patient, she could not explain the findings. With knowledge and consent of the family, removal was planned. Under anesthesia, one needle could be palpated just beneath the skin in the subxiphoid area and was easily
Educational research indicates that many Americans do not understand the written materials they come in contact with daily. For this reason, many industries have begun to rewrite their consumer literature so that it will be more readable for the general
removed. With fluoroscopic control, the second of the lower group could be seen moving synchronously with the heartbeat. Accord¬ ingly, an anterior incision was made in the fourth intercostal space. The first of the upper group of needles was encountered lying on the fourth rib. The pericardium was opened, and the second of the lower group was located with some difficulty in the extreme posterior aspect of the dia¬ phragmatic surface of the right atrium adjacent to the inferior vena cava. The next needle was in lung parenchyma overlying the aortic root, and the fifth needle was finally found in the third intercostal space musculature. The patient had an uneventful
public. Unfortunately, what specialists in a given field consider more readable language often fails to meet the reading requirements of the general public. The phrase "poison retriever" on a bottle may confuse more people
than it educates. A reader may infer that the contents are in some way toxic\p=m-\exactlythe opposite of the intended communication. The inclusion of a dog's picture as part of the logo may further confuse the message. The traditional obligation of physi¬ cians to teach is being underscored by the current consumer movement. The intention to inform the lay public, while praiseworthy, must be backed by a thoughtful critique of communication
Fig 1. —Lateral view of chest showing posi¬ tion of embroidery needles. Two not seen on this view are obscured by bony ster¬ num.
techniques.
Arthur H. Rosen,f MD New York
In Reply. \p=m-\Dr Rosen's well-intentioned letter misses our purpose, but we are pleased that the letter caught his attention. There were two points that we wished to bring to the attention of practicing physicians. There has been serious confusion of
ipecac
syrup with other
potentially products (Purepac Oil of Wintergreen and Purepac Tincture of Benzoin). Adopting a slogan identifying ipecac syrup as "The Poison Retriever" in educating the lay public harmful
may avoid confusion.
Pediatric care should include a discussion on safety and the hazards of poisonings. It is at this time that physicians can explain the need for obtaining "Syrup of Ipecac\p=m-\The Poison Retriever" for the home that has toddlers. The picture of the dog and the slogan are intended for education and recall purposes, not as a logo for the already overcrowded label on a 30-ml bottle of ipecac syrup. Joseph Greensher, MD Howard C. Mofenson, MD Poison Control Center, Nassau County Medical Center
Mineola, Long Island, NY
Unusual
Foreign Body Pathway
to the Heart
To the Editor.\p=m-\A wide variety of their way into the tracheobronchial tree1 and the heart.2 Most are ingested, inhaled, or iatrogenically3,4 introduced. In this case, five
foreign objects find
postoperative course.
Comment— This case is striking in that the foreign bodies entered the abdomen and thorax through the skin. By the time of the surgery, the chest wall mass had completely disappeared. It is a well-documented fact that intravascular foreign bodies can embolize via the blood stream.6 These needles appear to have migrated via a different mechanism, one traveling from abdominal wall through the diaphragm into the heart and another reaching into lung parenchyma. Psychiatric evaluation failed to dis¬ close a psychotic personality or a clue as to the time and mode of entry. The patient remains well several months after surgery. Patricia M. McCormack, MD William H. Knapper, MD Memorial
Sloan-Kettering
Cancer Center New York
Fig 2. —Posteroanterior view showing po¬ sition of embroidery needles. Arrow desig¬ nates one in subxiphoid area. delicate
embroidery needles emigrated through the skin of the abdomen and chest, and two reached the pericardium and lung parenchyma. A review of the
literature revealed one other case of a sewing needle self-introduced into the chest, resulting in traumatic pericardi-
tis.5 Report of a Case.\p=m-\A 58-year-old woman had two very tender masses: one, 2\m=x\5cm,
located between the clavicle and left breast near the axilla; a smaller ecchymotic mass was located 2 cm below the xiphoid process. She dated the onset to a fall backwards into a bathtub two weeks previously. Chest x-ray films disclosed the presence of five sewing needles, two associated with the lower mass and three with the upper (Fig 1 and 2). A chest x-ray film taken three months prior to this incident was normal. When the x-ray films were shown to the was
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/05/2015
1. Kantu K, Aretsky PJ, Polisar IA: Repeated aspiration of multiple hypodermic needles. Arch Otolaryngol
92:286-287, 1970. 2. King JF, Manley JC, Zeft HJ, et al: Nonsurgical removal of foreign body from right heart. J Thorac Cardiovasc Surg 71:785-786, 1976. 3. Yu JC, Cheng KK: Migration of broken sewing needle from left arm to heart. Chest 67:626-627, 1975. 4. McCanghan JS Jr, Miller PR: Migration of Steinmann pin from shoulder to lung, letter. JAMA 207:1917, 1969. 5. Berg E: Traumatic
pericarditis following self-injury
a needle: Case report. Munch Med Wochenschr 113:182-185, 1971. 6. Golkar RM, Bryant HH, Ghahramani AR, et al:
with
Bullet embolization to the heart: Report of a case and review of the literature on indications for removal of intracardiac foreign bodies. J Cardiovasc Surg 16:327-330, 1975.
