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 An assignment of copyright is essential for publication (see "Instructions for Authors ").
Blue Plans and Medical
Necessity To the Editor.\p=m-\The "Blue Plans Medical Necessity Program" (241: 2607, 1979) is made mandatory not just by fiscal restraints, but also by the daily problems that arrive at the offices of the intermediaries for Medicare as well as the Blue Plans. I have just retired as medical consultant to Travelers, Railroad Retirement, part B Medicare, covering nine upper Midwest states, with offices in Lansing, Ill. We were fortunate in having two superb nurses who made initial decisions of problems brought to them, with those too inexplicable referred for a medical decision. Following are a few examples that usually necessitated a telephone call to a physician even after receiving the requested operative report or progress notations on the hospital record: (1) Sometimes the diagnosis sent in was not related to examinations and tests; this was almost always due to the physician's failure to verify what his office had sent in. (2) Questioning of the daily hospital visits of a family physician or internist to his patient even though
primary management was surgery disclosed neither billing nor recorded hospital visits after the operation by the surgeon. (3) Occasionally, fees that were "not accepted assignments" required adjudication: $5,200 for noncomplicated removal of a small cyst from each of two pulmonary lobes; $2,200 for special glasses that did not provide additional vision; $1,200 for removal of two bunions; $5,400 for oral surgery required to fit "false teeth"; and billings for daily psycho¬ therapy sessions of three to 120 days for elderly persons with the diagnosis of senility with depression. There was Edited by John D. Archer, MD, Senior Editor.
bill for therapy consisting primarily of vitamins and coffee enemas, both disapproved and re¬ ported to the State Medical So¬ ciety. One routine approved by local Blue Plans is that pathologists receive a fee for "reviewing" laboratory re¬ ports. Does the patient's physician need the checkmarks indicating that even one
certain results on the report he received are out of the printed normal range? On the other hand, why were 25 to 30 different tests required once or twice a day, two to three times a week during an extensive hospital stay for final diagnoses such as ane¬ mia, malnutrition, diabetes, and ar¬ thritis in elderly persons? There was a bright side. Informa¬ tion supplied occasionally permitted substantial increases in units desig¬ nated by Medicare, utilizing the judg¬ ment of both the medical consultant
and especially physicians in all spe¬ cialties. That the great majority of
physicians provide quality medical care for fees that are reasonable, along with some examples of the aberrations listed here, must be made known to both the professionals and their students. It is a unique opportu¬ nity to study the spectrum of health
it actually is now. Our patients are also beginning to look over our shoulders. It is not just money. The question that is being widely written about, "ethics," must not be separated from the practical question of status and reasons that underlie what we label "medical judg¬ ment." In my years as a physician, I have been witness to the expanding miracles of accomplishing so much for so many. In contradistinction to years ago when all disease had an accompanying threat of death, now illness is supposed to be either preventable or curable. And no miscare as
takes, Doctor! Therefore,
to
repeat
the admonitions of our peers, it is for all of us the rigors of discipline and disciplining, or the rigidity of dicta¬ tion. Abraham Gelperin,
MD
Bay St Louis, Miss
Hazards of Dietary Supplements To the Editor.\p=m-\Recentlyone of us had occasion to embark on a protein\x=req-\ supplemented fast. While on the way to a noon meeting that promised to be particularly dull, and while suffering moderate hunger, this person purchased a package of 12 mints advertised as being sugar-free. Paying no attention to the label, he proceeded to consume all of the 12 mints during the two-hour meeting. Thirty minutes after the last mint was consumed, he began to experience marked abdominal
distention, passed extremely large flatus, and experienced
amounts of
abdominal cramping. This was followed shortly by the development of profuse, watery diarrhea that persisted for the next 30 minutes and amounted to an estimated 1 to 1.5 L of fluid. Five hours after consuming the mints, the subject ate his evening meal, which consisted of 180 g (6 oz) of steak, and noted persistent vague abdominal distress with considerable flatus. Thirty minutes after eating, he noticed the onset of severe epigastric pain of a constant sharp nature radiating straight through to the back. This pain persisted for the next four hours, was associated with diaphoresis, light-headedness, and transient hypotension (blood pres¬ sure, 80/40 mm Hg), which necessi¬ tated admission to a hospital. Physical examination demon¬ strated moderate tenderness in the epigastrium without guarding or
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rebound and mild dehydration. Sur¬ gical consultation was obtained to evaluate the possibility of posterior perforation of peptic ulcer. With conservative therapy consisting of intravenous feedings and observation, the pain resolved in the next 24 hours and did not recur. It was at this point that the mint package was inspected; it was found that the sucrose substitute in this product is sorbitol. The effects of sorbitol in producing osmotically in¬ duced diarrhea are well known and seem to explain many of the symp¬ toms present in this circumstance. While it is unlikely that many physicians might come in contact with patients who consumed an entire package at one sitting (aside from children or others with poor impulse control) it is likely that less extensive but still significant symptoms might be produced with smaller doses, particularly if the patient were unusually sensitive to the effects of sorbitol. This letter is written to call atten¬ tion to the presence of sorbitolcontaining "diet foods." It has now become part of our routine systems review in patients who have vague abdominal complaints to inquire about the intake of such compounds. R. M. GULLEY, MD Gerald J. McShane, MD
Peoria, III
Note.—Current Food and Drug Adminis¬ tration regulations state that the label and labeling of a food whose reasonable fore¬ seeable consumption may result in a daily ingestion of 50 g of sorbitol shall bear the statement: "Excess consumption may have a laxative effect. These regulations do not preclude a voluntary declaration when reasonable foreseeable consumption is less than 50 g.—Ed.
