Toxicity of complementary therapies: an eastern perspective

Risk factors and outcomes of peptic ulcer bleed in a Pakistani population: A single-center observational study

BACKGROUND

Peptic ulcer disease (PUD) remains a significant healthcare burden, contributing to morbidity and mortality worldwide. Despite advancements in therapies, its prevalence persists, particularly in regions with widespread nonsteroidal anti-inflammatory drugs (NSAIDs) use and Helicobacter pylori infection.

AIM

To comprehensively analyse the risk factors and outcomes of PUD-related upper gastrointestinal (GI) bleeding in Pakistani population.

METHODS

This retrospective cohort study included 142 patients with peptic ulcer bleeding who underwent upper GI endoscopy from January to December 2022. Data on demographics, symptoms, length of stay, mortality, re-bleed, and Forrest classification was collected.

RESULTS

The mean age of patients was 53 years, and the majority was men (68.3%). Hematemesis (82.4%) and epigastric pain (75.4%) were the most common presenting symptoms. Most patients (73.2%) were discharged within five days. The mortality rates at one week and one month were 10.6% and 14.8%, respectively. Re-bleed within 24 h and seven days occurred in 14.1% and 18.3% of patients, respectively. Most ulcers were Forrest class (FC) III (72.5%). Antiplatelet use was associated with higher mortality at 7 and 30 d, while alternative medications were linked to higher 24-hour re-bleed rates. NSAID use was associated with more FC III ulcers. Re-bleed at 24 h and 7 d was strongly associated with one-week or one-month mortality.

CONCLUSION

Antiplatelet use and rebleeding increase the risk of early mortality in PUD-related upper GI bleeding, while alternative medicines are associated with early rebleeding.

Treatment of Lupus Nephritis from Iranian Traditional Medicine and Modern Medicine Points of View: A Comparative Study

Objective

Nephritis or kidney inflammation is characterized as one of the most common renal disorders leading to serious damage to the kidneys. Nephritis, especially lupus nephritis (LN), has remained as the main cause of chronic renal failure which needs serious therapeutic approaches such as dialysis and kidney transplant. Heredity, infection, high blood pressure, inflammatory diseases such as lupus erythematosus and inflammatory bowel disease, and drug-related side effects are known as the main causes of the disease. According to Iranian traditional medicine (ITM), infectious diseases and fever are the main reasons of nephritis, which is called “Varam-e-Kolye” (VK).

Results

There are various plant-based remedies recommended by ITM for the treatment of nephritis, as discussed herein, comparing with those available in the modern medicine. There is no definite cure for the treatment of nephritis, and immunosuppressive drugs such as corticosteroids and nonsteroidal anti-inflammatory drugs, antibiotics, diuretics, analgesics, and finally dialysis and kidney transplantation are usually used. Based on the efficacy of medicinal plants, jujube (Ziziphus jujuba), almond (Prunus amygdalus), pumpkin seeds (Cucurbita pepo), purslane (Portulaca oleracea), and fig (Ficus carica) were found to be effective for the treatment of kidney inflammation in ITM.

Conclusion

Considering the fact that there is no efficient strategy for the treatment of nephritis, use of herbal medicine, particularly based on the fruits or nuts that have been safely used for several years can be considered as a versatile supplement along with other therapeutic methods.

O/W microemulsion droplets diffuse through hydrogel network to achieve enhanced transdermal drug delivery

To overcome the poor water solubility of total flavones of Arisaematis rhizoma, microemulsions (MEs) can be used as a carrier for transdermal administration to promote their solubilization and skin permeability. Here, we investigated the physical compatibility of MEs in hydrogels and their skin permeation-enhancing effects. Transparency of microemulsion-based hydrogels (MBGs) was analyzed to evaluate ME compatibility with different hydrogel matrices. Transmission electron microscopy (TEM) and Fourier transform infrared (FTIR) spectroscopy were used to explore the microstructures of MBGs and ME–hydrogel combinations. Uniform and transparent MBG was obtained by adding 1% sodium hyaluronate (SH) to the optimized ME. MBG prepared with SH as a matrix expressed pseudoplastic-fluid and shear-thinning characteristics, making it easy to apply in clinical settings. No new FTIR peak occurred in the MBG compared with ME and hydrogel matrix, indicating a physical combination of ME and the polymer network gel. Nanoscale droplets of ME migrated in the gel network, and the migration capacity and in vitro transdermal permeation flux negatively correlated with SH concentration in the gel system. In conclusion, in MBGs, ME can keep nanoscale droplets migrating in the hydrogel network, thereby enhancing transdermal drug delivery.

Ethnobotany, ethnopharmacology, and phytochemistry of traditional medicinal plants used in the management of symptoms of tuberculosis in East Africa: a systematic review

OBJECTIVE

Many studies on the treatment of tuberculosis (TB) using herbal medicines have been undertaken in recent decades in East Africa. The details, however, are highly fragmented. The purpose of this study was to provide a comprehensive overview of the reported medicinal plants used to manage TB symptoms, and to analyze scientific reports on their effectiveness and safety.

METHOD

A comprehensive literature search was performed in the major electronic databases regarding medicinal plants used in the management of TB in East Africa. A total of 44 reports were retrieved, and data were collected on various aspects of the medicinal plants such as botanical name, family, local names, part(s) used, method of preparation, efficacy, toxicity, and phytochemistry. The data were summarized into percentages and frequencies which were presented as tables and graphs.

RESULTS

A total of 195 species of plants belonging to 68 families and 144 genera were identified. Most encountered species were from Fabaceae (42.6%), Lamiaceae (19.1%), Asteraceae (16.2%), and Euphorbiaceae (14.7%) families. Only 36 medicinal plants (18.5%) have been screened for antimycobacterial activity. Out of these, 31 (86.1%) were reported to be bioactive with minimum inhibitory concentrations ranging from 47 to 12,500 μg/ml. Most tested plant extracts were found to have acceptable acute toxicity profiles with cytotoxic concentrations on normal mammalian cells greater than 200 μg/ml. The most commonly reported phytochemicals were flavonoids, terpenoids, alkaloids, saponins, cardiac glycosides, and phenols. Only Tetradenia riparia, Warburgia ugandensis, and Zanthoxylum leprieurii have further undergone isolation and characterization of the pure bioactive compounds.

