Description of the methods for describing and assessing the appropriateness of antibiotic prescribing and adherence to published treatment guidelines in an academic medical clinic

Overuse and inappropriate use of antibiotics have been associated with increased rates of antimicrobial resistance and increased healthcare expenditures. Tracking inpatient antimicrobial use has helped quantify the value of stewardship programs aimed at improving the rational use of antibiotics among hospitalized patients. Unfortunately, similar methods for tracking and assessing antibiotic use in the outpatient setting have not been well described. We developed a novel method to capture trends and assess appropriateness of antibiotic usage. This strategy is based on identification of antimicrobial prescriptions in an electronic medical record system, linking prescribing to patient data, and capturing information regarding dosing and indications for use. Using information on dose, frequency, and duration of the antibiotic prescribed, a parameter to quantify antibiotic exposure (Prescribed Therapeutic Regimen, PTR) is calculated. This parameter is compared to a database of information on agents recommended in published guidelines (Recommended Therapeutic Regimen, RTR). By linking an ICD-9 code and the prescribed antibiotic we determine the appropriateness of the PTR by comparing it to the RTR for a given indication. Data are used to establish a baseline pattern of antibiotic use in the clinic to gauge the impact of future stewardship activities. Additionally, individual clinics and prescribers are given a snapshot of their antibiotic use compared to other clinics and prescribers. This is a novel means of describing antibiotic use in the outpatient setting that could serve as a standardized model for various adult and pediatric outpatient practices.   Type: Original Researc

The effects of transport of 18-day old hatching eggs on physiology and behaviour of slow growing broiler chicken

Incubation and hatching commonly takes places at hatcheries, separate from the grow-out facilities where broiler chicks are raised. This means that chicks are sorted and transported immediately after hatch, during which time they typically do not have access to feed and water, and are subjected to transport stress. Recently, innovative housing systems are being developed in which fertilised eggs are transported on embryonic day 18 (E18) from the hatchery to the grow-out facility, where they hatch on day 21. In chicken, the hypothalamic– pituitary–adrenal (HPA)-axis becomes functional around embryonic day 14–16. It is therefore conceivable that transport of eggs at E18 may lead to a stress response in the chick embryo. Exposure to prenatal stress may affect the coping capacity of the individual and negatively impact its further development. We investigated whether prolonged transport on E18 has effects on the development of a slow growing broiler chicken strain (Hubbard JA257). E18 eggs were transported for either 41 min (short transport, ST) or 219 min (long transport, LT). Transportation significantly increased embryonic heart rate after ST. This increase continued during an intermediate measure at 120 min. The increased embryonic HR then remained high at measurement immediately following LT. We did not find effects of prolonged transport on behavioural parameters measured in the juvenile chicken in the tonic immobility and open field test. Concentrations of feather corticosterone as well as faecal corticosterone metabolites did not differ on postnatal day 36. We showed that transport leads to an autonomic stress response in chicken embryos at E18, but that this elevation had no further effects on other indicators of prenatal stress. Nevertheless, our results emphasise that transport of incubated eggs should be as refined as possible to minimise the exposure to stress

Real-world outcomes of sipuleucel-T treatment in PROCEED, a prospective registry of men with metastatic castration-resistant prostate cancer.

