Furthermore, there is a report2 of a
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 in length, and will be subject to editing. Letters
Letters, if clearly marked "For Publication", will be published are
not
acknowledged.
patient with hypersensitivity to cyanocobalamin injection, in which the al¬ lergen was not the cyanocobalamin itself, but the preservative phenylcarbinol (benzyl alcohol). A. A. Fisher, MD Woodside, NY
1. Fisher AA: Contact Dermatitis, ed 2. Philadelphia, Lea & Febiger, 1973, p 112. 2. Lagerholm B: Hypersensitivity to phenylcarbinol preservative in vitamin B12 for injection. Acta Allergol
12:295-296, 1958.
Trimethioprim-Sulfamethoxazole To the Editor.\p=m-\Inreference to the
article, "Evaluation of an Anti-Infective Combination: TrimethioprimSulfamethoxazole" (231:635, 1975), it should be pointed out that the cost to patient of 60 tablets, enough for a
for treatment of a urinary tract infection is $19 in our area. This fact should be borne in mind before the drug is used and would be a strong deterrent to its use as "primary medication for acute and chronic urinary tract infections."
two-week
course
directing the preparation of monographs on new drugs are very much aware of the relatively high
for
cost of many of the new medications. However, we must evaluate each drug on its merits without regard to cost if we are to be objective, and not deter a
from using a drug on the basis of cost alone. We must assume that the physician reading our mono¬ graph will practice good medicine in the sense that he is concerned about both the physical and financial wellbeing of his patient.
physician
Donald O. Schiffman, PhD
Michael H. Goloff, MD Berkeley, Calif
Reply.\p=m-\Thesentence to which Dr. Goloff refers was intended to convey the meaning that the combination of trimethoprim and sulfamethoxazole is an effective and therefore primary medication for treating certain urinary tract infections. It was not meant to imply that this mixture is the best possible anti-infective for
In
treating urinary tract infections or that it is necessarily a drug of choice
for such purposes. It is important for every physician to have some general concept of the cost of each prescription he writes, especially if his patient possesses limited financial means. Certainly there are several good, less expensive regimens for treating urinary tract infections than the trimethoprim-sulfamethoxazole mixture. Nevertheless, if special conditions arise to indicate that this combination may be the drug of choice or if a strain of microorganism refractory to other conventional forms of medication is found to be sensitive to this mixture, the cost of the prescription has to be a secondary consideration. Those of us in the AMA Depart¬ ment of Drugs who are responsible Edited
by John
D. Archer, MD, Senior Editor.
AMA
Department of Drugs Chicago
"B12 Shots"\p=m-\StillAnother Side of the Coin To the Editor.\p=m-\Inhis article "'B12 Shots': Flip Side" (231:289, 1975) McCurdy states: "My first article emphasized that most cyanocobalamin
injections have little justification, although they may sometimes have a placebo effect. The flip side of this coin: when cyanocobalamin therapy is
needed, it is really needed and needed permanently." To continue the metaphor, a three\x=req-\ sided coin would be needed, since,
cyanocobalamin shot is therapeutic or acts as a placebo, there is always the possibility of an allergic whether the
reaction. I have described such a reaction1 in a 63-year-old woman who noted that following each injection of cyanocobalamin the area of injection had become red, tender, and pruritic. Oral ingestion of cyanocobalamin produced similar flares in the sites of previous injections. This patient had positive patch reactions to a 2% aqueous solution of cobalt chloride and to cyanocobalamin solutions in the strengths of 100\g=m\g and 1,000\g=m\g/ ml. In addition, there were positive delayed scratch and intradermal reac¬ tions to the cyanocobalamin solutions.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/25/2015
Black
Lung Benefits Reform
Act
To the Editor.\p=m-\TheHouse Sub-Committee on Labor has recently been holding hearings on a bill HR 8, which is also known as the Black Lung Benefits Reform Act of 1975.I wish to call attention to certain proposals in this bill that are grossly unfair to the non\x=req-\ coal-mining working population and to the consumer. Were this bill to become law, any respiratory impairment that develops in a man who has worked for 25 years in a coal mine would be assumed to be due to his occupation. Such a presumption could only be rebutted on the basis of a blood gas test. After 35 years, the presumption of disability would become irrebuttable, and every miner who had worked for this period would be able to retire on "disability." The fact that there is no medical basis whatsoever for such a presumption is well known to those who are familiar with the literature.1 The provisions of this bill are grossly unfair to the non-coal-mining working population who are already receiving short shrift as a result of previous black lung legislation. Thus, the Federal Coal Mine, Health, and Safety Acts of 1969 and 1972 created a situation in which a disabled coal miner receives almost twice as much compensation as does the disabled steel worker. The injustice would only be compounded by introducing legis¬ lation that presumes disability in the absence of impairment, a concept that would eventually destroy the prevailing and equitable system on which the Social Security Adminis¬ tration awards compensation for pre¬ mature
disability.
