Towards Precision Medicine: Therapeutic Drug Monitoring–Guided Dosing of Vancomycin and β-lactam Antibiotics to Maximize Effectiveness and Minimize Toxicity

Purpose The goal of this review is to explore the role of antimicrobial therapeutic drug monitoring (TDM), especially in critically ill, obese, and older adults, with a specific focus on β-lactams and vancomycin. Summary The continued rise of antimicrobial resistance prompts the need to optimize antimicrobial dosing. The aim of TDM is to individualize antimicrobial dosing to achieve antibiotic exposures associated with improved patient outcomes. Initially, TDM was developed to minimize adverse effects during use of narrow therapeutic index agents. Today, patient and organism complexity are expanding the need for precision dosing through TDM services. Alterations of pharmacokinetics and pharmacodynamics (PK/PD) in the critically ill, obese, and older adult populations, in conjunction with declining organism susceptibility, complicate attainment of therapeutic targets. Over the last decade, antimicrobial TDM has expanded with the emergence of literature supporting β-lactam TDM and a shift from monitoring vancomycin trough concentrations to monitoring of the ratio of area under the concentration (AUC) curve to minimum inhibitory concentration (MIC). PK/PD experts should be at the forefront of implementing precision dosing practices. Conclusion Precision dosing through TDM is expanding and is especially important in populations with altered PK/PD, including critically ill, obese, and older adults. Due to wide PK/PD variability in these populations, TDM is vital to maximize antimicrobial effectiveness and decrease adverse event rates. However, there is still a need for studies connecting TDM to patient outcomes. Providing patient-specific care through β-lactam TDM and transitioning to vancomycin AUC/MIC monitoring may be challenging, but with experts at the forefront of this initiative, PK-based optimization of antimicrobial therapy can be achieved

Updated Clinical Guidelines for Diagnosing Fetal Alcohol Spectrum Disorders

The adverse effects of prenatal alcohol exposure constitute a continuum of disabilities (fetal alcohol spectrum disorders [FASD]). In 1996, the Institute of Medicine established diagnostic categories delineating the spectrum but not specifying clinical criteria by which diagnoses could be assigned. In 2005, the authors published practical guidelines operationalizing the Institute of Medicine categories, allowing for standardization of FASD diagnoses in clinical settings. The purpose of the current report is to present updated diagnostic guidelines based on a thorough review of the literature and the authors’ combined expertise based on the evaluation of >10 000 children for potential FASD in clinical settings and in epidemiologic studies in conjunction with National Institute on Alcohol Abuse and Alcoholism–funded studies, the Collaborative Initiative on Fetal Alcohol Spectrum Disorders, and the Collaboration on FASD Prevalence. The guidelines were formulated through conference calls and meetings held at National Institute on Alcohol Abuse and Alcoholism offices in Rockville, MD. Specific areas addressed include the following: precise definition of documented prenatal alcohol exposure; neurobehavioral criteria for diagnosis of fetal alcohol syndrome, partial fetal alcohol syndrome, and alcohol-related neurodevelopmental disorder; revised diagnostic criteria for alcohol-related birth defects; an updated comprehensive research dysmorphology scoring system; and a new lip/philtrum guide for the white population, incorporating a 45-degree view. The guidelines reflect consensus among a large and experienced cadre of FASD investigators in the fields of dysmorphology, epidemiology, neurology, psychology, developmental/behavioral pediatrics, and educational diagnostics. Their improved clarity and specificity will guide clinicians in accurate diagnosis of infants and children prenatally exposed to alcohol

Achievement of the planetary defense investigations of the Double Asteroid Redirection Test (DART) mission

