Variation in antibiotic treatment for diabetic patients with serious foot infections: A retrospective observational study

<p>Abstract</p> <p>Background</p> <p>Diabetic foot infections are common, serious, and diverse. There is uncertainty about optimal antibiotic treatment, and probably substantial variation in practice. Our aim was to document whether this is the case: A finding that would raise questions about the comparative cost-effectiveness of different regimens and also open the possibility of examining costs and outcomes to determine which should be preferred.</p> <p>Methods</p> <p>We used the Veterans Health Administration (VA) Diabetes Epidemiology Cohorts (DEpiC) database to conduct a retrospective observational study of hospitalized patients with diabetic foot infections. DEpiC contains computerized VA and Medicare patient-level data for VA patients with diabetes since 1998, including demographics, ICD-9-CM diagnostic codes, antibiotics prescribed, and VA facility. We identified all patients with ICD-9-CM codes for cellulitis/abscess of the foot and then sub-grouped them according to whether they had cellulitis/abscess plus codes for gangrene, osteomyelitis, skin ulcer, or none of these. For each facility, we determined: 1) The proportion of patients treated with an antibiotic and the initial route of administration; 2) The first antibiotic regimen prescribed for each patient, defined as treatment with the same antibiotic, or combination of antibiotics, for at least 5 continuous days; and 3) The antibacterial spectrum of the first regimen.</p> <p>Results</p> <p>We identified 3,792 patients with cellulitis/abscess of the foot either alone (16.4%), or with ulcer (32.6%), osteomyelitis (19.0%) or gangrene (32.0%). Antibiotics were prescribed for 98.9%. At least 5 continuous days of treatment with an unchanged regimen of one or more antibiotics was prescribed for 59.3%. The means and (ranges) across facilities of the three most common regimens were: 16.4%, (22.8%); 15.7%, (36.1%); and 10.8%, (50.5%). The range of variation across facilities proved substantially greater than that across the different categories of foot infection. We found similar variation in the spectrum of the antibiotic regimen.</p> <p>Conclusions</p> <p>The large variations in regimen appear to reflect differences in facility practice styles rather than case mix. It is unlikely that all regimens are equally cost-effective. Our methods make possible evaluation of many regimens across many facilities, and can be applied in further studies to determine which antibiotic regimens should be preferred.</p

EGFR-Mediated Carcinoma Cell Metastasis Mediated by Integrin αvβ5 Depends on Activation of c-Src and Cleavage of MUC1

Receptor tyrosine kinases and integrins play an essential role in tumor cell invasion and metastasis. We previously showed that EGF and other growth factors induce human carcinoma cell invasion and metastasis mediated by integrin αvβ5 that is prevented by Src blockade [1]. MUC1, a transmembrane glycoprotein, is expressed in most epithelial tumors as a heterodimer consisting of an extracellular and a transmembrane subunit. The MUC1 cytoplasmic domain of the transmembrane subunit (MUC1.CD) translocates to the nucleus where it promotes the transcription of a metastatic gene signature associated with epithelial to mesenchymal transition. Here, we demonstrate a requirement for MUC1 in carcinoma cell metastasis dependent on EGFR and Src without affecting primary tumor growth. EGF stimulates Src-dependent MUC1 cleavage and nuclear localization leading to the expression of genes linked to metastasis. Moreover, expression of MUC1.CD results in its nuclear localization and is sufficient for transcription of the metastatic gene signature and tumor cell metastasis. These results demonstrate that EGFR and Src activity contribute to carcinoma cell invasion and metastasis mediated by integrin αvβ5 in part by promoting proteolytic cleavage of MUC1 and highlight the ability of MUC1.CD to promote metastasis in a context-dependent manner. Our findings may have implications for the use and future design of targeted therapies in cancers known to express EGFR, Src, or MUC1

Neutrinos

229 pages229 pages229 pagesThe Proceedings of the 2011 workshop on Fundamental Physics at the Intensity Frontier. Science opportunities at the intensity frontier are identified and described in the areas of heavy quarks, charged leptons, neutrinos, proton decay, new light weakly-coupled particles, and nucleons, nuclei, and atoms

