Global impacts of an extreme solar particle event under different geomagnetic field strengths.

Solar particle events (SPEs) are short-lived bursts of high-energy particles from the solar atmosphere and are widely recognized as posing significant economic risks to modern society. Most SPEs are relatively weak and have minor impacts on the Earth's environment, but historic records contain much stronger SPEs which have the potential to alter atmospheric chemistry, impacting climate and biological life. The impacts of such strong SPEs would be far more severe when the Earth's protective geomagnetic field is weak, such as during past geomagnetic excursions or reversals. Here, we model the impacts of an extreme SPE under different geomagnetic field strengths, focusing on changes in atmospheric chemistry and surface radiation using the atmosphere-ocean-chemistry-climate model SOCOL3-MPIOM and the radiation transfer model LibRadtran. Under current geomagnetic conditions, an extreme SPE would increase NOx concentrations in the polar stratosphere and mesosphere, causing reductions in extratropical stratospheric ozone lasting for about a year. In contrast, with no geomagnetic field, there would be a substantial increase in NOx throughout the entire atmosphere, resulting in severe stratospheric ozone depletion for several years. The resulting ground-level ultraviolet (UV) radiation would remain elevated for up to 6 y, leading to increases in UV index up to 20 to 25% and solar-induced DNA damage rates by 40 to 50%. The potential evolutionary impacts of past extreme SPEs remain an important question, while the risks they pose to human health in modern conditions continue to be underestimated.

Stability of influenza A virus in droplets and aerosols is heightened by the presence of commensal respiratory bacteria.

Aerosol transmission remains a major challenge for control of respiratory viruses, particularly those causing recurrent epidemics, like influenza A virus (IAV). These viruses are rarely expelled alone, but instead are embedded in a consortium of microorganisms that populate the respiratory tract. The impact of microbial communities and inter-pathogen interactions upon stability of transmitted viruses is well-characterized for enteric pathogens, but is under-studied in the respiratory niche. Here, we assessed whether the presence of five different species of commensal respiratory bacteria could influence the persistence of IAV within phosphate-buffered saline and artificial saliva droplets deposited on surfaces at typical indoor air humidity, and within airborne aerosol particles. In droplets, presence of individual species or a mixed bacterial community resulted in 10- to 100-fold more infectious IAV remaining after 1 h, due to bacterial-mediated flattening of drying droplets and early efflorescence. Even when no efflorescence occurred at high humidity or the bacteria-induced changes in droplet morphology were abolished by aerosolization instead of deposition on a well plate, the bacteria remained protective. Staphylococcus aureus and Streptococcus pneumoniae were the most stabilizing compared to other commensals at equivalent density, indicating the composition of an individual's respiratory microbiota is a previously unconsidered factor influencing expelled virus persistence.IMPORTANCEIt is known that respiratory infections such as coronavirus disease 2019 and influenza are transmitted by release of virus-containing aerosols and larger droplets by an infected host. The survival time of viruses expelled into the environment can vary depending on temperature, room air humidity, UV exposure, air composition, and suspending fluid. However, few studies consider the fact that respiratory viruses are not alone in the respiratory tract-we are constantly colonized by a plethora of bacteria in our noses, mouth, and lower respiratory system. In the gut, enteric viruses are known to be stabilized against inactivation and environmental decay by gut bacteria. Despite the presence of a similarly complex bacterial microbiota in the respiratory tract, few studies have investigated whether viral stabilization could occur in this niche. Here, we address this question by investigating influenza A virus stabilization by a range of commensal bacteria in systems representing respiratory aerosols and droplets.

A bite force database of 654 insect species.

Bite force is a decisive performance trait in animals because it plays a role for numerous life history components such as food consumption, inter- and intraspecific interactions, and reproductive success. Bite force has been studied across a wide range of vertebrate species, but only for 32 species of insects, the most speciose animal lineage. Here we present the insect bite force database with bite force measurements for 654 insect species covering 476 genera, 111 families, and 13 orders with body lengths ranging from 3.76 to 180.12 mm. In total we recorded 1906 bite force series from 1290 specimens, and, in addition, present basal head, body, and wing metrics. As such, the database will facilitate a wide range of studies on the characteristics, predictors, and macroevolution of bite force in the largest clade of the animal kingdom and may serve as a basis to further our understanding of macroevolutionary processes in relation to bite force across all biting metazoans.

