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Letters to the Editor

The Cost of Treating Deaf and Hard-of-Hearing Patients

to the editor: The article¹ and editorial² on helping deaf and hard-of-hearing patients provide much useful information. I have treated deaf patients in the past and have arranged for medical interpreters. It is interesting that the author of the editorial comments that physicians "seem to have less enthusiasm for their deaf and hard-of-hearing patients than their hearing patients."² Unfortunately, no comment is made in either the article or the editorial regarding the unfair financial burden placed on physicians who would like to treat deaf patients.

Frequently, deaf patients have insurance that reimburses at a substantially discounted level. Medical interpreters are extremely expensive. The physician is billed from the time the interpreter leaves his or her door until the time that he or she returns--although the interpreter may spend only 15 minutes actually performing a service. Specifically, this amounts to about two hours at $50 per hour. Assuming that the patient has come to the office for a level III visit and that the reimbursement is from Medicare, the amount reimbursed is $35.41. Add to that the heavy-handed threat of a six-figure lawsuit for not providing an interpreter, and it does not take an accountant to understand why physicians may not be enthusiastic about treating these patients.

It is unfortunate that our society chooses to penalize physicians who treat deaf patients. It would be helpful for us to evaluate alternatives to placing the financial burden for medical interpreting on the individual's physician.

STEVEN G. HAMMER, M.D.
Waukesha Health Systems--Barstow
210 N.W. Barstow St., Ste. 300
Waukesha, WI 53188

REFERENCES

1. The Committee on Disabilities of the Group for the Advancement of Psychiatry. Issues to consider in deaf and hard-of-hearing patients. Am Fam Physician 1997;56:2057-64.
2. Zazove P. Understanding deaf and hard-of-hearing patients [Editorial]. Am Fam Physician 1997;56: 1953-4.

EDITOR'S NOTE: This letter was sent to the authors of "Issues to Consider in Deaf and Hard-of-Hearing Patients," who declined to reply.

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Ileoileal Intussusception with a Leading Meckel's Diverticulum

TO THE EDITOR: Intussusception most commonly affects infants between the ages of five and nine months,^1-3 but it may also occur in older children, teenagers and adults. The etiology is usually unknown in infants; older children and adults, however, often have lead points^1-3 such as a Meckel's diverticulum, intestinal polyps, neoplasms and foreign bodies.³ First-hand treatment of this condition is hydrostatic desinvagination.⁴ When this treatment is inappropriate or unsuccessful, surgical reduction is necessary.⁴ We report on two girls suffering from ileoileal intussusception with a leading Meckel's diverticulum.

The first case involved a 12-year-old girl with episodic, intermittent cramping abdominal pain over several years who was admitted to the surgical emergency department with lower abdominal pain. Previously she had been admitted for overnight observation and evaluation for appendicitis. At that time her symptoms subsided so no operation was performed. At the time of this admission, she presented with intense right lower quadrant tenderness on abdominal palpation. Despite normal laboratory values and the absence of fever, she was scheduled for appendectomy. At laparotomy, her appendix was normal in appearance. However, ileoileal intussusception with a Meckel's diverticulum as a lead point was found. The diverticulum was extirpated. Histologic analysis revealed a Meckel's diverticulum with some ectopic gastric mucosa. When contacted 14 months after the operation, the patient declared that she had not experienced any abdominal pain since the operation.

The second case involved an 18-year-old woman who presented with a history and clinical findings quite similar to those of the first case. Perioperative findings and the postoperative course, including histologic analysis and personal communication, were identical to those of the first case 13 months after the operation.

Intussusception is a fairly common disease in small children, but is considered rare in the adolescent or adult patient. After encountering the two reported cases, we question whether the incidence of ileoileal intussusception may be underestimated in adolescents. The fact that the two patients had a long history of episodes of abdominal pain, similar to the pain on the day of admission, makes it probable that they had actually suffered from several previous intussusceptions that perhaps resolved spontaneously.

