Using a problem detection study (PDS) to identify and compare health care provider and consumer views of antihypertensive therapy

The objectives of this study were to ascertain consumer knowledge and behaviour about hypertension and treatment and to compare these with health care providers' perceptions (of 'most' consumers). The design for the study was a problem detection study (PDS): focus groups and then survey. Focus groups and survey participants were convenience samples of consumers, doctors, nurses and pharmacists. The main outcome measures were agreement on a 5-point Likert scale with statements about consumers' knowledge and behaviour about high blood pressure and medication. The survey identified areas of consensus and disagreement between consumers and health providers. While general knowledge and concordance with antihypertensive therapy among consumers was good, consequences such as eye and kidney disease, interactions with herbal medicines, and how to deal with missing a dose were less well known. Side effects were a problem for over one-quarter of participants, and cost was a problem in continuing therapy. Half the consumers had not received sufficient written information. Providers overall disagreed that most consumers have an adequate understanding of the condition. They agreed that most consumers adhere to therapy and can manage medicines; and about their own profession's role in information provision and condition management. Consumers confirmed positive provider behaviour, suggesting opportunities for greater communication between providers about actions taken with their consumers. In conclusion, the PDS methodology was useful in identifying consumer opinions. Differences between consumer and provider responses were marked, with consumers generally rating their knowledge and behaviour above providers' ratings of 'most' consumers. There are clear gaps to be targeted to improve the outcomes of hypertension therapy.

Use of complementary and alternative medicine and quality of life: changes at the end of life

The purpose of this study was to compare the physical, psychological and social dimensions associated with quality-of-life outcomes over the last year of life, between advanced cancer users and nonusers of complementary and alternative medicine. One hundred and eleven patients were identified through Queensland Cancer Registry records, and followed up every four to six weeks until close to death using standardized protocols. Outcome measures were symptom burden, psychological distress, subjective wellbeing, satisfaction with conventional medicine and need for control over treatment decisions. At the initial interview, 36 (32%) participants had used complementary/ alternative medicine the previous week; mainly vitamins, minerals and tonics and herbal remedies. Among all participants, 53 (48%) used at least one form of complementary/ alternative medicine over the study period. Only six (11%) visited alternative practitioners on a regular basis. Overall, complementary/ alternative medicine users reported higher levels of anxiety and pain, less satisfaction with conventional medicine and lower need for control over treatment decisions compared with nonusers. These differences tend to change as death approaches. A more rigorous assessment of complementary/ alternative medicine use, psychological distress, pain and subjective wellbeing among patients with advanced cancer is needed in the clinical setting.

The antlepileptic Materia Medica of Pedoacus Dioscorides

Since it was written about the middle of the 1st Century AD, and up to comparatively recent times, the great Herbal, or Materia Medica, of Dioscorides provided medicine with its chief source of information about what were then considered therapeutic substances. The work contained data on various materials of botanical, biological and mineral origin which were claimed to provide benefit to sufferers from epilepsy, though often with no clear underlying rationale for their use. Some of these materials continued to be used as antiepileptic remedies over many centuries till they were finally recognised to be without useful effect in the disorder. The longest survivor amongst the Dioscoridean antiepileptic remedies was a rather esoteric one, viz. two stones taken from the belly of a young swallow during the rising phase of the moon and also whilst the swallow's parent birds were absent from the nest. The stones, or one of them, were worn against the skin of the seizure sufferer. The use of the swallow stones for epilepsy was recommended as late as in the writings of Thomas Willis (1675). (C) 2004 Elsevier Ltd. All rights reserved.

A prospective study of the use of alternative therapies by men with localized prostate cancer

