Bumping to a rollator walker: How pretibial hematomas create more costs than pretibial lacerations.

Pretibial lacerations (PL) and pretibial hematomas (PH) are debilitating traumas among the elderly and infirm. The injuries are frequently grouped together despite differences in treatment and symptoms. Patients are known to have multiple contacts in health care, perhaps because of inadequate treatment. Despite the burden, financial costs have not been assessed. Calculate and compare the treatment costs of PLs and PHs for differences and provide economic incentives to treat and diagnose patients optimally. From linkage to ICD10 diagnoses, we analysed NordDRG product invoices generated by the treatment of the patients. We calculated and compared the costs of treatment in both cohorts from the invoices. This method has not been previously used for analysing wound care costs. Mean treatment costs were 1800€ (PL) and 3300€ (PH). The total costs, emergency room, surgical treatment, and inpatient care of PHs were higher than PLs (P = .0486, P = .0002, P = .0058, P = .6526). PLs generate more costs from the outpatient clinic but were not statistically significant (P = .6533). PHs cause a higher economic burden than PLs. Costs arise from repeat ER visits and the need for surgeries because of delayed treatment. PLs have multiple contacts in the wound clinic. Improvement in the diagnosis and treatment of both injuries is needed.

Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns.

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

Population-Based Assessment of Aortic-Related Outcomes in Aortic Dissection, Intramural Hematoma, and Penetrating Aortic Ulcer.

BACKGROUND: The aim of the study was to analyze aortic-related outcomes after diagnosis of aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer (PAU) from a population-based approach. METHODS: Retrospective review of an incident cohort of AD, IMH, and PAU patients in Olmsted County, Minnesota from 1995 to 2015. Primary end point was aortic death. Secondary end points were subsequent aortic events (aortic intervention, new dissection, or rupture not present at presentation) and first-time diagnosis of an aortic aneurysm. Outcomes were compared with randomly selected population referents matched for age and sex in a 3:1 ratio using Cox proportional hazards regression adjusting for comorbidities. RESULTS: Among 133 patients (77 AD, 21 IMH, and 35 PAU), 57% were males, and mean age was 71.8 years (standard deviation, 14). Median follow-up was 10 years. Of 73 deaths among AD/IMH/PAU patients, 23 (32%) were aortic-related. Estimated freedom from aortic death was 84%, 80%, and 77% at 5, 10, and 15 years. There were no aortic deaths among population referents (adjusted hazard ratio [HR] for aortic death in AD/IMH/PAU, 184.7; 95% confidence interval [95% CI], 10.3-3,299.2; P < 0.001). Fifty (38%) AD/IMH/PAU patients had a subsequent aortic event (aortic intervention, new dissection, or rupture), whereas there were 8 (2%) aortic events among population referents (all elective aneurysm repairs; adjusted HR for any aortic event and aortic intervention in AD/IMH/PAU patients, 33.3; 95% CI, 15.3-72.0; P < 0.001 and 31.5; 95% CI, 14.5-68.4; P < 0.001, respectively). After excluding aortic events/interventions ≤14 days of diagnosis, AD/IMH/PAU patients remained at increased risk of any aortic event (adjusted HR, 10.8; 95% CI, 3.9-29.8; P < 0.001) and aortic intervention (adjusted HR, 9.6; 95% CI, 3.4-26.8; P < 0.001). Among those subjects with available follow-up imaging, the risk of first-time diagnosis of aortic aneurysm was significantly increased for AD/IMH/PAU patients when compared with population referents (adjusted HR, 10.9; 95% CI, 5.4-21.7; P < 0.001 and 8.3; 95% CI, 4.1-16.7; P < 0.001 for thoracic and abdominal aneurysms, respectively) and remained increased when excluding aneurysms that formed within 14 days of AD/IMH/PAU (adjusted HR, 6.2; 95% CI, 1.8-21.1; P = 0.004 and 2.8; 95% CI, 1.0-7.6; P = 0.040 for thoracic and abdominal aneurysms, respectively). CONCLUSIONS: AD/IMH/PAU patients have a substantial risk of aortic death, any aortic event, aortic intervention, and first-time diagnosis of aortic aneurysm that persists even when the acute phase (≤14 days after diagnosis) is uncomplicated. Advances in postdiagnosis treatment are necessary to improve the prognosis in these patients.