Digital rectal examination is mandatory in the evaluation of acute abdomen. Still, the value of digital rectal examination is somewhat limited in patients with intussusception, since not all patients with this condition will present with grossly bloody stools. However, since occult blood evaluation is frequently positive, combining this examination with testing for occult blood will increase the sensitivity.⁵ Ultrasound of the abdomen is the examination of choice for diagnosis of intussusception. It is a simple and well-tolerated examination, with good sensitivity.⁶

Hopefully this letter may serve as a reminder that although ileoileal intussusception may not be a common condition in adolescents and adults, it should be considered in cases with unexplained, recurrent abdominal pain.

RALPH PEEKER, M.D.
Institution for Surgical Science
Sahlgrenska University Hospital
413 45 Göteborg, Sweden

KELM HJÄLMÅS, M.D.
Department of Pediatric Surgery
Sahlgrenska University Hospital
Göteborg, Sweden

REFERENCES

1. Stringer MD, Pablot SM, Brereton RJ. Paediatric intussusception. Br J Surg 1992;79:867-76.
2. Gierup J, Jorulf H, Livaditis A. Management of intussusception in infants and children: a survey based on 288 consecutive cases. Pediatrics 1972; 50:535-46.
3. Pollack CV Jr, Pender ES. Unusual cases of intussusception. J Emerg Med 1991;9:347-55.
4. West KW, Stephens B, Vane DW, Grosfeld JL. Intussusception: current management in infants and children. Surgery 1987;102:704-10.
5. Losek JD, Fiete RL. Intussusception and the diagnostic value of testing stool for occult blood. Am J Emerg Med 1991;9:1-3.
6. Bhisitkul DM, Listernick R, Shkolnik A, Donaldson JS, Henricks BD, Feinstein KA, et al. Clinical application of ultrasonography in the diagnosis of intussusception. J Pediatr 1992;121:182-6.

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Massive Pericardia Effusion in Sarcoidosis

TO THE EDITOR: Sarcoidosis is a multisystem granulomatous disorder. Symptomatic cardiac involvement is present in up to 5 percent of patients with sarcoidosis; postmortem studies reveal cardiac involvement in 20 to 30 percent of cases. While small effusions occur in 19 percent of cases, massive pericardial effusion leading to cardiac tamponade secondary to sarcoidosis is exceedingly rare and only a few cases have been reported.^1,2 We report here a patient with sarcoidosis who presented with cardiac tamponade.

A 30-year-old black man was admitted with complaints of nonproductive cough and a 9.08-kg (20-lb) weight loss over the past two months. He was treated with oral antibiotics on two different occasions with no relief of symptoms. A previous admission one year earlier for transbronchial biopsy revealed a diagnosis of sarcoidosis. History was negative for medication use, tuberculosis exposure, smoking, alcoholism or drug abuse. Physical examination revealed a well-developed man in mild respiratory distress with a blood pressure of 100/60 mm Hg, a pulse rate of 96 beats per minute, a temperature of 38.1°C (100.6°F) and a respiratory rate of 22 breaths per minute. There was significant pulsus paradoxus of 20 mm Hg and obvious jugular venous distention.

The pulmonary examination revealed bilateral vesicular breath sounds. Heart sounds were distant with a three-component pericardial rub over the left parasternal area. Radiographic examination revealed mild cardiomegaly with clear lung fields. The electrocardiogram showed normal sinus rhythm. Routine laboratory parameters were within normal limits.

Transthoracic echocardiogram revealed a large pericardial effusion with early diastolic collapse of the right ventricle free wall suggestive of impending tamponade. During urgent pericardiocentesis, 600 mL of fluid was drained, and pericardial biopsy revealed fibrinous pericarditis. The pericardial fluid was exudative, and negative for acid fast bacilli and malignancy. The patient was started on treatment with prednisone, 60 mg per day orally, which was slowly tapered over the next few months. The patient showed a significant response to the treatment. Subsequent repeat echocardiograms over the next nine months did not show any pericardial effusion, and the patient has remained asymptomatic.

The clinical features of sarcoid heart disease include congestive heart failure, ventricular arrhythmia, conduction disturbances, ventricular aneurysms, pericardial effusion and sudden death, particularly in younger patients.^1,3-5 Arrhythmias are the most predictive indicators of cardiac involvement.⁶ Echocardiography is being increasingly used in patients with sarcoidosis to establish the cardiac involvement echo. Features include focal wall abnormalities, mitral valve prolapse, pericardial effusions, increased septal thickness, aneurysmal dilatation and atypical nonischemic ventricular wall motion abnormalities.

