Letters, if clearly marked "For Publication, will be published as space permits and at the discretion of the editor. They should be typewritten triple-spaced, with five or fewer "
references, should not exceed two pages are not acknowledged.
in
Plumbism\p=m-\Peopleand Pets? To the Editor.\p=m-\Dr.Robert Wilbur takes strong exception (231:485,1975) to the finding of Hankin et al that canned pet foods contain considerable amounts of lead and thus present a potential health hazard for human consumption (231:484, 1975). The main bone of contention (no pun intended) appears to stem from the citation by Hankin et al of a panel report to the US Senate Select Committee on Human Needs that alleges that pet foods are consumed by humans. According to Wilbur, "the panel report to the Senate Committee was based on a mistaken repetition of a mistaken previous report\p=m-\repeated in each case without any attempt to check back with the supposed source of the information." Without any intention of creating a controversy, it seems that Dr. Wilbur's objection is well taken. First, there is a lack of evidence that people are resorting to pet-food diets. Second, extensive records of kennels of pet-food manufacturers show no indication of lead poisoning in test animals. Third, Hankin et al have translated their data in terms of po¬ tentially toxic doses of lead for chil¬ dren. It is difficult, if not impossible, to find a significant number of par¬ ents who will be willing to replace their children's regular diet with the canned pet food. However, credit must be given where it is due. Hankin et al have also shown the likelihood of lead occurring sporadically in liverwurst. Also, the authors recently reported that the lead content of colored portions of wrappers from bakery confections, lollypops, chewing gum, and frozen confections tested ranged from 8 to 10,100 ppm (Clin Pediatr 13:1064, 1974). Thus, the handling of food wrappers printed with leaded inks, and the placement of such wrappers around the food while eating, or in the mouth as with straws, may constiEdited
by John D. Archer, MD, Senior Editor.
length, and will be subject to editing.
Letters
potential
health hazard for since the children may lick or chew the wrapper to remove any adhering edible material. Thus, while the communication of Hankin et al may be "sensationalistic," as Wilbur prefers to call it, it certainly does point out that the good old water pipe may not necessarily be the only source of lead ingestion. tute
a
children,
of the sigmoidoscope. All were positive on sequential stool guaiac screening. No matter whose statistics one uses, there is a great deal of bowel cancer undetectable by the scope, and any physician who enthusiastically scopes his physical examinees without sequential guaiac screening is lulling not only his patients but unfortunately himself into a false sense of security. The misplaced confidence in a negative sigmoidoscopic examination may cause insidious (but important) symptoms that arise during the following year to be ignored. Routine sigmoidoscopy? Absolutely. But always accompanied by a set of guaiac
slides.
David H. Greegor, MD Columbus, Ohio
IgA Myeloma
and
P. L.
Sternal Fracture
Boston
To the Editor.\p=m-\Apatient with multiple myeloma, IgA k, had a patholog-
Madan, PhD Boston Hospital for Women
Lead in Liverwurst To the Editor.\p=m-\Hankin et al (231:484, 1975), in their discussion of lead in pet foods and processed organ meats, comment on the occurrence of lead in
liverwurst and state, "It is likely that lead occurs sporadically in liverwurst." They analyzed seven samples of liverwurst and found significant concentrations of lead in each. Almost as an afterthought, in their last paragraph they mention analyzing 14 additional liverwurst samples and finding these 14 to be free of lead. On the basis of these data, they suggest that lead occurs "sporadically" in liv-
ical fracture of the sternum as an initial manifestation of the disease. Report of a Case.\p=m-\A61-year-old post-
man was seen in April 1973 with the complaint of shortness of breath. He had been treated at another hospital for a transverse fracture of the sternum following a trivial injury in June 1972. On examination he was a lethargic man who appeared much older than his age, with a marked deformity of the chest with angulated fracture of the sternum (Fig 1)
at the level of the second rib.
erwurst.
That
"sporadically" occurring
lead
in liverwurst would show up in all of seven
consecutive
samples of
a
first
run, and in none of 14 samples of a second analysis, suggests either a sta-
tistical miracle
or
faulty technique.
