Matched cohort study evaluating the hemostatic efficacy of fibrin sealant versus conventional approaches following dental surgery in patients with hemophilia.

Patients with hemophilia frequently require supplementary interventions, either invasive (suturing, gel foam, or cauterization) or non-invasive (fibrin sealant/glue), to attain hemostasis post dental procedures. This study aimed to compare the efficacy of fibrin sealant against traditional methods for achieving hemostasis post dental surgery. The medical records of patients with factor VIII or IX deficiency, or von Willebrand disease, who underwent dental procedures in the Department of Dentistry, Seth GSMC and KEM Hospital, were evaluated for inclusion in this retrospective matched cohort study. Cohort-1 included those treated with a fibrin sealant (Tisseel Lyo) with/without traditional hemostatic measures post-procedure, while cohort-2 (controls) included those in whom no fibrin sealant was used. A total of 128 patients, 64 in each group, were evaluated. There was no statistically significant difference in demographics, disease-related variables, dental complaints, or preoperative treatment given between the groups. However, there was a significant reduction (P < 0.001) in the requirement for secondary procedures for hemostasis (suturing, gel foam application, and/or cauterization) and postoperative requirement for factor replacement (P = 0.003) in the fibrin glue group as compared to the controls. In this study, fibrin sealant demonstrated superior efficacy in mitigating the necessity for active hemostasis control.

Donor site wound healing following free gingival graft surgery using platelet rich fibrin: A randomized controlled trial.

BACKGROUND: The primary purpose of this two-arm, parallel design, randomized controlled study is to compare healing of the palatal tissue donor site when platelet-rich fibrin (PRF) is used as a wound dressing compared to the use of a hemostatic agent. Secondary outcomes of patient pain perception and analgesic intake were also evaluated. METHODS: Seventy-four patients receiving free gingival grafts were randomized to receive either PRF (test) or hemostatic agent (control) as a palatal wound dressing by patients selecting a sealed envelope containing their group assignment (initially 37 envelopes for PRF group and 37 for hemostatic agent group). Patient pain assessment and analgesic consumption were documented using a 21-point numerical scale (NMRS-21) at 24, 48, and 72 hours post-surgery. At 1-, 2-, 3-, and 4-week follow-up appointments palatal early healing index (PEHI) scores including wound color, epithelialization, presence or absence of swelling, granulation tissue, and bleeding on gentle palpation were generated by direct intraoral examination by a blinded examiner unaware of the patients' treatment group. RESULTS: NMRS-21 pain scores showed a significant reduction in pain over time in both groups, with no significant difference between groups at any time point. No significant between-group difference was found in the amount of analgesics taken by patients at 24, 48, and 72 hours. There was significant improvement in PEHI scores over the 4-week time period in both groups, but there was no significant difference in PEHI score at each time point (1, 2, 3, 4 weeks) between groups.  CONCLUSIONS: Study findings suggest that there is no difference in early palatal wound healing, patient pain perception, or analgesic consumption between use of PRF or a hemostatic agent as donor-site wound dressings.

Effect of Thrombin-Containing Local Hemostatics on Postoperative Spinal Epidural Hematoma in Biportal Endoscopic Spinal Surgery.

STUDY DESIGN: Retrospective case-control study. PURPOSE: This study aimed to investigate the preventive effect of thrombin-containing local hemostatics (TCLH) on postoperative spinal epidural hematoma (POSEH) in biportal endoscopic spinal surgery (BESS). This study compared the incidence of morphometric and symptomatic POSEH with or without TCLH in BESS. OVERVIEW OF LITERATURE: POSEH is reported not uncommon in BESS when compared with conventional spine surgery (CSS). TCLH achieves hemostasis with a high success rate in CSS. However, few studies have examined the effect of TCLH on BESS. METHODS: Patients with and without TCLH were assigned to groups A and B, respectively. POSEH between the two groups was compared morphometrically and symptomatically. The risk factors for symptomatic and morphometric POSEH in BESS were identified. RESULTS: The morphometric POSEH was greater in group B, and the difference was significant (p =0.019). The incidence of symptomatic POSEH was lower in group A with 4.6% (5/109) than in group B with 9.5% (9/95); however, the rate was not significantly different (p =0.136). The morphometric POSEH was classified into two small (hG1 and hG2) and large (hG3 and hG4) and were compared between groups A and B, and the difference was significant (p =0.02). In the multivariable logistic regression, nonuse of TCLH (p =0.004) and preoperative diagnosis of stenosis (p =0.016) were variables found to be significant risk factors of morphometric POSEH. CONCLUSIONS: Severe compression of the thecal sac by POSEH is more common in patients without TCLH. The risk of hematoma formation was higher when bilateral decompression was needed and the cut bone surface was more exposed.

