Background
Discharge against medical advice (DAMA) occurs when an in‐patient chooses to leave the hospital before discharge is recommended by the treating clinicians. The long‐term outcomes of ...patients who DAMA are not well documented.
Aim
The objective of this long‐term and hospital‐wide study is to examine characteristics of patients who DAMA, their rates of readmission and mortality after self‐discharge.
Methods
Administrative data of admissions to Flinders Medical Centre between July 2002 and June 2011 were used to compare readmissions and mortality among patients who DAMA with those who did not. The outcomes were adjusted for age, gender, emergency admission status, comorbidity, mental health diagnoses, and alcohol and substance abuse.
Results
In the study period, 1562 episodes (1.3%) of 121 986 admissions to Flinders Medical Centre were DAMA. Compared with those who did not leave against medical advice, these patients were younger, more often male, more likely of indigenous ethnicity and had less physical comorbidity, but greater mental health comorbidity. Half of the DAMA group stayed less than 3 days. In multivariate analysis, the relative risk for 7‐day, 28‐day and 1‐year readmission in the DAMA group was 2.36 (95% confidence interval (CI), 1.99–2.81; P < 0.001), 1.66 (95% CI, 1.44–1.92; P < 0.001) and 1.31 (95% CI, 1.19–1.45; P < 0.001), respectively, compared with standard discharges. Furthermore, DAMA was associated with twofold (P = 0.02), 1.4‐fold (P = 0.025) and 1.2‐fold (P = 0.049) increase in 28‐day, 1‐year and up‐to‐9‐year mortality, respectively, compared with non‐DAMA.
Conclusions
Patients who self‐discharged against medical advice carry a significant risk of readmission and mortality. Patients with characteristics of ‘at risk of DAMA’ should have greater attention paid to their care before and especially after any premature discharge.
Biodegradable polycaprolactone and collagen nanofibers were produced by electrospinning, with fiber diameters of around 300–700
nm and features similar to the extracellular matrix of natural tissue. ...Human coronary artery smooth muscle cells (SMCs) seeded on nanofibrous matrices tend to maintain normal phenotypic shape and growth tends to be guided by the nanofiber orientation. The SMC and nanofibrous matrix interaction was observed by SEM, MTS assay, trypan blue exclusion method and laser scanning confocal microscopy. The results showed that the proliferation and growth rate of SMCs were not different on polycaprolactone (PCL) nanofibrous matrices coated with collagen or tissue culture plates. PCL nanofibrous matrices coated with collagen showed that the SMCs migrated towards inside the nanofibrous matrices and formed smooth muscle tissue. This approach may be useful for engineering a variety of tissues in various structures and shapes, and also to demonstrate the importance of matching both the initial mechanical properties and degradation rate of nanofibrous matrices to the specific tissue engineering.
Hydrogen sulfide production by sulfate reducing bacteria (SRB) is the primary cause of oil reservoir souring. Amending environments with chlorate or perchlorate collectively denoted (per)chlorate ...represents an emerging technology to prevent the onset of souring. Recent studies with perchlorate reducing bacteria (PRB) monocultures demonstrated that they have the innate capability to enzymatically oxidize sulfide, thus PRB may offer an effective means of reversing souring. (Per)chlorate may be effective by (i) direct toxicity to SRB; (ii) competitive exclusion of SRB by PRB; or (iii) reversal of souring through re-oxidation of sulfide by PRB. To determine if (per)chlorate could sweeten a soured column system and assign a quantitative value to each of the mechanisms we treated columns flooded with San Francisco bay water with temporally decreasing amounts (50, 25, and 12.5 mM) of (per)chlorate. Geochemistry and the microbial community structure were monitored and a reactive transport model was developed, Results were compared to columns treated with nitrate or untreated. Souring was reversed by all treatments at 50 mM but nitrate-treated columns began to re-sour when treatment concentrations decreased (25 mM). Re-souring was only observed in (per)chlorate-treated columns when concentrations were decreased to 12.5 mM and the extent of re-souring was less than the control columns. Microbial community analyses indicated treatment-specific community shifts. Nitrate treatment resulted in a distinct community enriched in genera known to perform sulfur cycling metabolisms and genera capable of nitrate reduction. (Per)chlorate treatment enriched for (per)chlorate reducing bacteria. (Per)chlorate treatments only enriched for sulfate reducing organisms when treatment levels were decreased. A reactive transport model of perchlorate treatment was developed and a baseline case simulation demonstrated that the model provided a good fit to the effluent geochemical data. Subsequent simulations teased out the relative role that each of the three perchlorate inhibition mechanisms played during different phases of the experiment. These results indicate that perchlorate addition is an effective strategy for both souring prevention and souring reversal. It provides insight into which organisms are involved, and illuminates the interactive effects of the inhibition mechanisms, further highlighting the versatility of perchlorate as a sweetening agent.
