Who Gets to Determine Whether Home Is "Unsafe" at the End of Life?

Background: At the end of life, some patients wish to be discharged directly home from the hospital, but health care teams may consider this unsafe, raising concerns for capacity and risk. However, defining risk is subjective and impacted by values, preferences, and clinical status. Accommodating patient preferences in discharge destinations can promote autonomy, dignity, and quality of life at the end of life. Observations: We developed a risk assessment framework to help clinicians objectively identify risk factors and protective factors and develop a comprehensive discharge plan. We applied this framework to a veteran nearing the end of life and he was able to successfully return home from the hospital. Conclusions: Approaching end-of-life discharges with a framework can inform discharge planning and lessen the risk of adverse events. Importantly, this framework can help clinicians communicate better and partner with patients and their loved ones in prioritizing patient values and preferences.

Tractography Analysis of 5 White Matter Bundles and Their Clinical and Cognitive Correlates in Early-Course Schizophrenia.

PURPOSE: Tractography is the most anatomically accurate method for delineating white matter tracts in the brain, yet few studies have examined multiple tracts using tractography in patients with schizophrenia (SCZ). We analyze 5 white matter connections important in the pathophysiology of SCZ: uncinate fasciculus, cingulum bundle (CB), inferior longitudinal fasciculus (ILF), superior longitudinal fasciculus, and arcuate fasciculus (AF). Additionally, we investigate the relationship between diffusion tensor imaging (DTI) markers and neuropsychological measures. METHODS: High-resolution DTI data were acquired on a 3 Tesla scanner in 30 patients with early-course SCZ and 30 healthy controls (HC) from the Boston Center for Intervention Development and Applied Research study. After manually guided tracts delineation, fractional anisotropy (FA), trace, radial diffusivity (RD), and axial diffusivity (AD) were calculated and averaged along each tract. The association of DTI measures with the Scales for the Assessment of Negative and Positive Symptoms and neuropsychological measures was evaluated. RESULTS: Compared to HC, patients exhibited reduced FA and increased trace and RD in the right AF, CB, and ILF. A discriminant analysis showed the possible use of FA of these tracts for better future group membership classifications. FA and RD of the right ILF and AF were associated with positive symptoms while FA and RD of the right CB were associated with memory performance and processing speed. CONCLUSION: We observed white matter alterations in the right CB, ILF, and AF, possibly caused by myelin disruptions. The structural abnormalities interact with cognitive performance, and are linked to clinical symptoms.

Surgeons do not listen: evaluation of compliance with antimicrobial stewardship program recommendations.

The purpose of this study was to determine if there are differences in interventions (int) required and compliance (comp) to recommendations (rec) by medical and surgical services as determined by an antimicrobial stewardship program (ASP). Concurrently collected ASP data from January 2008 through May 2011 were evaluated to determine number of int required and response to int. Results for medical (med) and surgical (surg) services were compared. There were 2322 int, of which 1108 were for med and 1214 were for surg. Recs were as follows: 242 appropriate coverage (AC) med versus 212 AC surg and 866 selective pressure (SP) med and 1002 SP surg. Comp with recs was higher for med: AC: 90.5 per cent (219 of 242) med versus 82.1 per cent (174 of 212) surg (P = 0.0086) and SP: 81.1 per cent (702 of 866) med versus 69.5 per cent (696 of 1002) surg (P < 0.0001). Overall surgical comp with ASP recs was better for AC than for SP. Moreover, less than half (seven of 15) of the surgical subspecialties demonstrated a comp of 75 per cent or greater with SP recs with only one-fifth having a comp over 80 per cent. Surgical services demonstrate poor compliance with ASP recommendations; this is especially true for interventions targeting selective pressure. By identifying services that are less compliant, programs can target their educational efforts to improve outcomes.