Management of overdoses of salvia, kratom, and psilocybin mushrooms: a literature review.

INTRODUCTION: Despite the relative reduction in opioid and other illicit substance overdoses in the past few years, clinicians must remain vigilant in keeping up to date on emerging trends with regard to potential substances of abuse. As overdoses of traditional drugs of abuse decrease in light of legislative and de-prescribing initiatives, it stands to reason that alternative agents, including natural products, have increased. Toxicities associated with these agents have been contributing to emergency department visits across the globe. AREAS COVERED: This evaluation covers salvia, kratom, and psilocybin mushrooms, and was accomplished through a comprehensive review of PubMed, SCOPUS, ProQuest Central, ProQuest Dissertations, and CINAHL. Thirty-one pieces of literature are included in this evaluation. The objective of this review is to provide clinicians with the information necessary to provide bedside care for overdoses of salvia, kratom, and psilocybin mushrooms. EXPERT OPINION: Salvia, kratom, and psilocybin mushrooms may not be an initial consideration when healthcare practitioners are triaging an overdose scenario; however, data from around the world demonstrate an increased use of these agents. While not typically fatal, clinicians must be prepared to assess these as a potential etiology of overdoses and provide appropriate supportive care.

Antidepressant Target Dose Optimization and Control of Severe Asthma Exacerbations in Uninsured and Underinsured Patients with Anxiety and/or Depression.

BACKGROUND: Generalized anxiety disorder (GAD) and major depressive disorder (MDD) are prevalent in patients with asthma. These disorders may increase asthma severity and decrease asthma control. No studies have evaluated the impact of achieving antidepressant target dose optimization compared with not achieving antidepressant target doses on asthma control in uninsured and underinsured patients. OBJECTIVE: To evaluate the impact of achieving antidepressant target dose optimization in uninsured and underinsured adult asthma patients with GAD and/or MDD on the risk of severe asthma exacerbations and number of asthma-related outcomes. METHODS: We conducted a retrospective cohort study of uninsured and underinsured adult asthma patients with GAD and/or MDD who have been initiated on a single antidepressant and maintained on a stable dose for 8 weeks (index date). Eligible patients were followed for 12-24 months after the index date and separated into those who achieved a target dose (target group) and those who did not (control group). Poisson regression was used to compare the risk of severe exacerbations, and analysis of covariance was used to compare the number of severe exacerbations and other asthma-related outcomes between the target and control groups during the 1- and 2-year post-index periods. RESULTS: A total of 61 patients (24 in the target group and 37 in the control group) met inclusion criteria. The target group had a reduced risk of severe asthma exacerbations compared with the control group during the 1-year post-index (adjusted risk reduction [RR] 0.46, 95% confidence interval [CI] 0.26-0.82) and 2-year post-index (adjusted RR 0.5, 95% CI 0.3-0.82) periods. The target group also experienced a lower number of severe asthma exacerbations and other asthma-related outcomes during the 1- and 2-year post-index periods compared with the control group after adjusting for confounders. CONCLUSIONS: Among uninsured and underinsured asthma patients with GAD and/or MDD who were initiated on a single antidepressant, those who were titrated to achieve target doses had a reduced risk of severe asthma exacerbations and a lower number of asthma-related outcomes than those who were not optimized to achieve target doses.

Preparing pharmacy students for postgraduate training through a residency preparedness elective course.

OBJECTIVE: To determine the benefit of a residency preparedness elective course and assess the ability of the course to provide students with the knowledge and experiences needed to competitively apply for residency programmes. METHODS: A pre-/postsurvey study on a 2-credit hour elective course for third-year pharmacy students. This course was designed to provide them with the knowledge and experiences needed to competitively apply for pharmacy residency programmes. KEY FINDINGS: Students' perceptions of the elective course were captured through pre- and postcourse evaluations utilizing a 15-item survey. The main reasons students participated in this course was to gain a better understanding of the residency application process (median Likert score = 5; 1 = strongly disagree and 5 = strongly agree), develop interviewing techniques (5) and enhance clinical competency (5). By the end of the course, students felt more confident with their understanding of pharmacy residency programmes (4 versus 5, P = 0.002) and of the residency application process (2 versus 5, P = 0.001). CONCLUSION: Upon completion of a pharmacy residency preparedness elective course, students felt more confident in their understanding and ability to apply for a residency programme.

Acute Care Pharmacy Practice: A Perspective for Pharmacy Students, Residents, and Other Health-Care Providers.

