Letters to the editor
To the Editor: I am writing to you regarding a recent article published by R. B. Buckingham et al., entitled ‘“Temporomandibular joint dysfunction syndrome: A close association with systemic joint laxity (the hypermobile joint syndrome),” published in ORAL SURGERY, ORAL MEDICINE,
ORAL PATHOLOGY,
1991;72:514-9.
This is a very interesting article. I want to point out to the readers that there is an association between hypermobility of joints and the general diagnosis of fibromyalgia or hbrositis. I would alsolike to point out a recent article in the Southern Medical Journal entitled ‘“Hypermobility and Deconditioning: Important Links to Fibromyalgia/Fibrositis,” authored by John Goldman, MD. This article cites certain referenceswhich may be of help in our overall understanding of temporomandibular joint disorders.
Robert Chuong, MD, DMD Maxillofacial Surgery Institute of Florida 111 SecondAvenue, NE St. Petersburg,FL 33701
To the Editor. I would like to comment on the recent article “Preoperative Laboratory Assessmentof Hemostasis for Orthognathic Surgery” by Holtzman et al. (ORAL SURG ORAL MED ORAL PATHOL 1992;73:403-6). Although the authors’ concern about possibletransfusions in orthognathic surgery is commendable and their recommendations for routine preoperative screening tests are indeed widely practiced throughout the profession (la.rgely out of litigation concerns), I offer some food for thought about routine testing. These comments are: based on trends in the medical literature (which are not likely to go unnoticed by third-party carriers). Ten billion laboratory tests are performed each year in the United States and accounted for approximately 20% of the nation’s health care bill in 1987.‘12 Although not addressing coagulation tests specifi-
tally, Pinckney’ noted that one of every seven tests (which he estimated at 4 million tests per day!) are either erroneous or unreliable for clinical application. Further, Wagner and Moore3 noted that unnecessary tests increasepatient risks and expenses,and the pursuit of borderline positive or false-positive tests further adds to those expenses.Indeed, several of my colleagues in Dallas have abandoned routine preoperative coagulation screenings because of the high numbersof misleading results being received from the laboratories. Wagner and Moore estimated that $12 billion to $18 billion a year could be saved in health care expensesif tests were performed only when indicated by a thorough history and physical examination. Erban et a1.4 studied routine prothrombin times (PT) and partial thromboplastin times concluded they were of low predictive value in asymptomatic patients and that the most sensitive method of screening is by a thorough medical history. They also noted that routine testing is not advocated by the American College of Physicians. Suchman and Mushlin5 studied PT and partial thromboplastin time as routine tests in 12,372 patients who had undergone invasive procedures and found that determination of activated partial thromboplastin time had little ability to predict hemorrhage potential in symptom-free patients. Eisenberget a1.6screened480 patients and found only 13 with abnormal test results; only one patient had postoperative hemorrhage problems, and even that one casewasbelieved to be unrelated to the discovered coagulation defect. Roher et a1.7studied 282 patients and found 4.1% abnormal test result, none of which were significant clinically. Kaplan et al.* monitored 2000 patients undergoing elective surgery and found that 60% of the routine tests performed would not have been done if testing had been requested only for recognizable indications, and in only four cases(0.22%) would the test abnormalities have affected surgical management. Seventysevenpercent of the PTs and activated partial thromboplastin times were not indicated, and none was abnormal. Of 407 tests of platelets, only two abnormalities were found. The authors concluded that
437
433
Letters to the editor
Om.~Su~ciOiu~
MEDORAL
October
