Charles D. Ponte

Infectious Vulvovaginitis: Current Trends and Management

Objective: To review the clinical presentation, diagnosis, and contemporary management of infectious vulvovaginitis. Data Sources: A MEDLINE search on English-language literature was performed, with emphasis on 1999 publications. Search terms included trichomoniasis, candida vaginitis, and bacterial vaginosis (BV). Personal files containing relevant published reviews and original research were also reviewed. Results: Vulvovaginitis is a common gynecologic disorder. The three most prevalent types of infectious vulvovaginitis are BV, candidiasis, and trichomoniasis. Patients typically report discharge, odor, itching, dysuria, or dyspareunia. The healthy vagina is resistant to pathogenic organisms due to an acidic pH and the production of hydrogen peroxide. Any disruption of the healthy vaginal ecosystem can result in infection. Candidiasis is an opportunistic infection that can be sexually transmitted and is diagnosed by presence of fungal hyphae or pseudohyphae in vaginal secretions. Treatment is usually initiated with topical imidazoles or triazoles, which are highly effective against Candida albicans; however, drug-resistant nonalbicans species (e.g., Candida glabrata) are becoming more prevalent and pose treatment challenges. Trichomoniasis is a sexually transmitted disease caused by Trichomonas vaginalis, a protozoan that invades the paraurethral structures of both sexes and is diagnosed by presence of motile trichomonads in vaginal secretions. Oral metronidazole is the only drug recommended for treatment; however, the incidence of metronidazoleresistant trichomoniasis is increasing and poses therapeutic challenges for the clinician. BV is characterized by an overgrowth of aerobic and anaerobic organisms that replace normal lactobacilli. Amsels criteria are useful in making the diagnosis of BV. Effective treatment is necessary since BV is associated with various gynecologic and obstetric complications. Recommended therapies include oral or topical metronidazole or clindamycin. Conclusions: Patient history and physical examination findings are paramount in diagnosing infectious vulvovaginitis. Despite effective oral and topical treatments, resistant organisms are becoming more prevalent, necessitating a search for more effective management of this disorder.

The management of dog bites

Objective To review the contemporary management of dog bites with an emphasis on clinical presentation, wound care, microbiology, antimicrobial prophylaxis, and treatment. Data Sources The published literature was searched by use of MEDLINE (1990-December 2000) and bibliographic reviews of relevant textbooks and review articles. Data Selection and Extraction Review articles, case reports, appropriate meta-analyses, and relevant textbook chapters dealing with mammalian bites and their management were evaluated. All pertinent information was synthesized and incorporated into the present review. Data Synthesis The incidence of serious and fatal dog bites has increased because of the acquisition of larger, more aggressive breeds. School-age children and young adults are at the highest risk. Most bites occur on the upper extremities, although head and neck bites are also common. The risk of infection is greatest for crush injuries, puncture wounds, and hand wounds. Infection tends to develop within 24–36 hours of the injury. Complications include osteomyelitis, septic arthritis, tenosynovitis, and septicemia. Most infections are polymicrobial and involve organisms isolated from the skin of the patient and the indigenous oral flora of the dog. Bites should be initially managed under accepted wound care protocols. Wound closure remains controversial and should be reserved for facial and head wounds. Immobilization and elevation are essential for therapeutic success. Prophylactic antibiotics should be reserved for bites at high risk for infection and the immunocompromised host. Whether for prophylaxis or treatment, empiric antimicrobial therapy should be directed against the most common bacteria: Pasteurella spp., streptococci, staphylococci, and anaerobes. Duration and route are dependent on the location and severity of the wound. Conclusions Dogs remain the major cause of mammalian bites in the US. It is important for clinicians to have an understanding of the contemporary management of dog bites. Good wound care is central to the prevention and treatment of complications. Appropriate antimicrobial therapy should be directed against both aerobic and anaerobic flora. Careful monitoring is imperative, and antibiotic changes should be made based on clinical response and, if appropriate, the results of culture and sensitivity reports.

