Search

Whether to perform umbilical hernia repair in patients with cirrhosis is a common dilemma for surgeons. We aimed to determine the incidence, morbidity, and mortality associated with emergency and nonemergency umbilical hernia repair in patients with and without cirrhosis, and to explore opportunities for nonemergency repair.Veterans diagnosed with cirrhosis between 2001 and 2014 and a frequency-matched sample of veterans without cirrhosis were followed through September 2017. Veterans Affairs Surgical Quality Improvement Program data provided outcomes and risk factors for mortality after umbilical hernia repair. We performed chart review of a random sample of patients undergoing emergency umbilical hernia repair.Among 119,605 veterans with cirrhosis and 118,125 matched veterans without cirrhosis, the Veterans Affairs Surgical Quality Improvement Program database included 1,475 and 552 open umbilical hernia repairs, respectively. In patients with cirrhosis, 30-day mortality was 1.2% after nonemergency umbilical hernia repair and 12.2% after emergency umbilical hernia repair, contrasting with zero deaths in patients without cirrhosis undergoing these repairs. In patients with cirrhosis but no ascites in the prior month, 30-day mortality after nonemergency umbilical hernia repair was 0.7%, compared to 2.2% in those with ascites. Chart review of patients requiring emergency umbilical hernia repair revealed that elective umbilical hernia repair may have been feasible in 30% of these patients in the prior year; fewer than half of those undergoing emergency umbilical hernia repair had received a general surgery consultation in the prior 2 years.Nonemergency open umbilical hernia repair was associated with relatively low perioperative mortality in patients with cirrhosis and no recent ascites. About 30% of patients undergoing emergency umbilical hernia repair may have been candidates for nonemergency repair in the prior year.

Morning report is one of the central activities of internal medicine residency education. The two most common morning report formats are scripted reports, which use preselected cases with prepared didactics, and unscripted reports in which a case is discussed without preparation. No previous study has compared these two formats.We conducted a prospective observational study of morning report conducted at 10 academic medical centers across the United States.A total of 198 case-based morning reports were observed. Of these, 169 (85%) were scripted and 29 (15%) were unscripted. Scripted reports were more likely to present a case with a known final diagnosis (89% vs 76%,Most contemporary morning reports are scripted. Compared with traditional unscripted reports, scripted reports are more likely to involve a case with a known diagnosis, use extensive electronic presentation slides, and consume more time in didactics, while unscripted reports consume more time in the early diagnostic process, including history, physical examination, and differential diagnosis. Residency programs interested in emphasizing these aspects of medical education should encourage unscripted morning reports.

BACKGROUND AND OBJECTIVES Length of stay is a common measure of efficiency of care. We aimed to reduce length of stay on a general medicine service through a structured quality improvement project. METHODS A reliable design strategy was implemented in successive stages at a 238-bed academically-affiliated VA hospital. Over a 2-year period, continuous improvement efforts were directed at discrete cohorts of patients deemed medically appropriate for discharge but who remained hospitalized because of discharge barriers. We compared the mean length of stay and medically-ready bed days of care for a hospital in statistical control charts. Pre- and post-intervention comparisons were made using t-tests. RESULTS In total, 5321 discharges were included in this improvement project, accounting for 35 852 bed days of care. Overall, average length of stay was reduced by 15.7%, from 7.62 to 6.40 days (P < .05). There was a significant reduction in the mean number of medically-ready bed days of care from 2.3 to 1.72. Statistical process control charts demonstrated special cause variation across patient cohorts. CONCLUSION A quality improvement project using reliable design principles was associated with shorter length of stay.