The neuraminidase activity of influenza A virus determines the strain-specific sensitivity to neutralization by respiratory mucus.

IMPORTANCE: The respiratory tract of humans is constantly exposed to potentially harmful agents, such as small particles or pathogens, and thus requires protective measures. Respiratory mucus that lines the airway epithelia plays a major role in the prevention of viral infections by limiting the mobility of viruses, allowing subsequent mucociliary clearance. Understanding the interplay between respiratory mucus and viruses can help elucidate host and virus characteristics that enable the initiation of infection. Here, we tested a panel of primary influenza A viruses of avian or human origin for their sensitivity to mucus derived from primary human airway cultures and found that differences between virus strains can be mapped to viral neuraminidase activity. We also show that binding of influenza A viruses to decoy receptors on highly glycosylated mucus components constitutes the major inhibitory function of mucus against influenza A viruses.

Inactivation mechanisms of influenza A virus under pH conditions encountered in aerosol particles as revealed by whole-virus HDX-MS.

Multiple respiratory viruses, including influenza A virus (IAV), can be transmitted via expiratory aerosol particles, and aerosol pH was recently identified as a major factor influencing airborne virus infectivity. Indoors, small exhaled aerosols undergo rapid acidification to pH ~4. IAV is known to be sensitive to mildly acidic conditions encountered within host endosomes; however, it is unknown whether the same mechanisms could mediate viral inactivation within the more acidic aerosol micro-environment. Here, we identified that transient exposure to pH 4 caused IAV inactivation by a two-stage process, with an initial sharp decline in infectious titers mainly attributed to premature attainment of the post-fusion conformation of viral protein haemagglutinin (HA). Protein changes were observed by hydrogen-deuterium exchange coupled to mass spectrometry (HDX-MS) as early as 10 s post-exposure to acidic conditions. Our HDX-MS data are in agreement with other more labor-intensive structural analysis techniques, such as X-ray crystallography, highlighting the ease and usefulness of whole-virus HDX-MS for multiplexed protein analyses, even within enveloped viruses such as IAV. Additionally, virion integrity was partially but irreversibly affected by acidic conditions, with a progressive unfolding of the internal matrix protein 1 (M1) that aligned with a more gradual decline in viral infectivity with time. In contrast, no acid-mediated changes to the genome or lipid envelope were detected. Improved understanding of respiratory virus fate within exhaled aerosols constitutes a global public health priority, and information gained here could aid the development of novel strategies to control the airborne persistence of seasonal and/or pandemic influenza in the future. IMPORTANCE It is well established that COVID-19, influenza, and many other respiratory diseases can be transmitted by the inhalation of aerosolized viruses. Many studies have shown that the survival time of these airborne viruses is limited, but it remains an open question as to what drives their infectivity loss. Here, we address this question for influenza A virus by investigating structural protein changes incurred by the virus under conditions relevant to respiratory aerosol particles. From prior work, we know that expelled aerosols can become highly acidic due to equilibration with indoor room air, and our results indicate that two viral proteins are affected by these acidic conditions at multiple sites, leading to virus inactivation. Our findings suggest that the development of air treatments to quicken the speed of aerosol acidification would be a major strategy to control infectious bioburdens in the air.

Comparison of ozonesonde measurements in the upper troposphere and lower Stratosphere in Northern India with reanalysis and chemistry-climate-model data.

The variability and trend of ozone (O3) in the Upper troposphere and Lower Stratosphere (UTLS) over the Asian region needs to be accurately quantified. Ozone in the UTLS radiatively heats this region and cools the upper parts of the stratosphere. This results in an impact on relative humidity, static stability in the UTLS region and tropical tropopause temperature. A major challenge for understanding ozone chemistry in the UTLS is sparse observations and thus the representation of precursor gases in model emission inventories. Here, we evaluate ozonesonde measurements during August 2016 at Nainital, in the Himalayas, against ozone from multiple reanalyses and the ECHAM6-HAMMOZ model. We find that compared to measurements both reanalyses and ECHAM6-HAMMOZ control simulation overestimate ozone mixing ratios in the troposphere (20 ppb) and in the UTLS (55 ppb). We performed sensitivity simulations using the ECHAM6-HAMMOZ model for a 50% reduction in the emission of (1) NOx and (2) VOCs. The model simulations with NOX reduction agree better with the ozonesonde observations in the lower troposphere and in the UTLS. Thus, neither reanalyses nor ECHAM6-HAMMOZ results can reproduce observed O3 over the South Asian region. For a better representation of O3 in the ECHAM6-HAMMOZ model, NOX emission should be reduced by 50% in the emission inventory. A larger number of observations of ozone and precursor gases over the South Asian region would improve the assessment of ozone chemistry in models.

