Letters will be published as space permits and at the discretion of the editor. They should be typewritten double-spaced, with five or fewer references, should not exceed 500 words in length, and will be subject to editing. Letters are not acknowledged. For other details, see "Instructions for Authors. "
The Value of Microscopic Examination of Urinary Sediment To the Editor.\p=m-\Anarticle appeared in The Journal entitled "Microscopic Look at Urine Often Unnecessary" (239:13, 1978). This report indicated that a low diagnostic yield was seen on microscopic examination if findings from a macroscopic urinalysis were negative. On the contrary, I think that microscopic findings may be meaningful even where findings from macroscopic studies, including chemical screening tests, are negative. I found this to be true in 1967 when I reported a study of 10,140 specimens. To see whether the conclusions drawn then are still valid, earlier this year I had a new study done on microscopic specimens by a laboratory that serves a great number of insurance companies and analyzes as many urine specimens as any other laboratory in the world. The processing technique for urinalysis involves centrifuging the 15\x=req-\ ml specimen at 3,000 rpm in a standard clinical centrifuge for four minutes. Then, 0.05 ml of the original specimen is examined in a counting chamber by experienced personnel. The RBC and WBC counts are reported per high-power field after 20 to 40 high-power fields have been counted. In our current study of 13,479 specimens, the criterion for a positive specimen was any of the following: (1) albumin value of 10 mg/dl or greater, (2) glucose value of
g/dl or greater, or (3) microscopic specimen showing any casts, five or
0.1
RBCs, or ten or more WBCs. On this basis we found the follow¬ ing: (1) 13.4% of all specimens had more
positive microscopic findings, (2) 12% of those with negative chemistry findings were positive microscopical¬ ly, (3) 34.8% of those with positive chemistry findings were positive mi¬ croscopically, and (4) 54.6% of those with a positive test for albumin were positive microscopically. Edited
by John
D.
Archer, MD, Senior Editor.
A separate study was done on the relationship of the dipstick test to positive microscopic findings. Al¬ though at times the dipstick test result was positive in the absence of identifiable RBCs, it was usually negative with ten or less RBCs on microscopic examination. On occasion a specimen with as many as 30 RBCs was negative by the dipstick test. The positive dipstick test result in the absence of identifiable RBCs might represent free hemoglobin from lysed cells but could also be caused by peroxidase produced by certain types
of yeast. It is my conclusion that there is a great value in a study of the urinary sediment done by experienced per¬ sonnel. Although this phase of labo¬ ratory work cannot be automated, efficient flow-sheet planning allows this to be accurately done in high volume (in excess of 1,000 microscopic examinations per day) at low cost per
specimen (under $2).
Robert M. Donauer, MD The Prudential Insurance Company of America
Chicago
The Case of the
Foreign Body
Triangular
To the Editor.\p=m-\Attimes foreign bodies present diagnostic dilemmas. The following is a case of an unusual but distinctly shaped foreign body in the esophagus.
Report of a Case.\p=m-\A54-year-old nurse with a five-year history of ovarian cancer had been treated with radiotherapy and later with HEXACAF (a combination of methenamine, cyclophosphamide, methotrexate, and fluorouracil). She originally responded to HEXACAF, but because of progressive disease, her therapy was switched to cis-diamminedichloroplatinum II on an every three-week schedule. During her admission on July 6, 1977, she had a routine chest roentgenogram that demonstrated what appeared to be a foreign body in the midesophageal region (Fig 1). The object was radiodense, with a rather distinctive triangular shape. The patient denied any history of dysphagia or dyspnea and in the last 12 hours had
Fig 1.—Admission chest roentgenogram with foreign body in esophagus.
Fig 2.—Pepto-Bismol tablet.
only one tablet of Pepto-Bismol (subsalicylate bismuth, phenyl salicylate, and phenolsulfonate zinc), which she felt helped her gastrointestinal distress from the platinum chemotherapy. With this additional history it was apparent that swallowed
what was present on the chest film was indeed a triangular tablet of Pepto-Bismol
(Fig 2).
