Management of HIV in the older adults: Clinical and public health challenge.

As a result of significant advances in antiretroviral therapy (ART), the number of people living with human immunodeficiency virus (PLWH) who are alive well into their senior years has increased significantly in recent years. While increased life expectancy is a highly desired outcome for PLWH, it brings with it a number of challenges that are only now starting to be understood and fully appreciated. These challenges include higher rates of co-morbidities, polypharmacy, drug side effects, and cognitive deficits, as well as numerous psychosocial issues such as stigma, loneliness, and depression. Older PLWH also face challenges related to housing, health insurance, and long-term care. This review will discuss many of the challenges faced by older PLWH and present clinical and public health responses with suggested interventions that may improve outcomes for this population.

The Explosion of a New Designer Drug, Flakka: Implications for Practice.

There are many challenges facing healthcare professionals. One such challenge is the continuous introduction of new synthetic drugs. Synthetic drugs pose many difficulties to providers, including identification of the drug ingested, management of symptoms, ensuring safety of the patient and his or her environment, and continual monitoring after the initial symptoms, because synthetic cathinones have many long-term effects on an individual. One such synthetic drug, flakka, is a potent second-generation synthetic cathinone. Because flakka inhibits the reuptake of norepinephrine and dopamine, which are involved in one's perception of pleasure, it causes inflated feelings and also causes signs and symptoms of psychosis. Flakka also induces various exaggerated symptoms, such as feelings of incredible strength, disorientation, aggression, and altered thought processes, and also can cause hyperthermia, coma, and death. Healthcare professionals need to understand the nature of flakka ingestion, the various symptoms a user may exhibit, and the long-term symptoms a person may have once the acute recovery phase has ended. Once the initial phase of ingestion is over and the patient is medically stabilized, the patient may experience signs and symptoms of psychosis or other psychiatric disorders. It is paramount that healthcare professionals are able to recognize the signs and symptoms of flakka ingestion, know the steps to take to ensure safety of the patient and those around him or her, and also know how to facilitate the patient's recovery.

Synthetic cannabinoids: the dangers of spicing it up.

Cannabinoids are the most commonly used illegal substances in the world. Spice and K2 are synthetic cannabinoid (SC) products that contain a mixture of herbs and plant matter combined with synthetic compounds similar to tetrahydrocannabinol, the psychoactive component of cannabis. Because the effects of Spice and K2 are similar to cannabis, many users are smoking these products as legal substitutes despite package labeling that they are not designed for human consumption. These SC products appeal to users because they are easily accessible and not readily detected in standard urine drug screens. The active components in SC products are highly potent and poorly characterized. Use of these agents has been associated with serious psychological and physiological side effects. Because abuse of SC products has become a national public health issue, nurses should be aware of the effects of SC compounds and must take a lead role in educating patients about the dangers of their use.

Teaching the pharmacology of antiarrhythmic drugs.

OBJECTIVE: To provide doctor of pharmacy (PharmD) students with highly integrated, comprehensive and up-to-date instruction related to the pharmacology of antiarrhythmic drugs. DESIGN: Students were taught the medicinal chemistry, pharmacology, and therapeutics of antiarrhythmic agents in the cardiology module presented in quarter 7 of the PharmD curriculum. Important foundational information for this topic was presented to students in prerequisite physiology courses and pathophysiology courses offered earlier in the curriculum. Emphasis was placed on student critical thinking and active involvement. Weekly recitation sessions afforded students the opportunity to apply the information they learned regarding arrhythmia pharmacotherapy to comprehensive patient cases. ASSESSMENT: Student comprehension was measured using class exercises, short quizzes, case write-ups, comprehensive examinations, group exercises, and classroom discussion. Students were afforded the opportunity to evaluate the course, and the instructors as well as rate the degree to which the course achieved its educational outcomes. CONCLUSION: Students learned about cardiac arrhythmias through a high-quality, interdisciplinary series of classes presented by faculty members with extensive experience related to the pharmacology and pharmacotherapy of cardiac arrhythmias.

Expectations of students enrolled in doctor of pharmacy, master's physician assistant, and anesthesia assistant programs.