Is spleen-preserving surgery safe for abdominal trauma?

BACKGROUND: Treatment of splenic trauma is currently based on non-surgical treatment or the use of interventional radiology. The conservative surgery of the spleen in splenic trauma remains marginal. OBJECTIVE: To analyze the safety and efficacy of conservative surgical treatment in splenic trauma. METHOD: A retrospective study was performed over a 16-year period with the intention of recording the diagnostic and therapeutic attitude in a second level hospital, focusing on patients who received conservative splenic surgical treatment for splenic trauma, excluding splenectomies and non-surgical treatment. RESULTS: 110 patients presented splenic trauma. Spleen-sparing surgery was performed in 15 patients. The grades of splenic lesions were: 1 patient with grade I, 1 patient with grade II, 7 patients with grade III and 6 patients with grade IV. Surgical treatment was splenorrhaphy in 5 patients (33%), hemostatic agents and polyglycolic acid mesh in 4 (26%), partial splenectomy with placement of polyglycolic acid mesh in 3 (20%), partial splenectomy in 2 (13%), and electrocautery in 1 (6%). None of the patients initially treated with conservative surgery required posterior splenectomy and no patient died. CONCLUSION: We provide evidence supporting the usefulness and safety of conservative splenic surgery in splenic trauma, which would have its place in grades II, III and IV trauma in health centers that do not have urgent interventional radiology.

ANTECEDENTES: El tratamiento del traumatismo esplénico se basa en medidas conservadoras no quirúrgicas o en el uso de radiología intervencionista. La cirugía conservadora del bazo en el traumatismo esplénico sigue siendo inusual. OBJETIVO: El análisis de seguridad y eficacia del tratamiento quirurgico conservador en el traumatismo esplénico. MÉTODO: Se realizó un estudio retrospectivo durante un período de 16 años con la intención de registrar la actitud diagnóstica y terapéutica en un hospital de segundo nivel, enfocándose en los pacientes que recibieron tratamiento quirúrgico conservador esplénico por traumatismo esplénico, excluyendo esplenectomías y tratamientos no quirúrgicos. RESULTADOS: 110 pacientes presentaron traumatismo esplénico. La cirugía conservadora esplénica se realizó en 15 pacientes. Los grados de lesiones esplénicas fueron: 1 paciente con grado I, 1 paciente con grado II, 7 pacientes con grado III y 6 pacientes con grado IV. El tratamiento quirúrgico fue esplenorrafia en 5 pacientes (33%), agentes hemostáticos y malla de ácido poliglicólico en 4 (26%), esplenectomía parcial con colocación de malla de ácido poliglicólico en 3 (20%), esplenectomía parcial en 2 (13%) y hemostasia con electrocauterio en 1 (6%). Ninguno de los pacientes tratados inicialmente con cirugía conservadora requirió esplenectomía posterior y ningún paciente falleció. CONCLUSIONES: La cirugía conservadora esplénica puede ser útil y segura en traumatismos esplénicos, la cual tendría su lugar en traumatismos de grados II, III y IV en centros hospitalarios en los que no se cuente con radiología intervencionista urgente.

Exploring Hematoma Expansion Shift With Recombinant Factor VIIa: A Pooled Analysis of 4 Randomized Controlled Trials.