Massive effusions are rare, with only 10 such cases found during review of the medical literature, and they are exudative in nature. Effusion may be secondary to systemic or pericardial disease, cor pulmonale, pericardial granuloma or left ventricular dysfunction.^4,5 A patchy distribution may lead to negative pericardial biopsies.⁴ Fortunately, the previous documentation of pulmonary involvement helped to establish the diagnosis. Treatment of cardiac sarcoidosis is still evolving. Steroids have been the mainstay of medical treatment including pericardial effusion. Refractory arrhythmias or heart block may necessitate surgical or pacemaker placement.

SONIA ARUNABH, M.D.
NAVIN VERMA, M.D.
TERENCE M. BRADY, M.D.
Department of Internal Medicine
The New York Hospital Medical Centre of Queens
Flushing, NY 11355

ARUNABH, M.D.
North Shore University Hospital at Forest Hills
Forest Hills, NY

REFERENCES

1. Verkleeren JL, Glover MU, Bloor C, Joswig BC. Cardiac tamponade secondary to sarcoidosis. Am Heart J 1983;106:601-3.
2. Israel RH, Poe RH. Massive pericardial effusion in sarcoidosis. Respiration 1994;61:176-80.
3. Bower SP, Thomson A. Two dimensional echocardiography and left ventriculography in cardiac sarcoidosis. Aust N Z J Med 1989;19:724-6.
4. Kinney E, Murthy R, Ascunce G, Donohoe R, Zelis R. Pericardial effusions in sarcoidosis. Chest 1979; 76:476-8.
5. Pesola G, Teirstein AS, Goldman M. Sarcoidosis presenting with pericardial effusion. Sarcoidosis 1987; 4:42-4.
6. Silverman KJ, Hutchins GM, Bulkley BH. Cardiac sarcoid: a clinicopathologic study of 84 unselected patients with systemic sarcoidosis. Circulation 1978;58:1204-11.

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Respiratory Arrest After Peak Expiratory Flow Measurement

TO THE EDITOR: Peak expiratory flow is a convenient tool for following and assessing patients with asthma. Patients are instructed in peak expiratory flow measurement as a means of home monitoring and adjustment of therapy, and it is considered to be safe, inexpensive and effective. However, at least two deaths caused by respiratory arrest following measurement of peak expiratory flow have been reported in young patients,¹ both of which occurred during an acute asthmatic attack. We recently saw a patient suffer respiratory arrest in the office following measurement of peak expiratory flow; however, the patient was not having an acute asthmatic attack at the time, but was instead in the office for a routine follow-up visit.

The patient, a 41-year-old man, is well known in our office. Almost 10 years earlier, he was treated for a positive purified protein derivative test with six months of isoniazid therapy, but he has no other medical problems besides asthma. He was in the office for routine follow-up and adjustment of medications. His vital signs were blood pressure 110/79 mm Hg, pulse rate 76 per minute and oxygen saturation 90 percent on room air. He was doing well, in fact better than his usual baseline, and his physician measured his peak expiratory flow in the office. It was 300 mL, significantly better than his usual measurements. She stepped out of the examination room to verify dosages of medication, when she heard him call for help. She immediately returned to the examination room where she witnessed the patient suffering respiratory arrest and progressing to cardiac arrest. Cardiopulmonary resuscitation, including chest compressions and medications, was required to resuscitate him. He was transferred to the intensive care unit, where he did well, and was subsequently discharged without sequelae.

We would caution physicians to be aware that measurement of peak expiratory flow, although generally considered safe, can trigger bronchospasm and the complications of respiratory or cardiac arrest.

ARLENE M. BROWN, M.D.
Family Practice Associates
304 Sudderth Drive
Ruidoso, NM 88345

REFERENCE

1. Lemarchand P, Labrune S, Herer B, Huchon GJ. Cardiorespiratory arrest following peak expiratory flow measurement during attack of asthma. Chest 1991;100:1168-9. *

Copyright 1998 by the American Academy of Family Physicians.
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The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors reserve the right to edit correspondence to meet style and space requirements.

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