Perioperative Care Considerations and Management of Complications Involving Surgical and Technology Procedures.

Technology impacts the lives of everyone nowadays and has had perhaps a greater impact on the lives of facial plastic surgeons and the patients they seek to help with both surgery and procedures. This article will discuss modern technology's impact on intervening in the aging process including technology used for facial and skin rejuvenation and reconstruction concentrating on the techniques and care to minimize complications as well as dealing with complication from the treatments.

Neck hematoma after major head and neck surgery: Risk factors, costs, and resource utilization.

BACKGROUND: Postoperative cervical hematoma after major head and neck surgery is a feared complication. However, risk factors for developing this complication and attributable costs are not well-established. METHODS: The Nationwide Inpatient Sample database was utilized compare patients with and without postoperative cervical hematoma. Logistic regression was used to analyze risk factors for hematoma formation and 30-day mortality. Total inpatient length of stay (LOS) and costs were fit to generalized linear models. RESULTS: Of 32 071 patients, 1098 (3.4%) experienced a postoperative cervical hematoma. Male sex (odds ratio [OR] 1.38; P < .0001), black race (OR 1.35; P = .010), 4 or more comorbidities (OR 1.66; P < .0001), or presence of a preoperative coagulopathy (OR 6.76; P < .0001) were associated. Postoperative cervical hematoma was associated with 540% increased odds of death (P < .0001). The LOS and total excess costs were 5.14 days (P < .0001) and $17 887.40 (P < .0001), respectively. CONCLUSION: Although uncommon, postoperative cervical hematoma is a life-threatening complication of head and neck surgery with significant implications for outcomes and resource utilization.

Successful percutaneous access for endovascular aneurysm repair is significantly cheaper than femoral cutdown in a prospective randomized trial.

OBJECTIVE: Because of its minimally invasive nature, percutaneous femoral access for endovascular aneurysm repair (pEVAR) is currently undergoing rapid popularization. Compared with surgical cutdown for femoral access (cEVAR), it offers the advantage of faster recovery after surgery as well as a reduction in wound complications. Despite proposed advantages, the method is largely considered uneconomical because of its reliance on costly closure devices. METHODS: There were 50 patients undergoing EVAR who were enrolled in this randomized prospective single-center trial. Each patient randomly received percutaneous access in one groin and surgical access in the other. The primary end points were access duration and cost. Secondary end points were wound complications and the postoperative pain levels. RESULTS: Surgery was performed per protocol in 44 patients. Mean access times for pEVAR and cEVAR were 11.5 ± 3.4 minutes and 24.8 ± 12.1 minutes (P < .001), respectively. Total access costs were €559.65 ± €112.69 for pEVAR and €674.85 ± €289.55 for cEVAR (P = .016). Eight complications in six patients were attributed to cutdown, none to pEVAR (P = .02). The percutaneously accessed groin was significantly less painful at day 1 and day 5 after surgery (P < .001). An intention-to-treat analysis (N = 50 patients) included six cases of pEVAR conversion due to technical failure in three patients (6%) and change of the operative strategy in another three patients (eg, aortouni-iliac stent graft followed by crossover bypass). The intention-to-treat analysis showed shorter mean overall access time for pEVAR (pEVAR, 14.65 ± 10.20 minutes; cEVAR, 25.12 ± 11.77 minutes; P < .001) and no cost difference between the two methods (pEVAR, €651.29 ± €313.49; cEVAR, €625.53 ± €238.29; P = .65). CONCLUSIONS: Our data confirm proposed potential benefits attributable to the minimally invasive nature of pEVAR while demonstrating cost-effectiveness despite the additional cost of closure devices. Taking into account pEVAR failures still does not increase pEVAR costs over cEVAR. Further considering reduced postoperative pain and wound complications, the technique deserves consideration in suitable patients.