Women's Health Issues and Counseling Behaviors: A Pilot Survey of West Virginia Pharmacists

Objective: To assess the counseling behaviors of pharmacists concerning womens health issues. Design: A 14-item survey was mailed to 1,050 pharmacists. Data were analyzed using descriptive statistics (frequency and cross-tabulation). An IBM-compatible microcomputer program, Epi Info Version 5, was used for data analysis. Stratified analysis of the data was conducted using chi-square testing. Correlation between selected variables was determined using statistical analysis software. Setting: West Virginia. Participants: Two hundred seven practicing West Virginia pharmacists who completed or partially completed the questionnaire. Outcome Measures: The degree and nature of counseling by West Virginia pharmacists pertaining to womens health issues. Results: Almost 77% of the pharmacists were engaged in community practice. Seventy-four percent (151/203) of pharmacists counsel women about healthcare issues at least sometimes during a typical week. Women most often initiate the interaction. Sixty-nine percent were somewhat comfortable counseling women. The most common topics discussed were vaginal infections and estrogen replacement therapy. The most common barriers to effective counseling were time constraints and lack of patient requests. Almost 33% of the pharmacists (n = 68) agreed that academic curricula inadequately prepared them to counsel women. If reimbursement mechanisms were available, 36% of pharmacists (n = 70) would charge up to

Diabetes Mellitus: A Brief Review

5 per session. Sixteen percent (n = 32) would charge no fee. Conclusions: The small sample size and design of the survey could affect interpretation of the study results. Future research should address the specific types of counseling performed and the methods used, the practice setting and its influence on counseling, curricular influences on counseling, and pharmacist reimbursement philosophy.

Diagnosis and Treatment of Bacterial Vaginosis: Survey of Family Physicians in West Virginia

Diabetes mellitus is a chronic condition that curxad rently afflicts approximately 12 million Amerixad cans. Half a million individuals have type I, or insulin-dependent diabetes mellitus ( IDDM), and the remainder have type II, or non-insulin-dependent diaxad betes mellitus (NIDDM) . The terms juvenile-onset diaxad betes mellitus and adult-onset diabetes mellitus are no longer acceptable and have been dropped from the offixad cial nomenclature. Diabetes mellitus is the third leading cause of death by disease for Americans. Complications involving the eye, kidney, cardiovascular system, and nervous sysxad tem are well known. These complications have taken both a physical and emotional toll on our population and the economic blow dealt to our nations economy has been enormous. The reported drain on our econxad omy has been estimated to be approximately

Rational Analgesic Use for Acute and Chronic Pain

18 bilxad lion per year. Other vital statistics involving diabetes mellitus can be found in Table l . 1 An increased awareness by both diabetic patients and health practitioners of the importance of maintaining near-normal blood glucose concentrations may ultixad mately have an impact upon patient well-being and reduce the aforementioned economic burden. Whether attempts at achieving normal blood glucose concentraxad tions can prevent the development of diabetic complixad cations awaits the results of ongoing and future research efforts. The optimal care of the diabetic patient involves the concerted efforts of physicians, dieticians, nurse eduxad cators, and pharmacists. Through such efforts the diaxad betic patient can receive appropriate care and achieve the stated goals of therapy. The pharmacist is in a