Surface tension models for binary aqueous solutions: a review and intercomparison.

The liquid-air surface tension of aqueous solutions is a fundamental quantity in multi-phase thermodynamics and fluid dynamics and thus relevant in many scientific and engineering fields. Various models have been proposed for its quantitative description. This Perspective gives an overview of the most popular models and their ability to reproduce experimental data of ten binary aqueous solutions of electrolytes and organic molecules chosen to be representative of different solute types. In addition, we propose a new model which reproduces sigmoidal curve shapes (Sigmoid model) to empirically fit experimental surface tension data. The surface tension of weakly surface-active substances is well reproduced by all models. In contrast, only few models successfully model the surface tension of aqueous solutions with strongly surface-active substances. For substances with a solubility limit, usually no experimental data is available for the surface tension of supersaturated solutions and the pure liquid solute. We discuss ways in which these can be estimated and emphasize the need for further research. The newly developed Sigmoid model best reproduces the surface tension of all tested solutions and can be recommended as a model for a broad range of binary mixtures and over the entire concentration range.

Experience with "Select Crowd Review" in Peer Review for The Thoracic and Cardiovascular Surgeon: 1-Year Experience.

OBJECTIVE: To evaluate the experience with a new peer review method, "Select Crowd Review" (SCR): anonymized PDFs of manuscripts are accessible to a reviewer crowd via an online platform. It has access for 10 days to enter anonymized comments directly into the manuscript. A SCR-Editor summarizes the annotations, giving a recommendation. Both reviewed PDF and summary are sent back to authors. Upon submission, authors are given a choice to accept or decline SCR. DESIGN: All manuscript submissions since introduction in July 2021 until July 2022 were analyzed regarding acceptance and quality. Manuscripts were sent to a crowd of 45 reviewers and regular double-blinded peer review at the same time. Efficiency and performance of the crowd's reviews were compared with those of regular review. For thoracic manuscripts, a crowd was not yet available. RESULTS: SCR was accepted by the authors for 73/179 manuscripts (40.8%). After desk rejections, 51 cardiac manuscripts entered SCR. For five manuscripts, the crowd did not respond. In all remaining papers, the crowd's recommendation concurred with that of the normal reviewers. Regular peer review took up to 6 weeks. Twelve manuscripts underwent repeated SCR after revision. A median of 2 (0-9) crowd members sent in reviews. In revisions, average response was one reviewer responding. CONCLUSION: SCR encountered good acceptance by authors. As the first experience showed concordant recommendations compared with traditional review, we have extended SCR to thoracic manuscripts for more experience. SCR may become the sole review method for eligible manuscripts. Efficiency should be increased, especially for re-review of revisions.

Annotating very high-resolution satellite imagery: A whale case study.

The use of very high-resolution (VHR) optical satellites is gaining momentum in the field of wildlife monitoring, particularly for whales, as this technology is showing potential for monitoring the less studied regions. However, surveying large areas using VHR optical satellite imagery requires the development of automated systems to detect targets. Machine learning approaches require large training datasets of annotated images. Here we propose a standardised workflow to annotate VHR optical satellite imagery using ESRI ArcMap 10.8, and ESRI ArcGIS Pro 2.5., using cetaceans as a case study, to develop AI-ready annotations.•A step-by-step protocol to review VHR optical satellite images and annotate the features of interest.•A step-by-step protocol to create bounding boxes encompassing the features of interest.•A step-by-step guide to clip the satellite image using bounding boxes to create image chips.

Expiratory Aerosol pH: The Overlooked Driver of Airborne Virus Inactivation.

