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.

Riot-related injuries managed at a hospital in Beirut, Lebanon.

BACKGROUND: Between October 2019 and February 2020, massive crowds protested in Lebanon against economic collapse. Various less than lethal weapons including riot control agents and rubber bullets were used by law enforcement, which led to several traumatic and chemical injuries among victims. This study describes the clinical presentation, management, outcome, and healthcare costs of injuries. METHODS: A retrospective review of the hospital records of all the casualties presenting to the Emergency Department of the American University of Beirut Medical Center between October 17th, 2019, and February 29th, 2020, was conducted. RESULTS: A total of 313 casualties were evaluated in the ED, with a mean age of 30.2 +/- 9.6 years and a predominance of males (91.1%). Most were protestors (71.9%) and arrived through EMS (43.5%) at an influx rate of one patient presenting every 2.7-8 min. Most patients (91.1%) presented with an Emergency Severity Index of 3. Most patients (77.6%) required imaging with 10% having major findings including fractures and hemorrhages. Stones, rocks, and tear gas canisters (30.7%) were the most common mechanism of injury. Musculoskeletal injuries were most common (62.6%), followed by lacerations (44.7%). The majority (93.3%) were treated and discharged home and 3.2% required hospital admission, with 2.6% requiring surgery. CONCLUSION: Less-than-lethal weapons can cause severe injuries and permanent morbidity. The use of riot control agents needs to be better controlled, and users need to be well trained in order to avoid misuse and to lessen the morbidity, mortality, and financial burden.

Third- and fourth-degree tears: A review of the current evidence for prevention and management.

BACKGROUND: Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development. AIMS: We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres. MATERIALS AND METHODS: We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic. RESULTS: Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births. CONCLUSIONS: Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.

Incidental Durotomy During Endoscopic Stenosis Lumbar Decompression: Incidence, Classification, and Proposed Management Strategies.

OBJECTIVE: We sought to review the types of incidental durotomies (IDs) that occurred during the endoscopic stenosis lumbar decompression through interlaminar approach (ESLD) and discuss the management strategies according to our classification. METHODS: A retrospective evaluation was performed for patients with spinal stenosis who underwent ESLD. Out of 330 patients, 27 patients of ID were clinically evaluated preoperatively and postoperatively on the basis of a visual analog scale score, Oswestry Disability Index, and MacNab's criteria. ID patterns are classified according to the size, location, and involvement of neural elements. Intraoperative and postoperative surgical management was evaluated. RESULTS: Intraoperative incidence of ID was 8.2%. According to lumbar levels, 11 (40.7%) occurred at L3-4, 12 (44.4%) at L4-5, and 4 (14.8%) at L5-S1 ID cases. IDs were divided into 4 types: 29.6% are type 1, 70% are type 2, 7.4% are type 3, and 3.7% are type 4. Overall for mean and standard deviation preoperative, 1 week postoperative, 3 months, and final follow-up for visual analog scale are 7.6 ± 1.4, 3.3 ± 1.1, 2.6 ± 1.1, and 1.9 ± 1.3, and for Oswestry Disability Index are 74.5 ± 9.0, 32.3 ± 9.4, 27.3 ± 7.2, and 24.4 ± 6.5 after patch blocking dura repair of ID. CONCLUSIONS: ID is a more common surgical complication in ESLD compared with the transforaminal approach. The endoscopic patch blocking dura repair technique should be considered in type 1 to type 3A of dura tear with good prognosis and clinical outcome. Consideration is made for conversion to open repair in types 3B, 3C and 4 dura tears with fair to poor outcome.

Wound Care Follow-Up From the Emergency Department Using a Mobile Application: A Pilot Study.

