Damage Control Strategy Research Articles

Continuous improvement in optimizing the timing of axial, hip, and femoral fracture fixation.

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality.

Experimental investigation of formation damage during drilling of ultradeep fractured carbonate reservoir

Severe formation damage easily occurs in ultradeep fractured carbonate reservoirs during drilling, yet the formation damage mechanisms have not been studied extensively. This study focused on typical fractured carbonate reservoirs in the Shunbei field, China. The multiscale reservoir space characteristics and core wettability of ultradeep fractured carbonate reservoirs were investigated. The results showed that the reservoirs mainly comprise a fourth-order fracture network. The high-temperature and high-pore-pressure steady-state method also identified fluid sensitivity and phase trapping damage. The fluid sensitivity damage at the formation temperature (170 °C) indicated that this reservoir is affected by water sensitivity, salt sensitivity (critical value: 3/4 formation water salinity (FWS)), alkali sensitivity (critical value: pH 7.5), and liquid phase trapping damage. Particle movement and deposition and liquid phase trapping damage are thought to be the primary damage mechanisms. Furthermore, abnormally low water saturation, mixed wettability, abundant clay minerals, and the fourth-order fracture network contribute to fluid sensitivity and liquid phase trapping damage. Finally, a formation damage control strategy was proposed.

Surface integrity and material removal mechanism in fluid jet polishing of optical glass

Fluid jet polishing (FJP) is a promising technology that has been increasingly used in the superfinishing of complex optical lenses, mirrors, and molds on several materials. The influence mechanism of polishing parameters on the damage characteristics, element composition, and surface quality of optical glass was studied through a series of FJP experiments to achieve the high-efficiency and low-damage ultra-precision polishing requirements of optical components. A numerical model for FJP was developed based on computational fluid dynamics (CFD), and the effects of slurry pressure and particle size on the flow field and particle motion characteristics were studied combined with statistical theory. The brittle-ductile transition model and erosion model when abrasive particles eroded optical glass were established to obtain a better understanding of the material removal mechanism during FJP. The damage control strategy can be clarified according to the coupling relationship between the impact velocity and particle size of abrasive particles when radial and transverse cracks are generated in the optical glass. The experimental results verify that the established model can predict the material removal characteristics well. The simulation results also indicate that the erosion removal of the optical glass by abrasive particles is a completely ductile mode under the polishing experimental conditions in this study. The results can provide solid theoretical support for equipment upgrade and process optimization of FJP.

Temporary arterial shunting following a complete transection of femoral artery in a resource-limited setting

The aim of a surgeon managing vascular trauma in an extremity is to save the life, limb, and function of the patient. The use of temporary intravascular shunting has been shown to be a successful damage control strategy in patients who present with hemodynamic instability. We present the first reported case of a penetrating arterial injury of the lower limb causing a large defect that was successfully treated with temporary intravascular shunting before definitive repair in the country of Liberia. In a low-resource setting such as ours, the surgeon often opts to amputate limbs with vascular injuries that are not believed to be candidates for primary repair. Using a pediatric feeding tube with good postoperative results, we demonstrated that temporary arterial shunting in damage control situations before definitive repair was not only feasible but also cost-effective and ultimately resulted in the preservation of the patient’s limb.

Decompressive Hemicraniectomies as a Damage Control Approach for Multilobar Firearm Projectile Injuries: A Single-Center Experience

While firearms projectile injuries to the head carry a high rate of morbidity and mortality, current literature in clinical management remains controversial. Decompressive hemicraniectomy (DHC) has been previously described in the neurosurgical literature for traumatic brain injuries, with positive results in the reduction of mortality. Here we aim to assess DHC as a damage control approach for multilobar firearm injuries to the head and compare our results with what is present in the literature. A retrospective review of patients who sustained multilobar firearm injuries to the head admitted to our center from January 2009 to April 2021 was performed. Exclusion criteria were a Glasgow Coma Scale (GCS) score <5, and/or brain stem dysfunction that persisted despite stabilization and medical therapy for intracranial hypertension. A total of 20 patients were analyzed, with an average GCS on admission of 8.35. The 60-day mortality rate for all 20 patients was 20% with a total of 4 deaths, 1 of which was due to pulmonary sepsis in the critical postoperative care unit. The mean hospital stay of surviving patients was 22 days. DHC should be considered as a damage control strategy for young patients with multilobar firearm injuries and GCS >5, having yielded favorable results in this study when compared to current literature.

