Using flowable gelatin in anterior cervical spine surgery in real-world practice: a retrospective cohort study.

AIM: To assess the clinical and economic impact of flowable gelatin hemostatic matrix (FGHM) in anterior cervical spine surgery (ACSS). PATIENTS & METHODS: A total of 451 patients with performed ACSS were included to compare FGHM with conventional hemostatic methods for clinical and cost outcomes using propensity score matching method. RESULTS: The comparisons of the matched 125 pairs observed that FGHM was associated with significantly lower blood transfusion volume (11.2 vs 36.3 ml; p = 0.039), shorter postsurgery hospital stay length (3.7 vs 4.7 days; p = 0.002), shorter operation time (103.5 vs 117.7 min; p = 0.004), lower drainage placement rate (51.2 vs 89.6%; p < 0.001) and also lower total hospital costs (median ¥64,717 vs ¥65,064; p = 0.035). CONCLUSION: Use of FGHM in ACSS improved perioperative outcomes without increasing hospital costs.

Gelatin Paste as an Alternative Cost-Effective Hemostatic Agent in Cranial Surgery: Doing More with Less.

OBJECTIVE: To present an alternative cost-effective hemostatic agent (HA) for cranial surgery and to describe the technique to produce it. METHODS: This HA has been used in 3 reference centers over the last year during 230 procedures, including different types of pathology, such as skull base, oncology, vascular, and trauma, either for endoscopic or open approaches. This agent was made from a low-cost and worldwide-available gelatin foam which was mixed with saline solution in 2 syringes and connected by a 3-way stopcock, making a useful hemostatic paste. RESULTS: The cost was 16 and 28 times less than SURGIFLO and FLOSEAL, respectively. The mean time to prepare the mix was 4 minutes. It was very effective for venous and low-flow bleeding. CONCLUSIONS: The presented technique offers a reliable and cost-effective way of achieving hemostasis in cranial surgery, therefore allowing hospitals with limited resources to perform advanced procedures in a safer way.

Cost-consequence analysis of a hemostatic matrix alone or in combination for spine surgery patients.

BACKGROUND: A five-year retrospective database analysis comparing the use of Floseal 1 flowable topical hemostat alone (F) and in combination with gelatin/thrombin (F + G/T) to achieve hemostasis and control surgical bleeding showed higher resource utilization for F + G/T cases relative to F matched pairs during spinal surgery. Lower resource use in the F group was characterized by shorter hospital length of stay and surgical time as well as fewer blood transfusions and less hemostat agent used per surgery. OBJECTIVE: To evaluate the cost-consequence of using F compared to F + G/T in minor, major and severe spinal surgery from the US hospital perspective. METHODS: A cost-consequence model was developed using the US hospital perspective. Model inputs include clinical inputs from the literature, cost inputs (hemostatic matrices, blood product transfusion, hospital stay and operating room time) from the literature, and an analysis of annual spine surgery volume (minor, major and severe) using the 2012 National Inpatient Sample (NIS) database. Costs are reported in 2017 US dollars. One-way and probabilistic sensitivity analyses address sources of variability in the results. RESULTS: A medium-volume hospital (130 spine surgeries per year) using F versus F + G/T for spine surgeries is expected to require 85 less hours of surgical time, 58 fewer hospital days and 7 fewer blood transfusions in addition to hemostat volume savings (F: 1 mL, thrombin: 1994 mL). The cost savings associated with the hospital resources for a medium-volume hospital are expected to be $317,959 (surgical hours = $154,746, hospital days = $125,237, blood transfusions = $19,023, hemostatic agents = $18,953) or $2445 per spine surgery. CONCLUSIONS: The use of F versus F + G/T could lead to annual cost savings for US hospitals performing a low to high volume of spinal surgeries per year.

Carboxymethyl Cellulose, Trichloroacetic Acid, and Unna Boot for Healing Venous Ulcers: A Comparative Study of Their Efficacy and Socioeconomic Impact.