Resource utilization associated with cervical hematoma after thyroid and parathyroid surgery.

BACKGROUND: Postoperative cervical hematoma (PCH) after thyroid and parathyroid surgery is a well-known complication. This study used data from the Nationwide Inpatient Sample to identify risk factors, estimate mortality, length of stay (LOS), and total costs attributable to PCH in patients undergoing procedures for thyroid and parathyroid diseases. METHODS: Patients aged >18 y who underwent thyroid or parathyroid surgery between 2001 and 2011 were identified and stratified by the occurrence of PCH. Univariate analyses of patient demographics, clinical and hospital characteristics were performed. Multivariable logistic regression was used to determine risk factors for hematoma formation. LOS and costs were fit to linear regression models to determine the effect of PCH after adjusting for patient and hospital characteristics. RESULTS: Of patients who underwent thyroid or parathyroid surgery, 619 patients (0.8%) had a PCH. Predisposing factors included nonelective admission (emergent: OR = 2.01, P < 0.0001; urgent: OR = 1.47, P = 0.003), diagnosis of Graves' disease (OR = 1.90, P < 0.0001), or other benign pathology (OR = 1.43, P = 0.011) and having ≥2 comorbidities (2-3 comorbidities, OR = 1.24; P = 0.036 and ≥ 4 comorbidities, OR = 2.28; P < 0.0001). After adjusting for those characteristics, the total excess LOS and costs attributable to PCH were 2.1 d (P < 0.0001) and $7316 (P < 0.0001), respectively. In addition, after risk adjustment, odds of mortality more than tripled (P < 0.0001) in the setting of PCH. CONCLUSIONS: Because risk for PCH is largely driven by preoperative patient risk factors, five clinicians have an opportunity to stratify patients accordingly and thereby minimize the resource utilization and health care spending among those with lowest risk.

Assessment, management and treatment of acute fingertip injuries.

Fingertip injuries with nail bed trauma can require specialist hand surgery, depending on severity. However, most of these injuries can be managed in well-equipped emergency departments by emergency nurses with an in-depth knowledge and understanding of the anatomy and physiology of the fingernail and surrounding structures, assessment and examination, pain management and treatment. This article describes the surface and underlying anatomy and physiology of the nail, the most common mechanisms of injury, relevant diagnostic investigations, and initial assessment and management. It also discusses treatment options, referral pathways, and patient discharge advice.

Acute external ear lesions: clinical aspects, assessment and management.

Acute external ear lesions: clinical aspects, assessment and management. We reviewed the literature concerning the assessment and the management of the external ear traumas, which is not very rich. Nevertheless, we outlined the practical attitudes in the four major conditions met: the auricular haematoma, the auricular perichondritis, the auricular laceration and auricular bums. All these pathologies must be promptly treated because there is a risk of perichondritis, which can destroy the cartilage and will result in a severely deformed ear. Auricular haematomas must be drained as soon as possible, lacerations with exposed cartilage must be stitched urgently, and burnt ears should be washed, coated with alginates (Flaminal@) and covered with a loose dressing. Antibioprophyl- axy should always be prescribed after a complete microbiological sampling.

Surgical Trial In Traumatic intraCerebral Haemorrhage (STITCH): a randomised controlled trial of Early Surgery compared with Initial Conservative Treatment.