Negotiating Lives

How do criminal agendas affect a peace process with violent non-state actors? This article endeavors to resolve this question by presenting a qualitative analysis of the gang truce in El Salvador during the government of Mauricio Funes, using the Peace Triangle as an analytical framework based on three study variables: issues, behavior, and attitudes. It aims to make a double contribution to peace studies, filling a gap in academic knowledge about the sustainability of peace processes and examining the relationship between criminal agendas and conflict resolution. The study reveals that the former Salvadoran president’s inadequate management of criminal agendas transformed the peace negotiation into a damage control strategy, as it was not intended to modify the scale of gang-committed predatory crimes but rather, to shape its behavior.

Study of damage control strategy for non-traumatic diseases: a single-center observational study

BackgroundDamage control strategy (DCS) has been introduced not only for trauma but also for acute abdomen, but its indications and usefulness have not been clarified. We examined clinical characteristics of patients who underwent DCS and compared clinical characteristics and results with and without DCS in patients with septic shock.MethodsWe targeted a series of endogenous abdominal diseases in Kansai Medical University Hospital from April 2013 to March 2019. Clinical characteristics of 26 patients who underwent DCS were examined. Then, clinical characteristics and results were compared between the DCS group (n = 26) and non-DCS group (n = 31) in 57 patients with septic shock during the same period.ResultsAll 26 patients who underwent DCS had septic shock, low mean arterial pressure (MAP) before the start of surgery, and required high-dose norepinephrine administration intraoperatively. Their discharge mortality rate was 12%. Among the patients with septic shock, the DCS group had a higher SOFA score (P = 0.008) and MAP was lower preoperatively, but it did not increase even with intraoperative administration of large amounts of fluid replacement and vasoconstrictor. There was no significant difference in 28-day mortality and discharge mortality between the two groups.ConclusionsDCS may be useful in patients with severe septic shock.

How Learning from Trauma Benefits the Obstetric Population? Damage Control Surgery

Abstract The recent implementation of trauma-validated damage control strategies in severe postpartum hemorrhage proves the importance of interdisciplinary management in the obstetric patient. Massive hemorrhage control techniques and damage control surgery are clear examples of how learning from trauma can benefit the obstetric population. Currently, most obstetric programs do not include training in this type of interventions. Nevertheless, it has been shown that these interventions are useful in the management of severe postpartum hemorrhage. The aim of this article is to introduce the application of damage control surgery principles in the management of massive obstetric hemorrhage. We propose to include appropriate training and the implementation of damage control surgery in obstetric management protocols. The prompt application of damage control principles can be considered in patients with persistent hemodynamic instability despite control of the source of bleeding.

A characterization of trauma laparotomies in a scandinavian setting: an observational study

BackgroundDespite treatment advances, trauma laparotomy continuous to be associated with significant morbidity and mortality. Most of the literature originates from high volume centers, whereas patient characteristics and outcomes in a Scandinavian setting is not well described. The objective of this study is to characterize treatments and outcomes of patients undergoing trauma laparotomy in a Scandinavian setting and compare this to international reports.MethodsA retrospective study was performed in the Copenhagen University Hospital, Rigshospitalet (CUHR). All patients undergoing a trauma laparotomy within the first 24 h of admission between January 1st 2019 and December 31st 2020 were included. Collected data included demographics, trauma mechanism, injuries, procedures performed and outcomes.ResultsA total of 1713 trauma patients were admitted to CUHR of which 98 patients underwent trauma laparotomy. Penetrating trauma accounted for 16.6% of the trauma population and 66.3% of trauma laparotomies. Median time to surgery after arrival at the trauma center (TC) was 12 min for surgeries performed in the Emergency Department (ED) and 103 min for surgeries performed in the operating room (OR). A total of 14.3% of the procedures were performed in the ED. A damage control strategy (DCS) approach was chosen in 18.4% of cases. Our rate of negative laparotomies was 17.3%. We found a mortality rate of 8.2%. The total median length of stay was 6.1 days.ConclusionThe overall rates, findings, and outcomes of trauma laparotomies in this Danish cohort is comparable to reports from similar Western European trauma systems.

