Severe Complications of Uterine Dehiscence Post-Lower Segment Cesarean Section: A Case Report Emphasizing the Importance of Timely Diagnosis and Intervention.

BACKGROUND Uterine dehiscence, an infrequent event often mistaken for uterine rupture, is rarely linked to post-cesarean section procedures and can result in severe complications, notably puerperal sepsis. In this report, we present a case that exemplifies the onset of puerperal sepsis and the emergence of intra-abdominal abscesses attributed to uterine dehiscence following a lower segment cesarean section (LSCS). CASE REPORT Our patient, a 28-year-old woman in her third pregnancy, underwent LSCS 1 week earlier. Subsequently, she returned to the hospital with lower abdominal pains, fever, and malodorous vaginal discharge. Computed tomography (CT) scan of whole abdomen verified uterine dehiscence and pus collection at the subhepatic region and right paracolic gutter. After referral to a specialized hospital, laboratory findings indicated an elevated white blood cell count and alkaline phosphatase levels, and coagulation abnormalities. She underwent an exploratory laparotomy, which unveiled uterine dehiscence, abscesses, and adhesions, necessitating a total abdominal hysterectomy and abdominal toileting. Pus culture analysis identified the presence of E. coli, which was susceptible to ampicillin/sulbactam. Complications were encountered after surgery, including wound dehiscence and pus re-accumulation. Successful management involved vacuum dressings and percutaneous drainage. Eventually, her condition improved and she was discharged, without additional complications. CONCLUSIONS This report underscores the importance of considering cesarean scar dehiscence as a diagnosis in women with previous cesarean deliveries who present during subsequent pregnancies with symptoms such as abdominal pain or abdominal sepsis. Diagnostic tools, such as CT, play pivotal roles, and the timely performance of an exploratory laparotomy is paramount when suspicion arises.

[Minimally invasive interventions for complications associated with intra-abdominal calculi after laparoscopic cholecystectomy]. / Vozmozhnosti minimal'no invazivnykh vmeshatel'stv v lechenii oslozhnenii, svyazannykh s vnutribryushnymi konkrementami posle videolaparoskopicheskoi kholetsistektomii.

OBJECTIVE: To study the possibilities of minimally invasive methods for removing intra-abdominal calculi after laparoscopic cholecystectomy. MATERIAL AND METHODS: There were 5 patients with abdominal abscesses associated with infected calculi after previous laparoscopic cholecystectomy at the Sklifosovsky Research Institute for Emergency Care between 2020 and 2023. Mean age of patients was 55±12 years. There were 3 (60%) women and 2 (40%) men. All patients underwent minimally invasive treatment. RESULTS: Four patients (80%) underwent percutaneous drainage of abscess with subsequent replacement by larger drains and removal of calculi with endoscopic assistance. Event-free period after cholecystectomy was 44±32 months. One patient developed subhepatic abscess in 72 months after laparoscopic cholecystectomy. This patient underwent transluminal removal of calculus through the duodenal wall. There was 1 calculus in 3 (60%) patients, 2 calculi in 1 (20%) patient and 3 calculi in 1 (20%) patient. CONCLUSION: The above-mentioned cases demonstrate successful minimally invasive interventions for symptomatic abdominal calculi after laparoscopic cholecystectomy. Minimally invasive treatment can reduce surgical aggression and accelerate rehabilitation.

The Intraperitoneal Use of Cephazolin: A Novelty in the Prevention of Intra-abdominal Abscess after Laparoscopic Appendectomy in Children.

BACKGROUND: Laparoscopic appendectomy followed by postoperative intravenous (IV) antibiotics is the standard of care for acute appendicitis and postoperative prevention of intra-abdominal abscesses. The aim of or study was to determine if intraperitoneal irrigation with antibiotics could help prevent intra-abdominal abscess formation after laparoscopic appendectomy for complicated appendicitis in pediatric patients. METHODS: A retrospective study was conducted on consecutive pediatric patients with acute appendicitis who had appendectomy in our Pediatric Surgery Department between August 2020 and February 2022. We compared two groups with similar age and symptoms. The first group (A) was treated with the normal standard of care, i.e., laparoscopic appendectomy and postoperative IV antibiotic therapy. For the second group (B) intraperitoneal cefazoline irrigation was added at the end of the laparoscopic procedure. Postoperative intra-abdominal abscess was diagnosed with ultrasound examination, performed after clinical suspicion/abnormal blood test results. RESULTS: One hundred sixty patients (males:females 109:51; median age 10.5 years [range 3-17 years]) who had laparosopic appendectomy for complicated appendicitis were included, 82 in group A and 78 in group B. In the first 7 days after surgery, 18 patients in group and 5 in group B developed an intra-abdominal abscess (p < 0.005). Drains were positioned in 38 patients in group A vs. 9 in group B. One patient in group A had a different complication which was infection of the surgical incision. CONCLUSIONS: Intraperitoneal cefazoline irrigation at the end of the laparoscopic appendectomy in pediatric patients significantly reduces the formation of intra-abdominal abscesses.

