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In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.Current Neurocritical Care Society guidelines on the management of cerebral edema recommend hypertonic saline (HTS) over mannitol in some scenarios, but practical questions remain regarding the appropriate administration method, concentration/dose, monitoring to ensure safe use, and storage. The aim of this article is to address these practical concerns based on the evidence currently available.Many different hypertonic solutions have been studied to define the optimal hyperosmolar substance to relieve acute cerebral edema in patients with conditions such as acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury. Mannitol and HTS are the main hyperosmolar therapies in use in contemporary neurocritical care practice. Contemporary use of HTS has followed a circuitous path in regards to the practical aspects of dosing and formulation, with evidence mainly consisting of retrospective or observational data. The effectiveness of bolus doses of HTS to lower acutely elevated intracranial pressure is well accepted. Adverse events with use of HTS are often mild and non-clinically significant if appropriate monitoring of serum sodium and chloride concentrations is performed. Available evidence shows that peripheral administration of HTS is likely safe in certain circumstances. Timely utilization of HTS is complicated by regulatory requirements for safe storage, but with appropriate safeguards HTS can be stored in patient care areas.HTS formulations, methods of administration, infusion rate, and storage vary by institution, and no practice standards exist. Central intravenous administration may be preferred for HTS, but peripheral intravenous administration is safe provided measures are undertaken to detect and prevent phlebitis and extravasation. The safe use of HTS is possible with proper protocols, education, and institutional safeguards in place.

Medicinal cannabinoid use continues to evolve across the United States, although legitimate federal recognition for medicinal purpose is lacking. Variability exists across states within the United States with respect to legislation, and health care institutions encounter challenges when patients present with a history of medicinal cannabinoid use. Emerging evidence in the field of neurosciences suggests a role of cannabinoids for neurologic medical conditions such as Parkinson disease, multiple sclerosis, and epilepsy. We aim to provide an overview of cannabinoids including a historical perspective, pharmacology, applications in neurosciences, and challenges in health care and academia. Knowledge of the appropriate role of cannabinoids in the clinical setting is essential for all health care practitioners including nursing.

Patients with Parkinson's disease (PD) face unique challenges when admitted to the hospital. The nature of the disease, complexity of the pharmacotherapeutic home regimens, and the medication-related policies of institutionalized care all contribute to the challenges patients and providers face. In addition, medication errors are common in this population. Incorrectly ordered or omitted home medications or delayed administration can have significant negative consequences including worsening of PD symptoms, dopamine agonist withdrawal syndrome, or malignant or hyperpyrexia syndrome. Also, this patient population may commonly encounter contraindicated medications ordered during their hospitalizations. These medication misadventures negatively affect patient care, which may lead to increased length of stay and significant adverse sequalae. Nurses, pharmacists, and other health care providers can help ease the anxiety of patients and their families by taking detailed medication histories, restarting home medication regimens, customizing medication administration to fit patients' needs, and screening patient profiles for drug-drug and drug-disease interactions. Education of hospital staff regarding the unique needs of this patient population and seeking the advice of specialists in PD can also promote improved patient care.