Ernist Epstein, MD San Mateo, Calif
Proctosigmoidoscopy and Guaiac Screening To the Editor.\p=m-\Iquite agree with Dr. Powers (231:750,1975) that (1) proctosigmoidoscopy is fast, simple, and short, and that (2) routine employment as part of a physical examina-
tion with appropriate polypectomy cuts the incidence of rectal carcinoma by 60% to 75%. In the last ten years in my practice of internal medicine, I have detected 22 large-bowel cancers, only two of which were within range
Figure
1.
Laboratory studies showed the following values: blood urea nitrogen, 75 mg/100 ml; serum uric acid, 58 mg/100 ml; serum calcium, 13 mg/100 ml; phosphate, 2.5 mg/100 ml; hemoglobin, 10 gm/100 ml; hematocrit,
30%; and white blood cell count, 4,500/cu
mm. The red blood cells were normocytic and normochromic, with a rouleaux formation. Urine test for Bence Jones protein was positive. Serum protein electrophoresis dis¬ closed a total protein of 12.5 gm/100 ml, with a monoclonal globulin value of 5.5 gm/100 ml. By agarose immunoelectrophoresis, this homogenous protein was found to consist of IgA, with ic light chain specificity. Quantitatively, the immunoglobulin levels were as follows: IgA, 4,878 mg/100 ml; IgG, 890 mg/100 ml; and IgM,
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/26/2015
86 mg/100 ml. Bone marrow aspiration showed normal cellular marrow, with 30% plasma cells, plasmablast cells, and megaloblastoid erythropoiesis. The patient was treated with intra¬ venous fluid, hydrocortisone, and furosemide, and recovered uneventfully from acute hypercalcemia and acute renal fail¬ ure. Melphalan and prednisone therapy was started and he died after a short pe¬ riod from aspiration pneumonitis. At autopsy, there was a pathological fracture of the sternum with diffuse infil¬ tration with sheet of plasma cells often separated by fine trabeculae (Fig 2), with widespread myelomatous lesions.
gated by papaverine. Interestingly enough, I have had two patients, both of whom were approximately 71 years old, female, and white and had long-standing classical Parkinson disease that responded well to levodopa therapy, and both of whom suffered not only reversal of response but also reappearance of adventitious movements when inadvertently given papaverine by their family physicians. In both instances, gait difficulty increased markedly, rigidity and bradykinesia definitely increased, and there was a definite deterioration in handwriting. Speech also deteriorated. Indeed, the only difference between these two patients and the woman reported by Dr. Duvoisin would seem to be the return of adventitious movements to a significant degree. I have no explanation for this phe¬ nomenon, but its relation to the ad¬ ministration of papaverine, at least in these two well-documented cases, was unquestionable, as a return of the beneficial effects of levodopa was noted in each instance approximately five to six days after the cessation of
papaverine therapy. Certainly, personal
Figure 2. A pathological fracture of the ster¬ nal bone is an extremely rare compli¬ cation; however, its occurrence should arouse suspicion of multiple mye¬ loma.' Ivan P. Law, MD Walter Reed Army Medical
Center
Washington,
Veterans Administration Wilmington, Del
1.
Snapper I, Kahn
tol 1:87-143, 1964.
AI:
Donald M. Posner, MD
Canaan, Vt
Chloramphenicol-
Hospital
Multiple myeloma. Sem Hema-
Antagonism of Levodopa By Papaverine To the Editor.\p=m-\Ithought it might be worthwhile commenting on Dr. Duvoisin's note (231:845, 1975) concerning the antagonism of levodopa by papaverine. I have come across roughly one patient per year in whom the beneficial effects of levodopa have in some way been inadvertently ne-
and
Fever
To the Editor.\p=m-\Thereport of chloram-
phenicol-resistant Salmonella typhi in Saigon (231:162, 1975) emphasized the poor clinical response of patients infected with chloramphenicol-resistant strains of S typhi to chloramphenicol alone. Chloramphenicol-resistant typhoid fever has also been noted in Bangkok, Thailand, with evidence of in vitro and in vivo resist-
to chloramphenicol.1-3 During 1974, thirty-two percent (22 of 67) of the S typhi strains from Children's Hospital, Bangkok, were ance
one
chloramphenicol. Forty-
percent (9 of 22) of these chloram-
phenicol-resistant strains were resistant to ampicillin also (minimal inhibitory concentrations > 128\g=m\g/ ml). Ampicillin has been ineffective therapy in patients with S typhi isolates resistant to ampicillin and chloramphenicol. One such patient receiving 150 to 200 mg/kg/day of ampicillin intravenously remained febrile, in a toxic condition, and had positive blood cultures after seven days of therapy. Recovery occurred following therapy with trimethoprimsulfamethoxazole. All of the S typhi
isolates have been sensitive to trimethoprim-sulfamethoxazole, and this drug has been effective therapy. We wish to emphasize that chloramphenicol-resistant typhoid fever is present in other parts of Southeast Asia, and that in vitro and in vivo re¬ sistance to ampicillin occurs as well. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. MAJ Richard M. Lampe, MC, USA Chiraphun Duangmani, MD US Army Medical Component SEATO Medical Research Laboratory Pethai Mansuwan, MD
experience
could lead me to agree strongly with Dr. Duvoisin that papaverine should not be administered to patients with parkinsonism. I might go one step further in my belief that papaverine really does not have any place in the treatment of cerebral arteriosclerosis, as I have never been convinced that it has any significant effect on intracerebral vasculature, except perhaps indirectly and adversely by means of "shunting" blood away from the brain to peripheral structures.