BACKGROUND: Hematoma expansion shift (HES) analysis can be used to assess the biological effect of a hemostatic therapy for intracerebral hemorrhage. In this study, we applied HES analysis to individual patient data from 4 randomized controlled trials evaluating rFVIIa (recombinant factor VIIa) 80 µg/kg to placebo. METHODS: We generated polychotomous strata of HES using absolute growth thresholds (≤0/<6/≥6 mL) and quintiles of percent volume change. The relationship between treatment and HES was assessed using proportional odds models. Differences in subgroups based on baseline volume (≥ or <20 mL), and time from symptom onset to treatment (≤ or >2 hours) were explored with testing for interactions. RESULTS: The primary analysis included 721 patients. At 24 hours, 36% (134/369) of rFVIIa-treated patients exhibited no hematoma expansion as compared with 25% of placebo (88/352)-treated patients. Significant expansion (≥6 mL) was reduced by 10% in those treated with rFVIIa-(adjusted common odds ratio [acOR], 0.57 [95% CI, 0.43-0.75]). An examination of percent change similarly showed a shift across the spectrum of expansion (acOR, 0.61 [95% CI, 0.47-0.80]). In both groups, mild-to-moderate expansion was observed in 38% to 47% of patients, depending on the threshold used. Differences in absolute HES between the rFVIIa and placebo groups were more pronounced in patients with baseline hemorrhage volumes ≥20 mL (acOR, 0.48 [95% CI, 0.30-0.76] versus <20 mL: acOR, 0.67 [95% CI, 0.47-0.95]; Pinteraction=0.02). No treatment interaction in patients treated within 2 or after 2 hours from onset was observed (acOR, 0.42 [95% CI, 0.19-0.91 versus >2 hours: acOR, 0.59 [95% CI, 0.44-0.79]; Pinteraction=0.30). CONCLUSIONS: The association between rFVIIa and hematoma growth arrest is most pronounced in patients with larger baseline volumes but is evident across the full spectrum of treated patients.

Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study.

Background: Restoring hemostasis in patients on oral anticoagulants presenting with major hemorrhage (MH) or before surgical intervention has changed, with the replacement of vitamin K antagonist (VKA) with direct oral anticoagulants (DOACs). Objectives: To observe the difference in urgent hemostatic management between patients on VKA and those on DOACs. Methods: A multicenter observational study evaluated the variation in laboratory testing, hemostatic management, mortality, and hospital length of stay (LOS) in patients on VKA or DOACs presenting with MH or urgent hemostatic restoration. Results: Of the 1194 patients analyzed, 783 had MH (61% VKA) and 411 required urgent hemostatic restoration before surgery (56% VKA). Compared to the international normalized ratio (97.6%), plasma DOAC levels were measured less frequently (<45%), and the time taken from admission for the coagulation sample to reach the laboratory varied widely (median, 52.3 minutes; IQR, 24.8-206.7). No significant plasma DOAC level (<50 ng/mL) was found in up to 19% of patients. There was a poor relationship between plasma DOAC level and the usage of a hemostatic agent. When compared with patients receiving VKA (96.5%) or dabigatran (93.7%), fewer patients prescribed a factor Xa inhibitor (75.5%) received a prohemostatic reversal agent. The overall 30-day mortality for MH (mean: 17.8%) and length of stay (LOS) (median: 8.7 days) was similar between VKA and DOAC patients. Conclusion: In DOAC patients, when compared to those receiving VKA, plasma DOAC levels were measured less frequently than the international normalized ratio and had a poor relationship with administering a hemostatic reversal agent. In addition, following MH, mortality and LOS were similar between VKA and DOAC patients.

Trends, Cost, and Predictors of Local Hemostatics Use in Major Urological Surgery.