BACKGROUND: Many patients presenting to emergency departments (EDs) do not have primary care and risk being lost to follow-up. Technology has been used successfully in surgical populations for wound care follow-up yet this is not well studied in ED populations. OBJECTIVE: We aimed to conduct a pilot study demonstrating "smartphone" application-based follow-up after wound care in the ED. METHODS: We enrolled participants in 2 urban EDs using a smartphone application called Mobile Post-Operative Wound Evaluator (mPOWEr) and defined participation as photographic submission at any time during the study period. We collected demographic data, frequency of use of mPOWEr, number of photographs uploaded, and timing of uploads. RESULTS: We approached patients for study enrollment, and 67 patients (28%) were not enrolled because they had no access to a smartphone. Seventy-one patients (30%) declined to enroll, leaving 100 (42%) successfully enrolled. Smartphone ownership was more common among patients <40 years of age (81% vs. 64%, p = 0.004), more common among white patients than nonwhite patients (75% vs. 15%, p = 0.046), more common among patients approached at the university medical center than the trauma center (84% vs. 66%, p = 0.003), and among patients with commercial or other insurance than those with Medicare or Medicaid (92% vs. 54%, p < 0.001). Of those enrolled, 58% submitted a photograph. CONCLUSIONS: Patients presenting for wound care to the ED will participate in smartphone-based app communication for wound care follow-up and are satisfied with this option. Disparities in smartphone access must be considered when using this follow-up method.

Acute lacerations: Assessment and non-surgical management.

BACKGROUND: Given appropriate case selection and capability, many acute lacerations can be managed in the primary care setting. An understanding of the basic pathophysiology, assessment and management principles is essential. OBJECTIVE: The aim of this article is to provide a basic framework for assessing and managing simple acute lacerations. DISCUSSION: The aim of assessment is initially to decide whether the laceration is suitable for office-based treatment, and then whether it requires formal surgical closure with sutures or staples. Two non-surgical techniques for skin closure in amenable wounds are described. A companion article in this issue provides details of surgical closure techniques and wound aftercare.

Skin tears and risk factors assessment: a systematic review on evidence-based medicine.

Skin tears represent a common condition of traumatic wounds, which may be encountered in some categories of individuals at the extremes of age, such as infants and the elderly. Despite the high prevalence and cost of these lesions, there has been little investigation into the risk factors that lead to this condition. The aim of this review was to systematically evaluate the main risk factors involved in development of skin tears. We planned to include all the studies dealing with risk factors related to skin tears. Only publications in English were considered. We excluded all the studies that did not properly fit our research question and those with insufficient data. Of the 166 records found, 24 matched our inclusion criteria. After reading the full-text articles, we decided to exclude seven articles because of the following reasons: (1) not responding properly to our research questions and (2) insufficient data; the final set included 17 articles. From a literature search, we found the following main issues related to risk factors, which have been described in detail in this section: age-related skin changes, dehydration, malnutrition, sensory changes, mobility impairment, pharmacological therapies and mechanical factors related to skin care practices. Our findings clearly show that in frail populations (especially infant and elderly), the stratification risk, as a primary prevention strategy, is an effective tool in avoiding the development of chronic wounds. The development and the implementation of prevention strategies based on appropriate knowledge of the risk factors involved and the adoption of correct techniques during skin care practices could reduce or even avoid the onset of skin tears.

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.

Development and preparation of a low-immunogenicity porcine dermal scaffold and its biocompatibility assessment.

Acellular dermal matrix (ADM) has been widely used in repair and reconstruction of tissue defect. Therapeutic effect of porcine ADM (PADM) is inferior to that of human ADM (HADM). Relatively high immunogenicity and the resulting strong inflammatory response are major issue in application of PADM. We therefore treated reticular layer PADM (Rl-PADM) with matrix metalloproteinase-7 (MMP-7) and obtained a low-immunogenicity porcine dermal scaffold (LIPDS). Highly immunogenic components, tissue structure, cytocompatibility, and postgrafting histological changes of LIPDS were further investigated. Compared with Rl-PADM, LIPDS showed that the epithelial root sheath, cell debris, laminin, and type IV collagen were almost entirely removed, the structure remained normal, and the interfibrous space was relatively enlarged. Cytocompatibility of LIPDS was similar to that of HADM but superior to Rl-PADM. With regard to the extent of tissue ingrowth in terms of host fibroblasts infiltration and vascularization, LIPDS exhibited clear advantages over Rl-PADM after they had been subcutaneously transplanted in a rat model. In addition, no excessive inflammatory response was observed in LIPDS group up to 28 days postgraft, and the morphosis of collagenous fibers kept essentially normal. However, there were stronger inflammatory response and obvious collagen spallation in Rl-PADM group. The processes of integration and remodeling after the LIPDS grafting were similar to those of a normal wound healing response. The LIPDS graft was vascularized at a relatively high speed. Thus, as an implantable scaffold material, LIPDS is a superior template for guiding tissue regeneration and remodeling.

The influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations.

PURPOSE: To determine the effect of patient insurance status on access to outpatient orthopedic care for acute flexor tendon lacerations. METHODS: The research team contacted 100 randomly chosen orthopedic surgery practices in North Carolina by phone on 2 different occasions separated by 3 weeks. The research team attempted to obtain an appointment for a fictitious 28-year-old man with an acute flexor tendon laceration. Insurance status was presented as Medicaid in 1 call and private insurance in the other call. Ability of an office to schedule an appointment was recorded. RESULTS: Of the 100 practices, 13 were excluded because they did not perform hand surgery, which left 87 practices. The patient in the scenario with Medicaid was offered an appointment significantly less often (67%) than the patient in the scenario with private insurance (82%). The odds of the patient with private insurance obtaining an appointment were 2.2 times greater than the odds of the Medicaid patient obtaining an appointment. The Medicaid patient was more likely not to be offered an appointment owing to the lack of a hand surgeon at a practice (28% of appointment denials) than privately insured patients (13% of appointment denials). CONCLUSIONS: For patients with acute flexor tendon lacerations, insurance status has an important role in the ability to obtain an orthopedic clinic appointment. We found that patients with Medicaid have more barriers to accessing care for a flexor tendon laceration than patients with private insurance. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

A descriptive cross-sectional international study to explore current practices in the assessment, prevention and treatment of skin tears.

This study presents the results of a descriptive, cross-sectional, online international survey in order to explore current practices in the assessment, prediction, prevention and treatment of skin tears (STs). A total of 1127 health care providers (HCP) from 16 countries completed the survey. The majority of the respondents (69·6%, n = 695) reported problems with the current methods for the assessment and documentation of STs with an overwhelming majority (89·5%, n = 891) favouring the development of a simplified method of assessment. Respondents ranked equipment injury during patient transfer and falls as the main causes of STs. The majority of the samples indicated that they used non-adhesive dressings (35·89%, n = 322) to treat a ST, with the use of protective clothing being the most common method of prevention. The results of this study led to the establishment of a consensus document, classification system and a tool kit for use by practitioners. The authors believe that this survey was an important first step in raising the global awareness of STs and to stimulate discussion and research of these complex acute wounds.

International Skin Tear Advisory Panel: a tool kit to aid in the prevention, assessment, and treatment of skin tears using a Simplified Classification System ©.

PURPOSE: To enhance the learner's competence with knowledge regarding utilization of a tool kit to aid in the prevention, assessment, and treatment of skin tears. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Demonstrate knowledge of skin tear prevention and classification as presented in the International Skin Tear Advisory Panel's tool kit.2. Apply information from the skin tear tool kit to patient care scenarios. ABSTRACT: The International Skin Tear Advisory Panel has created a tool kit for the prevention, identification, and treatment of skin tears. The tool kit is based on extensive literature reviews, international input from healthcare professionals, and on expert opinion. It has undergone a modified Delphi process.

Extent, nature and hospital costs of fireworks-related injuries during the Wednesday Eve festival in Iran.

BACKGROUND: Fireworks are commonly used in local and national celebrations. The aim of this study is to explore the extent, nature and hospital costs of injuries related to the Persian Wednesday Eve festival in Iran. METHODS: Data for injuries caused by fireworks during the 2009 Persian Wednesday Eve festival were collected from the national Ministry of Health database. Injuries were divided into nine groups and the average and total hospital costs were estimated for each group. The cost of care for patients with burns was estimated by reviewing a sample of 100 patients randomly selected from a large burn center in Tehran. Other costs were estimated by conducting semi structured interviews with expert managers at two large government hospitals. RESULTS: 1817 people were injured by fireworks during the 2009 Wednesday Eve festival. The most frequently injured sites were the hand (43.3%), eye (24.5%) and face (13.2%), and the most common types of injury were burns (39.9%), contusions/abrasions (24.6%) and lacerations (12.7%). The mean length of hospital stay was 8.15 days for patients with burns, 10.7 days for those with amputations, and 3 days for those with other types of injury. The total hospital cost of injuries was US$ 284 000 and the average cost per injury was US$ 156. The total hospital cost of patients with amputations was US$ 48 598. Most of the costs were related to burns (56.6%) followed by amputations (12.2%). CONCLUSIONS: Injuries related to the Persian Wednesday Eve festival are common and lead to extensive morbidity and medical costs. © 2013 KUMS, All rights reserved.