Respiratory viruses, including influenza virus and SARS-CoV-2, are transmitted by the airborne route. Air filtration and ventilation mechanically reduce the concentration of airborne viruses and are necessary tools for disease mitigation. However, they ignore the potential impact of the chemical environment surrounding aerosolized viruses, which determines the aerosol pH. Atmospheric aerosol gravitates toward acidic pH, and enveloped viruses are prone to inactivation at strong acidity levels. Yet, the acidity of expiratory aerosol particles and its effect on airborne virus persistence have not been examined. Here, we combine pH-dependent inactivation rates of influenza A virus (IAV) and SARS-CoV-2 with microphysical properties of respiratory fluids using a biophysical aerosol model. We find that particles exhaled into indoor air (with relative humidity ≥ 50%) become mildly acidic (pH ∼ 4), rapidly inactivating IAV within minutes, whereas SARS-CoV-2 requires days. If indoor air is enriched with nonhazardous levels of nitric acid, aerosol pH drops by up to 2 units, decreasing 99%-inactivation times for both viruses in small aerosol particles to below 30 s. Conversely, unintentional removal of volatile acids from indoor air may elevate pH and prolong airborne virus persistence. The overlooked role of aerosol acidity has profound implications for virus transmission and mitigation strategies.

Exposure assessment during paint spraying and drying using PTR-ToF-MS.

Spraying is a common way to distribute occupational products, but it puts worker's health at risk by exposing them to potentially harmful particles and gases. The objective of this study is to use time-resolved measurements to gain an understanding of spray applications at the process level and to compare them to predictions of exposure models. We used proton transfer reaction time-of-flight mass spectrometry (PTR-ToF-MS) at 1-s time resolution to monitor the gas phase concentration of the solvents acetone, ethanol, butyl acetate, xylene and 1-methoxy-2-propy acetate during outdoor spraying and indoor drying of metal plate under various conditions of outdoor air supply. We found that during spraying, gas-phase exposure was dominated by the more volatile solvents acetone and ethanol, which exhibited strong concentration variations due to the outdoor winds. During drying, exposure strongly depended on the strength of ventilation. Under conditions with high supply of outdoor air, our measurements show a near-exponential decay of the solvent concentrations during drying. Conversely, under conditions without outdoor air supply, the drying process required hours, during which the less volatile solvents passed through a concentration maximum in the gas phase, so that the exposure during drying exceeded the exposure during spraying. The concentrations measured during spraying were then compared for each of the substances individually with the predictions of the exposure models ECETOC TRA, Stoffenmanager, and ART using TREXMO. For these conditions, ECETOC TRA and Stoffenmanager predicted exposures in the measured concentration range, albeit not conservative for all solvents and each application. In contrast, ART largely overestimated the exposure for the more volatile solvents acetone and ethanol and slightly underestimated exposure to 1M2PA for one spraying. ECETOC TRA and ART do not have options to predict exposure during drying. Stoffenmanager has the option to predict drying together with spraying, but not to predict the drying phase independently. Our study demonstrates the importance of considering both the spray cloud and solvent evaporation during the drying process. To improve workplace safety, there is a critical need for enhanced exposure models and comprehensive datasets for calibration and validation covering a broader range of exposure situations.

Electrodynamic balance-mass spectrometry reveals impact of oxidant concentration on product composition in the ozonolysis of oleic acid.

The chemical and physical properties of atmospheric aerosol particles change upon oxidative ageing, influencing their interaction with radiation, their propensity to serve as nuclei for cloud condensation and ice formation, and their adverse effects on human health. The investigation of atmospheric aerosol oxidation processes is complicated by low oxidant concentrations and long timescales, which are difficult to represent in laboratory studies. Experimental work often attempts to compensate for short timescales with elevated concentrations of oxidative agents, assuming that the ageing progress depends only on the oxidant exposure, i.e. on the product of oxidant concentration and time, [Ox] × t, and not on [Ox] or t independently. The application of electrodynamic balance-mass spectrometry of single particles allows the validity of this assumption to be investigated, since it provides information on the molecular composition of aerosol particles for a wide range of reaction durations under well-defined oxidation conditions. Here, we demonstrate the capabilities of a new setup on levitated oleic acid droplets reacting with ozone at mixing ratios of 0.2 and 15 ppm, i.e. spanning almost two orders of magnitude in [Ox]. We show that the reactive removal of oleic acid can be accurately expressed as a function of ozone exposure [Ox] × t, whereas the product concentrations depend on [Ox] and t independently. As the underlying reason for the breakdown of the exposure metric, we suggest a competition between evaporation of volatile first-generation products and their accretion reactions with reactive Criegee intermediates, converting them into low-volatility dimers and oligomers. This hypothesis is supported by kinetic model simulations using the aerosol process model KM-SUB, which explicitly resolves the competition between evaporation and secondary chemistry as a function of the experimental timescale and ozone mixing ratio. The model successfully reproduces final product distributions. The findings are further supported by the recorded changes of droplet sizes during oxidation. As a heuristic, the breakdown of the exposure metric in a chemical reaction system is possible, when competition between first- and second-order processes of reactive intermediates determines important system properties.