Importance The COVID-19 pandemic disrupted graduate medical education, compelling training programs to abruptly transition to virtual educational formats despite minimal experience or proficiency. We surveyed residents from a national sample of internal medicine (IM) residency programs to describe their experiences with the transition to virtual morning report (MR), a highly valued core educational conference. Objective Assess resident views about virtual MR content and teaching strategies during the COVID-19 pandemic. Design Anonymous, web-based survey. Participants Residents from 14 academically affiliated IM residency programs. Main Measures The 25-item survey on virtual MR included questions on demographics; frequency and reason for attending; opinions on who should attend and teach; how the virtual format affects the learning environment; how virtual MR compares to in-person MR with regard to participation, engagement, and overall education; and whether virtual MR should continue after in-person conferences can safely resume. The survey included a combination of Likert-style, multiple option, and open-ended questions. Results Six hundred fifteen residents (35%) completed the survey, with a balanced sample of interns (39%), second-year (31%), and third-year (30%) residents. When comparing their overall assessment of in-person and virtual MR formats, 42% of residents preferred in-person, 18% preferred virtual, and 40% felt they were equivalent. Most respondents endorsed better peer-engagement, camaraderie, and group participation with in-person MR. Chat boxes, video participation, audience response systems, and smart boards/tablets enhanced respondents’ educational experience during virtual MR. Most respondents (72%) felt that the option of virtual MR should continue when it is safe to resume in-person conferences. Conclusions Virtual MR was a valued alternative to traditional in-person MR during the COVID-19 pandemic. Residents feel that the virtual platform offers unique educational benefits independent of and in conjunction with in-person conferences. Residents support the integration of a virtual platform into the delivery of MR in the future. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-06963-7.

BackgroundTimely lab results are important to clinical decision-making and hospital flow. However, at our institution, unreliable blood sample collection for patients with central venous access jeopardised this outcome and created staff dissatisfaction.MethodsA multidisciplinary team of nurses including a specialist clinical nurse leader (CNL), the hospital intravenous team and quality improvement (QI) consultants aimed to achieve >80% blood sample collection reliability among patients with central venous access by employing a simple signature/countersignature form coupled with audit-feedback and behavioural economics strategies. The form was piloted on one 25-bed unit. Data were collected for 60 weeks and interpreted per standard run chart rules.ResultsBlood sample collection reliability exceeded the 80% goal by week 22. The practice was sustained on the pilot unit and spread successfully to other wards despite significant operational threats including the COVID-19 pandemic.ConclusionsAt our institution, a simple signature/countersignature form supplemented by audit-feedback and behavioural economics strategies led to sustained practice change among staff. The pairing of CNL to QI consultant enhanced change potency and durability.

Objectives Prior studies have found suboptimal knowledge about post-acute care (PAC) among inpatient providers and poor communication at discharge that can lead to unsafe discharge transitions, but little is known about residents and the PAC transition. The aim of this study is to assess internal medicine residents’ knowledge, attitudes, and current practice regarding patient transitions to PAC. Design A multisite, cross-sectional 36-question survey. Setting and Participants Internal Medicine and Medicine-Pediatrics residents at 3 university-based Internal Medicine training programs in the United States. Methods: Survey delivered electronically to residents in 2018 and 2019. Survey responses were described by collapsing 4-point Likert responses into dichotomous variables, and thematic content analysis was used to evaluate free text responses. Results: Of 482 residents surveyed, 236 responded (49%). Despite high reported confidence in their ability to transition patients to PAC, only 31% of residents knew how often patients received skilled therapies at skilled nursing facilities (SNFs) and 23% knew how frequently nursing services are provided. The majority of residents (79%) identified the discharge summary as the main way they communicated care instructions to the SNF, but only 55% reported always completing it prior to discharge. Upper-level residents were more likely to know how much therapy patients received at a SNF, but resident knowledge about PAC did not vary by residency year in other domains. Residents who experienced a clinical rotation at a SNF had higher levels of knowledge compared to residents who did not. Conclusions This national survey of internal medicine residents identified common knowledge gaps regarding PAC. These knowledge gaps did not improve throughout residency without deliberate exposure to PAC environments. This suggests a need for dedicated curriculum development as discharges to PAC continue to rise exponentially.