CONCLUSION

East Africa has a rich diversity of medicinal plants that have been reported to be effective in the management of symptoms of TB. More validation studies are required to promote the discovery of antimycobacterial drugs and to provide evidence for standardization of herbal medicine use.

Influence of MAMA decoction, an Herbal Antimalarial, on the Pharmacokinetics of Amodiaquine in Mice

BACKGROUND AND OBJECTIVE

MAMA decoction (MD) is an antimalarial product prepared from the leaves of Mangifera indica L. (Anacardiaceae), Alstonia boonei De Wild (Apocynaceae), Morinda lucida Benth (Rubiaceae) and Azadirachta indica A. Juss (Meliaceae). A previous report showed that MD enhanced the efficacy of amodiaquine (AQ) in malaria-infected mice, thus suggesting a herb-drug interaction. The present study hence evaluated the effect of MD on the disposition of AQ in mice with a view to investigating a possible pharmacokinetic interaction.

METHODS

In a 3-period study design, three groups of mice (n = 72) were administered oral doses of AQ (10 mg/kg/day) alone, concurrently with MD (120 mg/kg/day), and in the 3rd period, mice were given AQ after a 3-day pre-treatment with MD. Blood samples were collected between 0 and 96 h for quantification of AQ and its major metabolite, desethylamodiaquine, by a validated high-performance liquid chromatography method.

RESULTS

Maximum concentrations of AQ increased by 12% with the concurrent dosing of MD and by 85% in the group of mice pre-treated with MD. The exposure and half-life of desethylamodiaquine increased by approximately 11% and 21%, respectively, with concurrent administration. Corresponding increases of approximately 20% and 33% of desethylamodiaquine were also observed in mice pre-treated with MD.

CONCLUSION

MD influenced the pharmacokinetics of AQ and desethylamodiaquine, its major metabolite. The increase in the half-life and systemic exposure of AQ following its co-administration with MD may provide a basis for the enhanced pharmacological effect of the combination in an earlier study in Plasmodium-infected mice.

Collective exposure to lead from an approved natural product-derived drug in Korea

Background

In Asian countries, including Korea, lead poisoning caused by traditional herbal medicines is often observed in the clinic. However, there have been no reports thus far of lead poisoning caused by drugs that were approved by the Korea Food and Drug Administration (KFDA). Here, we describe seven patients who ingested a problematic natural product-derived drug (NPD).

Case presentation

In July 2018, seven patients visited a university hospital after ingesting an NPD, S. capsules. These patients complained of various symptoms, and their blood lead levels (BLLs) were elevated relative to those of the general population (arithmetic mean: 19.5 ± 11.6 µg/dL, range: 6.28–35.25 µg/dL). The total doses and BLLs were directly proportional to each other among the patients (r = 0.943, p = 0.001). After the patients discontinued drug intake, their BLLs decreased gradually. The capsule was confirmed to contain lead above the standard value (arithmetic mean: 2,547 ± 1,821.9 ppm).

Conclusion

This incident highlights the need to strengthen standards for the management of NPD ingredients in Korea. NPDs are more likely to be contaminated than other drugs. Thorough management by the KFDA is essential to prevent a recurrence. Moreover, systematic health care is needed for many patients who have taken problematic NPDs.

Genotoxicity and antigenotoxicity study of aqueous and hydro-methanol extracts of Spondias mombin L., Nymphaea lotus L. and Luffa cylindrical L. using animal bioassays

Spondias mombin (Linn), Nymphaea lotus (Linn) and Luffa cylindrica (Linn) (syn Luffa aegyptiaca Mill) are plants traditionally used as food ingredients and in the management of diseases, including cancer, in Nigeria. Despite the therapeutic potentials attributed to these plants, reports on their genotoxicity are scanty. In this study, the genotoxicity of the aqueous and hydro-methanol extract of these plants was evaluated using mouse bone marrow micronucleus and sperm morphology assays. Antigenotoxicity was assessed by the bone marrow micronucleus test. The highest attainable dose of 5 000 mg/kg according to OECD guidelines was first used to assess acute toxicity of the aqueous and hydro-methanol extracts in Swiss albino mice. For each extract, there were five groups of mice (n=4/group) treated with different concentrations of the extract as against the negative and positive control group for the genotoxicity study. In the antigenotoxicity study, five groups of mice were exposed to five different concentrations of the extracts along with 60 mg/kg of methyl methane sulfonate (MMS), which was used to induce genotoxicity. The mice were administered 0.2 mL of extract per day for 10 days in the genotoxicity and antigenotoxicity groups. Administration of each of the extracts at the concentration of 5 000 mg/kg did not induce acute toxicity in mice. At the concentrations tested, all the extracts, except aqueous S. mombin, increased micronucleated polychromatic erythrocytes. The aqueous and hydro-methanol extracts of N. lotus increased the frequency of aberrant sperm cells. All the extracts were also able to ameliorate MMS induced genotoxicity in bone marrow cells of the exposed mice. The results showed the potential of the extracts to induce somatic and germ cell mutation in male mice. The extracts also ameliorated the genotoxic effect of MMS.

Identification of constituent herbs in ginseng decoctions by DNA markers

Background

DNA in herbal decoctions is usually fragmented by extensive boiling and is usually regarded as unsuitable for molecular authentication. This study aims to evaluate the feasibility for molecular authentication methods by multiplex polymerase chain reaction (PCR) and DNA sequencing for decoctions.

Methods

The DNA extraction procedure, sample pulverization and boiling time were examined in (1) single herb decoction with Panax ginseng (“ginseng”) or P. quinquefolius (“American ginseng”), (2) decoctions of two classical ginseng prescriptions of five herbal materials (Aconitum carmichaeli, Atractylodes macrocephala, P. ginseng, Glycyrrhiza uralensis and Zingiber officinale) and (3) a commercial ready-to-serve ginseng soup. Primers were designed from 26S-18S, ITS2 and trnH-psbA region, with DNA sequences obtained from GenBank. Multiplex PCR was also employed in ginseng or American ginseng decoctions to differentiate between these two herbs.

Results

All six herbal species tested in this study could be identified in decoctions. We had four main observations: (1) sample pulverization before boiling improved PCR detection; (2) prolonged boiling increased the DNA concentration but decreased the intactness of DNA fragments; (3) ginseng could be differentiated from American ginseng by multiplex PCR; (4) identification of individual herbs in multi-herb decoctions with prolonged boiling time of 180 min could be achieved.