The presumption that disability is unavoidable if a man works for more than 35 years in a coal mine is a doc¬ trine of defeat. One of the main pur¬ poses of the 1969 Act was to limit exposure to coal dust, and thereby lessen the prevalence and incidence of coal workers' pneumoconiosis. All the
evidence suggests is that if a stan¬ dard of 2 mg/cu m is adhered to, the likelihood of a miner reaching cate¬ gory 2 or above with 35 years of un¬ derground exposure is less than 3%.2 Implicit in the assumption that a miner is disabled after 35 years in a coal mine is the concept that no mat¬ ter how effective the dust control pro¬ gram proves to be, disability is inevi¬ table. There would, therefore, seem to be little purpose in having a dust con¬ trol program, and the millions of dol¬ lars that are currently being spent on dust control are being wasted. There is little doubt that for many years the US coal miner was treated unfairly, but past injustices are not expunged by creating a new set of in¬ justices that discriminate against the rest of the working population. If Congress wishes to expiate its past neglect of coal miners by creating a premature retirement system for them, let it do so openly and not by trying to justify social legislation by willfully misrepresenting the medical facts and by maudlin appeals to the public's guilty conscience. W. Keith C. Morgan, MD West Virginia University Medical Center
Morgantown Morgan WKC: Respiratory disease in coal miners. JAMA 231:1347-1348, 1975. 2. Jacobson M: Progression of coal workers' pneu1.
moconiosis in Britain in relation to environmental conditions underground. Proceedings of the Conference on Technical Measures of Dust Prevention and Suppression in Mines. Luxembourg, Commission of European Communities, 1973, pp 77-93.
Geriatric Doses To the Editor.\p=m-\Drs.Solomon and Vickers (231:280, 1975) do not appear to appreciate that geriatric doses of psychoactive medication are lower than doses for younger people. Acceptable therapeutic lithium ion levels for people more than 50-60 years of age is 0.2 to 0.9 mEq/liter. For older people, 300-mg tablets of lithium carbonate often have to be broken in half; 150 mg three times daily is a frequent geriatric dosage. Sometimes even less is appropriate. For this reason, tablet form is better than capsule form of lithium carbonate. Ruth Wharton, MD
Chicago
In Reply.\p=m-\Itis true that extra care should be exercised when prescribing medication for elderly patients because of the prevalence of side effects and complications. We do not agree, however, with the broad general-
ization that doses of psychoactive medications are lower than doses for younger people; each case must be treated individually to achieve a satisfactory serum level. We find that the use of capsules
produces
a more
predictable
serum
level. Studies we performed four years ago showed that some tablets remained intact and were excreted in the stools. The purpose of our article was to point out that dysphasia may occur as an isolated effect of lithium administration in the absence of true toxicity. The patient is almost unaware of the symptom and suffers no real inconvenience from it. We think that it is better not to give a medication at all if the dosage level is too low to produce a therapeutic effect; this would apply to the lower limits of the thera¬ peutic range acceptable to Dr. Whar¬ ton.
Raymond Vickers, MD Kenneth Solomon, MD Albany, NY
of chloroquine, 500 mg daily for five days. In each case, a slight to moderate transient rise in transaminase and uroporphyrin levels new course
followed the
new course
of chloro¬
quine therapy, but symptoms of a chloroquine reaction developed in only one of the five patients, and were
very mild.
Although
none of the patients showed clinical manifestations of PCT at the time of recurrent porphyrinuria, the experience suggests that porphyrin levels should be ob¬ served periodically in patients who have had PCT, or that chloroquine therapy should be repeated, at per¬ haps six-month intervals, to ensure
against relapse.