PURPOSE: To describe the acute care setting with a specific focus on acute care pharmacy practices. SUMMARY: Acute care is the sector of health care where time-sensitive episodes of illness are managed. Acute care pharmacy practice includes both hospital and clinical pharmacists serving, in a variety of domains, as medication experts and authority on patient-centered medication therapy. Pharmacists serving in this area can have a beneficial impact on patient care and the health-care system. CONCLUSION: The demand for acute care services is likely to grow as the population continues to grow and age. Pharmacists are key members of interdisciplinary teams in the acute care setting.

Management of overdoses of loperamide, gabapentin, and modafinil: a literature review.

Introduction: The current emphasis on combatting the opioid epidemic in the United States and across the globe is well warranted, but rates and variations of other drugs and substances of abuse may be inadvertently increasing as well. These drugs and substances deserve equal attention in the literature to equip healthcare practitioners with the knowledge to provide optimal care in overdose patients. Areas covered: This evaluation includes loperamide, gabapentin, and modafinil and was accomplished through a comprehensive literature review of PubMed, MEDLINE, SCOPUS, ProQuest Central, ProQuest Dissertations, and CINAHL. The results of forty-four pieces of literature are included in this evaluation. The objective of this review is to provide a repository of standard and emerging treatment modalities for loperamide, gabapentin and modafinil for the emergency medicine team. Expert opinion: Loperamide, gabapentin, and modafinil are becoming drugs of abuse, and as such, should be on the radar of healthcare providers. Recognizing their unique toxicity profiles is imperative in providing optimal resuscitative care.

Barriers and Contributors to Breastfeeding in WIC Mothers: A Social Ecological Perspective.

BACKGROUND: In response to the Surgeon General's Call to Action to Support Breastfeeding, the goal of this research was to assess the barriers and positive contributors to breastfeeding initiation and duration in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants using the social ecological model (SEM). MATERIALS AND METHODS: A cross-sectional design was used to survey WIC mothers (n = 283) in southern New Hampshire. Analysis of breastfeeding initiation and duration revealed statistically significant results primarily at the individual level of the SEM. Findings also showed influences at the interpersonal, community, and organizational levels. There were significant differences in beliefs toward breastfeeding between women who ever breastfed and women who never breastfed. Women who ever breastfed were more likely to agree that breastfeeding assists with losing baby weight (89% versus 77%; p = 0.03), babies fed breastmilk are less likely to get sick (86% versus 74%; p = 0.04), and breastfeeding helps mothers bond with their babies more quickly than formula feeding (88% versus 72%; p < 0.01). Breastfeeding duration was significantly related to employment status; among women who breastfed for 6 months or longer, 15% were employed full-time, 30% worked part-time, and 55% indicated "other" such as unemployed or stay-at-home mother (p = 0.01). Logistic regression revealed that maternal age was the most significant predictor of breastfeeding duration (odds ratio = 1.11; 95% confidence interval, 1.03, 1.19; p < 0.004). CONCLUSIONS: Results indicate opportunities to inform and support women in the prenatal and postpartum period, improve the social and built environment, and develop and advocate for policies in an effort to support breastfeeding.

Engaging field-based professionals in a qualitative assessment of barriers and positive contributors to breastfeeding using the social ecological model.

Despite broad recognition of benefits associated with breastfeeding, rates in the United States continue to be below targets established by Healthy People 2020, especially for economically disadvantaged women. This study engaged field-based professionals through a focus group process to collect perceptions on factors that determine a woman's decision to breastfeed. Field-based professionals participated in one of six focus groups. Following the social ecological model (SEM), focus group questions addressed barriers and contributors to breastfeeding at the individual, interpersonal, community, organizational, and public policy levels. Thematic content analysis was used in identifying, analyzing, and reporting on themes within the focus group data. Commonly reported themes were identified that negatively influence a mother's decision to breastfeed such as modesty/general discomfort to breastfeed in front of others, negative breastfeeding perceptions of family members, friends, boyfriends and co-workers, breastfeeding not being viewed as the societal "norm", and the availability of free formula samples. Despite identified barriers, commonly reported themes that positively influence a mother's decision to breastfeed included general knowledge on the benefits, positive breastfeeding perceptions of family members, friends, boyfriends, and co-workers, the availability of "mom and baby" groups, and Baby Friendly hospital practices. The findings provide field-based perspectives that identify opportunities to support breastfeeding through the lens of the SEM. Opportunities to better support breastfeeding include educating mothers and their social support systems on the specific benefits of breastfeeding, challenging existing breastfeeding norms, and working with hospitals on establishing policy to not provide free formula samples.