Chronic ulcers are defined as a breakdown of the long-term cutaneous barrier or frequent recurrence of breakdowns. Dressings are a form of treatment and, in view of the variety and high cost of the products on the market, three agents were selected for this investigation, regarding their efficacy and cost/benefit ratio. The objective of the investigation was to evaluate and compare the efficacy, costs, and benefits of carboxymethylcellulose in paste at 20% (CMC 20%), trichloroacetic acid at 90% (TCA 90%), and Unna boot for treatment of chronic venous ulcers. Three groups of 30 patients each were chosen randomly for ambulatory treatment with TCA 90% (G1), CMC 20% (G2), and Unna boot (G3). The evolution of the cicatricial process of each group separately and between groups was analyzed with measurement of the lesion areas in square centimeters (cm2) and observation of the amount of exudate from observation of the photographic record, until their healing, in the maximum period of 20 weeks. A significant reduction of lesion areas in all groups was observed (P=.0001), with a median reduction of 7.6 cm2 (38.1%) for G1, 3.9 cm2 (38.8%) for G2, and 16.2 cm2 (77.8%) for G3. There was a significant difference in the absolute delta of the lesion areas (P=.0001) of the groups. The three types of treatments promoted effective improvement, with acquisition and utilization of all three products in the public health services being recommended.

Versatile, Reusable, and Inexpensive Ultrasound Phantom Procedural Trainers.

We have constructed simple and inexpensive models for ultrasound-guided procedural training using synthetic ballistic gelatin. These models are durable, leak resistant, and able to be shaped to fit a variety of simulation scenarios to teach procedures. They provide realistic tactile and sonographic training for our learners in a safe, idealized setting.

Shooting with sound: optimizing an affordable ballistic gelatin recipe in a graded ultrasound phantom education program.

OBJECTIVES: The goal of this study was to investigate the durability and longevity of gelatin formulas for the production of staged ultrasound phantoms for education. METHODS: Gelatin phantoms were prepared from Knox gelatin (Kraft Foods, Northfield, IL) and a standard 10%-by-mass ordinance gelatin solution. Phantoms were durability tested by compressing to a 2-cm depth until cracking was visible. Additionally, 16 containers with varying combinations of phenol, container type, and storage location were tested for longevity against desiccation and molding. Once formulation was determined, 4 stages of phantoms from novice to clinically relevant were poured, and clinicians with ultrasound training ranked them on a 7-point Likert scale based on task difficulty, phantom suitability, and fidelity. RESULTS: On durability testing, the ballistic gelatin outperformed the Knox gelatin by more than 200 compressions. On longevity testing, gelatin with a 0.5% phenol concentration stored with a lid and refrigeration lasted longest, whereas containers without a lid had desiccation within 1 month, and those without phenol became moldy within 6 weeks. Ballistic gelatin was more expensive when buying in small quantities but was 7.4% less expensive when buying in bulk. The staged phantoms were deemed suitable for training, but clinicians did not consistently rank the phantoms in the intended order of 1 to 4 (44%). CONCLUSIONS: Refrigerated and sealed ballistic gelatin with phenol was a cost-effective method for creating in-house staged ultrasound phantoms suitable for large-scale ultrasound educational training needs. Clinician ranking of phantoms may be influenced by current training methods that favor biological tissue scanning as easier.

Improvement of glycemic control in streptozotocin-induced diabetic rats by Atlantic salmon skin gelatin hydrolysate as the dipeptidyl-peptidase IV inhibitor.

In our previous study, Atlantic salmon skin gelatin hydrolysed with flavourzyme possessed 42.5% dipeptidyl-peptidase (DPP)-IV inhibitory activity at a concentration of 5 mg mL(-1). The oral administration of the hydrolysate (FSGH) at a single dose of 300 mg per day in streptozotocin (STZ)-induced diabetic rats for 5 weeks was evaluated for its antidiabetic effect. During the 5-week experiment, body weight increased, and the food and water intake was reduced by FSGH in diabetic rats. The daily administration of FSGH for 5 weeks was effective for lowering the blood glucose levels of diabetic rats during an oral glucose tolerance test (OGTT). After the 5-week treatment, plasma DPP-IV activity was inhibited; the plasma activity of glucagon-like peptide-1 (GLP-1), insulin, and the insulin-to-glucagon ratio were increased by FSGH in diabetic rats. The results indicate that FSGH has the function of inhibiting GLP-1 degradation by DPP-IV, resulting in the enhancement of insulin secretion and improvement of glycemic control in STZ-induced diabetic rats.

How we do it: the absorbable gelatin sponge cube, an effective and economical approach to packing in ear surgery.