PURPOSE: To qualify educational perceptions and instructional expectations for students and faculty in three health professions training programs: master's in physician assistant (PA), master's in anesthesia assistant (AA), and doctor of pharmacy (PharmD). METHODS: This study surveyed preclinical students enrolled in PA, AA, and PharmD programs, as well as faculty involved in their didactic instruction. A 30-question survey sought data on study and reading habits, preferred lecture style, career goals, and previous undergraduate educational experiences. RESULTS: Baseline demographic data were stratified and survey results were compared within as well as across the target study population. PA students routinely purchased texts and read systematically, while AA and PharmD students often relied on faculty PowerPoint slides. CONCLUSION: Despite numerous baseline similarities, there were strikingly different educational expectations among students in the three programs as well as significant disparities between students and faculty with regards to course design, study habits, and expectations.

Therapeutic potential of n-3 polyunsaturated fatty acids in disease.

PURPOSE: The potential therapeutic benefits of supplementation with n-3 polyunsaturated fatty acids (PUFAs) in various diseases are reviewed, and the antiinflammatory actions, activity, and potential drug interactions and adverse effects of n-3 PUFAs are discussed. SUMMARY: Fish oils are an excellent source of long-chain n-3 PUFAs, such as eicosapentaenoic acid and docosahexaenoic acid. After consumption, n-3 PUFAs can be incorporated into cell membranes and reduce the amount of arachidonic acid available for the synthesis of proinflammatory eicosanoids (e.g., prostaglandins, leukotrienes). Likewise, n-3 PUFAs can also reduce the production of inflammatory cytokines, such as tumor necrosis factor alpha, interleukin-1, and interleukin-6. Considerable research has been conducted to evaluate the potential therapeutic effects of fish oils in numerous conditions, including arthritis, coronary artery disease, inflammatory bowel disease, asthma, and sepsis, all of which have inflammation as a key component of their pathology. Additional investigations into the use of supplementation with fish oils in patients with neural injury, cancer, ocular diseases, and critical illness have recently been conducted. The most commonly reported adverse effects of fish oil supplements are a fishy aftertaste and gastrointestinal upset. When recommending an n-3 PUFA, clinicians should be aware of any possible adverse effect or drug interaction that, although not necessarily clinically significant, may occur, especially for patients who may be susceptible to increased bleeding (e.g., patients taking warfarin). CONCLUSION: The n-3 PUFAs have been shown to be efficacious in treating and preventing various diseases. The wide variation in dosages and formulations used in studies makes it difficult to recommend dosages for specific treatment goals.

The pharmacology of immunosuppression.

OBJECTIVE: To provide students with a comprehensive, integrated presentation on the pharmacology of immuosuppression. DESIGN: Course content on the pharmacology of immunosuppression relating to organ transplantation and treatment of autoimmune disorders was presented in integrated sequence modules that included content from pharmacology, medicinal chemistry, and therapeutics. Weekly recitation sessions and active-learning exercises were incorporated to allow students to apply the information they learned to integrated patient cases and stimulate involvement and critical thinking. Fundamental material related to the components and functions of the immune system was presented to students early in curriculum with courses such as biochemistry, pathophysiology, and immunology/microbiology. ASSESSMENT: Comprehensive examinations, in-class quizzes, written case submissions, case discussions, review exercises, and group exercises were used to assess student learning. CONCLUSION: Students at South University received a comprehensive and detailed understanding of all aspects relating to immunosuppressive therapy. This was accomplished by integrating instruction on immunosuppressive therapy from various disciplines.

Vasopressin-receptor antagonists in heart failure.

PURPOSE: The role of arginine vasopressin in heart failure and the use of vasopressin receptor antagonists in the treatment of heart failure are reviewed. SUMMARY: Arginine vasopressin (AVP) functions in the regulation of plasma osmolarity and blood pressure. In heart failure, AVP worsens heart failure by causing vasoconstriction of arteries and veins, potentially contributing to remodeling of the left ventricle and causing fluid retention and worsening of hyponatremia. Two V(2)-receptor antagonists, tolvaptan and lixivaptan, and one combined V(1a)- and V(2)-receptor antagonist, conivaptan, have shown promise for use in patients with heart failure. All three agents have been shown to increase free water excretion and increase serum sodium levels while maintaining serum potassium levels. They have not been shown to decrease renal function or the glomerular filtration rate and are well tolerated, with thirst being the major adverse effect during clinical trials. Because of their effects on sodium, vasopressin antagonists need to be carefully monitored to ensure that serum sodium levels do not increase too quickly and put the patient at risk for overcorrection or osmotic demyelination syndrome. In addition, patients need to be monitored for signs of dehydration secondary to increased urine excretion. To date, studies have not consistently shown improvements in patient symptoms or weight reduction. However, early data suggest that at least one agent, tolvaptan, does not alter mortality. CONCLUSION: Based on data from available clinical trials, vasopressin antagonists may offer a new treatment option for patients with congestive heart failure. However, these agents do not currently appear to delay the progression of heart failure or decrease mortality.