BACKGROUND: Residents rate morning report (MR) as an essential educational activity. Little contemporary evidence exists to guide medical educators on the optimal content or most effective delivery strategies, particularly in the era of resident duty-hour limitations and shifts towards learner-centric pedagogy in graduate medical education. OBJECTIVE: Assess resident views about MR content and teaching strategies. DESIGN: Anonymous, online survey. PARTICIPANTS: Internal medicine residents from 10 VA-affiliated residency programs. MAIN MEASURES: The 20-item survey included questions on demographics; frequency and reason for attending; opinions on who should attend, who should teach, and how to prioritize the teaching; and respondents’ comfort level with participating in MR. The survey included a combination of Likert-style and multiple-choice questions with the option for multiple responses. KEY RESULTS: A total of 497 residents (46%) completed the survey, with a balanced sample of R1s (33%), R2s (35%), and R3s (31%). Self-reported MR attendance was high (31% always attend; 39% attend > 50% of the time), with clinical duties being the primary barrier to attendance (85%). Most respondents felt that medical students (89%), R1 (96%), and R2/R3s (96%) should attend MR; there was less consensus regarding including attendings (61%) or fellows (34%). Top-rated educational topics included demonstration of clinical reasoning (82%), evidence-based medicine (77%), and disease pathophysiology (53%). Respondents valued time spent on diagnostic work-up (94%), management (93%), and differential building (90%). Overall, 82% endorsed feeling comfortable speaking; fewer R1s reported comfort (76%) compared with R2s (87%) or R3s (83%, p = 0.018). Most (81%) endorsed that MR was an inclusive learning environment (81%), with no differences by level of training. CONCLUSIONS: MR remains a highly regarded, well-attended educational conference. Residents value high-quality cases that emphasize clinical reasoning, diagnosis, and management. A supportive, engaging learning environment with expert input and concise, evidence-based teaching is desired. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06351-7.

BACKGROUND: There are more than five hundred internal medicine residency programs in the USA, involving 27,000 residents. Morning report is a central educational activity in resident education, but no recent studies describe its format or content. OBJECTIVE: To describe the format and content of internal medicine morning reports. DESIGN AND PARTICIPANTS: Prospective observational study of morning reports occurring between September 1, 2018, and April 30, 2019, in ten different VA academic medical centers in the USA. MAIN MEASURES: Report format, number and type of learner, number and background of attending, frequency of learner participation, and the type of media used. Content areas including quality and safety, high-value care, social determinants of health, evidence-based medicine, ethics, and bedside teaching. For case-based reports, the duration of different aspects of the case was recorded, the ultimate diagnosis when known, and if the case was scripted or unscripted. RESULTS: A total of 225 morning reports were observed. Reports were predominantly case-based, moderated by a chief resident, utilized digital presentation slides, and involved a range of learners including medicine residents, medical students, and non-physician learners. The most common attending physician present was a hospitalist. Reports typically involved a single case, which the chief resident reviewed prior to report and prepared a teaching presentation using digital presentation slides. One-half of cases were categorized as either rare or life-threatening. The most common category of diagnosis was medication side effects. Quality and safety, high-value care, social determinants of health, and evidence-based medicine were commonly discussed. Medical ethics was rarely addressed. CONCLUSIONS: Although a wide range of formats and content were described, internal medicine morning report most commonly involves a single case that is prepared ahead of time by the chief resident, uses digital presentation slides, and emphasizes history, differential diagnosis, didactics, and rare or life-threatening diseases. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-06069-6) contains supplementary material, which is available to authorized users.

Sepsis is commonly seen in the emergency department and inpatient medical settings. Early identification and treatment are critical to reducing mortality. This teaching script is designed to help the learner describe the process of rapid sepsis identification and initial management.

Preoperative identification and management of hemostatic disorders minimizes bleeding complications from surgery. Taking a history is the most important part of assessing a patient’s perioperative bleeding risk, followed by lab testing if indicated. Management of specific disorders such as von Willebrand disease, hemophilia, and vitamin K deficiency in the perioperative period requires specific lab monitoring and product administration.

Perioperative cardiovascular complications pose serious risk, especially to patients with pre-existing cardiac disease. The degree of risk varies widely depending on the patient’s medical comorbidities and type of surgery. A careful medical evaluation before surgery can help inform a discussion of risk for patients and providers and suggest management strategies to mitigate risk. Guidelines from the American College of Cardiology/American Heart Association (ACC/AHA) and European Societies of Cardiology and Anaesthesiology (ESC/ESA) provide an evidence-based approach to perioperative cardiovascular risk stratification and testing.

