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ABSTRACT: Every year, approximately 6.2 million hospital admissions through emergency departments (ED) involve elderly patients who are at risk of developing pressure ulcers. We evaluated the cost-effectiveness of pressure-redistribution foam mattresses on ED stretchers and beds for early prevention of pressure ulcers in elderly admitted ED patients.
Using a Markov model, we evaluated the incremental effectiveness (quality-adjusted life-days) and incremental cost (hospital and home care costs) between early prevention and current practice (with standard hospital mattresses) from a health care payer perspective during a 1-year time horizon.
The projected incidence of ED-acquired pressure ulcers was 1.90% with current practice and 1.48% with early prevention, corresponding to a number needed to treat of 238 patients. The average upgrading cost from standard to pressure-redistribution mattresses was $0.30 per patient. Compared with current practice, early prevention was more effective, with 0.0015 quality-adjusted life-days gained, and less costly, with a mean cost saving of $32 per patient. If decisionmakers are willing to pay $50,000 per quality-adjusted life-year gained, early prevention was cost-effective even for short ED stay (ie, 1 hour), low hospital-acquired pressure ulcer risk (1% prevalence), and high unit price of pressure-redistribution mattresses ($3,775). Taking input uncertainty into account, early prevention was 81% likely to be cost-effective. Expected value-of-information estimates supported additional randomized controlled trials of pressure-redistribution mattresses to eliminate the remaining decision uncertainty.
The economic evidence supports early prevention with pressure-redistribution foam mattresses in the ED. Early prevention is likely to improve health for elderly patients and save hospital costs.
Annals of emergency medicine 08/2011; 58(5):468-78.e3. · 4.23 Impact Factor
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Ba' Pham,
Laura Teague, James Mahoney,
Laurie Goodman,
Mike Paulden,
Jeff Poss,
Jianli Li,
Nancy Joan Sikich,
Rosemarie Lourenco,
Luciano Ieraci,
Steven Carcone,
Murray Krahn
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ABSTRACT: Patients who undergo prolonged surgical procedures are at risk of developing pressure ulcers. Recent systematic reviews suggest that pressure redistribution overlays on operating tables significantly decrease the associated risk. Little is known about the cost effectiveness of using these overlays in a prevention program for surgical patients.
Using a Markov cohort model, we evaluated the cost effectiveness of an intraoperative prevention strategy with operating table overlays made of dry, viscoelastic polymer from the perspective of a health care payer over a 1-year period. We simulated patients undergoing scheduled surgical procedures lasting ≥90 min in the supine or lithotomy position.
Compared with the current practice of using standard mattresses on operating tables, the intraoperative prevention strategy decreased the estimated intraoperative incidence of pressure ulcers by 0.51%, corresponding to a number-needed-to-treat of 196 patients. The average cost of using the operating table overlay was $1.66 per patient. Compared with current practice, this intraoperative prevention strategy would increase slightly the quality-adjusted life days of patients and by decreasing the incidence of pressure ulcers, this strategy would decrease both hospital and home care costs for treating fewer pressure ulcers originated intraoperatively. The cost savings was $46 per patient, which ranged from $13 to $116 by different surgical populations. Intraoperative prevention was 99% likely to be more cost effective than the current practice.
In patients who undergo scheduled surgical procedures lasting ≥90 min, this intraoperative prevention strategy could improve patients' health and save hospital costs. The clinical and economic evidence support the implementation of this prevention strategy in settings where it has yet to become current practice.
Surgery 07/2011; 150(1):122-32. · 3.10 Impact Factor
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ABSTRACT: Median sternotomy infection and bony nonunion are two commonly described complications which occur in 0.4-5.1% of cardiac procedures. Although relatively infrequent, these complications can lead to significant morbidity and mortality. The aim of this retrospective study is to evaluate the initial experience of a transverse plate fixation system following wound complications associated with sternal dehiscence with or without infection following cardiac surgery.