The core of the matter: How do scientists judge trustworthiness of physical samples?

In recent years, research funding agencies, universities, and governments have become increasingly concerned with promoting the reuse of research datasets. Enabling researchers to evaluate the trustworthiness and fitness-for-use of research datasets produced by others is critical for facilitating the reuse of these datasets. Understanding how researchers make these evaluations is crucial for developing digital infrastructure and tools, such as data repositories and metadata schema, in a way that better supports researchers in making these evaluations. Physical samples such as rocks are critical for generating datasets in many scientific domains. Often, samples are collected on field expeditions conducted by large infrastructural projects. These projects comprise many human and non-human components that affect the quality and integrity of samples. However, little is known about whether and how prospective dataset users evaluate the samples' trustworthiness and sample collection processes underlying these datasets. Researchers'strategies for evaluating sample trustworthiness are explored through a longitudinal qualitative case study (ethnographic observation, interviews (n = 66), and document analysis) of subseafloor biosphere research, an earth sciences domain. Domain researchers use rock samples collected on research cruises conducted by the International Ocean Discovery Program (IODP). Subseafloor biosphere researchers are primarily concerned about samples being compromised by microbiological contamination. Researchers vary regarding the components of IODP infrastructure they consider when evaluating sample trustworthiness. These components include methods to process samples, people handling samples, IODP policies and procedures, and IODP organizational politics. Researchers'strategies vary according to their disciplinary background, with microbiologists employing more fine-grained judgments about methods; whether researchers have participated in IODP expeditions, with those who have employing more fine-grained judgments about people involved; and whether researchers have ever been involved in organizing cruises or serving on IODP committees, with those who have employing more fine-grained judgments about many aspects of cruises. Researchers who make less complex decisions may be prone to erroneously trusting contaminated samples; researchers who make more complex decisions may be prone to erroneously discarding uncontaminated samples. The paper concludes by considering implications for the design of digital infrastructures to support researchers in evaluating sample trustworthiness.

The out-of-pocket cost of breast cancer care at a public tertiary care hospital in Nigeria: an exploratory analysis.

Introduction: in Nigeria, the incidence of breast cancer has increased by over 80% in the last four decades. This study quantifies the out-of-pocket (OOP) cost of breast cancer management and the associated rate of catastrophic healthcare expenditure (CHE) at a public tertiary care facility in Ile-Ife, Nigeria. Methods: patients treated between December 2017 - August 2018 were identified from a prospective breast cancer database. A questionnaire was developed to capture the total cost of care, including direct and indirect expenses. Three commonly used thresholds for a CHE were used in this analysis. The cost of radiotherapy and targeted therapy were captured separately. Results: data was collected from 22 eligible patients. Sixty-eight percent had no form of health insurance. The mean cost of diagnosis and treatment was $2,049 (SD $1,854). At a threshold of 10% and 25% of annual income, 95% and 86% of households experienced a CHE. Based on a household´s capacity-to-pay, 90% experienced a CHE. The mean cost of radiotherapy was $462 (SD $223) and the mean cost of trastuzumab was $6,568 (SD $2,766). Cost precluded surgery in 14% of patients with resectable disease. As a result of accessing treatment, 72% of households had to borrow money and 9% of households interrupted a child´s education. Conclusion: the out-of-pocket cost of breast cancer care in Nigeria is significant. This results in a CHE for 68-95% of households, which has significant health and economic sequelae. Greater financial protection is essential as the burden of breast cancer increases in Nigeria.

European aerosol phenomenology - 8: Harmonised source apportionment of organic aerosol using 22 Year-long ACSM/AMS datasets.

