Timing of Palliative Care Consultation and the Impact on Thirty-Day Readmissions and Inpatient Mortality.

BACKGROUND: Inpatient palliative care consultation (PCC) may reduce 30-day readmissions and inpatient mortality among seriously ill patients. OBJECTIVE: To evaluate the impact of timing of PCC on 30-day readmissions and inpatient mortality. DESIGN: Retrospective, observational study comparing risk-adjusted, observed-to-expected (O/E) 30-day readmissions and inpatient mortality among patients receiving inpatient PCC to all other inpatients. SETTING/SUBJECTS: Adult patients with hospital length of stay (LOS) <30 days, primary diagnoses of circulatory, infectious, respiratory, neoplasms, injury/poisoning, and digestive system were included from eight hospitals in a single health care system. RESULTS: Compared with non-PCC patients (n = 43,463), PCC patients (n = 6043) had a greater proportion of African Americans, Medicare, LOS ≥7 days, intensive care unit stays, discharges to skilled nursing facility and hospice, primary diagnoses of infections and neoplasms, comorbidities of congestive heart failure, cancer, and dementia, Charlson comorbidity score ≥8 (p < 0.001), and fewer males (p = 0.03). Adjusted readmission reduction attributed to PCC among 0-2-, 3-6-, and 7-30-day subgroups was 14.1%, 19.2%, and 16.4%, respectively (usual care O/E = 0.904 vs. subgroup O/Es = 0.764, 0.713, 0.741, respectively). Adjusted mortality reductions attributed to PCC among the 0-2- and 3-6-day subgroups were 19.4% and 19.1%, respectively. A 12% mortality increase was observed in the 7-30-day subgroup (usual care O/E = 0.738 vs. subgroup O/Es = 0.544, 0.547, 0.858, respectively). CONCLUSIONS: Inpatient PCC reduces 30-day readmissions and inpatient mortality with the greatest impact demonstrated within six days of hospital admission. Early PCC should be encouraged for eligible patients.

Brain connectivity is not only lower but different in schizophrenia: a combined anatomical and functional approach.

BACKGROUND: Schizophrenia is hypothesized to involve disordered connectivity between brain regions. Currently, there are no direct measures of brain connectivity; functional and structural connectivity used separately provide only limited insight. Simultaneous measure of anatomical and functional connectivity and its interactions allow for better understanding of schizophrenia-related alternations in brain connectivity. METHODS: Twenty-seven schizophrenia patients and 27 healthy control subjects underwent magnetic resonance imaging with resting state functional magnetic resonance imaging and diffusion tensor imaging. Separate functional and anatomical connectivity maps were calculated and combined for each subject. Global, regional, and voxel measures and K-means network analysis were employed to identify group differences and correlation with clinical symptoms. RESULTS: A global connectivity analysis indicated that patients had lower anatomical connectivity and lower coherence between the two imaging modalities. In schizophrenia these group differences correlated with clinical symptom severity. Although anatomical connectivity nearly uniformly decreased, functional connectivity in schizophrenia was lower for some connections (e.g., middle temporal gyrus) and higher for others (e.g., cingulate and thalamus). Within the default mode network (DMN) two separate subsystems can be identified. Schizophrenia patients showed decoupling between structural and functional connectivity that can be localized to networks originating in posterior cingulate cortex as well as in the task-positive network and one of the DMN components. CONCLUSIONS: Combining two measures of brain connectivity provides more comprehensive descriptions of altered brain connectivity underlying schizophrenia. Patients show deficits in white matter anatomy, but functional connectivity alterations are more complex. Fusion of both methods allows identification of subsystems showing both increased and decreased functional connectivity.

Measuring brain connectivity: diffusion tensor imaging validates resting state temporal correlations.

Diffusion tensor imaging (DTI) and resting state temporal correlations (RSTC) are two leading techniques for investigating the connectivity of the human brain. They have been widely used to investigate the strength of anatomical and functional connections between distant brain regions in healthy subjects, and in clinical populations. Though they are both based on magnetic resonance imaging (MRI) they have not yet been compared directly. In this work both techniques were employed to create global connectivity matrices covering the whole brain gray matter. This allowed for direct comparisons between functional connectivity measured by RSTC with anatomical connectivity quantified using DTI tractography. We found that connectivity matrices obtained using both techniques showed significant agreement. Connectivity maps created for a priori defined anatomical regions showed significant correlation, and furthermore agreement was especially high in regions showing strong overall connectivity, such as those belonging to the default mode network. Direct comparison between functional RSTC and anatomical DTI connectivity, presented here for the first time, links two powerful approaches for investigating brain connectivity and shows their strong agreement. It provides a crucial multi-modal validation for resting state correlations as representing neuronal connectivity. The combination of both techniques presented here allows for further combining them to provide richer representation of brain connectivity both in the healthy brain and in clinical conditions.