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The intravenous (IV) formulation of esomeprazole, the S-isomer of the proton pump inhibitor (PPI) omeprazole, is currently under FDA review for the short-term treatment of gastroesophageal reflux disease (GERD) as an alternative in patients unable to continue taking oral esomeprazole. Clinical studies have shown esomeprazole to be equivalent to the other currently available PPIs with respect to safety. The intravenous formulation, given either as a 30-minute infusion or 3-minute injection, has been found to be comparable to the oral dosage form based on pharmacokinetic and pharmacodynamic studies in healthy subjects. Limited studies suggest that IV esomeprazole 40 mg/d may provide a more effective antisecretory profile than either IV lansoprazole 30 mg/d or IV pantoprazole 40 mg/d. Data on clinical efficacy is limited to 1 abstract that reported no significant differences in healing rates in subjects with erosive esophagitis administered esomeprazole either 40 mg orally or IV daily. More clinical studies are needed to define its limited role as an alternative in those patients with acid-related disorders unable to tolerate the oral formulations. [ABSTRACT FROM AUTHOR]

Tegaserod maleate (Zelnorm), an aminoguanidine indole, is the first selective partial 5- HT4 agonist approved by FDA for the short-term treatment of irritable bowel syndrome (IBS) in women whose primary bowel symptom is constipation. The safety and efficacy in men with the disorder have not been defined. Tegaserod is structurally similar to serotonin but tegaserod possesses only one-fifth the intrinsic activity. Tegaserod, when dosed at 6 mg twice daily, achieved more effective relief of abdominal pain/discomfort, constipation, and overall GI symptoms than placebo in 12-week studies. Tegaserod has shown no significant drug interactions or significant electrocardiographic effects. Tegaserod is well tolerated, with diarrhea reported as the most common adverse effect. Tegaserod may be beneficial for women with constipation-predominant IBS who do not respond to conventional treatments or cannot tolerate their adverse effects. [ABSTRACT FROM AUTHOR]

Esomeprazole, the S-isomer of the proton pump inhibitor (PPI) omeprazole, offers improved bioavailability and AUC concentrations relative to racemic omeprazole. It is under FDA review for treatment of symptomatic gastroesophageal reflux disease (GERD), for short-term and maintenance treatment of erosive esophagitis (EE), and for use with antibiotics for treatment of Helicobacter pylori (HP)-associated duodenal ulcer. Esomeprazole (when dosed at 40 mg/day) is the first PPI to achieve more effective acid suppression than omeprazole 20 or 40 mg/day in pharmacologic studies and the first to yield higher GERD/EE healing rates than omeprazole 20 mg/day in clinical trials. The usual doses used for GERD/EE in clinical trials have been 40 mg/day for short-term treatment and 20 or 40 mg/day for maintenance therapy. As part of triple therapy for H pylori, esomeprazole 20 mg twice daily has achieved eradication rates comparable to those of other PPIs. Like other PPIs, esomeprazole is well tolerated. [ABSTRACT FROM AUTHOR]

Objective: Graphical representation of information organizes and promotes meaningful learning. As an example of graphical organizers, flowcharts can simplify and summarize complex information. The evidence of classroom use of flowcharts as an instructional tool is unclear. We investigated the effectiveness of flowcharts on student learning as an in-class instructional tool in a cardiovascular therapeutic course. Student experiences with the use and application of flowcharts were explored., Methods: An explanatory sequential mixed-methods study was conducted with pharmacy students enrolled in an acute-care cardiovascular course from 2019-2021. The quantitative phase comprised a survey to determine flowchart effectiveness and a comparison of student performance in three content areas. The qualitative phase of the study used focused group interviews to understand student perceptions of flowchart use., Results: Survey results indicated that using flowcharts improved understanding (110/128, 86%), integration of material (114/128, 89%), and overall knowledge (111/128, 87%). Student performance in the 3 content areas, shock, arrhythmia, and acute coronary syndrome were statistically significant with flowcharts implementation. Emerging themes from student interviews were (1) used as a medium for retention and recall, (2) used as a study tool, and (3) used as a decision-making framework., Conclusion: Flowcharts provide an alternative approach to teaching complex content, which allows students to organize and summarize information that promotes meaningful learning. The ease of implementation combined with the generalized nature of flowcharts makes it an effective graphical organizer that can be used across various disciplines., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 American Association of Colleges of Pharmacy. Published by Elsevier Inc. All rights reserved.)