Although the use of alternative therapies is highly prevalent amongst men with prostate cancer, research about the predictors of such use is limited. The current study aimed to describe prospectively the use of alternative therapies by men diagnosed with localized prostate cancer and identify predictors of alternative therapy use. In all, 111 men newly diagnosed with localized prostate cancer (93% response) were recruited to the study prior to treatment. Men's use of alternative therapies and psychological variables including: psychological distress, orientation to health care, decisional conflict, and health locus of control, were assessed at three time points-(1) before treatment; (2) 2 months after completion of treatment; and (3) 12 months after completion of treatment. Demographic information was also obtained. The percentage of men using alternative therapies was 25, 17 and 14% before treatment, 2 and 12 months after treatment, respectively. In general, the most commonly used therapies were dietary changes, vitamins and herbal and nutrient remedies. Alternative therapy use was not related to final treatment choices. Before treatment, men who used alternative therapies were more uncertain about prostate cancer compared to men who were not using these therapies. Men who were using alternative therapies 12 months after treatment were less psychologically distressed that men who were not using these therapies. Health locus of control and orientation to health care were not found to be related to men's use of alternative therapies. In conclusion, men's use of alternative therapies after localized prostate cancer varied across time in terms of the incidence of use, the types of therapies used, and the psychological correlates of therapy use. Informational support that targets uncertainty about prostate cancer may assist men at diagnosis who are considering alternative therapy use. The potential for alternative therapies to have a supportive function in patient care requires further investigation. (C) 2003 Elsevier Ireland Ltd. All rights reserved.

Echinacea alkamide disposition and pharmacokinetics in humans after tablet ingestion

Echinacea is a widely used herbal remedy for the treatment of colds and other infections. However, almost nothing is known about the disposition and pharmacokinetics of any of its components, particularly the alkamides and caffeic acid conjugates which are thought to be the active phytochemicals. In this investigation, we have examined serial plasma samples from 9 healthy volunteers who ingested echinacea tablets manufactured from ethanolic liquid extracts of Echinacea angustifolia and Echinacea purpurea immediately after a standard high fat breakfast. Caffeic acid conjugates could not be identified in any plasma sample at any time after tablet ingestion. Alkamides were rapidly absorbed and were measurable in plasma 20 min after tablet ingestion and remained detectable for up to 12 h. Concentration-time curves for 2,4-diene and 2-ene alkamides were determined. The maximal concentrations for the sum of alkamides in human plasma were reached within 2.3 h post ingestion and averaged 336 +/- 131 ng eq/mL plasma. No obvious differences were observed in the pharmacokinetics of individual or total alkamides in 2 additional fasted subjects who took the same dose of the echinacea preparation. This single dose study provides evidence that alkamides are orally available and that their pharmacokinetics are in agreement with the one dose three times daily regimen already recommended for echinacea.

Cytochrome P450 enzyme-mediated degradation of Echinacea alkylamides in human liver microsomes

Echinacea preparations are widely used herbal remedies for the prevention and treatment of colds. In this study we have investigated the metabolism by human liver microsomes of the alkylamide components from an Echinacea preparation as well as that of pure synthetic alkylamides. No significant degradation of alkylamides was evident in cytosolic fractions. Time and NADPH-dependent degradation of alkylamides was observed in microsomal fractions suggesting they are metabolised by cytochrome P450 (P450) enzymes in human liver. There was a difference in the susceptibility of 2-ene and 2,4-diene pure synthetic alkylamides to microsomal degradation with (2E)-N-isobutylundeca-2-ene-8,10-diynamide (1) metabolised to only a tenth the extent of (2E,4E,8Z,IOZ)-N-isobutyldodeca-2,4,8,10-tetracnamide (3) under identical incubation conditions. Markedly less degradation of 3 was evident in the mixture of alkylamides present in an ethanolic Echinacea extract, suggesting that metabolism by liver P450s was dependent both on their chemistry and the combination present in the incubation. Co-incubation of 1 with 3 at equimolar concentrations resulted in a significant decrease in the metabolism of 3 by liver microsomes. This inhibition by 1, which has a terminal alkyne moiety, was found to be time- and concentration-dependent, and due to a mechanism-based inactivation of the P450s. Alkylamide metabolites were detected and found to be the predicted epoxidation, hydroxylation and dealkylation products. These findings suggest that Echinacea may effect the P450-mediated metabolism of other concurrently ingested pharmaceuticals. (c) 2005 Elsevier Ireland Ltd. All rights reserved.

Characteristics of older dietary supplement users: Review of the literature

Published literature reports rates of dietary supplement usage by individuals aged 60 years or more to be 16−60%. Prevalence figures are dependent on the population studied and the method of data collection. In general, older supplement users are female, Caucasian and well educated, with healthier lifestyle practices than non-supplement users, and they are less likely to be overweight or to smoke. Neither income nor self-rated health status are reliable predictors of supplement use in this group. In many cases older supplement users report higher intakes of several micronutrients from food than older non-supplement users. Current patterns of supplement use by the older person reveal that although they consume a range of products, they do not supplement with nutrients that are of particular benefit to them. The supplements most commonly consumed by individuals aged 60 years and over are multivitamins and minerals, vitamin C and vitamin E preparations. There is insufficient data to quantify the dosage, frequency and duration of supplement use by the older population. Obtaining this information and data about herbal medicine use is an important step towards minimising the risk of drug–nutrient–herbal interactions. Identifying the health professionals who monitor the appropriateness and safety of supplement use in older individuals, particularly given the already high use of medication in this population, also needs to be a focus of future utilisation investigations. This systematic review of the literature published between 1982 and 2003 aims to measure the patterns of dietary supplement use by community-living individuals aged 60 years and over and to profile the characteristics of older supplement users.