Towards a tailored approach for patients with acute diverticulitis and abscess formation. The DivAbsc2023 multicentre case-control study.

BACKGROUND: This multicentre case-control study aimed to identify risk factors associated with non-operative treatment failure for patients with CT scan Hinchey Ib-IIb and WSES Ib-IIa diverticular abscesses. METHODS: This study included a cohort of adult patients experiencing their first episode of CT-diagnosed diverticular abscess, all of whom underwent initial non-operative treatment comprising either antibiotics alone or in combination with percutaneous drainage. The cohort was stratified based on the outcome of non-operative treatment, specifically identifying those who required emergency surgical intervention as cases of treatment failure. Multivariable logistic regression analysis to identify independent risk factors associated with the failure of non-operative treatment was employed. RESULTS: Failure of conservative treatment occurred for 116 patients (27.04%). CT scan Hinchey classification IIb (aOR 2.54, 95%CI 1.61;4.01, P < 0.01), tobacco smoking (aOR 2.01, 95%CI 1.24;3.25, P < 0.01), and presence of air bubbles inside the abscess (aOR 1.59, 95%CI 1.00;2.52, P = 0.04) were independent predictors of failure. In the subgroup of patients with abscesses > 5 cm, percutaneous drainage was not associated with the risk of failure or success of the non-operative treatment (aOR 2.78, 95%CI - 0.66;3.70, P = 0.23). CONCLUSIONS: Non-operative treatment is generally effective for diverticular abscesses. Tobacco smoking's role as an independent risk factor for treatment failure underscores the need for targeted behavioural interventions in diverticular disease management. IIb Hinchey diverticulitis patients, particularly young smokers, require vigilant monitoring due to increased risks of treatment failure and septic progression. Further research into the efficacy of image-guided percutaneous drainage should involve randomized, multicentre studies focussing on homogeneous patient groups.

Surgical management of complicated Crohn's disease.

Surgical management of pediatric Crohn's disease is fundamentally palliative, aiming to treat the sequalae of complicated disease while preserving intestinal length. Multidisciplinary discussion of risk factors and quality of life should take place prior to operative intervention. Though the surgical management of pediatric Crohn's disease is largely based on the adult literature, there are considerations specific to the pediatric population - notably disease and treatment effects on growth and development. Intrabdominal abscess is approached with percutaneous drainage when feasible, reserving surgical intervention for the patient who is unstable or failing medical therapy. Pediatric patients with fibrostenotic disease should be considered for strictureplasty when possible, for maximum preservation of bowel length. Patients with medically refractory Crohn's proctocolitis should be treated initially with fecal diversion without proctocolectomy.

Utilizing Video-Assisted Retroperitoneal Debridement for Retroperitoneal Abscess Following Penetrating Trauma.

Retroperitoneal abscess as a sequela of penetrating trauma can pose a difficult clinical scenario for surgeons and literature to inform decision making is sparse. It is logical to follow a "step-up" approach applied to other etiologies of infected retroperitoneal fluid collections, such as infected pancreatic necrosis and perinephric abscess. Video-assisted retroperitoneal debridement (VARD) is a well-established approach in infected pancreatic necrosis when surgical debridement is warranted. Minimally invasive retroperitoneal approaches have emerged in a broadening range of etiologies and specialties. We describe our experience utilizing VARDs in two patients that developed retroperitoneal abscesses following gunshot injuries to bowel and proximal urinary system. Both failed a conservative approach including antibiotic and percutaneous drains. Rapid improvement and subsequent discharge were observed within days of VARD procedure. We believe VARD to be a viable approach to post-trauma retroperitoneal abscesses when surgical drainage is indicated, and anatomy is favorable.