BackgroundThe large registry, PROVENGE Registry for the Observation, Collection, and Evaluation of Experience Data (PROCEED)(NCT01306890), evaluated sipuleucel-T immunotherapy for asymptomatic/minimally symptomatic metastatic castration-resistant prostate cancer (mCRPC).MethodsPROCEED enrolled patients with mCRPC receiving 3 biweekly sipuleucel-T infusions. Assessments included overall survival (OS), serious adverse events (SAEs), cerebrovascular events (CVEs), and anticancer interventions (ACIs). Follow-up was for ≥3 years or until death or study withdrawal.ResultsIn 2011-2017, 1976 patients were followed for 46.6 months (median). The median age was 72 years, and the baseline median prostate-specific antigen level was 15.0 ng/mL; 86.7% were white, and 11.6% were African American. Among the patients, 1902 had 1 or more sipuleucel-T infusions. The median OS was 30.7 months (95% confidence interval [CI], 28.6-32.2 months). Known prognostic factors were independently associated with OS in a multivariable analysis. Among the 1255 patients who died, 964 (76.8%) died of prostate cancer (PC) progression. The median time from the first infusion to PC death was 42.7 months (95% CI, 39.4-46.2 months). The incidence of sipuleucel-T-related SAEs was 3.9%. The incidence of CVEs was 2.8%, and the rate per 100 person-years was 1.2 (95% CI, 0.9-1.6). The CVE incidence among 11,972 patients with mCRPC from the Surveillance, Epidemiology, and End Results-Medicare database was 2.8%; the rate per 100 person-years was 1.5 (95% CI, 1.4-1.7). One or more ACIs (abiraterone, enzalutamide, docetaxel, cabazitaxel, or radium 223) were received by 77.1% of the patients after sipuleucel-T; 32.5% and 17.4% of the patients experienced 1- and 2-year treatment-free intervals, respectively.ConclusionsPROCEED provides contemporary survival data for sipuleucel-T-treated men in a real-world setting of new life-prolonging agents, which will be useful in discussing treatment options with patients and in powering future trials with sipuleucel-T. The safety and tolerability of sipuleucel-T in PROCEED were consistent with previous findings

Baylisascaris procyonis Impacts Raccoon (Procyon lotor) Diets

Raccoons (Procyon lotor) are the definitive host for raccoon roundworms (Baylisascaris procyonis). Raccoon roundworm is responsible for a dangerous neurological disease known as larva migrans encephalopathy. Raccoons are omnivorous animals and rely on various food items. Dietary analyses help determine how a raccoon changes its diet in response to environmental features. Raccoons eat whatever food resource is most convenient and abundant. Parasite infections can potentially affect host eating habits in order to keep the host alive and active longer. In this study, we analyzed the diets of necropsied raccoons from ten townships of Clark and Greene Counties by examining their stomach contents. We categorized stomach contents by separating out plant material, vertebrate tissue, and invertebrate tissue. We measured the total stomach mass and the mass of plant material alone in order to compare and obtain a percentage of plant material in the raccoons’ diet. We conducted two chi-squared tests for equality of distributions. We tested the null hypotheses that raccoons from townships with high prevalence (\u3e60%) have the same vertebrate tissue and plant tissue prevalence as raccoons from townships with low roundworm prevalence

Does Baylisascaris procyonis Impact Raccoon (Procyon lotor) Genetics?

Raccoons (Procyon lotor) are the final host for raccoon roundworms (Baylisascaris procyonis). Raccoon roundworm is the leading cause of a dangerous neurological disease, known as larva migrans encephalopathy. Phylogenetic trees illustrate co-evolutionary events between species living in a symbiotic relationship with each other. Throughout the coevolution of host and parasite, many aspects of a population affect the way the members interact with one another and with symbiotic species. In order to evaluate the relationship between host and parasite in regards to diet, we isolated DNA from intestinal wall tissue, amplified a portion of exon 2 from MHC II, and sent our samples to Ohio State University for sequencing. We calculated heterozygosities for the nine townships we surveyed. We used a chi-squared test for equality of distributions to test whether raccoons from townships with above 60% prevalence have different heterozygosity for this locus than other raccoons. These data will help us to understand the relationship between raccoons and raccoon roundworm

Does Baylisascaris procyonis Phylogeny Correlate with That of the Raccoon (Procyon lotor)

Baylisacaris procyonis, commonly known as the raccoon roundworm, is a parasite that inhabits the small intestine of the North American raccoon (Procyon lotor). Although humans do not typically become the definitive host, humans can become infected through handling soil containing eggs. B. procyonis can induce serious health complications in cases of human infection, including degenerative retinal and behavioral changes, coma, and even death. High prevalence of B. procyonis in a raccoon population increases the probability of transference to human hosts. In our study, we analyzed the genetic structure of B. procyonis harvested from raccoons of southwestern Ohio, and compared this to the genetic structure of the raccoons they inhabited. It is our hypothesis that the genetic structuring of the roundworms is the same as the genetic structuring of the raccoons. We isolated DNA from the roundworms using the method outlined in the DNA Minikit (Qiagen). Our research team isolated DNA from each roundworm sample and sent it to the Plant-Microbe Genomics Facility at The Ohio State University for gene amplification and sequencing. We built phylogenetic trees using these sequences, and compared these trees to some constructed for the raccoons. The correlations drawn between the raccoon and B. procyonis phylogenetic trees will help us better understand the relationship between the two species

