- Email: [email protected]
Sternal Hump: In Response
LETTERS TO THE EDITOR
want to correct an important error in their article. They used the terms synephrine and phenylephrine equivalently. Although both compounds have the chemical formula C9H13NO2, in phenylephrine the hydroxyl group is located on the No. 3 carbon of the benzene ring, whereas in synephrine the hydroxyl group is located on the No. 4 carbon.2 This small difference produces important changes in the stereochemistry that might alter the biological activity of these 2 compounds. Therefore, they should not be used as equivalents. We believe that this confusion is influenced by the naming of the proprietary form of phenylephrine, which is sold as Neo-Synephrine. Nicole Bouchard, MD Robert S. Hoffman, MD New York City Poison Control Center New York, NY 1. Nasir JM, Durning SJ, Ferguson M, Barold HS, Haigney MC. Exerciseinduced syncope associated with QT prolongation and ephedra-free Xenadrine. Mayo Clin Proc. 2004;79:1059-1062. 2. The Merck Index: An Encyclopedia of Chemicals, Drugs, and Biologicals. 13th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2001.
In reply: We thank Drs Bouchard and Hoffman for drawing attention to the confusing (at least to us) nomenclature regarding sympathomimetic compounds. They suggest that we have conflated the names for chemically distinct compounds by identifying synephrine as phenylephrine. While we humbly yield to their expertise in organic chemistry, we point out that we followed the practice of other authors such as Penzak et al1 who identified the contents of Citrus aurantium by high-performance liquid chromatography. These authors equated msynephrine with phenylephrine and referred to m-synephrine, synephrine, and phenylephrine as components of C aurantium. Mark Haigney, MD Uniformed Services University of the Health Sciences Bethesda, Md 1. Penzak SR, Jann MW, Cold JA, Hon YY, Desai HD, Gurley BJ. Seville (sour) orange juice: synephrine content and cardiovascular effects in normotensive adults. J Clin Pharmacol. 2001;41:1059-1063.
Comment from the Editor-in-Chief: The dietary supplement Xenadrine EFX is derived primarily from plant materials.1 The original formulation of Xenadrine EFX contained extracts of Citrus aurantium (ie, bitter orange), a natural source of the sympathomimetic compound synephrine, and indeed the original formulation of Xenadrine EFX contained synephrine, 3 mg per capsule. Xenadrine EFX has since been reformulated to omit C aurantium. Although Mayo Clinic Proceedings is not prepared to comment on all sympathomimetics that are (or are not) present in the original and revised preparations, the manufacturer has informed the journal that chemical testing of their product by ChromaDex, Inc (Santa Ana, Calif), determined that Xenadrine EFX has never contained phenylephrine (ie, Neo-Synephrine) (S. H. Freedman, representing 1590
Mayo Clin Proc.
•
Nutraquest, Inc, written communication, September 29, 2004, and November 2, 2004). Hopefully, this exchange of letters, and the accompanying erratum statement published on page 1591 of the current issue, will clarify any misconceptions concerning phenylephrine content within Xenadrine EFX. 1. Nasir JM, Durning SJ, Ferguson M, Barold HS, Haigney MC. Exerciseinduced syncope associated with QT prolongation and ephedra-free Xenadrine. Mayo Clin Proc. 2004;79:1059-1062.
Sternal Hump To the Editor: The text that accompanied the medical image called “Sternal Hump”1 reminded me of a story that was current at the Boston City Hospital when I was an intern there in 1950. Dr Soma Weiss was making rounds in his ward with the house staff one morning and presented a patient with a prominent sternal hump. He explained to the staff that, although this swelling resembled an abscess, simple palpation would reveal a strong pulsation. The swelling was in fact the leading surface of a syphilitic aortic aneurysm that had eroded the sternum. Thoughtless incision of such an “abscess,” Dr Weiss warned, would result in rapid exsanguination and death of the patient. The house staff palpated the swelling gently and took the lesson to heart. That night, the medical intern on call noted that one of his patients had an untreated abscess over the sternum. He called in the night surgical intern who examined the patient and agreed that incision and drainage were in order. The surgical intern made an incision, drained the pus, inserted a wick, and covered the area with loose dressing. The next morning, Dr Weiss and his retinue were astounded to find the sternal bulge cut open and much smaller, as well as a more comfortable patient. One moral of the story was that luetic aneurysms that erode through the sternum produce an area of necrotic tissue between their advancing edge and the overlying skin. Another was that palpation should precede incision. Although the latter did not occur, the surgeon’s hand was under lucky guidance because had his blade gone a bit deeper, Dr Weiss’s prophecy would have come true. Perhaps apocryphal, this was one of many stories making the rounds in those days about the late great Soma Weiss. Luis Fernandez-Herlihy, MD West Newton, Mass 1. Sopeña B, Nodar A. Sternal hump. Mayo Clin Proc. 2004;79:1168.