Since the patient was asymptomatic from the foreign body, it was elected to proceed with the administration of cisplatin, a potent emetic as well as an effective cancer chemotherapeutic agent.' The pa¬ tient vomited up the Pepto-Bismol tablet two hours after platinum administration. Repeated chest roentgenogram showed that the foreign body had disappeared. The possibility of an esophageal diverticulum was entertained because of her history of PPD conversion. However, barium swallow was entirely within nor¬ mal limits.
Comment—There
are a
number of
reports of unusual foreign bodies
noted in the esophagus.23 The particu¬ lar foreign body noted in our case is of interest because of its distinctive shape as well as its roentgenographic density. Pepto-Bismol tablets contain subsalicylate bismuth, which ac¬ counts for its radiodensity. When a patient has a triangu¬ lar radiodense foreign body in the esophagus, one should entertain the
Downloaded From: http://jama.jamanetwork.com/ by a Southern Illinois University - Carbondale User on 06/06/2015
possibility of it being a Pepto-Bismol Daniel D. Von Hoff, MD N. Reed Dunnick, MD National Institutes of Health Bethesda, Md
Rozencweig M, Von Hoff DD, Slavik M, et al: Cisdiamminedichloroplatinum (DDP), a new anti-cancer agent with activity in testicular cancer. Ann Intern Med 1.
86:803-812, 1977.
2. Benedict FB: An extraordinary foreign body in the esophagus. N Engl J Med 269:146-147,1963. 3. Barbary AS, Badrawy R: Foreign bodies in the oesophagus: A record of 500 cases. J Egypt Med Assoc
51:325-336,1968.
Left-Coronary-Artery to Left\x=req-\
Ventricle Fistula
To the Editor.\p=m-\Weread with interest the report on a fistula originating from the left anterior descending coronary artery and terminating in the left ventricle by Housman and associates (240:372,1978). We recently reported a similar case in which the fistula was surgically closed and presented a movie of the same at the American Heart Association meeting in Anaheim, Calif, on Nov 17, 1975.1 Our patient's fistula involved the main left anterior descending coronary artery and not a diagonal or contributing branch. Consequently, the authors' statement, "to our knowledge, no reported case of left. to left-ventricle coronary-artery fistula exists in the English literature," is an incongruity. We congratulate the authors on their report but must point out that a more thorough perusal of the recent surgical literature would have discovered our recent contribution to the understanding of this interesting anomaly. .
.
...
Allen I. Midell, MD Gustavo A. Bermudez, MD Columbus Hospital
Chicago 1. Midell
AI, Bermudez GA, Replogle R: Surgical closure of left coronary artery\p=m-\leftventricular fistula: The second case reported in the literature and a review of five previously reported cases of coronary artery fistula terminating in the left ventricle. J Thorac Cardiovasc Surg 74:199-203,1977.
See also Palmer ED: "Who Was First?"
(JAMA
239:
1609, 1978).-Ed.
Inhibition by Raw Eggs of Vitamin B12 Absorption
To the Editor.\p=m-\Radiocyanocobalamin (57Co-B12), mixed separately in vitro
with ovalbumin and egg yolks, cooked and served to normal volunteers, was poorly absorbed as compared with a dose of crystalline 57Co-B12.1 This finding led to the conclusion that ovalbumin and egg yolk inhibit the gastroin-
Study
Results of
tablet.
