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Office diagnosis of sinus disorders: The role of ultrasound scanning
313
CURRENT LITERATURE
for the children who breathed through the mouth were as follows: 1) They had long faces. 2) Their faces were more retrognathic. 3) Their mandibles had more obtuse gonial angles. 4) Their palates were higher and narrower. 5) They were more likely to have posterior dental crossbites than children who breathed through their nose. While this evaluation substantiates the existence of long-face syndrome in children who appear to breathe predominantly through the mouth, it is suggested by the authors that a longitudinal study should be undertaken, documenting mode of breathing and variables of facial growth. Without such a study, it is impossible to be certain that orofacial abnormalities did not cause the breathing abnormalities rather than the COnVerSe.-MARION L. WAZNEY Reprint requests to Dr. Shapiro: Pediatric and Adolescent lergy. P.S., 3900 N.E. 45th St., Seattle, WA 98105. Cost Effectiveness 25213252, 1984
of Antibiotic
Al-
Use. Aldis WL. JAMA
An analysis of the cost effectiveness of antibiotic use in a small rural hospital was completed using an arbitrarily selected month that had 381 admissions. A highcost antibiotic usage group, defined as all patients for whom the cost of antibiotics was more than one standard deviation above the group mean for all patients receiving antibiotics, was identified. Of 169 patients receiving antibiotics, 38 patients were in this high-cost group. The records were reviewed to see whether a less expensive but equally effective antibiotic (or combination of antibiotics) could have been used. After review, 16 cases were identified for which a less expensive antibiotic could have been used. In many cases the cheaper antibiotic was distinctly preferable to the one actually used (e.g., using penicillin instead of cefamandole for pneumococcal pneumonia proven by Gram stain and culture). The cost of antibiotics for the 16 patients was $5.65845. If less expensive drugs had been used, the total cost would have been $2,190.25-a reduction in cost of 61%. An analysis of drugs used for the 16 patients showed that: I) Penicillin was the preferred drug for 4 patients, with no usage. 2) Semi-synthetic penicillins were preferred for 7 patients. with 1 use. 3) Cephalosporins were used for 13 patients and were indicated for only 3. Results showed that penicillin was underutilized and cephalosporins were used in excess. Further analysis showed a virtual disappearance of penicillin use in this particular hospital. In summary, this study revealed that considerable savings could be achieved by alternate antibiotic choices based on a cost effectiveness concept. It is suggested that formal reviews of antibiotic usage be completed monthly in every hospita].--CHARLES
RINCGOLD
Reprint requests to Dr. Aldis: Community Hospital, Sylva, NC. Fresh-frozen Plasma: 253~551, 1985
Indications
and Risks.
rounding the increasing use of FFP was made by convening a Consensus Development Conference in 1984. The consensus panel concluded that there is a paucity of definitive indications for FFP use to support the increasing use. This is of concern because of the potential risks of transmission of hepatitis and AIDS that FFP carries. Many patients who receive FFP can be managed more effectively and safely with alternative modalities. No justification exists for the use of FFP as a volume expander or nutritional source since safer alternatives exist. FFP is indicated for some coagulation factor de& ciencies and for some patients requiring massive transfusion. Other FFP indications include use for patients who have thrombotic thrombocytopenic purpura, protein-losing enteropathy, and certain immunodeficiencies. The article further details definitive indications for FFP use and gives alternative methods to use when FFP is not the ideal blood product available.-JAMes R. HUPP Reprint requests to Dr. Bernstein: Office of Medical Applications of Research, Bldg. I, Room 216, NIH, Bethesda. MD 20205.
