Influence of CYP2D6 Metabolizer Status on Risperidone and Paliperidone Tolerability in Children and Adolescents.

Background: Risperidone and, to a lesser extent, paliperidone are metabolized by CYP2D6; however, there are limited data related to variation in CYP2D6 phenotypes and the tolerability of these medications in children and adolescents. Furthermore, the impact of CYP2D6 on the association of risperidone and paliperidone with hyperprolactinemia in youth is not well understood. Methods: A retrospective chart review was performed in psychiatrically hospitalized children and adolescents prescribed risperidone (n = 263, age = 3-18 years, mean age = 13 ± 3 years, 49% female) or paliperidone (n = 124, age = 5-18 years, mean age = 15 ± 2 years, 44% female) who had CYP2D6 genotyping performed as part of routine care. CYP2D6 phenotypes were determined based on Clinical Pharmacogenetics Implementation Consortium guidelines and CYP2D6 inhibitors causing phenoconversion. Adverse effects were obtained from a review of the electronic health record, and patients were selected, in part, to enrich non-normal metabolizers. Results: Among risperidone-treated patients, 45% experienced an adverse effect, whereas 36% of paliperidone-treated patients experienced adverse effects. Discontinuation of risperidone due to lack of efficacy was more frequent in the CYP2D6 normal metabolizers and ultrarapid metabolizers compared with intermediate metabolizers (IMs) and phenoconverted poor metabolizers (pPMs) (54.5% vs. 32.7%, p < 0.001). Discontinuation due to weight gain was more common among risperidone- than paliperidone-treated patients (17% vs. 7%, p = 0.011). Among those taking paliperidone, CYP2D6 was associated with discontinuation due to side effects (p = 0.008), and youth with slower CYP2D6 metabolism (i.e., pPMs and IMs) were more likely to discontinue. Hyperprolactinemia was found in 10% of paliperidone-treated patients and 5% of risperidone-treated patients, and slower CYP2D6 metabolizers required higher risperidone doses to cause hyperprolactinemia (p = 0.011). Conclusions: CYP2D6 phenotype is associated with discontinuation of risperidone due to lack of efficacy and the dose of risperidone that induced hyperprolactinemia, as well as discontinuation of paliperidone due to adverse effects. Future studies should evaluate exposure-response and toxicity relationships in risperidone- and paliperidone-treated youth.

Characterizing the Biological Community before and after Partial Removal of an Offshore Gas Platform in the Northwestern Gulf of Mexico.

High Island A-389-A (HI-A-389-A) is a gas platform situated in 125 m water within Flower Garden Banks National Marine Sanctuary in the northwestern Gulf of Mexico, and provides habitat to a diverse array of benthic organisms and fish species. Platform production ceased in 2012, beginning the decommissioning process for structural removal. Rather than complete removal of the structure, the lower portion was left intact as an artificial reef and the upper 21 m was removed. The biological communities (benthic and fish) were characterized during diver and remotely operated vehicle surveys, both before and after removal of the upper structure. The platform's benthic community, primarily categorized as fouling organisms, was mainly composed of sponges, hydroids, macroalgae, bivalves, zoanthids, and stony corals. The dominant stony coral was orange cup coral (Tubastraea sp.), an exotic species, while native coral species were rare. Fish species were predominantly demersal planktivores. Analyses of the benthic and fish communities documented four distinct biological zones strongly associated with depth. Significant differences in the benthic community were observed after partial removal and varied with depth, including the loss of hydroids, increase in macroalgae cover, and sponge and coral community changes. Both demersal and pelagic fish communities exhibited significant differences by depth after removal but no significant changes were observed in federally managed species. Results reflect changes in benthic and fish communities after partial removal of the platform that is likely, in part, influenced by structure removal and temporal variations.

Depth and coral cover drive the distribution of a coral macroborer across two reef systems.

Bioerosion, the removal of calcium carbonate from coral frameworks by living organisms, influences a variety of reef features, from their topographic complexity to the net balance of carbonate budgets. Little is known, however, about how macroborers, which bore into reef substrates leaving traces greater than 0.1 mm diameter, are distributed across coral reefs, particularly reef systems with high (>50%) stony coral cover or at mesophotic depths (≥30 m). Here, we present an accurate and efficient method for quantifying macroborer densities from stony coral hosts via image analysis, using the bioeroding barnacle, Lithotrya dorsalis, and its host coral, Orbicella franksi, as a case study. We found that in 2014, L. dorsalis densities varied consistently with depth and host percent cover in two Atlantic reef systems: the Flower Garden Banks (FGB, northwest Gulf of Mexico) and the U.S. Virgin Islands (USVI). Although average barnacle density was nearly 4.5 times greater overall in the FGB than in the USVI, barnacle density decreased with depth in both reef regions. Barnacle density also scaled negatively with increasing coral cover in the study areas, suggesting that barnacle populations are not strictly space-limited in their distribution and settlement opportunities. Our findings suggest that depth and host coral cover, and potentially, local factors may strongly influence the abundance of macroborers, and thus the rate of CaCO3 loss, in a given reef system. Our image analysis method for quantifying macroborers can be standardized across historical and modern reef records to better understand how borers impact host growth and reef health.

