastrointest Endosc 20 162, 1974.
Reply.\p=m-\Ithink Dr. Slaughter's letthoughtful and constructive. I have believed that a neurologic mechanism must be responsible for the Laubry-Soulle syndrome because of the strictly localized nature of the gas collections (splenic flexure and stomach). Dr. Slaughter's idea is a good In
ter is
one, but I would think
hormonal exlikely if the gas were more generally distributed through the bowel. It doesn't explain the localization too well.
planation
would be
a
more
Eddy D. Palmer, MD Hackettstown, NJ
Diabetic Retinopathy To the Editor.\p=m-\Diabeticretinopathy is a leading cause of blindness in the United States. Certain patients who have been told in the past that their blindness is irreversible could benefit from recent advances. The purpose of this communication is to acquaint nonophthalmologists with these developments and to present some
tion of a strong flashlight held at various places in his visual field. 4. It is best if the patient can per¬ ceive colors, indicating that there is some functioning of the retinal cones. This relates to the condition of the macula. If these criteria are met, there is a reasonable chance that the patient will realize a significant return of vi¬ sion from this procedure. It is impor¬ tant to differentiate those who have proliferative traction-type retinal de¬ tachments from those who have only vitreous opacities. Vitrectomy in the former group would be of no avail and would not improve the visual acu¬
ity.
The illustration
was
prepared by Robert Etter. Frederick H. Davidorf, MD
Ohio State Columbus
The Sweet
University
Contraceptive
To the Editor.\p=m-\Thelighthearted editorial by Dr. Henry T. Ricketts (231:392, 1975) concerning the potential of 5-thio-glucose as a male contraceptive prompted a verse in the same
Vitrectomy instrument is inserted into eye via pars plana. Vitreous membranes and blood are removed by suction, while contents of vitreous cavity are replaced with a physiologic fluid.
screening techniques
to
identify
pa-
tients who might be helped. There are two major reasons for decreased vision in the diabetic patient. The formation of proliferative membranes with repeated vitreous hemorrhages and subsequent blindness is the most
devastating problem facing
This generally occurs in the juvenile diabetic who has had the disease for 15 to 20 years. The second type of blindness, not nearly so disabling, is a result of diabetic macular edema. This, in general, occurs in the adultonset diabetic patient and reduces vision to 20/400. These patients retain enough vision to get around in unfaus.
miliar
surroundings. Although argon laser has helped many patients with diabetic macular
edema, this
treatment is not a pan¬ and there are still a number of patients who lose their central vision despite laser therapy. The most devastating type of blindness is due to proliferative dia¬ betic retinopathy. There are two basic mechanisms for this: Nonresolving vitreous hemorrhages result in a dense membrane within the vitreous, reducing the patient's visual acuity. The second mechanism is a retinal de¬ tachment secondary to vitreous tracacea
tion, which does not respond to the or¬ dinary retinal procedures. The visual prognosis for patients with retinal detachments secondary to prolifera¬ tive diabetic retinopathy is still quite poor. However, there has been a ma¬ jor breakthrough in the past several years with the development and re¬ finement of pars plana vitrectomy. This procedure has helped quite a number of individuals who are blind due to vitreous opacities without an
accompanying Since this procedure
retinal detachment.
is fairly new, there are a number of patients who have been told their blindness was ir¬ reversible who could benefit from the procedure. To determine which pa¬ tients might be helped by vitrectomy, several relatively simple rules can
guidelines. patient should be suffi¬ ciently handicapped so that he cannot get around by himself in unfamiliar surroundings. serve as
1. The
2. In the eye to be considered for vitrectomy, there should not have been any active hemorrhaging for 6 to 12 months. 3. There should be enough retinal function to allow the patient to iden¬ tify a light source accurately, ie, he should be able to determine the loca-
Downloaded From: http://jama.jamanetwork.com/ by a New York University User on 06/09/2015
spirit:
Five-thio in mice competes with D\x=req-\ Perhaps it can work for you and me. Within the testis it gums the works So spermatogenesis no longer works.
No more hormones, IUDs, and the rest of that biz? Then hail 5-thio-glucose How sweet it is! Ira S. Schwartz, MD New Rochelle, NY
Drug Trademarks Erroneous. \p=m-\In the "Introduction" to the CURRENT CONCEPTS IN CANCER
series, published
in the Feb 3 issue (231:513-516, 1975), incorrect trademarks were given for fluorouracil in the "Nonproprietary Names and Trademarks of Drugs" list on page 516. The trademarks given were of formulations for topical use, while the form intended, for gastrointestinal use, is marketed under the nonproprietary name only and has no trademarks. Dr. McKusick, Not McCusick. \p=m-\In
the
INTERNATIONAL COMMENTS sec-
tion, published in the Feb 24 issue (231:873-874, 1975), an error oc-
curred in the item in column 2 on page 874 titled "Baltimore Physician Elected to French Academy." The surname of Victor A. McKusick, MD, was misspelled McCusick.