Office Diagnosis of Sinus Disorders: The Role of Ultrasound Scanning. Mabry RL. Laryngoscope 94: 10421044, 1984 Ultrasound scanning for the diagnosis and management of sinus disorders has recently been introduced into the United States. In the past, transillumination, sinoscopy, sinus irrigation, and radiographs have been used with greater frequency: however, advantages and disadvantages are present for each. By evaluating the reflective impulses of the ultrasound scan, the following diagnoses are possible: normal air-containing sinus; fluid retention within the sinus; mucosal swelling with or without associated fluid; cysts; and masses. Advantages of the ultrasound scan are freedom from radiation exposure, lesser expense, speed of testing, noninvasiveness, and accuracy. Disadvantages reported concern interpretation difficulties by the novice examiner, a constantly changing scan projection, limitation to sinuses that do not have air anterior to them (lack of conduction in air), and falsenegative results due to air before actual sinus pathology is present. In practice, the ultrasound scan’s usefulness in diagnosing and following maxillary and frontal sinus secretions and the ability to differentiate these from mucosal thickenings has been illicited. With an understanding of its limitations, experience in interpretation, and the availability of other diagnostic tools mentioned, the ultrasound scan can provide invaluable interpretation in the diagnosis and management of maxillary and frontal sinus disease.-MARK W, MITCHELL Reprint requests to Dr. Mabry: 122 West Colorado, Suite 204. Dallas, TX 75208.
JAMA
Fresh-frozen plasma (FFP) is defined as the fluid portion of 1 unit of human blood that has been centrifuged and frozen. FFP contains components of the coagulation, fibrinolytic, and complement systems, the proteins that maintain oncotic pressure and modulate immunity, and other proteins having diverse activities. The use of FFP has increased tenfold in the past ten years reaching 2 million units annually. An effort to resolve questions sur-
Microscopically Controlled Surgical Treatment for Squamous Cell Carcinoma of the Lower Lip. Mohs FE, Snow SN. Surg Gynecol Obstet 160:37-41, 1985 Microscopically controlled surgical treatment (MCS) was developed in the 1930s to provide a means for precisely determining the margins of a primary cancer in easily accessible areas of the body. The author presents the results of 46 years of experience using MCS for squamous cell carcinomas (SCC) of the lower lip. The tech-
CURRENT LITERATURE
for the children who breathed through the mouth were as follows: 1) They had long faces. 2) Their faces were more retrognathic. 3) Their mandibles had more obtuse gonial angles. 4) Their palates were higher and narrower. 5) They were more likely to have posterior dental crossbites than children who breathed through their nose. While this evaluation substantiates the existence of long-face syndrome in children who appear to breathe predominantly through the mouth, it is suggested by the authors that a longitudinal study should be undertaken, documenting mode of breathing and variables of facial growth. Without such a study, it is impossible to be certain that orofacial abnormalities did not cause the breathing abnormalities rather than the COnVerSe.-MARION L. WAZNEY Reprint requests to Dr. Shapiro: Pediatric and Adolescent lergy. P.S., 3900 N.E. 45th St., Seattle, WA 98105. Cost Effectiveness 25213252, 1984
of Antibiotic
Al-
Use. Aldis WL. JAMA
An analysis of the cost effectiveness of antibiotic use in a small rural hospital was completed using an arbitrarily selected month that had 381 admissions. A highcost antibiotic usage group, defined as all patients for whom the cost of antibiotics was more than one standard deviation above the group mean for all patients receiving antibiotics, was identified. Of 169 patients receiving antibiotics, 38 patients were in this high-cost group. The records were reviewed to see whether a less expensive but equally effective antibiotic (or combination of antibiotics) could have been used. After review, 16 cases were identified for which a less expensive antibiotic could have been used. In many cases the cheaper antibiotic was distinctly preferable to the one actually used (e.g., using penicillin instead of cefamandole for pneumococcal pneumonia proven by Gram stain and culture). The cost of antibiotics for the 16 patients was $5.65845. If less expensive drugs had been used, the total cost would have been $2,190.25-a reduction in cost of 61%. An analysis of drugs used for the 16 patients showed that: I) Penicillin was the preferred drug for 4 patients, with no usage. 2) Semi-synthetic penicillins were preferred for 7 patients. with 1 use. 3) Cephalosporins were used for 13 patients and were indicated for only 3. Results showed that penicillin was underutilized and cephalosporins were used in excess. Further analysis showed a virtual disappearance of penicillin use in this particular hospital. In summary, this study revealed that considerable savings could be achieved by alternate antibiotic choices based on a cost effectiveness concept. It is suggested that formal reviews of antibiotic usage be completed monthly in every hospita].--CHARLES
RINCGOLD
Reprint requests to Dr. Aldis: Community Hospital, Sylva, NC. Fresh-frozen Plasma: 253~551, 1985
Indications
and Risks.