Objectives: A validated means to predict inhospital cardiac arrest is lacking. The purpose of this study was to evaluate the changes in end-tidal carbon dioxide, as it correlates with the progression to inhospital cardiac arrest in ICU patients. Design, Setting, and Patients: Single-center, retrospective cohort study of mechanically ventilated ICU patients (age > 18 yr old) having inhospital cardiac arrest with advanced cardiac life support and continuous end-tidal carbon dioxide monitoring at a single academic center from 2014 to 2017. Demographics, clinical variables, and outcomes were collected. End-tidal carbon dioxide was collected from 5 to 2,880 minutes before inhospital cardiac arrest. Data were analyzed using descriptive statistics, and model estimates were generated using a repeated-measures categorical model with restricted maximum likelihood estimation and fully specified (autoregressive) covariance to assess the effect of time on changes in end-tidal carbon dioxide. Measurements and Main Results: A total of 788 patients were identified and 104 met inclusion criteria, where 62% were male with an average age of 58.5 years. Seventy-four percent required vasopressors and 72% experienced pulseless electrical activity. Mean end-tidal carbon dioxide 5 minutes prior to inhospital cardiac arrest was significantly lower than all evaluated time points except 180 minutes (p < 0.05). One patient survived to hospital discharge. In multivariate logistic regression modeling for return of spontaneous circulation, a greater change in the prearrest end-tidal carbon dioxide maximum to prearrest end-tidal carbon dioxide minimum was associated with a decreased likelihood of return of spontaneous circulation (odds ratio 0.903; 95% CI, 0.832–0.979; p = 0.014). Additionally, a change from prearrest end-tidal carbon dioxide maximum to prearrest end-tidal carbon dioxide minimum greater than 17 mm Hg was associated with a decreased likelihood of return of spontaneous circulation and odds ratio 0.150; 95% CI, 0.036–0.66; p = 0.012). Conclusions: Mean end-tidal carbon dioxide is significantly lower immediately before inhospital cardiac arrest. The statistical and clinical significance of end-tidal carbon dioxide may highlight its utility for predicting inhospital cardiac arrest in ICU patients. Comparison analysis and modeling explorations in a larger cohort are needed.

Study Objectives To characterize the balance of clinical and academic responsibilities of clinical track pharmacy faculty in the United States and evaluate organizational structures that promote satisfactory balance between these responsibilities. Design Prospective cross-sectional survey. Setting A 22-item online survey was developed and distributed via Qualtrics software. Participants Clinical faculty members of the American College of Clinical Pharmacy Adult Medicine, Ambulatory Care, Cardiology, Critical Care, Gastrointestinal/Liver/Nutrition, Immunology/Transplantation, Infectious Disease, and Pediatrics Practice and Research Networks (PRNs) were invited to participate via the PRN electronic mailing list. Measurements and Main Results The survey comprised questions related to demographics, organizational structure, and balance of clinical and academic responsibilities. A total of 344 participants responded to some or all of the survey questions. The demographics were relatively equally balanced between faculty at state and private academic institutions, academic rank, and practice setting. Expected and actual effort allocations were similar for each of the clinical and academic responsibilities, with direct patient care and clinical teaching representing more than 50% effort allocation cumulatively. Clinical faculty at state institutions devoted a larger proportion of time to clinical service, whereas clinical faculty at private institutions devoted a greater proportion of time to didactic teaching. When asked about time constraints, 157 (69.8%) of the 225 survey participants responding to this question did not believe they had sufficient time to fulfill their nonclinical academic needs. Clinical faculty who were provided “protected time” away from clinical service had a significantly more favorable opinion of this question. Conclusion Most of the clinical track pharmacy faculty indicated that they have insufficient time to fulfill their nonclinical academic responsibilities. Provision of protected time may alleviate some of these time constraints.

Purpose The outcomes associated with transdermal nicotine replacement therapy (NRT) in a neurosurgery intensive care unit (ICU) were studied. Methods Data from pharmacy records, neurosurgery ICU admission logs, and computerized patient charts at the University of Illinois Medical Center at Chicago from January 2001 through August 2008 were reviewed for patients older than 18 years who were admitted to the neurosurgery ICU for neurologic insults. Patients were categorized into three groups: smokers who received transdermal NRT ( n = 114), smokers who did not receive transdermal NRT ( n = 113), and nonsmokers ( n = 113). The primary outcome of this study was unfavorable disposition at discharge from the hospital. Secondary outcomes measured included overall mortality; lengths of hospital and neurosurgery ICU stays; and rates of subarachnoid hemorrhage (SAH) rebleeding, angiographic vasospasm, intracerebral hemorrhage rebleeding, and ischemic stroke. Results Overall, there was no difference in unfavorable discharge disposition among the three groups ( p = 0.17). However, the group who received NRT had higher admission rates of SAH, smoked more cigarettes for a longer period of time, and had longer stays in the neurosurgery ICU and hospital compared with the other groups. All patients who received NRT had prolonged hospital ( p = 0.014) and neurosurgery ICU (p = 0.006) stays compared with those who did not receive NRT. There were no differences in other secondary outcomes among the groups. Conclusion There was no significant difference in unfavorable discharge disposition among neurosurgery ICU patients who were smokers treated with NRT, smokers not treated with NRT, and nonsmokers not treated with NRT.