Ampicillin-Resistant Typhoid
DC
Charlotte Jones, MD
resistant to
Children's Hospital
Bangkok, Thailand Mansuwan P: Chloramphenicol-resistant Salmonella typhosa. N Engl J Med 289:1203, 1973. 2. Lampe RM, Mansuwan P, Duangmani C: Chloramphenicol-resistant typhoid. Lancet 1:623-624, 1974. 3. Oonsombat P: Chloramphenicol-resistant typhoid fever. Siriraj Hosp Gazette 26:1548-1554, 1974. 1.
Lampe RM,
Paraplegia After Surgery For Abdominal Aortic Aneurysms To the Editor.\p=m-\In1973, we reported two cases of paraplegia following the resection of aneurysms of the infrarenal abdominal aorta, and we were able to find reports of an additional 17 cases in the literature.1 Since that time, this complication has occurred in another patient in our institution, and five separate, additional cases have been reported.2-5 We have also received letters from surgeons throughout the country about paraplegia following aneurysm resection. This complication, although not mentioned in standard surgical textbooks, is more common than has been appreciated. The blood supply to the spinal cord is tenuous at best, coming from both the two-part anterior spinal arteries and the single posterior spinal
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/26/2015
references, should not exceed two pages are not acknowledged.
in
Plumbism\p=m-\Peopleand Pets? To the Editor.\p=m-\Dr.Robert Wilbur takes strong exception (231:485,1975) to the finding of Hankin et al that canned pet foods contain considerable amounts of lead and thus present a potential health hazard for human consumption (231:484, 1975). The main bone of contention (no pun intended) appears to stem from the citation by Hankin et al of a panel report to the US Senate Select Committee on Human Needs that alleges that pet foods are consumed by humans. According to Wilbur, "the panel report to the Senate Committee was based on a mistaken repetition of a mistaken previous report\p=m-\repeated in each case without any attempt to check back with the supposed source of the information." Without any intention of creating a controversy, it seems that Dr. Wilbur's objection is well taken. First, there is a lack of evidence that people are resorting to pet-food diets. Second, extensive records of kennels of pet-food manufacturers show no indication of lead poisoning in test animals. Third, Hankin et al have translated their data in terms of po¬ tentially toxic doses of lead for chil¬ dren. It is difficult, if not impossible, to find a significant number of par¬ ents who will be willing to replace their children's regular diet with the canned pet food. However, credit must be given where it is due. Hankin et al have also shown the likelihood of lead occurring sporadically in liverwurst. Also, the authors recently reported that the lead content of colored portions of wrappers from bakery confections, lollypops, chewing gum, and frozen confections tested ranged from 8 to 10,100 ppm (Clin Pediatr 13:1064, 1974). Thus, the handling of food wrappers printed with leaded inks, and the placement of such wrappers around the food while eating, or in the mouth as with straws, may constiEdited
by John D. Archer, MD, Senior Editor.
length, and will be subject to editing.