In reply: The clinical case described by Dr Fernandez-Herlihy shows the risk and difficulty of treating certain diseases before the era of computed tomography. This experience outlines how important a detailed physical exploration is when caring for patients. Also, his report reminds us that other diseases (Table 1) besides Hodgkin lymphoma must be included in the differential diagnosis of a sternal mass.1,2 Indeed, some of
December 2004;79(12):1585-1591
•
www.mayo.edu/proceedings
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
LETTERS TO THE EDITOR
TABLE 1. Causes of Sternal Masses1,2 Infectious Pyogenic osteomyelitis Tuberculosis Actinomycosis Syphilis Neoplasms Primary (enchondroma, osteochondroma, giant cell tumor, plasmacytoma, neurofibroma, hemangioma, osteogenic sarcoma, Ewing sarcoma) Metastatic disease (breast, lung, kidney, thyroid) Direct invasion from tumor (lymphoma, squamous carcinoma, bronchogenic carcinoma, thyroid) Lymphoma Other Paget disease Eosinophilic granuloma Aortic aneurysm
these entities can coexist in the same patient as Dr FernandezHerlihy correctly points out. Bernardo Sopeña, MD Andrés Nodar, MD Complejo Hospitalario Xeral-Cíes Vigo, Spain 1. Poulton TB, O’Donovan PB. Sternal mass. Chest. 1994;106:575-576. 2. Hall RA, Spiegel DA, Dormans JP, Meyer JS, Finn LS. Sternal mass in an 11-year-old boy. Clin Orthop. 1998;353:256-262.
CORRECTIONS
Incorrect use of term: In the article by Nasir et al entitled “Exercise-Induced Syncope Associated With QT Prolongation and Ephedra-Free Xenadrine,” published in the August 2004 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2004;79:1059-1062), the authors used the terms synephrine and phenylephrine (ie, 2 distinct sympathomimetic compounds) interchangeably when discussing the content of the dietary supplement Xenadrine EFX. Although early formulations of Xenadrine EFX contained known quantities of synephrine, Xenadrine EFX has never contained phenylephrine. Hence, any references to phenylephrine as a component of Xenadrine EFX are erroneous and should be disregarded. Additionally, the article contained 2 spellings of the dietary supplement, of which only “Xenadrine EFX” is correct. Incorrect phrase: The reply from Younge et al to the letter to the editor entitled “Calculating Likelihood Ratios in Patients With Giant Cell Arteritis” that was published in the October 2004 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2004; 79:1341) contained an incorrect phrase. The sentence beginning on the fourth line from the top of the right-hand column should read, “In the method we used, positive LRs are calculated as true positives divided by false positives, and negative LRs are calculated as true negatives divided by false negatives.”
The Editor welcomes letters and comments, particularly pertaining to recently published articles in Mayo Clinic Proceedings, as well as letters reporting original observations and research. Letters pertaining to a recently published Proceedings article should be received no later than 1 month after the article’s publication. A letter should be no longer than 500 words, contain no more than 5 references and 1 table or figure, be signed by no more than 3 authors, be in double-spaced, typewritten format, and not be published or submitted elsewhere. The letter must be signed and include the correspondent’s full address, telephone and fax numbers, and e-mail address (if available). It is assumed that appropriate letters will be published, at the Editor’s discretion, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with Proceedings style and to abridge them if necessary. Letters may be submitted by surface mail to Letters to the Editor, Mayo Clinic Proceedings, Room 770 Siebens Building, Rochester, MN 55905; by fax to (507) 284-0252; or by e-mail to [email protected]. (Note: Authors who submit letters by fax or e-mail must also send a copy by surface mail.)
Mayo Clin Proc.