“routine preoperative laboratory tests contribute little to patient care. . . .” Blood transfusions are a big concern these days, but the decision to routinely perform any procedure must be weighed with risks, benefits, and cost included in the formula. Johnson9 reminds us that tests should not be viewed as cost per test but as cost per bit of useful information in the overall patient population. He further emphasizes that even though courts of law may view a failure to exhaust all diagnostic procedures as an incomplete workup, nevertheless, the principle of maximum information is neither practically sound nor logically defensible. Although I appreciate and understand the authors’ concerns, I believe it academically important to point out that although their position may be appealing to the soul, it is not well supported in the scientific literature. Roger E. Alexander, DDS Assistant Professor Department of Oral and Maxillofacial Surgery Baylor College of Dentistry Dallas, Tex. REFERENCES I. Pinckney ER. The accuracy and significance of medical testing. Arch Intern Med 1983;143:512-4. 2. Going overboard on medical tests. Time, Apr 25, 1988:80-l. 3. Wagner JD, Moore DL. Preoperative testing for the oral and maxillofacial surgery patient. J Oral Maxillofac Surg 199 1; 49:177-82. 4. Erban SB, Kinman JL, Schwartz JS. Routine use of the prothrombin and partial thromboplastin times. JAMA 1989; 262:2428-32. 5. Suchman AL, Mushlin AI. How well does the activated partial thromboplastin time predict postoperative hemorrhage? JAMA 1986;256:750-3. 6. Eisenberg JM, Clarke JR, Sussman SA. Prothrombin and partial thromboplastin times as preoperative screening tests. Arch Surg 1982;117:48-51. 7. Rohrer MJ, Michelotti MC, Nahrwold DL. A prospective evaluation of the efficacy of preoperative coagulation testing. Ann Surg 1988;208:554-7. 8. Kaplan EB, Sheiner LB, Boeckman AJ, et al. The usefulness of preoperative laboratory screening. JAMA 1985;253:357681. 9. Johnson HA. Diminishing returns on the road to diagnostic certainty. JAMA 1991;265:2229-31.
To the Editor:
Dr. Alexander raises the old warhorse issue of the costs, both apparent and hidden, of unnecessary routine screening tests. We could not agree more that most routine preoperative tests are unnecessary. The standard battery of urinalysis, chemistry profile, prothrombin time and activated partial thromboplastin time complete blood cell count, and VDRL is neither
PATH~L
1992
cost effective from a case-finding perspective nor is it beneficial to the patient. As an example, when was the last time a serum chloride or phosphorus concentration, or a urinalysis, had a medical impact on a patient undergoing ambulatory surgery? The issue of preoperative screening tests of hemostasis is especially difficult. It is clear that many of these tests may be abnormal, reflecting underlying pathophysiologic processes, yet have no predictive value in relation to surgical bleeding.rq4 Nevertheless, two bleeding disorders can be associated with major surgical bleeding despite a completely negative patient history for bleeding. These are von Willebrand’s disease and Factor XI deficiency. Although the latter is rare, recent estimates of the prevalence of von Willebrand’s disease range from 0.6 to 1.2 per 100 population.5 Thus about 1% of all patients may have a completely negative bleeding history and have von Willebrand’s disease that requires presurgical treatment with dosmopressin acetate (DDAVP) to prevent surgical bleeding and the need for transfusions. In terms of cost, we are talking about a hospital cost of two dollars for reagents and labor to screen activated partial thromboplastin. This should be balanced against the significantly decreased cost of hospitalization and safe transfusion therapy in a patient treated prophylactically versus management of a case detected postoperatively, resulting in prolonged hospitalization and transfusion with potentially dangerous blood products. We should be limiting unnecessary testing, but cost constraints should be targeted to those conditions and tests which do not result in harm to the patient. With the stakes as high as they are in transfusion medicine, we recommend giving the patient the benefit of the doubt. Richard A. Kraut, DDS, FACD, FICD Montefiore Medical Center/ Albert EinsteinCollegeof Medicine Bronx, N.Y. REFERENCES 1. Burns ER, Lawrence C. Bleeding time: a guide to its diagnostic and clinical utility. Arch Path01 Lab Med 1989;113:121924. 2. Lind SE. The bleeding time does not predict surgical bleeding. Blood 1991;77:2547-52, 3. McVay PA, Toy PTCY. Lack of increased bleeding after iiver biopsy in patients with mild hemostatic abnormalities. Am J Clin Path01 1990;94:747-53. 4. McVay PA, Toy PTCY. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991;31:164-71. 5. Rodeghiero F, Castaman G, Dini E. Epidemiological investigation of the prevalence of von Willebrand’s disease. Blood 1987;69:454-9.