Alcohol abuse and alcohol withdrawal syndrome are major problems in the United States. This retrospective chart review assessed efficacy and safety of propofol plus dexmedetomidine used in combination as adjunctive therapy to benzodiazepines compared with either agent used alone in the treatment of severe alcohol withdrawal. Patients admitted to the intensive care unit and experiencing severe alcohol withdrawal between September 1, 2015 and September 30, 2018 were assessed for eligibility. Primary end points were change in the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) score and incidence of bradycardia and hypotension. The combination of propofol and dexmedetomidine was associated with a change in CIWA-Ar score of -10.4 (95%CI -13.5 to -7.3) points compared with -4.7 (95%CI -6.6 to -2.8) points with propofol and -4.4 (95%CI -7.4 to -1.4) with dexmedetomidine (P = .21). Bradycardia was experienced by 11.1% of patients receiving the combination, 15.4% of patients receiving propofol, and 28.6% of patients receiving dexmedetomidine (P = .40). Patients receiving dexmedetomidine experienced hypotension at a rate of 21.4% compared with 22.2% of patients receiving the combination and 38.5% of patients receiving propofol (P = .08). Patients in the combination group also had a shorter length of hospital and intensive care unit stay and shorter time to extubation when compared with the propofol and dexmedetomidine groups. Although no statistical significance was found, the combination was associated with better efficacy and safety outcomes than produced by either agent used alone., (© 2019, The American College of Clinical Pharmacology.)

Objectives: To describe and evaluate a novel practice setting for a pharmacist within an occupational health clinic., Setting: Ambulatory care facility., Practice Description: Implementation and evaluation of a new practice site embedding a clinical pharmacist into the workplace to provide ambulatory care services, such as comprehensive medication management, disease state management, and immunizations to a broad diversity of patients., Practice Innovation: A clinical pharmacist provides pharmacy services as part of a collaborative occupational health clinic at a large, self-insured company. The pharmacy services are open to employees and family members with any chronic disease states, elevated biometric results, or medication questions, with the goal of improving patient care on a consistent basis. During visits, the pharmacist works to identify and resolve drug-related problems by educating the patient or reaching out to the patient's health care provider and to develop strategies with the patient to achieve desired health care outcomes. The pharmacist assists with patient outreach events and immunizations during the flu clinic., Evaluation: Identification of drug-related problems, resolution status, patient satisfaction via survey results, immunizations provided., Results: In 4.3 years of operation, the pharmacist conducted 604 visits with 172 patients. During these visits, the pharmacist identified 611 drug-related problems, of which 49.4% have been confirmed as resolved. All patients who completed the patient satisfaction survey said that they would recommend the pharmacy services to others. For the past 3 years, the pharmacist and pharmacy students immunized approximately 1000 patients each year during the company flu clinic., Conclusion: An occupational health clinic is a unique and convenient location for a pharmacist to provide ambulatory care services to employees and family members, as long as methods to identify patients and appropriate sources of referral exist. The pharmacist was able to help patients resolve approximately 50% of identified drug-related problems, and patients were highly satisfied with services provided., (Copyright © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine current delirium practices in the intensive care unit (ICU) setting and evaluate awareness and adoption of the 2013 Pain, Agitation, and Delirium (PAD) guidelines with emphasis on delirium management., Design, Setting, and Participants: A large-scale, multidisciplinary, online survey was administered to physician, pharmacist, nurse, and mid-level practitioner members of the Society of Critical Care Medicine (SCCM) between September 2014 and October 2014. A total of 635 respondents completed the survey., Measurements and Main Results: Nonpharmacologic interventions such as early mobilization were used in most ICUs (83%) for prevention of delirium. A majority of respondents (97%) reported using pharmacologic agents to treat hyperactive delirium. Ninety percent of the respondents answered that they were aware of the 2013 PAD guidelines, and 75% of respondents felt that their delirium practices have been changed as a result of the new guidelines. In addition, logistic regression analysis of this study showed that respondents who use delirium screening tools were twice more likely to be fully aware of key components of the updated guidelines (odds ratio [OR] = 2.07, 95% confidence interval [CI] = 1.20-3.60)., Conclusions: Most critical care practitioners are fully aware and knowledgeable of key recommendations in the new guidelines and have changed their delirium practices accordingly.