Pharmacogenetics—A Brief Overview

Background: Vulvovaginitis is a common gynecologic complaint with millions of women seeking medical attention for this disorder. Bacterial vaginosis (BV) is the most common form of vaginal infection. Its nonspecific symptomatology and its diagnostic and therapeutic controversies pose many challenges. Methods: A 10-question self-administered survey was mailed to family physicians in West Virginia. The survey assessed the occurrence of BV, diagnostic criteria, and treatment options. The results were reported as descriptive statistics. Results: Overall, 107 physicians responded to the survey. Seventy-nine surveys were used in the tabulation of results. All respondents diagnosed vaginitis on a weekly basis. On average, BV is diagnosed in 25 percent of women with vaginal problems. Discharge, odor, and irritation were the most common signs/symptoms. History, physical examination, and microscopic examination of vaginal secretions were employed routinely for diagnosis. A detectable odor, a homogeneous discharge, and vaginal pH >4.5 were inconsistent objective clinical findings. However, the presence of clue cells was noted in the majority of patients. The preferred drug for the treatment of BV was metronidazole, usually administered in a dosage of 500 mg/d po bid for seven days. Fifty percent of the respondents treat men partners, and again, the drug of choice was metronidazole. The majority do not treat asymptomatic BV during pregnancy nor asymptomatic nonpregnant women during routine gynecologic examination. Recurrence was noted in fewer than 30 percent of treated women. Conclusions: On the basis of the results, BV is a common gynecologic diagnosis. Classic signs/symptoms were universally present and the diagnostic approach was consistent with established medical norms. The usual objective clinical findings were not always evident, although the presence of clue cells was a frequent finding. The therapeutic approach to the patient with BV was also consistent with contemporary medical practice in 1991. Whether the small sample size or inconsistent reporting affected the study results remains indeterminate. Future research will be directed toward larger patient populations and assessment of newer therapeutic modalities and their costs.

Women's Health—An Important Arena for Pharmaceutical Care Efforts

Pain is a common human experience that touches the lives of everyone. Pain is difficult to define and must be viewed as a complex subjective phexad nomenon. Despite an increased understanding of pain and improved treatment techniques, we still lack a unixad versally accepted system of pain measurement. We have come to realize that optimal pain management rexad quires an individualized and often a multimodal and multidisciplinary approach. Pain can be classified as both acute and chronic. Acute pain represents the bodys way of signaling that something is wrong. Signs and symptoms such as inxad creased sweating and heart rate and muscle tension are similar to those commonly observed with acute anxiety. One can rationalize that acute pain is part of the healing process and that it will get better with time. Pain folxad lowing abdominal surgery is an example. Chronic pain, however, cannot be rationalized as part of the healing process. It has no beginning or end; it may be considered a disease in and of itself. Chronic pain can make the person feel helpless and hopeless and occupy all of ones attention. The person ultimately will become isolated from his surroundings and experixad ence severe depression. Cancer pain is a classic example of chronic pain. Many cancer patients fear dying in pain although only 50 percent of these patients actually will experience severe pain. Unfortunately, approximately 20 percent of cancer patients will have persistent pain during the terminal stages of their disease. The appro-

The Children's Hospital of Philadelphia Guide to Asthma: How to Help Your Child Live a Healthier Life

There are many terms that pharmacy technician students must become familiar with during the course of their professional training program. Such terms as pharmacology, pharmaceutics, pharmaxad cokinetics, pharmacognosy, and biopharmaceutics, which have been part of the vernacular of practicing pharmacists for many years, must now be appreciated by the practicing pharmacy technician. Pharmacogenxad etics is a relatively new term that has become part of the pharmaceutical language. Simply stated, pharmacoxad genetics deals with the interaction between drugs and inherited traits. Stated in a different manner, pharmaxad cogenetics represents the influence of hereditary factors on the effects or metabolism of a particular drug. Since patients may be taking multiple drugs, the likelihood of an adverse effect or unexpected drug response is high. One must be aware that this unexpected drug response may be caused by pharmacogenetic influences. The possibility that adverse drug effects may be caused by inherited traits has been known for about 75 years, but it wasnt until 1959 that the term pharmacoxad genetics was coined. 1 Classic pharmacogenetic models were derived from studying suxamethonium metaboxad lism, glucose-6-phosphate dehydrogenase (G-6-PD)induced hemolytic reactions, and isoniazid and hydralaxad zine metabolism. Accepted research techniques have included the direct measurement of drug metabolizing enzymes in serum and using drugs as in vivo probes of genetic variation. 1 An example of this latter method would involve the study of pharmacokinetic parameters of a particular medication. Newer developments have