Refractory postoperative pancreatic fistula following laparoscopic distal pancreatectomy for pancreatic cancer caused by incomplete pancreas divisum: a case report.

Pancreas divisum (PD) represents a prevalent congenital pancreatic variant, typically arising from the failure of fusion between the ventral and dorsal pancreatic ducts. This condition is frequently associated with recurrent pancreatitis. We herein present a case involving an incomplete PD diagnosis following the identification of a refractory postoperative pancreatic fistula (POPF) after laparoscopic distal pancreatectomy (DP) for pancreatic cancer. A 74-year-old female patient, who had undergone laparoscopic DP for pancreatic cancer, developed a POPF accompanied by intraabdominal bleeding, necessitating urgent intervention radiology to avert life-threatening complications. Following this, intraabdominal drainage was performed through an intraoperative drainage root. Subsequent fistulography and endoscopic retrograde pancreatography unveiled the presence of an incomplete PD for the first time. Consequently, a stent was placed in the Santorini duct. However, the volume of pancreatic juice from the intraabdominal drainage tube exhibited no reduction. Despite repeated attempts to access the pancreatic duct via a guidewire through the drainage tube, these endeavors proved futile. Paradoxically, the removal of the external drainage tube led to a recurrence of intraabdominal abscess formation. Consequently, reinsertion of the drainage tube became imperative. Consideration was given to draining the abscess under endoscopic ultrasonography and performing pancreatic duct drainage. However, due to the diminution of the abscess cavity through the external fistula drainage procedure, coupled with the absence of pancreatic duct dilation and its tortuous course, it was deemed a formidable challenge. the patient necessitated a lifestyle adaptation with a permanently placed percutaneous drainage tube.

Gastrosplenic fistula due to splenic lymphoma: two case reports and review of the literature.

BACKGROUND: Gastrosplenic fistula is a rare and potentially fatal complication of various conditions. Lymphoma is the most common cause. It can occur spontaneously or after chemotherapy. Gastrosplenic fistula diagnosis can be confused with a splenic abscess because of the presence of air into the mass. The computed tomography identification of the fistulous tract is the key to a right diagnosis. Treatment modalities include surgical resection, chemotherapy, or a combination of both. CASE PRESENTATION: Here we report two patients with gastrosplenic fistula due to diffuse large B cell lymphoma. The first patient was a 54-year-old Caucasian woman with an enormous primary splenic diffuse large B cell lymphoma leading to the development of a spontaneous fistula in the stomach. The second patient was a 48-year-old Caucasian male patient with an enormous splenic diffuse large B cell lymphoma complicated by fistula after chemotherapy. Both patients died of septic shock several days after surgery. CONCLUSION: Gastrosplenic fistula is a rare complication with a poor-prognosis, for which surgery is currently the preferred treatment.

A Rare Case of Retroperitoneal Abscess Caused by Nephro-Colic Fistula Resulting from Staghorn Calculus.

BACKGROUND Nephro-colic fistulas are uncommon, generally caused by local inflammation, trauma, or neoplasia affecting the kidney or the colon. Their association with a coralliform stone is described in a few case reports, but their management is difficult and differs quite a lot, depending on the clinical situation. We report an atypical clinical case of a reno-colic fistula associated with a staghorn calculus. This case adds to the literature an iconography rarely found. CASE REPORT A 68-year-old woman presented to the Emergency Department with respiratory symptoms and chronic abdominal pain. The biological results showed a high inflammatory syndrome. The radiological assessment revealed a retroperitoneal and left retro-renal abscess, attributed to a left nephro-colic fistula associated with the partial passage of a lithiasis within the colonic lumen. Colonoscopy confirmed the diagnosis. Multiple recurrences of diverticulitis in this region could be the origin of the complication. First, the patient was treated with antibiotic therapy and radiological drainage. Second, she benefited from a left nephrectomy, left segmental colectomy, and splenectomy. The clinical and radiological evolution were favorable after surgery. The follow-up was disrupted by hospitalizations in the Cardiology Department for cardiac decompensation. CONCLUSIONS Kidney stones along with local inflammatory phenomena can be the cause of a nephro-colic fistula. Due to the lack of guidelines in such cases, their diagnosis and management are difficult to ascertain. Surgery is the right course of treatment.

