Frank Romanelli

Reexamining Syphilis : An Update on Epidemiology, Clinical Manifestations, and Management

Objective: To review the epidemiology, clinical features, diagnosis, and treatment of syphilis. Data Sources: Studies and reviews were abstracted from MEDLINE (1950–April 2007) using the search term syphilis. AN papers were cross-referenced to identify additional studies and reviews for inclusion. Study Selection and Data Extraction: Pertinent original research articles, review articles, and book chapters were evaluated. Data Synthesis: Syphilis is a spirochetal disease that has plagued mankind for centuries. Following a low incidence of syphilis in the US for the last 2 decades, rates are now increasing both in the US and other parts of (he world. Once acquired, syphilis can pass through 4 distinct stages of disease: primary syphilis. secondary syphilis, latent syphilis, and tertiary syphilis, with each stage being characterized by different symptoms and levels of infectivity. Diagnosis is made primarily by serologic assays with nontreponemal tests such as the Venereal Disease Research Laboratory and the Rapid Plasma Reagin assay used for screening. Treponemal tests including the Treponema pallidum particle agglutination and the fluorescent treponemal antibody absorption test are then used for confirmation. Recommended treatment regimens are based largely on uncontrolled trials and clinical experience. Penicillin is the treatment of choice, with the preparation and treatment duration varying for different stages. Benzathine penicillin is the treatment of choice lor all stages of syphilis except neurosyphilis, for which aqueous crystalline penicillin or procaine penicillin is used due to the central nervous system penetration of these formulations. Coinfection with both syphilis and HIV occurs frequently due to common risk factors. These 2 diseases interact with each other, making both diagnosis and treatment more complicated. Conclusions: Clinicians should be aware of the signs and symptoms of syphitis as well as current guidelines for the management and treatment of this disease.

Poppers: Epidemiology and Clinical Management of Inhaled Nitrite Abuse

Commonly referred to as “poppers,” inhaled nitrites have a long history of abuse. Poppers are rapid‐onset, short‐acting potent vasodilators that produce a rush characterized by warm sensations and feelings of dizziness. Poppers sometimes are used to facilitate anal intercourse because of their actions on the anal sphincter. Epidemiologically, the frequent use of nitrites by men who have sex with men has led some experts to implicate these chemicals in the pathogenesis of Kaposis sarcoma and acquired immunodeficiency syndrome. Controlled clinical trials to examine this potential correlation have not been conducted, and the use of nitrites simply may be a marker for other high‐risk behaviors such as unprotected sex. Although regulated in the United States, many nitrite compounds and isomers are sold at various venues including bars, bookstores, and over the Internet. Adverse effects associated with these products vary from mild allergic reactions to life‐threatening methemo‐globinemia. The potential for drug‐drug interactions and a propensity toward unsafe sex also exist. Clinicians should be familiar with the populations most likely to abuse these agents and with the clinical effects and management guidelines for acute ingestions.

Therapeutic dilemma The use of anticonvulsants in HIV-positive individuals

Article abstract The concurrent use of anticonvulsants and antiretrovirals is a poorly studied area that poses a therapeutic dilemma for the clinician caring for HIV-positive patients requiring both classes of medications. Anticonvulsants and antiretrovirals may interact through multiple mechanisms including competition for protein binding, enhanced or reduced liver metabolism, and increased viral replication. The authors present many of the challenges faced by clinicians caring for HIV-positive patients who may require anticonvulsant therapy.