Pharmacotherapy of asthma.

The pharmacotherapy of asthma is a complex and evolving topic. A detailed understanding of the pathophysiologic processes involved in the asthmatic response forms the basis for understanding the actions of drugs used to treat this condition. Likewise, a solid comprehension of the medicinal chemistry and pharmacologic properties of the numerous agents involved in the treatment of asthma is critical for rationalizing drug choices and understanding potential side effects. Asthma is addressed at several points in the PharmD curriculum at South University including in the Pathophysiology (quarter 2), Integrated Sequence III (quarter 6), and Critical Care (quarter 9) courses. Various teaching strategies are employed throughout, along with weekly case-based recitations. The content presented here includes a synopsis of the pathophysiology and pharmacology from our Integrated Sequence III block on inflammatory diseases and asthma. A short review of pertinent pathophysiology is followed by a detailed presentation on the various classes of asthma drugs which includes their chemistry, mechanism of action, pharmacokinetics, toxicity, and interactions. This presentation is designed to prepare students for asthma therapeutics, which follows next in the schedule. The complexities of asthma pharmacotherapy are stressed along with current controversies and future drug development.

The pharmacology of HIV drug resistance.

Drug resistance to human immunodeficiency virus (HIV) is a major factor in the failure of antiretroviral therapy.1 In order for practitioners to provide effective pharmaceutical care to their HIV patients, it is essential that they understand the mechanisms of HIV drug resistance as well as the various factors that can contribute to its emergence. This article is based on didactic content from the infectious disease section of the Integrated Sequence II Course in the PharmD program at South University. In the course, students are first given an overview that includes key structural components of HIV and a discussion of the HIV life cycle. A detailed presentation on the pharmacology of the various classes of antiretroviral agents follows. The clinical impact and prevalence of HIV drug resistance is then discussed along with factors that might contribute to it. Mechanisms of drug resistance for each class of antiretroviral agents are presented in detail followed by a discussion of the basis and clinical utility of HIV drug resistance testing. Finally, new targets for HIV pharmacotherapy are presented along with an overview of new antiretroviral agents that are being developed. Content taught in lecture is reinforced by relevant case studies that students work on in small groups during the recitation period.

Effects of insulin-like growth factor-1/binding protein-3 complex on muscle atrophy in rats.

Muscle atrophy and wasting is a serious problem that occurs in patients with prolonged debilitating illness, burn injury, spinal injury, as well as with space flight. Current treatment for such atrophy, which often relies on nutritional supplementation and physical therapy, is of limited value in preventing the muscle wasting that occurs. Considerable recent attention has focused on the use of anabolic growth factors such as insulin-like growth factor (IGF-1) in preventing muscle atrophy during limb disuse or with various catabolic conditions. However, potential side effects such as hypoglycemia appear to be limiting factors in the usefulness of IGF-1 for clinical treatment of muscle wasting conditions. The formulation of IGF-1 used in this study (IGF-1/BP3) is already bound to its endogenous-binding protein (BP3) and, as a result, has a greater specificity of action and significantly less hypoglycemic effect. Using a rat model of hind limb suspension (HLS) for 10 days, we induced marked muscle atrophy that was accompanied by enhanced muscle proteolysis and reduced muscle protein content. When HLS rats were treated with IGF-1/BP3 (50 mg/kg, b.i.d.), they retained greater body and muscle mass. Muscle protein degradation was significantly reduced and muscle protein content was preserved. The rate of protein synthesis, although somewhat reduced in HLS muscle, was not significantly elevated by IGF-1/BP3 treatment. Volume density of HLS-treated muscles were increased compared to untreated HLS rats and the actual number of fibers per area of muscle was likewise increased. The results of the current study suggest that IGF-1/BP3 might be useful for inhibiting muscle proteolysis in catabolic conditions and thus preserving muscle protein content and mass.