BACKGROUND: While it is accepted practice to remove extradural (EDH) and subdural haematomas (SDH) following traumatic brain injury, the role of surgery in parenchymal traumatic intracerebral haemorrhage (TICH) is controversial. There is no evidence to support Early Surgery in this condition. OBJECTIVES: There have been a number of trials investigating surgery for spontaneous intracerebral haemorrhage but none for TICH. This study aimed to establish whether or not a policy of Early Surgery for TICH improves outcome compared with a policy of Initial Conservative Treatment. DESIGN: This was an international multicentre pragmatic parallel group trial. Patients were randomised via an independent telephone/web-based randomisation service. SETTING: Neurosurgical units in 59 hospitals in 20 countries registered to take part in the study. PARTICIPANTS: The study planned to recruit 840 adult patients. Patients had to be within 48 hours of head injury with no more than two intracerebral haematomas greater than 10 ml. They did not have a SDH or EDH that required evacuation or any severe comorbidity that would mean they could not achieve a favourable outcome if they made a complete recovery from their head injury. INTERVENTIONS: Patients were randomised to Early Surgery within 12 hours or to Initial Conservative Treatment with delayed evacuation if it became clinically appropriate. MAIN OUTCOME MEASURES: The Extended Glasgow Outcome Scale (GOSE) was measured at 6 months via a postal questionnaire. The primary outcome was the traditional dichotomised split into favourable outcome (good recovery or moderate disability) and unfavourable outcome (severe disability, vegetative, dead). Secondary outcomes included mortality and an ordinal assessment of Glasgow Outcome Scale and Rankin Scale. RESULTS: Patient recruitment began in December 2009 but was halted by the funding body because of low UK recruitment in September 2012. In total, 170 patients were randomised from 31 centres in 13 countries: 83 to Early Surgery and 87 to Initial Conservative Treatment. Six-month outcomes were obtained for 99% of 168 eligible patients (82 Early Surgery and 85 Initial Conservative Treatment patients). Patients in the Early Surgery group were 10.5% more likely to have a favourable outcome (absolute benefit), but this difference did not quite reach statistical significance because of the reduced sample size. Fifty-two (63%) had a favourable outcome with Early Surgery, compared with 45 (53%) with Initial Conservative Treatment [odds ratio 0.65; 95% confidence interval (CI) 0.35 to 1.21; p = 0.17]. Mortality was significantly higher in the Initial Conservative Treatment group (33% vs. 15%; absolute difference 18.3%; 95% CI 5.7% to 30.9%; p = 0.006). The Rankin Scale and GOSE were significantly improved with Early Surgery using a trend analysis (p = 0.047 and p = 0.043 respectively). CONCLUSIONS: This is the first ever trial of surgery for TICH and indicates that Early Surgery may be a valuable tool in the treatment of TICH, especially if the Glasgow Coma Score is between 9 and 12, as was also found in Surgical Trial In spontaneous intraCerebral Haemorrhage (STICH) and Surgical Trial In spontaneous lobar intraCerebral Haemorrhage (STICH II). Further research is clearly warranted. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 19321911. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 70. See the NIHR Journals Library website for further project information.

Changing incidence and management of penetrating neck injuries in the South East London trauma centre.

INTRODUCTION: A total of 17 cases of penetrating neck injury were managed by the otolaryngology team at King's College Hospital over a 3-year period in the 1980s. In April 2010 King's College Hospital became the major trauma centre for South East London. This prospective cohort study compares the incidence, changing demographic features and treatment outcomes of penetrating neck trauma in South East London over the previous 23 years. METHODS: Data were collected over a 12-month period (April 2010 to March 2011) and a selective management protocol was introduced to standardise initial investigations and further treatment. RESULTS: The past 23 years have seen a 550% increase in the incidence of penetrating neck injuries in South East London, with a marked increase in gun crime. Only 38% of cases underwent negative neck exploration in 2011 compared with 65% in 1987. Selective conservative management based on the absence of haemodynamic instability or radiological findings reduces length of hospital stay, lightens surgical workload and cuts costs without affecting morbidity or mortality. CONCLUSIONS: The increased incidence of penetrating neck injury is a reflection of more interpersonal violence rather than a consequence of the larger South East London trauma centre catchment area. Tackling this problem requires focus on wider issues of community prevention. Sharing of data between the four London trauma centres and the police is needed to help prevent interpersonal violence and develop a universal treatment algorithm for other institutions to follow.

Retroperitoneal hematoma after percutaneous coronary intervention: prevalence, risk factors, management, outcomes, and predictors of mortality: a report from the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry.