•
December 2004;79(12):1585-1591
•
www.mayo.edu/proceedings
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1591
want to correct an important error in their article. They used the terms synephrine and phenylephrine equivalently. Although both compounds have the chemical formula C9H13NO2, in phenylephrine the hydroxyl group is located on the No. 3 carbon of the benzene ring, whereas in synephrine the hydroxyl group is located on the No. 4 carbon.2 This small difference produces important changes in the stereochemistry that might alter the biological activity of these 2 compounds. Therefore, they should not be used as equivalents. We believe that this confusion is influenced by the naming of the proprietary form of phenylephrine, which is sold as Neo-Synephrine. Nicole Bouchard, MD Robert S. Hoffman, MD New York City Poison Control Center New York, NY 1. Nasir JM, Durning SJ, Ferguson M, Barold HS, Haigney MC. Exerciseinduced syncope associated with QT prolongation and ephedra-free Xenadrine. Mayo Clin Proc. 2004;79:1059-1062. 2. The Merck Index: An Encyclopedia of Chemicals, Drugs, and Biologicals. 13th ed. Whitehouse Station, NJ: Merck Research Laboratories; 2001.
In reply: We thank Drs Bouchard and Hoffman for drawing attention to the confusing (at least to us) nomenclature regarding sympathomimetic compounds. They suggest that we have conflated the names for chemically distinct compounds by identifying synephrine as phenylephrine. While we humbly yield to their expertise in organic chemistry, we point out that we followed the practice of other authors such as Penzak et al1 who identified the contents of Citrus aurantium by high-performance liquid chromatography. These authors equated msynephrine with phenylephrine and referred to m-synephrine, synephrine, and phenylephrine as components of C aurantium. Mark Haigney, MD Uniformed Services University of the Health Sciences Bethesda, Md 1. Penzak SR, Jann MW, Cold JA, Hon YY, Desai HD, Gurley BJ. Seville (sour) orange juice: synephrine content and cardiovascular effects in normotensive adults. J Clin Pharmacol. 2001;41:1059-1063.
Comment from the Editor-in-Chief: The dietary supplement Xenadrine EFX is derived primarily from plant materials.1 The original formulation of Xenadrine EFX contained extracts of Citrus aurantium (ie, bitter orange), a natural source of the sympathomimetic compound synephrine, and indeed the original formulation of Xenadrine EFX contained synephrine, 3 mg per capsule. Xenadrine EFX has since been reformulated to omit C aurantium. Although Mayo Clinic Proceedings is not prepared to comment on all sympathomimetics that are (or are not) present in the original and revised preparations, the manufacturer has informed the journal that chemical testing of their product by ChromaDex, Inc (Santa Ana, Calif), determined that Xenadrine EFX has never contained phenylephrine (ie, Neo-Synephrine) (S. H. Freedman, representing 1590
Mayo Clin Proc.
•
Nutraquest, Inc, written communication, September 29, 2004, and November 2, 2004). Hopefully, this exchange of letters, and the accompanying erratum statement published on page 1591 of the current issue, will clarify any misconceptions concerning phenylephrine content within Xenadrine EFX. 1. Nasir JM, Durning SJ, Ferguson M, Barold HS, Haigney MC. Exerciseinduced syncope associated with QT prolongation and ephedra-free Xenadrine. Mayo Clin Proc. 2004;79:1059-1062.
Sternal Hump To the Editor: The text that accompanied the medical image called “Sternal Hump”1 reminded me of a story that was current at the Boston City Hospital when I was an intern there in 1950. Dr Soma Weiss was making rounds in his ward with the house staff one morning and presented a patient with a prominent sternal hump. He explained to the staff that, although this swelling resembled an abscess, simple palpation would reveal a strong pulsation. The swelling was in fact the leading surface of a syphilitic aortic aneurysm that had eroded the sternum. Thoughtless incision of such an “abscess,” Dr Weiss warned, would result in rapid exsanguination and death of the patient. The house staff palpated the swelling gently and took the lesson to heart. That night, the medical intern on call noted that one of his patients had an untreated abscess over the sternum. He called in the night surgical intern who examined the patient and agreed that incision and drainage were in order. The surgical intern made an incision, drained the pus, inserted a wick, and covered the area with loose dressing. The next morning, Dr Weiss and his retinue were astounded to find the sternal bulge cut open and much smaller, as well as a more comfortable patient. One moral of the story was that luetic aneurysms that erode through the sternum produce an area of necrotic tissue between their advancing edge and the overlying skin. Another was that palpation should precede incision. Although the latter did not occur, the surgeon’s hand was under lucky guidance because had his blade gone a bit deeper, Dr Weiss’s prophecy would have come true. Perhaps apocryphal, this was one of many stories making the rounds in those days about the late great Soma Weiss. Luis Fernandez-Herlihy, MD West Newton, Mass 1. Sopeña B, Nodar A. Sternal hump. Mayo Clin Proc. 2004;79:1168.