Necrotizing fasciitis.
pulses were intertrigo in
drainage) of greenish pus, which grew Enterococcus, Pseudomonas aeruginosa, Klebsiella, Escherichia coli, and Proteus
palpable.
complicated hospital course, planes of the right thigh, necessitating repeated surgical drainage. The patient died eight
minute, with a temperature of 37 \s=deg\C.Pedal
absent. There was notable both groin areas, under the breasts, and beneath the abdominal pannus. Calf and thigh measurements were equal bilaterally. Mild erythema was present over the right thigh. No crepitus was A WBC count of 14,500/cu mm was pres¬ on admission and remained elevated during the next three weeks. Numerous investigations failed to demonstrate a cause for the persistent leukocytosis, although a gallium scan did show some increased uptake in the right thigh. Even¬ tually a roentgenogram of the right knee ent
showed an air-fluid level above the patella. Additional roentgenograms were taken (Figure), and surgical exploration sub¬ stantiated the diagnosis of necrotizing fasciitis.
mirabilis.
During
months after admission.
Comment.—As in the early cases in Fisher's series, soft-tissue gas was found fortuitously in our patient and was the only indication of necrotizing fasciitis. Just before surgical drain¬ age, a succession splash was evident on movement of the right thigh. This physical finding may be a clinical clue to necrotizing fasciitis. J. Gray, MD, FRCP (C) T. Marrie, MD, FRCP (C) E. V. Haldane, MD, FRCP (C)
Surgical drainage produced copious amounts (approximately 1.5 L at initial
Dalhousie University Halifax, Nova Scotia
"
Roentgenographic Studies in
Necrotizing Fasciitis To the Editor.\p=m-\Fisheret al (241:803, 1979) recently drew attention to the importance of roentgenographic studies in the diagnosis of necrotizing
fasciitis. We would like to add additional report to their series.
an
Report of a Case.\p=m-\A 78-year-old woman
admitted to the Victoria General of dyspnea and chest discomfort. She cited a three-week history of "flu," characterized by dull pain in both hips, knees, and calves. She denied any localized pain and had had no fever or chills reported by the staff of the nursing home where she lived. The patient was not diabetic. Physical examination showed an extremely obese lady in mild respiratory distress. Pulse rate was 100 beats per was
Hospital because
Child Abuse and Children's Advocates, Inc To the Editor.\p=m-\Iam writing regarding the excellent article "Who Needs Counseling in Child Abuse?" by B. J. M. (242:132, 1979). The lack of protection for abused children in the United States is scandalous. They are frequently returned to dangerous environments by governmental agencies, hospitals, or physicians without legal representation, where they are the victims of repeated acts of cruelty. These children are crying out in anguish for help. In the United States there are an estimated 1 million cases of child abuse, and 4,000 deaths occur annually. Many severely abused children suffer permanent physical injury, and of those returned to their environment, at least 10% die. According to
a
pus reaccumulated in the fascial
Department of Health, Education, Welfare official, the plight of the majority of children who die from abusive treatment was previously known to some form of authority a
and
before the deaths. A revealing report by Berkeley Planning Associates, funded by the federal government, was issued in 1977. Data were collected on 1,724 parents who received treatment after abusing their children. A large per¬ centage of the parents in this study severely reabused or neglected their children while they were in treatment and afterward. The seriousness of the assault that brought a case into treat¬ ment had a strong relationship with reincidence of abuse. The report concluded that most current child abuse and neglect pro¬ grams cannot expect a success ratio of
Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/18/2015
Blue Plans and Medical
Necessity To the Editor.\p=m-\The "Blue Plans Medical Necessity Program" (241: 2607, 1979) is made mandatory not just by fiscal restraints, but also by the daily problems that arrive at the offices of the intermediaries for Medicare as well as the Blue Plans. I have just retired as medical consultant to Travelers, Railroad Retirement, part B Medicare, covering nine upper Midwest states, with offices in Lansing, Ill. We were fortunate in having two superb nurses who made initial decisions of problems brought to them, with those too inexplicable referred for a medical decision. Following are a few examples that usually necessitated a telephone call to a physician even after receiving the requested operative report or progress notations on the hospital record: (1) Sometimes the diagnosis sent in was not related to examinations and tests; this was almost always due to the physician's failure to verify what his office had sent in. (2) Questioning of the daily hospital visits of a family physician or internist to his patient even though