Conclusions

DNA could be amplified from extensively boiled ginseng decoctions, multi-herb decoctions and commercial soup although DNA degradation was critical to successful PCR.

Electronic supplementary material

The online version of this article (doi:10.1186/s13020-015-0029-x) contains supplementary material, which is available to authorized users.

Toxicity assessment of Arisaematis Rhizoma in rats by a 1H NMR-based metabolomics approach

A ¹H NMR based metabolomics approach combined with serum biochemistry and histopathological examination was used to study the toxicity of Arisaematis Rhizoma by intragastrical administration for the first time.

Adverse events associated with metal contamination of traditional chinese medicines in Korea: a clinical review

This study was performed to review studies carried out in Korea reporting toxic reactions to traditional Chinese medicines (TCMs) as a result of heavy metal contamination. PubMed (1966-August 2013) and International Pharmaceutical Abstracts (1965-August 2013) were searched using the medical subject heading terms of "Medicine, Chinese Traditional," "Medicine, Korean Traditional," "Medicine, Traditional," "Metals, Heavy," and "Drug Contamination". For Korean literature, Korea Med (http://www.koreamed.org), the Korean Medical Database (http://kmbase.medric.or.kr), National Discovery for Science Leaders (www.ndsl.kr), Research Information Sharing Service (http://www.riss.kr), and Google Scholar were searched using the terms "Chinese medicine," "Korean medicine," "herbal medicine," and "metallic contamination" in Korean. Bibliographies of case reports and case series, identified using secondary resources, were also utilized. Only literature describing cases or studies performed in Korea were included. Case reports identified clear issues with heavy metal, particularly lead, contamination of TCMs utilized in Korea. No international standardization guidelines for processing, manufacturing and marketing of herbal products exist. Unacceptably high levels of toxic metals can be present in TCM preparations. Health care providers and patients should be educated on the potential risks associated with TCMs. International advocacy for stricter standardization procedures for production of TCMs is warranted.

Complementary and alternative medications in hepatitis C infection

Chronic hepatitis C (CHC) infection affects almost 3% of the global population and can lead to cirrhosis, liver failure, and hepatocellular carcinoma in a significant number of those infected. Until recently, the only treatments available were pegylated interferon and ribavirin, which traditionally were not very effective and have considerable side effects. For this reason, interest in complementary and alternative medications (CAM) in the management of hepatitis C has been investigated. Some CAM has demonstrated therapeutic potential in chronic hepatitis C treatment. Unfortunately, some CAM has been shown to have the potential to cause drug-induced liver injury. This article will review and evaluate many of the natural molecules that interact with the hepatitis C virus (HCV) life cycle and discuss their potential use and safety in HCV therapy, as well as highlight some important interactions between medical and complementary treatments.

Acute adverse events from over-the-counter Chinese herbal medicines: a population-based survey of Hong Kong Chinese

Background

Although over-the-counter traditional Chinese herbal medicine (COTC) is commonly used to treat everyday illness in many parts of the world, no population-based study has been done to examine the prevalence and factors associated with COTC-related adverse events.

Methods

A cross-sectional telephone survey was conducted among Hong Kong Chinese adults in 2011 (n = 1100) with informed verbal consent. Stepwise logistic regression of demographic, attitudinal and behavioral variables was used to determine factors associated with past-year adverse events.

Results

Of study respondents, 71.7% (789/1100) reported past-year COTC use and 2.3% (25/1100) reported at least one COTC-related adverse event in the past year. Of the 27 adverse events cases reported among COTC users, the most common were allergic reactions (n = 11) dizziness (n = 5), and gastro-intestinal problems (n = 4). Pills/capsules were the dosage form that caused the highest proportion of adverse events (n = 10), followed by plasters (n = 7), creams/ointments (n = 5), and ingestible powders (n = 2).

Although COTC users reporting adverse events were more likely to report greater practices to avoid adverse events (OR = 6.47; 95% CI: 1.38-30.3); they were also more likely to possess lower education levels (OR = 9.64, 95% CI: 2.20-42.3) and to have received COTC information from non-reliable, mass-media information sources such as magazines (OR = 3.32; 95% CI: 1.01-8.50) or television (OR = 2.93; 95% CI: 1.03-10.7). Package labels were also felt to be unclear by 42.9% of COTC users. A large proportion of COTC users demonstrated low levels of COTC-related knowledge, while the main impediment to greater information-seeking was the belief that reliable COTC information is not obtainable from Western health professionals.

Conclusions

Despite global movements toward more stringent complementary medicine regulation, the limited accessibility of reliable information and widespread misperceptions among consumers present major challenges for the safe use of complementary medicine.

In vitro and in vivo safety evaluation of Acer tegmentosum

ETHNOPHARMACOLOGICAL RELEVANCE

Acer tegmentosum, which contains salidroside and tyrosol, has been used for the treatment of hepatic disorders in eastern Asia. However, little is known about its safety.

AIM OF THE STUDY

To determine the safety of Acer tegmentosum, we evaluated its acute oral toxicity and genotoxicity profiles.

MATERIALS AND METHODS

Salidroside and tyrosol present in Acer tegmentosum were quantified using high-performance liquid chromatography. Acute oral toxicity testing of Acer tegmentosum was performed in rats. Genotoxicity of Acer tegmentosum was assessed by bacterial reverse mutation, chromosomal aberration, and bone marrow micronucleus tests. All the tests were conducted in accordance with the good laboratory practices.

RESULTS

The amounts of salidroside and tyrosol in Acer tegmentosum were found to be 85.01±1.21mg/g and 3.12±0.04mg/g, respectively. In the bacterial reverse mutation test, Acer tegmentosum increased the number of revertant Salmonella typhimurium TA98 colonies, regardless of metabolic activation by S9 mixture. In contrast, Acer tegmentosum application did not significantly increase the number of chromosomal aberrations in Chinese hamster ovary (CHO)-K1 cells and micronucleated polychromatic erythrocytes in mice. In the acute oral toxicity test, the median lethal dose (LD50) of Acer tegmentosum was found to be >2000mg/kg in rats.

CONCLUSION

Take together, Acer tegmentosum exhibits mutagenicity, which was evident from the bacterial reverse mutation test. Further studies are needed to identify the components responsible for such an effect and the underlying mechanisms.