Letters
potential
health hazard for since the children may lick or chew the wrapper to remove any adhering edible material. Thus, while the communication of Hankin et al may be "sensationalistic," as Wilbur prefers to call it, it certainly does point out that the good old water pipe may not necessarily be the only source of lead ingestion. tute
a
children,
of the sigmoidoscope. All were positive on sequential stool guaiac screening. No matter whose statistics one uses, there is a great deal of bowel cancer undetectable by the scope, and any physician who enthusiastically scopes his physical examinees without sequential guaiac screening is lulling not only his patients but unfortunately himself into a false sense of security. The misplaced confidence in a negative sigmoidoscopic examination may cause insidious (but important) symptoms that arise during the following year to be ignored. Routine sigmoidoscopy? Absolutely. But always accompanied by a set of guaiac
slides.
David H. Greegor, MD Columbus, Ohio
IgA Myeloma
and
P. L.
Sternal Fracture
Boston
To the Editor.\p=m-\Apatient with multiple myeloma, IgA k, had a patholog-
Madan, PhD Boston Hospital for Women
Lead in Liverwurst To the Editor.\p=m-\Hankin et al (231:484, 1975), in their discussion of lead in pet foods and processed organ meats, comment on the occurrence of lead in
liverwurst and state, "It is likely that lead occurs sporadically in liverwurst." They analyzed seven samples of liverwurst and found significant concentrations of lead in each. Almost as an afterthought, in their last paragraph they mention analyzing 14 additional liverwurst samples and finding these 14 to be free of lead. On the basis of these data, they suggest that lead occurs "sporadically" in liv-
ical fracture of the sternum as an initial manifestation of the disease. Report of a Case.\p=m-\A61-year-old post-
man was seen in April 1973 with the complaint of shortness of breath. He had been treated at another hospital for a transverse fracture of the sternum following a trivial injury in June 1972. On examination he was a lethargic man who appeared much older than his age, with a marked deformity of the chest with angulated fracture of the sternum (Fig 1)
at the level of the second rib.
erwurst.
That
"sporadically" occurring
lead
in liverwurst would show up in all of seven
consecutive
samples of
a
first
run, and in none of 14 samples of a second analysis, suggests either a sta-
tistical miracle
or
faulty technique.
Ernist Epstein, MD San Mateo, Calif
Proctosigmoidoscopy and Guaiac Screening To the Editor.\p=m-\Iquite agree with Dr. Powers (231:750,1975) that (1) proctosigmoidoscopy is fast, simple, and short, and that (2) routine employment as part of a physical examina-
tion with appropriate polypectomy cuts the incidence of rectal carcinoma by 60% to 75%. In the last ten years in my practice of internal medicine, I have detected 22 large-bowel cancers, only two of which were within range
Figure
1.
Laboratory studies showed the following values: blood urea nitrogen, 75 mg/100 ml; serum uric acid, 58 mg/100 ml; serum calcium, 13 mg/100 ml; phosphate, 2.5 mg/100 ml; hemoglobin, 10 gm/100 ml; hematocrit,
30%; and white blood cell count, 4,500/cu
mm. The red blood cells were normocytic and normochromic, with a rouleaux formation. Urine test for Bence Jones protein was positive. Serum protein electrophoresis dis¬ closed a total protein of 12.5 gm/100 ml, with a monoclonal globulin value of 5.5 gm/100 ml. By agarose immunoelectrophoresis, this homogenous protein was found to consist of IgA, with ic light chain specificity. Quantitatively, the immunoglobulin levels were as follows: IgA, 4,878 mg/100 ml; IgG, 890 mg/100 ml; and IgM,
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/26/2015
86 mg/100 ml. Bone marrow aspiration showed normal cellular marrow, with 30% plasma cells, plasmablast cells, and megaloblastoid erythropoiesis. The patient was treated with intra¬ venous fluid, hydrocortisone, and furosemide, and recovered uneventfully from acute hypercalcemia and acute renal fail¬ ure. Melphalan and prednisone therapy was started and he died after a short pe¬ riod from aspiration pneumonitis. At autopsy, there was a pathological fracture of the sternum with diffuse infil¬ tration with sheet of plasma cells often separated by fine trabeculae (Fig 2), with widespread myelomatous lesions.