Canadians' willingness to receive care from physician assistants.

OBJECTIVE: To determine the willingness of Canadians to accept treatment from physician assistants (PAs). DESIGN: Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients' preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours. SETTING: Vancouver, BC. PARTICIPANTS: Two hundred twenty-nine mothers attending a hospital with their children. MAIN OUTCOME MEASURES: The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied. RESULTS: Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively). CONCLUSION: These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.

The assessment and management of skin tears in care homes.

This article discusses a project conducted in Worcestershire nursing homes to review current practices in the management of skin tears and the subsequent development and implementation of guidelines resulting in a standardised client care package. An initial audit in five care homes was followed by an in-depth audit in 52 homes over a 12-week period. This led to the development of resources and the 'STAR box' to assist with implementation of timely and appropriate care delivery.

[Biological fluid-related accidents amongst professionals working in clinical laboratories in Maracaibo, Venezuela]. / Accidentalidad por fluidos biológicos en profesionales de laboratorios clínicos de Maracaibo, Venezuela.

OBJECTIVE: Determining the occupational exposure to biological fluids of medical technicians working in public clinical laboratories caused by accidental percutaneous contact, associated factors and compliance with post-exposure biological measures. METHODS: This was a descriptive cross-sectional study. The sample consisted of 156 medical technicians assigned to clinical laboratories in the metropolitan area of Zulia state in Venezuela. Data was collected by applying an instrument for exploring exposure and related factors, as well as compliance with established post-biological exposure measures. RESULTS: There was evidence of exposure caused by percutaneous accidents, mainly represented by a moderate level of needle-pricks and cuts (2-3.99 mean). There was a moderate level of factors regarding percutaneous injury in the hands and fingers associated with hollow needles, blood and blood products and superficial severity in sample taking and processing areas when recapping needles or handling sharp or cutting objects. A medium level (2-3.99 mean) of compliance was obtained for post-exposure handling. A significant correlation was found (p<001) between percutaneous exposure and level of compliance with post-exposure management. CONCLUSION: The magnitude and characteristics of exposure to biological fluids detected in this work represents a problematic situation which can affect staff health and must be approached by institutions to ensure effective prevention management and risk control.

Assessment of disparities in the use of anxiolysis and sedation among children undergoing laceration repair.

OBJECTIVE: The aim of this study was to determine if race/ethnicity and socioeconomic status (SES) were associated with the provision of anxiolysis and/or sedation among children undergoing laceration repair. METHODS: A 1-year cross-sectional sample of children undergoing laceration repair in an urban tertiary-care pediatric emergency department was analyzed. Primary outcomes included the use of nonpharmacologic anxiolysis (presence of a child life specialist), pharmacologic anxiolysis, and procedural sedation. Predictors included race/ethnicity (Caucasian vs minority) and SES (represented by insurance status: private vs none/public). Bivariable analyses provided unadjusted odds ratios (ORs) for the association between predictors and outcomes, and logistic regression was used to obtain adjusted ORs for the provision of anxiolysis and sedation (adjusted for age, gender, acuity, provider type, length of laceration, complexity of repair, time of day, use of a topical anesthetic, and body site of laceration). RESULTS: In the unadjusted analysis, a higher proportion of Caucasian children than minority children received nonpharmacologic anxiolysis and sedation, and a higher proportion of children with high SES received nonpharmacologic anxiolysis compared with children of low SES. However, these associations were not statistically significant once potential confounders were controlled in the adjusted analysis. CONCLUSIONS: A very small proportion of children undergoing laceration repair at this single institution received pharmacologic anxiolysis and/or procedural sedation. We did not demonstrate racial/ethnic or socioeconomic disparities with respect to the management of procedure-related anxiety in children.