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• W1604082421 abstract "To the Editor: Although research on side effects of medication focuses almost exclusively on the drug itself, the detrimental effects of medication packages also deserve attention. A 75-year-old woman was admitted to the emergency department of a large community hospital with progressive abdominal pain of 2 weeks duration. A computed tomography scan of the abdomen showed a unit-dose press-through medication package (PTP) with an intact tablet in the small bowel (Figure 1). On laparotomy, two corners of the package were seen protruding through the ileal wall. Enterotomy was performed to remove the foreign object. In the postoperative period, the patient quickly recovered. Contrast-enhanced multidetector computed tomography scan. Axial source image through the right fossa. In the terminal ileum, there is a dense linear structure with a central hump (long arrow). The appearance suggests the presence of a foreign object, which was found at surgery to represent a press-through package. The presence of free fluid, fatty infiltration, and free air (short arrow) indicate that there is a perforation of the bowel wall. Complications due to ingestion of PTPs are uncommon but not exceptional. In a systematic review of the literature from 1973 until 2004, more than 140 reported cases were found. Only 16 articles were published in major international peer-reviewed journals. Most articles were in Japanese, often without an English abstract. A few case reports were published in English-language journals in India and Singapore or in Dutch- or French-language journals of national or regional importance. The scarcity of case reports in the international literature presumably explains why the accidental ingestion of a PTP has been considered a rare event, hardly worth reporting. Although the available data do not permit a reliable estimation of the worldwide incidence, it may be quite high. From 1986 until 1993, 32 cases were registered in a single university hospital department in Japan.1 From March 1996 until April 2000, one study examined consecutive cases of sharp foreign object impacted in the esophagus in one hospital department; in eight instances (36%), the foreign object was a PTP.2 The incidence of complications due to the accidental ingestion of a PTP is not only underestimated, it also appears to be increasing. Goto's statistical analysis of 32 cases reports an apparent increase in the number of incidents between 1986 and 1993.1 Moreover, in 1997 one study found that, in Japan, the number of PTPs involved in cases of foreign objects in the digestive tract was increasing.3 Patients who are elderly, are mentally or visually impaired, or wear dentures, which facilitate the ingestion of foreign objects, run a higher risk of accidentally ingesting a PTP.4,5 The aging population, the rising number of patients taking more than one drug, and the increasing number of drugs dispensed in blister packages may all contribute to an increase in the incidence of these accidents, although other factors may be involved. Blister packs are usually composites of a sheet of plastic, mostly polyvinyl chloride (PVC), in which preformed domes each contain one tablet, covered by a single sheet of aluminum or waterproof paper. Some of the PVC–aluminum blister packages have perforations allowing a unit dose to be broken off easily. The patient or a caregiver often clips medication packages that are not preperforated into single PTPs. Upon careful examination of the 18 photographs of recovered identifiable PTPs in the literature, 16 clipped off were counted, versus two preperforated ones. PVC–aluminum blisters seem to constitute a particular hazard, because the PVC is rigid, and clipping results in razor-sharp edges and corners. The pharmaceutical industry should intensify its efforts to develop safe alternatives to the dangerous PVC–aluminum blister packs. In the meantime, the package insert should contain a warning against clipping off medication unit doses. In hospitals and nursing homes, procedures should be instituted to ensure that only fully unpacked medication is distributed to patients. Health authorities should take measures to assure that patients and caregivers are aware of the risk. More research should be performed to investigate fully the extent of the problem. Finally, medical researchers should not only consult scientific literature in English, but actively investigate literature in other languages. To facilitate this, authors who publish in other languages should be encouraged to always include an English abstract. The authors wish to thank Mrs. Noriko Miyazaki for her help with articles in Japanese and Walter Luyten, MD, PhD, for his advice and assistance in the preparation of this manuscript. Financial Disclosure: None. Author Contributions: Jan M. L. Bosmans participated in the writing of the article, did the literature research, participated in the translation and interpretation of referenced articles in English, Dutch, French, and Japanese, and in the general preparation of the article. Maarten J. Spinhoven participated in the clinical work, the writing of the article, and the preparation of the figures. Filip P. Deckers, Marc M. J. Pouillon, and Filip J. Vanden Borre participated in the clinical work, the preparation of figures and text, and the reviewing of the manuscript. Paul M. R. Parizel coordinated the preparation of the text and the figures, participated in the writing of the parts on medical imaging, preparation of the text, and review of the manuscript. Sponsor's Role: No sponsor was involved in the design, methods, subject recruitment, data collection, analysis, or preparation of this letter." @default.
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• W1604082421 date "2006-09-01" @default.
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• W1604082421 title "ACCIDENTAL INGESTION OF A PRESS-THROUGH PACKAGE: AN UNDERESTIMATED CAUSE OF SERIOUS IATROGENIC DISEASE IN THE ELDERLY?" @default.
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