OBJECTIVES: This study sought to evaluate the prevalence, risk factors, outcomes, and predictors of mortality of retroperitoneal hematoma (RPH) following percutaneous coronary intervention. BACKGROUND: Retroperitoneal hematoma is a serious complication of invasive cardiovascular procedures. METHODS: The study sample included 112,340 consecutive patients undergoing percutaneous coronary intervention in a large, multicenter registry between October 2002 and December 2007. End points evaluated included the development of RPH and mortality. RESULTS: Retroperitoneal hematoma occurred in 482 (0.4%) patients. Of these, 92.3% were treated medically and 7.7% underwent surgical repair. Female sex, body surface area <1.8 m(2), emergency procedure, history of chronic obstructive pulmonary disease, cardiogenic shock, pre-procedural IV heparin, pre-procedural glycoprotein IIb/IIIa inhibitors, adoption of sheath size >or=8-F, and use of vascular closure devices were independent predictors of RPH, whereas the use of bivalirudin was associated with a lower risk. The development of RPH was associated with a higher frequency of post-procedure myocardial infarction (5.81% vs. 1.67%, p < 0.0001), infection and/or sepsis (17.43% vs. 3.00%, p < 0.0001), and heart failure (8.00% vs. 1.63%, p < 0.0001). In-hospital mortality was significantly higher in patients who developed RPH than in patients who did not (6.64% vs. 1.07%, p < 0.0001). Among patients with RPH, independent predictors of death were history of myocardial infarction, cardiogenic shock, pre-procedural creatinine >or=1.5 mg/dl, and left ventricular ejection fraction <50%. CONCLUSIONS: Retroperitoneal hematoma is an uncommon complication of contemporary percutaneous coronary intervention associated with high morbidity and mortality. The identification of risk factors for the development of RPH could lead to modification of procedure strategies aimed toward reducing its incidence.

Current practice in the management of muscle haematomas in patients with severe haemophilia.

Muscle haematomas (MH) represent 10-25% of all bleeds in patients with severe haemophilia. We performed a cross-sectional survey on current practice in the management of MH with participation from 22 consultants. The respondents reported 492 MH/year, corresponding an average of 25/centre, mostly associated with trauma. Iliopsoas (55%), calf (18%) and thigh (18%) bleeds were scored as most serious. Half of the respondents distinguished between contusion and strains, whereas the majority (68.2%) did not categorize bleedings as intra- or intermuscular, although 77.3% routinely used ultrasound. Half of the respondents used a standard protocol for the management of MH. Twenty of 22 (90.9%) respondents offered physiotherapy in the hospital following MH, with no clear consensus on timing and type of treatment. In a theoretical case, for a 70-kg patient with a soleus triceps haematoma, the average initial dose of factor VIII was 2730 U (range: 1750-4000) twice daily for 3-5 days. In a similar case of a patient with inhibitors, 31.8% reported first-line and only use of either recombinant factor VIIa (rFVIIa) or activated prothrombin complex concentrate (APCC), while 36.4% switched between bypassing agents. Using rFVIIa, the median dose was 100 µg/kg (range: 85-270) and with APCC, the median dose was 70 U kg(-1) (range: 50-100). The majority (68.2%) did not use antifibrinolytics. Resolution of pain (81.8% & 77.3%) was regarded as the key clinical marker of arrest of bleeding as compared with diminished swelling and improved range of motion. The survey outlines limited consensus in the management of MH in patients with haemophilia and highlights potential topics for future studies.

The value of suction wound drain after carotid and femoral artery surgery: a randomised trial using duplex assessment of the volume of post-operative haematoma.