Centralization of Major Trauma Influences Liver Availability for Transplantation in Northern Italy: Lesson Learned from COVID-19 Pandemic.

Background: During the COVID-19 pandemic, the centralization of patients allowed trauma and transplants referral centers to continue their routine activity, ensuring the best access to health care. This study aims to analyze how the centralization of trauma is linked with liver allocation in Northern Italy. Methods: Cluster analysis was performed to generate patient phenotype according to trauma-related variables. Comparison between clusters was performed to evaluate differences in damage control strategy procedures (DCS) performed and the 30-day graft dysfunction. Results: During the pandemic period, the centralization of major trauma has deeply impaired the liver procurement and allocation between the transplant centers in the metropolitan area of Milan (Niguarda: 22 liver procurement; other transplant centers: 2 organ procurement). Two clusters were identified the in Niguarda’s series: cluster 1 is represented by 17 (27.4%) trauma donors, of which 13 (76.5%) were treated with DCS procedures, and 4 (23.5%) did not; cluster 2 is represented by 45 trauma donors (72.6%), of which 22 (48.8%) underwent DCS procedures. A significant difference was found in the number of DCS procedures performed between clusters (3.18 ± 2.255 vs. 1.11 ± 1.05, p = 0.0001). Comparative analysis did not significantly differ in the number of transplanted livers (cluster1/cluster2 94.1%/95.6% p = 0.84) and the 30-day graft dysfunction rate (cluster1/cluster2 0.0%/4.8% p = 0.34). Conclusions: The high level of care guaranteed by first-level trauma centers could reduce the loss of organs suitable for donation, maintaining the good outcomes of transplanted ones, even in case of multiple organ injuries. The pandemic period underlined that the centralization of major trauma impairs the liver allocation between transplant centers.

Fat embolism syndrome in patients with bilateral femur fractures: a systematic review and case comparison.

Objectives:Fat embolism and fat embolism syndrome (FES) remain common complications following long bone fractures. Incidence is highest after bilateral femur fractures. We performed a systematic review of FES after bilateral femur fractures and present two cases.Data sources:Systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus, and, Web of Science Library databases was performed in August 2021. Terms used including plural and alternate spellings: “fat embolism,”“fat embolism syndrome,”“fat embolus,” and “bilateral femur fracture.” Articles in German and English were considered. No time frame was applied.Study selection:Original studies, case series and case reports on fat embolism after bilateral femur fracture were included. Insufficient documentation or patients with relevant previous heath conditions were excluded.Data extraction:s were organized using EndNote X9 by Carivate. Three authors independently screened the abstracts; cross check of the extracted data was performed by the senior author.Data synthesis:Scarcity of articles only allowed for a qualitative synthesis. Data was compared with our cases and situated within the scientific background.Results:Ten articles were included for qualitative synthesis (n = 144 patients). The symptoms were inhomogeneous with neurological deficits being most prominent. Degree of displacement was high, when reported. Although the modes and timing of surgery varied, this appeared unrelated with outcome.Conclusions:FES remains a relevant complication after bilateral femur fractures, despite damage control strategies and improved reaming techniques. Fracture displacement and reduction maneuvers might play a more substantial role in the formation than previously accredited.Level of evidence:4

The Evolving Strategic CSR Practices in Africa: Exploring the Multidimensional Implications for Telecommunication Firms’ Outcomes in Nigeria

