middle-aged subjects,3 and another study showed some improvement in four out of ten patients given 150 Mg/day for one to four months." However, in agreement with the Ira¬ nian results, a crossover experiment showed
no
difference in tolerance of
patients given 150 ¿¿g/day of chrom¬ ium (III) or placebo for 16 weeks.* The speedy hypoglycémie response of
chromium-deficient rats and mal¬ nourished infants contrasts complete¬ ly with the results on adult dia¬ betics. Although the dose rates were much higher and the species was different, recent work in this university found that a chromium (III) injection to rats caused a hyperglycémie response (Ghafghazi, personal communica¬ tion). Therefore, not only are the claims of a good effect of chromium (III) in diabetics based on shaky foun¬ dations, but in the Iranian experi¬ ment actual harm was done by chromium (III), which worsened the already hyperglycémie situation in the patients. It is hoped that this communication will prompt further investigations into the effects of chromium (III) and will also caution those who may like to try chromium (III) supplementation on their pa¬ tients. A. Wise, PhD University of Isfahan Isfahan. Iran
glucose tolerfactor, in Present Knowledge in Nutrition. New Nutrition York, Foundation, 1976, pp 365-375. 2. Glinsmann WH, Mertz W: Effect of trivalent chromium on glucose tolerance. Metabolism 15:510-520, 1. Mertz W: Effects and metabolism of
ance
1966. 3. Hopkins LL, Price MG: Effectiveness of chromium (III) in improving the impaired glucose tolerance of middle-aged Americans. Proceedings of the Western Hemisphere Nutrition Congress, Puerto Rico, 1968, vol 2,
p 40.
4. Levine RA, Streeten DHP, Doisy RJ: Effects of oral chromium supplementation on the glucose tolerance of elderly human subjects. Metabolism 17:114-125, 1968. 5. Sherman L, Glennon JA, Breck WJ, et al: Failure of trivalent chromium to improve hyperglycemia in diabetes mellitus. Metabolism 17:439-442, 1968.
Feeding Jejunostomy via
Stomach To the Editor.\p=m-\Arecent letter by Rachmilewitz and associates (240:20, 1978) described a method of introducing a small-diameter feeding jejunostomy tube via the nasal route. We have been interested in introducing feeding jejunostomy tubes intraoperatively, but have been discouraged with the complications of the standard method of introduction via the jejunum. This approach predisposes to small-bowel obstruction and intestinal leak. Because of these hazards we have devised a method of inserting
the jejunostomy tube via the anterior surface of the stomach, similar to the technique of a Stamm gastrostomy. A No. 8 F polyethylene pediatric feeding tube is advanced into the proximal jejunum with the aid of a No. 3 Fogarty catheter threaded into the lumen of the feeding tube. The inflated balloon provides a sufficient mass to advance the tube through the pylorus and duodenal C loop. Once satisfactory position is achieved, the balloon is deflated and the Fogarty catheter removed. This small-diameter feeding tube is most applicable to short-term alimen¬ tation. However, we have used this technique in a patient with pharyngeal carcinoma for three months without complications. Those requir¬
ing permanent feeding probably best served by a standard large-tube are
gastrostomy.
Steven C. Elerding, MD Ernest E. Moore, MD
University
of Colorado
Medical Center Denver General Hospital Denver
Enterobius in Location
an
Unusual
To the Editor.\p=m-\Enterobiusvermicularis is a parasite occasionally seen by a surgical pathologist. The usual location of the worm, eggs, or both is the appendix or an anal biopsy specimen. We recently examined a surgical specimen from a 15-year-old girl with the parasitic infection in a most unusual place.