Objective: To describe types of current training/support received and elicit opinions on the level of importance of specific skills and resources needed to build confidence in conducting research for early-career pharmacy practice faculty., Methods: A survey instrument regarding available resources, levels of importance of resources, and skills needed to improve research confidence was sent to all new early-career practice faculty members with 3 or less years of experience in academia at 129 US colleges and schools of pharmacy., Results: Few respondents indicated a formal research training existed at their institution. Overall, a majority of respondents identified at least 14 specific developmental areas as moderately to very important in building confidence. Over 75% of respondents rated 15 basic skills as moderately to very important in successfully starting an individual research program., Conclusion: Although different types of research training programs are available, confidence in conducting research in both informal and formal ones is low. Both groups of respondents identified similar important developmental research areas that would increase their confidence and skills in achieving their early research goals.

Monitoring the populations of probiotic strains of the species Lactobacillus casei in food is required by food industries in order to assure that a minimum concentration of these organisms will be ingested by consumers. In this context, Petrifilm™ AC plates can be used along with selective culture media to allow the enumeration of specific groups of lactic acid bacteria. The present study aimed to assess chemical substances as selective agents for Lb. casei in order to propose a selective culture medium to be used with Petrifilm™ AC plates as an alternative protocol for the enumeration of probiotic strains of this species in fermented milk. Twenty-six probiotic and starter cultures (including six strains of Lb. casei) were plated on de Man Rogosa and Sharpe (MRS) agar with distinct concentrations of nalidixic acid, bile, lithium chloride, metronidazole, sodium propionate, and vancomycin. Vancomycin at 10 mg/L demonstrated selective activity for Lb. casei. In addition, 2,3,5-triphenyltetrazolium chlorine was identified as a compound that did not inhibit Lb. casei, and Petrifilm™ AC plates used with MRS and vancomycin at 10 mg/L (MRS-V) demonstrated more colonies of this organism when incubated under anaerobic conditions than aerobic conditions. Acidophilus milk and yoghurt were prepared, added to Lb. casei strains, and stored at 4 °C. Lb. casei populations were monitored using MRS-V and MRTLV by conventional plating and associated with Petrifilm™ AC plates. All correlation indices between counts obtained by conventional plating and Petrifilm™ AC were significant (p < 0.05), but the best performance was observed for growth on MRS-V. The obtained data indicate the efficiency of using MRS-V associated with Petrifilm™ AC plates for the enumeration of Lb. casei strains in fermented milk. However, the selective potential of this culture medium must be evaluated considering the specific strains of Lb. casei and the starter cultures inoculated in the fermented milk that requires monitoring., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The purpose of this review is to describe cannabinoid hyperemesis syndrome (CHS), which is thought to be induced by long-term cannabis use, and provide clinical pharmacists with information to manage the hyperemetic phase of CHS., Method: Published literature was searched and reviewed using PubMed., Results: CHS is characterized by intractable nausea and vomiting without an obvious organic cause and associated learned compulsive hot water bathing behavior. Patients often seek care in the emergency department (ED) for symptomatic relief., Conclusion: CHS is potentially underrecognized and underdiagnosed in the ED, and it should be considered in the differential diagnosis in long-term cannabis use patients with CHS symptoms to avoid unnecessary extensive diagnostic workup including invasive radiologic imaging. Pharmacists have an important role in CHS recognition, education, and symptom management.