Cyclooxygenase (COX)-2 inhibitors are widely prescribed for their antiinflammatory and analgesic effects. The potential for COX-2 inhibitors to exert deleterious effects on renal function similar to those of traditional nonsteroidal antiinflammatory drugs is not well defined. Until recently, COX-1 was considered responsible for the synthesis of renal prostaglandins. However, COX-2 is also constitutively expressed in the human kidney Clinical studies have reported a significant decrease in glomerular filtration rate in young and elderly sodium-depleted volunteers given COX-2 inhibitors. We describe the case of a 71-year-old woman who developed acute renal failure after receiving a 50-mg dose of the selective COX-2 inhibitor rofecoxib.

Cancer is one of the most debilitating and deadly diseases that, broadly speaking, shows no preference for demographic, sex, age, or culture. It is the second leading cause of mortality of all Americans as a single disease [1], and the sheer potential for mortality from cancer can be a horrifying experience for anyone bearing this diagnosis. Pain is probably one of the most common of all cancer symptoms and can be very frightening for patients and their families. According to statistics published by the American Cancer Society in 2002 [2], 50–70% of patients with cancer experience pain, which usually only intensifies as the disease progresses. It was estimated that less than half of cancer patients get adequate relief of their pain, and 25% actually die in pain [3]. This is particularly disappointing because the pain endured by 90% of these patients could have been well managed with relatively simple interventions [4]. This chapter will discuss different options for treating cancer pain focusing on the pharmacological agents and surgical modalities currently available for pain management.

OBJECTIVE Severe coagulopathy in a neurosurgical patient with intracranial hemorrhage is a common and serious problem. Current therapy with vitamin K and fresh-frozen plasma (FFP) may be too slow in certain situations. There are reports of rapid reversal of coagulopathy using human recombinant factor VII. We present a retrospective controlled study of our experience with factor VII. METHODS We used factor VII as a second-line therapy after initial attempts at reversal with FFP had failed. Factor VII was given to 29 patients in the neurosurgical intensive care unit; 24 patients treated before the introduction of factor VII were control subjects. The groups were matched by age, sex, cause of coagulopathy, and presence of intracranial hemorrhage. RESULTS After initial FFP administration, the international normalized ratio (INR) changed from a mean of 2.57 to 1.67 in the factor VII group and from 2.17 to 1.85 in control subjects. In all patients, INR tended to rebound. Before administration of factor VII, the mean INR was 2.206. After 1.4 mg of factor VII, mean INR decreased to 1.12 (P < 0.05). Measured from admission, INR in the factor VII group normalized within 6.78 +/- 2.68 hours, and in control subjects, within 47.44 +/- 9.88 hours (P < 0.0005). Six factor VII patients and six control subjects died. The number of patients with good functional outcome (Glasgow Outcome Scale score of 5) was greater among patients treated with factor VII compared with those who received only vitamin K and FFP (nine versus two, P = 0.04). None of the deaths were the result of a thrombotic complication. There were no thrombotic complications in the factor VII group. CONCLUSION Factor VII is safe and highly effective when emergency reversal of coagulopathy is desired and may improve the functional outcome. We speculate that the use of factor VII as first choice may result in decreased use of FFP and thus increase patient safety.

Routine, self-initiated supplementation with nutritional, herbal, and other related products is common among individuals in the Western world (1,2). Among the most likely users of dietary supplements include middle-aged Caucasian women and elderly with preexisting medical conditions or chronic diseases often requiring medication. Therefore, the potential for drug-nutrient interactions (DNIs) is high and the resulting adverse reactions can be serious. Given the recent tragedies and reports implicating the use of dietary supplements (3–11), the potential risks and adverse effects of these products, ostensibly for health benefit, cannot be underestimated.