INTRODUCTION: The national usage and cost trends associated with hemostatic agents in major urologic procedures remain unknown. This study aims to describe the trends, costs, and predictors of local hemostatic use in major urologic surgeries. METHODS: We utilized the Premier Healthcare Database to analyze 385,261 patient encounters between 2000 and 2020. Our primary objective was to describe the usage patterns of topical hemostatic agents in open and laparoscopic/robotic major urological surgeries. The data from the last 5 years (2015-2020) were used to characterize specific cost trends, and multivariable regression analysis was performed to identify predictors of hemostatic agent use in relation to surgical approach, patient, and hospital characteristics. RESULTS: By 2020, at least 1 topical hemostatic agent was used in 37.3% (95% CI: 35.5-39.1) of laparoscopic/robotic prostatectomies and 30.7% (95% CI: 24.2-37.1) of open prostatectomies; 60.8% (95% CI: 57.6-64.1) of laparoscopic/robotic partial nephrectomies and 55.9% (95% CI: 47.3-64.5) of open partial nephrectomies; 40.7% (95% CI: 36.9-44.3) of laparoscopic/robotic radical nephrectomies and 43.2% (95% CI: 38.8-47.6) of open radical nephrectomies; and 40.52% (95% CI: 35.02-46.02) of open radical cystectomies. For the 2015-2020 cohort, predictors for hemostatic agent use varied by surgery type and included gender, race, surgical approach, insurance coverage, geographical location, urbanicity, and attending volume. The cost of the hemostatic agent accounted for less than 1.6% of the total cost of hospitalization for each procedure. CONCLUSIONS: The use of hemostatic agents in major urologic surgeries has grown over the past 2 decades. For all procedures, the specific cost of using a hemostatic agent constitutes a small fraction of the total hospitalization cost and does not vary significantly between open and laparoscopic/robotic approaches. Some patient, surgeon, and hospital characteristics are highly correlated with their use.

The role of hemostatic agents after tooth extractions: A systematic review and meta-analysis.

BACKGROUND: Hemostatic agents are used to control bleeding after tooth extraction and have been compared with conventional measures (that is, sutures or gauze pressure) in several studies. The objective of this systematic review was to evaluate the benefits of topical hemostatic agents for controlling bleeding after tooth extractions, especially in patients receiving antithrombotic therapy. TYPES OF STUDIES REVIEWED: The authors conducted a literature search in MEDLINE (PubMed), Scopus, and the Cochrane Central Register of Controlled Trials, including prospective human randomized clinical trials in which researchers compared hemostatic agents with conventional methods and reported the time to achieve hemostasis and postoperative bleeding events. RESULTS: Seventeen articles were eligible for inclusion. Hemostatic agents resulted in a significantly shorter time to achieve hemostasis in both healthy patients and patients taking antithrombotic drugs (standardized mean difference, -1.02; 95% CI, -1.70 to -0.35; P = .003 and standardized mean difference, -2.30; 95% CI, -3.20 to -1.39; P < .00001, respectively). Significantly fewer bleeding events were noted when hemostatic agents were used (risk ratio, 0.62; 95% CI, 0.44 to 0.88; P = .007). All forms of hemostatic agents (that is, mouthrinse, gel, hemostatic plug, and gauze soaked with the agent) had better efficacy in reducing the number of postoperative bleeding events than conventional hemostasis measures, except for hemostatic sponges. However, this was based on a small number of studies in each subgroup. CONCLUSIONS: The use of hemostatic agents seemed to offer better bleeding control after tooth extractions in patients on antithrombotic drugs than conventional measures. PRACTICAL IMPLICATIONS: Findings of this systematic review may help clinicians attain more efficient hemostasis in patients requiring tooth extraction. This systematic review is registered in the PROSPERO database. The registration number is CRD42021256145.

Clot Waveform Analysis for Hemostatic Abnormalities.

Clot waveform analysis (CWA) observes changes in transparency in a plasma sample based on clotting tests such as activated partial thromboplastin time (APTT), prothrombin time (PT), and thrombin time (TT). Evidence indicates that not only an abnormal waveform but also peak times and heights in derivative curves of CWA are useful for the evaluation of hemostatic abnormalities. Modified CWA, including the PT with APTT reagent, dilute PT (small amount of tissue factor [TF]-induced clotting factor IX [FIX] activation; sTF/FIXa), and dilute TT, has been proposed to evaluate physiological or pathological hemostasis. We review routine and modified CWA and their clinical applications. In CWA-sTF/FIXa, elevated peak heights indicate hypercoagulability in patients with cancer or thrombosis, whereas prolonged peak times indicate hypocoagulability in several conditions, including clotting factor deficiency and thrombocytopenia. CWA-dilute TT reflects the thrombin burst, whereas clot-fibrinolysis waveform analysis reflects both hemostasis and fibrinolysis. The relevance and usefulness of CWA-APTT and modified CWA should be further investigated in various diseases.