Report of a Case.\p=m-\The patient complained of a mass in the vagina. From examination, her physician thought she probably had a bartholin gland abscess and treated her with antibiotics. The area did not heal, and the patient was referred to
surgeon. The surgeon felt what he a
thought was a cystic mass in the posterior part of the vagina. He brought the patient to the operating room for incision and drainage of the lesion. The pathology department received two pieces of irregular, smooth, orange tissue measuring 2 cm and 1 cm in diameter. Sectioning of the tissue showed it to be covered by fairly normal vaginal mucosa with evidence of erosion. Deep within the subepithelial tissue was an inflammatory reaction intermixed with ova of E vermicularis and a portion of the worm (Figure). Postoperatively the pa¬ tient was treated with pyrvinium pamoate (Povan), as were members of her family. No clinical evidence of the parasite has been reported after six weeks. Comment—The usual symptom of E vermicularis infection is perianal
itching.
An occasional
patient
Ova of Enterobius vermicularis intermixed with inflammatory exúdate deep in subcuta¬ neous tissue of vagina (X440).
have acute appendicitis. Rarely, chronic endometritis, salpingitis, pul¬ monary nodules, abnormal liver func¬ tion tests, or urinary tract infection may occur. This patient probably had a preexisting vaginal ulcération that allowed penetration of the female adult into the subepithelial vaginal tissue, because primary penetration of mucosal barriers by E vermicularis is not thought to occur. In retrospect, the clinician thought that the mass actually was in the posterior aspect of the vaginal wall and not in the lateral wall, where the usual bartholin gland cyst is found. The patient lives in rural south¬ western Pennsylvania where expo¬ sure to the parasite is frequent. However, no previous perianal dis¬ comfort was noted. Thus, usual meth¬ ods of diagnosis such as cellophane tape examination of the perianal region were not done at the time. Paul Snow, MD Garry Cartwright, PhD Memorial Hospital Cumberland, Md Ross Rumbaugh, MD
Meyersdale, Pa
Ijopez, MD, and staff at the Disease Control, Atlanta, reviewed the case. Carlos K.
Center for
Malpractice Suits To the Editor.\p=m-\After reading the letter of Mr Alan Y. Medvin (240:346, 1978), "I feel compelled to respond." Mr Medvin contends that many malpractice actions are settled before trial because they generally involve the clearest cases of malpractice. I strongly doubt this statement. There are many nuisance cases that are settled out of court because insurance carriers find that it is less expensive to do it that way. The merits of these cases are
may
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/26/2015
ignored.
Harlan B. Moss. MD
Indianapolis
no
difference in tolerance of
patients given 150 ¿¿g/day of chrom¬ ium (III) or placebo for 16 weeks.* The speedy hypoglycémie response of
chromium-deficient rats and mal¬ nourished infants contrasts complete¬ ly with the results on adult dia¬ betics. Although the dose rates were much higher and the species was different, recent work in this university found that a chromium (III) injection to rats caused a hyperglycémie response (Ghafghazi, personal communica¬ tion). Therefore, not only are the claims of a good effect of chromium (III) in diabetics based on shaky foun¬ dations, but in the Iranian experi¬ ment actual harm was done by chromium (III), which worsened the already hyperglycémie situation in the patients. It is hoped that this communication will prompt further investigations into the effects of chromium (III) and will also caution those who may like to try chromium (III) supplementation on their pa¬ tients. A. Wise, PhD University of Isfahan Isfahan. Iran
glucose tolerfactor, in Present Knowledge in Nutrition. New Nutrition York, Foundation, 1976, pp 365-375. 2. Glinsmann WH, Mertz W: Effect of trivalent chromium on glucose tolerance. Metabolism 15:510-520, 1. Mertz W: Effects and metabolism of
ance
1966. 3. Hopkins LL, Price MG: Effectiveness of chromium (III) in improving the impaired glucose tolerance of middle-aged Americans. Proceedings of the Western Hemisphere Nutrition Congress, Puerto Rico, 1968, vol 2,
p 40.
4. Levine RA, Streeten DHP, Doisy RJ: Effects of oral chromium supplementation on the glucose tolerance of elderly human subjects. Metabolism 17:114-125, 1968. 5. Sherman L, Glennon JA, Breck WJ, et al: Failure of trivalent chromium to improve hyperglycemia in diabetes mellitus. Metabolism 17:439-442, 1968.