Are there too few women presenting at emergency medicine conferences?

INTRODUCTION: There is a perception that women are under-represented as speakers at emergency medicine (EM) conferences. We aimed to evaluate the ratio of male to female speakers and the proportion of presenting time by gender at major international EM conferences. METHODS: Conference programmes of the major English-speaking EM conferences occurring from 2014 to 2015 were obtained. The number of presentations, the gender of the speaker and the duration of each presentation were recorded. RESULTS: We analysed eight major EM conferences. These included 2382 presentations, of which 29.9% (range 22.5%-40.9%) were given by women. In total, 56 104 min of presentations were analysed, of which 27.6% (range 21%-36.7%) were delivered by women. On average, presentations by women were 95 s shorter than presentations by men (23 vs 21 min 25 s). CONCLUSIONS: Male speakers exceed female speakers at major EM conferences. The reasons for this imbalance are likely complex and multifactorial and may reflect the gender imbalance within the specialty.

Inbreeding compromises host plant defense gene expression and improves herbivore survival.

Inbreeding commonly occurs in flowering plants and often results in a decline in the plant's defense response. Insects prefer to feed and oviposit on inbred plants more than outbred plants--suggesting that selecting inbred host plants offers them fitness benefits. Until recently, no studies have examined the effects of host plant inbreeding on insect fitness traits such as growth and dispersal ability. In a recent article, we documented that tobacco hornworm (Manduca sexta L.) larvae that fed on inbred horsenettle (Solanum carolinense L.) plants exhibited accelerated larval growth and increased adult flight capacity compared to larvae that fed on outbred plants. Here we report that M. sexta mortality decreased by 38.2% when larvae were reared on inbred horsenettle plants compared to larvae reared on outbreds. Additionally, inbred plants showed a notable reduction in the average relative expression levels of lipoxygenease-D (LoxD) and 12-oxophytodienoate reductase-3 (OPR3), two genes in the jasmonic acid signaling pathway that are upregulated in response to herbivore damage. Our study presents evidence that furthers our understanding of the biochemical mechanism responsible for differences in insect performance on inbred vs. outbred host plants.

Patient expectations, outcomes and satisfaction: related, relevant or redundant?

STUDY DESIGN: A prospective case series of patients undergoing lumbar spine surgery. OBJECTIVE: Is there a correlation between patients' expectations before lumbar surgery, postoperative outcomes, and satisfaction levels? METHODS: A prospective study of 145 patients undergoing primary, single-level surgery for degenerative lumbar conditions was conducted. Oswestry Disability Index, back Visual Analog Scale (VAS), and leg VAS were assessed preoperatively and at 6 weeks and 6 months after surgery. Patients' expectations were measured preoperatively by asking them to score the level of pain and disability that would be least acceptable for them to undergo surgery and be satisfied. Satisfaction was assessed 6 weeks postoperatively with a Likert scale. Differences in patient expectations between actual and expected improvements were quantified. RESULTS: Most patients had a clinically relevant improvement, but only about half achieved their expectations. Satisfaction did not correlate with preoperative pain or disability, or with patient expectation of improvement. Instead, satisfaction correlated with positive outcomes. CONCLUSIONS: Patient expectations have little bearing on final outcome and satisfaction. [Table: see text].

The bullying aspect of workplace violence in nursing.

Workplace violence is becoming an issue that all organizations must be aware of. In healthcare organizations, these behaviors, especially that of bullying, are detrimental and affect staff, patients, and outcomes. Healthcare organizations that do not address this issue and instill measures to prevent it will soon see the effects that bullying and other forms of workplace violence can create: those of toxic work environments. Because bullying and other forms of workplace violence have become so prevalent, organizations such as The Joint Commission have addressed the need for healthcare organizations to address the issue. This article examines bullying, the most common type of workplace violence, and nursing, the profession where bullying most often occurs. Theories about why it exists and suggestions on how to prevent it and maintain a healthy workplace will be discussed.

Using electronic wristbands and a triage protocol to protect mental health patients in the emergency department.

In the emergency department of Mercy Hospital, concerns about possible elopement of mental health patients led to the use of the services of security officers, who were called for an average of 40 patient watches per week. Modified electronic wristbands, paired with a triage protocol, have significantly decreased the need for patient watches and decreased security costs.

Successful resuscitation after cardiac arrest following massive brown snake envenomation.

We report a 44-year-old Western Australian man who suffered a cardiac arrest several hours after a bite by a brown snake. He was successfully resuscitated after bolus administration of undiluted brown snake antivenom. We suggest that an initial bolus dose of at least five ampoules (5000 units) of undiluted brown snake antivenom should be given as primary therapy for cardiac arrest following brown snake envenomation in Western Australia.