Ethnopharmacological Survey of Plants Used in the Traditional Treatment of Gastrointestinal Pain, Inflammation and Diarrhea in Africa: Future Perspectives for Integration into Modern Medicine

There is a growing need to find the most appropriate and effective treatment options for a variety of painful syndromes, including conditions affecting the gastrointestinal tract, for treating both veterinary and human patients. The most successful regimen may come through integrated therapies including combining current and novel western drugs with acupuncture and botanical therapies or their derivatives. There is an extensive history and use of plants in African traditional medicine. In this review, we have highlighted botanical remedies used for treatment of pain, diarrheas and inflammation in traditional veterinary and human health care in Africa. These preparations are promising sources of new compounds comprised of flavonoids, bioflavanones, xanthones, terpenoids, sterols and glycosides as well as compound formulas and supplements for future use in multimodal treatment approaches to chronic pain, gastrointestinal disorders and inflammation. The advancement of plant therapies and their derivative compounds will require the identification and validation of compounds having specific anti-nociceptive neuromodulatory and/or anti-inflammatory effects. In particular, there is need for the identification of the presence of compounds that affect purinergic, GABA, glutamate, TRP, opioid and cannabinoid receptors, serotonergic and chloride channel systems through bioactivity-guided, high-throughput screening and biotesting. This will create new frontiers for obtaining novel compounds and herbal supplements to relieve pain and gastrointestinal disorders, and suppress inflammation.

Toxic element contamination of natural health products and pharmaceutical preparations

BACKGROUND

Concern has recently emerged regarding the safety of natural health products (NHPs)-therapies that are increasingly recommended by various health providers, including conventional physicians. Recognizing that most individuals in the Western world now consume vitamins and many take herbal agents, this study endeavored to determine levels of toxic element contamination within a range of NHPs.

METHODS

Toxic element testing was performed on 121 NHPs (including Ayurvedic, traditional Chinese, and various marine-source products) as well as 49 routinely prescribed pharmaceutical preparations. Testing was also performed on several batches of one prenatal supplement, with multiple samples tested within each batch. Results were compared to existing toxicant regulatory limits.

RESULTS

Toxic element contamination was found in many supplements and pharmaceuticals; levels exceeding established limits were only found in a small percentage of the NHPs tested and none of the drugs tested. Some NHPs demonstrated contamination levels above preferred daily endpoints for mercury, cadmium, lead, arsenic or aluminum. NHPs manufactured in China generally had higher levels of mercury and aluminum.

CONCLUSIONS

Exposure to toxic elements is occurring regularly as a result of some contaminated NHPs. Best practices for quality control-developed and implemented by the NHP industry with government oversight-is recommended to guard the safety of unsuspecting consumers.

Interventions for preventing infection in nephrotic syndrome

BACKGROUND

Infection is one of the most common complications and still remains a significant cause of morbidity and occasionally mortality in patients, especially children with nephrotic syndrome. Many different prophylactic interventions have been used or recommended for reducing the risks of infection in nephrotic syndrome in clinical practice. Whether the existing evidence is scientifically rigorous and which prophylactic intervention can be recommended for routine use based on the current evidence is still unknown.

OBJECTIVES

To assess the benefits and harms of any prophylactic intervention for reducing the risk of infection in children and adults with nephrotic syndrome.

SEARCH METHODS

We searched the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL) (in The Cochrane Library), MEDLINE and Pre-MEDLINE (from 1966), EMBASE (from 1980), China Biological Medicine Database (1979 to December 2009), Chinese Science and Technique Journals Database (to December 2009), China National Infrastructure (to December 2009), WangFang database (to December 2009), reference lists of nephrology textbooks, review articles, relevant studies and abstracts from nephrology meetings without language restriction.Date of last search: 6 February 2012

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing any prophylactic interventions (pharmacological or non-pharmacological) for preventing any infection in children and adults with nephrotic syndrome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted information. Information was collected on methods, participants, interventions and outcomes (appearance of infection, mortality, quality of life and adverse events). Results were expressed as risk ratios (RR) for dichotomous outcomes or as mean differences (MD) for continuous data with 95% confidence intervals (CI).

MAIN RESULTS

Twelve studies conducted in China, including 762 children with nephrotic syndrome were identified. No studies were identified in adults. All studies compared one kind of prophylactic pharmacotherapy (intravenous immunoglobulin (IVIG), thymosin, oral transfer factor, mannan peptide tablet, Bacillus Calmette-Guerin (BCG) vaccine injection, polyvalent bacterial vaccine (Lantigen B) and two kinds of Chinese medicinal herbs: a compound of Chinese medicinal herbs (TIAOJINING) and Huangqi (astragalus) granules) plus baseline treatment with baseline treatment alone. No RCTs were identified comparing antibiotics, non-pharmacological prophylaxis, or pneumococcal vaccination. Four studies showed a significantly beneficial effect of IVIG on preventing nosocomial or unspecified infection in children with nephrotic syndrome (RR 0.47, 95% CI 0.31 to 0.73). Thymosin (RR 0.50, 95% CI 0.26 to 0.97), oral transfer factor (RR 0.51, 95% CI 0.35 to 0.73), BCG vaccine injection (RR 0.68, 95% CI 0.48 to 0.95), Huangqi granules (RR 0.62, 95% CI 0.47 to 0.83) and TIAOJINING (RR 0.59, 95% CI 0.43 to 0.81) were also effective in reducing the risk of infection in children with nephrotic syndrome. However mannan peptide tablet (RR 0.46, 95% CI 0.21 to 1.01) and polyvalent bacterial vaccine (RR 0.24, 95% CI 0.06 to1.00) were not superior to baseline treatment in reducing the risk of infection for nephrotic children. No serious adverse events were reported.

AUTHORS' CONCLUSIONS

IVIG, thymosin, oral transfer factor, BCG vaccine, Huangqi granules and TIAOJINING may have positive effects on the prevention of nosocomial or unspecified infection with no obvious serious adverse events in children with nephrotic syndrome. However the methodological quality of all studies was poor, the sample sizes small, and all studies were from China, and thus there is no strong evidence on the effectiveness of these interventions.

