Osteomyelitis is a common and challenging condition for hospitalists to manage. The 3 main types of osteomyelitis that are commonly seen in the hospital setting are 1) contiguous spread from decubitus or diabetic ulcers, 2) hematogenous spread, such as in vertebral or long bone metaphyses, and 3) infections associated with a prosthetic joint. In patients with diabetes, osteomyelitis is the underlying cause of about 20% of foot infections, and greatly increases the chance that the patient will eventually need an amputation and be subject to perioperative risks. Osteomyelitis from hematogenous spread is increasing. The prevalence of vertebral osteomyelitis is also increasing, particularly in intravenous drug users and patients treated with immune-modulating agents. Prosthetic joint infections are perhaps the most challenging type to treat, and require hospitalists, orthopedic surgeons, and infectious disease specialists to work closely together to plan for effective treatment. Due to increasing antibiotic resistance, the microorganisms involved are also proving more difficult to treat. Emerging resistance to the commonly used antibiotics is resulting in changes in treatment choices. Community-acquired methicillin-resistant Staphylococcus aureus is commonly seen, and there is increasing concern about emerging vancomycin resistance. Treatment of osteomyelitis is still based largely on expert opinion rather than evidence from controlled studies.

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By use of recent data for hydrogen as a real gas, it has been shown that there is no need to introduce changes in the activities of condensed phases to explain the electromotive forces measured when the partial pressure of hydrogen in a calomel cell (0.1N HC1 as electrolyte) is increased up to 1035 atm at 25%In a classic investigation (1, 2) it was found at 25 ~ that the emf, e, of the cell 1-12 (g) Pt]HC1 (0.1N) [Hg2Cl2 (s) ]Hg (1) increased more rapidly than required by the Nernst equation when the partial pressure p of hydrogen, varied up to 1035 atm, was used in the calculation. The departure of hydrogen from ideal behavior was of course mainly responsible, and all but 2.3 mV of the difference at 1000 arm was accounted for by using a simple equation of state for this gas in a treatment based on the volume change attending the cell reaction. The residual difference was attributed in the main to an effect of hydrogen dissolved at high pressure on the partial mo~al volume of hydrochloric acid. Calculations reported here, which are based on recent data (3-6), show that this assumption is no longer necessary. Extensive preliminary calculations indicated the results of Michels et al. (5, 6) to be best for our purposes.Two sets of final calculations were made. In the first, the increment • resulting from an increase of p above 1 arm (101325 N/m 2) was obtained for each such increase from the familiar equation z~e _--(0.029580V)log fp/fl [1] which contains the fugacity quotient for the two partial pressures in question. The fugacities were obtained from In ~/p = (14.38P)/RT 4-(O.O06671P2)/2RT [2]where P is the pressure in atmospheres for a hydrogen Pv isotherm experiment; R has the value 82.056 cm 3 9 atm/kmol, and T is the temperature in Kelvins. The calculation assumes that P may be substituted for p, the partial pressure of hydrogen in the cell, when the two pressures are equaI. This assumption is tantamount to saying that the water vapor present does not change the fugacity of hydrogen. The first virial coefficient is the value of B for 25 ~ in Ref. (6); the second is that of (C --B2)/RT for the same temperature. In addition, a differential calculation was needed. This is based on three thermodynamic relations d In ~ = (pv/RT) d In p(v ----molar volume of He)[3]

Change seldom happens the way we expect, and plans are rarely executed exactly as we intend. That's the thing about change: it always retains that element of the unexpected. So how does a large company deal with change? First of all, I believe we have to embrace change—anticipate it and look for the opportunities it brings. We must listen to our customers and be flexible and innovative. These elements have never been more important than they are today.