Treatment of Epilepsy To the Editor. \p=m-\Inthe article "Reversible Renal Failure and Myositis Caused by Phenytoin Hypersensitivity" (236:2773-2775, 1976), Michael and Mitch reported the case of a patient taking phenobarbital and phenytoin simultaneously; a skin rash developed followed by a serious constellation of
symptoms that they concluded
were
"presumably caused by phenytoin hypersensitivity." Subsequently, Wilensky (237:2600-2601, 1977) challenged the etiologic role of phenytoin in this case
since both
phenobarbital
phenytoin have independently voked similar hypersensitivity
and
prosyn-
dromes in the past. We agree that it is usually impossible to identify unequivocally the offending agent when a patient has a hypersensitivity reaction while receiv-
ing multiple drug therapy; however, based on our experience in the treatment of thousands of patients with phenobarbital and phenytoin, singly
and in combination, we believe that the cutaneous eruption and the other hypersensitivity manifestations described by Michael and Mitch were more likely due to phenytoin. The primary purpose of this communication is to direct attention to the hazards associated with initiating anticonvulsant drug therapy with more than one medication. The major hazard was poignantly demonstrated in the case history: if two or more drugs are initially prescribed and the patient subsequently manifests an untoward reaction, such as a skin rash, the physi¬ cian may have considerable difficulty in determining which of the drugs was responsible and may therefore be compelled to discontinue the entire
therapeutic regimen. The practice of instituting therapy in an epileptic patient with two or more anticonvulsive drugs was very popular
for many years in the past but was gradually abandoned during the ensu¬
ing decades, thus, most experienced physicians now favor a monopharmaceutical approach. Unfortunately, how¬ ever, the archaic policy of instituting anticonvulsant drug therapy with more than one medication still persists, as evidenced by the case history reported by Michael and Mitch. The use of polypharmacy in initiating therapy is neither a scientific nor a systematic method of administering anticonvul¬ sive drugs, and treatment prescribed in this manner presents many problems in patients who are not by chance
controlled of their seizures. The follow¬ ing additional objections are offered: 1. In patients who continue to expe¬ rience seizures, the physician has no alternative but to increase the doses of all the drugs initially prescribed or to "toss a coin" to decide which drug dosage should be increased. 2. Since the number of authentically efficacious drugs currently available for the control of seizures is relatively small, and because the optimal dosage
of each medication varies from patient to patient, the physician may exhaust the anticonvulsant therapies before any one drug has been given a satisfac¬ tory trial. In this case administration of both phénobarbital and phenytoin had to be discontinued, thereby elimi¬ nating the possible benefit of one of these two excellent anticonvulsant
drugs.