NASA's Double Asteroid Redirection Test (DART) mission was the first to demonstrate asteroid deflection, and the mission's Level 1 requirements guided its planetary defense investigations. Here, we summarize DART's achievement of those requirements. On 2022 September 26, the DART spacecraft impacted Dimorphos, the secondary member of the Didymos near-Earth asteroid binary system, demonstrating an autonomously navigated kinetic impact into an asteroid with limited prior knowledge for planetary defense. Months of subsequent Earth-based observations showed that the binary orbital period was changed by –33.24 minutes, with two independent analysis methods each reporting a 1σ uncertainty of 1.4 s. Dynamical models determined that the momentum enhancement factor, β, resulting from DART's kinetic impact test is between 2.4 and 4.9, depending on the mass of Dimorphos, which remains the largest source of uncertainty. Over five dozen telescopes across the globe and in space, along with the Light Italian CubeSat for Imaging of Asteroids, have contributed to DART's investigations. These combined investigations have addressed topics related to the ejecta, dynamics, impact event, and properties of both asteroids in the binary system. A year following DART's successful impact into Dimorphos, the mission has achieved its planetary defense requirements, although work to further understand DART's kinetic impact test and the Didymos system will continue. In particular, ESA's Hera mission is planned to perform extensive measurements in 2027 during its rendezvous with the Didymos–Dimorphos system, building on DART to advance our knowledge and continue the ongoing international collaboration for planetary defense

A Novel QTL in Durum Wheat for Resistance to the Wheat Stem Sawfly Associated with Early Expression of Stem Solidness

The wheat stem sawfly (WSS) (Cephus cinctus Norton) is a major yield-reducing pest of wheat (Triticum aestivum L.). Varieties with pith-filled, or solid, stems provide a measure of resistance by inhibiting larval survival inside the stem. Durum wheat (Triticum turgidum L.) has resistance to the wheat stem sawfly even in the absence of known genes for stem solidness. To determine the genetic basis of resistance in durum wheat, a susceptible durum wheat, PI 41353, was identified from among 1,211 landrace accessions from around the world screened in WSS-infested sites. A recombinant inbred line (RIL) population of 105 individuals was developed from a cross of PI 41353 with a typically resistant variety, Pierce. The RIL were screened in a total of three WSS-infested locations in Montana over a two year period. A genetic map was constructed with 2,867 SNP-based markers. A quantitative trait locus (QTL) analysis identified six QTL associated with resistance. An allele from resistant cultivar Pierce at a QTL on chromosome 3A, Qss.msub-3AL, caused a 25% reduction in stem cutting. Assessment of near-isogenic lines that varied for alleles at Qss.msub-3AL showed that the Pierce allele was also associated with higher stem solidness as measured early in stem development, which is a critical stage for WSS oviposition and larval development. Stem solidness of Pierce and other resistant durum wheat lines largely disappeared later in plant development. Results suggest a genetic mechanism for WSS resistance observed in durum wheat, and provide an additional source of WSS resistance for hexaploid bread wheat

Whole Blood Resuscitation and Association with Survival in Injured Patients with an Elevated Probability of Mortality

Low titer group O whole blood (LTOWB) resuscitation is becoming common in both military and civilian settings and may represent the ideal resuscitation intervention. We sought to characterize the safety and efficacy of LTOWB resuscitation relative to blood component resuscitation.A prospective, multicenter, observational cohort study was performed using seven trauma centers. Injured patients at risk of massive transfusion who required both blood transfusion and hemorrhage control procedures were enrolled. The primary outcome was 4-hour mortality. Secondary outcomes included 24-hour and 28-day mortality, achievement of hemostasis, death from exsanguination and the incidence of unexpected survivors.1,051 patients in hemorrhagic shock met all enrollment criteria. The cohort was severely injured with over 70% of patients requiring massive transfusion. After propensity adjustment, no significant 4-hour mortality difference across LTOWB and component patients was found, (RR 0.90, 95%CI 0.59-1.39, p=0.64). Similarly, no adjusted mortality differences were demonstrated at 24-hours or 28 days for the enrolled cohort. When patients with an elevated prehospital probability of mortality were analyzed, LTOWB resuscitation was independently associated with a 48% lower risk of 4-hour mortality (RR 0.52, 95%CI 0.32-0.87, p=0.01) and a 30% lower risk of 28-day mortality (RR 0.70, 95%CI 0.51-0.96, p=0.03).Early LTOWB resuscitation is safe but not independently associated with survival for the overall enrolled population. When patients were selected with an elevated probability of mortality based upon prehospital injury characteristics, LTOWB was independently associated with a lower risk of mortality starting at 4 hours post arrival thru 28 days post-injury