Evidence for Improved Neuropharmacological Efficacy and Decreased Neurotoxicity in Mice with Traditional Processing of Rhizoma Arisaematis

Rhizoma Arisaematis (RA, the rhizome of Pinellia pedatisecta Schott) is a traditional Chinese medicine commonly used in the treatment of convulsions, inflammation, and cancer. Despite the fact that it has been used for more than 2000 years, the pharmacological and toxic effects of traditionally processed products of RA are still unclear. In this study, we attempted to investigate the effects exerted by untreated crude RA and different preparations of RA treated with alumen in combination with ginger juice (Zhinanxing) or bile juice (Dannanxing) in ICR mice. The results showed that both the Zhinanxing and Dannanxing water extracts exerted significantly increased sedative effects, as indicated by the inhibitory effects on ambulatory distances, jumps, vertical-plane entries, and prolonged pentobarbital-induced sleeping time. The extracts also exerted significantly increased analgesic effects (increase of tail flick latency in nociceptive testing) in mice than did the unprocessed crude RA after oral administration for one to three days, and effects persisted 18 days after the cessation of treatment. By contrast, the toxic effects, such as an increase in stereotype-1 episodes of locomotor activities and reduction of the retention time on a rotating rod (motor equilibrium dysfunction), were observed only in mice treated with the unprocessed crude RA for three consecutive days, and effects persisted for 18 days after the cessation of treatment. These neurotoxic effects were accompanied by an increase in plasma lipid peroxidation (LPO), decrease in whole blood nitric oxide (NOx) levels, and inhibition of Na +/ K +-ATPase activities in membrane fractions of erythrocytes and in the cerebral cortex. In conclusion, these findings provide scientific evidence that the processed RA indeed possesses not only enhanced neuropharmacological efficacy but also reduced neurotoxic effects as compared to the unprocessed crude RA. The signaling of NO x/oxidative stress/ Na +- K +- ATPase activities played a role, at least in part, in the underlying mechanisms of neurotoxic effects induced by the crude RA.

Sulfur fumigation processing of traditional chinese medicinal herbs: beneficial or detrimental?

Majority of traditional Chinese medicine (TCM) herbs need to undergo post-harvesting processing to convert raw material into the form readily used for prescription. In general, processing procedures are either according to China Pharmacopeia or based on traditional methods. Recently sulfur fumigation is increasingly used to replace traditional sun-drying for its pesticidal and anti-bacterial properties in a cheap and convenient manner. However, to date information on effects of sulfur fumigation on herbal safety and efficacy are limited. This article addresses potential destructive effects of sulfur fumigation on herbal efficacy and safety through reviewing currently available information. Since recently increased numbers of studies have demonstrated that sulfur fumigation-induced dramatic changes in chemical profiles of various sulfur-fumigated herbs, consequent alteration of efficacy, and/or potential incidence of toxicity are suspected. Therefore comprehensive investigations on effects of sulfur fumigation on toxicity, chemical profiles, pharmacokinetics, and bioactivities of TCM herbs are timely to provide scientific basis for standardization and regulation of this currently common but potentially harmful processing method.

Metals and disease: a global primary health care perspective

Metals are an important and essential part of our daily lives. Their ubiquitous presence and use has not been without significant consequences. Both industrial and nonindustrial exposures to metals are characterized by a variety of acute and chronic ailments. Underreporting of illnesses related to occupational and environmental exposures to chemicals including metals is of concern and presents a serious challenge. Many primary care workers rarely consider occupational and environmental exposures to chemicals in their clinical evaluation. Their knowledge and training in the evaluation of health problems related to such exposures is inadequate. This paper presents documented research findings from various studies that have examined the relationship between metal exposures and their adverse health effects both in developing and developed countries. Further, it provides some guidance on essential elements of a basic occupational and environmental evaluation to health care workers in primary care situations.

Interactions between herbal remedies and medicinal drugs--considerations about Cuba

The use of herbal products to treat a wide range of conditions is rapidly leading to increased intake of phytochemicals. This is one of the main reasons for reinforcing the surveillance of the safety, efficacy and quality control of traditional and complementary medicines. Herbal preparations can interact with a drug at pharmacokinetic, pharmacodynamic and pharmacogenetic levels. In this article interactions between herbal products and conventional medicines are reviewed. Reports about side effects of traditional medicines and main interactions between herbal medicines and conventional drugs in Cuba are also included. Herbal products are currently not subject to the rigorous testing indispensable for conventional drugs. However, if potential drug interactions are to be predicted, it is essential that the ability of herbal products to interfere with drug-metabolizing enzyme systems is fully established.

Quality and safety of Chinese herbal medicines guided by a systems biology perspective

Chinese herbal medicines, often referred as Chinese materia medica (CMM), are comprised of a complex multicomponent nature. The activities are aimed at the system level via interactions with a multitude of targets in the human body. This review aims at the toxicity aspects of CMM and its preparations at the different steps of production; harvesting, processing and the final formulation. The historic perspective and today's issues of the safety of CMM are introduced briefly, followed by the descriptions of the toxic CMM in the current Chinese Pharmacopoeia (2005). Subsequently, several aspects of safety are illustrated using a typical example of a toxic CMM, Aconitum roots, and some recent findings of our own research are included to illustrate that proper processing and multi-herbs formulation can reduce the level of toxic components. This also explains that in CMM, some herbs, such as Aconitum, Ephedra species are never used as single herb for intervention and that aconite is only used when it is processed and in combination with specific matched other herbs. The formulation principle of multi-herbs intervention strategy is a systems approach for the treatment and prevention of disease. In this light, the role of systems toxicology in the safety and quality of Chinese herbal medicine is proposed as a promising method. Moreover the principles of practiced-based and evidence-based research are discussed from a symbiotic perspective.

Unconventional medicine in dermatology outpatients in Turkey

BACKGROUND

Many people use unconventional therapies for health problems, but the extent and pattern of this use in dermatology have not been studied in detail. This article reports the first investigation on the use of unconventional therapies in dermatology in Turkey.

AIM

To determine the prevalence and characteristics of unconventional therapies used by dermatology outpatients in Turkey.

METHODS

A questionnaire was employed to determine the use of unconventional therapies in patients attending a dermatology clinic in Ankara, Turkey. The patients were questioned about the number of attendances at dermatology clinics, whether they had ever used unconventional therapies and/or drugs without the suggestion of a medical doctor for the current dermatologic disorder, and the forms of unconventional therapies employed. The data were compared statistically with the age, sex, and education status of the patients.