Case Report: A Case of Complicated Typhoid Fever with Rhabdomyolysis and Hemophagocytic Lymphohistiocytosis.

Typhoid fever can have diverse extra-intestinal complications including encephalitis, Guillain-Barré syndrome, endocarditis, myocarditis, osteomyelitis, renal abscess, and splenic abscesses. Secondary hemophagocytic lymphohistiocytosis with rhabdomyolysis is a rare complication of typhoid fever. Here, we present the case of an adolescent with typhoid fever complicated by rhabdomyolysis and hemophagocytic lymphohistiocytosis.

Negative pressure device used in pediatric patients with Hostile abdomen. Case series. / Dispositivo de presión negativa empleado en pacientes pediátricos con abdomen hostil: serie de casos.

INTRODUCTION: Hostile abdomen is a surgical condition characterized by loss of space between organs and structures in the abdomen. Negative pressure therapy use has been widely described in adults; the case is not the same for pediatric patients. The goal of this study is to present short-term results of negative pressure therapy use in pediatric patients with hostile abdomen due to different etiologies. MATERIAL AND METHODS: Pediatric hostile abdomen patients (< 18 years) who were treated Negative pressure therapy using ABTHERA were identified and retrospectively reviewed. RESULTS: 7 patients were included in this study. Median age was 16 (range: 9-17 yo). 5 (71.4%) were male and 2 (28.6%) females. 3 (43%) had significant past medical/surgical history (Systemic Lupus Erythematosus, complicated appendectomy and ventriculoperitoneal-shunt). The device was set at a continuous pressure ranging from -50 to -125 mmHg. Pre and post-surgical findings were reported using Bjork's classification. Devices were replaced every 4-7 days (median 5 days). Total amount of replacements was 1-4 (median 3). 5 (71.4%) patients required invasive mechanical ventilation during use of Negative pressure therapy based on clinical status. 4 (57%) patients received enteral nutrition. 1 (14%) patient required re-intervention posterior to definitive closure due to retroperitoneal abscess development. Outcome, evaluated by (oral tolerance, bowel movement and absence of pain), was favorable in all patients. CONCLUSION: Negative pressure therapy devices generate favorable results in hostile abdomen in pediatric population but further information is needed to assess pressure settings and device replacement frequency.

INTRODUCCION: El abdomen hostil es una patología quirúrgica caracterizada por una pérdida de espacio entre los órganos y estructuras del abdomen. La terapia de presión negativa se ha descrito de manera extensa en adultos, pero no así en pacientes pediátricos. El objetivo de este estudio es presentar los resultados a corto plazo de la terapia de presión negativa en pacientes pediátricos con abdomen hostil debido a distintas etiologías. MATERIAL Y METODOS: Identificación y análisis retrospectivo de los pacientes pediátricos con abdomen hostil (< 18 años) tratados con terapia de presión negativa ABTHERA. RESULTADOS: Se incluyó a 7 pacientes. La mediana de edad fue de 16 años (rango: 9-17). 5 (71,4%) eran niños y 2 (28,6%) niñas. 3 (43%) presentaban antecedentes médico-quirúrgicos de interés (lupus eritematoso sistémico, apendicectomía complicada y derivación ventriculoperitoneal). El dispositivo se empleó a presión constante, entre ­50 y ­125 mmHg. Los hallazgos preoperatorios y postoperatorios se notificaron mediante la clasificación de Bjork. Los dispositivos se sustituyeron cada 4-7 días (mediana de 5 días). La cantidad total de reemplazos fue de 1-4 (mediana de 3). 5 (71,4%) pacientes precisaron ventilación mecánica invasiva durante la terapia de presión negativa debido al estado clínico. 4 (57%) pacientes recibieron nutrición enteral. 1 (14%) paciente requirió reintervención posterior al cierre definitivo por el desarrollo de un absceso retroperitoneal. El resultado, evaluado en base a la tolerancia oral, el movimiento intestinal y la ausencia de dolor, fue favorable en todos los pacientes. CONCLUSION: Los dispositivos de terapia de presión negativa aportan resultados favorables en los pacientes pediátricos con abdomen hostil, aunque se necesita más información para evaluar los ajustes de presión y la frecuencia de reemplazo del dispositivo.