Michael J. Kowertz, MD Permanente Medical Group Sunnyvale, Calif
Neisseria lactamicus
Pharyngitis
To the Editor.\p=m-\A26-year-old man to Harbor General Hospital with fever, chills, and a sore throat. His temperature was 40 C (104 F) and came
Retreatment With Chloroquine in Porphyria Cutanea Tarda To the Editor.\p=m-\Twoyears ago, I
re-
ported in The Journal (223:515,1973) the correction of the hepatic abnor-
malities as well as the cutaneous manifestations of porphyria cutanea tarda (PCT) by the oral administration of chloroquine, and suggested that this agent, directly or indirectly, selectively destroyed those cells (or
their organelles) that were responsible for abnormal porphyrin synthesis. Although I still believe this to be the case, longer observation of the two patients reported, and of three additional patients with PCT who were similarly treated, has revealed a slight to moderate increase in uroporphyrin excretion six months to three years after initial treatment. This would imply that all porphyrinproducing structures had not been destroyed, or that they were capable of regeneration. The rise after only six months would favor the former explanation; the increase after three years, the latter. Alcohol intake was evidently not causally related to the rise. The patient whose urinary porphyrin levels remained normal longest and rose least after chloroquine treatment consumes large amounts of alcohol; one patient drinks no alcohol. In all five patients, the second episode of
porphyrinuria responded rapidly
to
a
there was marked pharyngeal and tonsillar inflammation, with a peritonsillar exudate. Pharyngeal culture grew Neisseria lactamicus in pure culture. This organism appears identical to N meningitidis on culture media, and distinction between the two can only be made on serologic or biochemical grounds.1,2 Neisseria lactamicus differs from N meningitidis in that it ferments lactose and produces a \g=b\-galactosidase. The carrier rate of N lactamicus in adults is 0% to 2%.2 The importance of distinguishing
the different Neisseria
species lac-
tamicus, meningitidis, and
gonor-
rhoeae) has obvious epidemiologic and therapeutic importance. S. Fisher, MD Paul Edelstein, MD Lucien B. Guze, MD Harbor General Hospital Larry
Torrance, Calif 1. Hollis
DG, Wiggins GL, Weaver RE: Neisseria lactamicus: A lactose-fermenting species resembling Neisseria meningitidis. Appl Microbiol 17:71-77, 1969. 2. Hollis DG, Wiggins GL, Weaver RE, et al: Current status of
Sci
lactose-fermenting
Neisseria. Ann NY Acad
174:444-449, 1970.
Health in the Developing World To the Editor.\p=m-\Dr.Tavassoli's article (230:1527, 1974), which stresses the inability of modern medicine to improve the health of people in the developing world, demonstrates the im-
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/25/2015
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 in length, and will be subject to editing. Letters
Letters, if clearly marked "For Publication", will be published are
not
acknowledged.
patient with hypersensitivity to cyanocobalamin injection, in which the al¬ lergen was not the cyanocobalamin itself, but the preservative phenylcarbinol (benzyl alcohol). A. A. Fisher, MD Woodside, NY
1. Fisher AA: Contact Dermatitis, ed 2. Philadelphia, Lea & Febiger, 1973, p 112. 2. Lagerholm B: Hypersensitivity to phenylcarbinol preservative in vitamin B12 for injection. Acta Allergol
12:295-296, 1958.
Trimethioprim-Sulfamethoxazole To the Editor.\p=m-\Inreference to the
article, "Evaluation of an Anti-Infective Combination: TrimethioprimSulfamethoxazole" (231:635, 1975), it should be pointed out that the cost to patient of 60 tablets, enough for a
for treatment of a urinary tract infection is $19 in our area. This fact should be borne in mind before the drug is used and would be a strong deterrent to its use as "primary medication for acute and chronic urinary tract infections."
two-week
course
directing the preparation of monographs on new drugs are very much aware of the relatively high
for
cost of many of the new medications. However, we must evaluate each drug on its merits without regard to cost if we are to be objective, and not deter a
from using a drug on the basis of cost alone. We must assume that the physician reading our mono¬ graph will practice good medicine in the sense that he is concerned about both the physical and financial wellbeing of his patient.
physician
Donald O. Schiffman, PhD
Michael H. Goloff, MD Berkeley, Calif
Reply.\p=m-\Thesentence to which Dr. Goloff refers was intended to convey the meaning that the combination of trimethoprim and sulfamethoxazole is an effective and therefore primary medication for treating certain urinary tract infections. It was not meant to imply that this mixture is the best possible anti-infective for
In
treating urinary tract infections or that it is necessarily a drug of choice
for such purposes. It is important for every physician to have some general concept of the cost of each prescription he writes, especially if his patient possesses limited financial means. Certainly there are several good, less expensive regimens for treating urinary tract infections than the trimethoprim-sulfamethoxazole mixture. Nevertheless, if special conditions arise to indicate that this combination may be the drug of choice or if a strain of microorganism refractory to other conventional forms of medication is found to be sensitive to this mixture, the cost of the prescription has to be a secondary consideration. Those of us in the AMA Depart¬ ment of Drugs who are responsible Edited