3. It invites the possibility of drug interaction. It should also be noted that the use of a multiple anticonvulsive drug program rather than a single antiepileptic agent on the basis of synergism has been recently challenged by the Buchthals,1 who state, "There is a venerable clinical belief that a combi¬ nation of anticonvulsant drugs is more apt to control seizures than one, and there is even a school which advocates giving a number of drugs in small doses in the belief that toxic effects
Errors in Course Listings. \p=m-\Thefollowing occurred in the "Continuing Educa-
errors
tion Courses for Physicians" supplement, published with the Aug 15 issue (238:653\x=req-\
836, 1977): On page 673, under New York, the entry for the 31st Postgraduate Assembly in Anesthesiology (sponsored by the NY State Soc of Anesthesiologists, Inc) should have listed the total hours of instruction as 26. On page 711, under Illinois, the entry for the Older Person as a Patient (sponsored by the Chicago Med Sch) should have listed the location for the course at N Chicago VA
Hosp, N Chicago 60064. On page 712, under Iowa, the entry for Introduction to Accounting, Prof Management, & Taxes (sponsored by the Creighton Univ Sch ofMed) should have been listed as Family Med Update. On page 713, under Nebraska, the entry for Introduction to Accounting, Prof Management, & Taxes (sponsored by the Creighton Univ Sch of Med) should have been listed as Family Med Update. On page 714, under South Dakota, the entry for Introduction to Accounting, Prof Management, & Taxes (sponsored by the Creighton Univ Sch of Med) should have been listed as Family Med Update. On page 719, under Kentucky, the entry for Liver, Biliary Tract, and Pancreas: An Update (sponsored by the Alton Ochsner Med Found) should have listed the dates for the
course as
Jan 19 to 21, not Feb 19 to
21.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/05/2015
will be avoided and that the drugs potentiate each other in anticonvulsant effect. There is no decisive proof that this is so, documented by the serum concentration." We are in complete agreement with the Buchthals' expres¬ sion, and since 1945 we have constantly advocated the use of a single drug as opposed to a combination of anticon¬ vulsant agents to initiate treatment of
epileptic seizures.2,3
Samuel Livingston, MD Lydia L. Pauli, MD Irving Pruce The Samuel Livingston Epilepsy Diagnostic and Treatment Center Baltimore
1. Buchthal
F, Lennox-Buchthal
MA:
Diphenylhydan-
toin: Relation of anticonvulsant effect to concentration in serum, in Woodbury DM. Penry JK, Schmidt RP (eds): Antiepileptic Drugs. New York, Raven Press, 1972. 2. Livingston S: The Diagnosis and Treatment of Convulsive Disorders in Children. Springfield, Ill, Charles C Thomas Publisher, 1954, pp 175-176. 3. Livingston S, Pauli LL, Pruce I: One-drug regimens for epilepsy. Lancet 1:1407-1408, 1976.
On page 727, under Indiana, the entry for Anxiety & Depression for Primary Care Phys (sponsored by Ind Univ Sch of Med) should be listed as Diagnosis & Manage¬ ment of Brain Disorder With Special Emphasis on Elderly Patients, Type: C, 2 days Fee: $125 Dates: 3/24/78 to 3/25/78; 12
hrs instruction. On page 733, the following course was omitted from the section on General Medi¬ cine under Ohio: Live-Visually Augmented Telephone Conferences for Phys (Two Way) (B) Ohio State Univ Coll of Med, Ctr for Cont Med Educ, A352 Starling Loving Hall, 320 W 10th Ave, Columbus 43210 At: Various hosps in USA & Canada Type: I, 1 hr/day, 1 day/wk for 30 wks Dates: 9/19/77 to 5/5/78; 30 hrs instruction Methods: AV, Lee, O, Pan, TV-R. On page 745, under Illinois, the entry for the 12th Annual Symposium on Diabetes Mellitus: New Horizons 1978 (sponsored by the Amer Diabetes Assn, Greater Chicago & Northern III Affiliate) should be listed as the 20th Annual Symposium on Diabetes Mellitus: New Horizons 1978. On page 767, under New York, the entry for Phaco-Emulsification (sponsored by David J. Kelman Research Found) should have listed the fee as $1,000. On page 813, under Texas, the entry for the Third Annual Central Diagnostic Radi¬ ology Seminar (sponsored by the Univ of Tex Health Science Ctr at Dallas) should be listed as the Third Annual General Diag¬ nostic Radiology Seminar.
