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Discharge against medical advice (DAMA) represents an increasingly burdensome public health issue that leads to worse outcomes for patients and high costs to society. While the rate of patients who DAMA is higher within certain institutions and geographic locations, the problem is present across all healthcare systems. DAMAs are often challenging as they occur suddenly and can be unsatisfactory. An opportunity exists to better meet the needs of this patient population; however, many providers are unsure of how they can prevent a DAMA. In this review, we discuss the broader impact, associated factors, the most common reasons, the consequences, and the prevention strategies for DAMA. Further research is needed to create tools for stratifying patients most likely to DAMA. Early identification and appropriate interventions for these patients will allow for safe discharges., Competing Interests: Conflict of interest The authors declare no conflict of interest., (Copyright © 2023 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Objective: To assess perinatal outcomes of first pregnancy after remission from gestational trophoblastic neoplasia and the impact of the time between the end of chemotherapy and the subsequent pregnancy., Data Sources: The Medical Subject Headings related to perinatal outcomes, chemotherapy, and gestational trophoblastic neoplasia were used alone or in combination to retrieve relevant articles. We searched all references registered until April, 2019 in Embase, LILACS, MEDLINE, the Cochrane Central Register of Controlled Trials, and Web of Science., Study Eligibility Criteria: We included any observational or interventional studies that evaluated perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic neoplasia. Animal studies, narrative reviews, expert opinions, and previous treatments with potential risks for future perinatal outcomes which may introduce confounding bias were excluded., Study Appraisal and Synthesis Methods: Two reviewers independently screened all identified references for eligibility and data extraction. Methodological quality and bias of included studies were assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies from the National Institutes of Health. For the meta-analysis, the measures of association were calculated using bivariate random-effects models. Statistical heterogeneity was evaluated with I 2 statistics and explored through sensitivity analysis. Publication bias was assessed by visual inspection of the funnel plot or Egger's test, according to the number of articles included. For all analyses, a P value of <.05 indicated statistical significance. This study was registered on PROSPERO (CRD42018116513)., Results: A total of 763 studies were identified after literature search and 23 original studies were included in the systematic review and in the meta-analysis. The combined data from the subgroup meta-analysis (outcome vs time after chemotherapy) showed an incidence of spontaneous abortion of 15.28% (95% confidence interval, 12.37-18.74; I 2 =73%), 3.30% of malformation (95% confidence interval, 2.27-4.79; I 2 =31%), 6.19% of prematurity (95% confidence interval, 5.03-7.59; I 2 =0), and 1.73% of stillbirth (95% confidence interval, 1.17-2.55; I 2 =0%). These results were not influenced by the time between the end of chemotherapy and the subsequent pregnancy in most of the studied outcomes, including malformation (P=.14, I 2 =31%), prematurity (P=.46, I 2 =0), and stillbirth (P=.66, I 2 =0). However, there was a higher occurrence of spontaneous abortion (P<.01, I 2 =73%) in pregnancies that occurred ≤6 months after chemotherapy., Conclusion: Chemotherapy for gestational trophoblastic neoplasia does not appear to increase the chance of unfavorable perinatal outcomes, except for the higher occurrence of spontaneous abortion in pregnancies occurring ≤6 months after chemotherapy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Recent neuroimaging data support the hypothesis of a multisensory interplay at low-level sensory-specific cortex., Objective: We used an on-line interference approach by rTMS to investigate the role of the left lateral occipital cortex (LOC) in audio-visual (AV) object recognition process., Methods: Fifteen healthy volunteers performed a visual identification task of degraded pictures presented alone or simultaneously to coherent or non-coherent sounds. Focal 10-Hz rTMS at an intensity of 100% resting motor threshold was delivered simultaneously to the picture. Two blocks of 60 pictures were randomly displayed in two different experimental conditions: rTMS of the left LOC and over Cz., Results: rTMS of the left LOC produced a worsening of the accuracy compared to rTMS over Cz specifically in the coherent AV condition., Conclusion: These data support the view that audio-visual interaction effect may occur at early stage of recognition processing., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Neurocognitive models of visual object identification have focussed on processes at the moment of identification, when perceivers can actually name what they see. Less well known is the timecourse of processes preceding and leading to actual identification. To track neuromental processes involved in visual identification, behavioral measures and event-related potentials (ERPs) were recorded in two experiments prior to, during and after the identification of fragmented objects, half of which had been shown in their complete versions in a previous study phase. Each object was revealed in a sequence of frames wherein the object was represented by an increasingly less and less fragmented image up to the complete version. A shift in ERPs, around 300 ms and beyond, from negativity to positivity, marked the transition from non-identification to identification. However, while for new stimuli such a shift appeared abruptly from non-identification to identification, for recently-studied objects a late positive wave emerged in response to unidentified fragments at a level just prior to overt identification. Thus, ERPs reflected covert processes associated with a successful match between the current visual information and episodic recently-stored memory traces, which predicted overt identification.