rounding the increasing use of FFP was made by convening a Consensus Development Conference in 1984. The consensus panel concluded that there is a paucity of definitive indications for FFP use to support the increasing use. This is of concern because of the potential risks of transmission of hepatitis and AIDS that FFP carries. Many patients who receive FFP can be managed more effectively and safely with alternative modalities. No justification exists for the use of FFP as a volume expander or nutritional source since safer alternatives exist. FFP is indicated for some coagulation factor de& ciencies and for some patients requiring massive transfusion. Other FFP indications include use for patients who have thrombotic thrombocytopenic purpura, protein-losing enteropathy, and certain immunodeficiencies. The article further details definitive indications for FFP use and gives alternative methods to use when FFP is not the ideal blood product available.-JAMes R. HUPP Reprint requests to Dr. Bernstein: Office of Medical Applications of Research, Bldg. I, Room 216, NIH, Bethesda. MD 20205.
Office Diagnosis of Sinus Disorders: The Role of Ultrasound Scanning. Mabry RL. Laryngoscope 94: 10421044, 1984 Ultrasound scanning for the diagnosis and management of sinus disorders has recently been introduced into the United States. In the past, transillumination, sinoscopy, sinus irrigation, and radiographs have been used with greater frequency: however, advantages and disadvantages are present for each. By evaluating the reflective impulses of the ultrasound scan, the following diagnoses are possible: normal air-containing sinus; fluid retention within the sinus; mucosal swelling with or without associated fluid; cysts; and masses. Advantages of the ultrasound scan are freedom from radiation exposure, lesser expense, speed of testing, noninvasiveness, and accuracy. Disadvantages reported concern interpretation difficulties by the novice examiner, a constantly changing scan projection, limitation to sinuses that do not have air anterior to them (lack of conduction in air), and falsenegative results due to air before actual sinus pathology is present. In practice, the ultrasound scan’s usefulness in diagnosing and following maxillary and frontal sinus secretions and the ability to differentiate these from mucosal thickenings has been illicited. With an understanding of its limitations, experience in interpretation, and the availability of other diagnostic tools mentioned, the ultrasound scan can provide invaluable interpretation in the diagnosis and management of maxillary and frontal sinus disease.-MARK W, MITCHELL Reprint requests to Dr. Mabry: 122 West Colorado, Suite 204. Dallas, TX 75208.
JAMA
Fresh-frozen plasma (FFP) is defined as the fluid portion of 1 unit of human blood that has been centrifuged and frozen. FFP contains components of the coagulation, fibrinolytic, and complement systems, the proteins that maintain oncotic pressure and modulate immunity, and other proteins having diverse activities. The use of FFP has increased tenfold in the past ten years reaching 2 million units annually. An effort to resolve questions sur-
Microscopically Controlled Surgical Treatment for Squamous Cell Carcinoma of the Lower Lip. Mohs FE, Snow SN. Surg Gynecol Obstet 160:37-41, 1985 Microscopically controlled surgical treatment (MCS) was developed in the 1930s to provide a means for precisely determining the margins of a primary cancer in easily accessible areas of the body. The author presents the results of 46 years of experience using MCS for squamous cell carcinomas (SCC) of the lower lip. The tech-