Effect of an aluminum chloride hemostatic agent on the dentin shear bond strength of a universal adhesive.

Objectives: This study investigated the effect of an aluminum chloride hemostatic agent on the shear bond strength (SBS) of a universal adhesive to dentin. Materials and Methods: Eighty extracted human molars were trimmed at the occlusal dentin surfaces and divided mesiodistally. According to hemostatic agent application, specimens were randomly allocated into control (C) and hemostatic agent (Traxodent; H) groups. Each group was divided into 4 subgroups according to the adhesive system (n = 20): Scotchbond Multi-Purpose (SBER), Clearfil SE Bond (CLSE), All-Bond Universal etch-and-rinse mode (ALER), and All-Bond Universal self-etch mode (ALSE). SBS was measured for half of the specimens at 24 hours, and the other half were thermocycled in water baths (group T). Fracture surfaces were examined to determine the failure mode. The SBS was measured, and data were analyzed using 1-way analysis of variance, the Student's t-test, and the Tukey honestly significant difference test (p = 0.05). Results: No significant differences in SBS were found between groups C and H for any adhesive system at 24 hours. After thermocycling, a statistically significant difference was observed between CT+ALSE and HT+ALSE (p < 0.05). When All-Bond Universal was applied to hemostatic agent-contaminated dentin, the SBS of H+ALSE was significantly lower than that of H+ALER (p < 0.05). The SBER subgroups showed no significant differences in SBS regardless of treatment and thermocycling. Conclusions: When exposed dentin was contaminated by an aluminum chloride hemostatic agent before dentin adhesive treatment, application of All-Bond Universal in etch-and-rinse mode was superior to self-etch mode.

Influence of bone wax on bone healing: a case report and literature review.

The purposes of this article are to report the clinical case of a patient who exhibited a foreign body reaction associated with the use of bone wax after extraction of an impacted third molar and to present an integrative literature review addressing the possible influences of this hemostatic agent on bone healing. A 26-year-old woman who underwent the extraction of her mandibular right third molar developed intense alveolar bleeding during surgery, requiring the use of bone wax. In the 2-month postoperative period, the patient presented with intraoral edema and discharge of a purulent secretion via the alveolar route. After cone beam computed tomographic images revealed increased hyperdensity inside the alveolus, alveolar curettage was performed and the material that was obtained was submitted to histopathologic examination. The results of the histopathologic analysis proved conclusive for an inflammatory foreign body reaction associated with exogenous material. A search of the PubMed, SciELO, and LILACS databases identified 22 studies that evaluated the influence of this hemostatic agent on bone healing, and an integrative review involving 367 animals and 75 humans was compiled. Bone wax is a nonresorbable material capable of negatively influencing bone healing. It is suggested that the product be used cautiously in amounts that are just enough to promote the sealing of the bone channels.

Peri-operative hemostatic management of tooth extraction in patients with hemophilia A, with and without inhibitors, receiving emicizumab prophylaxis.

INTRODUCTION: Emicizumab treatment may allow patients with hemophilia A without (PwHA) and with inhibitors (PwHA-I) to undergo some minor surgeries, such as tooth extraction, without peri-operative factor infusions. However, criteria for determining the necessity of factor infusions before minor surgeries are unknown. AIM: We report the peri-operative hemostatic management and outcomes of emicizumab-treated PwHA and PwHA-I cases who underwent tooth extractions using our institutional protocol. METHODS: We retrospectively evaluated PwHA and PwHA-I who underwent tooth extraction with emicizumab prophylaxis at our institution. Local bleeding risk was assessed based on the method, number, and site of tooth extraction. Hemostasis was monitored peri-operatively by rotational thromboelastometry (ROTEM). Hemostatic agents and a mouth splint were used. RESULTS: Twenty-nine extractions (17 interventions) were performed in eight PwHA and two PwHA-I. Based on ROTEM, pre-operative factor infusions were used in ten PwHA and four PwHA-I interventions. Among nine low local bleeding risk interventions, three (33.3%) each received no infusions, one dose of factor infusion pre-operatively, and pre- and post-operative factor infusions. All eight high local bleeding risk interventions involved planned factor infusions. Absorbable hemostats were used in all extractions. A mouth splint was used in 21/25 (84.0%) PwHA and in 4/4 (100%) PwHA-I extractions. No post-extraction bleeding or thrombotic events occurred. CONCLUSIONS: Use of a systemic hemostatic treatment plan according to the local bleeding risk, peri-operative coagulation status assessment using ROTEM, filling the extraction socket with hemostats, and use of a mouth splint can achieve effective and safe hemostatic management in emicizumab-treated PwHA and PwHA-I.