Endogenous Vitamin B„, ng
Vehicle
Ovalbumin (2 egg whites) Egg yolk (2 egg Water
0.10
Radioactivity, % Uriné Stool
Crystalline
"Co-B12,-
ng
0.56
87.1
0.7
yolks)_092_056_93J3_2.4
'Containing
0.5
0.56
0.0
radiocyanocobalamin. The present study eliminated this inconsistency of design by comparing the gastrointestinal absorption of
noncooked radioactive vitamin B12 administered in a watery solution with that of a similar dose incorporated into raw egg yolks and ovalbu-
(Table). Crystalline 57Co-B12 raw yolks of two eggs was ingested by a normal volunteer. The test was repeated two weeks later
effect of eggs on vitamin B,2 absorp¬ tion. The reason for this effect is not clear. Eggs are known to inhibit the assimilation of such substances as iron3,4 and biotin.5 To this list vitamin B12 should be added. The specific factor responsible for the inhibition of biotin absorption is avidin, a wellcharacterized biotin-binding sub¬ stance. The factor or factors respon¬ sible for the inhibition of iron and vitamin B12 absorption have not been defined.
min
Alfred Doscherholmen, MD Veterans Administration Hospital
mixed with the raw
ovalbumin from two eggs.
Absorption was studied by the fecal and urinary excretion methods.2 The results, compared with the absorption from the crystalline radioactive vita¬ min
21.0
¡xC\ radioactivity.
testinal assimilation of vitamin B12. The validity of this conclusion may be open to question, since it was based on a comparison between the absorption of cooked radioactive vitamin B12 in the eggs and noncooked crystalline
with
25.9
B12 alone, showed
an
almost
complete inhibition of the urinary radioactivity excretion when "Co-B,2 was given with the eggs. The stool excretion tests confirmed these re¬ sults. This study proves the inhibitory
Chromium Supplementation and Diabetes
Minneapolis
1. Doscherholmen A, McMahon J, Ripley D: Inhibitory effect of eggs on vitamin B12 absorption: Description of a simple ovalbumin 57Co-vitamin B12 absorption test. Br J
Haemotol 33:261-272,1976. 2. Doscherholmen A, Swaim WR: Impaired assimilation of egg Co57 vitamin B12 in patients with hypochlorhydria and achlorhydria and after gastric resection.
Gastroenterology 64:913-919,
1975.
mg/dl) were given chromium (1 mg/day as Cr Cl3) for six days. Previ-
378
reports have discussed the effect of chromium only on glucose tolerance, which in the present experiment showed no trends (1/2, one, and two hours). However, the fasting blood glucose level rose significantly (P
The Value of Microscopic Examination of Urinary Sediment To the Editor.\p=m-\Anarticle appeared in The Journal entitled "Microscopic Look at Urine Often Unnecessary" (239:13, 1978). This report indicated that a low diagnostic yield was seen on microscopic examination if findings from a macroscopic urinalysis were negative. On the contrary, I think that microscopic findings may be meaningful even where findings from macroscopic studies, including chemical screening tests, are negative. I found this to be true in 1967 when I reported a study of 10,140 specimens. To see whether the conclusions drawn then are still valid, earlier this year I had a new study done on microscopic specimens by a laboratory that serves a great number of insurance companies and analyzes as many urine specimens as any other laboratory in the world. The processing technique for urinalysis involves centrifuging the 15\x=req-\ ml specimen at 3,000 rpm in a standard clinical centrifuge for four minutes. Then, 0.05 ml of the original specimen is examined in a counting chamber by experienced personnel. The RBC and WBC counts are reported per high-power field after 20 to 40 high-power fields have been counted. In our current study of 13,479 specimens, the criterion for a positive specimen was any of the following: (1) albumin value of 10 mg/dl or greater, (2) glucose value of
g/dl or greater, or (3) microscopic specimen showing any casts, five or
0.1
RBCs, or ten or more WBCs. On this basis we found the follow¬ ing: (1) 13.4% of all specimens had more
positive microscopic findings, (2) 12% of those with negative chemistry findings were positive microscopical¬ ly, (3) 34.8% of those with positive chemistry findings were positive mi¬ croscopically, and (4) 54.6% of those with a positive test for albumin were positive microscopically. Edited
by John
D.
Archer, MD, Senior Editor.
