Background Approximately 20% of all geriatric patients who sustain low-energy hip fractures will die within 1 year of the injury, and approximately 3% will die during the initial inpatient hospital stay. Accordingly, the event of a geriatric hip fracture might be an apt prompt for discussing end-of-life care: in light of the risk of death after this injury, the topic of mortality certainly is germane. However, it is not clear to what degree physicians and patients engage in end-of-life planning even when faced with a hospital admission for this potentially life-threatening condition. Questions/purposes We assessed the frequency with which end-of-life care discussions were documented among a sample of geriatric patients admitted for hip fracture surgery. Methods We studied 150 adult patients, 70 years and older, admitted between September 2008 and July 2012 for the care of an isolated low-energy hip fracture, who did not have documented evidence of end-of-life care planning before the time of admission. For each patient, the medical record was scrutinized to identify documentation of end-oflife care discussions, an order changing ''code status,'' or a progress note memorializing a conversation related to the topic of end-of-life care planning. Results Of the 150 subjects who had no documented evidence of end-of-life care planning at the time of admission, 17 (11%) had their code status changed during the initial hospitalization for hip fracture, and an additional four patients (3%) had a documented conversation regarding end-of-life care planning without a subsequent change in code status. Accordingly, there were 129 (86%) patients who had no record of any attention to end-of-life care planning during the hospital stay for hip fracture surgery. Conclusions Our findings suggest that physicians may be missing a valuable opportunity to help patients and their families be better prepared for potential future health issues. End-of-life care planning respects patient autonomy and enhances the quality of care. Accordingly, we recommend that discussion of goals, expectations, and preferences should be initiated routinely when patients present with a fragility fracture of the hip. Level of Evidence Level IV, therapeutic study.

Background Adolescents with substance use disorder (SUD) and conduct problems exhibit high levels of impulsivity and poor self-control. Limited work to date tests for brain cortical thickness differences in these youths. Objectives To investigate differences in cortical thickness between adolescents with substance use and conduct problems and controls. Methods We recruited 25 male adolescents with SUD, and 19 male adolescent controls, and completed structural 3T magnetic resonance brain imaging. Using the surface-based morphometry software FreeSurfer, we completed region-of-interest (ROI) analyses for group cortical thickness differences in left, and separately right, inferior frontal gyrus (IFG), orbitofrontal cortex (OFC) and insula. Using FreeSurfer, we completed whole-cerebrum analyses of group differences in cortical thickness. Results Versus controls, the SUD group showed no cortical thickness differences in ROI analyses. Controlling for age and IQ, no regions with cortical thickness differences were found using whole-cerebrum analyses (though secondary analyses co-varying IQ and whole-cerebrum cortical thickness yielded a between-group cortical thickness difference in the left posterior cingulate/precuneus). Secondary findings showed that the SUD group, relative to controls, demonstrated significantly less right>left asymmetry in IFG, had weaker insular-to-whole-cerebrum cortical thickness correlations, and showed a positive association between conduct disorder symptom count and cortical thickness in a superior temporal gyrus cluster. Conclusion Functional group differences may reflect a more nuanced cortical morphometric difference than ROI cortical thickness. Further investigation of morphometric differences is needed. If replicable findings can be established, they may aid in developing improved diagnostic or more targeted treatment approaches.

To our knowledge, this is the first study to examine the DSM-5-defined conduct disorder (CD) with limited prosocial emotions (LPE) among adolescents in substance use disorder (SUD) treatment, despite the high rates of CD in this population. We tested previously published methods of LPE categorization in a sample of male conduct-disordered patients in SUD treatment (n=196). CD with LPE patients did not demonstrate a distinct pattern in terms of demographics or co-morbidity regardless of the categorization method utilized. In conclusion, LPE, as operationalized here, does not identify a distinct subgroup of patients based on psychiatric comorbidity, SUD diagnoses, or demographics.

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