Efficacy of gelatamp in controlling the postoperative sequelae following mandibular posterior teeth extraction - A split-mouth study.

Purpose: This study aimed to evaluate the effectiveness of gelatamp on soft tissue healing, bleeding, and pain following mandibular posterior teeth extraction. Methods: This study was designed as a split-mouth, prospective randomized double-blind controlled trial conducted in a single tertiary care center. Thirty-five subjects indicated for routine mandibular posterior teeth extraction were divided into two groups using the lottery technique: the experimental group (n = 30), which received gelatamp after extraction, and the control group (n = 30), which received no intervention. The primary outcomes included soft tissue healing(Landry, Turnbull, Howley index) and Pain(VAS score). The secondary outcomes assessed were bleeding(Maani et al. index) and swelling(Sauza and Consone assessment). Result: The results showed a statistically significant difference in soft tissue healing on the third and seventh days in the experimental group (p ≤ 0.05) than in the control group. A significant difference in bleeding scores at 5 min, 30 min, and 2 h postoperatively in the study group (p ≤ 0.05) was noted. There was no significant difference between the groups for pain on the first, third or seventh day postoperatively (p ≤ 0.05). The swelling assessment also showed no significant changes (p = 0.831) for the study and the control group. Conclusion: Based on the findings of this study, gelatamp can be effectively used to reduce postoperative sequelae such as bleeding with better soft tissue healing following extractions and surgical removal of tooth.

Effect of Hemostatic Agents on Shear Bond Strength of Orthodontic Eyelets Bonded with Conventional and Self-etch Adhesives.

Statement of the Problem: The risk of debonding of the orthodontic eyelets due to blood contamination from the impacted tooth is a clinical problem that orthodontists face routinely. Purpose: This study aimed to assess the effect of hemostatic agents (Viscostat clear and Astringedent X) on shear bond strength (SBS) of orthodontic eyelets bonded with conventional (Transbond XT) and universal adhesive (GC-G Premio bond) adhesives. Materials and Method: In this experimental study, 84 freshly extracted bovine lower incisors were randomly divided into 7 groups namely TBXT, Blood, SEP, VISCO + TBXT, VISCO + SEP, ASTX + TBXT, and ASTX + SEP groups. In the TBXT group, teeth were etched with phosphoric acid gel, and then, the Transbond XT primer was applied and eyelets were bonded with Transbond XT. In the blood group, first, contamination with blood was done followed by the same procedure as TBXT. In other groups, the teeth were etched with phosphoric acid and based on their group allocation, Transbond XT primer (in TBXT groups), GC-G Premio Bond (in SEP groups), ViscoStat Clear gel (in VISCO groups), or Astringedent X (in ASTX groups) were applied. The SBS was measured for each group and the adhesive remnant index (ARI) was determined. Results: The mean SBS was 20.79 MPa in VISCO+SEP group, 19.2 MPa in the TBXT group, 16.06 MPa in the SEP group, 15.43 MPa in VISCO+TBXT group, 9.39 MPa in AST-X+TBXT group, and 1.62 MPa in the blood group. The SBS of ASTX+SEP, blood and TBXT+ASTX groups had significant differences from the SBS of the control group (p< 0.05). The ARI score of 0 had the highest frequency in the blood group. Conclusion: Due to the high coagulative effect of Astringedent X and acceptable SBS of Astringedent X in combination with GC-G Premio bond, this combination can be recommended for exposure of impacted teeth that are at high risk of blood contamination.

Physician and Hospital-level Variation in Hemostatic Agent Use in Benign Gynecologic Procedures.