In reply: The clinical case described by Dr Fernandez-Herlihy shows the risk and difficulty of treating certain diseases before the era of computed tomography. This experience outlines how important a detailed physical exploration is when caring for patients. Also, his report reminds us that other diseases (Table 1) besides Hodgkin lymphoma must be included in the differential diagnosis of a sternal mass.1,2 Indeed, some of
December 2004;79(12):1585-1591
•
www.mayo.edu/proceedings
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
LETTERS TO THE EDITOR
TABLE 1. Causes of Sternal Masses1,2 Infectious Pyogenic osteomyelitis Tuberculosis Actinomycosis Syphilis Neoplasms Primary (enchondroma, osteochondroma, giant cell tumor, plasmacytoma, neurofibroma, hemangioma, osteogenic sarcoma, Ewing sarcoma) Metastatic disease (breast, lung, kidney, thyroid) Direct invasion from tumor (lymphoma, squamous carcinoma, bronchogenic carcinoma, thyroid) Lymphoma Other Paget disease Eosinophilic granuloma Aortic aneurysm
these entities can coexist in the same patient as Dr FernandezHerlihy correctly points out. Bernardo Sopeña, MD Andrés Nodar, MD Complejo Hospitalario Xeral-Cíes Vigo, Spain 1. Poulton TB, O’Donovan PB. Sternal mass. Chest. 1994;106:575-576. 2. Hall RA, Spiegel DA, Dormans JP, Meyer JS, Finn LS. Sternal mass in an 11-year-old boy. Clin Orthop. 1998;353:256-262.
CORRECTIONS
Incorrect use of term: In the article by Nasir et al entitled “Exercise-Induced Syncope Associated With QT Prolongation and Ephedra-Free Xenadrine,” published in the August 2004 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2004;79:1059-1062), the authors used the terms synephrine and phenylephrine (ie, 2 distinct sympathomimetic compounds) interchangeably when discussing the content of the dietary supplement Xenadrine EFX. Although early formulations of Xenadrine EFX contained known quantities of synephrine, Xenadrine EFX has never contained phenylephrine. Hence, any references to phenylephrine as a component of Xenadrine EFX are erroneous and should be disregarded. Additionally, the article contained 2 spellings of the dietary supplement, of which only “Xenadrine EFX” is correct. Incorrect phrase: The reply from Younge et al to the letter to the editor entitled “Calculating Likelihood Ratios in Patients With Giant Cell Arteritis” that was published in the October 2004 issue of Mayo Clinic Proceedings (Mayo Clin Proc. 2004; 79:1341) contained an incorrect phrase. The sentence beginning on the fourth line from the top of the right-hand column should read, “In the method we used, positive LRs are calculated as true positives divided by false positives, and negative LRs are calculated as true negatives divided by false negatives.”
The Editor welcomes letters and comments, particularly pertaining to recently published articles in Mayo Clinic Proceedings, as well as letters reporting original observations and research. Letters pertaining to a recently published Proceedings article should be received no later than 1 month after the article’s publication. A letter should be no longer than 500 words, contain no more than 5 references and 1 table or figure, be signed by no more than 3 authors, be in double-spaced, typewritten format, and not be published or submitted elsewhere. The letter must be signed and include the correspondent’s full address, telephone and fax numbers, and e-mail address (if available). It is assumed that appropriate letters will be published, at the Editor’s discretion, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with Proceedings style and to abridge them if necessary. Letters may be submitted by surface mail to Letters to the Editor, Mayo Clinic Proceedings, Room 770 Siebens Building, Rochester, MN 55905; by fax to (507) 284-0252; or by e-mail to [email protected]. (Note: Authors who submit letters by fax or e-mail must also send a copy by surface mail.)
Mayo Clin Proc.
•
December 2004;79(12):1585-1591
•
www.mayo.edu/proceedings
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
1591