Use of bisphosphonates in older adults: how long is long enough?

OBJECTIVE: To assess the benefits and risks of long-term bisphosphonates for treatment of osteoporosis in older adults. DATA SOURCES: A MEDLINE search was performed using PubMed from 1966 through 2011 to identify relevant publications. Key words searched included: adverse effects (AEs), aged, alendronate, atrial fibrillation, atypical fractures, bisphosphonate-associated osteonecrosis of the jaw, bisphosphonates, diaphyseal fractures, gastrointestinal cancer, ibandronate, musculoskeletal pain, osteoporosis, risedronate, subtrochanteric fractures, and zoledronic acid. Additional sources were obtained through bibliographic review of selected articles. STUDY SELECTION: Relevant studies that examined efficacy and safety of bisphosphonates in the treatment of osteoporosis were included. Focus was given to data involving older adults. Stronger levels of evidence (prospective trials) were given preference as the predominant body of literature, when available. DATA SYNTHESIS: Osteoporosis affects millions of elderly patients. Bisphosphonates represent first-line therapy. Recent literature has heightened concerns regarding AEs associated with long-term use, leading to the proposition of a "drug holiday." Additionally, there is a lack of literature concerning management of bisphosphonates in older adults. CONCLUSION: Evidence indicates that bisphosphonates maintain their efficacy and safety in older adults. Consideration must be given on a case-by-case basis to potential AEs associated with long-term use, as well as the derived benefit. Drug holidays may be appropriate given consideration of certain patient characteristics. Well-designed, prospective studies are needed to evaluate long-term use and AEs in older adults; therefore, clinical judgment combined with available evidence will have to suffice as the current practice.

Collaboration between a college of pharmacy and a for-profit health system at an academic medical center.

PURPOSE: The genesis and growth of a successful 14-year partnership between the University of Oklahoma (OU) college of pharmacy and the OU Medical Center (OUMC) department of pharmacy are described. SUMMARY: Pursuant to a 1998 joint operating agreement, the medical center and pharmacy school have achieved a high degree of collaboration on a wide range of educational and clinical initiatives. The close relationship has conferred a number of benefits on both institutions, including (1) expanded experiential education opportunities for pharmacy students, (2) joint faculty and staff funding arrangements that have facilitated the development and accreditation of OU pharmacy residency programs, and (3) patient care initiatives that have increased awareness of pharmacists' important contributions in areas such as venous thromboembolism prophylaxis, antibiotic stewardship, and core measures compliance. In addition to the formal integration of the college of pharmacy into the OUMC organizational structure, ongoing teamwork by clinicians and administrators at the two institutions has strengthened the 14-year partnership while helping to identify creative solutions to evolving communications, technology, and reimbursement challenges. Potential growth opportunities include the expansion of pharmacy services into additional service areas and greater involvement by OU pharmacy school faculty in the training of medical, nursing, and allied health professionals. CONCLUSION: A large for-profit academic medical center and a college of pharmacy developed a successful collaboration that is mutually beneficial and provides increased clinical, educational, and scholarly opportunities, advancing the mission of both institutions.

The beers criteria as an outpatient screening tool for potentially inappropriate medications.

OBJECTIVE: To determine the impact of using the Beers criteria (sometimes known as the Beers list) as an outpatient screening tool on the number or dosage of Beers criteria medications identified in patients' medication profiles immediately before an outpatient appointment. DESIGN: Nonrandomized, prospective pre-/post pilot study. SETTING: Six individual medicine and medicine-specialty clinics at a major academic medical center. PARTICIPANTS: All subjects were 65 years of age or older. INTERVENTIONS: Subjects 65 years of age or older had their medication profiles screened using the Beers criteria- medications potentially inappropriate for use in the elderly- prior to and directly after a scheduled appointment with their physician. Respective physicians were notified of any Beers criteria medications before the appointments. Physician options were to discontinue, continue, or change the dose of the medications identified with the option for justification of their decision. MAIN OUTCOME MEASURE: The difference from baseline (preappointment) to follow-up (postappointment) in the number or dosage of Beers criteria medications identified in patients' profiles. RESULTS: 120 eligible charts were reviewed. The average age of subjects was 74 years. Overall, 37.5% of subjects were on potentially inappropriate medications (PIMs) as defined by the Beers criteria. Sixty-three PIMs were flagged out of 120 profiles. For the primary outcome, 8/63 and 0/63 PIMs were discontinued or had a dosage change, respectively. This intervention resulted in a statistically significant reduction in the mean number of Beers criteria medications (P = 0.032). CONCLUSION: Use of the Beers criteria as a clinical intervention tool in an outpatient setting may be an effective method to reduce the number of PIMs prescribed in an elderly population.