Organic aerosol (OA) is a key component of total submicron particulate matter (PM1), and comprehensive knowledge of OA sources across Europe is crucial to mitigate PM1 levels. Europe has a well-established air quality research infrastructure from which yearlong datasets using 21 aerosol chemical speciation monitors (ACSMs) and 1 aerosol mass spectrometer (AMS) were gathered during 2013-2019. It includes 9 non-urban and 13 urban sites. This study developed a state-of-the-art source apportionment protocol to analyse long-term OA mass spectrum data by applying the most advanced source apportionment strategies (i.e., rolling PMF, ME-2, and bootstrap). This harmonised protocol was followed strictly for all 22 datasets, making the source apportionment results more comparable. In addition, it enables quantification of the most common OA components such as hydrocarbon-like OA (HOA), biomass burning OA (BBOA), cooking-like OA (COA), more oxidised-oxygenated OA (MO-OOA), and less oxidised-oxygenated OA (LO-OOA). Other components such as coal combustion OA (CCOA), solid fuel OA (SFOA: mainly mixture of coal and peat combustion), cigarette smoke OA (CSOA), sea salt (mostly inorganic but part of the OA mass spectrum), coffee OA, and ship industry OA could also be separated at a few specific sites. Oxygenated OA (OOA) components make up most of the submicron OA mass (average = 71.1%, range from 43.7 to 100%). Solid fuel combustion-related OA components (i.e., BBOA, CCOA, and SFOA) are still considerable with in total 16.0% yearly contribution to the OA, yet mainly during winter months (21.4%). Overall, this comprehensive protocol works effectively across all sites governed by different sources and generates robust and consistent source apportionment results. Our work presents a comprehensive overview of OA sources in Europe with a unique combination of high time resolution (30-240 min) and long-term data coverage (9-36 months), providing essential information to improve/validate air quality, health impact, and climate models.

Change in stroke presentations during COVID-19 pandemic in South-Western Sydney.

BackgroundAustralia managed relatively well during the global COVID-19 pandemic owing to our swift mandated public health response. During the NSW lockdown restrictions, we noted a decrease in acute stroke presentations at our institution, similar to what was subsequently reported worldwide. AimsWe aimed to test our hypothesis that (i) the true numbers of ischaemic strokes did not change, however patients were presenting later and (ii) the proportion of TIAs decreased. MethodsWe conducted a retrospective audit of all stroke and TIA presentations in 2020 and compared these with data from 2019. We collected information about stroke subtype, severity, time from stroke/TIA onset to presentation and acute reperfusion therapies. ResultsBetween January-February and April-March 2020, there was a 15% drop in acute stroke presentations (128 vs. 109). In the same period "stroke mimic" presentations dropped by 22%. The proportion of patients attending the emergency department within 4.5hrs was only 36% compared with 48% over the similar period in 2019. ConclusionsAlthough the raw numbers of ischemic stroke presentations remained stable during NSW Covid lockdown, the proportion of patients presenting within time window for acute reperfusion therapies fell. The number of TIAs similarly fell suggesting COVID-19 discouraged patients from presenting to hospital which placed them at higher risk of disabling stroke. The opportunity cost of lockdown restrictions on stroke outcome should be considered in future policy directives.

Augmented Renal Clearance of Vancomycin in Suspected Sepsis: Single-Center, Retrospective Pediatric Cohort.

OBJECTIVES: To identify associations between augmented renal clearance (ARC) in pediatric patients treated for suspected sepsis and vancomycin pharmacokinetics. ARC has been associated with lower serum drug levels in both adult and pediatric cohorts for multiple drugs. We hypothesize that presence of ARC is associated with subtherapeutic initial vancomycin trough level (VTL). DESIGN: Retrospective study, with patients divided into two groups based on the presence of ARC (estimated glomerular filtration rate [eGFR] above 130 mL/min/1.73 m2) in comparison with VTL. Multivariable logistic regression analysis was performed to evaluate the association between eGFR and subtherapeutic VTL. SETTING: Tertiary children's hospital. PATIENTS: Hospitalized children (0-18 yr) initiated on empiric vancomycin therapy for suspected sepsis. INTERVENTIONS: Retrospective measurement of VTL, eGFR, and clinical variables. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients were treated with empiric vancomycin for sepsis. ARC was present in 32 patients (44%). Subtherapeutic first VTL was present in 40 patients (55%). Higher eGFR was independently associated with subtherapeutic VTL in the multivariable logistic regression analysis. CONCLUSIONS: Subtherapeutic VTL is associated with ARC in our single-center retrospective cohort of children with suspected sepsis. This problem may present a potential risk of treatment failure in Gram-positive sepsis or longer time to clinical response. Prospective studies to investigate the clinical significance and effect of optimizing vancomycin dose in patients with ARC are recommended.