To the Editor: I am writing to you regarding a recent article published by R. B. Buckingham et al., entitled ‘“Temporomandibular joint dysfunction syndrome: A close association with systemic joint laxity (the hypermobile joint syndrome),” published in ORAL SURGERY, ORAL MEDICINE,
ORAL PATHOLOGY,
1991;72:514-9.
This is a very interesting article. I want to point out to the readers that there is an association between hypermobility of joints and the general diagnosis of fibromyalgia or hbrositis. I would alsolike to point out a recent article in the Southern Medical Journal entitled ‘“Hypermobility and Deconditioning: Important Links to Fibromyalgia/Fibrositis,” authored by John Goldman, MD. This article cites certain referenceswhich may be of help in our overall understanding of temporomandibular joint disorders.
Robert Chuong, MD, DMD Maxillofacial Surgery Institute of Florida 111 SecondAvenue, NE St. Petersburg,FL 33701
To the Editor. I would like to comment on the recent article “Preoperative Laboratory Assessmentof Hemostasis for Orthognathic Surgery” by Holtzman et al. (ORAL SURG ORAL MED ORAL PATHOL 1992;73:403-6). Although the authors’ concern about possibletransfusions in orthognathic surgery is commendable and their recommendations for routine preoperative screening tests are indeed widely practiced throughout the profession (la.rgely out of litigation concerns), I offer some food for thought about routine testing. These comments are: based on trends in the medical literature (which are not likely to go unnoticed by third-party carriers). Ten billion laboratory tests are performed each year in the United States and accounted for approximately 20% of the nation’s health care bill in 1987.‘12 Although not addressing coagulation tests specifi-
tally, Pinckney’ noted that one of every seven tests (which he estimated at 4 million tests per day!) are either erroneous or unreliable for clinical application. Further, Wagner and Moore3 noted that unnecessary tests increasepatient risks and expenses,and the pursuit of borderline positive or false-positive tests further adds to those expenses.Indeed, several of my colleagues in Dallas have abandoned routine preoperative coagulation screenings because of the high numbersof misleading results being received from the laboratories. Wagner and Moore estimated that $12 billion to $18 billion a year could be saved in health care expensesif tests were performed only when indicated by a thorough history and physical examination. Erban et a1.4 studied routine prothrombin times (PT) and partial thromboplastin times concluded they were of low predictive value in asymptomatic patients and that the most sensitive method of screening is by a thorough medical history. They also noted that routine testing is not advocated by the American College of Physicians. Suchman and Mushlin5 studied PT and partial thromboplastin time as routine tests in 12,372 patients who had undergone invasive procedures and found that determination of activated partial thromboplastin time had little ability to predict hemorrhage potential in symptom-free patients. Eisenberget a1.6screened480 patients and found only 13 with abnormal test results; only one patient had postoperative hemorrhage problems, and even that one casewasbelieved to be unrelated to the discovered coagulation defect. Roher et a1.7studied 282 patients and found 4.1% abnormal test result, none of which were significant clinically. Kaplan et al.* monitored 2000 patients undergoing elective surgery and found that 60% of the routine tests performed would not have been done if testing had been requested only for recognizable indications, and in only four cases(0.22%) would the test abnormalities have affected surgical management. Seventysevenpercent of the PTs and activated partial thromboplastin times were not indicated, and none was abnormal. Of 407 tests of platelets, only two abnormalities were found. The authors concluded that
437
433
Letters to the editor
Om.~Su~ciOiu~
MEDORAL
October