Possible Paroxetine-Induced Bruxism

OBJECTIVE: To report the case of a patient with possible paroxetineinduced bruxism that was effectively treated with buspirone. CASE SUMMARY: A 20-year-old woman with no active medical conditions besides acne and no history of dental problems was seen in an outpatient psychiatry clinic for the evaluation of ongoing depression. The patient was prescribed paroxetine 10 mg every morning. After 5 days of therapy the patient reported no adverse effects, and the paroxetine dosage was increased to 20 mg every morning. Due to increased somnolence, the dosing schedule was subsequently changed to 20 mg hs. Two months later during a dental visit for a tooth extraction, the dentist noted that the patients teeth appeared damaged in what he believed to be a pattern consistent with the grinding and clenching of teeth. Prior to this time, dental examinations had not revealed any tooth damage. The patient was thought to have paroxetine-induced bruxism and, based on earlier case reports, was treated with buspirone 5 mg hs. On day 4 of buspirone therapy the patient reported a significant reduction in the extent of gritting, tooth pain, and jaw tenderness. DISCUSSION: The selective serotonin reuptake inhibitors (SSRIs) fluoxetine and sertraline have been associated with bruxism in previous reports. This case suggests paroxetine-induced bruxism. The exact mechanism of SSRI-induced bruxism remains unclear. Many theories have been proposed, including sleep disturbance, serotonergic-mediated inhibition of dopamine manifesting as akathisia, and SSRI-induced anxiety. According to published reports, SSRI-induced bruxism may respond to therapy with buspirone. Consistent with these reports, this patient responded favorably to buspirone therapy. CONCLUSIONS: Clinicians should be aware that the potential for paroxetine-induced bruxism exists and that buspirone may be an appropriate therapeutic intervention.

Recreational use of sildenafil by HIV-positive and -negative homosexual/bisexual males.

OBJECTIVE: To conduct an epidemiologic review of sildenafil in homosexual and bisexual males focusing on concurrent use with club drugs and/or antiretroviral medications. DATA SOURCES: A search of MEDLINE was conducted (1966–September 2003), and an extensive manual review of journals was performed using the key search terms club drugs, sildenafil, antiretrovirals, and HIV. STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and information deemed relevant was included. DATA SYNTHESIS: Several epidemiologic studies have reported that sildenafil is abused in a recreational fashion, typically with agents commonly known to be “club drugs.” In this setting, sildenafil may reverse the impotence-inducing effects of the club drugs and restore sexual capabilities. Many implications of both recreational and nonrecreational use of sildenafil exist in relation to HIV disease. Concern has been raised regarding the potential effects on high-risk sexual practices. Also, several researchers have documented interactions between sildenafil and various club drugs, as well as with antiretrovirals intended for HIV disease. CONCLUSIONS: Serious concerns exist regarding the concurrent use of sildenafil with antiretrovirals and/or club drugs. Clinicians prescribing sildenafil to patients receiving protease inhibitor—containing antiretroviral regimens should be aware of the potential for reduced sildenafil metabolism with resultant adverse effects. Additionally, untoward effects may also occur when sildenafil is used concurrently with various club drugs including amyl and butyl nitrites (“poppers”).

Clinical Effects and Management of Methamphetamine Abuse

Methamphetamine is a highly potent and addictive drug that is abused in the United States and around the world. The drug is inexpensive and easily manufactured from simple chemicals such as pseudoephedrine. These features, coupled with its long half‐life and highly addictive nature, contribute to the increasing problem of illicit methamphetamine use. Abuse of this agent has both acute and chronic serious health consequences. Policy makers and public health officials must continue to develop programs that educate the public and limit the abuse associated with methamphetamine.

Macrocytosis as an Indicator of Medication (Zidovudine) Adherence in Patients with HIV Infection