Objective: To review recent clinical studies regarding the role of dexmedetomidine for prevention and treatment of delirium in intensive care unit (ICU) patients., Data Sources: MEDLINE and PubMed searches (1988-Feburary 2013) were conducted, using the key words delirium, dexmedetomidine, Precedex, agitation, α-2 agonists, critical care, and intensive care. References from relevant articles were reviewed for additional information., Study Selection and Data Extraction: Clinical trials comparing dexmedetomidine with other sedatives/analgesics or with antipsychotics for delirium were selected. Studies that evaluated the use of dexmedetomidine for sedation for more than 6 hours were included in this review., Data Synthesis: Dexmedetomidine is a highly selective α-2 receptor agonist that provides sedation, anxiolysis, and modest analgesia with minimal respiratory depression. Its mechanism of action is unique compared with that of traditional sedatives because it does not act on γ-aminobutyric acid receptors. In addition, dexmedetomidine lacks anticholinergic activity and promotes a natural sleep pattern. These pharmacologic characteristics may explain the possible anti delirium effects of dexmedetomidine. Eight clinical trials, including 5 double-blind randomized trials, were reviewed to evaluate the impact of dexmedetomidine on ICU delirium., Conclusions: Currently available evidence suggests that dexmedetomidine is a promising agent, not only for prevention but also for treatment of ICU-associated delirium. However, larger, well-designed trials are warranted to define the role of dexmedetomidine in preventing and treating delirium in the ICU.

Tenofovir therapy in patients with human immunodeficiency virus (HIV) infection has been associated with acute renal failure (ARF) and Fanconi syndrome. In the past 2 years, we diagnosed tenofovir-associated ARF in 5 HIV-infected patients who were receiving tenofovir therapy and who had classic findings of acute tubular necrosis, and we compared findings for our patients with data on 22 patients described in the literature. The mean serum creatinine level increased from 0.9 to 3.9 mg/dL, and it decreased to 1.2 mg/dL during recovery. ARF resolved in 22 of 27 patients after discontinuation of tenofovir therapy. The most common drugs given with tenofovir were ritonavir or lopinavir-ritonavir (21 of 27 patients), atazanavir (5 of 27 patients), and didanosine (9 of 27 patients). Tenofovir-associated ARF manifests as acute tubular necrosis that may not resolve with tenofovir withdrawal. Tenofovir is associated with multiple drug interactions, leading to an increased risk of ARF. Frequent monitoring of renal function is warranted for any patient receiving these combinations.

Background: Acid peptic disease is a common problem, with a similar prevalence of gastroesophageal reflux disease (GERD) in adults and children. The presentation of GERD in infants and children varies from crying, irritability, or sleep disturbance to feeding difficulties, vomiting, or rumination. Helicobacter pylori (HP)-related diseases and gastric and duodenal ulcers are much more common in adults than in children, who are more likely to have gastritis or duodenitis. However, because HP infection is most likely acquired in childhood, treatment of children with endoscopically documented active HP disease may minimize the potential risk for peptic ulcer or gastric cancer in adulthood, although this is yet to be proved., Objective: Omeprazole has been shown to be effective in the treatment of acid-related diseases. This paper reviews the literature on the use and administration of omeprazole for the treatment of GERD, peptic ulcer disease, HP infection, and other acid-related conditions in children., Methods: Studies were identified through searches of MEDLINE and Science Citation Index for the period 1986 to November 2000, and from the reference lists of identified articles. The search terms used included omeprazole, proton pump inhibitor (PPI), children, pediatrics, routes of administration, GERD, HP infection, esophagitis, and administration. In addition, the manufacturer of omeprazole was asked for relevant unpublished information., Results: Marketed and extemporaneous formulations of omeprazole have been administered to children aged 2 months to 18 years for the treatment of erosive esophagitis, gastric ulcer, duodenal ulcer, HP infection, and related conditions at dosages of 5 to 80 mg/d (0.2-3.5 mg/kg/d) for periods ranging from 14 days to 36 months with a low incidence of adverse effects. The initial dose most consistently reported to heal esophagitis and provide relief of symptoms of GERD appears to be 1 mg/kg per day., Conclusions: In uncontrolled clinical trials and case reports to date, omeprazole has been effective and well tolerated for the acute and chronic treatment of esophageal and peptic ulcer disease in children, particularly those who had failed to respond to previous treatment with histamine2-receptor antagonists. Should future long-term, controlled clinical trials in children demonstrate safety and efficacy, this PPI is likely to find a place in the armamentarium of pediatric pharmacotherapy.