Neutrino flux predictions for the NuMI beam

Knowledge of the neutrino flux produced by the Neutrinos at the Main Injector (NuMI) beamline is essential to the neutrino oscillation and neutrino interaction measurements of the MINERvA, MINOS+, NOvA and MicroBooNE experiments at Fermi National Accelerator Laboratory. We have produced a flux prediction which uses all available and relevant hadron production data, incorporating measurements of particle production off of thin targets as well as measurements of particle yields from a spare NuMI target exposed to a 120 GeV proton beam. The result is the most precise flux prediction achieved for a neutrino beam in the one to tens of GeV energy region. We have also compared the prediction to in situ measurements of the neutrino flux and find good agreement

Evidence for Neutral-Current Diffractive π0 Production from Hydrogen in Neutrino Interactions on Hydrocarbon

The MINERvA experiment observes an excess of events containing electromagnetic showers relative to the expectation from Monte Carlo simulations in neutral-current neutrino interactions with mean beam energy of 4.5 GeV on a hydrocarbon target. The excess is characterized and found to be consistent with neutral-current π0 production with a broad energy distribution peaking at 7 GeV and a total cross section of 0.26±0.02(stat.)±0.08(sys.)×10-39 cm2. The angular distribution, electromagnetic shower energy, and spatial distribution of the energy depositions of the excess are consistent with expectations from neutrino neutral-current diffractive π0 production from hydrogen in the hydrocarbon target. These data comprise the first direct experimental observation and constraint for a reaction that poses an important background process in neutrino-oscillation experiments searching for νμ to νe oscillations

Cross sections for νμ and ν μ induced pion production on hydrocarbon in the few-GeV region using MINERvA CROSS SECTIONS for νμ and ν μ ... C. L. MCGIVERN et al

Separate samples of charged-current pion production events representing two semi-inclusive channels νμ-CC(π+) and νμ-CC(π0) have been obtained using neutrino and antineutrino exposures of the MINERvA detector. Distributions in kinematic variables based upon μ±-track reconstructions are analyzed and compared for the two samples. The differential cross sections for muon production angle, muon momentum, and four-momentum transfer Q2 are reported, and cross sections versus neutrino energy are obtained. Comparisons with predictions of current neutrino event generators are used to clarify the role of the Δ(1232) and higher-mass baryon resonances in CC pion production and to show the importance of pion final-state interactions. For the νμ-CC(π+) [νμ-CC(π0)] sample, the absolute data rate is observed to lie below (above) the predictions of some of the event generators by amounts that are typically 1-to- 2σ. However the generators are able to reproduce the shapes of the differential cross sections for all kinematic variables of either data set

Measurement of partonic nuclear effects in deep-inelastic neutrino scattering using MINERvA

The MINERvA Collaboration reports a novel study of neutrino-nucleus charged-current deep inelastic scattering (DIS) using the same neutrino beam incident on targets of polystyrene, graphite, iron, and lead. Results are presented as ratios of C, Fe, and Pb to CH. The ratios of total DIS cross sections as a function of neutrino energy and flux-integrated differential cross sections as a function of the Bjorken scaling variable x are presented in the neutrino-energy range of 5-50 GeV. Based on the predictions of charged-lepton scattering ratios, good agreement is found between the data and prediction at medium x and low neutrino energy. However, the ratios appear to be below predictions in the vicinity of the nuclear shadowing region, x<0.1. This apparent deficit, reflected in the DIS cross-section ratio at high Eν, is consistent with previous MINERvA observations [B. Tice (MINERvA Collaboration), Phys. Rev. Lett. 112, 231801 (2014).] and with the predicted onset of nuclear shadowing with the axial-vector current in neutrino scattering

Measurement of K+ production in charged-current νμ interactions

Production of K+ mesons in charged-current νμ interactions on plastic scintillator (CH) is measured using MINERvA exposed to the low-energy NuMI beam at Fermilab. Timing information is used to isolate a sample of 885 charged-current events containing a stopping K+ which decays at rest. The differential cross section in K+ kinetic energy, dσ/dTK, is observed to be relatively flat between 0 and 500 MeV. Its shape is in good agreement with the prediction by the genie neutrino event generator when final-state interactions are included, however the data rate is lower than the prediction by 15%