Huge uterine abscess after myomectomy: A case report.

RATIONALE: Uterine abscess is a rare gynecologic entity and only a few cases have been reported so far. This study aimed to describe our clinical experience in this case. Initially, hematoma was diagnosed without detail previous medical record. Finally, laparotomy was performed due to refractory fever and highly possible diagnosis of uterine abscess. We successfully performed a hysterectomy and the patient had an uneventful recovery. PATIENT CONCERNS: A 44-year-old nulliparous woman underwent myomectomy in the local hospital, 45 days ago. She complained of irregular fever (up to 40 °C) without abdominal pain since the surgery. DIAGNOSES: Due to lack of her detail medical record, equivocal images and her strong intention to preserve uterus, she was misdiagnosed with hematoma and treated with antibiotic treatment. Finally, intraoperative findings revealed that the huge myometrial abscess contained a mass of pus. INTERVENTIONS: Laparotomy was performed due to refractory high-grade fever and highly possible diagnosis of uterine abscess. Total hysterectomy was performed to avoid the possibility of life-threatening sepsis. OUTCOMES: The postoperative course was uneventful and the patient was discharged 10 days after surgery. LESSONS: Complete imaging examinations are recommended prior myomectomy to facilitate the differential diagnosis of postoperative complications. In addition, several measures, such as maintaining aseptic conditions during surgery and postoperative drainage, play a critical role in preventing nosocomial infections. Rare uterine abscess is often mistaken for hematoma with fever. If the patient develops high fever after myomectomy, accompanied by a mass in the myometrium, the possibility of infection or even abscess formation should not be excluded. For women who need to preserve their fertility, the early diagnosis and timely administration of appropriate medication is crucial for preventing uterine loss.

Invasive pneumococcal disease serotype 23B1 causing multifocal septic arthritis, myositis and retroperitoneal abscess.

We describe a case of a previously healthy unvaccinated man in his 70s who developed penicillin-susceptible bacteraemic invasive pneumococcal disease due to non-vaccine serotype 23B with the unusual manifestations of multifocal myositis, intramuscular abscesses, polyarticular septic arthritis and synovitis. Blood cultures drawn prior to antibiotic therapy and culture of iliopsoas collection were helpful in making the diagnosis. At follow-up, he had persistent hip pain attributed to avascular necrosis of the head of femur, a possible late complication of his pyomyositis.

Extrahepatic abscess and dropped gallstones: a case report and a narrative review of an unusual delayed complication of laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is the most common minimally invasive abdominal surgery procedure performed in Western countries; it offers several advantages over laparotomy but still carries some risks, such as intraoperative spillage of bile and gallstones. Diagnosis of dropped gallstones could be challenging, it is frequently delayed, and this can lead to further complications such as abscesses formation. METHODS: We report the history of a 51-year-old male with persistent dull abdominal pain in association to appetite loss, vomiting episodes and changes in regular bowel habits, a past medical history of laparoscopic cholecystectomy for biliary lithiasis (1.5 years earlier) and minimum elevation of inflammatory markers and gamma-GT values. RESULTS: Ultrasound examination showed perihepatic stones and magnetic resonance imaging revealed the presence of multiple perihepatic abscesses, findings compatible with fibrotic-inflammatory phenomena from 'dropped gallstones'. A re-laparoscopy was then performed with an abscess collection containing multiple gallstones; a liver wedge resection was also required due to strong adhesions. At follow up, the patient had improved both on clinical and biochemical perspective. CONCLUSION: Dropped gallstones are an underreported cause of morbidity and diagnostic dilemmas in subjects who underwent to laparoscopic cholecystectomy, in relation to infectious complications that can occur even several months or years after surgery. Imaging represents a valuable aid in the correct non-invasive diagnostic process, but proper awareness of this insidious condition is necessary. Surgeons and radiologists should always consider this eventuality in the differential diagnosis of a patient presenting with abdominal abscesses and history of cholecystectomy.

Primary Repair Versus Resection for AAST Grade I and II Colon Injuries: Does the Type of Repair Matter?