Trimethoprim-sulfamethoxazole-induced hyponatremia.

An 86-year-old Caucasian male developed hyponatremia while on trimethoprim-sulfamethoxazole (TMP-SMX) 80/400 mg, one tablet by mouth twice daily. Upon discontinuation of therapy, his serum sodium and symptoms improved. He was inadvertently rechallenged several months later with TMP-SMX and had similar symptoms and laboratory abnormalities. TMP-SMX-induced hyponatremia is a rare occurrence. Previous publications have most often reported this phenomenon in combination with hyperkalemia. However, this patient represents a case of TMP-SMX-induced hyponatremia independent of hyperkalemia and provides a rare opportunity to observe a challenge and rechallenge with the offending medication. Although the mechanism behind this adverse drug reaction remains unclear, a score of 7 on the Naranjo probability scale indicates a probable likelihood that TMP-SMX was the cause of the hyponatremia in this patient. This case demonstrates that TMP-SMX can result in the development of hyponatremia independent of hyperkalemia. Health care providers should be aware of the potential for hyponatremia associated with TMP-SMX and consider monitoring electrolytes and renal function during therapy.

Biomonitoring polybrominated diphenyl ethers in human milk as a function of environment, dietary intake, and demographics in New Hampshire.

Human milk is a valuable biological specimen for biomonitoring lipid-soluble polybrominated diphenyl ethers (PBDEs). The purpose of this study was to determine the levels of PBDEs in human milk from New Hampshire and to examine potential relationships between PBDE levels in human milk and stage of lactation, maternal characteristics, living environment and dietary intake. Forty women provided up to three human milk samples at the end of their first, second and third month of breastfeeding for evaluation of day-to-day and month-to-month variation in PBDE levels. Participants completed four questionnaires, which provided maternal, living environment, and diet information. The sigma PBDE concentrations in human milk over the 3-month collection period ranged from 6.5 to 166.7 ng g(-1) lipid. The median for the 3-month period was 29.7 ng g(-1). BDE-47 was the predominant congener, however, BDE-153 predominated in 20% of the participants' samples. Day-to-day variation in sigma PBDEs was negligible; there was no significant difference in mean PBDE levels from month-to-month. Positive associations were seen between BDE-153 and age, postpartum saturated fat consumption, and the home model. There was a negative association between PBDE levels and fruit consumption during the third trimester. Our results indicate that PBDE levels in human milk from New Hampshire are within the range that has been reported in the US, and levels are stable during the first 3-months of lactation. Our findings revealed a higher predominance pattern with BDE-153 compared to other studies, and indicate that PBDE levels are influenced by diet and the home environment.

Developing a biomonitoring educational pamphlet for potential participants in a breast milk biomonitoring study.

Over the past decade, biomonitoring research initiatives in the United States have increased because of growing concern over the accumulation of environmental chemicals in the human body. One matrix that has become a viable biological sample for estimating human exposure to environmental chemicals is breast milk. However, breast milk biomonitoring research can induce anxiety and confusion about breastfeeding if communication is lacking between researchers, community partners, and participants. To bridge this communication gap, an informative, reassuring 8-page pamphlet was developed to educate community partners and potential participants about research on 1 class of environmental chemicals-polybrominated diphenyl ethers. Not only did the pamphlet assist in participant recruitment, but it forged positive relationships with valuable community partners.

Effect of reduced maternal protein intake in pregnancy in the rat on the fatty acid composition of brain, liver, plasma, heart and lung phospholipids of the offspring after weaning.

Reduced protein intake during pregnancy decreased maternal hepatic and plasma docosahexaenoic acid concentrations and impaired docosahexaenoic acid accumulation into fetal brain in the rat. The present study investigated whether restriction of maternal protein intake during pregnancy in the rat alters membrane phospholipid fatty acid composition in the offspring after weaning. Female rats (six per group) were mated and fed diets containing either 180 or 90 g protein/kg throughout pregnancy. Mothers were transferred to standard chow after delivery and the litters reduced to eight pups. Weaning was at 28 d and pups were killed 5 to 6 d later. Tissue weights or membrane total phosphatidylcholine (PC) and phosphatidylethanolamine (PE) concentrations in the offspring did not differ between dietary groups. There were significant differences between the 180 and 90 g/kg groups in liver, brain, lung and heart fatty acid composition that differed between tissues and phospholipid classes. For example, docosahexaenoic and arachidonic acid concentrations were 23 and 10 % lower respectively in hepatic PC, but not PE, in the 90 g/kg group. In brain, docosahexaenoic acid concentration was 17 % lower in PC, but not PE, while arachidonic acid content was 21 % greater in PE but unchanged in PC. The greatest differences were in unsaturated fatty acids, which suggests alterations to desaturase activities and/or the specificity of phospholipid biosynthesis. These results suggest that restricted maternal protein intake during pregnancy results in persistent alterations to membrane fatty acid content.