Feeding Jejunostomy via
Stomach To the Editor.\p=m-\Arecent letter by Rachmilewitz and associates (240:20, 1978) described a method of introducing a small-diameter feeding jejunostomy tube via the nasal route. We have been interested in introducing feeding jejunostomy tubes intraoperatively, but have been discouraged with the complications of the standard method of introduction via the jejunum. This approach predisposes to small-bowel obstruction and intestinal leak. Because of these hazards we have devised a method of inserting
the jejunostomy tube via the anterior surface of the stomach, similar to the technique of a Stamm gastrostomy. A No. 8 F polyethylene pediatric feeding tube is advanced into the proximal jejunum with the aid of a No. 3 Fogarty catheter threaded into the lumen of the feeding tube. The inflated balloon provides a sufficient mass to advance the tube through the pylorus and duodenal C loop. Once satisfactory position is achieved, the balloon is deflated and the Fogarty catheter removed. This small-diameter feeding tube is most applicable to short-term alimen¬ tation. However, we have used this technique in a patient with pharyngeal carcinoma for three months without complications. Those requir¬
ing permanent feeding probably best served by a standard large-tube are
gastrostomy.
Steven C. Elerding, MD Ernest E. Moore, MD
University
of Colorado
Medical Center Denver General Hospital Denver
Enterobius in Location
an
Unusual
To the Editor.\p=m-\Enterobiusvermicularis is a parasite occasionally seen by a surgical pathologist. The usual location of the worm, eggs, or both is the appendix or an anal biopsy specimen. We recently examined a surgical specimen from a 15-year-old girl with the parasitic infection in a most unusual place.
Report of a Case.\p=m-\The patient complained of a mass in the vagina. From examination, her physician thought she probably had a bartholin gland abscess and treated her with antibiotics. The area did not heal, and the patient was referred to
surgeon. The surgeon felt what he a
thought was a cystic mass in the posterior part of the vagina. He brought the patient to the operating room for incision and drainage of the lesion. The pathology department received two pieces of irregular, smooth, orange tissue measuring 2 cm and 1 cm in diameter. Sectioning of the tissue showed it to be covered by fairly normal vaginal mucosa with evidence of erosion. Deep within the subepithelial tissue was an inflammatory reaction intermixed with ova of E vermicularis and a portion of the worm (Figure). Postoperatively the pa¬ tient was treated with pyrvinium pamoate (Povan), as were members of her family. No clinical evidence of the parasite has been reported after six weeks. Comment—The usual symptom of E vermicularis infection is perianal
itching.
An occasional
patient
Ova of Enterobius vermicularis intermixed with inflammatory exúdate deep in subcuta¬ neous tissue of vagina (X440).
have acute appendicitis. Rarely, chronic endometritis, salpingitis, pul¬ monary nodules, abnormal liver func¬ tion tests, or urinary tract infection may occur. This patient probably had a preexisting vaginal ulcération that allowed penetration of the female adult into the subepithelial vaginal tissue, because primary penetration of mucosal barriers by E vermicularis is not thought to occur. In retrospect, the clinician thought that the mass actually was in the posterior aspect of the vaginal wall and not in the lateral wall, where the usual bartholin gland cyst is found. The patient lives in rural south¬ western Pennsylvania where expo¬ sure to the parasite is frequent. However, no previous perianal dis¬ comfort was noted. Thus, usual meth¬ ods of diagnosis such as cellophane tape examination of the perianal region were not done at the time. Paul Snow, MD Garry Cartwright, PhD Memorial Hospital Cumberland, Md Ross Rumbaugh, MD
Meyersdale, Pa
Ijopez, MD, and staff at the Disease Control, Atlanta, reviewed the case. Carlos K.
Center for
Malpractice Suits To the Editor.\p=m-\After reading the letter of Mr Alan Y. Medvin (240:346, 1978), "I feel compelled to respond." Mr Medvin contends that many malpractice actions are settled before trial because they generally involve the clearest cases of malpractice. I strongly doubt this statement. There are many nuisance cases that are settled out of court because insurance carriers find that it is less expensive to do it that way. The merits of these cases are
may
Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/26/2015
ignored.
Harlan B. Moss. MD
Indianapolis