by John
D. Archer, MD, Senior Editor.
AMA
Department of Drugs Chicago
"B12 Shots"\p=m-\StillAnother Side of the Coin To the Editor.\p=m-\Inhis article "'B12 Shots': Flip Side" (231:289, 1975) McCurdy states: "My first article emphasized that most cyanocobalamin
injections have little justification, although they may sometimes have a placebo effect. The flip side of this coin: when cyanocobalamin therapy is
needed, it is really needed and needed permanently." To continue the metaphor, a three\x=req-\ sided coin would be needed, since,
cyanocobalamin shot is therapeutic or acts as a placebo, there is always the possibility of an allergic whether the
reaction. I have described such a reaction1 in a 63-year-old woman who noted that following each injection of cyanocobalamin the area of injection had become red, tender, and pruritic. Oral ingestion of cyanocobalamin produced similar flares in the sites of previous injections. This patient had positive patch reactions to a 2% aqueous solution of cobalt chloride and to cyanocobalamin solutions in the strengths of 100\g=m\g and 1,000\g=m\g/ ml. In addition, there were positive delayed scratch and intradermal reac¬ tions to the cyanocobalamin solutions.
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/25/2015
Black
Lung Benefits Reform
Act
To the Editor.\p=m-\TheHouse Sub-Committee on Labor has recently been holding hearings on a bill HR 8, which is also known as the Black Lung Benefits Reform Act of 1975.I wish to call attention to certain proposals in this bill that are grossly unfair to the non\x=req-\ coal-mining working population and to the consumer. Were this bill to become law, any respiratory impairment that develops in a man who has worked for 25 years in a coal mine would be assumed to be due to his occupation. Such a presumption could only be rebutted on the basis of a blood gas test. After 35 years, the presumption of disability would become irrebuttable, and every miner who had worked for this period would be able to retire on "disability." The fact that there is no medical basis whatsoever for such a presumption is well known to those who are familiar with the literature.1 The provisions of this bill are grossly unfair to the non-coal-mining working population who are already receiving short shrift as a result of previous black lung legislation. Thus, the Federal Coal Mine, Health, and Safety Acts of 1969 and 1972 created a situation in which a disabled coal miner receives almost twice as much compensation as does the disabled steel worker. The injustice would only be compounded by introducing legis¬ lation that presumes disability in the absence of impairment, a concept that would eventually destroy the prevailing and equitable system on which the Social Security Adminis¬ tration awards compensation for pre¬ mature
disability.
The presumption that disability is unavoidable if a man works for more than 35 years in a coal mine is a doc¬ trine of defeat. One of the main pur¬ poses of the 1969 Act was to limit exposure to coal dust, and thereby lessen the prevalence and incidence of coal workers' pneumoconiosis. All the
evidence suggests is that if a stan¬ dard of 2 mg/cu m is adhered to, the likelihood of a miner reaching cate¬ gory 2 or above with 35 years of un¬ derground exposure is less than 3%.2 Implicit in the assumption that a miner is disabled after 35 years in a coal mine is the concept that no mat¬ ter how effective the dust control pro¬ gram proves to be, disability is inevi¬ table. There would, therefore, seem to be little purpose in having a dust con¬ trol program, and the millions of dol¬ lars that are currently being spent on dust control are being wasted. There is little doubt that for many years the US coal miner was treated unfairly, but past injustices are not expunged by creating a new set of in¬ justices that discriminate against the rest of the working population. If Congress wishes to expiate its past neglect of coal miners by creating a premature retirement system for them, let it do so openly and not by trying to justify social legislation by willfully misrepresenting the medical facts and by maudlin appeals to the public's guilty conscience. W. Keith C. Morgan, MD West Virginia University Medical Center
Morgantown Morgan WKC: Respiratory disease in coal miners. JAMA 231:1347-1348, 1975. 2. Jacobson M: Progression of coal workers' pneu1.
moconiosis in Britain in relation to environmental conditions underground. Proceedings of the Conference on Technical Measures of Dust Prevention and Suppression in Mines. Luxembourg, Commission of European Communities, 1973, pp 77-93.