Microbial sulfate reduction is a primary cause of oil reservoir souring. Here we show that amendment with chlorate or perchlorate collectively (per)chlorate potentially resolves this issue. ...Triplicate packed columns inoculated with marine sediment were flushed with coastal water amended with yeast extract and one of nitrate, chlorate, or perchlorate. Results showed that although sulfide production was dramatically reduced by all treatments, effluent sulfide was observed in the nitrate (10 mM) treatment after an initial inhibition period. In contrast, no effluent sulfide was observed with (per)chlorate (10 mM). Microbial community analyses indicated temporal community shifts and phylogenetic clustering by treatment. Nitrate addition stimulated Xanthomonadaceae and Rhizobiaceae growth, supporting their role in nitrate metabolism. (Per)chlorate showed distinct effects on microbial community structure compared with nitrate and resulted in a general suppression of the community relative to the untreated control combined with a significant decrease in sulfate reducing species abundance indicating specific toxicity. Furthermore, chlorate stimulated Pseudomonadaceae and Pseudoalteromonadaceae, members of which are known chlorate respirers, suggesting that chlorate may also control sulfidogenesis by biocompetitive exclusion of sulfate-reduction. Perchlorate addition stimulated Desulfobulbaceae and Desulfomonadaceae, which contain sulfide oxidizing and elemental sulfur-reducing species respectively, suggesting that effluent sulfide concentrations may be controlled through sulfur redox cycling in addition to toxicity and biocompetitive exclusion. Sulfur isotope analyses further support sulfur cycling in the columns, even when sulfide is not detected. This study indicates that (per)chlorate show great promise as inhibitors of sulfidogenesis in natural communities and provides insight into which organisms and respiratory processes are involved.
To evaluate the incidence of urinary tract injury due to hysterectomy for benign disease.
Patients were enrolled prospectively from 3 sites. All patients undergoing abdominal, vaginal, or ...laparoscopic hysterectomy for benign disease underwent diagnostic cystourethroscopy.
Four hundred seventy-one patients participated. Ninety-six percent (24/25) of urinary tract injuries were detected intraoperatively. There were 8 cases of ureteral injury (1.7%) and 17 cases of bladder injury (3.6%). Ureteral injury was associated with concurrent prolapse surgery (7.3% vs 1.2%;
P
=
.025). Bladder injury was associated with concurrent anti-incontinence procedures (12.5% vs 3.1%;
P
=
.049). Abdominal hysterectomy was associated with a higher incidence of ureteral injury (2.2% vs 1.2%) but this was not significant. Only 12.5% of ureteral injuries and 35.3% of bladder injuries were detected before cystoscopy.
The incidence of urinary tract injury during hysterectomy is 4.8%. Surgery for prolapse or incontinence increases the risk. Routine use of cystoscopy during hysterectomy should be considered.
Zinc oxide nanowire arrays were hydrothermally grown on a Si(100) substrate coated with randomly oriented seed crystallites to characterize the process of geometrical selection. The theory suggests ...that randomly oriented rod-like crystallites can be grown into a film or array of nanowires with the maximal growth rate direction approximately normal to the substrate; in the case of ZnO, this is the c-axis direction. To examine this growth phenomenon experimentally, ZnO nanowire arrays with a random initial orientation were grown, and the number of wires that survived the geometrical selection up to a certain distance, h, from the substrate was measured. The resulting number density of the survived wires decreased as h –0.8, while the geometrical selection model predicted the decrease to be ∼h –1. As developed originally, the model can also apply universally to other three-dimensional (3D) crystal ensembles besides ZnO. Understanding geometrical selection will allow assessment of if and when this theory can be used to obtain films with certain characteristics, such as the orientation and scattering of the nanowire array, that is relevant for specific applications.
Long‐term effectiveness of high‐explosive devices necessitates maintaining a level of specific surface area of initiating powder components within specified margins. This ensures that ignition and ...detonation performance of the powder does not degrade significantly over time. Flow permeametry is a commonly employed surface characterization tool in this context, as embodied in the Fisher sub‐sieve surface area (FSSA). Recently we made alterations to the commercial permeametry apparatus that enables accurate in situ measurements of FSSA using only ∼100 mg samples. In this work we report on a 24‐month aging study in such modified sample holders at elevated temperatures of 40 °C and 60 °C. Through a process called time‐temperature‐superposition (TTS) the resulting isotherms are translated into a single master curve that predicts powder FSSA evolution over decades under ambient temperature conditions. We generate master curves for two different powders, i. e., pure PETN and 1 wt% added TriPEON, and show that the TriPEON‐doped powder coarsens at a rate a few times slower than the non‐doped powder. Activation barriers computed from the TTS shift factors shed some light on the coarsening mechanisms.
Table 1 Odds ratio (OR) for a positive endoscopic retrograde cholangiopancreatography Variables Univariate analysis Multivariate analysis OR (95% CI) P value OR (95% CI) P value Age 0.99 (0.97–1.01) ...0.51 Gender (F) 3.55 (1.11–11.3) 0.03 1.22 (0.08–18.3) 0.88 Bilirubin 0.99 (0.97–1.01) 0.5 Type of IOC abnormality † 0.59 (0.25–1.37) 0.22 Number of stones in IOC ‡ 0.57 (0.17–1.85) 0.35 Filling defect on MRCP 9.0 (1.03–78.6) 0.047 9.1 (1.03–79.9) 0.047 †Filling defect or no flow to the duodenum. ‡Single. The complication rates are as high as 15% across the studies and include pancreatitis, bleeding, perforation, cholangitis, cholecystitis, and instrument-related complications (e.g. stent-migration), which may often be fatal. 8 Post-ERCP pancreatitis is the most frequent among them, ranging between 2% and 15% of cases and accounts for substantial morbidity, occasional mortality, and increased healthcare expenditures. 9 Interestingly, a single-center case–control study showed a fivefold increased risk of post-ERCP pancreatitis following a positive IOC compared with an age–sex matched cohort. 10 In our study, similar to previous studies, 5 post-ERCP pancreatitis was encountered in about 5% of cases, including two patients who had a negative ERCP. The limitations of our study are the retrospective nature of data collection, single-center experience, and the relatively small number of subjects.
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