“routine preoperative laboratory tests contribute little to patient care. . . .” Blood transfusions are a big concern these days, but the decision to routinely perform any procedure must be weighed with risks, benefits, and cost included in the formula. Johnson9 reminds us that tests should not be viewed as cost per test but as cost per bit of useful information in the overall patient population. He further emphasizes that even though courts of law may view a failure to exhaust all diagnostic procedures as an incomplete workup, nevertheless, the principle of maximum information is neither practically sound nor logically defensible. Although I appreciate and understand the authors’ concerns, I believe it academically important to point out that although their position may be appealing to the soul, it is not well supported in the scientific literature. Roger E. Alexander, DDS Assistant Professor Department of Oral and Maxillofacial Surgery Baylor College of Dentistry Dallas, Tex. REFERENCES I. Pinckney ER. The accuracy and significance of medical testing. Arch Intern Med 1983;143:512-4. 2. Going overboard on medical tests. Time, Apr 25, 1988:80-l. 3. Wagner JD, Moore DL. Preoperative testing for the oral and maxillofacial surgery patient. J Oral Maxillofac Surg 199 1; 49:177-82. 4. Erban SB, Kinman JL, Schwartz JS. Routine use of the prothrombin and partial thromboplastin times. JAMA 1989; 262:2428-32. 5. Suchman AL, Mushlin AI. How well does the activated partial thromboplastin time predict postoperative hemorrhage? JAMA 1986;256:750-3. 6. Eisenberg JM, Clarke JR, Sussman SA. Prothrombin and partial thromboplastin times as preoperative screening tests. Arch Surg 1982;117:48-51. 7. Rohrer MJ, Michelotti MC, Nahrwold DL. A prospective evaluation of the efficacy of preoperative coagulation testing. Ann Surg 1988;208:554-7. 8. Kaplan EB, Sheiner LB, Boeckman AJ, et al. The usefulness of preoperative laboratory screening. JAMA 1985;253:357681. 9. Johnson HA. Diminishing returns on the road to diagnostic certainty. JAMA 1991;265:2229-31.
To the Editor:
Dr. Alexander raises the old warhorse issue of the costs, both apparent and hidden, of unnecessary routine screening tests. We could not agree more that most routine preoperative tests are unnecessary. The standard battery of urinalysis, chemistry profile, prothrombin time and activated partial thromboplastin time complete blood cell count, and VDRL is neither
PATH~L
1992
cost effective from a case-finding perspective nor is it beneficial to the patient. As an example, when was the last time a serum chloride or phosphorus concentration, or a urinalysis, had a medical impact on a patient undergoing ambulatory surgery? The issue of preoperative screening tests of hemostasis is especially difficult. It is clear that many of these tests may be abnormal, reflecting underlying pathophysiologic processes, yet have no predictive value in relation to surgical bleeding.rq4 Nevertheless, two bleeding disorders can be associated with major surgical bleeding despite a completely negative patient history for bleeding. These are von Willebrand’s disease and Factor XI deficiency. Although the latter is rare, recent estimates of the prevalence of von Willebrand’s disease range from 0.6 to 1.2 per 100 population.5 Thus about 1% of all patients may have a completely negative bleeding history and have von Willebrand’s disease that requires presurgical treatment with dosmopressin acetate (DDAVP) to prevent surgical bleeding and the need for transfusions. In terms of cost, we are talking about a hospital cost of two dollars for reagents and labor to screen activated partial thromboplastin. This should be balanced against the significantly decreased cost of hospitalization and safe transfusion therapy in a patient treated prophylactically versus management of a case detected postoperatively, resulting in prolonged hospitalization and transfusion with potentially dangerous blood products. We should be limiting unnecessary testing, but cost constraints should be targeted to those conditions and tests which do not result in harm to the patient. With the stakes as high as they are in transfusion medicine, we recommend giving the patient the benefit of the doubt. Richard A. Kraut, DDS, FACD, FICD Montefiore Medical Center/ Albert EinsteinCollegeof Medicine Bronx, N.Y. REFERENCES 1. Burns ER, Lawrence C. Bleeding time: a guide to its diagnostic and clinical utility. Arch Path01 Lab Med 1989;113:121924. 2. Lind SE. The bleeding time does not predict surgical bleeding. Blood 1991;77:2547-52, 3. McVay PA, Toy PTCY. Lack of increased bleeding after iiver biopsy in patients with mild hemostatic abnormalities. Am J Clin Path01 1990;94:747-53. 4. McVay PA, Toy PTCY. Lack of increased bleeding after paracentesis and thoracentesis in patients with mild coagulation abnormalities. Transfusion 1991;31:164-71. 5. Rodeghiero F, Castaman G, Dini E. Epidemiological investigation of the prevalence of von Willebrand’s disease. Blood 1987;69:454-9.