INTRODUCTION: There is currently a lack of robust evidence on the best form of packing for otological surgery. We describe the use of the absorbable gelatin sponge, a packing material that does not require removal and has the benefit of being considerably cheaper compared to other common forms of ear packing. METHODS: A comparison was made of the financial cost of several forms of packing for common otological procedures. In addition, a retrospective audit of complications was undertaken of all patients in whom the absorbable gelatin sponge was used over the past three years. RESULTS: The absorbable gelatin sponge was shown to be cheaper to purchase per unit and also more economical to use. It has been the exclusive form of packing used in 519 procedures over the past three years at the William Harvey Hospital in Ashford (UK), with very few complications noted at the follow-up review. CONCLUSION: We strongly advocate using the absorbable gelatin sponge, a packing material that is kinder to the patient, has similar efficacy to other forms of packing and is also much cheaper to use compared to other common forms of packing.

Improvement of gel strength and melting point of fish gelatin by addition of coenhancers using response surface methodology.

UNLABELLED: Fish gelatin is a potential alternative to mammalian gelatin. However, poor gel strength and low melting point limit its applications. The study was aimed at improving these properties by adding coenhancers in the range obtained from response surface methodology (RSM) by using Box-Behnken design. Three different coenhancers, MgSO4, sucrose, and transglutaminase were used as the independent variables for improving the gel strength and melting point of gelatin extracted from Tiger-toothed croaker (Otolithes ruber). Addition of coenhancers at different combinations resulted gel strength and melting point in the range of 150.5 to 240.5 g and 19.5 to 22.5 °C, respectively. The optimal concentrations of coenhancers for predicted maximum gel strength (242.8 g) obtained by RSM were 0.23 M MgSO4, 12.60% sucrose (w/v), and 5.92 mg/g transglutaminase and for predicted maximum melting point (22.57 °C), the values were 0.24 M MgSO4, 10.44% sucrose (w/v), and 5.72 mg/g transglutaminase. By addition of coenhancers at these optimal concentrations in verification experiments, the gel strength and melting point were improved from 170 to 240.89 g and 20.3 to 22.7 °C, respectively. These experimental values agreed well with the predicted values demonstrating the fitness of the models. Results from the present study clearly revealed that the addition of coenhancers at a particular combination can improve the gel strength and melting point of fish gelatin to enhance its range of applications. PRACTICAL APPLICATION: There is a growing interest in the use of fish gelatin as an alternative to mammalian gelatin. However, poor gel strength and low melting point of fish gelatin have limited its commercial applications. The gel strength and melting point of fish gelatin can be increased by incorporation of coenhancers such as magnesium sulphate, sucrose, and transglutaminase. Results of this work help to produce the fish gelatin suitable for wide range of applications in the food industry.

Fish gelatin.

Gelatin is a multifunctional ingredient used in foods, pharmaceuticals, cosmetics, and photographic films as a gelling agent, stabilizer, thickener, emulsifier, and film former. As a thermoreversible hydrocolloid with a narrower gap between its melting and gelling temperatures, both of which are below human body temperature, gelatin provides unique advantages over carbohydrate-based gelling agents. Gelatin is mostly produced from pig skin, and cattle hides and bones. Some alternative raw materials have recently gained attention from both researchers and the industry not just because they overcome religious concerns shared by Jews and Muslims but also because they provide, in some cases, technological advantages over mammalian gelatins. Fish skins from a number of fish species are among the other sources that have been comprehensively studied as sources for gelatin production. Fish skins have a significant potential for the production of high-quality gelatin with different melting and gelling temperatures over a much wider range than mammalian gelatins, yet still have a sufficiently high gel strength and viscosity. Gelatin quality is industrially determined by gel strength, viscosity, melting or gelling temperatures, the water content, and microbiological safety. For gelatin manufacturers, yield from a particular raw material is also important. Recent experimental studies have shown that these quality parameters vary greatly depending on the biochemical characteristics of the raw materials, the manufacturing processes applied, and the experimental settings used for quality control tests. In this review, the gelatin quality achieved from different fish species is reviewed along with the experimental procedures used to determine gelatin quality. In addition, the chemical structure of collagen and gelatin, the collagen-gelatin conversion, the gelation process, and the gelatin market are discussed.

Coated prostheses are associated with prolonged inflammation in aortic surgery: a cost analysis.