Surgery is commonly performed every day throughout the world, with a growing number of procedures in medically complex patients. Both surgery and anesthesia have inherent risks, and medicine consultants are often involved in the perioperative evaluation and management of surgical patients to help reduce perioperative risks. Models of perioperative medical care include consultative and co-management, with an increasing number of healthcare systems focusing on co-management services.

Postoperative pulmonary complications are common, costly, and associated with substantial perioperative morbidity and mortality. Thus, physicians must be vigilant for patient- and procedure-related risk factors that contribute to postoperative pulmonary complications, as well as opportunities to prevent them.

Objective To describe the incidence and risk factors for mortality and morbidity in patients with cirrhosis undergoing elective or emergent abdominal surgeries. Background Postoperative morbidity and mortality are higher in patients with cirrhosis; variation by surgical procedure type and cirrhosis severity remain unclear. Methods We analyzed prospectively-collected data from the Veterans Affairs (VA) Surgical Quality Improvement Program for 8193 patients with cirrhosis, 864 noncirrhotic controls with chronic hepatitis B infection, and 5468 noncirrhotic controls without chronic liver disease, who underwent abdominal surgery from 2001 to 2017. Data were analyzed using random-effects models controlling for potential confounders. Results Patients with cirrhosis had significantly higher 30-day mortality than noncirrhotic patients with chronic hepatitis B [4.4% vs 1.3%, adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.57-4.98] or with no chronic liver disease (0.8%, aOR 4.68, 95% CI 3.27-6.69); mortality difference was highest in patients with Model for End-stage Liver Disease (MELD) score ≥10. Among patients with cirrhosis, postoperative mortality was almost 6 times higher after emergent rather than elective surgery (17.2% vs. 2.1%, aOR 5.82, 95% CI 4.66-7.27). For elective surgeries, 30-day mortality was highest after colorectal resection (7.0%) and lowest after inguinal hernia repair (0.6%). Predictors of postoperative mortality included cirrhosis-related characteristics (high MELD score, low serum albumin, ascites, encephalopathy), surgery-related characteristics (emergent vs elective, type of surgery, intraoperative blood transfusion), comorbidities (chronic obstructive pulmonary disease, cancer, sepsis, ventilator dependence, functional status), and age. Conclusions Accurate preoperative risk assessments in patients with cirrhosis should account for cirrhosis severity, comorbidities, type of procedure, and whether the procedure is emergent versus elective.

BACKGROUND AND AIMS: Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures. METHODS: We conducted a comprehensive review of the literature from 1998–2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review. RESULTS: Overall, perioperative mortality is 2–10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP Class A, or MELD 15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate. CONCLUSIONS: Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management, which warrant further investigation.

A 54-year-old man presented to the emergency department with a 1-month history of edema in the lower legs and a 1-week history of upper abdominal pain. He also reported intermittent nausea, early satiety, and diarrhea but did not have fevers, chills, or vomiting.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

A variety of factors have conspired to reduce the frequency, as well as the quality, of bedside teaching. However, the benefits of bedside teaching, for both learners and patients, remain profound and worthy of our efforts to resurrect this practice. At the bedside, the attending physician is charged with diagnosing the patient, then diagnosing the learner, and finally teaching. Many attending physicians are uncomfortable with bedside teaching—anxiety about extemporaneous teaching, frustration with frequent interruptions, or concern about disrupting the residents’ autonomy may play a role. Bedside teaching is a complex task requiring preparation, clear definitions of roles and responsibilities of all team members, and, ideally, the presentation of selected topics in a concise fashion. This chapter presents practical steps to accomplish these tasks.

A 73-year-old man presented to the emergency department with a 4-day history of nonproductive cough that worsened at night. He did not have fever, chills, headache, myalgia, rhinorrhea, nasal congestion, sore throat, hemoptysis, chest pain, or dyspnea.