A separate study was done on the relationship of the dipstick test to positive microscopic findings. Al¬ though at times the dipstick test result was positive in the absence of identifiable RBCs, it was usually negative with ten or less RBCs on microscopic examination. On occasion a specimen with as many as 30 RBCs was negative by the dipstick test. The positive dipstick test result in the absence of identifiable RBCs might represent free hemoglobin from lysed cells but could also be caused by peroxidase produced by certain types
of yeast. It is my conclusion that there is a great value in a study of the urinary sediment done by experienced per¬ sonnel. Although this phase of labo¬ ratory work cannot be automated, efficient flow-sheet planning allows this to be accurately done in high volume (in excess of 1,000 microscopic examinations per day) at low cost per
specimen (under $2).
Robert M. Donauer, MD The Prudential Insurance Company of America
Chicago
The Case of the
Foreign Body
Triangular
To the Editor.\p=m-\Attimes foreign bodies present diagnostic dilemmas. The following is a case of an unusual but distinctly shaped foreign body in the esophagus.
Report of a Case.\p=m-\A54-year-old nurse with a five-year history of ovarian cancer had been treated with radiotherapy and later with HEXACAF (a combination of methenamine, cyclophosphamide, methotrexate, and fluorouracil). She originally responded to HEXACAF, but because of progressive disease, her therapy was switched to cis-diamminedichloroplatinum II on an every three-week schedule. During her admission on July 6, 1977, she had a routine chest roentgenogram that demonstrated what appeared to be a foreign body in the midesophageal region (Fig 1). The object was radiodense, with a rather distinctive triangular shape. The patient denied any history of dysphagia or dyspnea and in the last 12 hours had
Fig 1.—Admission chest roentgenogram with foreign body in esophagus.
Fig 2.—Pepto-Bismol tablet.
only one tablet of Pepto-Bismol (subsalicylate bismuth, phenyl salicylate, and phenolsulfonate zinc), which she felt helped her gastrointestinal distress from the platinum chemotherapy. With this additional history it was apparent that swallowed
what was present on the chest film was indeed a triangular tablet of Pepto-Bismol
(Fig 2).
Since the patient was asymptomatic from the foreign body, it was elected to proceed with the administration of cisplatin, a potent emetic as well as an effective cancer chemotherapeutic agent.' The pa¬ tient vomited up the Pepto-Bismol tablet two hours after platinum administration. Repeated chest roentgenogram showed that the foreign body had disappeared. The possibility of an esophageal diverticulum was entertained because of her history of PPD conversion. However, barium swallow was entirely within nor¬ mal limits.
Comment—There
are a
number of
reports of unusual foreign bodies
noted in the esophagus.23 The particu¬ lar foreign body noted in our case is of interest because of its distinctive shape as well as its roentgenographic density. Pepto-Bismol tablets contain subsalicylate bismuth, which ac¬ counts for its radiodensity. When a patient has a triangu¬ lar radiodense foreign body in the esophagus, one should entertain the
Downloaded From: http://jama.jamanetwork.com/ by a Southern Illinois University - Carbondale User on 06/06/2015
possibility of it being a Pepto-Bismol Daniel D. Von Hoff, MD N. Reed Dunnick, MD National Institutes of Health Bethesda, Md
Rozencweig M, Von Hoff DD, Slavik M, et al: Cisdiamminedichloroplatinum (DDP), a new anti-cancer agent with activity in testicular cancer. Ann Intern Med 1.
86:803-812, 1977.
2. Benedict FB: An extraordinary foreign body in the esophagus. N Engl J Med 269:146-147,1963. 3. Barbary AS, Badrawy R: Foreign bodies in the oesophagus: A record of 500 cases. J Egypt Med Assoc
51:325-336,1968.
Left-Coronary-Artery to Left\x=req-\
Ventricle Fistula
To the Editor.\p=m-\Weread with interest the report on a fistula originating from the left anterior descending coronary artery and terminating in the left ventricle by Housman and associates (240:372,1978). We recently reported a similar case in which the fistula was surgically closed and presented a movie of the same at the American Heart Association meeting in Anaheim, Calif, on Nov 17, 1975.1 Our patient's fistula involved the main left anterior descending coronary artery and not a diagonal or contributing branch. Consequently, the authors' statement, "to our knowledge, no reported case of left. to left-ventricle coronary-artery fistula exists in the English literature," is an incongruity. We congratulate the authors on their report but must point out that a more thorough perusal of the recent surgical literature would have discovered our recent contribution to the understanding of this interesting anomaly. .