gated by papaverine. Interestingly enough, I have had two patients, both of whom were approximately 71 years old, female, and white and had long-standing classical Parkinson disease that responded well to levodopa therapy, and both of whom suffered not only reversal of response but also reappearance of adventitious movements when inadvertently given papaverine by their family physicians. In both instances, gait difficulty increased markedly, rigidity and bradykinesia definitely increased, and there was a definite deterioration in handwriting. Speech also deteriorated. Indeed, the only difference between these two patients and the woman reported by Dr. Duvoisin would seem to be the return of adventitious movements to a significant degree. I have no explanation for this phe¬ nomenon, but its relation to the ad¬ ministration of papaverine, at least in these two well-documented cases, was unquestionable, as a return of the beneficial effects of levodopa was noted in each instance approximately five to six days after the cessation of
papaverine therapy. Certainly, personal
Figure 2. A pathological fracture of the ster¬ nal bone is an extremely rare compli¬ cation; however, its occurrence should arouse suspicion of multiple mye¬ loma.' Ivan P. Law, MD Walter Reed Army Medical
Center
Washington,
Veterans Administration Wilmington, Del
1.
Snapper I, Kahn
tol 1:87-143, 1964.
AI:
Donald M. Posner, MD
Canaan, Vt
Chloramphenicol-
Hospital
Multiple myeloma. Sem Hema-
Antagonism of Levodopa By Papaverine To the Editor.\p=m-\Ithought it might be worthwhile commenting on Dr. Duvoisin's note (231:845, 1975) concerning the antagonism of levodopa by papaverine. I have come across roughly one patient per year in whom the beneficial effects of levodopa have in some way been inadvertently ne-
and
Fever
To the Editor.\p=m-\Thereport of chloram-
phenicol-resistant Salmonella typhi in Saigon (231:162, 1975) emphasized the poor clinical response of patients infected with chloramphenicol-resistant strains of S typhi to chloramphenicol alone. Chloramphenicol-resistant typhoid fever has also been noted in Bangkok, Thailand, with evidence of in vitro and in vivo resist-
to chloramphenicol.1-3 During 1974, thirty-two percent (22 of 67) of the S typhi strains from Children's Hospital, Bangkok, were ance
one
chloramphenicol. Forty-
percent (9 of 22) of these chloram-
phenicol-resistant strains were resistant to ampicillin also (minimal inhibitory concentrations > 128\g=m\g/ ml). Ampicillin has been ineffective therapy in patients with S typhi isolates resistant to ampicillin and chloramphenicol. One such patient receiving 150 to 200 mg/kg/day of ampicillin intravenously remained febrile, in a toxic condition, and had positive blood cultures after seven days of therapy. Recovery occurred following therapy with trimethoprimsulfamethoxazole. All of the S typhi
isolates have been sensitive to trimethoprim-sulfamethoxazole, and this drug has been effective therapy. We wish to emphasize that chloramphenicol-resistant typhoid fever is present in other parts of Southeast Asia, and that in vitro and in vivo re¬ sistance to ampicillin occurs as well. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. MAJ Richard M. Lampe, MC, USA Chiraphun Duangmani, MD US Army Medical Component SEATO Medical Research Laboratory Pethai Mansuwan, MD
experience
could lead me to agree strongly with Dr. Duvoisin that papaverine should not be administered to patients with parkinsonism. I might go one step further in my belief that papaverine really does not have any place in the treatment of cerebral arteriosclerosis, as I have never been convinced that it has any significant effect on intracerebral vasculature, except perhaps indirectly and adversely by means of "shunting" blood away from the brain to peripheral structures.
Ampicillin-Resistant Typhoid
DC
Charlotte Jones, MD
resistant to
Children's Hospital
Bangkok, Thailand Mansuwan P: Chloramphenicol-resistant Salmonella typhosa. N Engl J Med 289:1203, 1973. 2. Lampe RM, Mansuwan P, Duangmani C: Chloramphenicol-resistant typhoid. Lancet 1:623-624, 1974. 3. Oonsombat P: Chloramphenicol-resistant typhoid fever. Siriraj Hosp Gazette 26:1548-1554, 1974. 1.
Lampe RM,
Paraplegia After Surgery For Abdominal Aortic Aneurysms To the Editor.\p=m-\In1973, we reported two cases of paraplegia following the resection of aneurysms of the infrarenal abdominal aorta, and we were able to find reports of an additional 17 cases in the literature.1 Since that time, this complication has occurred in another patient in our institution, and five separate, additional cases have been reported.2-5 We have also received letters from surgeons throughout the country about paraplegia following aneurysm resection. This complication, although not mentioned in standard surgical textbooks, is more common than has been appreciated. The blood supply to the spinal cord is tenuous at best, coming from both the two-part anterior spinal arteries and the single posterior spinal
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/26/2015