Although women have traditionally shouldered the responsibility of contraception, up to one-third of couples worldwide employ a male form of contraception (e.g., vasectomy or condoms). Vasectomy should be considered irreversible and long-term use of condoms is associated with a relatively high failure rate (pregnancy). Because many women are unable to use hormonal contraception and men want more contraceptive options, there is a need for a safe, effective, reversible and well-tolerated male hormonal contraceptive agent. Two large multicentre, multinational trials sponsored by the World Health Organization in the 1990s showed that high-dosage exogenous testosterone provided contraceptive efficacy similar to currently available female oral contraceptives. However, the supraphysiological dosages of testosterone used resulted in androgen-related adverse effects such as weight gain and suppression of high-density lipoprotein cholesterol levels. Subsequent efforts have been directed at combining testosterone wi...

Although women have traditionally shouldered the responsibility of contraception, up to a third of couples worldwide employ a male form of contraception (e.g., condoms or vasectomy). Some women are unable to use hormonal contraception; vasectomy is best considered irreversible; and long-term use of condoms is associated with a relatively high failure rate (pregnancy). Thus, a need exists for a safe, effective, reversible, well-tolerated male hormonal contraceptive agent. Two large multi-centre, multi-national trials sponsored by the World Health Organization in the 1990s showed that high-dosage exogenous testosterone provided contraceptive efficacy similar to existing female oral contraceptives. However, the supraphysiological dosages of testosterone used resulted in androgen-related adverse effects such as weight gain and suppression of high-density lipoprotein cholesterol levels. Subsequent efforts have been directed at combining testosterone with other agents, such as progestogens or gonadotropin-releasing hormone analogues, to decrease the dosage of testosterone (and thus androgen-related side effects) while achieving uniform azoospermia. This review discusses the latest developments in male hormonal contraception.

A 68-year-old man originally from the Philippines presented with a three-month history of increasing dyspnea on exertion and orthopnea. He also reported an unintentional weight loss of 7 kg (15 lb), night sweats, and abdominal bloating.

Up to 25% of hospitalized patients will have an indwelling urinary catheter inserted (1). While most of these catheters are required for optimal patient care, about one in five is unnecessary (2). Catheter-related urinary tract infections are the leading cause of nosocomial infection. They account for up to 40% of hospital-acquired infections, with an incidence of 3% to 10% per day of indwelling catheterization (1,3–5). Bacteremia occurs in 1% to 4% of those who develop nosocomial bacteriuria (6). Most patients also find an indwelling urinary catheter to be uncomfortable and activity restricting (7). Given these potential morbidities, it is remarkable how infrequently the use of a urinary catheter is documented by a physician’s order in the medical record (8). The strongest predictor for catheter-associated bacteriuria is the duration of catheterization (3,4). Thus, methods to shorten this period should reduce the risk of nosocomial urinary tract infection, yet physicians are often unaware that their own hospitalized patients have a urinary catheter in place (9). Furthermore, these “forgotten” catheters were about twice as likely to be unnecessary as those remembered by the physician (9). Thus, a system that would remind physicians which of their patients had urinary catheters might shorten the duration of catheterization. One such approach involves using automatic reminders to physicians through computerized medical record systems (10 –15). At our Veterans Affairs (VA) medical center, nearly all patient records and orders are entered into a computer. We hypothesized that a computer-based order for inserting an indwelling urinary catheter, combined with computer-generated reminders to remove the catheter, would improve documentation of urinary catheters, alert physicians that the catheter was in place, and encourage discontinuing catheterization that was no longer required.

Early studies of prophylactic perioperative beta-blockade (i.e., started prior to surgery to reduce adverse cardiovascular outcomes) suggested benefit and led to relatively widespread clinical use. However, a subsequent large randomized controlled clinical trial demonstrated harm and led to more conservative recommendations.