Educational research indicates that many Americans do not understand the written materials they come in contact with daily. For this reason, many industries have begun to rewrite their consumer literature so that it will be more readable for the general
removed. With fluoroscopic control, the second of the lower group could be seen moving synchronously with the heartbeat. Accord¬ ingly, an anterior incision was made in the fourth intercostal space. The first of the upper group of needles was encountered lying on the fourth rib. The pericardium was opened, and the second of the lower group was located with some difficulty in the extreme posterior aspect of the dia¬ phragmatic surface of the right atrium adjacent to the inferior vena cava. The next needle was in lung parenchyma overlying the aortic root, and the fifth needle was finally found in the third intercostal space musculature. The patient had an uneventful
public. Unfortunately, what specialists in a given field consider more readable language often fails to meet the reading requirements of the general public. The phrase "poison retriever" on a bottle may confuse more people
than it educates. A reader may infer that the contents are in some way toxic\p=m-\exactlythe opposite of the intended communication. The inclusion of a dog's picture as part of the logo may further confuse the message. The traditional obligation of physi¬ cians to teach is being underscored by the current consumer movement. The intention to inform the lay public, while praiseworthy, must be backed by a thoughtful critique of communication
Fig 1. —Lateral view of chest showing posi¬ tion of embroidery needles. Two not seen on this view are obscured by bony ster¬ num.
techniques.
Arthur H. Rosen,f MD New York
In Reply. \p=m-\Dr Rosen's well-intentioned letter misses our purpose, but we are pleased that the letter caught his attention. There were two points that we wished to bring to the attention of practicing physicians. There has been serious confusion of
ipecac
syrup with other
potentially products (Purepac Oil of Wintergreen and Purepac Tincture of Benzoin). Adopting a slogan identifying ipecac syrup as "The Poison Retriever" in educating the lay public harmful
may avoid confusion.
Pediatric care should include a discussion on safety and the hazards of poisonings. It is at this time that physicians can explain the need for obtaining "Syrup of Ipecac\p=m-\The Poison Retriever" for the home that has toddlers. The picture of the dog and the slogan are intended for education and recall purposes, not as a logo for the already overcrowded label on a 30-ml bottle of ipecac syrup. Joseph Greensher, MD Howard C. Mofenson, MD Poison Control Center, Nassau County Medical Center
Mineola, Long Island, NY
Unusual
Foreign Body Pathway
to the Heart
To the Editor.\p=m-\A wide variety of their way into the tracheobronchial tree1 and the heart.2 Most are ingested, inhaled, or iatrogenically3,4 introduced. In this case, five
foreign objects find
postoperative course.
Comment— This case is striking in that the foreign bodies entered the abdomen and thorax through the skin. By the time of the surgery, the chest wall mass had completely disappeared. It is a well-documented fact that intravascular foreign bodies can embolize via the blood stream.6 These needles appear to have migrated via a different mechanism, one traveling from abdominal wall through the diaphragm into the heart and another reaching into lung parenchyma. Psychiatric evaluation failed to dis¬ close a psychotic personality or a clue as to the time and mode of entry. The patient remains well several months after surgery. Patricia M. McCormack, MD William H. Knapper, MD Memorial
Sloan-Kettering
Cancer Center New York
Fig 2. —Posteroanterior view showing po¬ sition of embroidery needles. Arrow desig¬ nates one in subxiphoid area. delicate
embroidery needles emigrated through the skin of the abdomen and chest, and two reached the pericardium and lung parenchyma. A review of the
literature revealed one other case of a sewing needle self-introduced into the chest, resulting in traumatic pericardi-
tis.5 Report of a Case.\p=m-\A 58-year-old woman had two very tender masses: one, 2\m=x\5cm,
located between the clavicle and left breast near the axilla; a smaller ecchymotic mass was located 2 cm below the xiphoid process. She dated the onset to a fall backwards into a bathtub two weeks previously. Chest x-ray films disclosed the presence of five sewing needles, two associated with the lower mass and three with the upper (Fig 1 and 2). A chest x-ray film taken three months prior to this incident was normal. When the x-ray films were shown to the was
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/05/2015
1. Kantu K, Aretsky PJ, Polisar IA: Repeated aspiration of multiple hypodermic needles. Arch Otolaryngol
92:286-287, 1970. 2. King JF, Manley JC, Zeft HJ, et al: Nonsurgical removal of foreign body from right heart. J Thorac Cardiovasc Surg 71:785-786, 1976. 3. Yu JC, Cheng KK: Migration of broken sewing needle from left arm to heart. Chest 67:626-627, 1975. 4. McCanghan JS Jr, Miller PR: Migration of Steinmann pin from shoulder to lung, letter. JAMA 207:1917, 1969. 5. Berg E: Traumatic
pericarditis following self-injury
a needle: Case report. Munch Med Wochenschr 113:182-185, 1971. 6. Golkar RM, Bryant HH, Ghahramani AR, et al:
with
Bullet embolization to the heart: Report of a case and review of the literature on indications for removal of intracardiac foreign bodies. J Cardiovasc Surg 16:327-330, 1975.