In developing African countries, a considerable body of knowledge exists about the evolving stages of corporate social responsibility (CSR) practices from mere philanthropic actions to damage control strategy, especially in the mining sector. However, little is known about the emerging strategic CSR as a competitive strategy particularly its dimensional outcomes among diverse sectors in the region. Applying a multidimensional perspective of corporate social responsibility activities, we explored how customers’ perception of a firm’s economic, legal, ethical, and social responsibility actions influence the firm’s product rating, consumer loyalty, and firms’ strategic legitimacy among telecoms subscribers in Nigeria. A probability sampling technique was used to select 126 subscribers with a proportionate representation of the five mobile phone service providers in Nigeria. From the collected data, descriptive statistics were applied to analyze the demographic profile of the participants while the partial least squares structural equation modeling (PLS-SEM) was used to test the hypotheses. Contrary to expectations, the outcomes suggest that consumer perception of telecoms firms’ economic responsibilities has no significant positive influence on the firms’ product rating, consumer loyalty, and the firms’ strategic legitimacy. Conversely, the outcomes support our propositions that the consumer perception of telecoms firms’ social, legal, and ethical responsibility actions has a significant positive influence on the firms’ product rating, consumer loyalty, and firms’ strategic legitimacy. The findings suggest the need for telecoms firms to focus on social, legal, and ethical responsibility dimensions as competitive strategies.

Organ Donation after Damage Control Strategy in Trauma Patients: Experience from First Level Trauma Center in Italy.

Background: Organ donation (OD) remains the only therapeutic option for end-stage disease in some cases. Unfortunately, the gap between donors and recipients is still substantial. Trauma patients represent a potential yet underestimated pool of organ donors. In this article, we present our data on OD after damage control strategy (DCS). Materials and Methods: A retrospective, observational cohort study was conducted through a complete revision of data of consecutive adult trauma patients (>18 years old) who underwent OD after DCS between January 2018 and May 2021. Four subgroups were created [Liver (Li), Lungs (Lu), Heart (H), Kidneys (K)] to compare variables between those who donated the organ of interest and those who did not. Results: Thirty-six patients underwent OD after DCS. Six patients (16.7%) were excluded: 2(5.6%) for missing data about admission; 4(11.1%) didn’t receive DCS. Mean ISS was 47.2 (SD ± 17.4). Number of donated organs was 113 with an organs/patient ratio of 3.8. The functional response rate was 91.2%. Ten organs (8.8%) had primary nonfunction after transplantation: 2/15 hearts (13.3%), 1/28 livers (3.6%), 4/53 kidneys (7.5%) and 3/5 pancreases (60%). No lung primary nonfunction were registered. Complete results of subgroup analysis are reported in supplementary materials. Conclusion: Organ donation should be considered a possible outcome in any trauma patient. Aggressive damage control strategy doesn’t affect the functional response rate of transplanted organs.

Awareness of damage control surgery and resuscitation practice: Rational emergency surgical trends in mass trauma events in Syria.

Mass trauma is an event in which the number of patients temporarily exceeds the capacity of medical personnel to provide optimal care. Looking at the global terrorism index, Syria is one of the most terrorism-affected countries in the Middle East, and the threat of terrorist attacks that can cause mass trauma persists. When it comes to dealing with mass trauma, the damage control approach has come to the forefront in recent years. In our study, we aimed to assess the awareness and training effectiveness of emergency physicians and surgeons on damage control surgery and resuscitation in Northwest Syria, where mass trauma due to terrorist attacks and social events is common. A trauma team from Çobanbey Hospital in Northwest Syria conducted training on damage control and resuscitation. Syrian physicians who participated in this training were administered a damage control and resuscitation questionnaire before and after the training. A total of 43 subjects were enrolled in the study, and their mean age was 44.04±9.01 years. The majority of the physicians who participated in the training were from Elbab (23.3%), Afrin (23.3%), and Çobanbey (20.9%). The average work experience of the physicians was 14 years and the average number of non-elective surgeries performed in the last year was 47.5. While the average total score (pre-test) before the training was 67, the average total score (post-test) after the training increased to 72, and this difference was statistically significant (p=0.008). While the pre-test and post-test scores of those who were trained and had practiced placing intrathoracic clamp-wound clamp and trauma laparotomy were significantly higher than those who were not trained and had not used them (p<0.05), the difference between the pre-test and post-test scores of those who were not trained and had not used them was statistically significant (p<0.05). It is well known that there have been internal unrest and terrorist attacks in Northwest Syria for more than 10 years. It is important for physicians in this region to know the damage control strategies. In this regard, we have found that awareness among physicians has increased as a result of the training we have provided on damage control.