BACKGROUND: The use of vacuum suction drains after carotid endarterectomy (CEA) and groin dissection for arterial reconstruction surgery remains controversial. A large multicentre prospective randomised trial would be needed to show any difference if clinical end points (infection and haematoma) are used. Therefore, we conducted a study to evaluate the value of wound drainage using accurate duplex measurement of haematoma expecting a 25% difference in volume between drained and non-drained wounds. PATIENTS AND METHODS: Seventy consecutive patients undergoing CEA and 73 patients who underwent 106 groins dissection were separately and blindly randomised into two groups: group (a) with wound drain and group (b) without wound drain. A duplex scan was carried out post-operatively to document the presence and volume of any wound haematoma. RESULTS: The majority of wounds did not show any evidence of collections. 1. In the CEA patients duplex scan revealed wound haematoma in 8 patients with a median volume of 25 ml (5-65) in group (a) in comparison to 7 wound haematomas 31 ml (3-72) in group (b). Median suction drain drainage was 42 ml (10-120) when used. There was no significant difference between the two groups. Three patients 4.3% (two from the drain group) underwent evacuation of haematoma post-operatively.2. In the groin dissection patients most of the documented collections were trivial. Ultrasound scans showed 21 collections (20%), of these 7 (34%) were in group (a) and 14 (66%) were in group (b). There was no significant difference in wound collections between the two groups (p = 0.28). Only 5 collections (75%) exceeded 10 ml, three of them were in the drain group. One patient (1%), who did not have a drain, developed a wound collection, which needed re-exploration. When a drain was used the median drainage was 64.5 ml (range 10-220). CONCLUSION: These results based on accurate measurement of wound collection suggest that there is no benefit in terms of reduction of the volume of haematoma on wound drainage after CEA or arterial reconstruction surgery involving the groin. A selective policy of use of drainage is therefore recommended.

Incidence and management of esophageal stricture formation, ulcer bleeding, perforation, and massive hematoma formation from sclerotherapy versus band ligation.

OBJECTIVES: The aim of this study was to compare the incidence and endoscopic management of esophageal stricture formation, significant ulcer bleeding, massive esophageal hematoma, and perforation resulting from endoscopic band ligation or sclerotherapy of esophageal varices. METHODS: Consecutive esophagogastroduodenoscopies in which band ligation or sclerotherapy was performed for acute or obliterative therapy were entered into a computerized endoscopy database during a 7-yr period. Patients were excluded if they died within 72 h of treatment session from complications unrelated to the procedure. Sclerotherapy was performed using a 25-gauge needle with 1.5% sodium tetradecyl sulfate and banding was primarily performed with a Wilson-Cook 6 or 10 shooter. Complications were assessed at scheduled endoscopy and outpatient clinic visits, review of quality assurance data tallied on a monthly basis, and patient records. RESULTS: Two hundred twenty-one cases of sclerotherapy were performed in 59 patients compared to 110 cases of band ligation in 52 patients. Five patients were excluded because of death within 72 h of the procedure. The incidence of complications from sclerotherapy:banding on a per patient basis included: esophageal stricture formation 25.6%:1.9%, ulcer bleed 25.4%:5.7%, esophageal perforation 2.2%:0%, and massive esophageal hematoma 1.6%:0%. A significant difference in complications between sclerotherapy and band ligation was noted for both stricture formation (p < 0.0005) and ulcer bleeding (p < 0.0001). The majority of ulcer bleeds required no therapeutic intervention, whereas stricture formation required multiple dilation sessions. CONCLUSIONS: Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. The majority of complications can be managed with endoscopic interventions.

Use of a collagen hemostatic closure device to achieve hemostasis after arterial puncture: a cost-effectiveness analysis.

PURPOSE: To evaluate whether a collagen hemostatic closure device is a safe, cost-effective alternative to manual compression for achieving hemostasis at arterial puncture sites. MATERIALS AND METHODS: A cost-effectiveness analysis, based on a meta-analysis of published data, was performed from the perspective of the health-care system. The gain in effectiveness was expressed as the decrease in rate of puncture-site complications that required treatment. Costs associated with achieving hemostasis and treating complications were included. RESULTS: Use of a collagen closure device decreased the number of puncture-site complications from 31:1,000 to 16:1,000. The average cost of using the device was $177 per patient compared with $42 per patient for manual compression. The incremental cost of averting one complication exceeded $9,000. CONCLUSION: Use of a collagen closure device to achieve hemostasis after an arterial puncture may reduce the complication rate, but the additional cost per complication averted is very high.