STUDY OBJECTIVE: To identify recent nationwide trends in hemostatic agent (HA) use and to explore factors associated with HA use in 3 benign gynecologic surgery contexts: isolated hysterectomy, pelvic organ prolapse repair, and anti-incontinence surgery. DESIGN: Retrospective cohort study. SETTING: Vizient Clinical Database. PATIENTS: Three cohorts of female patients of ≥18 years who underwent benign isolated hysterectomy, pelvic organ prolapse repair, or anti-incontinence procedures were identified between October 2015 and December 2019. INTERVENTIONS: HAs are topically applied procoagulant products used for surgical hemostasis and use during included encounters was determined by charge codes. MEASUREMENTS AND MAIN RESULTS: Subject-, hospital-, and surgeon-level characteristics and costs were captured. Data were initially analyzed in the aggregate and based on procedure category using the chi-square test or independent samples t tests as appropriate. A bootstrap forest model was used to identify the factors most predictive of HA use. In the final cohort of 184 070 encounters, HAs were used most frequently in hysterectomy (20.7%) and least in anti-incontinence surgery (10.9%). The use of HAs increased from 15.6% in quarter 4 2015 to 19.2% in quarter 4 2019 (p <.001). Encounters using HAs cost more than encounters without HAs ($6271.10 vs $4572.00; p <.001). A bootstrap forest model inclusive of all variables found surgeon and hospital identity cumulatively predictive of 84.9% of HA use, 65.5% and 19.4%, respectively. There was significant variation in HA use among individual surgeons, with 59.9% never using HAs. Of those who did use HAs, 72.8% used HAs more frequently than the mean provider HA use rate (19.4%) and 9.2% used HAs in every case he/she performed. CONCLUSION: The significant variation in HA use is driven primarily by physician and hospital identity, suggesting that use of HA in these benign gynecologic surgical contexts may be determined more by physician- and hospital-level factors than patient-level factors.

Comparative Evaluation of the Effectiveness of a Combination of Absorbable Gelatin Sponge and Calendula officinalis with Absorbable Gelatin Sponge Used Alone as a Hemostatic Agent-An In-Vitro Study.

Excessive bleeding can complicate surgical intervention; this could be managed using an effective hemostatic agent that provides immediate and early bleeding control. Gelatin sponge and Calendula officinalis have been proven to have good hemostatic properties. The present In-vitro study analyzed the cytotoxicity and hemostatic properties of gelatin sponge and Calendula officinalis. The cytotoxic concentration/effective concentration of Calendula officinalis was determined by MTT (3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide) assay. The drug release was determined using a vertical Franz diffusion cell apparatus; solid-state characterization was assessed using Fourier-transform infrared spectroscopy (FTIR) and a differential scanning calorimeter (DSC). The MTT assay showed 7% Calendula officinalis to be cytocompatible, and there was an increase in cell proliferation. When the 7% Calendula officinalis was loaded into the sponge, it was compatible, and the drug content was found to be 56.28 ± 13.84%. The time taken for the blood clot formation was measured using the Lee-White method. The gelatin sponge's time for clot formation was 161.70 ± 3.11 s, and the Calendula officinalis loaded gelatin sponge's time for clot formation was 158.75 ± 4.60 s. Hence, it could be concluded that when Calendula officinalis is incorporated into a gelatin sponge, it shows material compatibility and cytocompatibility, reduces the time for clot formation, and could be used as an alternative to other hemostatic agents.

[Hemostatic efficacy of tranexamic acid and ε-aminocaproic acid in hip and knee arthroplasty:a Meta-analysis].