Damage control strategy in surgical treatment of patients with severe gastroduodenal bleeding

To objectify patient condition and improve treatment outcomes in patients with benign severe gastroduodenal bleeding. We analyzed the immediate results of staged surgical treatment of patients with benign severe gastroduodenal bleeding according to the accepted concept of «Damage Control Surgery». The Rockall risk scoring system and the Glasgow-Blatchford score (GBS) were used. We preferred two-stage intervention in patients with Rockall score ≥5 and Glasgow-Blatchford score ≥11. Staged approach according to the concept of «Damage Control Surgery» in patients with benign severe gastroduodenal bleeding ensures positive results by minimizing surgical trauma and perioperative bleeding, early stabilization of hemostasis and subsequent successful restoration of digestive function. The concept of «Damage Control Surgery» in patients with benign severe gastroduodenal bleeding can reduce mortality and incidence of postoperative complications.

ダメージコントロール戦略で救命した広範囲非閉塞性腸管虚血の1例(A case of massive non–occlusive mesenteric ischemia survived by damage control strategy)

要旨症例は72歳の女性。既往に壊死性大腸炎にて大腸全摘術。前日からの嘔吐，意識障害のため救急搬送された。画像検査で小腸の全体的な拡張，右側腹部の小腸壁の造影不良を認めた。搬入時よりショック状態であり，血液検査ではアシドーシスと凝固障害を認めた。非閉塞性腸管虚血症，敗血症性ショックと診断してdamage control surgeryを含む集学的加療の方針とした。初回手術では，人工肛門から口側100cmの範囲でまだら状に色調不良を呈していたため同部位を切除し，術後に上腸間膜動脈から血管拡張薬療法を施行した。2回目の手術でさらに切除断端より口側80cmを追加切除した。また，十二指腸に色調不良を認めたため，術後に総肝動脈造影を施行したところ十二指腸壁の部分的描出不良を確認し，総肝動脈に対して選択的血管拡張薬動注療法を追加した。第5病日より循環動態が安定し，昇圧剤は終了とした。第18病日から経管栄養を開始，第125病日にリハビリ目的で転院となった。十二指腸を含む広範囲非閉塞性腸管虚血であり，また重篤な基礎疾患を有していたが，ダメージコントロール戦略を用いた手術と選択的血管拡張薬動注療法を組み合わせることで救命しえた症例を経験したため，報告する。

胃原発悪性T細胞リンパ腫による大量出血に対して胃内ガーゼパッキングで救命しえた1例(Primary gastric peripheral T–cell lymphoma presenting as massive bleeding treated with intragastric gauze packing: a case report)

要旨 症例は66歳の男性。吐血を主訴に救急搬送された。上部消化管内視鏡検査で胃3型腫瘍からの出血と診断され経過観察目的に入院した。搬入10時間後，1L以上の吐血を来し出血性ショックとなり，大動脈閉塞バルーン留置下で緊急開腹した。胃穹窿部後壁に潰瘍化した腫瘍を認め, 同部位から出血が持続していた。縫合止血が困難であり胃内ガーゼパッキングで一時止血を得た。集学的管理で全身状態を改善させ，2日後に再開腹しガーゼを抜去すると，腫瘍が脾動脈に浸潤しており，同部位からの再出血を認めた。腫瘍は膵尾部・脾門部・横隔膜に浸潤しており，胃全摘術・膵尾部脾合併切除術を行った。病理組織検査で非特定型末梢性T細胞リンパ腫と診断した。胃原発悪性リンパ腫は稀に大量出血を来すことがあり，damage control strategyが要求される可能性がある。胃腫瘍からの大量出血に対するdamage control surgeryとして胃内ガーゼパッキングが有用であると考えられる。

Choice of operative procedure in diverticular disease : Taking the latest treatment strategies into consideration