primary management was surgery disclosed neither billing nor recorded hospital visits after the operation by the surgeon. (3) Occasionally, fees that were "not accepted assignments" required adjudication: $5,200 for noncomplicated removal of a small cyst from each of two pulmonary lobes; $2,200 for special glasses that did not provide additional vision; $1,200 for removal of two bunions; $5,400 for oral surgery required to fit "false teeth"; and billings for daily psycho¬ therapy sessions of three to 120 days for elderly persons with the diagnosis of senility with depression. There was Edited by John D. Archer, MD, Senior Editor.
bill for therapy consisting primarily of vitamins and coffee enemas, both disapproved and re¬ ported to the State Medical So¬ ciety. One routine approved by local Blue Plans is that pathologists receive a fee for "reviewing" laboratory re¬ ports. Does the patient's physician need the checkmarks indicating that even one
certain results on the report he received are out of the printed normal range? On the other hand, why were 25 to 30 different tests required once or twice a day, two to three times a week during an extensive hospital stay for final diagnoses such as ane¬ mia, malnutrition, diabetes, and ar¬ thritis in elderly persons? There was a bright side. Informa¬ tion supplied occasionally permitted substantial increases in units desig¬ nated by Medicare, utilizing the judg¬ ment of both the medical consultant
and especially physicians in all spe¬ cialties. That the great majority of
physicians provide quality medical care for fees that are reasonable, along with some examples of the aberrations listed here, must be made known to both the professionals and their students. It is a unique opportu¬ nity to study the spectrum of health
it actually is now. Our patients are also beginning to look over our shoulders. It is not just money. The question that is being widely written about, "ethics," must not be separated from the practical question of status and reasons that underlie what we label "medical judg¬ ment." In my years as a physician, I have been witness to the expanding miracles of accomplishing so much for so many. In contradistinction to years ago when all disease had an accompanying threat of death, now illness is supposed to be either preventable or curable. And no miscare as
takes, Doctor! Therefore,
to
repeat
the admonitions of our peers, it is for all of us the rigors of discipline and disciplining, or the rigidity of dicta¬ tion. Abraham Gelperin,
MD
Bay St Louis, Miss
Hazards of Dietary Supplements To the Editor.\p=m-\Recentlyone of us had occasion to embark on a protein\x=req-\ supplemented fast. While on the way to a noon meeting that promised to be particularly dull, and while suffering moderate hunger, this person purchased a package of 12 mints advertised as being sugar-free. Paying no attention to the label, he proceeded to consume all of the 12 mints during the two-hour meeting. Thirty minutes after the last mint was consumed, he began to experience marked abdominal
distention, passed extremely large flatus, and experienced
amounts of
abdominal cramping. This was followed shortly by the development of profuse, watery diarrhea that persisted for the next 30 minutes and amounted to an estimated 1 to 1.5 L of fluid. Five hours after consuming the mints, the subject ate his evening meal, which consisted of 180 g (6 oz) of steak, and noted persistent vague abdominal distress with considerable flatus. Thirty minutes after eating, he noticed the onset of severe epigastric pain of a constant sharp nature radiating straight through to the back. This pain persisted for the next four hours, was associated with diaphoresis, light-headedness, and transient hypotension (blood pres¬ sure, 80/40 mm Hg), which necessi¬ tated admission to a hospital. Physical examination demon¬ strated moderate tenderness in the epigastrium without guarding or
Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/18/2015
rebound and mild dehydration. Sur¬ gical consultation was obtained to evaluate the possibility of posterior perforation of peptic ulcer. With conservative therapy consisting of intravenous feedings and observation, the pain resolved in the next 24 hours and did not recur. It was at this point that the mint package was inspected; it was found that the sucrose substitute in this product is sorbitol. The effects of sorbitol in producing osmotically in¬ duced diarrhea are well known and seem to explain many of the symp¬ toms present in this circumstance. While it is unlikely that many physicians might come in contact with patients who consumed an entire package at one sitting (aside from children or others with poor impulse control) it is likely that less extensive but still significant symptoms might be produced with smaller doses, particularly if the patient were unusually sensitive to the effects of sorbitol. This letter is written to call atten¬ tion to the presence of sorbitolcontaining "diet foods." It has now become part of our routine systems review in patients who have vague abdominal complaints to inquire about the intake of such compounds. R. M. GULLEY, MD Gerald J. McShane, MD
Peoria, III
Note.—Current Food and Drug Adminis¬ tration regulations state that the label and labeling of a food whose reasonable fore¬ seeable consumption may result in a daily ingestion of 50 g of sorbitol shall bear the statement: "Excess consumption may have a laxative effect. These regulations do not preclude a voluntary declaration when reasonable foreseeable consumption is less than 50 g.—Ed.