OBJECTIVE: To systematically evaluate the hemostatic efficacy of tranexamic acid and ε-aminocaproic acid in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Randomized controlled trials (RCT) and retrospective case-control studies about tranexamic acid and ε-aminocaproic acid for the comparison of THA or TKA were searched electronically in PubMed, EMbase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, VIP from the time of building databases to July 2020. Two investigators carried out literature screening and data extraction according to the inclusion and exclusion criteria respectively. The methodological quality of the included randomized controlled studies was evaluated through the Cochrane Handbook, and the methodological quality of the included retrospective case-control studies was evaluated through the NOS scale. Blood loss, the incidence of thrombosis complications, per capita input of hemoglobin were Meta-analyzed by Review Manager 5.3 software. RESULTS: A total of 6 articles were included, including 4 RCTs and 2 retrospective case-control studies. A total of 3 174 patients, including 1 353 in the tranexamic acid group and 1 821 in the ε-aminocaproic acid group. Meta-analysis results showed that there were no difference statistical significance in blood loss [MD=-88.60, 95%CI(-260.30, 83.10), P=0.31], blood transfusion rate [OR=1.48, 95%CI(0.96, 2.27), P=0.08], thrombotic complications [OR=0.80, 95%CI(0.07, 8.83), P=0.85], per capita hemoglobin input [MD=0.04, 95%CI(-0.02, 0.10), P=0.18] between tranexamic acid group and ε-aminocaproic acid group during THA. While in TKA, the blood loss of the tranexamic acid group was less than that of the ε-aminocaproic acid group [MD=-147.13, 95%CI(-216.52, -77.74), P<0.0001], the difference was statistically significant. The blood transfusion rate [OR=1.30, 95%CI(0.74, 2.28), P=0.37], thrombotic complications [OR=0.95, 95%CI(0.38, 2.36), P=0.92], per capita hemoglobin input [MD=-0.00, 95%CI(-0.05, 0.06), P=0.48], tourniquet time [MD=1.54, 95%CI(-2.07, 5.14), P=0.40] were similar between two groups, the difference was not statistically significant. CONCLUSION: In THA, tranexamic acid and ε-aminocaproic acid have similar hemostatic effects, while in TKA, tranexamic acid can effectively reduce the patient's blood loss and has a better hemostatic effect. Tranexamic acid is recommended as one of the first choice hemostatic drugs for TKA.

Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations.

Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.

Experimental Evaluation of Chitosan Membrane and Collagen Sponge (TachoSil®) as Sealants in Cardiovascular Surgery.

INTRODUCTION: The objectives of this study are to experimentally evaluate the haemostatic effects of two organic substances, a membrane of chitosan and a collagen sponge coated with thrombin and human fibrinogen (TachoSil®), in sealing 7-0 needle stitches holes on the femoral arteries of rats as well as to evaluate local histological reactions. METHODS: Twenty-four rats were included, and four holes were made in each common femoral artery. In the control group, haemostasis was achieved only by compression with gauze sponge; and in the two other groups, haemostasis was achieved with application of one of these two substances. RESULTS: Membrane of chitosan and TachoSil® showed a power to reduce the time to achieve haemostasis compared with the control group (P=0.001), and the haemostatic effects of these two substances were comparable. There was lower blood loss in the groups where these two substances were used when compared with the control group, but no difference was found comparing the two substances. CONCLUSION: The use of these sealants did not promote more adhesion or local histological reactions when compared to the control group. Since chitosan is easy to find in nature, has a positive effect to promote haemostasis, and did not bring considerable local reactions, it might be used as a sealant in cardiovascular surgery.

Experimental Evaluation of Chitosan Membrane and Collagen Sponge (TachoSil®) as Sealants in Cardiovascular Surgery

ABSTRACT Introduction: The objectives of this study are to experimentally evaluate the haemostatic effects of two organic substances, a membrane of chitosan and a collagen sponge coated with thrombin and human fibrinogen (TachoSil®), in sealing 7-0 needle stitches holes on the femoral arteries of rats as well as to evaluate local histological reactions. Methods: Twenty-four rats were included, and four holes were made in each common femoral artery. In the control group, haemostasis was achieved only by compression with gauze sponge; and in the two other groups, haemostasis was achieved with application of one of these two substances. Results: Membrane of chitosan and TachoSil® showed a power to reduce the time to achieve haemostasis compared with the control group (P=0.001), and the haemostatic effects of these two substances were comparable. There was lower blood loss in the groups where these two substances were used when compared with the control group, but no difference was found comparing the two substances. Conclusion: The use of these sealants did not promote more adhesion or local histological reactions when compared to the control group. Since chitosan is easy to find in nature, has a positive effect to promote haemostasis, and did not bring considerable local reactions, it might be used as a sealant in cardiovascular surgery.