Refeeding syndrome in hospitalized pediatric patients.

Refeeding syndrome has been well documented over the years, primarily through case reports and literature reviews. Awareness of refeeding syndrome is crucial in preventing the occurrence of, and the metabolic and physiologic complications associated with, aggressive nutrition support in malnourished populations. Once compromised patients have been identified to be at risk of refeeding syndrome, nutrition rehabilitation should be cautiously initiated. We have found a lack of clinical validation for instituting nutrition support in high-risk pediatric patients who may develop refeeding syndrome. The purposes of our investigation were to determine the incidence of refeeding syndrome in pediatric hospitalized patients beginning on parenteral nutrition and to determine how consistently the Department of Clinical Nutrition standards of care for screening and prevention were followed at our institution.

Increased systolic blood pressure in rats induced by a maternal low-protein diet is reversed by dietary supplementation with glycine.

When rat dams consume a diet low in protein during pregnancy, their offspring develop high blood pressure. On a low-protein diet, the endogenous formation of the amino acid glycine is thought to become constrained. Glycine may become conditionally essential, as its rate of endogenous formation is inadequate to meet metabolic needs, and may be limiting for the normal development of the fetus. In the present study, five groups of Wistar rats were provided during pregnancy with one of five diets: a control diet containing 18% (w/w) casein (CON), a low-protein diet containing 9% casein (MLP), or the low-protein diet supplemented with 3% glycine (MLPG), alanine (MLPA) or urea (MLPU). The offspring were weaned on to standard laboratory chow, and blood pressure was measured at 4 weeks of age. Blood pressure was significantly increased in the MLP, MLPA and MLPU groups compared with the CON group, but for the MLPG group blood pressure was not significantly different from CON. Compared with the CON group, body weight was significantly reduced for the MLP, MLPA and MLPG groups, but for the MLPU group body weight was not different from CON. These data show that different forms of non-essential dietary nitrogen, when consumed during pregnancy, exert different effects upon the growth and function of the offspring. The availability of glycine appears to be of critical importance for normal cardiovascular development.

Effect of reduced dietary protein intake on hepatic and plasma essential fatty acid concentrations in the adult female rat: effect of pregnancy and consequences for accumulation of arachidonic and docosahexaenoic acids in fetal liver and brain.

During pregnancy, the accumulation of long-chain polyunsaturated fatty acids (LCPUFA) in fetal tissues places a substantial demand upon maternal lipid metabolism. As lipid metabolism is intimately linked to aspects of protein metabolism, a reduced protein intake in pregnancy may impair activities of enzymes and transport proteins responsible for supplying LCPUFA to the fetus, thereby compromising fetal development. We have investigated the effect of reduced protein intake on LCPUFA status in the non-pregnant rat and in the pregnant rat, and in fetus at day 20 of gestation. Female rats (n 5 per group) were either mated and fed the control diet (180 g protein/kg) or low-protein diet (90 g protein/kg, LPD) diet throughout pregnancy, or fed the control diet or LPD for 20 d (non-pregnant animals). The fatty acid compositions of maternal liver and plasma, and fetal liver and brain were determined by GC. Feeding the LPD did not lead to any gross changes either in adult or fetal growth, or in total lipid concentrations in adult rat liver. However, the LPD was associated specifically with lower liver (42.6 %) and plasma (19.4 %) phosphatidylcholine (PC), and plasma triacylglycerol (28.6 %) docosahexaenoic acid (DHA) concentrations in pregnant rats and reduced fetal brain PC- (26.1 %) and phosphatidylethanolamine- (25.6 %) DHA concentrations. Together, these results show that variations in maternal dietary protein consumption alter DHA status in pregnancy and modify DHA accumulation into the fetal brain. The present results suggest that lower maternal protein intakes reduce delivery of DHA from the mother to the fetus, which may impair development and function of the fetal brain.