Baylisascaris procyonis prevalence in raccoons (Procyon lotor) and its relation to landscape features

Raccoons (Procyon lotor) are the final host for raccoon roundworm (Baylisascaris procyonis). Raccoon roundworm is the leading cause of a dangerous neurological disease known as larva migrans encephalopathy. Land fragmentation occurs when natural environments are broken up by urban or agricultural landscapes. Raccoons thrive in urban environments, while raccoons in agricultural settings forage over larger areas than raccoons in urban settings do. Land fragmentation affects concentrations of B. procyonis parasites in intermediate hosts. We calculated the prevalence of raccoon roundworm in 9 townships of Greene and Clark Counties by necropsying 226 raccoon intestines. Prevalence is defined as the number of raccoons infected with roundworm divided by the total number of raccoons sampled. We determined that the prevalence of B. procyonis from Beavercreek township is significantly lower than the other townships (χ2 = 25.19, p-value = 0.0007). Prevalence of raccoon roundworm in this region is lower than many areas in the Midwestern United States, suggesting the need for further research to determine reasons for the lower prevalence in the Ohio region

American Society of Clinical Oncology Clinical Practice Guideline Update on Chemotherapy for Stage IV Non–Small-Cell Lung Cancer

The purpose of this article is to provide updated recommendations for the treatment of patients with stage IV non–small-cell lung cancer. A literature search identified relevant randomized trials published since 2002. The scope of the guideline was narrowed to chemotherapy and biologic therapy. An Update Committee reviewed the literature and made updated recommendations. One hundred sixty-two publications met the inclusion criteria. Recommendations were based on treatment strategies that improve overall survival. Treatments that improve only progression-free survival prompted scrutiny of toxicity and quality of life. For first-line therapy in patients with performance status of 0 or 1, a platinum-based two-drug combination of cytotoxic drugs is recommended. Nonplatinum cytotoxic doublets are acceptable for patients with contraindications to platinum therapy. For patients with performance status of 2, a single cytotoxic drug is sufficient. Stop first-line cytotoxic chemotherapy at disease progression or after four cycles in patients who are not responding to treatment. Stop two-drug cytotoxic chemotherapy at six cycles even in patients who are responding to therapy. The first-line use of gefitinib may be recommended for patients with known epidermal growth factor receptor (EGFR) mutation; for negative or unknown EGFR mutation status, cytotoxic chemotherapy is preferred. Bevacizumab is recommended with carboplatin-paclitaxel, except for patients with certain clinical characteristics. Cetuximab is recommended with cisplatin-vinorelbine for patients with EGFR-positive tumors by immunohistochemistry. Docetaxel, erlotinib, gefitinib, or pemetrexed is recommended as second-line therapy. Erlotinib is recommended as third-line therapy for patients who have not received prior erlotinib or gefitinib. Data are insufficient to recommend the routine third-line use of cytotoxic drugs. Data are insufficient to recommend routine use of molecular markers to select chemotherapy

Preliminary seismological and geological studies of the San Fernando, California, earthquake of February 9 1971

The San Fernando earthquake was the largest earthquake to occur in the metropolitan Los Angeles area in more than 50 years. It has tentatively been assigned a magnitude, M_L of 6.6, a focal depth of 13.0 km, and an epicentral location about 12 km east of Newhall, California, at 34°24.0'N, 118°23.7'W (Figure 1), but these figures undoubtedly will be modified as further data become available. Although the focal depth is not as well defined as the epicenter, it is consistent with other observations suggesting thrusting on a fault plane dipping north about 45 ° and breaking the surface in the Sylmar-San Fernando area (Figure 1). It should be emphasized that the hypocenter of the main shock represents only the point of initial rupture. Breaking, presumably, then propagated southward and upward from this point, so that the main geological and engineering effects were observed farther south where the fault was shallower and the displacement greater. The location of the main shock is based on readings from permanent stations of the Caltech network, as well as the U. S. Geological Survey station at Point Mugu (SBLG) and the California Department of Water Resources stations at Pyramid (PYR) and Cedar Springs (CSP). Portable Caltech seismographs were installed in the epicentral area as early as 3 hr following the main shock, and, within a few days, there were at least 30 portable units in the region operated by various groups and agencies