A retrospective chart review of 40 consecutive patients who required sternal wound reconstruction post sternotomy was performed. Soft tissue debridement with removal of all compromised tissue was performed. Sternal debridement was carried using ronguers to healthy bleeding bone. All patients underwent sternal fixation using three rib plates combined with a single manubrial plate (Titanium Sternal Fixation System®, Synthes). Incisions were closed in a layered fashion with the pectoral muscles being advanced to the midline. Data were expressed as mean±SD, Median (range) or number (%). Statistical analyses were made by using Excel 2003 for Windows (Microsoft, Redmond, WA, USA).
There were 40 consecutive patients, 31 males and 9 females. Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge. Thirty eight patients went on to heal their wounds. Two patients developed recurrent wound infection and required VAC therapy. Both were immunocompromised. Median post-op ICU stay was one day with the median hospital stay of 18 days after plating.
Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability. Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.
Journal of Cardiothoracic Surgery 01/2011; 6:63. · 1.19 Impact Factor
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C David Mazer,
Howard Leong-Poi,
Tejinder Chhina,
Zuhair Alfardan,
Harry Lapierre,
Zhilan Wang,
Zane S Jackson,
Beiping Qiang, James Mahoney,
David Latter,
Gregory M T Hare,
Bradley H Strauss,
Jerome Teitel
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ABSTRACT: Recombinant factor VIIa can decrease postoperative bleeding after cardiac surgery. However, the potential for recombinant factor VIIa to cause early vascular graft occlusion at the site of new vascular anastomoses has not been fully explored. We hypothesized that recombinant factor VIIa would cause a dose-dependent reduction in vascular graft patency in rabbits.
Reversed end-to-end interpositional vein grafts were sutured into the carotid artery of heparinized rabbits, and then recombinant factor VIIa (300 μg/kg, 90 μg/kg, or 20 μg/kg intravenously) or placebo was administered (n = 16/group). Graft patency was assessed at 24 hours using a vascular ultrasound probe. Factor VII activity levels were measured using a prothrombin time-based assay. In different rabbits, the patency of venous end-to-side anastomoses and simple carotid arterial repairs was assessed (recombinant factor VIIa, 300 μg/kg vs placebo, n = 8/group). Data were analyzed using Fisher's exact test, t tests, or analysis of variance.
Physiologic variables (activated clotting time, hemoglobin, pH, Pao(2)) and vessel diameter were not different between groups. Vein graft patency was reduced (93.8%, 81.2%, 13.8%, and 6.3%) as factor VII activity levels increased (1.8 ± 0.4, 4.4 ± 2.1, 11.8 ± 4.7, and 23.6 ± 16.9 U/mL, respectively) with increasing doses of recombinant factor VIIa administered (0, 20, 90, and 300 μg/kg, respectively, P < .05). Patency in the arterial repairs and end-to-side venous grafts was also reduced in recombinant factor VIIa-treated rabbits (P < .05 for both).
This study suggests that recombinant factor VIIa is associated with a dose-dependent increase in fresh vascular graft occlusion. Higher doses of recombinant factor VIIa may be associated with increased thrombotic outcomes.
The Journal of thoracic and cardiovascular surgery 01/2011; 142(2):418-23. · 3.41 Impact Factor
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ABSTRACT: Sternal instability with mediastinitis is a very serious complication after median sternotomy. Biomechanical studies have suggested superiority of rigid plate fixation over wire cerclage for sternal fixation. This study tests the hypothesis that sternal closure stability can be improved by adding plate fixation in a human cadaver model.
Midline sternotomy was performed in 18 human cadavers. Four sternal closure techniques were tested: (1) approximation with six interrupted steel wires; (2) approximation with six interrupted cables; (3) closure 1 (wires) or 2 (cables) reinforced with a transverse sternal plate at the sixth rib; (4) Closure using 4 sternal plates alone. Intrathoracic pressure was increased in all techniques while sternal separation was measured by three pairs of sonomicrometry crystals fixed at the upper, middle and lower parts of the sternum until 2.0 mm separation was detected. Differences in displacement pressures were analyzed using repeated measures ANOVA and Regression Coefficients.