.
...
Allen I. Midell, MD Gustavo A. Bermudez, MD Columbus Hospital
Chicago 1. Midell
AI, Bermudez GA, Replogle R: Surgical closure of left coronary artery\p=m-\leftventricular fistula: The second case reported in the literature and a review of five previously reported cases of coronary artery fistula terminating in the left ventricle. J Thorac Cardiovasc Surg 74:199-203,1977.
See also Palmer ED: "Who Was First?"
(JAMA
239:
1609, 1978).-Ed.
Inhibition by Raw Eggs of Vitamin B12 Absorption
To the Editor.\p=m-\Radiocyanocobalamin (57Co-B12), mixed separately in vitro
with ovalbumin and egg yolks, cooked and served to normal volunteers, was poorly absorbed as compared with a dose of crystalline 57Co-B12.1 This finding led to the conclusion that ovalbumin and egg yolk inhibit the gastroin-
Study
Results of
tablet.
Endogenous Vitamin B„, ng
Vehicle
Ovalbumin (2 egg whites) Egg yolk (2 egg Water
0.10
Radioactivity, % Uriné Stool
Crystalline
"Co-B12,-
ng
0.56
87.1
0.7
yolks)_092_056_93J3_2.4
'Containing
0.5
0.56
0.0
radiocyanocobalamin. The present study eliminated this inconsistency of design by comparing the gastrointestinal absorption of
noncooked radioactive vitamin B12 administered in a watery solution with that of a similar dose incorporated into raw egg yolks and ovalbu-
(Table). Crystalline 57Co-B12 raw yolks of two eggs was ingested by a normal volunteer. The test was repeated two weeks later
effect of eggs on vitamin B,2 absorp¬ tion. The reason for this effect is not clear. Eggs are known to inhibit the assimilation of such substances as iron3,4 and biotin.5 To this list vitamin B12 should be added. The specific factor responsible for the inhibition of biotin absorption is avidin, a wellcharacterized biotin-binding sub¬ stance. The factor or factors respon¬ sible for the inhibition of iron and vitamin B12 absorption have not been defined.
min
Alfred Doscherholmen, MD Veterans Administration Hospital
mixed with the raw
ovalbumin from two eggs.
Absorption was studied by the fecal and urinary excretion methods.2 The results, compared with the absorption from the crystalline radioactive vita¬ min
21.0
¡xC\ radioactivity.
testinal assimilation of vitamin B12. The validity of this conclusion may be open to question, since it was based on a comparison between the absorption of cooked radioactive vitamin B12 in the eggs and noncooked crystalline
with
25.9
B12 alone, showed
an
almost
complete inhibition of the urinary radioactivity excretion when "Co-B,2 was given with the eggs. The stool excretion tests confirmed these re¬ sults. This study proves the inhibitory
Chromium Supplementation and Diabetes
Minneapolis
1. Doscherholmen A, McMahon J, Ripley D: Inhibitory effect of eggs on vitamin B12 absorption: Description of a simple ovalbumin 57Co-vitamin B12 absorption test. Br J
Haemotol 33:261-272,1976. 2. Doscherholmen A, Swaim WR: Impaired assimilation of egg Co57 vitamin B12 in patients with hypochlorhydria and achlorhydria and after gastric resection.
Gastroenterology 64:913-919,
1975.
mg/dl) were given chromium (1 mg/day as Cr Cl3) for six days. Previ-
378
reports have discussed the effect of chromium only on glucose tolerance, which in the present experiment showed no trends (1/2, one, and two hours). However, the fasting blood glucose level rose significantly (P
