Cornelis H. van der Vlies

Costs of burn care: a systematic review

Burn care is traditionally considered expensive care. However, detailed information about the costs of burn care is scarce despite the increased need for this information and the enhanced focus on healthcare cost control. In this study, economic literature on burn care was systematically reviewed to examine the problem of burn‐related costs. Cost or economic evaluation studies on burn care that had been published in international peer‐reviewed journals from 1950 to 2012 were identified. The methodology of these articles was critically appraised by two reviewers, and cost results were extracted. A total of 156 studies met the inclusion criteria. Nearly all of the studies were cost studies (n = 153) with a healthcare perspective (n = 139) from high‐income countries (n = 127). Hospital charges were often used as a proxy for costs (n = 44). Three studies were cost‐effectiveness analyses. The mean total healthcare cost per burn patient in high‐income countries was

Consensus strategies for the nonoperative management of patients with blunt splenic injury: A Delphi study

88,218 (range

Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review.

704–

Literature Review of the Role of Ultrasound, Computed Tomography, and Transcatheter Arterial Embolization for the Treatment of Traumatic Splenic Injuries

717,306; median

Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs.

44,024). A wide variety of methodological approaches and cost prices was found. We recommend that cost studies and economic evaluations employ a standard approach to improve the quality and harmonization of economic evaluation studies, optimize comparability, and improve insight into burn care costs and efficiency.

External validation of the revised Baux score for the prediction of mortality in patients with acute burn injury.

BACKGROUND Nonoperative management is the standard of care in hemodynamically stable patients with blunt splenic injury. However, a number of issues regarding the management of these patients are still unresolved. The aim of this study was to reach consensus among experts concerning optimal treatment and follow-up strategies. METHODS The Delphi method was used to reach consensus among 30 expert trauma surgeons and interventional radiologists from around the world. An online survey was used in the two study rounds. Consensus was defined as an agreement of 80% or greater. RESULTS Response rates of the first and second rounds were 90% and 80%, respectively. Consensus was reached for 43% of the (sub)questions. The American Association for the Surgery of Trauma organ injury scale for grading splenic injury is used by 93% of the experts. In hemodynamically stable patients, observation or splenic artery embolization (SAE) can be applied in the presence of a small or no hemoperitoneum combined with an intraparenchymal contrast extravasation or no contrast extravasation, regardless of the presence of an arteriovenous (AV) fistula/pseudoaneurysm. Hemodynamic instability is an indication for operative management, irrespective of computed tomographic characteristics and grade of splenic injury (≥82% of the experts). Operative management is also indicated in the presence of associated intra-abdominal injuries and/or the need for five or more packed red blood cell transfusions (22 of 27 experts, 82%). Recommended time span to start SAE in a stable patient with an intraparenchymal contrast extravasation is 60 minutes (19 of 24 experts). Patients should be admitted 1 to 3 days to a monitored setting (27 of 27 experts, 100%). Serial hemoglobin checks are performed by all experts, every 4 to 6 hours in the first 24 hours and once or twice a day after that (21 of 24 experts, 88%), in nonoperative management as well as after SAE. Routine postdischarge imaging is not indicated (21 of 24 experts, 88%). CONCLUSION Although treatment should always be adjusted to the specific patient, the results of this study may serve as general guidelines.

Failure rate and complications of angiography and embolization for abdominal and pelvic trauma.