Lansoprazole is the second member of the substituted benzimidazole class of antisecretory agents approved for use in the United States. These drugs decrease parietal cell acid secretion by inhibiting H+, K(+)-adenosine triphosphatase, the final step in the secretion of acid. Lansoprazole has been studied extensively for the short-term treatment of duodenal and gastric ulcers, reflux esophagitis, and Helicobacter pylori-positive peptic ulcer disease; long-term treatment of Zollinger-Ellison syndrome; and maintenance treatment of erosive esophagitis. A dosage of 30 mg/day produced higher healing rates and equivalent or faster relief of ulcer symptoms than ranitidine or famotidine in patients with duodenal or gastric ulcers and reflux esophagitis. Compared with omeprazole 20 mg/day, that dosage provided faster epigastric pain relief in these patients after 1 week, although healing rates for the two agents were equivalent at 4 and 8 weeks. In patients with peptic ulcer refractory to 8-week therapy with histamine2-receptor antagonists, healing rates were not significantly different between lansoprazole and omeprazole. In patients with Zollinger-Ellison syndrome, lansoprazole was superior to histamine2-receptor antagonists and was similar in efficacy, safety, and duration of action to omeprazole. Combinations of lansoprazole or omeprazole with one or two antibiotics produced equivalent eradication of H. pylori. In clinical trials, lansoprazole was well tolerated, with frequency of adverse effects similar to that reported with ranitidine, famotidine, and omeprazole.

We attempted to determine if an association exists between vancomycin serum concentrations resulting from traditional dosing regimens, and efficacy and toxicity outcomes. We reviewed the medical charts of 273 consecutive patients prescribed 273 courses of vancomycin therapy for documented, gram-positive bacteremia. Of the 273 courses of therapy, 45 and 31 patients met all criteria and were evaluated for toxicity and efficacy, respectively. The duration of fever and abnormal white blood cell counts, length of hospital stay, overall mortality, serum creatinine, and serum vancomycin concentrations were evaluated retrospectively. No association between initial peak or trough levels with mortality was noted. However, patients were more likely to become afebrile within 72 hours if peak and trough concentrations were 20 micrograms/ml or greater and 10 micrograms/ml or greater, respectively (p < 0.01). Patients were also more likely to have their white blood cell count return to normal within 72 hours if trough concentrations were 10 micrograms/ml or above (p < 0.01). No statistically significant correlation between nephrotoxicity and initial serum creatinine, days of hospital stay, or days of vancomycin therapy were found. Serum concentrations of vancomycin, assessed before the development of nephrotoxicity, were significantly higher in patients who became nephrotoxic. Mean (SD) trough concentrations were 23.2 (2.5) micrograms/ml and 10.2 (3.8) micrograms/ml in nephrotoxic and nonnephrotoxic patients, respectively. Our results suggest that the commonly accepted therapeutic range for vancomycin trough concentrations (< 10 micrograms/ml) may be too restrictive in patients receiving vancomycin therapy alone.

Objective: To report a case probable ceftriaxone-induced acute pancreatitis., Case Summary: A patient with a history of short-bowel syndrome on home total parenteral nutrition developed fever, chills, and right flank pain. She was diagnosed with gram-negative catheter sepsis and prescribed antibiotic therapy to be administered for four weeks. After completion of the first week of therapy, the antibiotic regimen was changed to intravenous injections of ceftriaxone to be given daily at home. Prior to discharge the patient developed acute abdominal pain, leukocytosis, jaundice, and markedly elevated lipase and amylase concentrations consistent with acute pancreatitis. The patient's condition improved upon discontinuation of the ceftriaxone and the remainder of her stay was uneventful., Discussion: There is only one other case report in the literature of probable ceftriaxone-induced pancreatitis. Multiple other medications have been implicated in causing acute pancreatitis. The exact mechanism of this uncommon adverse effect of ceftriaxone is unknown., Conclusions: There was a temporal relationship between the development of this patient's signs and symptoms and the administration of ceftriaxone. We could not identify any other factors that may have been responsible for the development of her acute pancreatitis. Ceftriaxone should be considered as a possible etiologic agent in patients who present with acute abdominal pain and elevated lipase and amylase concentrations.