st 13 One-half century ago, Dr. Paul Beeson astutely recognized the role of the indwelling urinary catheter in predisposing to urinary tract infection.1 He observed that inserting an indwelling urinary catheter is “commonly regarded as a comparatively harmless procedure”1(p1) and recommended that “the decision to use this instrument should be made with the knowledge that it involves risk of producing a serious disease.”1(p3) Over the ensuing 50 years, physicians’ attitudes regarding urinary catheterization appear to have changed little. Up to 25% of hospitalized patients will have an indwelling urinary catheter inserted.2 Surprisingly, over 50% of these may be unnecessary.3 Yet, in a recent national survey of US hospitals, more than half of the institutions did not monitor which patients had had a urinary catheter placed, and nearly three-quarters did not track the duration of urinary catheterization.4 In an era in which we are emphasizing patient safety, this oversight is difficult to understand and harder to justify. In a recent review of 14 hospitals, Saint et al.5 found that although most gave low priority to preventing hospital-acquired urinary tract infection, they professed substantial recognition of the value to patients of early removal of a urinary catheter. Urinary tract infection is the most common hospital-acquired infection, accounting for 40% of nosocomial infections, and most of these are caused by an indwelling urinary catheter.2,6 The incidence of bacteriuria in catheterized patients is approximately 5% per day,2,6-8 emphasizing the need to remove the device as soon as possible. Of grave concern is that bacteremia occurs in 1% to 4% of those patients who develop nosocomial bacteriuria.9,10 In addition to causing this morbidity and occasional mortality, catheter-associated urinary tract infection substantially increases hospital costs.11,12 In this issue of the journal, Fakih et al.13 add to a small but growing body of evidence that relatively simple interventions can reduce the use of indwelling urinary catheters in hospitalized patients. The study used a quasi-experimental design with data gathering before, during, and after their intervention. A

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Skin and skin structure infections are frequently encountered in clinical practice. Fortunately, these infections usually produce only mild to moderate symptoms and signs. Some, however, are severe and may even be life-threatening.To review the approach to the evaluation and treatment of patients with complicated skin and skin structure infections and to discuss when to consider using either established antibiotics or recently licensed agents for treating these infections.In addition to a non-systematic literature review of complicated skin and skin structure infections and necrotizing fasciitis, we identified recent articles examining the microbiology and describing recently licensed antibiotics for treating these infections.Clinicians must learn to recognize the early symptoms and signs of severe skin and skin structure infections to ensure they select appropriate empiric antibiotic therapy and, when needed, obtain prompt surgical consultation. While the recent approvals of new agents for treating these infections are welcome, particularly in light of the continued emergence of antibiotic-resistant bacteria, traditional antibiotic regimens remain appropriate for most cases.

Bacteriuria and urinary tract infection occur relatively frequently in older men, but data regarding the causative microorganisms are limited. We retrospectively identified all positive cultures of urine specimens (n = 4943) obtained over a 5-year period at our institution. We determined the frequency of causative microorganisms and grouped these by Gram type, setting of patient care, and method of urine specimen collection. We also assessed the performance characteristics of the Gram-stained smear of uncentrifuged urine. Among our patients, Gram-positive cocci (GPC) were isolated as often as Gram-negative rods (GNR). Escherichia coli was the single or predominant isolate in only 14% of cases, and Enterococcus was the single most commonly identified genus (22.5%). The Gram stain was accurate in predicting the culture results (positive likelihood ratio, 7.0 for GPC and 8.1 for GNR). We conclude that the microorganisms causing bacteriuria in older male veterans are substantially different from those found in women, and the Gram-stained smear provides useful information on the causative organisms.

Background We sought to determine the prevalence of low health literacy (LHL) among patients in a preoperative clinic, the characteristics associated with LHL, and the association between LHL and adherence to preoperative instructions. Methods We conducted a cohort study and interviewed patients at a VA preoperative clinic. We administered a health literacy test and collected sociodemographic information. When patients returned for their scheduled surgical procedures, adherence to preoperative instructions was assessed. Results Of 332 participants, 12% (n = 40) had LHL. Low health literacy was more prevalent among older adults (more than 65 years) compared with those under age 65. Patients with LHL were more likely to be nonadherent to preoperative medication instructions (odds ratio = 1.9; 95% confidence interval: 0.8 to 4.8), but this was of borderline statistical significance. Conclusions Low health literacy was common among older patients and appeared to be associated with lower adherence to preoperative medication instructions.