BACKGROUND Contradictory findings are reported in the literature concerning prognostic factors for failure of nonoperative management (NOM) in the treatment of adults with blunt splenic injury. The objective of this systematic review was to identify prognostic factors for failure of NOM, with or without angiography and embolization. METHODS MEDLINE, Embase, and the Cochrane Library databases were searched. Prospective or retrospective cohort studies addressing failure of nonoperative treatment, with and/or without angiography and embolization, of blunt abdominal injuries were included. Methodological quality of the studies was assessed. RESULTS A total of 335 titles and abstracts were screened, of which 31 fulfilled the inclusion criteria. No randomized controlled trials were found. Ten articles were qualified as high-quality articles and used for data extraction (best-evidence synthesis). A total of 25 prognostic factors were investigated, of which 14 were statistically significant in one or more studies. Strong evidence exists that age of 40 years or above, Injury Severity Score (ISS) of 25 or greater, and splenic injury grade of 3 or greater are prognostic factors for failure of NOM. Moderate evidence was found for a splenic Abbreviated Injury Scale score of 3 or greater, trauma and ISS of less than 0.80, the presence of an intraparenchymal contrast blush, as well as transfusion of 1 unit of packed red blood cells or more. Limited evidence was found for large hemoperitoneum, lower Revised Trauma Score, lower Glasgow Coma Scale score, lower systolic blood pressure, male sex, the presence of traumatic brain injury, and splenic embolization as protective factor for failure of NOM. CONCLUSION Awareness for failure of NOM is required in patients aged 40 years or older, in patients with an ISS of 25 or higher or those with splenic injury grade 3 or higher. The prognostic factors for failure that we identified should be confirmed in future prospective cohort studies or meta-analyses using individual patient data. LEVEL OF EVIDENCE Systematic review, level III.

Routine urinalysis in patients with a blunt abdominal trauma mechanism is not valuable to detect urogenital injury

IntroductionThe spleen is the second most frequently injured organ following blunt abdominal trauma. Trends in management have changed over the years. Traditionally, laparotomy and splenectomy was the standard management. Presently, nonoperative management (NOM) of splenic injury is the most common management strategy in hemodynamically stable patients. Splenic injuries can be managed via simple observation (OBS) or with angiography and embolization (AE). Angio-embolization has shown to be a valuable alternative to observational management and has increased the success rate of nonoperative management in many series.DiagnosticsImproved imaging techniques and advances in interventional radiology have led to a better selection of patients who are amenable to nonoperative management. Despite this, there is still a lot of debate about which patients are prone to NOM.Angiography and EmbolizationThe optimal patient selection is still a matter of debate and the role of CT and angio-embolization has not yet fully evolved. We discuss the role of sonography and CT features, such as contrast extravasation, pseudoaneurysms, arteriovenous fistulas, or hemoperitoneum, to determine the optimal patient selection for angiography and embolization. We also review the efficiency, technical considerations (proximal or selective embolization), logistics, and complication rates of AE for blunt traumatic splenic injuries.

Long-term scar quality in burns with three distinct healing potentials: A multicenter prospective cohort study.

BackgroundIn recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization.AimThe purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney.ResultsThe management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey.ConclusionsThe progress in imaging techniques has contributed to NOM being currently the treatment of choice for hemodynamically stable patients. Angioembolization can be used as an adjunct to NOM and has increased the success rate to 95%. However, to date many controversies exist about the optimum patient selection for NOM, the proper role of angioembolization in NOM, the best technique and material to use in angioembolization, and the right follow-up strategy of patients sustaining blunt abdominal injury. Conducting a well-designed prospective clinical trial or a Delphi study would be preferable.

The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale; translation and validation of the Dutch language version for ankle fractures

BACKGROUND Since the original Baux score was outdated and inhalation injury was recognized as an important contributor to mortality, Osler et al. developed a revised Baux score for the prediction of mortality of burn patients in an American population. The aim of this study was to validate the revised Baux score with data of patients admitted to the Rotterdam Burn Center (RBC) in the Netherlands. METHODS Prospectively collected data were analyzed for all patients with acute burn injury admitted to the RBC from 1987 to 2009 (n = 4,389), including sex, age, total body surface area involved, inhalation injury, mortality, and premorbid conditions. Logistic regression analysis was used to determine the relationship between mortality and possible contributing variables. The discriminative power of the revised Baux score was assessed by receiver operating characteristics curve analysis. RESULTS Overall mortality in our center was 6.5%; mortality in patients with intention to treat was 4.4%. Age, total body surface area, inhalation injury, as well as premorbid circulatory and central nervous system conditions were significant independent predictors of in-hospital mortality. Revised Baux score in the RBC population (area under the curve, 0.96; 95% confidence interval, 0.95–0.97) performed less specific and sensitive in a selected group of patients with high Baux scores (area under the curve, 0.81; 95% confidence interval, 0.76–0.84). CONCLUSION The revised Baux score is a simple and accurate model for predicting mortality in patients with acute burn injuries in a burn center setting. LEVEL OF EVIDENCE Prognostic study, level III.