Andrew J. Hale

Background: Diabetic foot osteomyelitis (DFO) poses significant challenges due to its high morbidity and recurring nature. Current treatments involve prolonged antibiotics and often surgical intervention; however, the optimal route of antibiotic administration is unknown. This study evaluated the effect of route of antibiotic administration on treatment failure among patients with diabetic foot osteomyelitis. Methods: The authors conducted a retrospective cohort study among patients with unresected diabetic foot osteomyelitis. A propensity score was used to match the treatment exposure groups. The primary outcome was treatment failure, defined as either (1) treatment with additional antibiotic course or (2) additional surgical debridement/amputation at the original site of infection within 1 year of initial treatment. Secondary outcomes included the impacts of hemoglobin A1c, peripheral arterial disease, obesity, and infection severity on treatment failure. Results: Among 152 patients meeting criteria, 49 matched pairs were analyzed. Treatment failure rates did not significantly differ between oral and intravenous groups (OR 0.98, 95% CI 0.30–3.19, p > 0.9). A time-to-event analysis similarly found no significant outcome disparities between groups (p = 0.3). Conclusions: The study results support the previously published literature that demonstrates comparable treatment outcomes between routes of antibiotic administration when treating diabetic foot osteomyelitis.

The management of native vertebral osteomyelitis (NVO) can be challenging due to imperfect prognostic tools to predict treatment outcome. It is common practice to utilize serial serum C-reactive protein (CRP) to help decide treatment response, although limited evidence supports this practice. We evaluated whether CRP assessment predicts treatment failure in NVO. We conducted a multisite retrospective cohort study at the University of Vermont Health Network among adults with NVO managed with at least 6 weeks of antibiotics and in whom there were at least two documented CRP values at least a week apart. The primary outcome was microbiologic or clinical failure of antibiotic therapy within 6 months of the initial diagnosis. Among 628 patients identified by the initial screening criteria, 143 met inclusion criteria. In univariate analyses, median last CRP differed between patients with treatment success and failure (8.9 mg/dL vs 21.0 mg/dL, p < 0.01) as did median percent decrease from first to last CRP (88.9% vs 76.9% reduction, p = 0.03). However, in multivariate analyses adjusting for Staphylococcus aureus infection and epidural abscess we observed that there were only weak and non-significant associations between CRP values and treatment failure: median last CRP (OR 1.02, p = 0.06) and median percent difference CRP (0.99, p = 0.11). Serial CRP measurements were only weakly statistical associated with treatment failure in NVO. This common clinical practice is likely of little value.

Background: Infective endocarditis (IE) is associated with significant morbidity and mortality and current treatment guidelines recommend a prolonged course of intravenous antibiotics. However, individuals experiencing homelessness face greater barriers to standard IE care. The aim of this study was to compare IE characteristics and outcomes in an unhoused population versus a housed population. Methods: A retrospective cohort study encompassing 2010–2020 was conducted in Burlington, Vermont, comparing characteristics and outcomes of patients with IE who did or did not experience homelessness at the time of their infection. Primary outcomes included 30-day, 90-day, and 365-day mortality, IE-related mortality, and IE-related readmission rates. Secondary outcomes included rates of microbiologic failure and treatment failure. Results: Of 378 included patients with IE, 30 (7.9%) experienced homelessness and 348 (92.1%) did not. The unhoused cohort was more likely to have right-sided IE involving the tricuspid valve (50.0% vs 21.6%, P = 0.006) and for the causative organism to be methicillin-resistant Staphylococcus aureus (MRSA) [9 (30.0%) vs 43 (12.4%), P = 0.039]. Mortality, IE-related mortality, and IE-related readmission rates were not significantly different between groups at any time point measured. For secondary outcomes, differences in microbiologic failure [5 (16.7%) vs 36 (10.3%), P = 0.543] and treatment failure [9 (30.0%) vs 105 (30.2%), P = 1.000] were also not statistically significant. Conclusions: Future research should elucidate factors that entail increased risk of poor outcomes in this important underserved population and how to best mitigate them.

Background: Infective endocarditis (IE) is an increasingly common infection that results in significant morbidity and mortality. An important but under-analyzed subpopulation of patients with IE are those with concomitant cirrhosis. This study compared the characteristics and outcomes of patients with and without cirrhosis who were hospitalized with IE. Methods: The authors conducted a retrospective cohort study in adult patients with IE admitted at a single center from 2010 to 2020, comparing outcomes between those with and without cirrhosis at the time of admission. Results: A total of 22 patients with a history of cirrhosis and 356 patients without a history of cirrhosis were included. Over a quarter (27.3%) of those with cirrhosis experienced a decompensation event within two years of their admission for IE. Clinical features, microbiology, and direct complications from IE were largely similar between groups. There was no significant difference in IE-related mortality rates between groups, although, in an overall survival analysis, the group with cirrhosis did have a higher risk of all-cause mortality at 2 years (HR = 2.85; p = 0.012). Conclusions: This study highlights that IE in patients with cirrhosis may contribute to or trigger decompensation events. Further research is warranted to better understand morbidity outcomes in patients with cirrhosis who develop IE.