Intrathoracic pressure required to cause 2.0 mm separation increased significantly from 183.3 +/- 123.9 to 301.4 +/- 204.5 in wires/cables alone vs. wires/cables plus one plate respectively, and to 355.0 +/- 210.4 in the 4 plates group (p < 0.05). Regression Coefficients (95% CI) were 120 (47-194) and 142 (66-219) respectively for the plate groups.
Transverse sternal plating with 1 or 4 plates significantly improves sternal stability closure in human cadaver model. Adding a single sternal plate to primary closure improves the strength of sternal closure with traditional wiring potentially reducing the risk of sternal dehiscence and could be considered in high risk patients.
Journal of Cardiothoracic Surgery 01/2009; 4:19. · 1.19 Impact Factor
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ABSTRACT: To determine the outcome of single-stage soft tissue and osseous reconstruction using the Ilizarov method and soft-tissue transfer.
A retrospective review.
: A university-affiliated, tertiary-care center.
We identified 11 patients from a retrospective review from January 1994 to July 1999 who underwent single-stage soft tissue and osseous reconstruction using the Ilizarov method. All 11 patients had an initial traumatic mechanism to their tibia and had previous operative intervention before the combined procedure. The Ilizarov procedure was performed for infected tibial nonunion (8 cases), or complex fracture with soft-tissue loss (3 cases).
Soft tissue transplant survival, union, range of motion, leg length discrepancy, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, radiographic parameters.
There were 8 concomitant free tissue flaps and 3 local pedicled flaps. Two patients had primary bone grafting, and 5 others had addition of an antibiotic impregnated bone substitute. There were 8 cases of elective reconstructive surgery and 3 cases of acute traumatic fracture. The mean duration of Ilizarov application was 26 weeks (range, 7 to 42). Eight tibiae united primarily, and 3 healed after delayed bone grafting. There were 2 major flap complications. Both were successfully managed with repeat surgery. One patient sustained a repeat open fracture and subsequently received an amputation. According to the ASAMI score, there were 9 excellent results, 1 good result, and 1 poor result.
Our study suggests that concomitant osseous and soft-tissue reconstruction with the Ilizarov technique and free or pedicled flaps is a viable option for patients with composite tissue defects.
Journal of Orthopaedic Trauma 04/2008; 22(3):183-9. · 2.13 Impact Factor
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ABSTRACT: Postoperative hemorrhage following cardiac surgery increases morbidity, mortality, and costs. Several case reports have described the successful use of recombinant factor VIIa to decrease or stop bleeding in patients undergoing cardiac surgery. The mechanism of action of recombinant factor VIIa is thought to be increased site-specific thrombin generation by tissue factor-mediated activation of coagulation or from activated platelets. However, there have also been many reports of thrombotic complications after recombinant factor VIIa administration. Randomized clinical trials and further laboratory studies should help better clarify the efficacy, safety, cost-effectiveness, and optimal dosing of recombinant factor VIIa in the cardiac surgical setting.
Seminars in Cardiothoracic and Vascular Anesthesia 01/2008; 11(4):261-4.
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ABSTRACT: Carpal tunnel syndrome is one of the most common and disabling work injuries in North America. Patients with carpal tunnel syndrome are often associated with substantial productivity loss and cost both at work and at home. Several studies have examined the relationship of social supports as a predictor of returning to work following carpal tunnel release surgery (CTRS). However, no studies published to date have examined the relationship between social support and the ability to perform activities of daily living after having CTRS.
To examine whether a correlation exists between the degree of social support and hand function in terms of the ability to perform activities of daily living in patients who have had CTRS.
Patients in the present cross-sectional study were evaluated with two standardized questionnaires at least two months postoperatively following CTRS. The questionnaires consisted of the Multidimensional Scale of Perceived Social Support, which evaluated social support, and QuickDASH, which evaluated hand function. A correlation analysis was then performed to identify any relationships between the two questionnaires.