INTRODUCTION: The management of traumatic colon injuries has evolved over the past two decades. Recent evidence suggests that primary repair or resection over colostomy may decrease morbidity and mortality. Data comparing patients undergoing primary repair versus resection are lacking. We sought to compare the outcomes of patients undergoing primary repair versus resection for low-grade colon injuries. METHODS: A retrospective review of all patients who presented with American Association for the Surgery of Trauma grade I and II traumatic colon injuries to our Level I trauma center between 2011 and 2021 was performed. Patients were further dichotomized based on whether they underwent primary repair or resection with anastomosis. Outcome measures included length of stay data, infectious complications, and mortality. RESULTS: A total of 120 patients met inclusion criteria. The majority of patients (76.7%) were male, and the average age was 35.6 ± 13.1 y. Most patients also underwent primary repair (80.8%). There were no statistically significant differences between the groups in arrival physiology or in injury severity score. Length of stay data including hospital length of stay, intensive care unit length of stay, and ventilator days were similar between groups. Postoperative complications including pneumonia, surgical site infections, fascial dehiscence, the development of enterocutaneous fistulas, and unplanned returns to the operating room were also all found to be similar between groups. The group who underwent resection with anastomosis did demonstrate a higher rate of intra-abdominal abscess development (3.1% versus 26.1%, P < 0001). Mortality between both groups was not found to be statistically significant (7.2% versus 4.3%, P = 0.4) CONCLUSIONS: For low-grade (American Association for the Surgery of Trauma I and II) traumatic colon injuries, patients undergoing primary repair demonstrated a decreased rate of intra-abdominal abscess development when compared to patients who underwent resection with anastomosis.

Acute Peritonitis and Pelvic Abscess Secondary to Abdominal Tuberculosis.

Tuberculosis (TB), caused by Mycobacterium tuberculosis, continues to be a global health concern with high morbidity and mortality rates. Extrapulmonary TB (EPTB), which affects various organs beyond the lungs, presents a diagnostic challenge due to its diverse clinical and radiological manifestations. Herein, we describe the case of a middle-aged woman with severe lower abdominal pain, vomiting, night fevers, and other symptoms. Clinical and radiological examinations revealed pelvic abscesses and peritonitis. Exploratory laparoscopy uncovered intraabdominal adhesions, a pus-containing abscess cavities, and biopsies confirmed Mycobacterium tuberculosis infection. Post-operative pulmonology consultations comprising sputum cultures for TB detection were conducted, and the patient was started on anti-tuberculosis medications. This case highlights the complexity of diagnosing abdominal TB and the importance of a comprehensive diagnostic approach.

Lack of Routine Postoperative Labs Not Associated With Complications in Pediatric Perforated Appendicitis.

INTRODUCTION: Postoperative (postop) management of pediatric perforated appendicitis varies significantly, and postop intra-abdominal abscesses (IAA) remain a significant issue. Between 2019 and 2020, our standardized protocol included routine postop labs after an appendectomy for perforated appendicitis. However, given the lack of predictive utility of these routine labs, we discontinued this practice in 2021. We hypothesize that discontinuing routine postop labs will not be associated with an increase in complication rates after an appendectomy for pediatric perforated appendicitis. METHODS: A single-institution, retrospective review of all pediatric appendectomies for perforated appendicitis from January 2019 to December 2021 was conducted at University Hospitals Rainbow Babies and Children's Hospital in Cleveland, Ohio. Data were collected on rate of complications (IAA development, re-admissions, bowel obstructions, superficial surgical site infections, intensive care unit transfers, Clostridium difficile infections, allergic reactions, and transfusions), postop imaging, postop interventions, and length of stay. Statistical analysis was completed using Fisher's exact test and Mann-Whitney U-test. RESULTS: A total of 109 patients (2019-2020 n = 61, 2021 n = 48) were included in the study. All 61 patients from 2019 to 2020 had postop labs compared to only eight patients in 2021. There was no statistically significant difference between the two groups in overall complication rates, but there was a decrease in IAAs reported in 2021 (P = 0.03). There were no statistically significant differences in other complications, postop imaging usage, or postop interventions. The median length of stay was 4.5 d in 2021 compared to 6.0 d in 2019-2020 (P = 0.009). CONCLUSIONS: Discontinuing routine postop labs is not associated with an increase in overall complications rates. Further studies are needed to determine whether routine postop labs can be safely removed in pediatric patients with perforated appendicitis, which would reduce patient discomfort and care costs.