OBJECTIVES: Although proficient systems-based practice is a foundational skill for physicians, how best to teach it has not been well established. An elective course for fourth-year medical students wherein participants had an immersive experience with multiple interprofessional staff was created and analyzed. The authors hypothesized that participating students and interprofessional staff would show gains in systems-based knowledge and interprofessional communication. METHODS: The course was a 2-week elective experience for fourth-year medical students at the Larner College of Medicine at the University of Vermont, Burlington, VT, USA. Participants integrated into a variety of interprofessional, non-physician, and administrative roles within the hospital system. Pre- and post-elective systems-based knowledge and interprofessional communication were assessed. Participating interprofessional staff were also surveyed on their experiences RESULTS: From 2019 through 2022, 14 students participated in the elective, all of whom provided data. All participating students showed a quantitative improvement in systems-based knowledge and qualitatively commented on the high value of the elective in furthering their understanding of interdisciplinary care and communication. Of the 22 participating interprofessional staff surveyed, 17 responded (response rate 77%), and data showed high satisfaction with the experience and that having students learn more about their jobs improved their own job satisfaction. CONCLUSIONS: An immersive, hands-on experience with interprofessional colleagues showed dual benefits for both students and staff alike. Such an elective experience is scalable to other institutions nationally and should become a standard part of medical student curricula.

OBJECTIVES: Improved knowledge of hepatitis C virus (HCV) screening, linkage to care, and treatment is needed among nonspecialist medical professionals to combat the HCV epidemic. The authors sought to implement and analyze the impact of an HCV curriculum for primary care professionals (PCPs) across the state of Vermont, USA. METHODS: This investigation was a retrospective analysis of uptake of a Vermont HCV educational curriculum and its impact on HCV direct-acting antiviral (DAA) prescribing rates within the state before and after the study period. The curriculum was delivered online and in-person over 2 years from 2019 to 2020. The primary outcome was health care professional performance on a pre- and post-curriculum short-term knowledge assessment exam. The secondary outcome was assessing the number of unique healthcare professionals within a single payor database prescribing DAA treatment for HCV in Vermont before and after the study intervention, from January 1, 2017 until December 1, 2021. RESULTS: There were 31 unique respondents on the pre- and post-intervention examinations, which represented 9% of known participants. Respondents included physicians (n = 15), nurse practitioners (n = 8), and nurses (n = 8). Pre- and post-intervention knowledge scores increased significantly across all provider groups, from 3.2 (SD 0.6) to 4.5 (SD 0.4) 1 to 5 scale ( P = .01). The total number of unique HCV DAA therapy prescribers decreased over the study period, from 17 in 2017 to 9 in 2021. CONCLUSIONS: A Vermont statewide HCV curriculum for PCPs was successful at increasing short-term HCV-related knowledge. However, this did not obviously translate to an increase in new professionals treating HCV.

Objectives: Although some US medical schools have incorporated high-value care into their preclinical curriculum, there is no standardized approach and major curricular overhaul can be prohibitively onerous. The objectives of this study were to develop a feasible and effective high-value care curriculum, integrate it into an existing pre-clinical course, and assess student and faculty perceptions of the educational value of the curriculum. Methods: Between 2019 and 2021, University of Vermont preclinical medical students participating in the Students & Trainees Advocating for Resource Stewardship (STARS) program collaborated with the faculty director of the preclinical pathophysiology course to identify Choosing Wisely® recommendations relevant to course topics. For each recommendation, STARS students created a case-based, multiple-choice question, answer key and rationale to accompany standard course materials. At each year's course completion, participating students and faculty were invited to complete a survey to assess their perceptions of the curriculum. Results: Seventeen case-based questions were integrated into existing pathophysiology course sessions each year. Over the 3-year period, 420 students and 35 teaching faculty participated in the course, and 171 (40.7%) students and 24 (68.6%) faculty completed the post-course survey. Among student respondents, 80% agreed the curriculum increased their awareness of high-value care, 79% agreed they would be more likely to apply high-value care concepts during their medical career, and 92% agreed it was valuable to discuss Choosing Wisely® recommendations during the second year of medical school. Conclusion: A student-led initiative to incorporate high-value care content within an existing pre-clinical course was well-received by medical students, who reported increased awareness of and intention to apply high-value care principles. This model may offer a feasible and effective approach to high-value care education in the absence of an extensive formal curriculum.

Patients who receive splenectomy are at risk for overwhelming postsplenectomy infection (OPSI). Guidelines recommend that adult asplenic patients receive a complement of vaccinations, education on the risks of OPSI, and on-demand antibiotics. However, prior literature suggests that a majority of patients who have had a splenectomy receive incomplete asplenic patient care and thus remain at increased risk. This study assessed the impact of standardized involvement of infectious diseases (ID) providers on asplenic patient care outcomes in patients undergoing splenectomy. A quasi-experimental study design compared a prospective cohort of patients undergoing splenectomy from August 2017 to June 2021 who received standardized ID involvement in care of the asplenic patient with a historic control cohort of patients undergoing splenectomy at the same institution from January 2010 through July 2017 who did not. There were 11 components of asplenic patient care defined as primary outcomes. Secondary outcomes included the occurrence of OPSI, death, and death from OPSI. Fifty patients were included in the prospective intervention cohort and 128 in the historic control cohort. There were significant improvements in 9 of the 11 primary outcomes in the intervention arm as compared with the historic controls. Survival analysis showed no statistically significant difference in the incidence of OPSI-free survival between the groups (P = .056), though there was a trend toward improvement in the prospective intervention arm. Standardized involvement of an ID provider in the care of patients undergoing splenectomy improves asplenic patient care outcomes. Routine involvement of ID in this setting may be warranted.