An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences.

Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.

Spontaneous bacterial peritonitis caused by Gram-negative bacteria: an update of epidemiology and antimicrobial treatments.

Introduction: Spontaneous bacterial peritonitis (SBP) is a main infectious complication in end-stage liver disease (ESLD) patients. The increasing trend of bacterial resistance in ESLD patients with SBP has been associated with low treatment efficacy of traditional therapy. Cephalosporin use has been restricted to community-acquired infections and in areas/health care settings with low rates of multidrug-resistant (MDR) bacteria. To date, several changes are necessary with regard to empiric therapy recommendations in areas/health care settings with high rates of MDR bacteria. Areas covered: An overview of the epidemiology and antimicrobial treatments of SBP caused by Gram-negative bacteria. Expert opinion: Broad-spectrum antibiotics have been recommended as empiric therapy for suspected SBP in areas/health care settings with high rates of MDR bacteria and secondary treatment, with newer antibiotics, for SBP caused by MDR-Gram-negative bacteria (i.e. new beta-lactam/beta-lactamase inhibitor combinations, cefiderocol, plazomicin, and eravacycline) either alone or in combination.

New antimicrobial options for the management of complicated intra-abdominal infections.

Complicated intra-abdominal infections (cIAIs) are a common cause of morbidity and mortality in surgical patients. Optimal management of cIAI requires early source control in combination with adequate antimicrobial treatment and aggressive fluid resuscitation. cIAIs are mainly caused by Gram-negative bacilli and anaerobes. Broad-spectrum single-agent or combination drug regimens against these microorganisms are the mainstay of therapy. However, development of antimicrobial resistance has become an increasingly large concern: multidrug-resistant organisms are associated with a higher rate of inadequate antimicrobial therapy, which in turn is associated with higher mortality rate, longer hospital stay, and increased cost compared to adequate antimicrobial therapy. In this mini-review, we discuss the effectiveness of several new antimicrobial agents, recently approved or in advanced phases of clinical development, for the treatment of cIAIs, including the new beta-lactam and beta-lactamase inhibitor combinations (ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam, aztreonam/avibactam), siderophore cephalosporins (cefiderocol), aminoglycosides (plazomicin), and tetracyclines (eravacycline).

Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

BACKGROUND: Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. OBJECTIVE: The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. DESIGN: Comparative review of patients at 2 institutions in the same metropolitan area were conducted. SETTINGS: The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. PATIENTS: A total of 350 patients with colorectal cancer from each hospital were evaluated. MAIN OUTCOME MEASURES: Overall survival across hospital systems was measured. RESULTS: The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). LIMITATIONS: This was a retrospective review, reporting from medical charts. CONCLUSIONS: Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues. See Video Abstract at http://links.lww.com/DCR/A454.

The Trump Effect: With No Peer Review, How Do We Know What to Really Believe on Social Media?

Social media is a source of news and information for an increasing portion of the general public and physicians. The recent political election was a vivid example of how social media can be used for the rapid spread of "fake news" and that posts on social media are not subject to fact-checking or editorial review. The medical field is susceptible to propagation of misinformation, with poor differentiation between authenticated and erroneous information. Due to the presence of social "bubbles," surgeons may not be aware of the misinformation that patients are reading, and thus, it may be difficult to counteract the false information that is seen by the general public. Medical professionals may also be prone to unrecognized spread of misinformation and must be diligent to ensure the information they share is accurate.

Association of Spouse Deployment on Pregnancy Outcomes in a U.S. Military Population.

OBJECTIVE: To evaluate the association of spousal deployment during the antenatal period on maternal and neonatal outcomes and to estimate whether group prenatal care may be beneficial in reducing adverse outcomes when spouses are deployed. METHODS: Primigravid women who delivered at Womack Army Medical Center, Fort Bragg, North Carolina, were prospectively enrolled and selected for participation on a random basis between January 2013 and January 2014. Women whose spouses were deployed to a combat zone during the entire pregnancy (deployed group) were compared with women whose spouses were not deployed during the pregnancy (nondeployed group). Pregnancy and neonatal outcomes were compared between groups. RESULTS: Three hundred ninety-seven women were enrolled with 183 (46.1%) in the deployed group and 214 (53.9%) in the nondeployed group. Spouse deployment was associated with increased risk of preterm delivery (38 [20.8%] compared with 16 [7.5%], P<.001) and postpartum depression (30 [16.4%] compared with 13 [6.1%], P=.001) when compared with women in the nondeployed group. There were no differences in the incidence of preterm delivery and postpartum depression for women in the deployed group who participated in group prenatal care when compared with women participating in traditional care (preterm delivery 6 [14.6%] compared with 32 [22.5%], P=.38; postpartum depression 4 [9.8%] compared with 26 [18.3%], P=.24). CONCLUSION: Women who have a spouse deployed during their pregnancy are at increased risk for preterm birth and postpartum depression. Larger studies are needed to evaluate whether spouse deployment during pregnancy has other perinatal effects and whether group prenatal care may have a positive effect on adverse perinatal outcomes in this population. LEVEL OF EVIDENCE: II.

Adipsin is an adipokine that improves ß cell function in diabetes.