Geriatric Doses To the Editor.\p=m-\Drs.Solomon and Vickers (231:280, 1975) do not appear to appreciate that geriatric doses of psychoactive medication are lower than doses for younger people. Acceptable therapeutic lithium ion levels for people more than 50-60 years of age is 0.2 to 0.9 mEq/liter. For older people, 300-mg tablets of lithium carbonate often have to be broken in half; 150 mg three times daily is a frequent geriatric dosage. Sometimes even less is appropriate. For this reason, tablet form is better than capsule form of lithium carbonate. Ruth Wharton, MD
Chicago
In Reply.\p=m-\Itis true that extra care should be exercised when prescribing medication for elderly patients because of the prevalence of side effects and complications. We do not agree, however, with the broad general-
ization that doses of psychoactive medications are lower than doses for younger people; each case must be treated individually to achieve a satisfactory serum level. We find that the use of capsules
produces
a more
predictable
serum
level. Studies we performed four years ago showed that some tablets remained intact and were excreted in the stools. The purpose of our article was to point out that dysphasia may occur as an isolated effect of lithium administration in the absence of true toxicity. The patient is almost unaware of the symptom and suffers no real inconvenience from it. We think that it is better not to give a medication at all if the dosage level is too low to produce a therapeutic effect; this would apply to the lower limits of the thera¬ peutic range acceptable to Dr. Whar¬ ton.
Raymond Vickers, MD Kenneth Solomon, MD Albany, NY
of chloroquine, 500 mg daily for five days. In each case, a slight to moderate transient rise in transaminase and uroporphyrin levels new course
followed the
new course
of chloro¬
quine therapy, but symptoms of a chloroquine reaction developed in only one of the five patients, and were
very mild.
Although
none of the patients showed clinical manifestations of PCT at the time of recurrent porphyrinuria, the experience suggests that porphyrin levels should be ob¬ served periodically in patients who have had PCT, or that chloroquine therapy should be repeated, at per¬ haps six-month intervals, to ensure
against relapse.
Michael J. Kowertz, MD Permanente Medical Group Sunnyvale, Calif
Neisseria lactamicus
Pharyngitis
To the Editor.\p=m-\A26-year-old man to Harbor General Hospital with fever, chills, and a sore throat. His temperature was 40 C (104 F) and came
Retreatment With Chloroquine in Porphyria Cutanea Tarda To the Editor.\p=m-\Twoyears ago, I
re-
ported in The Journal (223:515,1973) the correction of the hepatic abnor-
malities as well as the cutaneous manifestations of porphyria cutanea tarda (PCT) by the oral administration of chloroquine, and suggested that this agent, directly or indirectly, selectively destroyed those cells (or
their organelles) that were responsible for abnormal porphyrin synthesis. Although I still believe this to be the case, longer observation of the two patients reported, and of three additional patients with PCT who were similarly treated, has revealed a slight to moderate increase in uroporphyrin excretion six months to three years after initial treatment. This would imply that all porphyrinproducing structures had not been destroyed, or that they were capable of regeneration. The rise after only six months would favor the former explanation; the increase after three years, the latter. Alcohol intake was evidently not causally related to the rise. The patient whose urinary porphyrin levels remained normal longest and rose least after chloroquine treatment consumes large amounts of alcohol; one patient drinks no alcohol. In all five patients, the second episode of
porphyrinuria responded rapidly
to
a
there was marked pharyngeal and tonsillar inflammation, with a peritonsillar exudate. Pharyngeal culture grew Neisseria lactamicus in pure culture. This organism appears identical to N meningitidis on culture media, and distinction between the two can only be made on serologic or biochemical grounds.1,2 Neisseria lactamicus differs from N meningitidis in that it ferments lactose and produces a \g=b\-galactosidase. The carrier rate of N lactamicus in adults is 0% to 2%.2 The importance of distinguishing
the different Neisseria
species lac-
tamicus, meningitidis, and
gonor-
rhoeae) has obvious epidemiologic and therapeutic importance. S. Fisher, MD Paul Edelstein, MD Lucien B. Guze, MD Harbor General Hospital Larry
Torrance, Calif 1. Hollis
DG, Wiggins GL, Weaver RE: Neisseria lactamicus: A lactose-fermenting species resembling Neisseria meningitidis. Appl Microbiol 17:71-77, 1969. 2. Hollis DG, Wiggins GL, Weaver RE, et al: Current status of
Sci
lactose-fermenting
Neisseria. Ann NY Acad
174:444-449, 1970.
Health in the Developing World To the Editor.\p=m-\Dr.Tavassoli's article (230:1527, 1974), which stresses the inability of modern medicine to improve the health of people in the developing world, demonstrates the im-
Downloaded From: http://jama.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/25/2015
