Application of pharmacokinetic/pharmacodynamic concepts to the development of treatment regimens for sporadic canine urinary tract infections: Challenges and paths forward

Antimicrobial efficacy can be predicted based on infection site exposure to the antimicrobial agent relative to the in vitro susceptibility of the pathogen to that agent. When infections occur in soft tissues (e.g., muscle, blood, and ligaments), exposure at the infection site is generally assumed to reflect an equilibrium between the unbound concentrations in plasma and that in the interstitial fluids. In contrast, for sporadic urinary tract infections (UTIs) in dogs and uncomplicated UTIs in humans, the primary site of infection is the bladder wall. Infection develops when bacteria invade the host bladder urothelium (specifically, the umbrella cells that form the urine-contacting layer of the stratified uroepithelium) within which these bacteria can avoid exposure to host defenses and antimicrobial agents. Traditionally, pathogen susceptibility has been estimated using standardized in vitro tests that measure the minimal concentration that will inhibit pathogen growth (MIC). When using exposure-response relationships during drug development to explore dose optimization, these relationships can either be based upon an assessment of a correlation between clinical outcome, drug exposure at the infection site, and pathogen MIC, or upon benchmark exposure-response relationships (i.e., pharmacokinetic/pharmacodynamic indices) typically used for the various drug classes. When using the latter approach, it is essential that the unbound concentrations at the infection site be considered relative to the MIC within the biological matrix to which the pathogen will be exposed. For soft tissue infections, this typically is the unbound plasma concentrations versus MICs determined in standardized media such as cation-adjusted Mueller Hinton broth, which is how many indices were originally established. However, for UTIs, it is the unbound drug concentrations within the urine versus the MICs in the actual urine biophase that needs to be considered. The importance of these relationships and how they are influenced by drug resistance, resilience, and inoculum are discussed in this review using fluoroquinolones and beta-lactams as examples.

Therapeutic Drug Monitoring and Individualized Medicine of Dasatinib: Focus on Clinical Pharmacokinetics and Pharmacodynamics

Dasatinib is an oral second-generation tyrosine kinase inhibitor known to be used widely in Philadelphia chromosome-positive (Ph+) chronic myeloid leukemia (CML) and Ph+ acute lymphoblastic leukemia (ALL). Notably, although a high pharmacokinetic variability in patients and an increased risk of pleural effusion are attendant, fixed dosing remains standard practice. Retrospective studies have suggested that dasatinib exposure may be associated with treatment response (efficacy/safety). Therapeutic drug monitoring (TDM) is gradually becoming a practical tool to achieve the goal of individualized medicine for patients receiving targeted drugs. With the help of TDM, these patients who maintain response while have minimum adverse events may achieve long-term survival. This review summaries current knowledge of the clinical pharmacokinetics variation, exposure-response relationships and analytical method for individualized dosing of dasatinib, in particular with respect to therapeutic drug monitoring. In addition, it highlights the emerging insights into several controversial issues in TDM of dasatinib, with the aim of presenting up-to-date evidence for clinical decision-making and insights for future studies.

Action Levels for the Prevention of Work-Related Musculoskeletal Disorders in the Neck and Upper Extremities: A Proposal

There are several well-known risk factors for work-related musculoskeletal disorders (MSDs). Despite this knowledge, too many people still work in harmful conditions. The absence of occupational exposure limits (OELs) for physical workload impedes both supervision and preventive work. To prevent myalgia, tendon disorders, and nerve entrapments in the upper musculoskeletal system, we propose action levels concerning work postures, movement velocities and muscular loads recorded by wearable equipment. As an example, we propose that wrist velocity should not exceed 20°/s as a median over a working day. This has the potential to reduce the prevalence of carpal tunnel syndrome (CTS) in highly exposed male occupational groups by 93%. By reducing upper arm velocity in highly exposed female groups to the suggested action level 60°/s, the prevalence of pronounced neck/shoulder myalgia with clinical findings (tension neck syndrome) could be reduced by 22%. Furthermore, we propose several other action levels for the physical workload. Our ambition is to start a discussion concerning limits for physical workload, with the long-term goal that OELs shall be introduced in legislation. Obviously, the specific values of the proposed action levels can, and should, be discussed. We hope that quantitative measurements, combined with action levels, will become an integral part of systematic occupational health efforts, enabling reduction and prevention of work-related MSDs.

Quantification of the exposure and effects of road traffic noise in a dense Asian city: a comparison with western cities

BACKGROUND

Particularly in Asia, dense, traffic-intense, and usually high-rise cities are increasingly the norm. Is existing knowledge on exposure to road traffic noise, and on people's response to such exposure, garnered primarily from western cities, equally applicable in these?

METHODS

Hong Kong has high population and traffic density and a high-rise building form. Road traffic noise exposure was estimated, and residents' responses to traffic noise measured, for a sample of 10,077 dwellings. Noise level estimates were based on three-dimensional modelling. Best international survey practice measured self-reported annoyance and sleep-disturbance. Benchmark estimates of exposure, and of annoyance and self-reported sleep disturbance, are provided. We compare Hong Kong exposure with those of European cities, and the exposure-response relationship for annoyance in Hong Kong to those reported from elsewhere - based on the tolerance limits of previous syntheses. Exposure-response for self-reported sleep disturbance is also compared.

RESULTS

The distribution of exposures of dwellings in high-rise, high-density, Hong Kong is different from those reported from Europe, but not at the higher noise levels. The exposure-annoyance relationship for road traffic noise was from the same population of exposure-response relationships, being well within the tolerance limits, of studies used to generate the synthesized Miedema and Oudshoorn curves. The exposure-response curve for self-reported sleep disturbance was parallel to that of Miedema and Vos but slightly lower.

CONCLUSIONS

The proportion of the Hong Kong population exposed to high levels (>70 dB) is similar to that found in Europe. However, a much higher proportion, compared to European cities, is exposed to Lden levels of 60-64 dB, and a much lower proportion to lower levels (<55 dB). There is no evidence that the exposure-response relationships for annoyance and self-reported sleep disturbance in Hong Kong are different from relationships synthesized from earlier studies - despite the western bias and temperate-climate bias in the studies available in the syntheses. This is an important finding for urban planning and traffic noise management of the growing mega-cities in the world whose built forms can be expected to reflect that of Hong Kong more than of cities in the west.