The results from this analysis indicated that surgery time, risk of blood transfusion, and amount of matrix used are greater with Surgiflo patients, compared to Floseal patients. Choice of matrix did not appear to impact hospital LOS or risk of surgical complications. Future research should evaluate the cost consequences of increased clinical and resource utilization by choice of hemostatic matrix in spine surgery.

Objectives: A recently published retrospective analysis comparing two different active flowable hemostatic matrices (FLOSEAL and SURGIFLO Kit with Thrombin) showed significantly increased resource use and complications (surgery time, risk of blood product transfusion, and amount of matrix used) with SURGIFLO use compared to FLOSEAL in major spine surgery, and also significantly increased surgical time with SURGIFLO use in severe spine surgery. This analysis was developed as a follow-up to this prior analysis, to evaluate the cost-consequence of using FLOSEAL vs SURGIFLO in major and severe spine surgery. Methods: A cost consequence model was constructed from a US hospital provider perspective. Model parameters combined clinical inputs from the published retrospective analysis with supplemental analyses on annual spine surgery volume using the 2012 National Inpatient Sample (NIS) database. Cost of hemostatic matrices, blood product transfusion, and operating room time were identified from published literature. Various one-way and probabilistic sensitivity analyses were performed. Results: The base case for a medium volume hospital showed that, compared to SURGIFLO, patients receiving FLOSEAL required three fewer blood product transfusions and saved 27 h of OR time, resulting in annual savings of $151 per major and $574 per severe spine surgery. Additional scenarios for high and low volume hospitals supported cost savings in the base case. Probabilistic sensitivity analysis revealed FLOSEAL was cost-saving in 76% of simulations in major spine and 97% of iterations in severe spine surgery. Conclusions: This economic analysis indicates that use of FLOSEAL instead of SURGIFLO hemostatic matrices to induce hemostasis in both major and severe spine surgery could potentially lead to sizable cost savings in US hospitals, regardless of spinal surgery case-mix. ARTICLE HISTORY

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The trainee's problem The patient is a 16-year-old girl and the elder daughter of intensely religious school-teaching parents. She herself has always seemed a fairly happy child and has recently been "converted" to the same beliefs her parents hold-apparently of her own free will and without regret. She attends the local comprehensive school and is making adequate progress. She is hoping to enter nursing, and her parents seem pleased about this.Her medical history was fairly uneventful until about two years ago since when she has had recurring bouts of abdominal pain, sometimes in the centre of the abdomen and colicky, sometimes in the right iliac fossa and more constant. It is difficult to determine any pattern underlying these attacks, which have now produced some eight episodes of consultation. During one episode a year ago she was admitted to hospital as having possible acute appendicitis. Her pain settled quickly, and no operation was needed. No cause for her symptoms was found, and the discharge diagnosis was, perhaps unfortunately, mild acute appendicitis. Two months ago she was again seen at hospital on her own initiative-at a weekend when another practice was covering but was not admitted. I saw her again yesterday with stabbing pain in the right iliac fossa. She is