Treatment of Epilepsy To the Editor. \p=m-\Inthe article "Reversible Renal Failure and Myositis Caused by Phenytoin Hypersensitivity" (236:2773-2775, 1976), Michael and Mitch reported the case of a patient taking phenobarbital and phenytoin simultaneously; a skin rash developed followed by a serious constellation of
symptoms that they concluded
were
"presumably caused by phenytoin hypersensitivity." Subsequently, Wilensky (237:2600-2601, 1977) challenged the etiologic role of phenytoin in this case
since both
phenobarbital
phenytoin have independently voked similar hypersensitivity
and
prosyn-
dromes in the past. We agree that it is usually impossible to identify unequivocally the offending agent when a patient has a hypersensitivity reaction while receiv-
ing multiple drug therapy; however, based on our experience in the treatment of thousands of patients with phenobarbital and phenytoin, singly
and in combination, we believe that the cutaneous eruption and the other hypersensitivity manifestations described by Michael and Mitch were more likely due to phenytoin. The primary purpose of this communication is to direct attention to the hazards associated with initiating anticonvulsant drug therapy with more than one medication. The major hazard was poignantly demonstrated in the case history: if two or more drugs are initially prescribed and the patient subsequently manifests an untoward reaction, such as a skin rash, the physi¬ cian may have considerable difficulty in determining which of the drugs was responsible and may therefore be compelled to discontinue the entire
therapeutic regimen. The practice of instituting therapy in an epileptic patient with two or more anticonvulsive drugs was very popular
for many years in the past but was gradually abandoned during the ensu¬
ing decades, thus, most experienced physicians now favor a monopharmaceutical approach. Unfortunately, how¬ ever, the archaic policy of instituting anticonvulsant drug therapy with more than one medication still persists, as evidenced by the case history reported by Michael and Mitch. The use of polypharmacy in initiating therapy is neither a scientific nor a systematic method of administering anticonvul¬ sive drugs, and treatment prescribed in this manner presents many problems in patients who are not by chance
controlled of their seizures. The follow¬ ing additional objections are offered: 1. In patients who continue to expe¬ rience seizures, the physician has no alternative but to increase the doses of all the drugs initially prescribed or to "toss a coin" to decide which drug dosage should be increased. 2. Since the number of authentically efficacious drugs currently available for the control of seizures is relatively small, and because the optimal dosage
of each medication varies from patient to patient, the physician may exhaust the anticonvulsant therapies before any one drug has been given a satisfac¬ tory trial. In this case administration of both phénobarbital and phenytoin had to be discontinued, thereby elimi¬ nating the possible benefit of one of these two excellent anticonvulsant
drugs.