This prospective study was conducted to compare inflammatory responses between patients receiving coated and uncoated vascular prostheses, and to examine their effect on length of stay and cost of patients undergoing abdominal aortic aneurysmectomy. Patients undergoing elective vascular reconstruction of an abdominal aortic aneurysm were assigned randomly to coated-graft or uncoated-graft groups (n = 20, for each group). Interleukin (IL)-6, granulocyte elastase, white blood cell count, C-reactive protein (CRP), and body temperature (BT) were prospectively recorded preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. In-hospital stay and hospitalized costs were also analyzed. IL-6 and CRP concentrations in the coated-graft group were higher than those in the uncoated-graft group (P = 0.01 and 0.05). BT was more frequently elevated >37 degrees C at POD 14 in the coated-graft group than in the uncoated-graft group (P =0.03). Discharge was delayed, and overall hospitalization cost was higher in the coated-graft group than in the uncoated group (17.6 vs. 13.5 days, and 2 010 000 vs. 1 780 000 yen, P = 0.006 and P = 0.002, respectively). Coated vascular prosthesis demonstrated more profound inflammatory reaction than noncoated prosthesis, postoperatively.

Hydroxyethyl starch 130/0.4 versus modified fluid gelatin for volume expansion in cardiac surgery patients: the effects on perioperative bleeding and transfusion needs.

In this prospective, randomized, open controlled study we compared the effects on net red blood cell loss of 6% hydroxyethyl starch 130/0.4 (HES: n = 64) and 3% modified fluid gelatin (GEL: n = 68) administered for intravascular volume management in patients undergoing coronary surgery. Blood losses were calculated from determination of circulating blood volume and measurement of preoperative and postoperative hematocrit. Amount of colloids that could be administered was limited to 50 mL/kg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Both groups were similar with regard to demographic and intraoperative variables. Total study drug was 48.9 +/- 17.2 mL/kg in the HES group and 48.9 +/- 14.6 mL/kg in the GEL group. Total red blood cell loss was 544 +/- 305 mL in the HES group and 504 +/- 327 mL the GEL group. Measured blood losses were also similar in both groups (HES, 19.4 +/- 12.3 mL/kg; GEL, 19.2 +/- 14.5 mL/kg). Exposure to allogeneic blood product was comparable in both groups. In the conditions of the present study, HES 130/0.4 up to 50 mL/kg is a valuable alternative to modified fluid gelatin for plasma volume expansion during and after cardiac surgery.

Cost-effectiveness of Apligraf in the treatment of venous leg ulcers.

Venous ulcers are the most common chronic wounds of the lower leg. Skin substitutes recently have been introduced to stimulate nonhealing wounds. To conduct an incremental cost-effectiveness analysis, a model was developed to compare the four-layer bandage system, with and without one application of skin substitute, for the outpatient treatment of venous leg ulcers. The model estimated the costs and consequences of treatment with and without the skin substitute application. Two analytic horizons were explored: 3 months and 6 months. Determined by seven physicians, data and assumptions for the 3-month model were based on information from a clinical trial, published studies, and clinical experience. Data for the 6-month model were extrapolated from the shorter model. The model results indicate that over 3 months, the use of the skin substitute provided a benefit of 22 ulcer days averted per patient at an incremental cost of $304 (societal). The incremental cost-effectiveness ratio was $14 per ulcer day averted. Over 6 months, the incremental cost-effectiveness ratio was less than $5 per ulcer-day averted. The skin substitute plus a four-layer bandage was more costly and more effective than the four-layer bandage alone. The skin substitute is increasingly cost-effective over a longer analytic horizon and in a subgroup of patients with ulcers of long duration (greater than 1-year duration at baseline). The results come from a model that is based on a series of estimates and assumptions, and accordingly, confirmation of this finding in a prospective study is encouraged.

Edema control in the management of disabling chronic venous insufficiency.

This study was undertaken to assess the biomedical and socioeconomic rationale of edema control in disabling chronic venous insufficiency (CVI). In this 15-year retrospective survey (1974 through 1988) edema control was achieved by use of Unna's boot for leg ulcerations and by compressive hosiery for prevention of ulcerations. The study included 2,317 self- or physician-referred patients with disabling CVI, of whom 998 presented with venous stasis ulcers, many with recurrent ulcerations. Two hundred thirty-six patients were seen and treated only once and never returned. They were listed as not healed. Including patients who never returned after the first visit, the overall healing rate was 60.9%. Excluding the nonreturning patients, the overall rate of verified healing was 73.3%. The healing rate was 91% for first ulcers of complaint patients (patients treated at least 12 times in 32 weeks). The Unna's boot, being a functional substitute for the failing muscle pump in CVI, is a noninvasive and ambulatory method of controlling edema and treating ulcers in CVI. It does not interfere with patients' activities, it is inexpensive, and it is adaptable to middle aged and elderly ambulatory populations.