Necrotizing fasciitis.
pulses were intertrigo in
drainage) of greenish pus, which grew Enterococcus, Pseudomonas aeruginosa, Klebsiella, Escherichia coli, and Proteus
palpable.
complicated hospital course, planes of the right thigh, necessitating repeated surgical drainage. The patient died eight
minute, with a temperature of 37 \s=deg\C.Pedal
absent. There was notable both groin areas, under the breasts, and beneath the abdominal pannus. Calf and thigh measurements were equal bilaterally. Mild erythema was present over the right thigh. No crepitus was A WBC count of 14,500/cu mm was pres¬ on admission and remained elevated during the next three weeks. Numerous investigations failed to demonstrate a cause for the persistent leukocytosis, although a gallium scan did show some increased uptake in the right thigh. Even¬ tually a roentgenogram of the right knee ent
showed an air-fluid level above the patella. Additional roentgenograms were taken (Figure), and surgical exploration sub¬ stantiated the diagnosis of necrotizing fasciitis.
mirabilis.
During
months after admission.
Comment.—As in the early cases in Fisher's series, soft-tissue gas was found fortuitously in our patient and was the only indication of necrotizing fasciitis. Just before surgical drain¬ age, a succession splash was evident on movement of the right thigh. This physical finding may be a clinical clue to necrotizing fasciitis. J. Gray, MD, FRCP (C) T. Marrie, MD, FRCP (C) E. V. Haldane, MD, FRCP (C)
Surgical drainage produced copious amounts (approximately 1.5 L at initial
Dalhousie University Halifax, Nova Scotia
"
Roentgenographic Studies in
Necrotizing Fasciitis To the Editor.\p=m-\Fisheret al (241:803, 1979) recently drew attention to the importance of roentgenographic studies in the diagnosis of necrotizing
fasciitis. We would like to add additional report to their series.
an
Report of a Case.\p=m-\A 78-year-old woman
admitted to the Victoria General of dyspnea and chest discomfort. She cited a three-week history of "flu," characterized by dull pain in both hips, knees, and calves. She denied any localized pain and had had no fever or chills reported by the staff of the nursing home where she lived. The patient was not diabetic. Physical examination showed an extremely obese lady in mild respiratory distress. Pulse rate was 100 beats per was
Hospital because
Child Abuse and Children's Advocates, Inc To the Editor.\p=m-\Iam writing regarding the excellent article "Who Needs Counseling in Child Abuse?" by B. J. M. (242:132, 1979). The lack of protection for abused children in the United States is scandalous. They are frequently returned to dangerous environments by governmental agencies, hospitals, or physicians without legal representation, where they are the victims of repeated acts of cruelty. These children are crying out in anguish for help. In the United States there are an estimated 1 million cases of child abuse, and 4,000 deaths occur annually. Many severely abused children suffer permanent physical injury, and of those returned to their environment, at least 10% die. According to
a
pus reaccumulated in the fascial
Department of Health, Education, Welfare official, the plight of the majority of children who die from abusive treatment was previously known to some form of authority a
and
before the deaths. A revealing report by Berkeley Planning Associates, funded by the federal government, was issued in 1977. Data were collected on 1,724 parents who received treatment after abusing their children. A large per¬ centage of the parents in this study severely reabused or neglected their children while they were in treatment and afterward. The seriousness of the assault that brought a case into treat¬ ment had a strong relationship with reincidence of abuse. The report concluded that most current child abuse and neglect pro¬ grams cannot expect a success ratio of
Downloaded From: http://jama.jamanetwork.com/ by a RYERSON UNIVERSITY LIBRARY User on 06/18/2015