In a sample of 20 patients, correlation analyses revealed that perceived social support was significantly associated with hand function scores postoperatively (r=-0.73, P<0.01). In addition, a statistically significant relationship existed between social support and the preoperative self-rating pain scores (r=-0.51, P<0.05). These results indicate that there is a strong association between the degree of social support and the ability to perform hand activities of daily living following CTRS.
The Canadian journal of plastic surgery, Journal canadien de chirurgie plastique 01/2008; 16(4):216-20. · 0.18 Impact Factor
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ABSTRACT: Vacuum-assisted closure is an adjunctive therapy that utilizes negative pressure to remove fluid from open wounds through a sealed dressing and tubing which is connected to a collection container. Although introduced into practice for individuals with chronic wounds, evidence to support its use is limited. To compensate for the current gap between the evidence base and the need for best vacuum-assisted closure practices in the treatment of chronic wounds, the existing evidence base (case reports, case series, and studies) for pressure ulcers, diabetic foot ulcers, heel ulcers, and venous leg ulcers was retrieved and tabulated from relevant literature in PubMed and other sources. In addition, expert opinion was obtained through an 11-member Delphi panel of interdisciplinary wound care opinion leaders and educators. The panel included frequent (6) and less-frequent (5) vacuum-assisted closure users. The tabulated responses and the existing literature formed the basis of the best practice statements that serve to guide treatment approaches and stimulate further study.
Ostomy/wound management 12/2003; 49(11):52-66. · 1.08 Impact Factor
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Brian O'Sullivan,
Patrick Gullane,
Jonathan Irish,
Peter Neligan,
Fred Gentili, James Mahoney,
Susanna Sellmann,
Charles Catton,
John Waldron,
Dale Brown,
Ian Witterick,
Jeremy Freeman,
Robert Bell
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ABSTRACT: Combination surgery and radiotherapy (RT) is frequently used in soft tissue sarcoma (STS). Because lower doses and smaller irradiation volumes are possible in preoperative RT (pre-op RT), this approach can be especially valuable in anatomic settings where critical organs are in close proximity to the RT target area. A recent multicenter phase III trial (SR.2 trial of the National Cancer Institute of Canada Clinical Trials Group) comparing pre-op RT against post-op RT for extremity STS has shown significantly higher major wound complication rates (35%) with pre-op RT. We postulated that wound complication rates may be less frequent in the head and neck with better vascularity and wider use of secondary wound reconstruction. Using a prospective database, we identified 40 consecutive patients with head and neck STS treated with pre-op RT (50 Gy) and subsequent (4 to 6 weeks later) resection between 1/89 and 8/99 in a single institution setting. Major wound complications (MWC) were classified by the identical criteria used in the SR.2 trial. Intracranial extension was evident in 5 patients, whereas 50% of the patients had large tumors (> 5 cm). Deep tumor was present in 34 (85%), and 6 (15%) were superficial to fascia. In this series, 31 patients (77.5%) had secondary reconstruction of the acquired soft tissue deficit. The actuarial 2-year local relapse-free rate was 80%, and the metastatic relapse-free rate was 85%. Major wound complications occurred in 8 of 40 patients (20%) within 120 days of surgery according to the SR.2 criteria: secondary wound surgery (3), readmission or prolonged hospital admission for wound care (2), deep packing (0), prolonged dressing changes (2), and invasive procedure for wound care (1). The latter was a minor wound management problem (a single outpatient drainage of a seroma) for the combined rate of 8/20 or 20%. Our findings show that (1) pre-op RT in head and neck STS is associated with lower rates of major wound complications compared to extremity cases; (2) pre-op RT provides high rates of local control in an adverse group of cases of adult head and neck STS; (3) the choice of scheduling of RT should be based on anatomic issues with emphasis on the trade-offs between RT doses and volumes versus wound morbidity for individual patients. This is especially important when tumor may be adjacent to critical head and neck structures which may be protected from the high-dose RT area.
World Journal of Surgery 07/2003; 27(7):875-83. · 2.36 Impact Factor