This retrospective chart review was conducted in an outpatient human immunodeficiency virus (HIV) clinic to determine if macrocytosis can be used as a clinical indicator of zidovudine adherence in HIV-infected outpatients. This study included 71 HIV-positive patients who were taking zidovudine and 93 HIV-positive controls who were not taking zidovudine, for 8 weeks or longer. One control and 16 subjects were excluded secondary to insufficient laboratory data or preexistence of other macrocytosis-inducing etiologies. The incidence of macrocytosis (mean corpuscular volume [MCV] >/= 100 fL) was significantly different among subjects and controls: 78% versus 32.6% (p < 0.001), respectively. Adherence (determined by documentation from a physician/pharmacist) was assessed among subjects for whom zidovudine was prescribed, comparing those with and without macrocytosis. Adherence was observed in 77% and 18% of the macrocytosis-positive and macrocytosis-negative subjects, respectively (p < 0.001). Macrocytosis was also observed in patients receiving stavudine (another thymidine analogue, in the class of nucleoside reverse transcriptase inhibitors). Twenty-seven of the 41 patients for whom stavudine was prescribed developed macrocytosis (65.8%). These results indicate that macrocytosis may be useful in assessing adherence to zidovudine-containing antiretroviral regimens and may also have a role in assessing stavudine adherence.

Tenofovir Disoproxil Fumarate

OBJECTIVE: To review the pharmacology, virology, pharmacokinetics, efficacy, safety, resistance profile, and clinical use of tenofovir disoproxil fumarate. DATA SOURCES: A MEDLINE search was performed (1966–August 2002) using the following terms: tenofovir, tenofovir disoproxil fumarate, PMPA (9-(R)-[2-(phosphonomethoxy)propyl]adenine), and Viread. Abstracts from HIV-related meetings were reviewed. DATA EXTRACTION AND STUDY SELECTION: Publications and meeting abstracts regarding tenofovir were reviewed. The most recent and pertinent items were included. DATA SYNTHESIS: Tenofovir disoproxil fumarate is a nucleotide prodrug that is diphosphorylated to its active moiety, tenofovir diphosphate. In this form, tenofovir acts as a reverse transcriptase inhibitor to inhibit HIV-1 replication. In clinical trials, tenofovir was effective at suppressing HIV-1 RNA and boosting CD4+ cell counts. Tenofovir has a long intracellular half-life, which permits once-daily dosing. Since tenofovir does not interact with the cytochrome P450 pathway, it exhibits minimal drug interactions, with the exception of didanosine. Compared with other reverse transcriptase inhibitors, tenofovir may have advantages in terms of toxicity and medication adherence profiles. Ongoing studies are also analyzing tenofovirs activity against hepatitis B virus. CONCLUSIONS: Tenofovir has been shown to be active against HIV-1 in combination with other antiretrovirals. The drugs benefit as a single-agent intensifier of highly active antiretroviral therapy in treatment-experienced patients has been established, and preliminary data for treatment-naïve patients are encouraging.

The Use of Valproic Acid in HIV-Positive Patients

OBJECTIVE: To review the use of valproic acid in HIV-positive patients. DATA SOURCES: Clinical literature was accessed through a MEDLINE search (January 1966–November 1998). Key search terms included HIV, AIDS, seizures, valproic acid, and glutathione. DATA SYNTHESIS: Patients with HIV often develop neurologic manifestations; therefore, valproic acid may be considered in the management of this population. It has been demonstrated that valproate may increase viral burden by potentiating replication. An evaluation of studies addressing the use of valproic acid in HIV-positive patients was conducted. CONCLUSIONS: The potential for valproate-induced increases in viral replication exists. Although further studies are warranted, clinicians should exercise caution when using valproate in HIV-positive patients.

Academic Entitlement in Pharmacy Education

The constructs of academic entitlement and student consumerism refer to students’ attitudes toward education as a commodity and the underlying belief that as consumers, they should be catered to and given the opportunity to participate in the education process according to their preferences. Most discussions regarding these attitudes are anecdotal, but the pervasiveness of these accounts and the troubling effects that ensue warrant attention. Grade inflation, student incivility, altered classroom practices, and decreased faculty morale are all potential aftereffects of teaching students who hold academic entitlement beliefs. Numerous factors are posited as attributing to academic entitlement including personal issues, societal pressures, and broad academic practices. This paper discusses these factors and offers faculty members and administrators recommendations regarding practices that may curb or alleviate issues associated with academically entitled students.