Objective: To determine the sparing effect of clonidine (C) on fentanyl (F) demand in burned patients under PCA., Study Design: Prospective, randomized, double blind study versus placebo., Patients: Twelve consecutive patients with mean burn surface area of 20 +/- 9%, studied between the third and the eighth day post-burn., Methods: F was delivered by a PCA pump (bolus: 1 mg.kg-1). In the morning, burn patients received additional F (5 mg.kg-1) before hydrotherapy. After randomisation, C or placebo (P) were alternatively infused over 24 hours. Demands for F during the morning, the afternoon and the evening were noted. Pain scores were measured on a visual analogic scale. In eight patients, plasma levels of F (pF) were iteratively measured. Heart rate, arterial pressure, respiratory rate and SpO2 were monitored., Results: Analgesic demands were 19.5/day under P and 9.5 under C (P < 0.0001). Pain reoccurred for pF of 4.1 under C vs 5.7 under P (P < 0.05) with same pain scores in the two groups. After a pain stimulus, pain scores were lower under F, despite lower pF (P < 0.05). Arterial pressure and heart rate were significantly lowered during the first hour of C infusion., Conclusion: Doses of F and pF required to reach analgesia were very high. Adding C decreases by 50% the F demand and lowers pF. Minor haemodynamic effects were observed during the first hour of C infusion.

A case of Saccharomyces boulardii fungaemia in a burn patient is reported. S. boulardii was administered in order to improve the digestive tolerance to enteral nutrition. After a surgical procedure, a sepsis syndrome occurred, with a white blood cell count increase, abdominal meteorism and respiratory insufficiency, associated with seven blood cultures positive to S. boulardii. Digestive translocation of the yeast seems to be the most likely origin of this fungaemia. Some fungaemias from S. boulardii have been published. However it is not usual to find such severe clinical features as in our case which leads us to reconsider the therapeutic use of S. boulardii in situations including a gastrointestinal tract suffering.

Mivacurium, a new short acting non depolarizing neuromuscular blocker, is metabolized, as suxamethonium, by plasma cholinesterase. Therefore its duration of action is increased in patients with reduced plasma cholinesterase activity. We report a case of prolonged neuromuscular block after an i.v. bolus of mivacurium (0.20 mg.kg-1) in a 69 year-old ASA II woman with an unrecognized cholinesterase deficiency undergoing a lumbar sympathectomy for arteriopathy of the lower limbs. The duration of the block was 6 h and plasma cholinesterase concentrations were very low (540 and 610 UI.L-1), as well as the dibucaine number (16%), which suggests an homozygous enzymatic deficiency. Mechanical ventilation and sedation were continued until spontaneous return of full neuromuscular function.

Visual evoked potentials were recorded from occipital and temporal leads in the two cerebral hemispheres of eight fencers and eight control subjects. The stimulus was a checkerboard subtending a small (1 degree) or large (30 degrees) visual field. Significant differences in P60, N75 and P100 latency and amplitude were found between the two subject groups, especially during the processing of the large visual field. In fencers and left-handers shorter latencies were found for the large visual field condition, whereas right-handers showed an opposite trend. The results give further evidence of special patterns of visual processing in athletes, like fencers, in agreement with the literature.