RESULTS

The respondents included 443 men and 563 women, with a total of 1006 patients. The mean age of the patients was 36.62 +/- 17.55 years. Of the 1006 patients, 337 (33.5%) had used at least one form of unconventional therapy. The most common diagnoses of the patients using unconventional therapy were acne, psoriasis, contact dermatitis, and fungal infections. The most frequent forms of unconventional therapy used by the patients were humectants, cologne, spiritual healing, and herbs. Unconventional therapy use according to the sex, age, and education status of the patients did not show any significant difference. A significant relationship was found between some forms of unconventional therapy and some skin disorders, including: generalized pruritus and application of cologne; warts and spiritual healing; fungal infections and application of henna; psoriasis and herbal therapy or spiritual healing; alopecia areata and application of garlic; acne and application of lemon juice, clay, or cosmetics.

CONCLUSION

Regardless of patient age, sex, and education status, dermatology outpatients use unconventional therapies for their health. Dermatologists should be aware of the tendency of patients to use unconventional therapies and should guide patients towards the use of harmless treatments.

Diarylheptanoid phytoestrogens isolated from the medicinal plant Curcuma comosa: biologic actions in vitro and in vivo indicate estrogen receptor-dependent mechanisms

BACKGROUND

Diarylheptanoids isolated from Curcuma comosa Roxb. have been recently identified as phyto estrogens. However, the mechanism underlying their actions has not yet been identified.

OBJECTIVES

We characterized the estrogenic activity of three active naturally occurring diarylheptanoids both in vitro and in vivo.

METHODS

We characterized mechanisms of estrogenic action of the diarylheptanoids (3S)-1,7-diphenyl-(6E)-6-hepten-3-ol (D1), 1,7-diphenyl-(6E)-6-hepten-3-one (D2), and (3R)-1,7-diphenyl-(4E,6E)-4,6-heptadien-3-ol (D3) by using a real-time polymerase chain reaction assay, a mammalian transfection model, and a uterotrophic assay in mice.

RESULTS

All diarylheptanoids up-regulated estrogen-responsive genes in estrogen-responsive breast cancer cells (MCF-7). In HepG2 cells transfected with estrogen receptor (ER) beta or different ERalpha functional receptor mutants and the Vit-ERE-TATA-Luc reporter gene, all diarylheptanoids induced transcription through a ligand-dependent human ERalpha-ERE-driven pathway, which was abolished with ICI 182,780 (ER antagonist), whereas only D2 was active with ERbeta. An ERalpha mutant lacking the functional AF2 (activation function 2) region was not responsive to 17beta-estradiol (E(2)) or to any of the diarylheptanoids, whereas ERalpha lacking the AF1 domain exhibited wild-type-like activity. D3 markedly increased uterine weight and proliferation of the uterine epithelium in ovariectomized mice, whereas D1 and D2 were inactive. D3, like E(2), up-regulated lactoferrin (Ltf) gene expression. The responses to D3 in the uterus were inhibited by ICI 182,780. In addition, D3 stimulated both classical (Aqp5) and nonclassical (Cdkn1a) ER-mediated gene regulation.

CONCLUSIONS

The results suggest that the D3 diarylheptanoid is an agonist for ER both in vitro and in vivo, and its biological action is ERalpha selective, specifically requiring AF2 function, and involves direct binding via ER as well as ERE-independent gene regulation.

A study of western pharmaceuticals contained within samples of Chinese herbal/patent medicines collected from New York City’s Chinatown

In America, recent growth in the popularity of Chinese herbal/patent medicines (CHM/CPM) has generated concerns as to the safety of these and other herbal remedies. Lack of strict federal regulations has lead to the possibility of improper labeling and even adulteration of these products with western drugs or other chemical contaminants. Our laboratory has conducted an analytical study to determine the presence of undeclared pharmaceuticals and therapeutic substances within CHM/CPM sold in New York City's Chinatown. Ninety representative samples randomly purchased in the form of pills, tablets, creams and teas were screened by appropriate analytical techniques including TLC, GC/MS and HPLC. Five samples contained nine different western pharmaceuticals. Two of these samples contained undeclared or mislabeled substances. One sample contained two pharmaceuticals contraindicated in people for whom the product was intended. Drugs identified include promethazine, chlormethiazole, chlorpheniramine, diclofenac, chlordiazepoxide, hydrochlorothiazide, triamterene, diphenhydramine and sildenafil citrate (Viagra).

Efficacy and safety of herbal medicines for idiopathic Parkinson's disease: a systematic review

The objective of this study is to assess the efficacy and safety of herbal medicines (HMs), as a monotherapy or adjunct therapy, compared to placebo or conventional approaches in the treatment of idiopathic Parkinson's disease (PD). We conducted a systematic review of randomized controlled trials from both conventional and alternative medicine sources. Outcome measures were overall improvement, quality of life, reduction of levodopa dose, and adverse events. Nine studies were included, each testing a different HM. Six of the trials had limited internal validity due to major flaws in design, including the lack of proper randomization; insufficient blinding; unclear inclusive criteria in terms of diagnostic criteria, baseline staging, and duration of disease; lack of proper sample size calculation; and insufficient data analysis. Imbalances in gender and ethnicity among the patients in the included trials were observed. No major adverse events emerged, and no specific pattern was detected from the trials describing such data. In addition to major methodological defects, heterogeneity in (1) HM tested, (2) control treatment, and (3) outcome measure hindered in-depth data analysis and synthesis. Current evidence is insufficient to evaluate the efficacy and safety of various HMs. Further studies with improved trial design and reporting, with assessment on cost-effectiveness, quality of life, and qualitative data are warranted.

Helping Patients Make Decisions About Complementary and Alternative Treatments

Increasingly people are using complementary and alternative modalities (CAM) to cope with and manage cancer. Many patients, however, do not know how to access credible information and make informed treatment decisions. Social workers are in a unique position in the healthcare team to facilitate patients' decision-making about CAM. Skills and techniques to educate patients and to help them communicate with their healthcare practitioners about CAM are described. The authors introduce questions patients should ask to make better-informed treatment decisions, and describe social work interventions to help patients explore their choices in the context of personal history, meaning, beliefs and lifestyle. Lastly, the position of the social worker vis à vis the institution and its stance on CAM is explored.