A hallmark of type 2 diabetes mellitus (T2DM) is the development of pancreatic ß cell failure, which results in insulinopenia and hyperglycemia. We show that the adipokine adipsin has a beneficial role in maintaining ß cell function. Animals genetically lacking adipsin have glucose intolerance due to insulinopenia; isolated islets from these mice have reduced glucose-stimulated insulin secretion. Replenishment of adipsin to diabetic mice treated hyperglycemia by boosting insulin secretion. We identify C3a, a peptide generated by adipsin, as a potent insulin secretagogue and show that the C3a receptor is required for these beneficial effects of adipsin. C3a acts on islets by augmenting ATP levels, respiration, and cytosolic free Ca(2+). Finally, we demonstrate that T2DM patients with ß cell failure are deficient in adipsin. These findings indicate that the adipsin/C3a pathway connects adipocyte function to ß cell physiology, and manipulation of this molecular switch may serve as a therapy in T2DM.

Defining intractability: comparisons among published definitions.

PURPOSE: Intractable epilepsy is the focus of much research; however, this concept is defined in no single way. Individual studies use different definitions, creating difficulties for comparisons of results across studies. A head-to-head comparison of definitions could highlight these differences and motivate the development of consensus guidelines. METHODS: Within a single prospective study of 613 children in Connecticut with newly diagnosed epilepsy (1993-1997), six different published definitions or indicators for intractability were applied and compared. All definitions were assessed at various times within the first 5 years after diagnosis, with the exact timing reflecting how they were used in their initial reports. Observed and chance-adjusted agreement (kappa) were computed. The associations of each definition with remission status 7-10 years after diagnosis were quantified with a relative risk. RESULTS: Depending on the specific definition, the epilepsy of 9-24% of children was considered intractable. Observed agreements among the definitions ranged from a low of 0.83 to a high of 0.96. Kappas ranged from low of 0.45 to 0.79. More similar definitions had higher levels of agreement. All definitions were strongly associated with remission status as of last follow-up. CONCLUSIONS: Agreement among the different definitions is strong but imperfect. All definitions were significantly associated with longer-term outcome. No single preferred definition of intractable epilepsy exists. Some discussion within the field of epilepsy and a consensus process should be considered as a future step for enhancing comparability of research efforts and clinical guidelines. Consideration should be given to whether a single definition will suit all purposes or whether different types of definitions are needed for different purposes.

Mitochondria as integrators of information in an early-evolving animal: insights from a triterpenoid metabolite.

Mitochondria have the capacity to integrate environmental signals and, in animals with active stem cell populations, trigger responses in terms of growth and growth form. Colonial hydroids, which consists of feeding polyps connected by tube-like stolons, were treated with avicis, triterpenoid electrophiles whose anti-cancer properties in human cells are mediated in part by mitochondria. In treated hydroids, both oxygen uptake and mitochondrial reactive oxygen species were diminished relative to controls, similar to that observed in human cells exposed to avicins. While untreated colonies exhibit more stolon branches and connections in the centre of the colony than at the periphery, treated colonies exhibit the opposite: fewer stolon branches in the centre of the colony than at the periphery. The resulting growth form suggest an inversion of the normal pattern of colony development mediated by mitochondrial and redox-related perturbations. An as-yet-uncharacterized gradient within the colony may determine the ultimate phenotypic effects of avicin perturbation.

Laboratory-acquired brucellosis.

We report two laboratory-acquired Brucella melitensis infections that were shown to be epidemiologically related. Blood culture isolates were initially misidentified because of variable Gram stain results, which led to misdiagnoses and subsequent laboratory exposures. Notifying laboratory personnel who unknowingly processed cultures from brucellosis patients is an important preventive measure.

Detection, isolation, and molecular subtyping of Escherichia coli O157:H7 and Campylobacter jejuni associated with a large waterborne outbreak.

The largest reported outbreak of waterborne Escherichia coli O157:H7 in the United States occurred in upstate New York following a county fair in August 1999. Culture methods were used to isolate E. coli O157:H7 from specimens from 128 of 775 patients with suspected infections. Campylobacter jejuni was also isolated from stools of 44 persons who developed diarrheal illness after attending this fair. There was one case of a confirmed coinfection with E. coli O157:H7 and C. jejuni. Molecular detection of stx(1) and stx(2) Shiga toxin genes, immunomagnetic separation (IMS), and selective culture enrichment were utilized to detect and isolate E. coli O157:H7 from an unchlorinated well and its distribution points, a dry well, and a nearby septic tank. PCR for stx(1) and stx(2) was shown to provide a useful screen for toxin-producing E. coli O157:H7, and IMS subculture improved recovery. Pulsed-field gel electrophoresis (PFGE) was used to compare patient and environmental E. coli O157:H7 isolates. Among patient isolates, 117 of 128 (91.5%) were type 1 or 1a (three or fewer bands different). Among the water distribution system isolates, 13 of 19 (68%) were type 1 or 1a. Additionally, PFGE of C. jejuni isolates revealed that 29 of 35 (83%) had indistinguishable PFGE patterns. The PFGE results implicated the water distribution system as the main source of the E. coli O157:H7 outbreak. This investigation demonstrates the potential for outbreaks involving more than one pathogen and the importance of analyzing isolates from multiple patients and environmental samples to develop a better understanding of bacterial transmission during an outbreak.