3. It invites the possibility of drug interaction. It should also be noted that the use of a multiple anticonvulsive drug program rather than a single antiepileptic agent on the basis of synergism has been recently challenged by the Buchthals,1 who state, "There is a venerable clinical belief that a combi¬ nation of anticonvulsant drugs is more apt to control seizures than one, and there is even a school which advocates giving a number of drugs in small doses in the belief that toxic effects
Errors in Course Listings. \p=m-\Thefollowing occurred in the "Continuing Educa-
errors
tion Courses for Physicians" supplement, published with the Aug 15 issue (238:653\x=req-\
836, 1977): On page 673, under New York, the entry for the 31st Postgraduate Assembly in Anesthesiology (sponsored by the NY State Soc of Anesthesiologists, Inc) should have listed the total hours of instruction as 26. On page 711, under Illinois, the entry for the Older Person as a Patient (sponsored by the Chicago Med Sch) should have listed the location for the course at N Chicago VA
Hosp, N Chicago 60064. On page 712, under Iowa, the entry for Introduction to Accounting, Prof Management, & Taxes (sponsored by the Creighton Univ Sch ofMed) should have been listed as Family Med Update. On page 713, under Nebraska, the entry for Introduction to Accounting, Prof Management, & Taxes (sponsored by the Creighton Univ Sch of Med) should have been listed as Family Med Update. On page 714, under South Dakota, the entry for Introduction to Accounting, Prof Management, & Taxes (sponsored by the Creighton Univ Sch of Med) should have been listed as Family Med Update. On page 719, under Kentucky, the entry for Liver, Biliary Tract, and Pancreas: An Update (sponsored by the Alton Ochsner Med Found) should have listed the dates for the
course as
Jan 19 to 21, not Feb 19 to
21.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/05/2015
will be avoided and that the drugs potentiate each other in anticonvulsant effect. There is no decisive proof that this is so, documented by the serum concentration." We are in complete agreement with the Buchthals' expres¬ sion, and since 1945 we have constantly advocated the use of a single drug as opposed to a combination of anticon¬ vulsant agents to initiate treatment of
epileptic seizures.2,3
Samuel Livingston, MD Lydia L. Pauli, MD Irving Pruce The Samuel Livingston Epilepsy Diagnostic and Treatment Center Baltimore
1. Buchthal
F, Lennox-Buchthal
MA:
Diphenylhydan-
toin: Relation of anticonvulsant effect to concentration in serum, in Woodbury DM. Penry JK, Schmidt RP (eds): Antiepileptic Drugs. New York, Raven Press, 1972. 2. Livingston S: The Diagnosis and Treatment of Convulsive Disorders in Children. Springfield, Ill, Charles C Thomas Publisher, 1954, pp 175-176. 3. Livingston S, Pauli LL, Pruce I: One-drug regimens for epilepsy. Lancet 1:1407-1408, 1976.
On page 727, under Indiana, the entry for Anxiety & Depression for Primary Care Phys (sponsored by Ind Univ Sch of Med) should be listed as Diagnosis & Manage¬ ment of Brain Disorder With Special Emphasis on Elderly Patients, Type: C, 2 days Fee: $125 Dates: 3/24/78 to 3/25/78; 12
hrs instruction. On page 733, the following course was omitted from the section on General Medi¬ cine under Ohio: Live-Visually Augmented Telephone Conferences for Phys (Two Way) (B) Ohio State Univ Coll of Med, Ctr for Cont Med Educ, A352 Starling Loving Hall, 320 W 10th Ave, Columbus 43210 At: Various hosps in USA & Canada Type: I, 1 hr/day, 1 day/wk for 30 wks Dates: 9/19/77 to 5/5/78; 30 hrs instruction Methods: AV, Lee, O, Pan, TV-R. On page 745, under Illinois, the entry for the 12th Annual Symposium on Diabetes Mellitus: New Horizons 1978 (sponsored by the Amer Diabetes Assn, Greater Chicago & Northern III Affiliate) should be listed as the 20th Annual Symposium on Diabetes Mellitus: New Horizons 1978. On page 767, under New York, the entry for Phaco-Emulsification (sponsored by David J. Kelman Research Found) should have listed the fee as $1,000. On page 813, under Texas, the entry for the Third Annual Central Diagnostic Radi¬ ology Seminar (sponsored by the Univ of Tex Health Science Ctr at Dallas) should be listed as the Third Annual General Diag¬ nostic Radiology Seminar.