Applying Evidence-Based Medicine to Traditional Chinese Medicine: Debate and Strategy

Drawing on recent paper published literature in both English and Chinese, this explores reactions to the evaluation of Chinese medicine using randomized controlled trials (RCTs) and the standards of evidence-based medicine (EBM). The literature review revealed a few sources which contend that Chinese medicine should not be evaluated on the basis of RCTs, but a far greater number which advocate for applying RCT and EBM standards to Chinese medicine. This paper describes the position of the detractors and points out ways in which their arguments contain oversimplified representations of Chinese medicine, biomedicine, EBM, and RCTs. In describing the position of the proponents, the analysis outlines some of the numerous innovative techniques they are developing for dealing with issues of control and standardization in efficacy research. Overall, the analysis indicates that important refinements are being generated in Chinese medicine research and clinical trial design in response to the challenges posed by the forced encounter of these two paradigms.

Migraine during pregnancy: options for therapy

Migraine is common during pregnancy, but fortunately this combination of conditions obviously exists for only a finite period. The greatest frequency of migraine attacks occurs during the first trimester. Accurate diagnosis is a sine qua non in this setting as in any headache patient. It is in the first trimester that the fetus is at greatest risk from abortifacient and teratogenic drugs, and when very early pregnancy may be undiagnosed. Ergot alkaloids (including methysergide) should be avoided during pregnancy because of their teratogenicity, and most other drug classes should be used only when unavoidable. The use of prophylactic agents during pregnancy should be the exception, not the rule, and preferably only during the second and third trimesters; propranolol is probably safest in this situation. De novo headache during pregnancy usually requires expert review of the patient. Treatment tactics for uncomplicated migraine in pregnancy depend on the concurrent clinical situation. Paracetamol (acetaminophen) is the mainstay for the patient whose typical attacks continue into the first trimester. If paracetamol is insufficient, then partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters (which is uncommon). 'Chronic migraine' in pregnancy, i.e. >or=15 headache days per month, is rare, and is the greatest therapeutic challenge. Co-morbidities such as depression or epilepsy require specialised approaches. The complexities associated with these tactics are discussed in this article, and it is emphasised that none has the specific approval of regulatory authorities. Heightened pharmacovigilance will better inform the future pregnant migraineur. However, this type of information is less likely to be available for novel classes of neuropharmacological agents than for existing ones.

Kidney injury from alternative medicines

In the developing world, up to 80% of the population uses traditional medicine for primary health care. In industrialized countries, adaptations of traditional medicine, termed "complementary" or "alternative" medicine (CAM), are used by a growing number of patients for preventive or palliative care. However, alternative medicine (AM) may be an important risk for the development of acute and chronic kidney injury because of several factors: nonconventional preparations rarely meet the required essential standards of consistency in composition and biological activity; many of these products contain undisclosed over-the-counter or prescription drugs or can be adulterated with hormones and glandular extracts; herbal preparations can be contaminated by pesticides and heavy metals; and because of errors in plant identification and confusing terminology, opportunities for mistakes and deliberate substitution can occur. Furthermore, there is a lack of reports of adverse events and drug interactions because of a lack of professional surveillance, and specific data on systemic and kidney toxicity are not easily available. Kidney injury/kidney syndromes caused by AM consist of acute tubular necrosis/toxicity (eg, Fanconi's syndrome), acute interstitial nephritis, papillary necrosis, hypertension, kidney stones, urinary retention, chronic tubulointerstitial nephritis with fibrosis, urinary tract carcinoma, and acute rejection of the kidney transplant. To improve the care for patients using AM, extension of physicians' knowledge about its possible hazards and toxicity is essential. This review deals with acute and chronic kidney toxicity caused by animal-, plant-, and mineral-based, nonconventional medicine and kidney failure caused by drug interactions with AM.

Chinese medicinal herbs for acute pancreatitis

BACKGROUND

Acute pancreatitis is a relatively common acute abdominal emergency but there is no specific therapy for it. Traditional Chinese medicinal herbs have been used widely for many years in China to treat acute pancreatitis, and several controlled trials have been carried out to investigate their efficacy.

OBJECTIVES

To assess the efficacy and safety of traditional Chinese medicinal herbs for acute pancreatitis.

SEARCH STRATEGY

The following electronic databases were searched, in September 2002: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2002, MEDLINE, EMBASE, AHMED (Allied and Complementary Medicine Database) and SIGLE (System for Information on Grey Literature). Four Chinese journals and conference proceedings were handsearched. No language restriction was used. The searches were updated in October 2003 (The Cochrane Library Issue 3, 2003).

SELECTION CRITERIA

All randomized controlled trials involving traditional Chinese medicinal herbs in the treatment of acute pancreatitis and published in any language, regardless of whether they were single-blinded, double-blinded, or not blinded.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. The methodological quality of trials was evaluated using the Jadad scale plus allocation concealment.

MAIN RESULTS

Eleven randomized clinical trials (including a total of 658 participants) were identified in which Chinese medicinal herbs or Chinese medicinal herbs plus routine treatment were compared with routine treatment. All of these trials were published in Chinese and all included inpatients. None of the articles described the method of randomisation. The large heterogeneity of the intervention prevented us from doing a meaningful subgroup analysis. There appeared to be some benefit from Chinese medicinal herbs over control for mortality rates, length of hospital stay and operative intervention but the trials were of low quality and this benefit did not reach statistical significance.

AUTHORS' CONCLUSIONS

Some Chinese medicinal herbs may work in acute pancreatitis. However, the evidence is too weak to recommend any single herb. Rigorously designed, randomized, double-blind, placebo-controlled trials are required.

Herbs and the kidney

The use of herbal therapy has increased dramatically in past years and may lead to renal injury or various toxic insults, especially in renal patients. In most countries, herbal products are not regulated as medicines. Herbal poisoning may be secondary to the presence of undisclosed drugs or heavy metals, interaction with the pharmacokinetic profile of concomitantly administered drugs, or association with a misidentified herbal species. Various renal syndromes were reported after the use of medicinal plants, including tubular necrosis, acute interstitial nephritis, Fanconi's syndrome, hypokalemia or hyperkalemia, hypertension, papillary necrosis, chronic interstitial nephritis, nephrolithiasis, urinary retention, and cancer of the urinary tract. It seems critical that caregivers be aware of the potential risk of such often underreported therapy and carefully question their patients about their use of this popular branch of alternative medicine.