Gingerol content of diploid and tetraploid clones of ginger (Zingiber officinale Roscoe)

Ginger (Zingiber officinale, Roscoe), a monocotyledonous, sterile cultigen, is widely used as a spice, flavoring agent, and herbal medicine. The pungency of fresh ginger is due to a series of homologous phenolic ketones of which [6]-gingerol is the major one. The gingerols are thermally unstable and can be converted to their corresponding shogaols, which are present in dried ginger, Fresh rhizomes of 17 clones of Australian ginger, including commercial cultivars and experimental tetraploid clones, were assayed by HPLC for gingerols and shogaols. [6]-Gingerol was identified as the major pungent phenolic compound in all samples, while [8]- and [10]-gingerol occurred in lower concentrations. One cultivar known as Jamaican contained the highest concentrations of all three gingerols and was the most pungent of the clones analyzed. Gingerols were stable in ethanolic solution over a 5-month period when stored at 4 degrees C. Shogaols were not identified in the extracts prepared from fresh rhizomes at ambient temperature, confirming that these compounds are not native constituents of fresh ginger, In contrast to previous findings, this study did not find significant differences in gingerol concentrations between the tetraploid clones and their parent diploid cultivar.

Modulation of macrophage immune responses by Echinacea

Echinacea preparations are widely used herbal medicines for the prevention and treatment of colds and minor infections. There is little evidence for the individual components in Echinacea that contribute to immune regulatory activity. Activity of an ethanolic Echinacea extract and several constituents, including cichoric acid, have been examined using three in vitro measures of macrophage immune function - NF-kappa B, TNF-alpha and nitric oxide (NO). In cultured macrophages, all components except the monoene alkylamide (AA1) decreased lipopolysaccharide (LPS) stimulated NF-kappa B levels. 0.2 mu g/ml cichoric acid and 2.0 mu g/mL Echinacea Premium Liquid (EPL) and EPL alkylamide fraction (EPL AA) were found to significantly decrease TNF-alpha production under LPS stimulated conditions in macrophages. In macrophages, only the alkylamide mixture isolated from the ethanolic Echinacea extract decreased LPS stimulated NO production. In this study, the mixture of alkylamides in the Echinacea ethanolic liquid extract did not respond in the same manner in the assays as the individual alkylamides investigated. While cichoric acid has been shown to affect NF-kappa B, TNF-alpha and NO levels, it is unlikely to be relevant in the Echinacea alterations of the immune response in vivo due to its nonbioavailability - i.e. no demonstrated absorption across the intestinal barrier and no detectable levels in plasma. These results demonstrate that Echinacea is an effective modulator of macrophage immune responses in vitro.

Bilberry adulteration using the food dye amaranth

Vaccinium myrtillus or bilberry fruit is a commonly used herbal product. The usual method of determining the anthocyanin content is a single-wavelength spectrophotometric assay. Using this method, anthocyanin levels of two extracts were found to be 25% as claimed by the manufacturers. When high-performance liquid chromatography (HPLC) was used, however, one extract was found to contain 9% anthocyanins probably not derived from V. myrtillus but from an adulterant. This adulterant was subsequently identified, using HPLC, mass spectroscopy, and nuclear magnetic resonance, as amaranth, that is, 3-hydroxy-4-[(4-sulfo-1-naphthalenyl)azo]-2,7-naphthalenedisulfonic acid trisodium saltsa synthetic dark red sulfonic acid based naphthylazo dye. As described in this study, if deliberate adulteration occurs in an extract, a single-wavelength spectrophotometric assay is inadequate to accurately determine the levels of compounds such as anthocyanins. Detection of deliberate adulteration in commercial samples thus requires the use of alternative, more sophisticated, methods of analysis such as HPLC with photodiode array detection as a minimum.