There are various procedures to be considered in the surgical treatment of complicated diverticulitis, which must be selected depending on the classification of diverticular disease (CDD) type and the condition of the patient. Comparison of surgical procedures with respect to aspects such as morbidity, mortality, reconstructive surgery and postoperative quality of life. Evaluation, analysis and assessment of the current literature on surgical treatment of diverticular disease. Laparoscopic sigmoid resection with primary anastomosis is now considered the standard procedure for complicated sigmoid diverticulitis. It is preferable to open resection because of the better results of the minimally invasive approach with respect to the incidence of wound infections, abdominal abscesses and the occurrence of fascial dehiscence. In an emergency situation with perforation and peritonitis (CDD type2c1/2), primary anastomosis with protective ileostomy should be favored over discontinuity resection (Hartmann's procedure). In particular, it must be taken into account that in alarge proportion of patients there is no restoration of continuity after Hartmann's operation. The damage control strategy can be used in perforated sigmoid diverticulitis with generalized peritonitis (CDD type2c1/2). In individual cases, laparoscopic lavage with insertion of adrainage may be considered as atherapeutic treatment strategy for perforated sigmoid diverticulitis with purulent peritonitis (CDD type2c1). Selection of the surgical procedure for complicated sigmoid diverticulitis remains challenging. Randomized controlled trials of new treatment strategies as well as robotic-assisted surgery should be considered in the choice of surgical procedure in the future.

Challenges and outcomes in the treatment of floating knees. A case series of ipsilateral femur and tibia fractures around the knee.

Ipsilateral femur and tibia fractures around the knee (floating knee) are rare injuries that threaten both limb viability and patient life. A correct surgical strategy is essential to reduce complications and sequelae. The aim of this study was to evaluate characteristics and results of treatment in patients with a floating knee treated at a single trauma center. This is a retrospective and non-consecutive case series of 18 floating knees occurred in 17 patients. All patients were operated in a single third-level public and university hospital from December 2010 to December 2018. Data on demographics, injuries, treatment and follow-up were collected. A general health questionnaire (SF-12) and a knee functional questionnaire (KOOS-PS) were used to display results. We identified 13 men and 4 women, aged between 16 and 52. Mean follow-up period was 16.49months. High-energy trauma following a traffic collision was the most frequent mechanism. Mean Injury Severity Score (ISS) was 39.05, and a damage control strategy was used in 15 (83.33%) injuries. Extra-articular fractures (Fraser I) largely predominated, resulting in double intramedullary nailing in 72.22% of cases. Eleven injuries (61.11%) presented with an open fracture. Complications appeared in 6 (33.33%) injuries, being 3 infections. Mean score for the SF-12 was 35.59 for the physical dimension and 50.44 for mental dimension. Mean score for the KOOS-PS was 43.64. Floating knee injuries usually occur in polytrauma contexts. Visceral involvement and exposed fractures are common, so the most appropriate strategy is usually a staged treatment. Complications and sequelae are frequent.

Damage control strategy in perforated diverticulitis with generalized peritonitis

BackgroundThe best treatment for perforated colonic diverticulitis with generalized peritonitis is still under debate. Concurrent strategies are resection with primary anastomosis (PRA) with or without diverting ileostomy (DI), Hartmann’s procedure (HP), laparoscopic lavage (LL) and damage control surgery (DCS). This review intends to systematically analyze the current literature on DCS.MethodsDCS consists of two stages. Emergency surgery: limited resection of the diseased colon, oral and aboral closure, lavage, vacuum-assisted abdominal closure. Second look surgery after 24–48 h: definite reconstruction with colorectal anastomosis (−/ + DI) or HP after adequate resuscitation. The review was conducted in accordance to the PRISMA-P Statement. PubMed/MEDLINE, Cochrane central register of controlled trials (CENTRAL) and EMBASE were searched using the following term: (Damage control surgery) AND (Diverticulitis OR Diverticulum OR Peritonitis).ResultsEight retrospective studies including 256 patients met the inclusion criteria. No randomized trial was available. 67% of the included patients had purulent, 30% feculent peritonitis. In 3% Hinchey stage II diverticulitis was found. In 49% the Mannheim peritonitis index (MPI) was greater than 26. Colorectal anastomosis was constructed during the course of the second surgery in 73%. In 15% of the latter DI was applied. The remaining 27% received HP. Postoperative mortality was 9%, morbidity 31% respectively. The anastomotic leak rate was 13%. 55% of patients were discharged without a stoma.ConclusionDCS is a safe technique for the treatment of acute perforated diverticulitis with generalized peritonitis, allowing a high rate of colorectal anastomosis and stoma-free hospital discharge in more than half of the patients.