Application of headspace solid-phase microextraction (HS-SPME) and comprehensive two-dimensional gas chromatography (GC x GC) for the chemical profiling of volatile oils in complex herbal mixtures

The coupling of headspace solid-phase microextraction (HS-SPME) with comprehensive two-dimensional gas chromatography (GC x GC) was shown to be a powerful technique for the rapid sampling and analysis of volatile oils in complex herbal materials. When compared to one-dimensional (1-D) GC, the improved analytical capabilities of GC x GC in terms of increased detection sensitivity and separation power were demonstrated by using HS-SPME/GC x GC for the chemical profiling (fingerprinting) of essential/volatile oils contained in herbal materials of increasing analytical complexity. More than 20 marker compounds belonging to Panax quinquefolius (American ginseng) can be observed within the 2-D contour plots of ginseng itself, a mixture of ginseng and another important herb (P. quinquefolius/Radix angelicae sinensis), as well as a mixture of ginseng and three other herbs (P. quinquefolius /R. angelicae sinensis/R. astragali/R. rehmanniae preparata). Such analytical capabilities should be important towards the authentication and quality control of herbal products, which are receiving increasing attention as alternative medicines worldwide. In particular, the presence of Panax in the herb formulation could be readily identified through its specific peak pattern in the 2-D GC x GC plot.

Metabolic, antioxidant, nutraceutical, probiotic, and herbal therapies relating to the management of hepatobiliary disorders

Many nutraceuticals, conditionally essential nutrients, and botanical extracts have been proposed as useful in the management of liver disease. The most studied of these are addressed in terms of proposed mechanisms of action, benefits, hazards, and safe dosing recommendations allowed by current information. While this is an area of soft science, it is important to keep an open and tolerant mind, considering that many major treatment discoveries were in fact serendipitous accidents.

Chinese herbal medicines for type 2 diabetes mellitus

BACKGROUND

Traditional Chinese herbal medicines have been used for a long time to treat diabetes, and many controlled trials have been done to investigate their efficacy.

OBJECTIVES

To assess the effects of Chinese herbal medicines in patients with type 2 diabetes mellitus.

SEARCH STRATEGY

We searched the following electronic databases: The Cochrane Library (CENTRAL), the Chinese BioMedical Database, MEDLINE, EMBASE, and LILACS, combined with hand searches on Chinese journals and conference proceedings. Date of last search was April 2004. No language restriction was used.

SELECTION CRITERIA

Randomised trials of herbal medicines (with at least two months treatment duration) compared with placebo, pharmacological or non-pharmacological interventions were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. The methodological quality of trials was evaluated using the parameters of randomisation, allocation concealment, double blinding, and drop-out rates. Meta-analyses were performed where data were available.

MAIN RESULTS

Sixty-six randomised trials, involving 8302 participants, met the inclusion criteria. Methodological quality was generally low. Sixty-nine different herbal medicines were tested in the included trials, which compared herbal medicines with placebo, hypoglycaemic drugs, or herbal medicines plus hypoglycaemic drugs. Compared with placebo, Holy basil leaves, Xianzhen Pian, Qidan Tongmai, traditional Chinese formulae (TCT), Huoxue Jiangtang Pingzhi, and Inolter showed significantly hypoglycaemic response. Compared with hypoglycaemic drugs including glibenclamide, tolbutamide, or gliclazide, seven herbal medicines demonstrated a significant better metabolic control, including Bushen Jiangtang Tang, Composite Trichosanthis, Jiangtang Kang, Ketang Ling, Shenqi Jiangtang Yin, Xiaoke Tang, and Yishen Huoxue Tiaogan. In 29 trials that evaluated herbal medicines combined with hypoglycaemic drugs, 15 different herbal preparations showed additional better effects than hypoglycaemic drugs monotherapy. Two herbal therapies combined with diet and behaviour change showed better hypoglycaemic effects than diet and behaviour change alone. No serious adverse effects from the herbal medicines were reported.

REVIEWERS' CONCLUSIONS

Some herbal medicines show hypoglycaemic effects in type 2 diabetes. However, these findings should be carefully interpreted due to the low methodological quality, small sample size, and limited number of trials. In the light of some positive findings, some herbal medicines deserve further examination in high-quality trials.

Interventions for preventing infection in nephrotic syndrome

BACKGROUND

Infection is one of the most common complications and still remains a significant cause of morbidity and occasionally mortality in patients, especially children with nephrotic syndrome. Many different prophylactic interventions have been used or recommended for reducing the risks of infection in nephrotic syndrome in clinical practice. Whether the existing evidence is scientifically rigorous and which prophylactic intervention can be recommended for routine use based on the current evidence is still unknown.

OBJECTIVES

To assess the benefits and harms of any prophylactic interventions for reducing the risk of infection in children and adults with nephrotic syndrome.

SEARCH STRATEGY

We searched the Cochrane Renal Group Specialised Register (January 2003), The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 1, 2003), MEDLINE and Pre-MEDLINE (1966 - February 2003), EMBASE (1980 - February 2003), China Biological Medicine Database (CBMdisc, 1979 - December 2002), reference lists of nephrology textbooks, review articles, relevant trials and abstracts from nephrology scientific meetings without language restriction.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing any prophylactic interventions (pharmacological or non-pharmacological) for preventing any infection in children and adults with nephrotic syndrome.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed and extracted information. Information was collected on method, participants, interventions and outcomes ( appearance of infection, mortality, quality of life and adverse events).

MAIN RESULTS

Five RCTs conducted in China, including 308 children with nephrotic syndrome were identified. No trials were identified in adults. All trials compared one kind of prophylactic pharmacotherapy (IVIG, thymosin or a compound of Chinese medicinal herbs - TIAOJINING) in addition to baseline treatment with baseline treatment alone. No RCTs were identified comparing antibiotic or non-pharmacological prophylaxis, or pneumococcal vaccination. Three trials showed a significantly better effect of IVIG on preventing nosocomial or unspecified infection in children with nephrotic syndrome (RR 0.39, 95% CI 0.18 to 0.82). Thymosin and TIAOJINING were also effective for reducing the risks of infection in children with nephrotic syndrome with RR 0.50 (95%CI 0.26 to 0.97) and 0.59 (95%CI 0.43 to 0.81) respectively. No serious adverse events were reported.

REVIEWERS' CONCLUSIONS

IVIG, thymosin and TIAOJINING may have positive effects on prevention of nosocomial or unspecified infection with no obvious serious adverse events in children with nephrotic syndrome. However the methodological quality of all trials was poor, the sample sizes small and all studies were from China, and thus there is no strong evidence on the effectiveness of these interventions.